Alexandra Reeves

Assignment 5.3- Special Topics Paper- PTSD

CNS 762
2017June12

Introduction
Posttraumatic stress disorder or PTSD is listed under the Trauma-and Stressor- Related

Disorders section of the DSM-5. This disorder is becoming more and more researched due to the

spot light on the current war on terror. Originally, the disorder was thought to apply only to war

veterans. But this was later expanded to others that might have even witnessed a traumatic event,

like a life ending car accident. Research continues to show that many types of people in different

professions can suffer from PTSD. This also includes individuals that hear about a traumatic

event happening to a family member or close friend. The details of the diagnostic criteria are

listed in the proceeding sections.

The reason behind this disorder being highlighted in the following case study, is the

ongoing need to learn more about the disorder and how to help clients with PTSD. On top of this,

the military is continuing to see an increase in troops that are coming home from overseas and

have symptoms of PTSD that make them unable to continue their careers. In order to better help

the military personal as well as the individuals that are affected in other careers, it is important to

continue the research and incorporate theories and interventions that are proven to be effective.

The following case study will represent a military veteran that has recently come home from

fighting in Afghanistan. The treatment plan will outline the plan for the therapist during the

course of the sessions. A review of existing literature will be provided in order to detail

interventions and treatments that are helpful when treating PTSD.

 Review of Existing Literature

The diagnostic criteria in the DSM-5 for PTSD is detailed and lists the ways in which

someone could be exposed to an event that would cause the symptoms associated with PTSD.

The following criteria is listed:

A. Exposure to actual or threatened death, serious injury, or sexual violence in

one or more of the following ways:

1. Directly experiencing the traumatic event(s).

2. Witnessing, in person, the event(s) as it occurred to others.

3. Learning that the traumatic event(s) occurred to a close family

member or close friend. In cases of actual or threatened death of a

family member or friend, the event(s) must have been violent or

accidental,

4. Experiencing repeated or extreme exposure to aversive details of

the traumatic event(s) (e.g., first responders collecting human

remains; police officers repeatedly exposed to details of child

abuse). (DSM-5, 2013).

In addition to one of these events happening, there should be one of the following intrusion

symptoms associated with the traumatic events: Recurrent memories of the event, recurrent

dreams of the event, dissociative reactions, intense or prolonged psychological distress, and

marked physiological reactions to internal or external cues (DSM-5, 2013). These symptoms

must be occurring for longer than 1 month (DSM-5, 2013).

 Each individual that is diagnosed with PTSD can experience the symptoms differently.

Some individuals may experience fear-based reexperiencing, emotional, and behavioral

symptoms as the predominate symptoms (DSM-5, 2013). Others might have the most discomfort

from anhedonic or dysphoric mood states and negative cognitions (DSM-5, 2013). Other ways

that individuals can display symptoms is in an arousal and reactive-externalizing pattern or even

have dissociative symptoms be prominent (DSM-5, 2013). An individual could also any

combination of these symptom categories (DSM-5, 2013).

There are multiple clinically proven techniques when working with clients that have

PTSD. There is also evidence based treatments that are not used as widely in clinical settings.

One of these treatments is exposure based (Becker & Zayfert, 2001). There have been high rates

of attrition, suicidality, dissociation, destructive impulsivity, and chaotic life problems that have

been reported by clinicians and are the reasons behind these clinicians no longer using exposure

treatment (Becker & Zayfert, 2001).

PTSD is often accompanied by a co-occurring disorder. Many times, this is a substance

use disorder (SUD). In a study conducted with 42 patients that had both PTSD and SUD, when

questioned about the relationship between their two disorders, they commented that if one

worsened then the other did as well (Brown, Stout, & Gannon-Rowley, 1998). In this study, it

was also found that patients with PTSD and SUD preferred to have treatment for both disorders

at the same time (Brown, Stout, & Gannon-Rowley, 1998). The major difference between the

participants that were successful in treatment vs unsuccessful was the lack of trust that the

unsuccessful participants had with the clinicians (Brown, Stout, & Gannon-Rowley, 1998).

In addition, following information is provided in another article that discusses PTSD and

SUD. In this study, 100 male PTSD-SUD patients attended a substance use treatment facility
then received 1, 2, and 5 year follow ups (Ouimette, Moos, &Finney, 2003). From this study,

SUD remission was predicted from the first year of 12-step attendance and PTSD treatment

(Ouimette, Moos, &Finney, 2003). Clients that were able to received PTSD treatment 3 months

after being discharged from the program and continued that treatment for longer than a year were

more likely to be remitted by the 5th year follow up (Ouimette, Moos, &Finney, 2003). The

findings of the study concluded that the PTSD treatment that the participants received after SUD

treatment helped them have long term remission from SUD (Ouimette, Moos, &Finney, 2003).

