PTSD, Nightmares, and Profiling

Shawn, a patient in a hospital-based methadone clinic, was brought to my attention by his counselor because “he's saying really weird things.” Not all of the substance abuse counselors I supervised in the clinic had a lot of training or experience with mental illness, so they brought their confusing clients to my attention quickly.

“What's going on, Shawn?” I asked.

“I need to transfer to another clinic,” he said, trembling.

“Why do you need to transfer?” I asked.

He ran his finger along a long scar that sloped from his ear to the middle of his neck. “I know he's still after me,” he said. “The guy who stabbed me. He's still trying to kill me.” Shawn had survived this attack almost a year prior; physically, the scar was small, but emotionally the trauma still loomed.

“That sounds very frightening,” I said. I wanted to validate his feelings, if not the substance of his fears. “But I thought he was in prison,” I continued.

“Doesn't matter,” said Shawn. “He's got people in this clinic working with him.” He leaned forward and whispered, “I can tell the security guards are keeping tabs on me for him, and they call him when they see me. So he knows to send someone here to kill me.”

“It must be very hard to come to a place where you don't feel like you can trust the people working there,” I said.

“Yes!” he said, then checked behind himself to see if anyone was watching, although we were alone in my office.

“You know you're safe in here with me,” I said.

“I know,” he said, “but I have to travel more than an hour to get here. At any point someone could jump out and try to cut me. I have to keep watch every second.”

“Sounds exhausting,” I said. “How are you sleeping?”

“Bad,” he said. “I have nightmares of him attacking me, and I wake up all sweaty. It feels like it's happening again.”

“Shawn, that sounds like PTSD,” I said. “Have you heard of PTSD?”

“It's what soldiers get from being in a war,” he said. “I haven't been in a war.”

“No, but you've been attacked, and you've suffered a trauma,” I said. “You lost a baby grandchild recently, didn't you?” I asked, and he began to cry. Feeling foolish for pushing him too hard, I soothed him, reminding him he was safe with me and I was going to help him.

When he was calmer, I said, “I think you might need to talk to a doctor, Shawn. Your feelings are very powerful and painful—you might need medicine to help you cope with them.”

I was trying to be tactful, but he saw my meaning quickly. “I'm not crazy!” he said.

“I know you're not crazy,” I said. “But I do think you're ill and you're suffering, so I'm trying to suggest something that I think will help you feel better. Also, if you go to the hospital for a few days, you'll be protected. Nobody who wants to hurt you would be able to find you.”

Shawn wasn't convinced, so I called in one of the nurses to check his blood pressure and encourage him to engage in treatment. Stan was a retired NYPD detective, very matter-of-fact but also warm and kind.

“I'm not crazy,” Shawn repeated to Stan.

“You're definitely not crazy,” Stan agreed. “After 15 years as a cop on the beat, I know crazy when I see it. But you're having these nightmares, and you told me that sometimes when you're awake it feels like the attack is happening again. Those are key symptoms of PTSD. The good news is, because it's something we can recognize, we can treat it.”

Reexperiencing trauma, whether awake or asleep, is one of the most disorienting symptoms of PTSD. Consciousness is fragmented and disturbed. Even purely emotional trauma has a physical impact on the brain; it impairs the brain's ability to regulate the sleep-wake cycle. Shawn didn't report much of a psychiatric history, but PTSD can occur in someone without any prior experience of psychopathology.

Shawn agreed to let us call an ambulance, and he was transferred to the psychiatric ward. Two weeks later, he returned and showed me his discharge papers. The diagnosis? Paranoid schizophrenia.

I was saddened but not shocked. White clinicians have been shown more often to diagnose patients of color with psychotic rather than mood or anxiety disorders. Shawn was in his late 30s, well beyond the usual age of initial schizophrenia diagnosis. He didn't struggle to express his thoughts clearly, the way a person with schizophrenia often does. But he responded well to the Haldol he was prescribed, expressing significantly less distress and sleeping well. In the end, what matters most is symptom relief, not diagnosis.