Efficacy of Stress Inoculation Training in A Case of Posttraumatic Stress Disorder (PTSD) Seconda

Clinical Case Studies http://ccs.sagepub.
com
Efficacy of Stress Inoculation Training in a Case of Posttraumatic Stress Disorder (PTSD) Secondary to
Emergency Gynecological Surgery
Angie M. Trzepacz and James K. Luiselli
Clinical Case Studies 2004; 3; 83
DOI: 10.1177/1534650103258981
The online version of this article can be found at:

http://ccs.sagepub.com/cgi/content/abstract/3/1/83
Published by:
http://www.sagepublications.com
Additional services and information for Clinical Case Studies can be found at:
Email Alerts: http://ccs.sagepub.com/cgi/alerts
Subscriptions: http://ccs.sagepub.com/subscriptions
Reprints: http://www.sagepub.com/journalsReprints.nav
Permissions: http://www.sagepub.com/journalsPermissions.nav
Downloaded from http://ccs.sagepub.com by Adela Bian on February 28, 2007

© 2004 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.
ARTICLE
CLINICALLuiselli
10.1177/1534650103258981
Trzepacz, CASE /STUDIES
STRESS INOCULATION
/ January 2004 TRAINING
Efficacy of Stress Inoculation Training

in a Case of Posttraumatic Stress
Disorder (PTSD) Secondary to
Emergency Gynecological Surgery
ANGIE M. TRZEPACZ
JAMES K. LUISELLI
The May Institute Inc.
The May Center for Applied Research
Abstract: Stress inoculation training (SIT) was evaluated as treatment for posttraumatic
stress disorder (PTSD) in a 27-year-old who experienced emergency gynecological surgery
(hysterectomy) 3 weeks after delivering her first child. She was seen at an outpatient mental
health center with complaints of sleep disturbance, flashbacks, prolonged crying, avoid-
ance of landmarks associated with the surgery, and chronic distress in response to multiple
environmental stimuli. SIT was instituted during eight treatment sessions in which she was
taught progressive muscle relaxation, deep breathing, guided imagery, covert modeling,
thought stopping, and thought replacement procedures. Evaluated in a single-case experi-
mental design format, the effects of treatment were that the woman no longer had stress-
inducing experiences and her level of discomfort in the presence of identified environmen-
tal triggers essentially was eliminated. However, at a follow-up session she reported other
life circumstances that had not improved contemporaneously. The case is discussed with
reference to evidence-based treatments for PTSD.
Keywords: posttraumatic stress disorder; stress inoculation training; single-case design.
1 THEORETICAL AND RESEARCH BASIS
Posttraumatic stress disorder (PTSD), according to the Diagnostic and Statistical

Manual of Mental Disorders (4th ed.) (American Psychiatric Association, 1994), is a
condition that can develop when a person is exposed to a traumatic stressor involving
actual or threatened death, serious injury, or threat to physical integrity. Individuals diag-
AUTHORS’ NOTE: Please direct correspondence and requests for reprints to: James K. Luiselli, Vice President Applied
Research and Peer Review, The May Institute Inc., One Commerce Way, Norwood, Massachusetts 02062; e-mail:
jluiselli@mayinstitute.org.
CLINICAL CASE STUDIES, Vol. 3 No. 1, January 2004 83-92
DOI: 10.1177/1534650103258981
© 2004 Sage Publications
83

