Abstract
Introduction
Chronic hypoarousal and hyperarousal states are 2 key features for the diagnosis of post-traumatic stress disorder (PTSD). They represent an out of tolerance window zones and can negatively affect receiving, processing, and integration of stimuli. They are debilitating clusters of symptoms that reduce quality of life and significantly interfere with the individual’s daily functioning. Moreover, chronic significant hyperarousal- hypoarousal shifts can interfere with patient’s engagement in psychotherapy. Addressing these out of tolerance window states may reduce patient’s distress and improve his/ her quality of life and psychotherapy outcome.

Case presentation
This report describes a clinical case of psychotherapy- resistant PTSD key symptoms in a 32-year-old female patient. Stand-alone psychotherapy in the form of Eye Movement Desensitization and Reprocessing (EMDR) failed to lessen the PTSD symptoms. Persistence of PTSD hypo- and hyper-arousal symptoms significantly interfered with the patient’s daily functions and limited the progress and effectiveness psychotherapy.
Given the nature and severity of her illness, the patient had been reassessed. Re-assessment included a clinical interview, blood tests, vital signs, ECG, anthropometric characteristics, assessment for attention deficit hyperactivity disorder (ADHD) and borderline personality disorder (BPD).
Diagnosis of comorbid ADHD has been confirmed and the patient has been commenced on methylphenidate (MPH) with adjunct propranolol for associated paroxysmal sinus tachycardia. The effect and side effects of the treatment were monitored during a follow-up period of 7 weeks. Main parameters assessed were flashbacks, nightmares, dissociation and fainting, and hypervigilance with paranoid symptoms. Within one week of commencing the treatment the patient reported improvement in all psychotherapy- resistant PTSD symptoms. Remission of symptoms remained until the last follow up review (7 weeks post-treatment).

Conclusion
PTSD- related hypoarousal and hyperarousal symptoms reduce patient’s quality of life, impair his/her daily functioning, and could hinder the effective progress of psychotherapy, a corner stone in the treatment of PTSD. Pre-psychotherapy diagnosis and treatment of PTSD comorbidities such as ADHD may decrease PTSD symptoms severity. MPH seems to play a clinically meaningful role in the treatment of PTSD-related hyperarousal- hypoarousal symptoms and thereby reduces patient distress and improves patient’s quality of life and may facilitate successful psychotherapy outcome.

Key words: PTSD, treatment-resistant PTSD, psychotherapy, methylphenidate