Trauma Study
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ExamplesofGoodCaseStudyOrganizationandContent1.docxExamples of Good Case Study Organization
Brief Summary
Concise and Thorough Introduction Summary
Rose is a 38-year-old female, married, and mother of three who presented with increased anxiety, nightmares, negative moods, anhedonia, and decreased appetite. Her score on the Mini Mental Status Examination indicated that she has normal cognitive functioning. Rose reported a decrease in sleep and daily flashbacks of an accident that occurred three weeks ago. Additionally, her score on the Beck Depression Inventory indicated severe depression, and the Beck Anxiety Inventory indicated mild to moderate anxiety. Rose presented sad and anxious, memory intact, sleep decreased, and appetite is decreased. Rose denied suicidal ideation and homicidal ideation. Protective factors include husband and children, a job she has found satisfying before the accident, and her health. The clinician noted Rose's resiliency from Rose's life events checklist reports that indicated she experienced multiple trauma as a child.
First Assessment Instrument Interpretation
(write a good paragraph here summarizing your answer choices)
Life Events Checklist for DSM-5 Interpretation
VA.Gov | Veterans Affairs (n.d.) stated the Life Events Checklist for DSM-5 (LEC-5) is a self-report assessment that targets an individual’s life experiences to assess their exposures to 16 events that would result in PTSD. In addition, one additional item identifies any remarkable stressful event not identified in the first 16 items. Rose's responses to the life events checklist indicated multiple traumatic experiences. The reasoning for each checklist item is below.
Happened to Me
· Natural disaster - Rose experienced an earthquake when she lived in Tokyo, Japan at the age of 12.
· Transportation accident - Rose was involved in a car accident three weeks ago.
· Life-threatening illness or injury - During the car accident Rose “felt like she was suffocating”.
Witnessed It
· Fire or explosion - Rose witnessed a bomb go off when she lived in Turkey at the age of 10.
· Physical assault - Rose witnessed police in Paris, France beat protestors during a riot at the age of 15.
· Assault with a weapon - Rose witnessed the French police beat the protestors with truncheons.
· Severe human suffering - Rose witnessed the carnage from the bomb explosion in Turkey to include dead bodies of adults and children.
· Sudden violent death - Rose witnessed the carnage from the bomb explosion in Turkey to include dead bodies of adults and children.
Second Assessment Instrument Interpretation
(write a good paragraph here summarizing your answer choices)
Clinician-Administered PTSD Scale for DSM-5
The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) is a structured interview template administered by a clinician with formal interviewing training and an understanding of the symptoms related to PTSD (National Center for PTSD, 2020). According to the responses in the CAPS-5 interview, Rose does not meet the diagnostic criteria for a diagnosis of PTSD. However, the reasoning was that her symptoms have not lasted over a month. It is recommended that Rose be reassessed after one month since the car accident. A summary of Rose’s CAPS-5 assessment is listed in table 3.
Table 3
Summary of the CAPS-5 assessment for Rose.
Third Assessment Instrument Interpretation
(write a good section here summarizing your answer choices)
This should be presented in the same format as shown in the examples for the First Assessment Instrument and the Second Assessment Instrument.
Primary and Secondary Diagnostic Impressions
Prior to the initial interview, Rose took a Beck Depression Inventory that indicated she had severe depression. She also took the Beck Anxiety Inventory which indicated she had mild to moderate anxiety. Her Mini-Mental Status Exam indicated she had normal cognitive functioning. Taking into consideration the results from the Life Events Checklist for DSM-5 Interpretation, the PTSD Checklist for DSM-5 Interpretation, and the Clinician-Administered PTSD Scale for DSM-5 Interpretation, this author has come to the following conclusion of both a primary and secondary diagnosis.
Primary Diagnosis with Culture/Gender Issues, Suicidal Risks
Primary Diagnosis
According to the DSM-5 acute stress disorder criteria (American Psychiatric Association, 2013), Rose has met and surpassed the required symptoms for this diagnosis. These symptoms include exposure to a traumatic event and the presence of nine or more symptoms broken down into five categories, beginning or worsening after the traumatic event (American Psychiatric Association, 2013). In addition to those symptoms, the duration of an individual’s symptoms must be three days to one month following the event, cause clinically significant distress in the individual’s daily life and functioning, and cannot be attributable to substances, a medical condition, or a brief psychotic disorder (American Psychiatric Association, 2013). The DSM-5 criteria for acute stress disorder and corresponding evidence as indicated by assessments and interviews taken from Rose are listed below in table 4.