84 CLINICAL CASE STUDIES / January 2004
nosed with PTSD (a) experience recurrent distressing dreams and flashbacks of the trau-
matic event, (b) have intense psychological distress when exposed to cues resembling
the traumatic event, and (c) avoid thoughts, feelings, conversations, locations, and peo-
ple associated with the traumatic event. Additional symptoms include markedly dimin-
ished interest or participation in activities, feelings of detachment from others, difficulty
falling or remaining asleep, and anger outbursts. Although a variety of trauma situations
may be responsible for PTSD, those reported and studied most frequently are military
combat (Boudewyns, Hyer, Woods, Harrison, & McCranie, 1990; Keane, Fairbank,
Caddell, & Zimering, 1989), sexual assault (Foa et al., 1999), motor vehicle accidents
(Blanchard, Hickling, Vollmer, Loos, Buckley, & Jaccard, 1995), and being witness to
violence such as a shooting or homicide (Feske, 2001).
Stress inoculation training (SIT) was developed as a coping skills therapy to treat
anxiety-related symptoms following rape (Kilpatrick & Amick, 1985; Veronen &
Kilpatrick, 1983). As described by Foy, Resnick, and Lipovsky (1993), SIT “includes
instruction in coping skills for management of anxiety and other assault-related distress
in physiological, cognitive, and behavioral response channels” and “is designed to facili-
tate new adaptive responses to trauma-related stimuli by teaching clients active skills to
be used in the face of anxiety-related cues” (p. 240). Muscle relaxation, breath control,
covert modeling, role-playing, thought stopping, and guided self-dialogue are the usual
components of SIT (Calhoun & Resick, 1993).
SIT has been explored primarily with victims of rape (Foa, Riggs, Dancu, &
Rothbaum, 1993; Foy et al., 1993; Kilpatrick & Amick, 1985) but is applicable to other
trauma-inducing events. In this report, we describe an unusual case of PTSD secondary
to emergency gynecological surgery that was treated using an abbreviated course of SIT
at an outpatient mental health center. Notable features of the case were the assessment
of outcome via a single-case evaluation design (Hersen & Barlow, 1984), measurement
of multiple clinical indices, and extension of SIT to a client whose disorder was un-
related to sexual assault.
2 CASE PRESENTATION
Mary was a 27-year-old Caucasian woman who referred herself to a community

mental health center. She had been married for 2 years and was a full-time student work-
ing toward a second associate’s degree. Six months before her first appointment, she had
given birth to her first child. Three weeks after the birth, she experienced heavy bleeding
and was rushed to a hospital by ambulance, where an emergency hysterectomy was per-
formed. It was this surgery that precipitated her subsequent distress. Against her hus-
band’s wishes, she was planning legal action against the physician who delivered the
baby.

Trzepacz, Luiselli / STRESS INOCULATION TRAINING 85
3 PRESENTING COMPLAINTS
At her intake interview, Mary reported that she was experiencing flashbacks and
nightmares related to the emergency surgery and events surrounding it. Also, she was
feeling depressed and angry about not being able to have more children or provide a son
for her husband. She was having difficulty falling asleep and was waking up from night-
mares reliving the scenario. Mary had switched to a new physician because she was
unable to enter the hospital building for her follow-up visit. She altered her route to
school to avoid the train station that was near the hospital. Furthermore, she was anxious
about encountering people who might have been working at the hospital the day of the
surgery and knew what had happened to her.
Whenever she heard an ambulance siren, Mary had to pull over to calm herself
and stop crying. Bouts of crying also were provoked easily by comments from acquain-
tances about having more children, seeing her husband play with his nephews, and
hearing her baby cry. Mary reported crying every day, often when in the shower so that
no one would hear her. In response to her distressed state, her husband’s attitude was,
“It’s in the past, get over it and move on.” This reaction caused Mary to believe she could
not turn to him for support. She judged her marital relationship to have been strained
almost to the point of separation even before the pregnancy.
4 HISTORY
Mary was the youngest of four children from what she described as a close-knit
family. All her siblings lived nearby to hear and she visited with them regularly. Simi-
larly, Mary had a good relationship with her parents, who also resided in a neighboring
community.
Mary had received an associate’s degree in criminal justice and as noted previously,
was enrolled as a full-time student. She was pursuing a vocation as a legal secretary. Her
husband was employed in a family business. Mary had no history of receiving mental
health services.
5 ASSESSMENT
Assessment focused on three dependent measures. During her first session (Week
1), Mary completed a rating scale that sampled her subjective level of distress relative to
eight areas/situations she identified as significantly anxiety provoking: (a) ambulance
siren, (b) train station, (c) people’s comments about having more children, (d) falling
asleep, (e) dreams, (f) flashbacks, (g) husband, and (h) daughter. Ratings were scored on

