PTSD

Human Trafficking & PTSD:Rebekah’s Story : 

Human Trafficking & PTSD:Rebekah’s Story Audrey han Lissa haro Remy hereford Vanessa hughes Jessica jones

Meet Rebekah : 

Meet Rebekah Rebekah is a twenty-one-year old woman who ran away from home at the age of fourteen after a fight with her parents. Out on the streets alone, cold and hungry, Rebekah was grateful when a kind man stopped and offered her help- shelter, food, clothing, and, most of all, support. Rebekah felt understood by the man and went home with him, only to be received by a group of men who repeatedly took turns raping her.

Meet Rebekah : 

Meet Rebekah She was told that she would be working for them now, and that if she tried to run away or tell anybody, that they would kill her loved ones. For seven long years, men came daily to have sex with her, paying her captors large amounts of money to be exploit her. By the time Rebekah was rescued three months ago, she was dejected and had given up on life completely. Haunted by the painful memories, she began to see a therapist who diagnosed Rebekah with Post-Traumatic Stress Disorder.

What is Post-Traumatic Stress Disorder? : 

What is Post-Traumatic Stress Disorder? PTSD occurs when: A person has been exposed to a traumatic event in which s/he experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others The person’s response involved intense fear, helplessness, or horror

Rebekah’s Journal : 

Rebekah’s Journal May 10, 2010 Well, I called the number on the card they gave me when they got me out. The lady seemed nice enough and I will go see her in a couple days. She said she deals with lots of girls who have been through what I went through. I don’t know, we’ll see. It can’t be worse than what’s already happened to me… Kidnapped at 14, a sex slave for 7 years, and then, when the cops did a raid and “rescued” me, they treated me like just another prostitute. But she seemed nice, maybe she won’t handcuff, fingerprint, and strip search me.

Therapist’s Notes : 

Therapist’s Notes May 10, 2010 I had an initial phone consultation with a young adult woman who is a trafficking victim. Client reported having been enslaved for 7 years from the age of 14 and rescued by law enforcement personnel 3 months ago. Client refused treatment at the time of rescue. Client reported having been “treated like I was just a prostitute” by law enforcement and “wanted none of their so-called help.”

What is Post-Traumatic Stress Disorder? : 

What is Post-Traumatic Stress Disorder? PTSD occurs when: The traumatic event is persistently reexperienced in one (or more) of the following ways: recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions recurrent distressing dreams of the event

Rebekah’s Journal : 

Rebekah’s Journal May 13, 2010 I woke up again last night with another nightmare. It was one of the dreams I have a lot. I am sitting on a curb when a big, brown car pulls up next to me. I feel the arms grab me. The man’s hand covers my mouth…I can’t breathe because his hand is blocking my air. I am thrown into the back seat. The next thing I know, I am on my stomach with some big, sweaty man above me. I hurt. He hears me cry so he grabs the back of my hair and smashes my face in the pillow; I can’t breathe. I wake up crying with my face in my pillow, soaking wet, and with that same horrific fear I had back then. I don’t think it will ever go away.

What is Post-Traumatic Stress Disorder? : 

What is Post-Traumatic Stress Disorder? acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

Therapist’s Notes : 

Therapist’s Notes May 15, 2010 Client entered the therapy room, sat down, and immediately changed her posture with a horrified look on her face. She began to shake and her words became difficult to understand. After working through this response it was revealed that the scent of the cologne that had lingered in the air was the same as her captors’. Therapist made clear notes not to schedule this client on the same day as the previous client.

What is Post-Traumatic Stress Disorder? : 

What is Post-Traumatic Stress Disorder? PTSD occurs when there is: Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following: efforts to avoid thoughts, feelings, or conversations associated with the trauma efforts to avoid activities, places, or people that arouse recollections of the trauma inability to recall an important aspect of the trauma

Therapist’s Notes : 

Therapist’s Notes May 15, 2010 Client seems unable to recall many elements of her trauma. She cannot recall details of her experiences of abuse or how she came to eventually accept her role as a sexual slave. Client has a noticeably difficult time talking about her traumatic experiences and defensively avoids discussing certain topics.

What is Post-Traumatic Stress Disorder? : 

What is Post-Traumatic Stress Disorder? markedly diminished interest or participation in significant activities

Rebekah’s Journal : 

Rebekah’s Journal May 17, 2010 All I wanted was to be free and home while I was away. Now that I can leave whenever I want, eat whenever I want, and even use the phone, I don’t want to. I don’t want to go out with people, I don’t want to talk to anyone.