Table 4
Evidence for acute stress disorder diagnosis.
|
Diagnostic Category |
Evidence to Meet Criteria |
|
Cluster A (1 required) |
|
|
A1- Direct exposure to a traumatic event |
Rose reported she was in a car accident in which she feared for her life. |
|
Cluster B (9 required) |
|
|
B1- Intrusive distressing memories of the traumatic event |
Rose reports daily memories of the car accident. |
|
B2- Recurrent distressing dreams |
Rose reports repeated dreams of the crash. |
|
B3-Dissociative reactions (e.g., flashbacks) |
Rose reports daily “flashbacks” of the car accident. |
|
B4- Psychological distress or marked physiological reactions |
Rose reports physiological reactions such as shortness of breath, nausea, chest pain, and shaking when she thinks of the accident. |
|
B5-Inability to experience positive emotions |
Rose reports she “feels numb.” |
|
B6- Efforts to avoid distressing memories |
Rose reports she wants to avoid thinking about the accident "at all costs." |
|
B7- Efforts to avoid external reminders |
Rose reports she avoids conversations with others regarding the accident because it causes her to “relive” the accident. |
|
B8- Sleep disturbance |
Rose reports that she is only sleeping three to four hours a night due to avoiding dreams of the car accident. |
|
B9- Irritable behavior and angry outbursts |
Rose reports irritability and anger toward her children. |
|
B10- Hypervigilance |
Rose reports hypervigilance when driving. |
|
B11- Problems with concentration |
Rose reports difficulty concentrating while at work occasionally. |
|
Cluster C (1 required) |
|
|
C1- Duration of Symptoms- three days to one month |
Rose reports the car accident occurred three weeks ago, with symptoms beginning two weeks ago. |
|
Cluster D (1 required) |
|
|
D1- The symptoms cause clinically significant distress in daily functioning |
Rose reports clinically significant problems related to her functioning as a mother, wife, employee, and family member/friend. |
|
Cluster E (1 required) |
|
|
E1- Symptoms not attributable to the physiological effects of a substance or another medical condition and are not better explained by a brief psychotic disorder. |
Rose does not appear to have any concerns regarding a psychotic, as evidenced by the results of the Mini-Mental Status Exam. Rose reports pain medicine prescribed, but no mention if she has been taking the medication. Rose does not have any brain injuries. |
Primary Diagnosis Culture/Gender Issues, Suicidal Risks
According to the diagnostic features mentioned in the DSM-5, Rose's narrative does not indicate any cultural-related diagnostic issues (American Psychiatric Association, 2013). Concerning gender diagnostic concerns, acute stress disorder is more prevalent among females. In addition to this, some studies have linked differentiated neurobiological stress responses between males and females that may indicate increased risk among females (American Psychiatric Association, 2013). Finally, Rose does not report any suicidal ideation; however, she remarks that she has recurrent thoughts of death and dying when she is alone. Suicidal ideation will need to be closely monitored.
Secondary Diagnosis with Culture/Gender Issues, Suicidal Risks (continue if you find more)
The secondary diagnosis this author would recommend for Rose would be Internal Classification of Disease (ICD) Code 296.33 (F33.2), Major Depressive Disorder (Severe). This is supported by the Beck Depression Inventory that Rose took with a score of 33 indicating severe depression. Schupp (2015), points out that major Depressive Disorder is focused on the inability to experience pleasure or see happiness in the future.
Listing of Criteria Met
· A-1. Depressed mood most of the day - Rose stated, “but now they don’t want to be around me that much . . ., and I just don’t want to be around them, either.”
· A-2. Markedly Diminished interest in pleasure - “We used to go hiking about every three weeks, but I just do not find that relaxing anymore, and would rather stay home.”
· A-3. Significant weight loss - She said, “I’ve lost 10 pounds over the last month because I don’t like eating at all.”
· A-4. Insomnia - Rose is getting up at night (after the dream) several times per week because “who can sleep after a nightmare like that!”
· A-7. Feelings of worthlessness and inappropriate guilt - Rose says she is “beginning to feel useless and guilty that she’s not being the wife and mother she should be.”
· A-8. Diminished ability to concentrate - Rose stated, “I can’t concentrate on what I need to work on for my clients, and my accounts are getting behind.”