an 11-point scale that ranged from 0 = no distress to 10 = maximum distress. The scale was
readministered at approximately the halfway point in treatment (Week 12) and at a
follow-up session (Week 30).
Mary also completed the Outcome Questionnaire (Lambert, Okiishi, Arthur, &
Johnson, 1998) at Weeks 1, 12, and 30. It is composed of 45 questions about how the
respondent has been feeling during the past week. The questionnaire produces an over-
all score and three subscale scores that sample (a) symptoms of distress, (b) interpersonal
functioning, and (c) school/occupational functioning. Ratings range from 0 = never to 4
= always. The range of scores is from 0 to 100 (symptoms of distress), from 0 to 44 (inter-
personal functioning), from 0 to 36 (school/occupational functioning), and from 0 to
180 (total score). Scores that surpass a cutoff criterion place the client in the clinical pop-
ulation (symptoms of distress cutoff = 36, interpersonal functioning cutoff = 15, school/
occupational functioning cutoff = 12, total score cutoff = 63).
The third method of assessment was a self-recording form that Mary completed
each week between treatment sessions. She was instructed to document on the form any
“stress-provoking incident” she experienced, including her reaction to it. An example
would be Mary becoming agitated and upset after an acquaintance asked if she planned
to have more children. These data were summarized as the number (frequency) of inci-
dents entered on the self-recording form weekly.
6 CASE CONCEPTUALIZATION
Based on her presentation at intake and review of clinical symptomatology, Mary

received a diagnosis of PTSD (309.81) according to the DSM-IV. Consistent with a
social-learning perspective, we conceptualized that Mary’s disorder was influenced by
behavioral, physiological, and cognitive elements. Specifically, certain cues (experi-
enced in vivo or imagined) elicited intense emotional distress that in turn, produced
avoidance, negative thinking, and causal misattribution. Because SIT addresses the
three-way interaction of behavioral-physiological-cognitive factors (Foy et al., 1993), we
judged it applicable as a treatment approach on an outpatient basis. In effect, it appeared
that Mary would be able to self-manage treatment under natural conditions, first by
learning to induce a relaxed state and overcome disturbing bodily sensations. Cognitive
control strategies would be used by her to stop “negative” thinking and beliefs that only
contributed to her problems. The focus on behavior was to encourage and direct Mary to
“work through” situations that were associated with avoidance, anxiety, and emotional
reactivity.

7 COURSE OF TREATMENT AND ASSESSMENT OF PROGRESS
A 1-hour session was scheduled with Mary and the senior author every 3 weeks.
The first phase of treatment dealt with countering physiological arousal and elevated
anxiety by teaching Mary deep breathing, progressive muscle relaxation, and guided
imagery procedures. Mary felt the most comfortable with imagery, so she was told to use
it when distressing events occurred or when she noticed she was beginning to get upset.
This extension of techniques learned in sessions to “real-life” situations was emphasized
throughout the course of treatment.
At Week 10 (Phase 2), covert modeling was introduced by having Mary imagine a
potentially upsetting situation and then visualize herself coping with it successfully.
Multiple trial exposures, which encompassed the full range of anxiety-provoking cues,
were conducted during sessions. The therapist routinely prompted Mary to attend
closely to the positive consequence of implementing a coping strategy. Finally, Mary
was encouraged to practice this visualization technique whenever she thought of it,
rather than waiting for an actual upsetting event to occur.
The third treatment phase, initiated at Week 16, added thought stopping and
thought replacement. These techniques were to be used by Mary when she had distress-
ing cognitions, first to interrupt the thoughts and then to refocus on something more pos-
itive. For example, if she woke up from a nightmare, she could get out of bed and drink a
glass of water or watch television instead of remaining in bed thinking about the night-
mare. Similarly, she was taught to alter her beliefs about intrusive thoughts by referring
to self-statements such as, “I’m not going to dwell on this—I’m going to think about my
upcoming vacation plans.”
In total, Mary was seen for 8 sessions of SIT and a follow-up meeting. Her treat-
ment progress is presented in Figures 1 through 3. As depicted in Figure 1, each phase of
SIT was associated with a progressive decrease in the frequency of stress-inducing experi-
ences each week, from an average of 5.6 per week at baseline to none reported during the
final 7 weeks of treatment. At her follow-up session, Mary reported no incidents during
the prior 5 weeks.
Figure 2 shows the distress rating (range = 0 to 10) Mary recorded for the eight
high-stress areas/situations identified at the beginning of treatment. All eight mea-
sures were elevated (average = 8.6) at Week 1 (baseline), had decreased (average = 4.0)
at Week 12 (midtreatment), and were reduced further (average = 1.1) at Week 30
(follow-up).
Mary’s scores on the Outcome Questionnaire are presented in Figure 3. Her scores
on the three subscales, as well as the total score, changed only slightly between Weeks 1
and 12, but all were under the clinical cutoff criteria. However, at follow-up all four
scores had moved into the clinical range.

