Running Head: CHRONIC POSTTRAUMATIC STRESS DISORDER
Posttraumatic Stress Disorder Chronic
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Course
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CHRONIC POSTTRAUMATIC STRESS DISORDER 1
Part 1
Basic Case Summary
The initial assessment for this case was conducted on 1 October 2023 with Robert
McNeil, a 32-year-old African-American male. Mr. McNeil works part-time in a local
supermarket, which reflects his current work situation. In addition, he is also a part-time student
pursuing a Business Major at the University of Virginia. This adds another dimension to his
personal life as he aims to get a balance between his academic and work commitments.
Moreover, Mr. McNeil's age illustrates that he is in early adulthood, usually characterized by
significant development and life transitions. This is demonstrated in his pursuit of personal
growth and career development. It is also noteworthy that Mr. McNeil is divorced, which
demonstrates the significant aspect of his personal life that could have contributed to his current
mental health concerns, as divorce is a stressful life event that could have long-lasting and
complex emotional impacts.
Reason for Referral/Presenting Concern
Robert McNeil sought counselling on his condition due to the triggering events and
exacerbation of symptoms related to Chronic Posttraumatic Stress Disorder (PTSD). He
presented concerns revolving around his traumatic experiences during military service in Iraq
when he was only 24 years old and the aftermath of his divorce. Mr. McNeil reported, "I have
been feeling overwhelmed with emotions and memories and this is making me feel like I am
stuck in a never-ending nightmare." He described the intrusive nightmares and thoughts about his
traumatic experiences during his Iraq deployment. He claimed, "The images keep haunting me
even when I am awake." Moreover, McNeil's symptoms have extended to hypervigilance and
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emotional numbness, affecting his daily life. He explained, "I rarely connect with people
anymore. I am always vigilant when in public and always scanning for danger yet I am not even
in Iraq anymore. This has contributed to my relationships falling apart after my divorce, affecting
my concentration at school and at work." Furthermore, the triggering events of his divorce have
also intensified. He claimed that the event was painful and added another layer to his trauma as
he has to live with the feeling of failure and guilt, worsening his experiences. The symptoms
reported by the client and their impact on his relationships, academics, and work align with the
criteria for PTSD outlined in DSM-5. Pervasive negative alterations in cognition and mood,
avoidance behaviors, and distress align with the diagnosis of chronic PTSD (ICD-10 code F-
13.12).
History
Family and Home/Religious Background
Robert McNeil is from a close-knit family with strong religious beliefs. His parents, Job
McNeil, father, 62 years old, retired military, and mother, Jane McNeil, 60 years, nurse, have
been married for the past 35 years. Robert has one brother, James McNeil, aged 28, and an
elementary school teacher. McNeil's family has a strong religious background, as they are always
involved in their local church and attend services regularly. Robert described his family to be
very supportive but emotionally reserved. He recalls how feelings were not openly discussed
while growing up in this family, which could have contributed to his difficulty expressing
emotions. One critical incident of the family involved the deployment of his father and James to
Iraq when Robert was a teenager, which had an emotional strain on the family since they
grappled with fear and anxiety for their safety in the war zone, and this could have acted as a
precursor for Robert's traumatic symptoms.
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Educational History
Robert's educational journey was through public schools in his local hometown, and he
graduated with a high school diploma. He always displayed a strong passion for academics and
was recognized as an honor student throughout his schooling. However, Robert's academic
achievements took a downturn during his senior year, which coincided with his father and
brother's deployment to Iraq; this was marked by his notable shift in his attitude toward
education and reflected in his performance. He recorded struggling to focus and engage in class,
thus leading to an increasing feeling disconnected from school.
Mental Health
Robert has historically struggled with mental health issues related to his traumatic
experiences when he was recruited to military service in Iraq, aged only 24. After the mission in
Iraq, which he decided to quit, he started experiencing PTSD symptoms involving
hypervigilance, flashbacks, and nightmares, which intensified and persisted over time, leading to
his diagnosis of chronic PTSD (ICD-10 code F-13.12). His mental assessment included high
scores on the DSM-5 cross-cutting symptom measure, which indicated that he had experienced
significant distress across various life domains. Moreover, filling out the Beck Depression
Inventory revealed elevated scores consistent with severe depression.
Client’s Physical Health
Robert McNeil had a history of mild high blood pressure, which he constantly managed
with medications. He is under the primary care of a personal physician who regularly monitors
his health condition. However, the physical health issues are not a major focus in the current
treatment plan since it is under control and has no significant impact on his mental and emotional
well-being.