What is Post-Traumatic Stress Disorder? : 

What is Post-Traumatic Stress Disorder? feeling of detachment or estrangement from others restricted range of affect (e.g., unable to have loving feelings) sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

Rebekah’s Journal : 

Rebekah’s Journal May 19, 2010 I’m never going to be normal again. People treat me weird. They whisper and think I can’t hear them. They seem to not know how to act around me, but I don’t know how to act around them. I want hugs, but I feel like I can’t breathe when anyone gets too close. I pull away and then freak them out. People come around less and less…that’s okay, I am more comfortable that way. I figure I should feel bothered, but I don’t feel anything. It’s not like I will ever actually find someone who will marry someone like me. It’s not like I’ll ever have kids. I can’t even stand to be touched on the arm. It is like I am wandering around like a zombie. Sometimes I wonder why they didn’t just kill me and get it over with.

What is Post-Traumatic Stress Disorder? : 

What is Post-Traumatic Stress Disorder? PTSD occurs when there are: Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following: difficulty falling or staying asleep irritability or outbursts of anger difficulty concentrating Hypervigilance exaggerated startle response

Therapist’s Notes : 

Therapist’s Notes May 22, 2010 Client missed appointment today, I called to check up on her and learned that she missed therapy because she was in police custody for assault. Client reported being “zoned out” on a bus on her way to a meeting. According to client, someone tapped her to ask if the seat next to her was available and she jumped up, kicking the person in the face and chest. Other passengers reportedly grabbed her to restrain her and further set her off. Client was then taken into police custody. No charges were filed against her.

Therapist’s Notes : 

Therapist’s Notes May 22, 2010 Client also reports difficulty falling asleep and sleeping throughout the night. She also reports “zoning out” and having trouble keeping her mind on things. I have obtained a release from the client to speak with her physician about the possibility of medication for the time being.

What is Post-Traumatic Stress Disorder? : 

What is Post-Traumatic Stress Disorder? PTSD occurs when: Duration of the disturbance is more than 1 month. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Therapist’s Notes : 

Therapist’s Notes May 29, 2010 Client and I established some goals of treatment today: Reduce negative impact that trauma has had on many aspects of life and return to pre-trauma level of functioning Develop and implement effective coping skills to carry out normal responsibilities and participate constructively in relationships Recall traumatic event without becoming overwhelmed with negative thoughts, feelings, or urges. Terminate destructive behaviors that serve to maintain escape and denial while implementing behaviors that promote healing, acceptance of the past events, and responsible living.

Rebekah’s Journal : 

Rebekah’s Journal May 29, 2010 I felt really hopeful after therapy today. My therapist and I set some goals. I also felt overwhelmed, like, can I really do this? This seems like so much. It is like a huge house of bricks crashed down on me and I can hardly breathe. I want to just curl up and wait to die the rest of the way. But these goals make it seem do-able. Like there is a system to getting these bricks off of me. Like there really is a way to organize all my chaos. That gives me hope and makes me excited about the coming weeks. I guess I feel better knowing I am working towards something. Also, looking at it in these smaller pieces makes it seem possible I can be back to normal.

Rebekah’s Journal : 

Rebekah’s Journal May 29, 2010 For example, a goal is to get back to how I lived my life before all this happened - learn how to have friendships and maybe even a boyfriend again in a normal way. Getting to the point where I can remember the horrible stuff and not totally freak out. And the last one, probably the hardest for me, stop doing all this junk that I do to deal. Stop lashing out, withdrawing and whatnot. But learn how to accept the bad things that have happened and learn to heal from it, not try to make it go away, because it is never going to go away. All I can do is learn how to live a life like everyone else even despite what’s happened to me.

Therapist’s Notes : 

Therapist’s Notes May 29, 2010 During treatment, I will have these as therapy techniques to aid in clients treatment: I will monitor and assess for drug/alcohol abuse, suicidality, self harming behaviors, symptoms of depression As much as is safe and healthy for the clients overall mental and emotional state, I will have client describe her traumatic event in as much detail as possible.

Therapist’s Notes : 

Therapist’s Notes May 29, 2010 Client has a strong sense of powerlessness due to the nature of her trauma. To help empower her and allow her to regain power and knowledge of what is going on with her and what will occur and why, I will help client to understand PTSD through psycho- education. Due to the severity of her trauma and her severe reactions, I will encourage client to remain under the care of a physician for psychotropic medication and maintain communication with her physician to monitor the client’s progress.

Drug Indication for Prozac (Fluoxetine) : 

Drug Indication for Prozac (Fluoxetine) Prozac is a Serotonin Reuptake Inhibitor (SSRI) used commonly to treat major depressive disorder, bulimia nervosa, obsessive-compulsive disorder, panic disorder, and pre-menstrual dysphoric disorder.

