Case Assessment and Formulation Case Study

Differential Diagnosis

The patient has been given a diagnosis of Post Traumatic Stress Disorder (PTSD) and Major Depressive Disorder. Since depressive symptoms are common in PTSD we would need to consider whether the depression or the PTSD is the primary diagnosis.

An essential step in the assessment of Posttraumatic Stress Disorder is to identify major traumas in the client’s. We know that Sarah reports being raped at a young age, but we need to know more about the effects of these experiences. Structured Diagnostic Interviews and Self-Report Instruments have been developed with the purpose of assessing traumas in more detail (Barlow, 2008). Some of the difficulties in assessing PTSD aside from diagnosing it incorrectly when another diagnosis would be appropriate would include the unreliability of self-report data. Patients often exaggerate or over report symptoms in an effort to gain the alliance of an assessing physician or psychologist. Care should be taken to get corroboration of severe symptoms based on self-report measures such as interviews or to include measures of exaggeration on standardized assessments (Barlow, 2008). Another issue, especially with standardized measures, is the issue of the base rate of the disorder and the psychometric properties of the instrument. For instance, an assessment tool with a high sensitivity and specificity of .9 can be expected to misdiagnose 100 cases in a thousand for a disorder where the prevalence rate is .1. Thus, the use of multiple assessment tools is advised (Sutker & Allain, 1996). Finally, the experience level of the clinician can also be a factor with less-experienced clinicians more likely to make diagnostic errors (Barlow, 2008).

Case Assessment and Formulation

Referral Source and Referral Objectives

Sarah referred herself for treatment.

Presenting Problem

Sarah reported experiencing marital distress, symptoms of anxiety, depression, ill-health and significant adjustment difficulties.

Medical/psychiatric history

Medical History

Sarah has a history of diabetes, but at this time we do not know if it is Type I or Type II. This is a very important distinction to make, as Type I diabetes if left unchecked can lead to depressive-like symptoms and anxiety like symptoms. She was taking Metformin, so we would assume that she has Type II. She has a history of hypertension, depression.

Psychiatric History

As previously stated Sarah has been diagnosed with PTSD and Major Depressive disorder.

Current Psychosocial Setting

Sarah is not working, separated from her husband, and the four children have been given over to her sister by APS. Thus, she is in a major psychosocial crisis. Moreover, she is not taking her prescribed medication.

Client Strengths

Sarah demonstrates a number of strengths that will be beneficial during treatment. First, she demonstrates the ability to maintain close personal relationships despite her distress. She has been able to marry and have children despite her history of abuse, so there is some evidence of resiliency. She is motivated as she referred herself.

Provisional Formulation

DMS IV-TR Diagnoses

Axis 1: Post Traumatic Stress Disorder (Primary)

Major Depressive Disorder (Secondary)

Axis II: Deferred

Axis III: Diabetes, hypertension.

Axis IV Separated from husband, custody of children given to sister, unemployed, history of martial conflict, history of sexual abuse.

Axis V Global assessment of functioning (GAF): 60 (Severe impairment at intake).

Treatment Plan

According to Barlow (2008) there have been four predominant forms of therapy for PTSD including: coping, skills-focused treatments, exposure and combination treatment and eye movement desensitization and reprocessing (EMDR). The current treatment drew upon these intervention strategies with the exception of EMDR. However, according to Barlow (2008) some clinical trials have indicated that Cognitive Behavior Therapy intervention including exposure and cognitive elements statistically superior to EMDR. Therefore the empirical literature supports the use of exposure, imagery, relaxation and breathing, and psychoeducation in the treatment of PTSD; however, many clinicians may not be trained in the proper use of these techniques.

In addition, research has also determined that African-American women benefit from CBT therapy for PTSD at the same rate as Caucasian women; however, African-American women do demonstrate a higher drop-out rate despite benefitting. This is believed to be due to greater motivation of African-American women in psychotherapy due to the stigmatization of therapy and assistance to them (Lester, Artz, Resick, & Young-Xu, 2010). It would be important to maintain rapport with the patient to keep her involved in therapy as long as possible.

Variations of Cognitive Behavioral Therapy (CBT) are reliably effective for treating PTSD and exposure therapy is a prominent and effective ingredient in decreasing PTSD symptoms. For example, exposure therapy is considered the first-line treatment for PTSD. A recent Institute of Medicine (IOM) report concluded that exposure therapy is the only treatment with sufficient empirical evidence to recommend it in the treatment of PTSD (IOM, 2008). However, many licensed psychologists do not use prolonged imaginal exposure (perhaps the most consistently documented efficacious treatment for PTSD (Becker, Zayfert, & Anderson, 2004). Several of the reasons for this include: 1.) Many clinicians are not trained in the application of exposure therapy. Such training involves a combination of graduate level training in basic psychological science such as learning theory and cognitive psychology and supervised experience with a skilled CBT practitioner. 2.) CBT interventions are relatively structured treatments that require focused agendas and a large degree of assertiveness by the clinician. Some find such structured treatments overly restrictive or find themselves overwhelmed by the diffuse emotional distress of some PTSD sufferers. CBT interventions that use either exposure can generate at least momentary distress in clients during such exposure. Many clinicians are uncomfortable with this. 3.) Some clinicians are leery of CBT interventions because of either their theoretical orientation or because of ignorance of the scientific foundations of CBT treatments. The implementation of CBT exposure, relaxation and cognitive restructuring requires focus, diligence, and adequate training by the clinician.