· A-9. Recurrent thoughts of death - Rose mentioned that she did not have any specific suicidal ideations but, she does have recurrent thoughts about death and dying.
· B. Distress or impairment in social occupation, or other areas of functioning - “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.” Her coworkers are “really great,” but have been asking her why “she looks so sad and tearful lately?” Concentration at work has caused her to comment “I can’t concentrate on what I need to work on for my clients, and my accounts are getting behind.”
· C. Not attributed to substance abuse or another medical condition - Rose does not have any substance abuse symptoms or medical conditions that this author is aware of through the documentation provided.
· D. Not explained by another disorder - Rose does not have any other disorders that this author is aware of
· E. Manic or hypomanic episode - There has never been a manic episode or hypomanic episode that this author is aware of.
Secondary Diagnosis Culture/Gender Related Issue, Suicidal Risks
Females experience a higher rate than males with respect to depressive disorders. The rates are 1.5 to 3 fold higher and this begins in early adolescence (APA, 2013).There are no stated cultural linkages with respect to specific symptoms. Furthermore, in most countries depression symptoms go unrecognized (APA, 2013). Suicidal risk is prevalent with Major Depressive Disorder and is always a possibility. Having feeling of hopelessness is listed as a factor that increases the risk (APA, 2013). Rose has shown signs of hopelessness. Specifically, at the end of the interview when she stated, “Am I going crazy? I must be crazy. I should be over this by now. I think I am ruined forever, aren’t I?”
Recommendations
Recommendation 1
Long-Term Goal 1 – “Stabilize physical, cognitive, behavioral, and emotional reactions to the trauma while increasing the ability to function on a daily basis” (Kolsky et al., 2015, p. 13). Rose reported feeling tired, negative moods, irritability, emotional numbness, and taking sick days as part of avoidance. Cognitive-behavioral therapy interventions:
Short-Term Goal/Objective 1 – Rose will verbalize her understanding of distorted cognitive messages that contributes to fear, worry, and anxiety and its treatment (Kolsky et al., 2015).
1. Discuss the car accident facts and assist Rose by exploring the distorted cognitive messages that contribute to negative emotional and behavioral reactions.
2. Help Rose develop reality-based cognitive messages to decrease fears and anxiety.
Short-Term Goal/Objective 2 – Rose will describe feelings connected to the trauma and how daily functioning has been impacted. Interventions include (Kolsky et al., 2015):
1. Build rapport and trust with Rose through consistent eye contact, unconditional positive regard, and acceptance to explore emotional reactions at the time of the accident.
2. Help Rose develop a timeline to identify how the car accident impacted her life.
3. Utilizing the Trauma Symptom Inventory-2, assess the client’s frequency, intensity, and duration of traumatic reactions on her emotional, cognitive, and behavioral functioning.
Recommendation 2
Long-Term Goal 2 - “Diminish intrusive images and the alteration in functioning or activity level that is due to stimuli associated with the trauma” (p. 14). Rose’s primary concerns were the daily memories and flashbacks. Additionally, she reported decreased functioning at home and at work. Dialectical Behavioral Therapy interventions:
Short-Term Goal/Objective 1 – Rose will implement behavioral strategies to reduce physical stress reactions.
1. Together with Rose, develop a physical exercise plan (walking, bike riding) that will improve stress reactions; reinforce success.
2. Explore with Rose her reduction of stress with scheduled activities. Reinforce her participation in the activities and encourage her to incorporate them into daily activities.
3. Develop a visual schedule that consistently phases in activities and review/monitor progress with Rose.
Short-Term Goal/Objective 2 – Rose will learn and successfully implement relaxation techniques to reduce cognitive, emotional, and behavioral stress reactions.
1. Teach Rose relaxation techniques (deep rhythmic breathing, progressive muscle relaxation) and how to use them daily.
2. Refer Rose to acupuncture to relieve symptoms of stress, review progress.
Recommendation 3
Long-Term Goal 3 – “Reduce overall frequency, intensity, and duration of anxiety so that daily functioning is not impaired” (p. 21). Rose's history of trauma and resiliency is a good foundation to encourage successful adaptation.
Short-Term Goal/Objective 1 – Assist Rose in identifying, challenging, and replacing biased, fearful self-talk with positive, realistic, and empowering self-talk. Encourage Rose to monitor self-talk.
1. Explore Rose’s schema and self-talk and challenge biases. Assist her in replacing distorted thoughts with reality-based alternatives and positive self-talk.
