PTSD Vignette: Trauma, Anxiety, and Therapy for Jacki

Evaluation and Assessment

The description of Jacki’s case points to the possibility of her suffering from anxiety and trauma. Her gender and sexual orientation put her in a compromised situation. Nonetheless, it appears that the past experiences hurt her more than the current occurrences. The previous two incidences of sexual assault while young and the escaped date rape are likely the causes of her fear and trauma. Her antisocial behavior and expression of stress related to the past circumstances suggest that Jacki could be suffering from post-traumatic stress disorder (PTSD) and hence the need to evaluate and assess its likelihood.

PTSD is a psychological problem resulting from a person holding on to a past unfavorable experience. It is a syndrome emanating from exposure to death-related and injury-inflicting occasions or sexual harassment (Mann & Marwaha, 2022). PTSD, therefore, develops in the wake of a traumatic happening. In this respect, the two probable lead events in Jacki’s case are the escaped date rape and the sexual abuse by her uncle at her tender age. Mann and Marwaha (2022) postulate that comorbidity, mortality, impairment, and suicidal ideations are related to PTSD. Nonetheless, Jacki denies having suicidal thoughts.

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Specific symptoms characterize PTSD and Jacki exhibits most of them. The primary indicators of PTSD encompass constantly re-experiencing the traumatic incident (s), having nightmares, dissociation, guilt, adverse reaction to an event or object that recreates mental exposure to the traumatic situation, avoidance of traumatic triggers, and sleep challenges (Lok et al., 2018; Tural & Iosifescu, 2020). Jacki hardly trusts anyone, fears leaving the dormitory, struggles to sleep, experiences horrific nightmares, and feels that the sexual assault by her uncle would put the family in shame, signaling similar behaviors with a confirmed PTSD case. Notwithstanding, one must display the symptoms for more than one month to qualify as a PTSD patient (Mann & Marwaha, 2022). Jacki qualifies as a PTSD patient because she has portrayed the symptoms for a long time.

A comprehensive assessment must follow the general evaluation for better case analysis and confirmation. A functional assessment involves the impairment, comorbidity, malingering, and symptom advancement determination (Lancaster et al., 2016). Comorbidity assessment helps establish the existence of other underlying conditions. Lancaster et al. (2016) assert that other psychiatric disorders, such as major depressive disorders and alcoholism, often accompany PTSD. Despite Jacki showing PTSD symptoms, she has no other comorbidities since she has no history of suicidal ideation or substance use. Assessing the symptom severity is critical in assessing a psychiatric condition. A psychiatric expert can utilize several symptom frequencies and intensity testing instruments. The most useful tool is the PTSD checklist, which is a self-assessment questionnaire (Lancaster et al., 2016). Accordingly, Jacki’s symptoms keep advancing a she currently feels terrified.

The other fundamental assessment process is neurobehavioral and neurocognitive impairment characterization. Attention, memory, and information processing may characterize other disorders other than PTSD. For instance, general anxiety and trauma, addiction, chronic pain, and sleep disorders share symptoms with PTSD (Lancaster et al., 2016). Correspondingly, Jacki could be suffering from general anxiety due to her sexual orientation and severe sleep disorder besides PTSD, and thus the need for a differential diagnosis. Moreover, malingering is a factor for consideration. Malingering is exaggerating or falsifying PTSD symptoms. Over-reporting PTSD symptoms significantly affect the treatment plan (Agnes et al., 2020). Nevertheless, there is no suspicion of malingering in Jacki’s case.

Differential Diagnosis

There are many other psychiatric disorders that share symptoms with PTSD, and this differential diagnosis is necessary to rule out that Jacki is not suffering from any of the following other than PTSD.

Acute stress disorder: Acute stress disorder and PTSD are often confused together or interchanged because of the highly matching symptoms. However, acute stress disorder’s symptoms last less than one month, and thus, symptoms lasting longer than that signal PTSD.

Depression: It is almost true that all patients suffering from PTSD are also depressed. Besides, PTSD predisposes patients to depression symptoms and suicidal ideation/attempts.