Rebekah’s Journal : 

Rebekah’s Journal June 5, 2010 I had an appointment with Dr. Jones today. He prescribed me this medication called Prozac that is apparently used to treat my panic-like symptoms. I’ve never taken it before but I’ve heard of it… I think they think I’m crazy. Why would I need such a crazy drug? I don’t think I’m going to take it. I’m not crazy. I’m just going through a rough time. I’m seeing a therapist - that should be enough! My therapist started doing this thing called EMDR with me. I just look at this machine and follow the light that it shoots out and it helps me to process everything I’m going through. It’s really crazy. I can’t explain it, but it’s already making me feel a little better. Maybe there is hope, after all.

Therapist’s Notes : 

Therapist’s Notes May 30, 2010 Client came in and indicated that she was non-compliant on taking her medication. I educated the client about Prozac and its mode of action, explaining the effects of the increase of serotonin on the client’s neurological processes that would decrease her symptoms. Client stated that she would think about it.

Mode of Action for Prozac (Fluoxetine) : 

Mode of Action for Prozac (Fluoxetine) Fluoxetine works to increase the concentration of serotonin at the synapse and reinforce serotonergic neuronal transmission by specifically inhibiting neuronal re-uptake of serotonin.

Rebekah’s Journal : 

Rebekah’s Journal May 30, 2010 Well, my therapist explained the drug to me and how it works. It helped me understand a little bit better what it actually does. I guess I had tons of ideas because of all the stuff I heard about it, but it seems okay enough. I think I’m going to try it. Dr. Jones said I have to take it a couple times a day, which is a bummer. He said it would take a few weeks before it starts to work. I’ll be counting the days. I hope this works. Oh, and my therapist started doing this thing called EMDR with me. I just look at this machine and follow the light that it shoots out and it helps me to process everything I’m going through. It’s really crazy. I can’t explain it, but it’s already making me feel a little better. Maybe there is hope, after all.

Dosage for Prozac (Fluoxetine) : 

Dosage for Prozac (Fluoxetine) 20 mg to 60 mg daily, 40mg+ per day. SSRI Has active metabolite- thus may take several weeks to achieve steady state with this medication

Dosage for Prozac (Fluoxetine) : 

Dosage for Prozac (Fluoxetine) Dose Selection—SEROQUEL should generally be administered with an initial dose of 25 mg twice daily, with increases in total daily dose of 25 mg - 50 mg divided in two or three doses on the second and third day, as tolerated, to a total dose range of 300 mg to 400 mg daily by the fourth day. Further dosage adjustments, if indicated, should generally occur at intervals of not less than 2 days, as steady-state for SEROQUEL would not be achieved for approximately 1-2 days in the typical patient. When dosage adjustments are necessary, dose increments/ decrements of 25 mg - 50 mg divided twice daily are recommended. Most efficacy data with SEROQUEL were obtained using three times daily dosing regimens, but in one controlled trial 225 mg given twice per day was also effective.

Pharmacokinetics for Prozac (Fluoxetine) : 

Pharmacokinetics for Prozac (Fluoxetine) Systemic Bioavailability: In man, following a single oral 40 mg dose, peak plasma concentrations of fluoxetine from 15 to 55 ng/mL are observed after 6 to 8 hours. Prozac weekly capsules which are a delayed-release formula, contain enteric-coated pellets that resist dissolution until reaching a segment of the gastrointestinal tract where the pH exceeds 5.5. The enteric coating delays the onset of absorption of fluoxetine 1 to 2 hours relative to the immediate-release formulations.

Pharmacokinetics for Prozac (Fluoxetine) : 

Pharmacokinetics for Prozac (Fluoxetine) Protein Binding — Over the concentration range from 200 to 1000 ng/mL, approximately 94.5% of fluoxetine is bound in vitro to human serum proteins, including albumin and α1-glycoprotein. Fluoxetine is a racemic mixture (50/50) of R-fluoxetine and S-fluoxetine enantiomers. In animal models, both enantiomers are specific and potent serotonin uptake inhibitors with essentially equivalent pharmacologic activity. The S-fluoxetine enantiomer is eliminated more slowly and is the predominant enantiomer present in plasma at steady state.