8 Baseline Stress Inoculation Training (SIT)

Frequency of Stress-Inducing Experiences
7
Phase 1
4
Phase 2
1 Phase 3
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 30
Weeks
Figure 1. Frequency of Stress-Inducing Experiences Each Week
8 COMPLICATING FACTORS
There were no significant complications to Mary’s treatment, she missed only one
scheduled appointment, and with the exception of Weeks 4 and 5 at baseline, faithfully
completed the between-session self-recording protocol. As treatment evolved, however,
several issues became apparent. During her sixth session, for example, Mary revealed for
the first time that she had been having migraine headaches daily since her teen years and
had been dependent on prescription sleep medication for several years before becoming
pregnant. In her last session at Week 25, she informed the therapist that she was ready to
terminate treatment but then acknowledged that she was contemplating a separation
from her husband. Their sexual relationship at the time was nonexistent and she was
resentful toward him because should they “split up,” he could have more children but
she could not. Despite the therapist’s suggestion that Mary and her husband seek marital
counseling, she refused, stating instead that “we need to be able to work it out on our
own.”
Two weeks prior to the follow-up session, Mary’s father died from a heart attack and
she was devastated by his loss. She tried to hide her distress from her family, was crying a
lot, and had difficulty concentrating on her schoolwork. These circumstances, com-
bined with her ongoing marital problems, likely contributed to the poor clinical profile

10
7
Distress Rating
6
Baseline: Week 1
5 SIT: Week 12
Follow-up: Week 30
4
0
Train Ambulance People's Falling Dreams Flashbacks Husband Daughter
Station Comments Asleep
Experiences
Figure 2. Distress Ratings
that was demonstrated on the Outcome Questionnaire she completed at the follow-up
session.
9 MANAGED CARE CONSIDERATIONS
Mary’s outpatient treatment was covered by her managed care plan. She had a co-
payment arrangement and maintained her financial obligation accordingly. There were
no problems approving her care.
10 FOLLOW-UP
As indicated in the assessment of progress, the therapist saw Mary at a follow-up ses-
sion that was scheduled 5 weeks after terminating treatment. She was no longer bothered
by stress-inducing experiences related to her surgery and her level of discomfort associ-
ated with environmental stimuli, flashbacks, and family members was insignificant.
Other facets of her life were not as positive and would benefit from further therapeutic
support. Unfortunately, once again she refused further treatment and subsequently, did
not respond to a follow-up phone call and letter from the therapist.

