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Case Report

AGGRESION IN PTSD: A CASE REPORT

Kaur Samiksha,1 Yadav J.S.,2

1Psychologist SRLNMHospital, 2Assist.prof. AIIMS New Delhi

 

Abstract

Posttraumatic stress disorder (PTSD) is an emotional illness, classified as an anxiety disorder and usually develops as a result life-threatening, any trauma or that severely compromises the emotional well-being of an individual or intense fear. Such events often include severe accident or physical injury, life-threatening medical diagnosis, kidnapping or torture, exposure to war combat or to a natural disaster, or terrorist attack, being the victim of rape, mugging, robbery, or assault, enduring physical, sexual, emotional, or other forms of abuse, as well as involvement in civil conflict. PTSD has only been recognized as a formal diagnosis since 1980. However, it was called by different names as American Civil War, “soldier's heart." In World War I, symptoms referred to as "combat fatigue."  In World War II its call "gross stress reaction," "post-Vietnam syndrome" and "battle fatigue”. Complex posttraumatic stress disorder (C-PTSD) usually results from prolonged exposure to a traumatic event by long-lasting problems with many aspects of emotional and social functioning. Statistics regarding this illness indicate that approximately 7%-8% of people.

 

Introduction

Aggressive behavior is a complex phenomenon, and many theories have been describing its nature. The most common approach is to define aggressive behavior based upon its underlying motivation, distinguishing between reactive aggression and instrumental aggression. Reactive aggression is a any automatic and emotional aggressive behavior that occurs as a response to a perceived threat or provocation 1,2, instrumental aggression relates to aggressive behavior with the purpose of achieving certain goals or gaining social status 3,4,5, meta-analyses explanation confirmed that human aggressive behavior has two different facets 6, and that a distinction must be made. Undoubtedly, there is a reactive form with the purpose of repelling a particular threat. This is associated with a high state of arousal and a negative emotional state. It is the struggle to reduce this negative arousal that motivates and drives this aggression. This form of aggression has been examined extensively in numerous laboratory and field studies. In contrast to this, another form of aggression, termed ‘appetitive aggression’, has been put forth in recent years, based on anthropological observations of cruel human behavior. 7,8 PTSD and anger often occur simultaneously. In fact, anger is so common in PTSD. Anger in PTSD may be difficult to manage. As a result, some people with PTSD may act in aggressive ways. When discussing anger and PTSD, it does not mean that they also have intense anger. Anger is just one symptom of PTSD not for diagnosis. In the same way, anger is not the same thing as being violent. So a person with PTSD may experience high levels of anger, but not be violent. Violent or aggressive behavior is just one way someone might express or attempt to manage their anger. More often than not, someone with PTSD with high levels of anger is going to try to push down, suppress, or hide their anger (which can have its own negative consequences).

According to DSM IV and ICD 10 point out that traumatic phenomena could be of multiple nature, starting with war trauma, concentration camp imprisonment, deportation, detention, cumulative oppression, sexual abuse, natural disasters, traffic or (especially collective) work accidents, social crisis, aggression, information deprivation. DSM IV PTSD criteria are: 9

1) Death or serious injury, or a threat to the physical integrity

2)Recurrent and intrusive distressing recollections of the event,

3) Efforts to avoid thoughts, feelings, or conversations associated with the trauma;

4) Difficulty falling or staying asleep; irritability or outbursts of anger; difficulty concentrating; hyper-vigilance; exaggerated startle response.

5) Duration of the disturbance is more than one month.

6) The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning 9.

PTSD is also associated with  social maladjustment10, inferior quality of life11, medical comorbidity 12 sociolphobia13, proneness to guilt, anger and anger management difficulties13,14, cognitive alterations 15 unemployment and domestic conflicts. 16,17 PTSD also associated with comorbid disorders including substance abuse, major depression, psychosis, personality disorders, anxiety, summarization, panic attacks, bipolar disorder, phobia, disassociate disorders, sexual dysfunctions, eating disorders. 18 Although; PTSD symptoms are usually classified into three basic clusters (re-experiencing, avoidance/numbness and hyperarousal). A diagnostic meets the validity criteria only if one symptom from the first cluster, three symptoms of avoidance and two of hyperarousal are fulfilled, thus a precipitating traumatic event defines a necessary but not a sufficient condition for the PTSD diagnosis9.

 

 

Case history- Mr. A 58 year old Muslim male came in the OPD for treatment of aggression. He complains he doesn’t control his aggression. At the time of aggression he loses many valuable things. By profession he was gold smith and he was satisfied his profession.