2. Teach Rose to use an automatic thought record to become more aware of fearful self-talk and replace it with empowering self-talk; review and reinforce success by providing feedback for improvement.
Short-Term Goal/Objective 2 – Utilize exposure techniques to reduce anxiety.
1. Educate Rose to gain insight that worry is a way of avoiding a feared problem that creates chronic stress.
2. Ask Rose to imagine worst-case consequences and hold in mind (30 minutes) until anxiety decrease; discuss alternatives to the worst-case consequences.
Cognitive-behavioral therapy (exposure and cognitive processing therapy), dialectical behavioral therapy, and eye movement desensitization and reprocessing therapy are known therapeutic approaches to treat trauma disorders (Reyes et al., 2008) (Schwartz, 2017). Rose’s narrative indicated primary issues surrounding the emotions and physiological reactions to the car accident. In the past, she experienced several traumatic events, which may contribute to an increase in resiliency. However, she should be assessed/monitored for "cumulative effect" (Jacobs, 2016, p. 163). Early intervention is important (Reyes et al., 2008), and it will prove beneficial that she is willing to participate in therapy. Additionally, she has protective factors to include family, health, and a job she enjoyed, contributing to healing and restoration.
Recommendations
Recommendation 1
Based on Rose's primary and secondary diagnoses, it is recommended that she seek trauma-informed therapy. According to a robust amount of literature and evidence, trauma-informed therapies are the most efficacious in helping individuals cope with the memories, thoughts, and feelings surrounding a traumatic event (Watkins et al., 2018). An example of a recommended therapy is cognitive-behavioral therapy (CBT). The goals of CBT are two-fold: 1) target the thoughts surrounding the traumatic event and 2) help the individual cope with the effects of the trauma within their daily functioning (Levers, 2012). In addition to CBT, the American Psychological Association (APA) and Veterans Affairs/Department of Defense (VA/DoD) also recommend prolonged exposure (PE) and cognitive processing therapy (CPT) as psychotherapeutic modalities for the treatment of trauma-related stressors (Watkins et al., 2018).
Recommendation 2
The second recommendation for treatment Rose is group psychotherapy. The curative factors related to group therapy can profoundly benefit trauma survivors (Levers, 2012). According to Resick et al. (2015), treating PTSD in a group setting has shown significant efficacy in improving symptoms, and this modality appears to be highly accepted among trauma survivors. Moreover, it should also be noted that the curative factors of group psychotherapy (universality, catharsis, etc.) have been found to be vital healing components for individuals suffering from trauma-related disorders (Levers, 2012).
Recommendation 3
The final recommendation for Rose is psychopharmacology treatment. A combination of pharmacological and psychotherapeutic treatment has been determined to be highly successful in improving the psychological symptoms and treatment outcomes of individuals suffering from post-traumatic stress disorders (Davis et al., 2006; Duek et al., 2021, APA, 2017; Levers, 2012; Shiner et al., 2020) and depressive disorders (APA, 2019; Grover, 2017). Moreover, studies have also shown that medication effectively prevents “relapse and symptom exacerbation” (Davis, 2006, p. 465) associated with various mental health disorders.
References
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5(5th ed.). American Psychiatric Publishing
Gradus, J. L., Antonsen, S., Svensson, E., Lash, T. L., Resick, P. A., & Hansen, J. G. (2015). Trauma, comorbidity, and mortality following diagnoses of severe stress and adjustment disorders: A nationwide cohort study. American Journal of Epidemiology, 182(5), 451–458. https://doi.org/10.1093/aje/kwv066
Gradus, J. L., Qin, P., Lincoln, A. K., Miller, M., Lawler, E., Sorensen, H. T., & Lash, T. L. (2010). Acute stress reaction and completed suicide. International Journal of Epidemiology, 39(6), 1478–1484. https://doi.org/10.1093/ije/dyq112
Hardt, J., Bernert, S., Matschinger, H., Angermeier, M., Vilagut, G., Bruffaerts, R., de Girolamo, G., de Graaf, R., Haro, J., Kovess, V., & Alonso, J. (2015). Suicidality and its relationship with depression, alcohol disorders and childhood experiences of violence: Results from the ESEMeD study. Journal of Affective Disorders, 175, 168–174. https://doi.org/10.1016/j.jad.2014.12.044
Jacobs, G. A. (2016). Community-Based psychological first aid: A practical guide to helping individuals and communities during difficult times (1st ed.). Butterworth-Heinemann.