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Occupational History
Robert previously held several part-time jobs while pursuing his education after quitting
military service for personal reasons. I felt unimpressed with the profession and wanted to focus
on something else. Currently, he is working as a part-time employee at the local supermarket as a
cashier. However, despite his strong academic achievement, his vocational history has always
involved sporadic employment. He has reported dissatisfaction with his current job and desires a
more fulfilling career aligning with his business studies.
Sexual Adjustment
His sexual adjustment appears within the normal range, and he has reported no significant
disturbances or problems. He has only focused on addressing his chronic PTSD and related
symptoms.
Substance Use History
Robert has acknowledged occasional alcohol use, but this can only be associated with his
current mental health issues since he has no significant history of drug use. He has illustrated that
he always consumes alcohol socially, during weekends, and at parties, reporting that he has not
had any problematic patterns in use or dependence.
Spiritual Assessment
Having been born and raised in a spiritual family, Robert identifies as a Christian and has
regularly attended church services, which was a norm for the family. Robert has illustrated that it
has been a significant coping mechanism for him in the wake of his challenges, as it gives him a
sense of hope and purpose. He describes God as a source of strength and believes his faith will
help him overcome his challenges.
Cultural/Social Justice Factors
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Robert has identified that his experiences throughout his life have been impacted by
cultural factors, especially being an African American. He has acknowledged that this has
occasionally exposed him to racial bias and discrimination. However, this has not been attributed
to his current mental health concerns.
Barriers to Treatment/Success
The assessment has revealed several barriers that Robert might face in his attempts to
achieve treatment. Firstly, his emotional reserve, which he learned from his family's upbringing,
may hinder his ability to express his emotions in therapy easily. Moreover, his Chronic PTSD
symptoms, like emotional numbness, can also challenge his engagement in treatment plans.
Finally, the stigma associated with mental health issues in the community and military culture
can also influence his willingness to seek and commit to treatment.
Other Pertinent Data
The motivation demonstrated by the client for treatment can be essential in his treatment
and recovery process. Robert states, "I want to reclaim my life since I do not want to be
controlled by the emotions and memories but instead, I want to be the one controlling them.
Despite this not being easy, I will be ready to confront my past and successfully move forward."
Such motivation can be essential in implementing the treatment plan and Robert's recovery
process.
Mental Status Examination
During the initial assessment, Robert McNeil appeared to be exhausted and disheveled.
His clothing appeared clean but needed more detail, indicating decreased self-care and grooming.
Despite appearing slightly unkempt, his hygiene appeared adequate, thus illustrating how the
chronic PTSD symptoms could have influenced his overall self-presentation. Regarding his
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interpersonal characteristics and approach to the evaluation, he was very willing and cooperative
since he appropriately conversed with the clinician. Still, he exhibited a reserved demeanor,
which aligns with his reported emotional numbness. He had a clear and articulate speech but
sometimes reflected a slower pace, which could indicate his struggles in expressing his emotions.
Throughout the assessment, Robert maintained intermittent eye contact, although he often
looked away and avoided sustained gaze. Such behavior is associated with hypervigilance and
discomfort by such individuals when discussing their traumatic experiences (Adams & Turk,
2018). His receptive and repressive language appeared intact, and he lacked any deficits in
communication. Regarding his orientation, Robert fully understands person, place, and time. He
remained alert throughout the assessment period, which enabled him to maintain coherence and a
logical thought process. Despite this alertness in assessment, his attention span and concentration
appeared compromised since he frequently showed signs of distraction and a tendency to drift
into thoughts related to traumatic experiences.
Moreover, Robert showed no delusions or hallucinations during the assessment and
displayed insight into his mental health. This is because he acknowledged the impacts of the
Chronic PTSD symptoms on his daily life, relationships, and overall well-being. He mainly had a
normal range of intellectual ability, evidenced by his coherence to the tasks and questions. His
mood assessment revealed a pervasive sense of sadness, which was consistent with his diagnosis
of depression. These effects were notably blunted as he demonstrated limited emotional
expressiveness, indicating difficulty conveying and expressing emotions. Despite the adverse
experiences, Robert did not report any homicidal or suicidal ideations during this assessment and
did not indicate any risk of violence. Therefore, the mental status exam of Robert McNeil aligns
with the diagnosis of chronic PTSD (ICD-10 code F-13.12) and major depressive disorder since
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his symptoms of hypervigilance, sadness, and emotional numbness are associated with the
condition.
Answer Key
DSM-5 Diagnostic Criteria: disorder name
and code number
Client’s Reported Symptoms:
Criterion A: Exposure to threatened or actual
death, sexual offense, or serious injury
Robert experienced direct exposure to
traumatic events during his military service in
Iraq, life-threatening events, and combat
situations.
