Civilian Case Study

1 CIVILIAN CASE STUDY Civilian Case Study Janelka Williams School of Behavior Sciences, Liberty University TRMA830: Assessment and Testing in the Treatment of Trauma (B01) Professor- Clay Peters September 10, 2023

2 CIVILIAN CASE STUDY always show same full title in bold here as you put on the title page -1 Brief Summary  Rose is a 38-year-old married mother of three children (9, 7, and 2-years-old), and works full-time as pharmaceutical representative to various doctors and medical practices in her region. She typically drives anywhere between 700 to 1000 miles per week in a company-provided car. She is in good health, likes to run on her days off, and generally enjoys working in her yard and garden. Rose had some traumatic experiences in her childhood, her family moved around a lot due to her father being in the diplomatic core of the State Department. A bombing just feet away from where she was staying and seeing dead bodies and blood everywhere, a 7.1 earthquake a couple years later, where she was dragged out to the middle of the street and glass crashing everywhere, and just a few years after that witnessing a demonstration where folks were beaten and arrested in front of her. Those scenarios alone should have caused major PTSD side effects that maybe she has not opened up about, or even remembered or realized she was having . Then you have this major accident where she feels crushed, like she could not three her neck was twisted, and she worried about dying and never seeing her family again for 30 minutes until she was rescued. I often say that old trauma brings a new trauma. And although we don't hear much about those traumatic events in her childhood affecting her, I believe it all came crashing down with the last event.   Rose’s presenting issues are severe depression and moderate anxiety. She also has nightmares, trouble sleeping, losing weight, thoughts of dying and anxiety when thinking or having to talk about the accident. Rose tries to avoid the subject and anything that may remind

4 CIVILIAN CASE STUDY          Furthermore, numbers six and seven on the list being physical assault also with the weapon would include her experience when she was around 15-years-old when her father was stationed in Paris, France, during some of the demonstrations that took place over jobs and wages.  She happened to be shopping with her mom and heard shouting and saw people running their way being “chased” by a cloud of smoke and police dressed in riot gear and carrying shields.  She and her mom were able to get inside a small shop and watched with the other customers and shop owner as a large crown of people ran by, and few of them tripping and falling and being beat with truncheons by the police until they were either handcuffed and led away bleeding or managed to get up and run.          It is evident that Rose has endured several challenging and stressful life events, either through personal experience or witnessing them. Her most recent car accident likely triggered traumatic memories from her childhood, adding to the emotional burden she carries. PTSD Checklist for DSM-5 Interpretation According to the PTSD Checklist for DSM-5 (PCL-5) Rose scored a fifty-two on the entirety of the checklist. According to the checklist it could be broken up into sections. Numbers one through five (cluster B) Rose scored a 14. Which explains after her car accident in the last month, she has been experiencing, having repeated dreams of the crash, especially “hanging upside down” that has bothered her quite a bit. That started causing her to get up at night (after the dream) several times per week because “who can sleep after a nightmare like that!”  It has also started making her delay going to bed because she “never knows when the dream will happen.” (This justifies the scoring for cluster E.)   Not sleeping has caused her to “feel tired all the time now” and “only getting three or four hours of sleep.”  And while the dreams are bad enough, she also started having daily

5 CIVILIAN CASE STUDY memories or “flashbacks” of the accident that have caused considerable distress when she is at work, sometimes to the point of having to either go calm down in the bathroom, take a walk outside, or take a sick day to try and help her “get the thoughts and images of the crash” out of her mind. These symptoms are combination of cluster B and E. She says it has become too painful to think about, and if she does, she starts to feel panicky, so she just wants to avoid them at all costs.  When family and friends ask how she is doing, she just wants to “switch the topic as fast as possible” so she doesn’t have to “relive it all over again.”  This is an explanation of questions 6-7 which is considered cluster C where she scored eight.   Rose scored 18 in cluster D by stating, “I’m not really feeling anything like I used to.  We all used to be so close, but I just feel emotionally numb.  I don’t even want to hug or play with my two-year-old.”, “what kind of mother says things like that?”  She continues: “I’ve always loved being the ‘mom in the stands’ to cheer my kids on as they play their sports, but now I just want to stay home and not be around anyone.  Not only that, but I find myself being irritable and snapping or yelling at the kids for every little thing.”  She turns and looks out the window and quietly adds: “we used to do so many things together, but now they don’t want to be around me that much . . ., and I just don’t want to be around them, either.  We used to go hiking about every three weeks, but I just do not find that relaxing anymore, and would rather stay home.”  She notes that this emotional distance has put a big strain on her marriage.  Her husband “has been amazing through all of this, but now I can tell he is afraid it will never be over, and he feels helpless because there is nothing he can do.”  She says she is “beginning to feel useless and guilty that she’s not being the wife and mother she should be.”

