Awareness during surgery is estimated to effect between 40,000 to 140,000 patients per year in the United States, and there is a growing literature suggesting that this event can lead to the development of posttraumatic stress disorder (PTSD). The current article describes treatment implemented from a manualized protocol of a woman diagnosed with PTSD following awareness during a routine surgery. Prolonged exposure therapy was delivered to the client over 12 sessions. Treatment consisted of psychoeducation, imaginal exposure, in-vivo exposure, breathing retraining, progressive muscle relaxation, and homework assignments. At treatment completion and at follow-up 10 weeks after completion of therapy, the client no longer met criteria for PTSD. Prolonged exposure therapy for PTSD is an effective treatment that alleviates symptoms of PTSD from awareness during surgery.
Failure of general anesthesia to render a patient insensate (i.e., awareness) is estimated to affect between 40,000 to 140,000 patients in the United States yearly (Osterman, Hopper, Heran, Keane, & van der Kolk, 2001). Individuals who awake during surgery report a variety of experiences, including hearing sounds and voices, feeling touch, pain, paralysis, helplessness, anxiety, fear, and severe panic (Schwender et al., 1998). Many people who experience awareness during surgery report continued distress years after surgery (Lenmarken, Bildfors, Enlund, Samuelsson, & Sandin, 2002), including the re-occurrence of pain symptoms associated with the surgery (Salomons, Osterman, Gagliese, & Katz, 2004). However, only a small number of studies have assessed symptoms of posttraumatic stress disorder (PTSD) after awareness. The studies that have assessed such symptoms report that a significant portion of individuals experience symptoms of PTSD: Osterman et al. (2001) reported that 9 out of 16 individuals (56.3%) who were aware during surgery (conducted on average 18 years prior to the assessment; range 1–38 years) met criteria for PTSD. In comparison, zero controls met criteria for PTSD. Leslie, Chan, Myles, Forbes, and McCulloch (2010) found that 7 out of 13 individuals (71%) met criteria for PTSD after awareness, whereas 3 out of 25 (12%) matched controls (who had surgery but not awareness) fulfilled criteria for PTSD. In these individuals, the median onset of symptoms was 14 days after surgery, and the median duration of symptoms was 4.7 years.
Given that awareness during surgery can lead to significant mental distress, it is necessary to explore treatments that may alleviate such suffering. The most strongly supported treatments for PTSD are cognitive behavioral therapies (CBT) such as cognitive processing therapy (CPT; Resick & Schnicke, 1992) and prolonged exposure therapy (PET; e.g., Foa et al., 2005). However, some researchers have specifically recommended the use of eye-movement desensitization reprocessing (EMDR) or hypnosis for PTSD resulting from awareness during surgery (Bruchas et al., 2011 and Lennmarken and Sydsjo, 2007). A growing literature suggests the effective component in EMDR is exposure (Lilienfeld, 2008 and Steketee and Goldstein, 1994), making the recommendation of EMDR in particular of unclear value. More generally, we find no compelling reason to believe that PTSD resulting from awareness during surgery requires a different modality of treatment than PTSD more generally. To date, no specific evidence has been presented regarding the use of standard, manualized treatment for this specific trauma.
Nixon, Bryant, and Moulds (2006) were the first to publish a report on the treatment of PTSD produced by awareness under anesthesia. These authors delivered eight sessions of CBT that consisted of exposure and cognitive restructuring (i.e., using CBT principles but no specific manual). At follow-up the client no longer met criteria for PTSD. Similarly, Mashour, Wang, Esaki, and Naughton (2008) reported use of systematic desensitization over the course of 7 months. In this treatment the patient completed in-vivo exposures in an operating room with anesthesiologists. At the end of treatment the psychologist reported that the patient no longer had PTSD. Though these initial results are encouraging, neither of the available case studies focuses on a well-established, manualized protocol. Demonstrating that this particular form of PTSD can be successfully treated using an established manual would be useful because that manual could then be used in future treatment, as well as research regarding this specific traumatic event. Furthermore, although there are appealing aspects to including in-vivo exposures in operating rooms, doing so would typically be expensive or impossible. Ideally, such treatment could also take place without special access to operating rooms. Our goals in the current study were to provide an example of a feasible treatment for PTSD from awareness using a manualized protocol that clinicians may use to treat similar clients. Further, we hope to illustrate some of the unique challenges that a clinician may encounter during such treatment and how the use of flexibility within the bounds of the evidence-based protocol may enhance treatment.
Current conceptualizations of the treatment of PTSD suggest that PET is an effective treatment of PTSD in many trauma populations (Foa et al., 2005). PET is based on emotional processing theory and works under the assumption that to recover from PTSD one must process the emotional memories connected to the traumatic event. However, PET has not explicitly been tested within a population presenting with PTSD from awareness during surgery. In the current study, we tested the use of PET using the manual Treatments that Work: Prolonged Exposure Therapy for PTSD ( Foa, Hembree, & Rothbaum, 2007) with a woman who developed PTSD after awareness during a routine surgery.