Pharmacokinetics for Prozac (Fluoxetine) : 

Pharmacokinetics for Prozac (Fluoxetine) Metabolism — Fluoxetine is extensively metabolized in the liver to norfluoxetine and a number of other unidentified metabolites. The only identified active metabolite, norfluoxetine, is formed by demethylation of fluoxetine. In animal models, S-norfluoxetine is a potent and selective inhibitor of serotonin uptake and has activity essentially equivalent to R- or S-fluoxetine. R-norfluoxetine is significantly less potent than the parent drug in the inhibition of serotonin uptake. The primary route of elimination appears to be hepatic metabolism to inactive metabolites excreted by the kidney.

Therapist’s Notes : 

Therapist’s Notes May 30, 2010 Client complied with medication recommendation and has begun taking Prozac. Client has been taking medication as prescribed for 3 weeks. I reiterated possible side effects to watch for, including insomnia, nausea, weakness, headache, and diarrhea, as well as loss of appetite, drowsiness, anxiety, nervousness, and shakiness among the most common ones. Because many of the possible side effects mimic her PTSD symptomology, I will encourage her to monitor these specifically to ensure that the medication does not worsen them (insomnia, anxiety, nervousness etc).

Side Effects for Prozac (Fluoxetine) : 

Side Effects for Prozac (Fluoxetine) Occasional reports of significant bradycardia (heart beating too slowly) Possible agitation- usually resolves in 2-4 weeks and can be managed with gradual increase in dose or in short-term use of benzodiazepines There have been cases of visual hallucinations- often occurs with addition of MAO inhibitors, to avoid be aware of long half life- usually 5-week washout

Side Effects for Prozac (Fluoxetine) : 

Side Effects for Prozac (Fluoxetine) Depersonalization (“spaciness”)- to manage limit does or escalate slowly, if persists switch to different antidepressant Headache- dose dependent, worsening of migraines Panic attack or anxiety Sedation- often seen in high doses (more than 45mg)- usually occurs in first 2 wks

Side Effects for Prozac (Fluoxetine) : 

Side Effects for Prozac (Fluoxetine) Suicidal ideation- risks should be closely monitored during first few weeks of treatment Tremor- can be treated with temporary use of benzodiazepines Vivid dreaming/ nightmares Gastrointestinal side effects (nausea, vomiting, anorexia, dyspepsia) tolerance usually developed within 2 wks of treatment

Side Effects for Prozac (Fluoxetine) : 

Side Effects for Prozac (Fluoxetine) Dry mouth Sexual effects- decreased libido Allergic reaction- rash, urticaria, pruritus, photosensitivity, arthraligia, fever, and lip swelling, jaundice, hepatitis -if this occurs, refer to MD immediately.

Rebekah’s Journal : 

Rebekah’s Journal June 17, 2010 I have been feeling sooo irritated lately. Everything pisses me off and I’ve been getting headaches all the time. I’ve even had thoughts about killing myself again. Things were starting to look better for a while and now I don’t know. Doing EMDR has been great but it keeps bringing back memories that I don’t want to remember. And I keep thinking I see things that aren’t there. I feel like I’m going crazy!! And on top of all that, my panic attacks and nightmares have been getting worse lately. I don’t know what to think or feel anymore. I hate my life.

Therapist’s Notes : 

Therapist’s Notes June 20, 2010 Client reported that she was having strong suicidal ideation as well as an increase in several other symptoms. After speaking with her physician, he suggested that the client switch to a different medication, Seroquel. Client appears to be frustrated with process of healing and is exhibiting signs of hopelessness. EMDR seems to be helping her process her experiences and their effects little by little but there is still significant resistance of client.

Drug Indication for Seroquel (Quetiapine) : 

Drug Indication for Seroquel (Quetiapine) Quetiapine is an anti-psychotic that is usually used for treatment of schizophrenia and bipolar disorder. However, it is also used off-label to treat insomnia and anxiety disorders.

Mode of Action for Seroquel (Quetiapine) : 

Mode of Action for Seroquel (Quetiapine) Although the mechanism of action of quetiapine is unknown, like other anti-psychotics, it inhibits communication between nerves of the brain. It does this by blocking receptors on the nerves for several neurotransmitters, the chemicals that nerves use to communicate with each other. It is thought that its beneficial effect is due to blocking of the dopamine type 2 (D2) and serotonin type 2 (5-HT2) receptors.

Rebekah’s Journal : 

Rebekah’s Journal June 27, 2010 I met with Dr. Jones today. He changed my medication to Seroquil and said that I may have better luck with this one. I was sure to ask more questions about this one to make sure I know what I’m getting myself into this time! He said that this one would have similar benefits with less serious side effects. Thank God!! I start taking Seroquil next week because I have to wait for the Prozac to filter out of my system. Supposedly they react together. I’m feeling hopeful again.