7 CIVILIAN CASE STUDY C2- She hold to steering wheel tight when worrying about an accident, and hesitant when passing the spot where the accident occurred. Not really a significant avoidance of external reminders. Cluster D- Cognitive and Mood Symptoms- Severe D1- N/A she is able to recall aspects of the event D2- “You must think I'm crazy”, “Am I going crazy?” “I should be over this by now.” “ I think I'm ruined forever, aren't I?” D3- Not present. D4- She has recurring thoughts of “death and dying”, and she is “beginning to feel useless and guilty that she is not being the wife and mother she should be.” D5- “We used to go hiking, I just do not find that relaxing anymore, I would rather stay home” “I used to be the mom cheering in the stands but now I just want to stay home and not be around anyone” D6- “We used to do so many things together but now they don't want to be around me that much… and I just don't want to be around them either.” “I don't even want to hug or play with my two-year-old what kind of mother says things like that?” D7- All of the above is consistent Cluster E- Arousal and Reactivity Symptoms- Mild E1- “I find myself being irritable and snapping or yelling at the kids for every little thing” E2- Not present. E3- When she is driving she “ is extremely focused for any bad spots in the road” or on other “cars getting too close to hers” causing her to grip the steering was so tight her “hands hurt after about 30 minutes of driving.” E4- Not Present

8 CIVILIAN CASE STUDY E5- “I can't concentrate on what I need to work on for my clients, accounts are getting behind.” E6- Nightmares are forcing her to “get up several times a week” in the middle of the night. Now she “delays going to bed because of nightmares”, “who can sleep after nightmare like that!” This has caused her to “feel tired all the time now.” And only getting three or four hours of sleep.” In section F, it is evident that Rose has been experiencing these symptoms for a little under a month, and in section G she is experiencing subjective distress and is noticeably impairing her social and occupational functioning according to her statements in section D and E concerning not wanting to be around her friends and family and not being able to concentrate at work. Rose is experiencing some depersonalization and the derealization symptoms. However, because she has not been experiencing these symptoms for a month or 30 days an does not have PTSD. Primary and Secondary Diagnostic Impressions Rose is diagnosed F43.0 Acute Stress Disorder, with a follow-up in a week to 10 days to see if criteria F is met then. Rose met the criteria sections A, B, C, D and E of the DSM-5. Rose’s duration of the disturbance The disturbance causes clinically significant distress or impairment in social, occupational, and other important areas of functioning. According to criteria H in the DSM-5 this disturbance is not attributable to the psychological effects of a substance for another medical condition ( American Psychiatric Association, 2013) Primary Diagnosis with Culture/Gender Issues, Suicidal Risks It is important for clinicians to be aware of these cultural and gender-related issues to ensure accurate diagnosis and appropriate treatment of PTSD. A culturally sensitive and gender-

10 CIVILIAN CASE STUDY abuse. It is worth noting that post-traumatic stress disorder (PTSD) is closely linked to thoughts of suicide and suicide attempts. In fact, the presence of this disorder may serve as an indicator for identifying individuals who might progress from ideation to formulating an actual suicide plan or attempting suicide. In Rose's case, she openly acknowledges that thoughts of death frequently cross her mind due to a near-death experience. Nevertheless, it is important to emphasize that she does not harbor any suicidal thoughts, nor does she have any intentions or plans to take her own life (APA, 2013). based on her complaints/symptomatology, certain PCL-5 and CAPS-5 items, and her BDI-II of 33, there is enough there to give her a diagnosis of “ F32.2 Major Depressive Disorder, Single Episode, Severe .” Even a diagnosis of “ F32.9 Unspecified Depressive Disorder” could be made at a minimum. Also, there is enough there to give her (based on her complaints, certain PCL-5 and CAPS-5 items, and her BAI of 15) at a minimum “ F41.9 Unspecified Anxiety Disorder, with Panic Attacks,” or even “F43.22 Adjustment Disorder with Anxiety” -2 Recommendations Recommendation 1          Psychotherapy: Originally developed by Aaron Beck in the 1960s, Cognitive Behavior Therapy (CBT) is still considered one of the most effective types of counseling for PTSD (Schwartz, 2016). It is recommended that Rose seek evidence-based psychotherapy interventions for PTSD, such as (CBT ) or Eye Movement Desensitization and Reprocessing (EMDR). These therapies have shown effectiveness in treating PTSD symptoms and can help Rose process her traumatic experiences, manage distressing thoughts, and develop coping strategies. CBT helps you recognize the relationships between your thoughts and emotions and behaviors. Rose would benefit from Cognitive Processing Therapy (CPT) a form of CBT which produces the power of fearful memories by activating a fearful memory while simultaneously introducing new information that is incompatible surrounding the memory. She would also