Adjustment disorder: Adjustment disorder is the immediate possible diagnosis when PTSD fails to meet the formulated criteria.

Anxiety disorders: When a patient reports or shows adverse emotional and psychological reactions, it can signify either anxiety disorders or PTSD. However, anxiety disorders are associated with panic attacks, while trauma attacks are associated with PTSD.

Traumatic brain injury (TBI): Cognitive impairment is a symptom of both TBI and PTSD. Nonetheless, TBI follows a brain injury, whereas PTDS is not necessarily associated with brain injury.

The DSM-5 diagnostic criteria for PTSD below give reference for the differential and confirmation diagnoses.

1. Exposure to an actual or life-threatening event, injury, or sexual assault by either:
2. Directly being exposed to the traumatic event.
3. Witnessing a victim of a traumatic event.

• Discovering the exposure of a family member or close friend to a traumatizing situation.

1. Indirect exposure to any components of the traumatic events.
2. The patient exhibit one or more of these symptoms:
3. Persistent, sudden thoughts about the traumatic event.
4. Distressing nightmares, where the patient dream about the traumatic event.

• Dissociative reactions, in the form of flashbacks, as one seeks to recreate the traumatic event.

1. Intense distress upon exposure to traumatic triggers.
2. Unusual physiological reactivity.
3. Prolonged avoidance of traumatic situation stimuli by:
4. Avoiding memories of the traumatic situation.
5. Avoiding external reminders of events, especially places, people, objects, and activities.
6. Negative mood and cognition alterations characterized by:
7. Inability to recall critical parts of the traumatic occurrence due to amnesia and not head injury or drug abuse.
8. Loss of self-esteem by expressing disbelief in one’s expectations.

• Persistent self-blame and blaming others for the traumatic experience.

1. Expressing fear, shame, or guilt.
2. Portraying dull behavior.
3. Exhibiting social disconnection.

• Showing negative emotions.

1. A drastic change in reactivity and arousal depicted by:
2. Increased aggression.
3. Sudden recklessness.

1. Abnormal startle response.
2. Poor concentration.
3. Sleep imbalances.
4. The principal symptoms persist for more than a month.
5. The symptoms cause great functional impairment.
6. The disturbance has no association with substance use or medical background.

With reference to the DSM-5 guided diagnostic criteria for PTSD, the following criteria confirm Jacki suffers from PTSD:

1. Jacki has been exposed to the traumatic situation where she:
2. Experienced life-threatening, severe physical injury-inflicting, and demeaning events.
3. Response with great fear and feel horrified.
4. The traumatizing circumstances continually re-occur through:
5. Flashbacking by way of thoughts and perceptions.
6. Horrific nightmares of the escaped date rape and sexual assault by the uncle.
7. Fear of interacting with people.
8. Having a strained relationship with her partner.
9. Continual avoidance of trauma event triggers evident through:
10. Feeling irritated recalling the event or discussing it with anyone, including her family members.
11. Avoiding going out with the fear of encountering a repeat of the attempted rape or meeting with people or objects that can trigger the reconstruction of the attempted rape event.
12. Losing interest in social activities.
13. Compromised intimacy.
14. Persistent exacerbated arousal symptoms depicted through sleeping difficulty, irritability, and/or reduced concentration.
15. The symptoms in criteria 2, 3, and 4 have persisted for more than one month.
16. The symptoms propagate clinical distress and significantly impaired functioning.
17. The symptoms are not associated with substance use, diseases, or medication, as Foa et al. (2018) suggest.

Treatment Plan

Several factors must be considered when designing Jacki’s treatment. The fundamental elements include the nature of the confirmed diagnosis and the cultural aspects involved. It is confirmed that Jacki is suffering from moderate PTSD and the two appropriate treatments are thus, exposure therapy and solution-focused therapy, which are brief psychotherapies. Dewan et al. (2018) affirm that culture affects patient perception of appropriate treatment. In this regard, it is essential to acknowledge that Jacki is a Japanese American aged 21 years and admits to being a lesbian. Accordingly, Jacki will be put under 16 combined exposure-based and solution-focused psychotherapy sessions of 10 and 6 sessions, respectively, which are sensitive to her cultural profile, as highlighted below.

