PTSD in a blind patient

Authors
Amy Au-Yong * BSc (Hons)
Medical student
University of Leicester
Wilson Firth BSc(Hons), MBChB, MRCP, MRCPsych
Consultant Psychiatrist
Leicestershire Partnership NHS Trust

Abstract
Post-traumatic Stress Disorder (PTSD) in blind patients is a rare clinical entity. We present a case of a young male patient who has developed chronic PTSD. The case illustrates and discusses the additional challenges which blind patients face with this disorder and the reasons that they are at particular risk in development of chronic PTSD.

Mr MK is a 24 year-old student, who has been blind since birth. Two years ago, he was a passenger in his father’s car, which was involved in a road traffic accident. He remembers his father pulling out at a junction then feeling a jolt and hearing his father’s chest hit the steering wheel. MK sustained back and shoulders injuries at the time.

He has been experiencing flashbacks which started a week after the event, and have persisted throughout the two years following it. During such flashbacks, he re-experiences himself sitting in the car, as on the day of the accident, describing the car he is in and the road with cars going in both directions. He remembers his father pulling out at a junction, the collision with another car, and the images of his father and front of the car destroyed. Perceptions of sounds often predominate in these flashbacks. In addition he experiences physical symptoms of anxiety during these attacks including tachypnoea, tachycardia and excessive sweating. He also experiences a marked sleep disturbance and nightmares in relation to the accident. These nightmares have the same content as the flashbacks he has been experiencing. At the time of interview his sleep was disturbed by these nightmares at least twice a week.
Over the two year time period, he has experienced flashbacks on a daily basis, sometimes a few times each day, and this has persisted up to the time of interview with little improvement in the intervening period.

He has curtailed his activities since the event and actively avoids any situations involving public transport or cars, or any films depicting these concepts. He also has mild symptoms of depression. He has less interest in his course and is finding it difficult to concentrate during lectures because of poor attention caused by intrusive flashbacks. As a result of this his results have suffered. He has been short tempered and has had a number of violent episodes.
Pre-morbidly he enjoyed a wide range of hobbies and activities, including cycling, skateboarding, rock climbing, and attending the cinema. He also has strong family ties and a strong network of friends.
His past medical and psychiatric history is unremarkable.

He fulfils diagnostic criteria for post traumatic stress disorder according to the Diagnostic statistical Manual (DSM IV) [1] and Clinician Administered PTSD scale [2].

This is an unusual case of post-traumatic stress disorder in a blind patient. To our knowledge, there is only one other case report in the literature [3]. Post-traumatic disorder was first described in the late 19th century [4]. DSM IV diagnostic criteria include experience of an event which involves death, injury or threat of to the integrity of ones health, frequent re-experiencing of the traumatic event, by thought intrusions, flashbacks, nightmares, with associated physiological reactivity, and avoidance of stimuli associated with the trauma. Increased arousal, symptom duration of over a month and disturbance of social and occupational functioning constitute the other necessary criteria that must be fulfilled to make the diagnosis.

Blind people rely on heightened auditory alertness to compensate for the lack of visual cues. Our patient had a great difficulty reconstructing or describing visual images and perceptions of sounds predominated his flashbacks. Furthermore, disturbed attention which is a known symptom of PTSD [5] seems to have profound effects on our patient. A recent study demonstrated that deficits in attention in sighted patients could persist for up to 2 to 3 years and resulted in diminished performance in simple tests [4] .Auditory attention is particularly important in blind patients and its disruption is likely to account for his difficulty concentrating in lectures and poor recent academic performance.
Sleep disturbance was a dominant feature of our patient’s illness. A recent study showed that patients with visual impairment (not affected by PTSD) are at particular risk of sleep disturbance [6]. This occurs because there is limited input of light to the suprachiasmatic nucleus, the central hypothalamic circadian clock via the optic nerves and retinohypothalamic tracts. The suprachiasmatic nucleus in turn controls the pineal gland’s melatonin rhythm, which mediates the circadian sleep cycle. The sleep-wake cycle is affected by other cues other than light (non-photic cues) and these include mealtimes, daily routine and emotional disturbances, such as those experienced by our patient. The disturbance of daily routine by PTSD symptoms no doubt contributes to the patient’s sleep disturbance.

Auditory flashbacks, disturbed attention and sleep disturbance are prominent symptoms in blind patients who suffer from PTSD.

[1] Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association; 4th edition (May 1, 1994)

[2] Blake DD, Weathers F, Nagy LM, Kaloupek DG et al (1997) Clinician Administered PTSD Scale for DSM-IV. Current and Lifetime Diagnostic Version. National Centre for Post Traumatic Stress Disorder.

[3] Posttraumatic stress disorder and blindness. McFarlane AC (1988)Comprehensive Psychiatry, 29:6 558-460

[4] Erichsen FE, On railway and other injuries of the nervous system. London: Walton and Moberley 1866

[5] Meewisse ML, Nijdam MJ et al Disaster-related posttraumatic stress symptoms and sustained attention: Evaluation of depressive symptomatology
and sleep disturbances as mediators Journal of Trauma and Stress, 2005 Aug;18(4):299-302.

[6] Tabandeh H, Lockley SW et al, Disturbance of Sleep in Blindness. Am J Ophthalmol 1998;126:707–712.

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Ethical Considerations
The patient was fully competent at the time of interview and has given his full consent to publication of this case report.

Acknowledgments
Dr. Najat Khalifa for his valuable guidance.
Dr. Iain Au-Yong for his help with the manuscript.

Post Traumatic Stress Disorder (PTSD)in a blind patient