11 CIVILIAN CASE STUDY benefit from exposure therapy which involves desensitizing oneself to the trauma by repeatedly talking about your traumatic memories, so you feel less overwhelmed by them. Recommendation 2 Medication Evaluation: Considering Rose's symptoms and level of distress, it may be beneficial for her to consult with a psychiatrist or primary care physician for a medication evaluation. Certain antidepressant or anti-anxiety medications, such as selective serotonin reuptake inhibitors (SSRIs), have been shown to alleviate PTSD symptoms (Cloitre et al., 2014). Recommendation 3 Support Groups: Encouraging Rose to join a support group or attend group therapy sessions specifically designed for individuals with PTSD can provide her with a sense of community, validation, and understanding. Talking about her trauma with others who have similar histories can help her feel more comfortable with the past and reduce her sense of isolation. Support groups can also offer practical advice and strategies for managing symptoms (Schwartz, 2016). Recommendation 4 Self-Care and Stress Reduction: Emphasize the importance of self-care activities that promote relaxation and stress reduction. Encourage Rose to engage in activities she enjoys, such as exercise, mindfulness, journaling, or engaging in hobbies, as these can help alleviate symptoms and improve overall well-being. Relaxation techniques are beneficial for the healing of PTSD. Some of the most common and well researched techniques include progressive muscle relaxation (PMR), visualization, and diaphragmatic breathing (Schwartz, 2016). Recommendation 5 Referral to Trauma- Informed Therapist: Given the severity of Rose's symptoms and the

13 CIVILIAN CASE STUDY Cloitre, M., Garvert, D. W., Weiss, B., Carlson, E. B., & Bryant, R. A. (2014). Distinguishing PTSD, Complex PTSD, and borderline personality disorder: A latent class analysis.  European Journal of Psychotraumatology ,  5 (1 ). Cohen, Judith A., Mannarino, Anthony P., Deblinger, Esther. (2017).  Trauma Focused CBT for Children and Adolescents: Treatment Applications.  New York, NY: Guilford Press ISBN: 9781462527779. Diagnostic and statistical manual of mental disorders: DSM-5 . (2017 ). American Psychiatric Association.  Show the DSM reference like this: -1 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Author. Schwartz, A. (2016).  The complex PTSD workbook: A mind-body approach to regaining emotional control and becoming whole . Sheldon Press.  This is just an abbreviated version of the full rubric for ease when I’m grading Intro (5) Assessm ents (50) Dx Imp (14) Recom m (15) Org / Title/ Headin gs/ Margin s/ indents/ spacing (11) Style / spell/ Gram/ Punc/ APA/ Refs/Cits (15) 3+ Res (10) Late/saved Total (120) 1 1111 5 112 1 11111 - -20 good analysis and interpretation, Janelka. good insight on what the assessments are supposed to do, and how they can lead us to the most accurate diagnoses possible. make sure to look through all the criteria very carefully; the client in this case does not meet criterion F (duration), so Rose cannot be diagnosed with PTSD (yet); Acute Stress Disorder (ASD) is the most appropriate primary diagnosis. also, don’t forget her anxiety and

14 CIVILIAN CASE STUDY depressions symptoms; you had the BAI and BDI scores to reference and see that something is going on there as well as the ASD. your recommendations are solid and can lead to a strong treatment plan. Refer to the graded paper for my comments on any points that were taken off in the rubric. keep working on your APA, too—remember that we are using APA 7 th edition as per the Announcements page; review this paper carefully to not make the same mistakes on the next two papers. good job overall on your first one, and I look forward to seeing your second case! Dr. Peters NOTE: the instructions for the CAPS-5 stated: “You will write a good paragraph summarizing your scoring and interview answers. When you write this paragraph, use the client’s own answers to justify your scoring!” You left off discussing your choices on the CAPS-5 and why you chose them based on the client’s narrative for the DSM-5 criteria B, C, D, and E. If you would like the opportunity to earn up to 3 points back, please let me know if you would like to do this, write up what you missed (making sure to label each specific criteria you find), and then email it to me via LU email (Canvas is having problems loading attachments) to me ASAP.