100
90
80
70
60
Baseline: Week 1
Score
50 SIT: Week 12
Follow-up: Week 30
40
30
20
10
0
Symptoms of Distress Interpersonal School/Occupational Total Score
Functioning Functioning
Category
Figure 3. Scores on Outcome Questionnaire
11 TREATMENT IMPLICATIONS OF THE CASE
The empirical evaluation of SIT with Mary suggests that it was effective as a treat-
ment for PTSD. She experienced symptom relief and improved capacity to function
within situations that previously were triggers for avoidance behavior, negative thinking,
and emotional distress. Mary reported that the skills she learned in treatment helped her
cope with the conditions that were disruptive and problematic. Notwithstanding the
interpretive limitations inherent in a case study evaluation, it appears that SIT can be
clinically efficacious with a trauma population beyond female victims of sexual assault.
The other difficulties Mary expressed as treatment evolved and following termina-
tion reveal that the effects of SIT may be “situation specific.” That is, overcoming PTSD
does not guarantee corresponding improvement in other functional areas. As seen in this
case report, Mary gained control over a significant issue in her life but still faced addi-
tional challenges. The most obvious implication from this outcome is that using a thera-
peutic model such as SIT to target trauma-induced clinical disorders may be the first
step in a more comprehensive and prolonged intervention. We would add that although
posttreatment assessment was conducted with Mary, a longer follow-up period is advised
given the possibility of resensitization that often is encountered in persons who have
PTSD.

12 RECOMMENDATIONS TO CLINICIANS AND STUDENTS
This case report illustrates that adults diagnosed with PTSD can present a complex
clinical profile that demands close attention to matters of assessment, treatment formula-
tion, and evaluation of therapeutic efficacy. The importance of functional assessment in
isolating the source of distress cannot be emphasized enough. Determining the func-
tional relationships among environmental, interpersonal, and cognitive influences and
PTSD symptomatology enables the clinician to pinpoint strategic interventions. In
Mary’s case, treatment with SIT was initiated only after multiple stressors were identi-
fied. These stimuli and situations, in turn, were incorporated into the assessment process
to verify that treatment was effective. Functional assessment, therefore, plays a dual role
in both defining the conditions that set the occasion for (provoke) and maintain
(reinforce) a disorder as well as producing critical outcome data.
We recommend that SIT be considered as one of several evidence-based treat-
ments for PTSD (Foa, Rothbaum, Riggs, & Murdock, 1991; Keane, Fairbank, Caddell,
Zimering, & Bender, 1985; Resick & Schnicke, 1992). Because this therapy encourages
clients to work through distress-provoking experiences by utilizing cognitive-mediated
and physiology-control strategies, it shares characteristics of exposure therapies that have
documented success for persons diagnosed with PTSD (Keane, 1995). The exposure
component of PTSD treatment, however, can generate increased anxiety and reactivity
to memories of the trauma, and for this reason, special care should be taken to prepare
the client. A final emphasis is to alert clinicians to the fact that psychiatric comorbidity is
common in PTSD (Keane & Kaloupek, 1997; Kimble, 2000), a consideration that will
influence choices about immediate and long-range treatment planning.
REFERENCES
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.).
Washington, DC: Author.
Blanchard, E. B., Hickling, E. J., Vollmer, A. J., Loos, W. R., Buckley, T. C., & Jaccard, J. (1995). Short-term
follow-up of posttraumatic stress disorder in motor vehicle accident victims. Behaviour Research and
Therapy, 33, 369-377.
Boudewyns, P. A., Hyer, L. A., Woods, M. G., Harrison, W. R., & McCranie, E. (1990). Physiological
response to combat memories and preliminary treatment outcome in Vietnam veteran PTSD patients
treated with direct therapeutic exposure. Behavior Therapy, 21, 63-87.
Calhoun, K. S., & Resick, P. A. (1993). Posttraumatic stress disorder. In D. H. Barlow (Ed.), Clinical hand-
book of psychological disorders: A step-by-step treatment manual (pp. 48-98). New York: Guilford.
Feske, U. (2001). Low-income and African American women with posttraumatic stress disorder: A case
series. Behavior Therapy, 32, 585-601.
Foa, E. B., Dancu, C. V., Hembree, E. A., Jaycox, L. H., Meadows, E. A., & Street, G. P. (1999). A compari-
son of exposure therapy, stress inoculation training, and their contribution for reducing posttraumatic
stress disorder in female assault victims. Journal of Consulting and Clinical Psychology, 67, 194-200.
Foa, E. B., Riggs, D. S., Dancu, C. V., & Rothbaum, B. O. (1993). Reliability and validity of a brief instru-
ment for assessing posttraumatic stress disorder. Journal of Traumatic Stress, 6, 473-495.

