This case describes a 30-year-old male lower enlisted soldier in the combat arms with one GWOT deployment (material is used with his consent and identifying details/dates are disguised). The patient had no premorbid (pre-combat) treatment or identified BH conditions. He did have a comorbid gastrointestinal condition, which was diagnosed early in his military career, and this condition is often considered psychosomatic or at least significantly influenced by emotional stress. The patient, a married man, in his early 30s, is a self-described “country person” from a long line of “poor country people.” He grew up in the rural South. He joined the army in his mid-twenties because he always wanted to be in the army and be a policeman, and the army afforded him the opportunity to do both. He said he would have joined the army earlier, but he had to take care of his family first. In so doing, owning a home at age 21, prior to enlisting, was one of the accomplishments for which he was most proud, and something that no one else in his family was able to do.

He was raised by his biological parents, who were married. His father was often unemployed due to the unpredictability of construction work. His mother worked as a secretary and provided stable income and “held the family together.” He had a close family member of approximately the same age who had “some sort of emotional problems.” The patient described frequent angry outbursts from this relative and emotional lability/affective instability, with which the parents were apparently frequently engaged.

After graduating from high school, he went to work at a warehouse. Soon after graduating from high school, his mother was diagnosed with colon cancer and died after battling the cancer with surgery and radiation/chemotherapy. He described how, growing up, he learned to tell the truth, keep his word, work hard, take care of the family, and respect others.

He had been in the army for 5 years when I saw him. His first duty station was outside of the continental US, where he worked in the military corrections facility for a year. He was then stationed for 2 years at a large army base in the Midwest. He reenlisted to be stationed at a post in the southern USA so that he could be closer to his roots. It was from there that he was deployed to the Middle East for a year.

Consistent with most complex treatment-resistant patients in the military, his course had several stages, including initial treatment from primary care manager (PCM), then walk-in BH, then being followed by a psychiatric nurse practitioner, a series of consults from a neurologist, my initial assessment, my initial psychotherapy, then psychoanalysis. The patient presented in early September 2012 to primary care with complaints of pervasive anxiety, hypervigilance in crowds, nightmares, sleep problems, and an upper arm tremor. Consistent with military programs to emphasize primary care screening and management of BH conditions (Respect.mil), his PCM consulted (via electronic communication) with the Respect.mil psychiatrist. The consultation was essential to start SSRIs and refer for specialist care. After 2 days of his PCM appointment and with his PCM’s guidance, the patient walked in to “sick call.” The “sick call” psychiatrist continued him on paroxetine (a medication FDA approved for the treatment of PTSD), and propranolol was added. Additionally, the provider referred the patient to neurology for his tremor, a definitive management in the BH clinic, and told the patient to continue follow-up in “sick call” while this was being arranged.

Due to demand for BH services and neurology, the patient was not able to be scheduled for another 2 months. My colleague, the walk-in psychiatrist, had three visits in the “sick call” clinic, during which supportive psychotherapy and attempts at adding adjunctive buspirone, prazosin, and buproprion were attempted.

By December 2012, 3 months after presentation, the patient had his first appointment with his assigned provider, a psychiatric nurse practitioner, who switched him to venlafaxine and continued supportive psychotherapy. These visits continued for the next few months. It was during the December-through-March time period that I learned of the case since I had the responsibility of reviewing the cases managed by the nurse practitioner. I worked with the neurologist to ensure completion of the brain magnetic resonance imaging (MRI), electroencephalogram (EEG), neurological exams, all of which were normal and showed no neurologic cause for the tremor. In an attempt at symptomatic treatment, propranolol was continued and primidone was added but were discontinued after a few months due to lack of effect on the tremor.

It was in early April that I, on behalf of the entire treatment team, contacted the unit commander since there had been some questions about duty limitations. He was essentially given a non-deployable profile, and his other duty limitations were formalized (the unit had—months ago—limited his work to administrative duties due to his “shakes”). At the patient’s request, I also met him with his wife for a session, and she confirmed the various anxiety and PTSD symptoms and confirmed the time line of the symptoms, as being a change from baseline and starting during deployment.

Since I was already significantly involved, the psychiatric nurse practitioner and I agreed that he would terminate and that I would manage the patient, whose symptoms had remained basically unchanged since presentation. It was in early May 2013 that the patient and I had our first formal appointment (this was approximately 8 months after he had initially presented to our clinic). Since he had already experienced initial evidence-based psychopharmacology (SSRI) and supportive psychotherapy, I consider this as the point that he transitioned to a treatment-resistant category. Moreover, the neurologist had also shared the normal MRI, EEG, and exam findings with the patient and was ending care with a “non-physiologic” diagnosis. When I met with the patient in early May, I shared my discussion with the neurologist and that “anxiety might be contributing or causing this.” The patient seemed to take this without much reaction. He was tacitly agreeable and accepting, but my impression was that the patient still held out that there may be a physical etiology for his tremor. The patient and I also noted that coming in seemed to be helpful for him as well as the venlafaxine, by now, 225 mg/d. So, I recommended that we embark on a more formal course of psychotherapy, and I would continue to monitor his prescription. I suggested that we meet twice a week for the next 6 weeks in a 12-session brief treatment and then make some decisions about the longer term at the end. Our scheduled 12 sessions ran throughout May and June.

Regarding the content of our twice weekly psychotherapy, it presaged the themes of the psychoanalysis. Psychotherapy themes included: coming from a family where not expressing emotions was valued; beliefs that angry emotions were necessarily linked with destructive actions; anger was adjudged as a “bad” emotion; significant resistance to combat discussion with anxious tearful affect and worsening tremor when discussing combat; he did connect his “stress” with his psychiatric and tremor symptoms; beliefs that he needed to comply with authority and sorting through interpersonal experiences to figure out what was wanted by authority, especially military authorities; controlling emotions was very important to him, and when he was not in complete control he feared becoming overwhelmed. The details of traumatic events from deployment were probed directly, but the patient was unable to elaborate much since the process of telling his story in detail generated overwhelming levels of anxiety (the transcribed sessions below do include some narration of traumatic events which occurred while he was deployed). Consistent with many combat veterans, the trauma often involves several demarcated events, but it also seems to be a cumulative experience of the deployment being traumatic in total. At the very least, this veteran had been on several patrols during which he perceived his life to be in imminent danger.

At the end of our scheduled sessions, with no remission, I felt like I could offer a proper military retention decision. I opined that he needed a medical discharge since he remained symptomatic despite full evaluation and treatment trials and due to the possibility of decompensation if he would to deploy again. With regard to the initial psychotherapy, manualized treatments, such as CPT or PE or EMDR, were not tried. Consistent with the treatment guidelines, our work did involve cognitive restructuring and elements of exposure in addition to narration, relaxation skills, and psychoeducation.

Since he got benefit from the psychotherapy (though clearly not curative), I recommended that we continue to meet starting the next month in psychoanalysis. This next phase is what I want to specifically highlight in a treatment approach for a treatment-resistant PTSD patient. I told him we would continue in ways similar to our recent meetings but that he would come in four times per week, lie on the couch, and speak aloud what was coming to mind. I also told him that I would be sitting behind him and probably ask less than he was used to in the therapy sessions. Regarding the technique, I saw it as my role, as an analyst, to set the psychological frame to allow the possibility of having his mental experiences symbolized with words, in the context of appropriate containment and psychological holding.

In order to demonstrate the process, examples of two back-to-back complete early psychoanalytic sessions are given below: