Trauma Study

Trauma Case Study: Civilian Template

For the Trauma Case Study: Civilian Assignment, using the “Trauma Case Study: Civilian Narrative,” you will give an overview of what you have determined via specific assessments of what is happening with this client. Note that each “bullet” below is required to be a minimum of one paragraph! In your write-up, you will need to provide (review the rubric for more detail):

· In the first paragraph, write a short synopsis of this client, expounding on their presenting problem, history, and what issues “jumped out” at you first.

· In the second section (refer to page 2 on how the paper is to be divided up), using the Life Events Checklist (LEC) for DSM-5 (Standard Version) found in the Trauma Case Study: Civilian Resources section. Read the instructions for use/scoring, then scroll to the bottom and download the LEC-5 (standard self-report) (PDF) and fill it out (just use “X’s” or checkmarks) based on the information you gleaned from the narrative. Then, 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 will scan or take a picture and include a copy of just the scored LEC Standard Self-report table ( page 3 only ) showing how/where you placed your “X’s” when you upload your paper (scroll down and read the note about “CamScanner”).

· The third section will be done using the PTSD Checklist for DSM-5 (PCL-5) found in the Trauma Case Study: Civilian Resources section. Read the instructions for use/scoring, then scroll to the bottom and download the PCL-5 (PDF), and circle the answers based on the information you collected from the narrative. Then, you will write a good paragraph summarizing your scoring, interview answers, and total score. When you write this paragraph, use the client’s own answers to justify your scoring! You will also scan or take a picture and include a copy of just the scored PCL-5 table ( page 3 only ) showing what you circled. Make sure to total up the items you circled and show the sum at the bottom of the page!

· Your fourth section will be done using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) found in the Trauma Case Study: Civilian Resources section. Since the CAPS-5 is considered the “gold standard” for assessing clients with a possible PTSD diagnosis, download and print out and then fill it in (freehand) while reading over the client narrative. You will also scan or take a picture and include a copy of just the scored CAPS-5 Summary Table ( pages 19 & 20 only ) showing how you scored each item, total severity and symptoms, and your final conclusion on p. 20. You will then write a good paragraph summarizing your scoring, interview answers, and your totals for symptoms and severity. When writing this, use the client’s own answers to justify your scoring!

· From the data gathered in sections 2, 3, and 4, in Section 5 answer these questions using the DSM-5: what is the primary diagnosis (use the ICD-10 F-code number [without the parentheses], the name of the diagnosis, the severity, and any appropriate specifiers) for this client, putting your diagnosis in bold, and based on the criteria, show how you were able to come to that conclusion (include any information from the three assessments and client statements to support this diagnosis). Write a few sentences concerning any culture and/or gender-related diagnostic issues that may be present, as well as a few separate sentences regarding any potential suicide/self-harming risks for this particular diagnosis. Does the client have any possible secondary diagnoses (show the same way as the primary and in bold)? If so, which one(s), and what criteria do they meet? Are there any culture and/or gender-related diagnostic issues and suicide risks for this particular diagnosis?

· The final section is writing about recommendations and referrals as well as other resources you would want to put in place for this client (minimum of three, each separated as shown below. Provide your reasoning and cited resources for each one. Note that this section is NOT meant to be a complete treatment plan, but to assist the client towards getting into treatment!

To assist the professor in making sure that all sections/parts are submitted, divide your paper up as shown below using level 1 and level 2 headings (starting on p. 2 – no abstract is needed):

Title of Paper

Brief Summary

Life Events Checklist for DSM-5 Interpretation

(write several good paragraphs here summarizing your answer choices)

PTSD Checklist for DSM-5 Interpretation

(write several good paragraphs here summarizing your answer choices)

Clinician-Administered PTSD Scale for DSM-5 Interpretation

(write a good section here summarizing your answer choices)

Primary and Secondary Diagnostic Impressions

Primary Diagnosis with Culture/Gender Issues, Suicidal Risks

Secondary Diagnosis with Culture/Gender Issues, Suicidal Risks (continue if you find more)

Recommendations

Recommendation 1

Recommendation 2

Recommendation 3

References

Note that your upload will consist of four documents: your paper (saved last name, first name, CaseStudyCivilian), a picture or PDF copy of p. 2 of the LEC-5, and a picture or PDF copy of p. 3 of the PCL-5, and a picture or PDF copy of pp. 19 & 20 of the CAPS-5.

Cam Scanner is an “app” that allows any picture you take of a document be "turned" into a PDF. You can find the link on the Trauma Case Study: Civilian Resources section. It is easy to do, and you can email the new PDF to yourself, and then upload into Blackboard.

To see a listing of all the assessments the Veterans Administration has for free download, please visit the Trauma Case Study: Civilian Resources section.