Case Study 11-1: A Patient With PTSD, Treatment Interventions Including Virtual Reality Exposure, and Outcomes

Mary is a 20-year-old college student who presented to the university counseling service with fear of driving on busy freeways, especially at night. The problem emerged 12 months ago after she was involved in a five-car accident while returning late from college. Another driver who swerved from the outside lane into her lane caused the accident. She was sideswiped by the car, and the resulting accident involved three other cars. No one was killed. However, one other driver had serious injuries. Mary had to be cut from her car, which took over 5 hours. Throughout the incident, Mary remembers thinking she was going to die. Before this, Mary had not experienced any significant anxiety and had been able to drive in any conditions. Since the accident, Mary has stopped driving; has become anxious, leading to avoidance of many situations; experiences poor sleep due to nightmares; is easily startled; and feels depressed. Mary's college work and social life are severely affected, and she is in danger of failing. She has been to her family practitioner, who has prescribed 50 mg of sertraline daily. Mary often forgets to take her medicine and believes it does not really help. The counseling service referred Mary to the community psychiatric/mental health nurse, who helps Mary recognize that her fear of driving is a symptom of post-traumatic stress disorder. The nurse has suggested several approaches to Mary's problems. First, they work to improve sleep problems using a standard sleep hygiene approach. Second, she tackles her nondriving-related avoidances, such as agreeing to meet friends and go shopping. Finally, the nurse helped Mary to see the benefits and disadvantages of her medication. This discussion led to Mary's agreeing to take her medication regularly to see if it would help. After 2 months of weekly sessions, Mary began to show some general improvement. However, her fear of driving remained and she continued to struggle at college. One week, Mary told the nurse about a TV program showing a virtual reality (VR) driving simulator treatment for people who have been in car accidents. The nurse stated she knew of this and would find out if it were available. The nurse was able to arrange a VR demonstration in the next session. After seeing how the simulator could help, Mary agreed to use it. Both the nurse and Mary were fitted with VR glasses, and different driving experiences were introduced. At first, Mary practiced quiet daytime driving and progressed to busy freeway night driving. Mary's anxiety about driving reduced quickly over 3 weeks. However, she still had not returned to driving. The nurse suggested that Mary repeat the VR exercises but in her own car. This involved graded live exposure. At first, Mary drove with friends and family in quiet times, moving to driving with others at night and then finally on her own at night. After 6 weeks, she had completely returned to driving, her college and social life was back to normal, and she experienced no anxiety.