By implementing some core CBT techniques the patient’s distress can be addressed and relieved over time. Core CBT techniques for PTSD are based on the following empirically demonstrated methods:

Behavioral Modification or Behavioral Activation involves a structured approach to increasing PTSD patients’ participation in avoided activities and scheduling events for homework. This appears to be relevant for individuals where there are symptoms of avoidance and social isolation (Mulick & Naugle, 2004). However, some studies have not demonstrated a reduction in depression scores for these individuals (Wagner, Zatzick, Ghesquiere, and Jurkovich, 2007). These results do not imply that the use of such behavioral modification techniques are alone sufficient to address the entire PTSD symptom picture and instead indicate that cognitive behavioral activation is a solid component of an overall treatment approach rather than a standalone treatment for PTSD.

Trauma Management Therapy (TMT) is a form of cognitive behavioral therapy that was developed by Frueh, Turner, Beidel, Mirabella and Jones (1996) to address negative symptoms including social withdrawal, numbing, and interpersonal difficulties. It implements the use of psychoeducation and exposure in individual sessions. Then a social and emotional rehabilitation (SER) phase is implemented in small groups that include social skills training to relearn how to establish and maintain friendships and is promising, although in some cases the length of the overall treatment may the prohibitive. That should not be the case here. SER techniques can also be performed during individual practice sessions with the therapist if needed. The relaxation and imagery component will be based on Imagery Re-scripting (Smucker, Dancu, Foa & Niederee, 1995). This based on an expanded information processing model where the key goal of therapy to facilitate cognitive change in the meaning of the events and the pathogenic schemas associated with them. The theory acknowledges that imagery has a more powerful impact on positive emotion than verbal processing, and therefore cognitive behavioral techniques used to promote positive change should also employ imagery as well as cognitive restructuring (Holmes, Arntz, & Smucker, 2007). The treatment begins with imaginal exposure which is immediately followed by re-scripting during which the patient is encouraged to imagine the trauma experience while developing mastery imagery. This is most often used with patients recovering from early trauma and by imagining themselves as an adult entering the room during the trauma and rescuing and protecting the vulnerable child, but can be successfully re-scripted for adults (Grunert, Weis, Smucker, & Christianson, 2007). It is important for the patient to be moved at an even pace and not be rushed in order to maintain steady progress without overextending the patient’s tolerance.

The current treatment plan would include the following:

A. Psychoeducation: The first step in the process was to educate the patient about Post Traumatic Stress Disorder. Topics covered the presentation of depression and anxiety recovery related to traumatic experiences and the concept of psychological injury and recovery as well as the relationship between personality and coping skills anxiety and depression management. Education would focus on the development of support networks understanding how relapses occur.

The patient is not taking her medications and an effort to educate her on the need to continue her medication regime.

B. Referral to a psychiatrist who has experience with trauma is appropriate in order to assist with medical management of this patient’s symptoms was considered.

C. Counseling: The goals of psychotherapy are to identify any underlying hopeless and fearful thoughts, assist the patient overcoming feelings of loss of control and goal planning, setting self-management goals and following through on them.

D. Therapeutic techniques would include but not be limited to:

1. Cognitive Restructuring: Challenging behaviour and dysfunctional thoughts from a number of different viewpoints. Areas of concentration include but are not limited to: cognitions/feelings about past trauma; cognitions/feelings about relationships, her husband, and how she views these; views of the world and others; self-worth, self-efficacy; others as need to be addressed in therapy. Use a combination of CBT and dynamic methods such as redirecting, using transference, and dream interpretation to assist here.

2. Gradual Exposure and Mental Imagery Program: During the course of treatment utilizing relaxation skills, imagery, and discussion transference issues.

3. Teaching relaxation techniques and breathing exercises.

E. Relationship counseling. If possible and if the client agrees, couples therapy might also be beneficial in this case. However, given the controlling nature of the husband it appears that he might not be agreeable to this. Therefore, in line with cognitive restructuring it is important to understand her conceptualization of how the relationship she is in is structured, why she allows herself to be controlled and manipulated, and how she can address this in the context of her cultural background and personal experience.

