Dydrek "

Dydrek is a 48 year old married man on sick leave from his job as a foreman in a food processing factory, a position he has held for some five years following a redundancy from a previous employer. Nearly 2 1/2 years ago, Dydrek was in charge of a production line and witnessed one of his fellow workers, a young man of 16 years of age, fall into a piece of machinery resulting in horrible injuries. Dydrek accompanied the injured man to hospital, but was prevented from entering the treatment room, where he later died. Immediately after the incident, Dydrek took the train home, but missed his station stop. He appears to have spent a number of hours wandering the street in the dark, disorientated, eventually being picked up by the police and taken home. He was signed off from his work for a couple of weeks and has little recall of the period following the accident. Dydrek returned to his work two weeks later, fearing reprisals from his employers. He was telling himself to "pull himself together", neither understanding why he was feeling so bad, nor believing that there was any justifiable reason for taking more time off work. He regarded failure to cope as a sign of weakness which would not be looked well upon by his colleagues. The incident which had occurred at work was not discussed, and Dydrek perceived that he was being ostracized by his work colleagues. He believed that they must blame him for the death, and he feared that the parents of the young man, who lived in the same community, would exact revenge. The incident report at the food processing factory had apparently concluded that the accident had occurred as a result of machinery failure. DYDREK, who has been unable to attend the inquiry, nonetheless continued to believe that he must have been responsible, and that he could have done more to prevent the risk of the accident occurring. Two months later, following a period of increasing time off work, because of poor time-keeping and increased alcohol consumption, Dydrek was sent home as unfit for his duties. Dydrek did not easily talk about his difficulties, but his GP managed to learn that Dydrek had been unable to sleep since the incident, and had taken to self-medicating with alcohol. Dydrek complained of having no energy and of increased irritability with his wife and children. His manner was withdrawn, and Dydrek appeared to be consumed with self-hatred. The GP signed him off his work as suffering from depression. He has not since returned to work. Dydrek's GP prescribed a short course of benzodiazepines to help him to withdraw from alcohol, but this was unsuccessful. He was then prescribed lofepramine 75mg (a low dose of antidepressant medication), but still did not improve. After a further 4 months, his wife dragged him to the GP, complaining that his drinking had worsened and that he was verbally aggressive to her and their children. The GP made a referral to the Alcohol Problems Clinic. It later emerged that Dydrek had failed to attend and was discharged in his absence. Meanwhile, his wife and the children had moved out. One night, Dydrek had gone to his wife's new address, shouting and throwing stone up at the windows, demanding to see the children. A neighbour called the police, and Dydrek was charged with breach of the peace. A duty psychiatrist was called to the cells, where Dydrek reported that he had taken an overdose of his stored-up medication, lofepramine. His knuckles were bleeding, resulting from Dydrek hitting his right fist against the wall, something which he said helped him to stop his mind from racing. He expressed thoughts of hopelessness and despair and that he couldn't guarantee his safety. He was transferred to the Infirmary overnight. On admission, he became acutely disturbed and required heavy sedation. Dydrek told the duty psychiatrist that he was suffering from unbearable involuntary memories of the workplace accident. He was unable to sleep, unless drunk, for fear of the nightmares which tormented him. He believed that he was being blamed by his work colleagues, and avoided his place of work, ignoring the 'phone and any mail which could relate to work. He had, until now, managed to avoid the Infirmary, where the young man had died, and had experienced a severe panic attack the night before, when brought into the hospital. Dydrek presented with guilt and self-blame. He had isolated himself from his work-mates and his friends. He reported no current social contacts, only the strained contact with his wife, who forbade him to see their children unless he was sober. Dydrek reported extreme levels of stress and edginess, he was noticeably jumpy in the consultation. He was vague about his daily life, and it transpired that he was spending much of the day at home. His self-care was impoverished and he described that he couldn't account for the time, finding that he was spending long hours staring into space or feeling "out of it". The psychiatrist asked about the sores on his right fist, and Dydrek said that when things get too much for him, he hits his hand against the wall. He said that he deserves it because his life is "shit", and that it helps him to forget for a while. Sometimes he says that he gets upset and is not aware that he is hitting his hand. He feared that his marriage was over, and that he will lose contact with his children. It was his second marriage, the first was ended with divorce, 15 years ago, because of his alcohol problems at the time. He had, until recently, been abstinent of alcohol in this 9 year long marriage. The duty psychiatrist referred Dydrek to the Rivers Centre with a diagnosis of PTSD and secondary depression. She requests an urgent appointment - the waiting list for treatment is over 6 months. When Dydrek is sent an appointment for assessment, he fails to attend. He attends for a second appointment with his separated wife. He does not smell of alcohol, but is twitchy. He is subdued and monosyllabic. His wife is angry and complains, "This shouldn't have been allowed to happen. Something should have been done about him months ago". Dydrek was born and brought up in a working-class area of Edinburgh. His mother is now elderly and physically infirm. She has lived for the past 5 years with Dydrek's sister in Canada. Dydrek's father, a hard-drinking, heavy-smoking stonemason, died of a sudden heart-attack in his forties, when Dydrek was 9. He describes that he hadn't ever cried since his father's death, believing that, as the oldest son, he was expected to be brave and to look after his grieving mother. After the death, his mother "went to pieces", and didn't manage to return to paid work for a number of years. Dydrek has hazy, idealised memories of his father. Following his death, Dydrek got in with a crowd of older boys, truanting from school, smoking, drinking and stealing. He left school at 15, working at various odd jobs, until at 21, he married his childhood sweetheart. He found work as a minicab driver, and the couple moved to Fife. Their first child was stillborn, and shortly after this, Dydrek was charged with drunk-driving and lost his license. There were growing arguments at home, mostly about his drinking, and the ensuing financial difficulties. They had separated, after the birth of their son, and Dydrek had returned to Edinburgh, living at first with his mother, and later in a solitary bed-sit. Dydrek's second marriage had marked the most stable period of his life. He had found stable employment, within which he had acquired a position of some responsibility. Despite a temporary hitch in coping at the time of his redundancy, Dydrek had done well in acquiring a foreman's position in the local food reprocessing factory, where his wife worked as a secretary. He had friends among his colleagues, and with his wife's income, they had managed to create a comfortable home. The stable environment enabled Dydrek to build a relationship with his 15 year old son from the first marriage, and they soon had two girls of their own. Dydrek described his second wife, 8 years his junior, as bossy and in charge of family life. She was a devoted mother and house-keeper, in charge of the family finances and decision making regarding the children and house-hold affairs. Dydrek appeared to have taken a passive role, saying that she tended to mother him and that he couldn't have coped without her. She had been tolerant of his apparent withdrawal into himself at the time of his redundancy and during episodes of stress regarding access to his oldest son. Nonetheless, their relationship had deteriorated substantially since the incident at work. After a long period of waiting for him to return to normal, she had started to lose patience. She had become watchful of his movements and was extremely angry and resentful of his growing alcohol problem, and the ways in which he was destroying all that they had worked so hard to build. She had gradually begun to restrict his access to the children, by arranging for them to be at her parents when he had been drinking, and following the ensuing arguments. She was aware that he was unwell, and that he had started hitting his hand and forehead against the walls. She, however, felt unable to reach him. He would not talk to her and appeared not to care. She eventually chose to move in with her parents. Dydrek is reluctant to discuss details of the trauma, but agrees fairly readily to meet for 6 individual sessions to address "here and now" issues. He appears pre-occupied with the separation from his wife, and his feelings of failure as a husband and father. He starts fluoxetine (Prozac), prescribed by his GP, and dispensed on a weekly basis. He tolerates a fairly high dose, though without clear benefit. He fails to appear for the 3rd session, but arrives at your clinic 3 days later, smelling of alcohol, weeping, begging for help, saying that he "can't stand it any longer". He says that he has been having recurrent images of the accident, and increasing episodes of lost time. He is despairing and hopeless, saying that he is "a wreck", and that his wife and family would be better off without him. He refuses to see his GP, whom he says is unable to help him any more.

