The patient, being very motivated, also developed treatments that worked well. He would stare at a blank white wall approximately 2 feet away, focusing on one location. One of his family members would take a laser pointer and start very far away, then slowly move the light closer to the patient’s center of vision. JD would tell his family member when he could see the light and they would move on to a different portion of his visual field.
After 3 months, we retested JD’s vision, which showed great improvement. JD felt he had significant improvement in his vision. The ophthalmologist retested JD about 2 months later and he passed a visual test well enough to obtain a modified driving license so he could return to his work as an agronomist.
Treatment of PTSD
Therapy for PTSD is complex and best approached with a long-term, multifaceted plan.20 Both pharmacotherapy and psychotherapy can be considered for initial treatment; however, no placebo-controlled randomized trials comparing the 2 modalities have been conducted. Combination therapy can also be employed.
Drug therapy, particularly selective serotonin reuptake inhibitors (SSRIs), has been shown to be generally effective in ameliorating positive symptoms associated with PTSD, such as nightmares and flashbacks. But they are less effective at treating negative symptoms such as withdrawal and avoidance.21,22
There is no clinical evidence to support the use of anxiolytics such as benzodiazepines in treating PTSD-specific symptoms. One small study did find a significant reduction in anxiety with alprazolam compared with placebo; however, the response was modest, and specific PTSD symptoms were unchanged.2 Given the high prevalence of comorbid substance abuse in PTSD, benzodiazepines are best avoided since evidence for their effectiveness is lacking.23
Both CBT and eye movement desensitization and reprocessing (EMDR) can be effective therapy for PTSD.24 Both modalities center on desensitization through exposure to traumatic recollections and symptom triggers.
The CBT approach we used focused on JD’s phobic reaction to ammonia that prevented his return to work. First, he listened to relaxation CDs to practice deep breathing and relaxation techniques. Once he was familiar with the techniques, he practiced them in the presence of the shed that contained ammonia products, which was a trigger for his anxiety. At first he was only able to approach the shed while using the breathing exercises to calm his anxiety. Over several weeks, he became more comfortable moving closer to the shed, and he eventually stepped into the shed and began staying for longer periods of time. The course of therapy took several months, but by the end of the sessions he was able to perform necessary tasks in the he was able to perform necessary tasks in the shed with only mild anxiety.
He also suffered from persistent troubling nightmares that significantly affected his sleep and led to physical symptoms of headache and vomiting. These, too, were overcome with the CBT approach.25 We instructed him to immediately write down as much as he could recall of a nightmare upon waking from it. During the following day, he re-read the dream and attempted to re-experience it while using the relaxation techniques to temper anxiety. Over several months of therapy, his nightmares lessened and eventually stopped.
On the last day of therapy, JD reported he had 3 job offers and 2 more interviews lined up, and that he was excited about his opportunities. We congratulated him on his visual recovery and applauded him for his hard work.
Discussion
While it is possible that JD spontaneously recovered his vision loss, it’s more likely that treatment can be credited, given that he did not improve in the 6 months prior to treatment and that his condition resolved over the 3-month rehabilitation period.
Research that guides practice must necessarily limit variables, but real-life patients often have multiple variables complicating both diagnosis and treatment. Our patient is a graphic example. He was exposed to anhydrous ammonia with its multiple physiologic sequelae and it was a traumatic event leading to additional sequelae. Furthermore, his inability to perform his job and fulfill social obligations contributed to his impairment.
JD’s referral to a neural-ophthalmologist did not provide a definitive diagnosis. He then followed up on a referral to the local residency clinic, where the family physician/psychologist team treats patients from a biopsychosocial perspective. Although physicians feel most comfortable when they arrive at a specific diagnosis with a specific evidence-based treatment that predicts a good outcome, this case yielded no definitive diagnosis. Instead, the psychologist and family physician relied on general research findings showing that in the context of traumatic injury or illness followed by debilitating anxiety symptoms, desensitization and rehabilitation provide the best chance of improvement. This shift in treatment approach very likely was responsible for the patient’s improvement.