They have no any economical problem. He was married and has four children. Two girls are studying MBBS and son is preparing for competition. His aggression terror was famous in his family, no body argues to them. According to patient he loves too much child and never beaten nor aggression on any child, If they lose any think. But my behavior is just opposite for adult, if any person or customer required any things ask for two or more time, for any demand on his shop then he request and ask politely two time but if customer ask again and again or ask for hurry or ask they have no time please do fast then he out of control and use abusive language with aggression and ask go out my shop. After few minute he realizes; he did not well. But he was unable to control his aggression that time. He told many examples about his life. This was basically done between he was busy and person request again and again. This is not only at the shop but any where. But he want to control his aggression but not able to control. He was consulting many times with doctor and also psychiatrist but unable to control they give tranquillizers he slept too much then he left medicine. By appearance he was soft and cool, well dressed come with his friend. During the session taking was soft and response was satisfactory. His friend circle was good and all was known about his aggression, so they not ask directly if he do any mistake but after some time they realize him; when he becomes normal. He told know I control my aggression too much then before. During the consultation he told I was beaten my teacher because he was wrong but was not accepted. And my friend suggested me due to your aggressive personality you will not become a businessmen. But I was confident that know I am a good businessman. At the time of consultation, when he sheared his problem he started weeping he told mam my childhood was very traumatic. I don’t want to remember and he was weeping again and again with his friend. By the nature he never discussed his problem, grief with any one. He weeping alone, never weeping in front of family member (his brother was die every one weeping but he was not weep in front of family) after the crimination he weep to much at the roof.  He doesn’t show his grief in front of family. He shows he is bold (conflict bold/ week) no bodies understand to him. After the gone of all children he feels alone and again he weeps in bathroom contentiously seven days but not shear with child and wife. He asked I never use abusive language with my child and wife but all are fear to me, they talk with me eat with me play with me but they are not close with me why I don’t know. During the discussion it was found her mother was dying when he was 7 year old and his step mother behavior was not good.

Physical Examination Hematological examinations were normal.

Tools Aggression scale

Back Depression Scale

Hamilton Anxiety Scale

PTSD Scale

I and others

TAT

 

Result On the bases of psychological evaluation it was proof that aggression was severe, TAT result shows poor relation of mother and father, on 8 card out of 10.  He perceives his past life with unhappy ending on TAT. On the back depression and anxiety scale results was mild. I and others scale it was found that he was happy with family. Family counseling and psychotherapy trauma focused cognitive behavior therapy (TFCBT19, interpersonal) was done 8 times the result was positive. During the counseling it was asking to patient tell the past life with your child and wife. He did same and given some suggestion to the patient. And clear the conflict of his personality, fear and loneliness. On that time it was found that family was supportive and caring for his aggression. His daughter was tells my father was too much caring, affectionate; overall his behavior was nice left aggression.

 

Discussion on this case e report we found that child hood trauma play a great role and its effect on long term. It was found family violence can predispose an individual to PTSD. Approximately 25% of children exposed to family violence can experience PTSD in a study of 337 school age children 20 Aggression is more common in the case of PTSD it was clear in our case report during the childhood he was aggressive to his mother behavior but not discussed with any family member. It was also reported anger and anger management was difficult to management in PTSD 13,14. During the consultation it was found that his life was traumatic when he was 7 year old boy his mother was died with leave 5 more child. After two year his father does marriage. It was mention DSM IV criteria that death or serious injury, or a threat to the physical integrity of oneself or others; the person’s response involved intense fear, helplessness, or horror (in children, it may be expressed instead by disorganized or agitated behaviour);9 it was found in the result of TAT out of 10 card, 8 card have unhappy ending. Gradually his father knows the reality and want to divorced but family member not agree for that due to family prestige. His step mother pregnant eight time and born eight child but unfortunately all was live only two months and die. He was laugh and happy when her child was die. But he was not tolerating her tortures then he weep alone and covered the mouth with pillow on his bed. He remembers after death of his mother he never weeps in front of his family because he knows; his father knows every think but he was unable. It was shows in Parents with violence-related PTSD clinical findings suggested that a failure to provide adequate treatment to children after they suffer a traumatic experience, depending on their vulnerability and the severity of the trauma, will ultimately lead to PTSD symptoms in adulthood.21,22 He never told about that behavior of step mother to his grandmother and others family member. Always say she was good. But her duel behaviors change his personality because he  know no body can understand his emotion. It was found domestic conflict increases the symptoms of PTSD. 16,17  in our case report patients aggression was a result of family violence on the aggression scale it was higher. but it was not discussed  by doctors due to adult but is was prove in study  that child abuse interact with mutations in a stress-related gene to increase the risk of PTSD in adults, in a cross-sectional study of 900 school age children.23 During the session discussion of childhood he was weeping with his friend. Her step mother want excuse for her misbehave when she gone to makka. But Mr. A was silent and shocked for her behavior and think she shows drama in front of family. When family member asked kindly pardon then he say I pardon for that behave you do unconsciously I never pardon for those behavior you done with consciously. It was proof that he was still aggressive with them and unconsciously her violence. But before death when she asks sorry for her misbehaves then he asks his mother ok I pardon you, please go. But he was not feel well and relax in his life know he was adult but nor forget of childhood so it was proof in this case report it was necessary to keen observation during the complaint of any psychological case if they adult or child.

 

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