Foa, E. B., Rothbaum, B. O., Riggs, D. S., & Murdock, T. B. (1991). Treatment of posttraumatic stress disor-
der in rape victims: A comparison between cognitive behavioral procedures and counseling. Journal of
Consulting and Clinical Psychology, 59, 715-723.
Foy, D. W., Resnick, H. S., & Lipovsky, J. A. (1993). Posttraumatic stress disorder in adults. In R. T.
Ammerman & M. Hersen (Eds.), Handbook of behavior therapy with children and adults (pp. 236-247).
Boston: Allyn & Bacon.
Hersen, M., & Barlow, D. H. (1984). Single-case experimental designs: Strategies for studying behavior
change. New York: Pergamon.
Keane, T. M. (1995). The role of exposure therapy in the psychological treatment of PTSD. National Center
for Posttraumatic Stress Disorder Clinical Quarterly, 5, 1-6.
Keane, T. M., Fairbank, J. A., Caddell, J. M., & Zimering, R. T. (1989). Implosive (flooding) therapy
reduced symptoms of PTSD in Vietnam combat veterans. Behavior Therapy, 20, 245-260.
Keane, T. M., Fairbank, J. A., Caddell, J. M., Zimering, R. T., & Bender, M. E. (1985). A behavioral
approach to assessing and treating posttraumatic stress disorder in Vietnam veterans. In C. R. Figley
(Ed.), Trauma and its wake (pp. 245-260). New York: Brunner/Mazel.
Keane, T. M., & Kaloupek, D. G. (1997). Comorbid psychiatric disorders in PTSD. In A. C. McFarlane &
R. S. Yehuda (Eds.), Psychobiology of posttraumatic stress disorder (pp. 821-840). New York: Annals New
York Academy of Sciences.
Kilpatrick, D. G., & Amick, A. E. (1985). Rape trauma. In M. Hersen & C. Last (Eds.), Behavior therapy
casebook (pp. 86-103). New York: Springer.
Kimble, M. O. (2000). Treating PTSD in the presence of multiple comorbid disorders: The case of Howard.
Cognitive and Behavioral Practice, 7, 133-137.
Lambert, M. J., Okiishi, J. C., Arthur, E., & Johnson, L. O. (1998). Outcome assessment: From conceptual-
ization to implementation. Professional Psychology: Research and Practice, 29, 63-70.
Resick, P. A., & Schnicke, M. K. (1992). Cognitive processing therapy for sexual assault survivors. Newbury
Park, CA: Sage.
Veronen, L. J., & Kilpatrick, D. G. (1983). Stress management for rape victims. In D. Meichenbaum &
M. E. Jaremko (Eds.), Stress reduction and prevention (pp. 341-374). New York: Plenum.
Angie M. Trzepacz, Ph.D., is staff psychologist at The May Counseling Center, Walpole, Massachusetts, a
behavioral health care clinic operated by The May Institute, Norwood, Massachusetts. Her interests are
behavior therapy, clinical assessment, and treatment of child and adult disorders.
James K. Luiselli, Ed.D., ABPP, BCBA, is senior vice president of applied research, clinical training, and
peer review at The May Institute, Norwood, Massachusetts. He also is director of the institute’s Predoctoral
Internship Program in Clinical Psychology. His interests are applied behavior analysis, behavior therapy,
self-harming behaviors, and the integration of research and clinical practice.


Efficacy of Stress Inoculation Training in A Case of Posttraumatic Stress Disorder (PTSD) Seconda

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Efficacy of Stress Inoculation Training in A Case of Posttraumatic Stress Disorder (PTSD) Seconda

Uploaded by

Copyright:

Available Formats

Clinical Case Studies http://ccs.sagepub.

The online version of this article can be found at:

Email Alerts: http://ccs.sagepub.com/cgi/alerts

Downloaded from http://ccs.sagepub.com by Adela Bian on February 28, 2007