He experienced the traumatic experience of
his parents' separation when his father was
deployed to Iraq.
Criterion B: Presence of Intrusive symptoms Robert reported involuntary and recurrent
distressing memories, including nightmares
and thoughts.
He also experienced physiological distress
and reactions when exposed to cues
resembling traumatic experiences.
Criterion C: Persistent avoidance of stimuli
associated with the traumatic experience.
He reported avoiding conversations, feelings,
and thoughts associated with his traumatic
experience.
He actively avoided reminders of his
traumatic events, like crowded places.
Criterion D: Negative alterations in mood and
cognition
Robert has persistent negative beliefs and
perceptions about himself.
He reported feelings of guilt and blame.
Criterion E: Marked alterations in reactivity
and arousal
Robert experienced hypervigilance,
aggression, and irritability.
He reported sleep disturbance.
Criterion F: Duration of the Disturbance for
Criteria B, C, D, and E
They had persisted beyond one month.
Treatment Recommendations
Two Treatment Recommendations
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In addressing Robert's chronic PTSD symptoms, I will recommend trauma-focused
Cognitive Behavioral Therapy (TF-CBT). TF-CBT will be highly recommended since his
diagnosis of chronic PTSD has significantly impacted his daily life. This evidence-based therapy
is designed to help individuals with a history of trauma exposure and PTSD. Research by
Deblinger et al. (2020) has demonstrated that TF-CBT is essential in reducing PTSD symptoms,
particularly those having arousal symptoms, avoidance behaviors, and intrusive thoughts. The
therapy integrates cognitive-behavioral techniques with trauma-specific interventions, and this
will be efficient in helping clients like Robert reframe their traumatic memories and thoughts and
enable them to develop healthier coping mechanisms. This treatment recommendation will
mainly emphasize exposure-based exercises, relaxation techniques, and psychoeducation to
empower Robert to regain control of his life.
Moreover, it will also be appropriate to incorporate mindfulness-based stress reduction
(MBSR) into Robert's treatment plan. This counseling-focused approach promotes stress
reduction, emotional regulation, and self-awareness, which is particularly efficient for
individuals with PTSD. Research has determined that MBSR effectively reduces PTSD
symptoms involving negative mood states, hyperarousal, and emotional reactivity (Boyd et al.,
2020). This study also determined that the treatment option enhanced emotional regulation and
reduced symptoms of depression and anxiety, which are comorbid with PTSD. The intervention
option can help Robert develop mindfulness skills, enabling him to manage his physiological and
emotional distress and responses triggered by his traumatic memories.
Medication Consideration
In Robert's case, it will be appropriate for him to consider medication evaluation because of
the severity of his symptoms and the chronicity of his condition. The symptoms are severe in this
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case as they have persisted for an extended period, affecting various aspects of his life, involving
academic pursuits, employment, and relationships. Moreover, the condition has turned out to be
chronic as it has persisted for several years, and given such durations, it is likely to exhibit
treatment resistance and a higher risk of comorbid conditions like anxiety and depression. The
medication that can be considered involves selective serotonin reuptake inhibitors (SSRIs) and
serotonin-norepinephrine reuptake inhibitors (SNRIs). A meta-analysis by Cipriani et al. (2018)
has determined that SSRIs and SSRIs are effective in treating patients with PTSD. The
symptoms that benefit from this medication involve sleep disturbance, depression, anxiety, and
hyperarousal.
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References
Adams, L. M., & Turk, D. C. (2018). Central sensitization and the biopsychosocial approach to
understanding pain. Journal of Applied Biobehavioral Research, 23(2), e12125.
Boyd, J. E., Lanius, R. A., & McKinnon, M. C. (2018). Mindfulness-based treatments for
posttraumatic stress disorder: a review of the treatment literature and neurobiological
evidence. Journal of Psychiatry and Neuroscience, 43(1), 7-25.
Cipriani, A., Williams, T., Nikolakopoulou, A., Salanti, G., Chaimani, A., Ipser, J., ... & Stein, D.
J. (2018). Comparative efficacy and acceptability of pharmacological treatments for
posttraumatic stress disorder in adults: a network meta-analysis. Psychological Medicine,
48(12), 1975-1984.
Deblinger, E., Pollio, E., Cooper, B., & Steer, R. A. (2020). Disseminating trauma-focused
cognitive behavioral therapy with a systematic self-care approach to addressing
secondary traumatic stress: PRACTICE what you preach. Community Mental Health
Journal, 56, 1531-1543.