Case Study

Ryan is a 26 y/o, Caucasian male, that is a trained Navy Seal. He has a bachelors degree

that he earned while in the service but remains an enlisted sailor. The client is married. The client

presents with a groomed beard, tidy haircut, and is wearing a hat. Ryan presents for his

evaluations with a consistently cooperative attitude and calm demeanor. His mood was generally

sad. His affect has been congruent with his mood and full ranging. Ryan has served 3 overseas

deployments to Iraq and Afghanistan. On Ryans last deployment, he was involved in an IED

explosion where his best friend was killed. He witnessed it and became covered in his friends

blood and limbs during the blast. The client thought upon ending his deployment that he was

going to be able to move on with his life but he became extremely irritable and started to drink

heavily.

After drinking one night, he told his wife he was going to kill himself and that it should

have been him that died, not his friend. He also told his wife that he cant get that day out of his

head, when he sleeps and is awake he sees it happening over and over again. His wife requested

that he sought help and notified his command. He currently reports that he is feeling more like

himself but smells like alcohol during session. The client is reporting to therapy under the orders
of his command and does not feel that he needs it. The presenting problem is the clients inability

to process the grief of losing his friend, the trauma from the event, survivors guilt, and a

substance use issue.

Ryan reports that this event happened 4 months ago and his symptoms began a month

after it happened. Until this point, Ryan does not report seeking any psychological help and has a

clear medical history. Ryan comes from a very close family. His parents are highly involved in

his life and live 10 minutes away from him. He has a twin sister he is close with. The client also

has a wife that he has been married to for 5 years and they have had a happy, healthy marriage.

The clients parents are still married. Ryan has not received counseling in the past. The current

traumatic experience is all the Ryan is reporting.

Case Conceptualization

The client is reporting with Posttraumatic stress disorder with dissociative symptoms

(presentation). The PTSD symptoms stem from an experience on the clients last deployment.

This was when he witnessed his best friend blow up in an IED explosion right next to him. These

symptoms worsen with the client is drinking (precipitant). The client reports being unable to

sleep due to his dreams but needing to stay drunk because he has memories of the event when he

is awake as well. The client also explains that he feels like real life is a dream and time is moving

extremely slowly. Because of not being able to sleep, the client is extremely irritable and

isolating himself from his friends, family, and wife (pattern). The client does possess multiple

strengths. These include his intelligence, his attempted solutions, and the relationships that he

has created in the past. These genuine relationships include a happy healthy married with his

wife, a relationship with his twin sister, a close relationship with his parents, and a group of

friends from his career field. The client became a Navy Seal when he was 19 years old. He has
excelled in his career. The client has attempted to cope with his emotions and has reached out to

his sister for help. He was attempting to use alcohol to cope with his emotions but has been

attempting to stop this behavior. The client is trying to establish healthy coping skills to ensure

that his relationships stay intake (perpetuants).

The client identifies as a middle class, Caucasian male (cultural identity). He is educated

and had advanced in his field on an accelerated track. He is highly acculturated, and there is no

obvious acculturative stress (culture-acculturation). The information on his parents in relation to

this subject is unknown. The client feels that the symptoms are something that he cannot control

but would like to develop coping strategies so he is able to go back to work (cultural

explanation). There are no cultural factors that influence his behavior, but rather that his

personality has a great effect on his current clinical presentation (culture v. personality).

The therapist will attempt to educate the client on the symptoms of PTSD and

have the client keep a log of the number of drinks he is having throughout the day. This will help

narrow down times of day and experiences that is making the client want to drink more which

can help lead to a discussion about why that is happening. The client will need to be monitored

due to his suicidal ideation. Weapons will need to be removed from the house or put in a lock

box. The client will be monitored to determine if medication would be beneficial during the

course of treatment. After treatment, the client will attend group therapy for military personal

experiencing PTSD. The client reports that he becomes increasingly irritable when he starts to

drink since he no longer feels like himself or in control. He has attempted to stop drinking, but

then his isolation becomes worse. The client has practiced deep breathing in the past but did not

find it useful. The goals of treatment include increased knowledge and understanding of the

situation, improve coping, problem solving, and decision making, relieve symptoms, promote
use of support, and enhance strengths. Treatment will begin immediately in order to help client

with feeling of isolation and loneliness and occur weekly (treatment interventions).

The client does present with multiple obstacles in treatment. This includes his inability to

admit he has a problem, the support system that has been pushed away by the client, and the

clients want to return to work before he is ready (treatment obstacles). The prognosis for the

client is fair due to his understanding that his current behavior is not normal but he does not want

to admit the reason for the behavior. If the client is able to use his support system and refrain

from consuming alcohol will learning effective coping strategies, the client will be successful in

treatment (treatment prognosis).

Treatment Plan

Client presents with Posttraumatic stress disorder with dissociative symptoms.

