Question

Vignette Analysis:

Jacob is a 32-year old African American man who just returned from his 2^nd tour of duty overseas. Before he is able to begin a 3^rd tour of duty, his commanding officer is mandating that he seek counseling due to what Jacob describes as “odd behaviors”. Jacob admits that over the past few weeks, he does not feel safe, but he cannot tell you why. He cannot leave the house without checking that all the doors are locked 3 times. Once he feels the house is safe, he is hypervigilant about walking the property to make sure that the outside is secure and that no one is lurking in dark corners. He does not believe that this impairs his life nor interferes with his judgment and ability to meet his daily responsibilities. He is only seeing you because he shared this with his commanding officer who is now requiring that he seek counseling.

During your intake session, Jacob discloses that he grew up in a rough neighborhood where it was not uncommon to hear gun shots and people screaming. When he was 6-years old, he witnessed his uncle being shot to death, but cannot tell you details. He describes his parents as very loving, trying to shield both he and his brother from life on the streets. His uncle’s death was never talked about. He does admit that he used to have flashbacks and nightmares of his uncle’s death, but that they went away.

Jacob also has experienced violence during his last tour overseas. While he denies actually seeing or participating in direct combat, he does admit to hearing gun fire and the cries of other soldiers. During this time, he admits to recurring thoughts of his uncle’s death. He is able to correlate his military experience with his childhood experience of trauma and violence. He describes his ability to compartmentalize those experiences as ‘the past’ and wants to move forward. Jacob sees the military as his family and wants to dedicate his life to his country.   He is adamant about not wanting a wife or family of his own, for fear that “what if something would happen to them and that I would not be able to protect them”.

1. Formulate a Differential Diagnosis for Jacob. Consider what comorbid disorders may exist and what additional information you may need to confirm your diagnostic impression.  Choose one provisional diagnosis for Jacob. Support your diagnostic impressions by walking thru the DSM-5 diagnostic criteria (letter by letter) for the proposed diagnosis and match each DSM-5 criterion with vignette content. (See Sample Vignette Analysis located under Resources for guidance)
2. Choose two (2) theoretical models and explain how each may conceptualize Jacob’s clinical presentation. From the perspective of each theoretical model, discuss how you would provide clinical treatment. Integrate vignette content to illuminate your treatment approach.

Answer 1

Based on the information given above and the symptoms experienced by the subject he has suffering from Post Truamatice Disorder (PSTD). Posttraumatic stress disorder (PTSD) is a psychiatric disorder that can occur in people who have experienced or witnessed a traumatic event. In the case of this subject for example when he was 6-years old, he witnessed his uncle being shot to death.

People with PTSD have intense, disturbing thoughts and feelings related to their experience that last long after the traumatic event has ended. They may relive the event through flashbacks or nightmares; they may feel sadness, fear or anger; and they may feel detached or estranged from other people. People with PTSD may avoid situations or people that remind them of the traumatic event, and they may have strong negative reactions to something as ordinary as a loud noise or an accidental touch.

The main symptoms of PTSD are the following.

1. Intrusive thoughts such as repeated, involuntary memories, distressing dreams or flashbacks of the traumatic event. Flashbacks may be so vivid that people feel they are re-living the traumatic experience or seeing it before their eyes.
2. Avoiding reminders of the traumatic event may include avoiding people, places, activities, objects and situations that bring on distressing memories. People may try to avoid remembering or thinking about the traumatic event. They may resist talking about what happened or how they feel about it.
3. Negative thoughts and feelings may include ongoing and distorted beliefs about oneself or others, ongoing fear, horror, anger, guilt or shame; much less interest in activities previously enjoyed; or feeling detached or estranged from others.
4. Arousal and reactive symptoms may include being irritable and having angry outbursts; behaving recklessly or in a self-destructive way; being easily startled; or having problems concentrating or sleeping.

So we can conclude that the subject provisional diagnosis is PTSD. Here the comorbidity of Disorder may can occure Obsessive Compulsive Disorder (OCD), Depression or Anxiety Disorder.

According to Payne et al, trauma is often described as a normal body reaction to an abnormal event. When an individual is faced with a perceived life-threatening situation the instinctual limbic part of the brain takes prevalence over the rational thinking neocortex. The autonomic nervous system (ANS) activates an instinctive motor plan for survival. This mechanism involves activation of the sympathetic nervous system in a coordinated preparation for strong energy expenditure, most commonly known as ‘fight-or-flight’ response. It activates the body systems responsible for survival: the motor system increases muscle tension and preparedness to act, the endocrine system releases high levels of stress hormones , and the central nervous system sharpens the sensory alertness to increase awareness of the danger.

Cognitive factors are important in the development and maintenance of PTSD. One model suggests that two key processes are crucial such as disturbances in memory for the event, and negative appraisals of the trauma and its aftermath. According to this theory, some people who experience traumas do not form coherent memories of the trauma; memories of the traumatic event are poorly encoded and, thus, are fragmented, disorganized, and lacking in detail. Therefore, these individuals are unable remember the event in a way that gives it meaning and context.

The psychotherapheutic treatment can provide;

1. Cognitive Processing Therapy

The therapist talks about the traumatic event with the subject and how his or her thoughts related to it have affected their day to day life. Then the subject asked about to  write in detail about what happened. This process helps them to examine how they think about their trauma and figure out new ways to live with it.

2. Prolonged Exposure Therapy

If the subject has been avoiding things that remind of the traumatic event, PE T will help the subject confront them. Early on in treatment, therapist will teach breathing techniques to ease the subject's anxiety when they think about what happened. Later, the therapist asked the subject to make a list of the things he or she  been avoiding and learn how to face them, one by one. In another session, the subject recount the traumatic experience to therapist, then go home and listen to a recording of themeselves.