Practicum Assessing Client Families PTSD

ASSESSING CLIENT FAMILIES

Assignment: Practicum – Assessing Client Families

Demographic information: Client Y is a 33 year old African-American woman. Client Y has been married to X for the last 7 years. X is a 39 year old Hispanic male. They have two children together – a 3-year-old boy and a 5-year old girl. Client Y is an interior designer while X works as a sales agent in the real estate industry.

Presenting problem: Client Y has for the past 4 months been experiencing distressful dreams in which case the recurrent theme has been violence. She also claims that she experiences extreme psychological distress whenever she does something that has the possibility of annoying her husband. Specifically, she points out that she is often afraid of associating with members of the opposite sex and claims that whenever a male client reaches out to make enquiries about a certain aspect of the business, she is overcome by “unexplainable fear” and “shakes uncontrollably.” In some instances, the psychological distress she experiences when engaging members of the opposite sex is so intense that she has to halt any further association with an existing or potential client. She points out that this is negatively impacting her business. She also observes that over the last few months, she has lost interest in most of the things that she used to enjoy doing such as trying out new recipes. Now, she just cooks “the very same meals day in, day out.” She also observes that she no longer loves her husband like she did when she first met him. Indeed, she is of the opinion that “all that love has been replaced by fear…” It is also important to note that the client observes that she often has trouble falling asleep and has realized that she gets angry at her co-workers more frequently than was the case before.

History or present illness: Client Y observes that she has been experiencing the symptoms highlighted over the last 4 months.

Past psychiatric history: Denies any diagnosed mental health issue.

Medical history: Hypertension

Substance use history: Client Y points out that she has never used any drugs of mind altering substances.

Developmental history: The relevant milestones (from birth to present time) appear to have been met.

Family psychiatric history: No close family member has been diagnosed with a mental health issue.

Psychosocial history:

Financial Assessment: Client does not have immediate pressing financial needs. Her family could be described as financially stable.

Family History: Client comes from a single-mother family. She never met her father. Client’s mother is still alive. She is the first-born in a family of six.

Educational History: Client is a college graduate.

Spiritual Assessment: Client is not deeply religious. However, she identifies as Roman Catholic.

History of abuse and/or trauma:

Client Y never had any physical confrontation with her husband – until 5 months ago. They had sorted their issues amicably and were “on the same page most of the time.” However, on the material day, X found out that Client Y’s previous boyfriend had spent two nights at their home when he was away on a business trip. It was at this point that all hell broke loose and X appeared to have “gone berserk.” Client Y claims she had never seen him that angry. As a matter of fact, she points out that he instantly morphed into a person she did not really know. He accused her of having an affair with the said boyfriend and set on her with kicks and blows. She points out that X was so vicious in his attack on her that he bit off her left index finger, broke two of her ribs, twisted her neck, and bruised her entire body. All the while, he was calling her names and swearing to kill her. She passed out and woke up 24 hours later in a HDU. Client Y and the said boyfriend had remained friends even after splitting “many years ago.” She claims that the said boyfriend, who incidentally lived two block from her home had been thrown out of his apartment for rent arrears and sought refuge at her place. She says that for the two days that she offered him shelter, he slept “downstairs in the couch and nothing happened between us.” She also claims that she opted to keep this from X for fear that she would upset him. X only got to know of this from a mutual friend.

Review of systems:

General: Client Y denies fatigue. She also denies any recent unexplained weight loss/gain. Client also points out that she has not recently experienced night chills/sweats.

HEENT: Client is sensitive to bright light. She, however, denies double vision. Client has no dentures or appliances. Denies sinus infection as well as any ear pain. Client has not experienced any significant changes in her hearing abilities or sense of smell.

Respiratory: Client denies any breathing difficulties.

Cardiovascular: Client denies heart palpations. Client points out that she has not experienced any chest pains in the recent past.

Neurological: Client denies any loss in sensation or difficulties with her memory. Client also denies any dizziness or lightheadedness.

Physical assessment:

Vital Signs: T 97.9 orally; BP 134/80; BMI 30.22

Mental status exam:

Appearance: Client was well-groomed. Her clothes were pressed and clean. The client appeared obese (taking into consideration her weight and height).

Behavior: The client consistently avoided eye contact. To a large extent, she appeared distant. She appeared to be finding it difficult to concentrate.

Speech: The client was slow in as far as her speech rate is concerned. At times, she mumbled words that were largely inaudible. She was soft-spoken.

Language: At times, the client appeared illogical in her reasoning as well as form of thought. At times, the words she uttered were incoherent.

Mood and Effect: The client responded with, “like a ship lost at sea – afraid of a pirate attack at any time” when asked how she was feeling. Upon further probing, it appeared the client meant that she had lost her past enthusiasm and lived in constant fear of the unknown.

Thought Content: The client’s thoughts appeared anxious (and even depressed). She was delusional especially with regard to how married couples ought to relate. Client did not appear to harbor any suicidal thoughts.

Cognition: Patient’s cognition about the cause of the traumatic event described was distorted. She largely blamed herself for her husband’s behavior.

Insight and Judgment: The client appeared to appreciate the need to get better and live a more productive life. She stated that she would “give anything for this nightmare to go away, and for my days and those of my family to be bright again” (sic).

Differential diagnosis: Major Depressive Disorder

Case formulation:

The primary diagnosis in this case is posttraumatic stress disorder (PTSD). According to Ford (2009), PTSD could be defined as “a mental health condition that's triggered by a terrifying event — either experiencing it or witnessing it” (p. 231). Some of the key symptoms of the disorder, as Taylor (2006) points out, are unstoppable thoughts about the event, anxiety, nightmares, as well as flashbacks. In the present case, Client Y experienced a terrifying event. Her husband - a person she had known to be calm and collected - turned on her, savagely beat her up and almost killed her. It appears that the said event was so scary and shocking for Client Y that she developed the disorder approximately a month after the terrifying event.

It is important to note that as per the DSM-5 criteria for PTSD, the client in this case presents with symptoms consistent with those of PTSD. According to Tull (2019), there is an eight-symptom criteria that ought to be met for a client to be diagnosed with this particular disorder under DSM-5.

1. As per criterion A, the event that Client Y describes involved both serious injury and threatened death. She was directly involved.

2. Under criterion B, Client Y has had dreams whose content relates to the event she described.