Dosage for Seroquel (Quetiapine) : 

Dosage for Seroquel (Quetiapine) The recommended starting dose is 20 milligrams (mg) a day, usually taken in the morning. If needed, the doctor may gradually increase the dose up to a maximum of 80 mg a day. The usual daily dose ranges from 20 to 60 mg. Daily doses above 20 mg should be taken in the morning or in two smaller doses taken in the morning and at noon.

Pharmacokinetics for Seroquel (Quetiapine) : 

Pharmacokinetics for Seroquel (Quetiapine) Quetiapine fumarate activity is primarily due to the parent drug. The multiple-dose pharmaco-kinetics of quetiapine are dose-proportional within the proposed clinical dose range, and quetiapine accumulation is predictable upon multiple dosing. Elimination of quetiapine is mainly via hepatic metabolism with a mean terminal half-life of about 6 hours within the proposed clinical dose range. Steady-state concentrations are expected to be achieved within two days of dosing. Quetiapine is unlikely to interfere with the metabolism of drugs metabolized by cytochrome P450 enzymes.

Therapist’s Notes : 

Therapist’s Notes July 7, 2010 Client came in for session today and seemed to be doing much better than before. Client stated that she was able to sleep and that her anxiety had lessened, although she still becomes anxious when she thinks about her trauma. Client appears to be healthier and has improved her ability to articulate her thoughts. There has been a significant improvement in a short period of time.

Side Effects for Seroquel (Quetiapine) : 

Side Effects for Seroquel (Quetiapine) Headache Agitation Dizziness Drowsiness Weight gain Upset stomach Orthostatic hypotension (a drop in blood pressure upon standing that can lead to dizziness or fainting), especially during first 3-5 day period of treatment, when it is restarted after temporary discontinuation, and after an increase in dosage.

Rebekah’s Journal : 

Rebekah’s Journal July 7, 2010 I am feeling so much better. I am finally able to sleep well and my nightmares have even stopped. I feel more secure going out and I don’t think about dying anymore. I actually went out with my friends a couple nights ago to a comedy club and had a really good time… it felt so good to laugh again. It’s been a while. I’m glad that rough patch is behind me. my therapist says that I will keep getting better but that I will probably have some bumps down the road, too. But I’m okay with that because I know it won’t last forever.

For the first time in a long time, I can see the light at the end of the tunnel.-Rebekah- : 

For the first time in a long time, I can see the light at the end of the tunnel.-Rebekah-

References : 

References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.). University of Michigan: American Psychiatric Association Task Force on DSM-IV. Anthony. (2006, July 6). Prozac (fluoxetine hydrochloride) for ptsd. Message posted to http://www.ptsdforum.org/threads/239-Prozac-(fluoxetine-hydrochloride)-for-PTSD Drugs.com: Drug Information Online. (2010). Side effects of seroquel- for the consumer. Retrieved from: http://www.drugs.com/sfx/seroquel-side-effects.html F. & M. (2010, March 28). Ptsd, depression, anxiety. Message posted to http://www.askapatient.com/viewrating.asp?drug=20639&name=SEROQUEL Monson, K. & Schoenstadt, A. (2009). Lexapro side effects: An introduction. Retrieved from: http://depression.emedtv.com/lexapro/lexapro-side-effects.html Monson, K. & Schoenstadt, A. (2009). Prozac side effects: An introduction. Retrieved from: http://depression.emedtv.com/prozac/prozac-side-effects.html Ogbru, O. & Marks, J. (2006). Medications and drugs. Retrieved from: http://www.medicinenet.com/quetiapine/article.htm

References : 

References PTSD Support Services (2008). Medications. Retrieved from: http://www.ptsdsupport.net/ptsd_medication.html Purse, M. (2006) Sinequan/doxepin/adapin side effects. Retrieved from: http://bipolar.about.com/cs/sfx/a/sfx_sinequan.htm Rambourg-Schepens, M.O. & Dawling, S. (1999). Fluoxetine. Retrieved from: http://www.inchem.org/documents/pims/pharm/pim651.htm RxList. (2009). Prozac. Retrieved from: http://www.rxlist.com/prozac-drug.htm United States Department of Veterans Affairs: National Center for PTSD. (2010). Clinician’s guide to medications for ptsd. Retrieved from: http://www.ptsd.va.gov/professional/pages/clinicians- guide-to-medications-for-ptsd.asp#spec-meds Zimmerman, C. Hossain, M., Yun, K., Roche, B., Morison, L., & Watts, C. (2006) Stolen Smiles: A Summary Report on the Physical and Psychological Health Consequences of Women and Adolescents Trafficked in Europe. Retrieved from: www.humantrafficking.org