PTSD Assessment and Treatment Plan for a Family Client
This paper presents a comprehensive clinical assessment of a 33-year-old woman referred to as Client Y, who sought therapy following a severe domestic violence incident perpetrated by her husband. The paper documents her demographic background, presenting problems, psychiatric and medical history, psychosocial context, and a full mental status examination. Using the DSM-5 diagnostic criteria, the clinician formulates a primary diagnosis of posttraumatic stress disorder (PTSD), distinguishing it from the differential diagnosis of major depressive disorder. The treatment plan centers on psychotherapy — specifically cognitive-behavioral therapy with a focus on cognitive restructuring — and incorporates the husband as a participant to support a holistic recovery process.
- Client Background and Presenting Problem: Demographics, symptoms, and initial complaint overview
- History and Psychosocial Assessment: Medical, trauma, family, and psychosocial history
- Mental Status Examination: Vital signs, behavior, mood, and cognition findings
- Case Formulation and PTSD Diagnosis: DSM-5 criteria applied to support PTSD diagnosis
- Treatment Plan: CBT and cognitive restructuring as treatment approach
- References: Cited academic and clinical sources
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What makes this paper effective
- The paper follows a structured clinical format, moving logically from intake data to diagnosis to treatment, which mirrors real-world practicum documentation and demonstrates professional competency.
- The DSM-5 criterion-by-criterion mapping is a strength — each diagnostic criterion is explicitly linked to a symptom the client presents, making the diagnostic reasoning transparent and defensible.
- The use of direct client quotations (e.g., "like a ship lost at sea") grounds abstract clinical observations in the patient's own voice, adding authenticity and illustrative detail.
Key academic technique demonstrated
The paper demonstrates evidence-based clinical reasoning by anchoring every diagnostic claim to both the client's reported symptoms and DSM-5 criteria, while also citing peer-reviewed sources to support the choice of treatment modality. This dual grounding — in standardized diagnostic frameworks and in academic literature — is a hallmark of graduate-level clinical writing.
Structure breakdown
The paper is organized as a clinical intake report with clearly labeled sections: demographic and presenting information, history (psychiatric, medical, developmental, psychosocial, and trauma), a systems review, a physical and mental status examination, differential diagnosis, case formulation with numbered DSM-5 criterion mapping, and a treatment plan. This conventional clinical structure makes findings easy to locate and evaluate, which is essential for practicum and professional documentation contexts.
Client Background and Presenting Problem
Demographic information: Client Y is a 33-year-old African-American woman who has been married to her husband, referred to here as X, for the past seven 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 works as an interior designer, while X is employed as a sales agent in the real estate industry.
Presenting problem: For the past four months, Client Y has been experiencing distressing dreams with a recurrent theme of violence. She also reports extreme psychological distress whenever she does something that might annoy her husband. Specifically, she states that she is afraid of associating with members of the opposite sex. Whenever a male client contacts her about her business, she is overcome by what she describes as an "unexplainable fear" and "shakes uncontrollably." In some instances, this distress is so intense that she must end contact with existing or potential clients, which she acknowledges is negatively affecting her business.
Client Y also reports that over the past several months she has lost interest in activities she previously enjoyed, such as trying new recipes — noting that she now cooks "the very same meals day in, day out." She further observes that she no longer feels love for her husband as she once did, stating that "all that love has been replaced by fear." She also reports difficulty falling asleep and notices that she becomes angry with her co-workers more frequently than before.
History of present illness: Client Y reports that the symptoms described above began approximately four months ago.
Past psychiatric history: Client denies any previously diagnosed mental health condition.
Medical history: Hypertension.
Substance use history: Client Y states that she has never used drugs or mind-altering substances.
Developmental history: Relevant developmental milestones from birth to the present appear to have been met.
Family psychiatric history: No close family member has been diagnosed with a mental health condition.
History and Psychosocial Assessment
Financial assessment: Client Y does not have immediate pressing financial needs. Her family may be described as financially stable.
Family history: Client Y comes from a single-mother household and never met her father. Her mother is still living. She is the eldest of six children.
Educational history: Client Y is a college graduate.
Spiritual assessment: Client Y is not deeply religious but identifies as Roman Catholic.
History of abuse and/or trauma: Client Y had no history of physical confrontation with her husband until five months ago. By her account, they had previously resolved conflicts amicably and were "on the same page most of the time." The precipitating incident occurred when X discovered that Client Y's former boyfriend had stayed at their home for two nights while X was away on a business trip. Upon learning this, X became enraged in a manner Client Y had never witnessed. She describes him as having "gone berserk" and states that he "instantly morphed into a person she did not really know."
X accused Client Y of having an affair with the former boyfriend and physically attacked her. She reports that he bit off her left index finger, broke two of her ribs, twisted her neck, and bruised her entire body. During the assault, he threatened to kill her. Client Y lost consciousness and woke up 24 hours later in a high-dependency care unit.
Client Y explains that she and the former boyfriend had remained friends long after their relationship ended. The boyfriend, who lived two blocks from her home, had been evicted from his apartment for unpaid rent and asked to stay temporarily. She states that during the two nights he was there, "he slept downstairs on the couch and nothing happened between us." She chose not to tell X about the arrangement, fearing it would upset him. X learned of the situation from a mutual friend.
Review of systems:
General: Client Y denies fatigue, recent unexplained weight loss or gain, and night chills or sweats.
HEENT: Client is sensitive to bright light but denies double vision. She has no dentures or appliances and denies sinus infection or ear pain. She reports no significant changes in hearing or sense of smell.
Respiratory: Client denies any breathing difficulties.
Cardiovascular: Client denies heart palpitations or recent chest pain.
Neurological: Client denies any loss of sensation, memory difficulties, dizziness, or lightheadedness.
Case Formulation and PTSD Diagnosis
The primary diagnosis in this case is posttraumatic stress disorder (PTSD). According to Ford (2009), PTSD may be defined as "a mental health condition that's triggered by a terrifying event — either experiencing it or witnessing it" (p. 231). Key symptoms of the disorder, as Taylor (2006) notes, include unstoppable thoughts about the event, anxiety, nightmares, and 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 attacked her, and nearly killed her. The event appears to have been sufficiently traumatic that she developed the disorder approximately one month after the incident.
As per the DSM-5 criteria for PTSD, Client Y presents with symptoms consistent with this diagnosis. According to Tull (2019), eight criteria must be met for a client to receive this diagnosis under DSM-5. The following maps Client Y's presentation to each criterion:
1. Criterion A: The event Client Y described involved both serious injury and a threat to her life. She was directly involved as the victim.
2. Criterion B: Client Y has experienced recurrent dreams whose content relates to the traumatic event.
3. Criterion C: Client Y actively avoids upsetting her husband out of fear that his anger could escalate to violence. She also avoids close interactions with members of the opposite sex.
4. Criterion D: The client blames herself for the traumatic event and has lost interest in activities she previously enjoyed.
5. Criterion E: The client demonstrated difficulty concentrating during assessment and reports ongoing sleep difficulties.
6. Criterion F: The client has been experiencing these symptoms for the past four months, meeting the duration requirement.
7. Criterion G: The client has experienced significant functional distress as a result of these symptoms, including negative effects on her professional life and relationships.
8. Criterion H: The client denies drug or substance use and denies any pre-existing diagnosed mental health condition, ruling out substance-induced or other disorder-related causes.
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