Exposure-Based Therapy

Exposure-based therapy helps the patient deal with the fears related to the trauma. Dewan et al. (2018) confirm that exposure-based therapy reduces post-traumatic stress. Prolonged exposure therapy is one of the best empirically-supported forms of exposure-based treatment suitable for a PTSD patient (Lancaster et al., 2016). The approach aims at creating a safe environment for exposing Jacki to the things she fears and avoids as they relate to the attempted rape and the previous sexual abuse. The treatment will be administered through systematic desensitization, which is gradual with relaxation exercises. The therapy goals include enhanced fear and avoidance extinction, improved self-efficacy, and increased emotional processing.

The prolonged exposure therapy will be conducted twice a week, with each encounter lasting for 2 hours. In the initial sessions, Jacki will be offered the necessary psycho-education, especially on the PTSD symptoms, the contributing factors to the persisting symptoms, and the proposed treatment plan in brief. After that, she will be trained in short relaxation breathing exercises. The following several sessions will be imaginal exposure, which involves the patient revising and narrating the ordeals loudly to extinguish the fear of thoughts (Lancaster et al., 2016). Moreover, Jacki will undergo in vivo exposure by being trained on the coping measures for avoided trauma-associated circumstances. After the eighth session, Jacki should demonstrate a positive behavioral change, which aligns with the exposure-based therapy’s stipulated goals.

Solution Focused Therapy

Solution-focused therapy focuses more on solutions rather than trauma-related problems. Dewan et al. (2018) assert that solution-focused therapy is useful in addressing focal problems of adjustment and anxiety. The treatment method will encompass having brief and specific problem-solving discussions and swiftly devising solutions. The primary goal will be to establish the particular situations triggering the PTSD symptoms and address them.

Solution-focused therapy is more patient-centered than exposure-based therapy. In this case, Jacki will be informed of the assumptions made for the successful therapy sessions. Some of the assumptions include the fact that change is inevitable, we will emphasize what is changeable, Jacki must be willing to demonstrate the desired behavioral transformation, solutions are pegged on her, and the commitment that we will concentrate on the future alone. Consequently, the crucial techniques that will be used comprise questioning that trigger thinking, tracking a trauma-associated behavior to alter, and posing questions that amplify wins.

References

Agnes, v. M., Birgit, v. D., Eline, M. V., Anouk, W., & Ad, J. (2020). The effects of symptom overreporting on PTSD treatment outcome. European Journal of Psychotraumatology, 11(1), 1794729. https://doi.org/10.1080/20008198.2020.1794729

Dewan, M. J., Steenbarger, B. N., & Greenberg, R. P. (Eds.). (2018). The art and science of brief psychotherapies: A practitioner’s guide. (3^rd ed.). American Psychiatric Publishing.

Foa, E. B., Asnaani, A., Zang, Y., Capaldi, S., & Yeh, R. (2018). Psychometrics of the child PTSD symptom scale for DSM-5 for trauma-exposed children and adolescents. Journal of Clinical Child Adolescence Psychology, 47(1), 38-46.

Lancaster, C. L., Teeters, J. B., Gros, D. F., & Back, S. E. (2016). Posttraumatic stress disorder: Overview of evidence-based assessment and treatment. Journal of Clinical Medicine, 5(11), 105. doi: 10.3390/jcm5110105

Lok, A., Frijling, J. L., & van Zuiden, M. (2018). Posttraumatic stress disorder: Current insights in diagnostics, treatment and prevention. Nederlands Tijdschrift Voor Geneeskunde 161(3), D1905.

Mann, S. K., & Marwaha, R. (2022). Posttraumatic stress disorder. StatPearls Publishing.

Tural, U., & Iosifescu, D. V. (2020). Neuropeptide Y in PTSD, MDD, and chronic stress: A systematic review and meta-analysis. Journal of Neuroscience Research, 98(5), 950-963.