SYNOPSIS"

Multi-Axial Assessment"•  Axis I – PTSD (Severe), Depression (Secondary Type) (Moderate), Alcoholism (Residual), Suicidal Ideations

•  Axis II – Deferred •  Axis III – Deferred •  Axis IV – Primary, Social, Work

•  Axis V – <50

Primary Issues or Problems"

•  Unbearable involuntary memories of the accident.

•  Unable to sleep unless drunk for fear of nightmares.

•  Extreme levels of stress and edginess.

•  Despairing and hopeless.

Cognitive Behavioral Therapy "The basic premise of CBT is that emotions are difficult to change directly, so CBT targets emotions by changing

thoughts and behaviors that are contributing to the distressing emotions.

Core Concepts"

Behavioral"•  Applied Behavior Analysis

•  Neobehavioristic Meditational Stimulus-Response Model

•  Social-Cognitive Theory

Cognitive"

•  Strategies –  Schemas –  Cognitive Shift –  Cognitive Vulnerabilities

•  Techniques  –  Collaborative Empiricism

–  Guided Discovery

Therapy Sessions"

1st Session"•  Obtain Consent •  Build Rapport •  Orient Patient to CBT •  Assess Concern –(Self Report Inventory)

•  Set Initial Treatment Plan/Goal •  SASSI •  Medical Referral

2nd Session"

Inpatient"

• Detox • Group Therapy • Individual Therapy

 

 

28 days later…

Outpatient"

3rd Session"

Individual Therapy"

•  Bridging Session •  CBT •  EMDR •  Cognitive Restructuring

•  Behavioral Activation

4th Session"

Group Therapy"

•  Review HW •  Continued AA •  Family

Continued Therapy"

•  AA •  Individual •  Family •  Depression •  Weekly Check-Ups

Final Session?"

Comments and Statements"

•  Believes that co-workers blame him for his colleague’s death.

•  Feared parents of the young man killed would exact revenge.

•  Appears to be consumed with self hatred. •  Has guilt and self blame. •  Losing track of time staring into space. •  Unaware he is physically hurting himself. •  Seems pre-occupied with the separation from his wife.

•  Feelings of failure as a husband and father.

Success and Failures"

•  Completes Rehab Program •  Cognitive Distortions •  Managing Mood •  Emotional/Social/Relationship Problems

•  Marital Stress •  Family Stress