Objectives of treatment include increased knowledge and understanding of the situation, improve

coping, problem solving, and decision making, relieve symptoms, promote use of support, and

enhance strengths. The assessments used with the client will be as follows; measures of transient

anxiety, depression, and stress and problem checklists. The clinician will be flexible, yet

structured and present oriented. Also, the clinician will be skilled in diagnosis and treatment of a

broad range of disorders. The clinician will also be optimistic. The treatment location will be

outpatient. The following interventions will be used with the client; crisis intervention, trauma-

focused CBT, DBT, Mindfulness based stress reduction, and strengthening and development of

coping skills, such as assertiveness, decision making, communication, relaxation, and reframing.

The emphasis of treatment will have a moderate emphasis on support, probing will only be used

when relevant to current concerns, and the focus will be determined by specific precipitant and

response. The client will participate in individual therapy. Also, couples therapy will be
recommended. The treatment will take place over 12-20 sessions on a weekly basis with rapid

pacing. At this time, medication will not be used but if symptoms do not improve over course of

therapy, this will be revisited. The following adjunct services will be provided; inventories to

clarify goals and direction, education and information, and peer support groups composed of

people with similar concerns. The prognosis for the client is excellent if cause can be accepted

since no underling mental disorder is present and the client has good premorbid functioning and

self-esteem.

Advocacy, Multicultural, and Legal/Ethical Considerations

A great tool for advocacy is veterans and veteran organizations. While PTSD does not

only affect military personal, there is a lot of grant funding that goes towards the treatment of

veterans and the VA. This money can be used to continue studies and figure out the best

treatment for PTSD. Also, the grant money can be used to train professionals in the effective

interventions. Veterans and active duty military have a great platform and it should be utilized to

its full extent.

PTSD is found more in females than in males (Reichenberg & Seligman, 2016). Rates of

PTSD in the United States is 8.7% across their lifetime and rates are lower in European and most

Asian, African, and Latin American countries (Reichenberg & Seligman, 2016). PTSD rates do

increase in certain types of employment (Reichenberg & Seligman, 2016). These include:

veterans, emergency medical personal, police, and firefighters which end up having rates as high

as 30% (Reichenberg & Seligman, 2016). The highest rates of PTSD are reported from people

who have survived rape, military combat, and being held captive (Reichenberg & Seligman,

2016). Based on the information described by Reichenberg and Seligman (2016), a client from

Europe, Asian, Africa, or Latin America, might not know a lot about the disorder since it is not
as common in their countries. It would be important to describe the symptoms and provide

psychoeducation for the client.

Legal and Ethical issues can arise when working with any client with any presenting

symptoms or disorders. When it comes to PTSD, non-maleficence can potentially be an issue

when practicing exposure therapy. This could harm the client if not done properly and not

processed after the session. Respect for autonomy would also come into question when a client

does not feel that they have a problem but their symptoms are putting their life at risk as well as

others. While fidelity might be questioned by the client, this is something that can be gained

while building rapport and a therapeutic alliance.

The ACA Code of Ethics (2014), outlines the ethical principles that a counselor is

required to uphold. This code has nine main areas that address all aspects of the counseling

relationships and practices. The most important ethical code is A.1. Client Welfare. It is the duty

of the counselor to respect and help the client (ACA Code of Ethics, 2014). The counselor should

do no harm. Each ethical principle applies to a range of different diagnosis and is the core of the

counseling profession. If at ever a question, supervision should be sought and re-read the Code

of Ethics.
 References:

American Counseling Association (2014). ACA Code of Ethics. Alexandria, VA: Author.

Carolyn Black Becker, Claudia Zayfert, Integrating DBT-based techniques and concepts to
facilitate exposure treatment for PTSD, Cognitive and Behavioral Practice, Volume 8,
Issue 2, Spring 2001, Pages 107-122, ISSN 1077-7229, https://doi.org/10.1016/S1077-
7229(01)80017-1

Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). (2014). Washington:
American Psychiatric Publishing.

Ouimette, Paige; Moos, Rudolf H.; Finney, John W., PTSD treatment and 5-year remission
among patients with substance use and posttraumatic stress disorders, Journal of
Consulting and Clinical Psychology, Vol 71(2), Apr 2003, 410-
414. http://dx.doi.org/10.1037/0022-006X.71.2.410

Pamela J. Brown, Robert L. Stout, Jolyne Gannon-Rowley, 15Substance Use Disorder-PTSD

Comorbidity: Patients Perceptions of Symptom Interplay and Treatment Issues, Journal
of Substance Abuse Treatment, Volume 15, Issue 5, SeptemberOctober 1998, Pages
445-448, ISSN 0740-5472, https://doi.org/10.1016/S0740-5472(97)00286-9.

Reichenberg, L. W., & Seligman, L. (2016). Selecting Effective Treatments: A Comprehensive,

Systematic Guide to Treati (5th ed.). John Wiley & Sons.

Sperry, Len; Sperry, Jonathan (2012). Case Conceptualization: Mastering this Competency with
Ease and Confidence. Retrieved from http://www.eblib.com