Post-traumatic stress disorder (single-incident)
PTSD after a serious motor vehicle accident 14 months prior; avoiding driving, intrusive imagery, sleep disruption.
Presenting concern
PCL-5 at intake: 52. Intrusive memories of the accident, nightmares 4-5x/week, hypervigilance on the road, total avoidance of highway driving, irritability impacting his marriage. PHQ-9: 12 (secondary depression).
History
Single index event (rear-ended at highway speed, brief loss of consciousness, ER visit). Previously well-functioning, no prior psychiatric history. Tried to 'tough it out' for a year before seeking help.
- Untreated for 14 months (consolidated avoidance patterns)
- Secondary depression
- Marital strain from irritability
- Job involves some driving (functional impairment)
- Single-incident, no prior trauma history
- Stable life context
- Engaged spouse
- Strong motivation (driving is necessary for work)
Conceptualization across modalities
Trauma memory is unprocessed and over-encoded with danger. Avoidance of trauma-related stimuli (driving, reminders) prevents extinction learning. Stuck points include 'I should have seen it coming' and 'the world is unsafe.' Imaginal and in-vivo exposure target both.
- Psychoeducation on PTSD as a memory disorder
- Imaginal exposure (repeated narrative)
- In vivo hierarchy — driving as central target
- Cognitive restructuring of stuck points
Memory is stored in maladaptive form per AIP model. The brain has the capacity to integrate the memory when bilateral stimulation creates the conditions. Negative cognition: 'I'm not safe / I should have prevented this.' Positive cognition target: 'I survived and I can handle the road.'
- History and resourcing (Phase 1–2)
- Assessment of target memory with negative cognition, image, SUDS, VOC
- Reprocessing sets (Phase 4)
- Installation of positive cognition and body scan (Phase 5–6)
Treatment plan
Preparation (1–3)
Psychoeducation, breathing/grounding, hierarchy or target list.
Active treatment (4–12)
PE or EMDR — pick one, do it well, full dose.
Consolidation (13–16)
Return to highway driving, address residual avoidance, marital check-in.
Differential diagnosis
- Acute stress disorder (ruled out — duration >1 month)
- Adjustment disorder (ruled out by symptom cluster and severity)
- Mild TBI from LOC — neuropsych screen recommended; symptoms overlap
- Specific phobia, driving — secondary, not primary
Session arc
PTSD psychoed, rationale for exposure, breathing/grounding skills, hierarchy build.
Repeated narrative of the accident; hotspot identification; processing 'I should have seen it coming.'
Surface streets → on-ramp → highway → highway at speed/night; spouse as coach.
Address residual avoidance, marital repair, return-to-baseline routines.
Masculine 'tough it out' script delayed help-seeking by 14 months. Naming that script — not pathologizing it — opens the door. For clients in fields where driving = livelihood (trucking, sales, rideshare, EMS), exposure work has direct vocational stakes that increase both motivation and pressure.
His articulate, regulated presentation can lull the clinician into pacing exposure too slowly. Conversely, his motivation can pressure the clinician to skip preparation. Pick a protocol (PE or EMDR) and dose it.
Between-session work
- Listen to imaginal exposure recording daily between sessions
- In vivo driving practice 4x/week, logged with SUDS pre/post
- Stop-the-tough-it-out: tell spouse one feeling per day
Common pitfalls
- Avoiding the worst moment in the imaginal — gains will stall
- Letting secondary depression become a separate treatment focus before PTSD work is done (usually remits with PE)
- Skipping the LOC/mild-TBI workup — a real symptom can be misread as PTSD
- "Am I pacing exposure to his anxiety or to the protocol?"
- "What's my plan if SUDS doesn't drop within the imaginal session?"
- "How do I handle the spouse's understandable urge to protect him from distress?"
PCL-5 dropped to 18 by session 12 with PE. Returned to highway driving by session 9. Secondary depression remitted without separate treatment.