Treatment Goals

Goals for treatment should be formulated in conjunction with the patient. Preliminary treatment goals include:

1. Resume normal activity levels at home and in social situations. Return to employment if desired.

2. Return to taking prescribed medications.

3. Discuss and implement a strategy for dealing with her husband. Review patient’s wants and needs and assist patient.

4. Build self-esteem to a healthy level.

5. Communicate effectively.

6. Maintain relationships.

7. Continue therapy until goals are met.

References

American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th Ed.). Arlington, VA: Author.

Barlow, DH (2008). Clinical handbook of psychological disorders: A step-by-step treatment manual (4th Ed.). New York, USA: Guildford Press.

Becker, C.B., Zayfert, C., & Anderson, E. (2004). A survey of psychologists. Attitudes towards and utilization of exposure therapy for PTSD. Behaviour Research and Therapy, 42, 277-292.

Berzoff, J., Flanagan, L.M., and Hertz, P. (1996).Inside out and outside in: Psychodynamic clinical theory and practice in contemporary multicultural contexts. New Jersey: Jason

Aronson, Inc.

Carlson, J., & Sperry, L. (Eds.). (2000). Brief Therapy with Individuals & Couples. Phoenix, AZ: Zeig, Tucker & Theisen, Inc.

de Shazer, S. (1985). Keys to solution in brief therapy. New York: Norton.

Frueh, B.C., Turner, S.M., Beidel, D.C., Mirabella, R.F., & Jones, W.J. (1996). Trauma Management Therapy: A preliminary evaluation of a multicomponent behavioral treatment for chronic combat-related PTSD. Behavior Research and Therapy, 34(7), 533-543.

Grunert, B.K., Weis, J.M., Smucker, M.R., & Christianson, H.F. (2007). Imagery rescripting and reprocessing therapy after failed prolonged exposure for posttraumatic stress disorder following industrial injury. Journal of Behavior Therapy and Experimental Psychiatry, 38(4), 317-328.

Holmes, E.A., Arntz, A., & Smucker, M.R. (2007). Imagery rescripting in cognitive

behaviour therapy: Images, treatment, techniques and outcomes. Journal of Behavior Therapy and Experimental Psychiatry, 38(4), 297-305.

Institute of Medicine (IOM). (2008). Treatment of posttraumatic stress disorder: An assessment of the evidence. Washington, DC: The National Academies Press.

Kendall-Tackett, K. (2009). Psychological trauma and physical health: A psychoneuroimmunology approach to etiology of negative health effects and possible interventions. Psychological Trauma: Theory Research, Practice, and Policy, 1(1), 35-48.

Kessler, R.C., Barker, P.R., Colpe, L.J., Epstein, J.F., Gfroerer, J.C., Hiripi, E., Howes, M.J, Normand, S-L.T., Manderscheid, R.W., Walters, E.E., Zaslavsky, A.M. (2003). Screening for serious mental illness in the general population. Archives of General Psychiatry. 60(2), 184-189.

Kessler, R.C., Andrews, G., Colpe, L.J., Hiripi, E., Mroczek, D.K., Normand, S.-L.T., Walters, E.E., & Zaslavsky, A. (2002). Short screening scales to monitor population prevalances and trends in nonspecific psychological distress. Psychological Medicine. 32(6), 959-976.

Lester, K., Artz, C., Resick, P., & Young-Xu, Y. (2010). Impact of race on early treatment termination and outcomes in posttraumatic stress disorder treatment. Journal of Consulting and Clinical Psychology, 78, 480-489.

Mulick, P.S., & Naugle, A.E. (2004). Behavioral activation for comorbid PTSD and major depression: A case study. Cognitive and Behavioral Practice, 11(4), 378-387.

Powell, T.J. (1992). The mental health handbook. Bicester: Winslow Press.

Powell, T.J. (2009). The mental health handbook: A cognitive behavioural approach (Third Edition). Bicester: Winslow Press.

Reber, S., & Reber, E.S. (2001). Dictionary of psychology. St. Ives Plc, England: Penguin.

Simms-Brown, R. (1982). The female in the black family: dominant mate or helpmate?

Journal of Black Psychology, 9 (1), 45-55.

Smucker, M.R., Dancu, C.V., Foa, E.B., & Niederee, J.L. (1995). Imagery rescripting: A new treatment for survivors of childhood sexual abuse suffering from posttraumatic stress. Journal of Cognitive Psychotherapy, 9(1), 3-17.

Sommers-Flanagan, J., & Sommers-Flanagan, R. (2003). Clinical interviewing. Hoboken, New Jersey: John Wiley & Sons.

Sutker, P.B. & Allain, A.N., Jr. (1996). Assessment of PTSD and other mental disorders in World War II and Korean Conflict POW survivors and combat veterans. Psychological Assessment, 8(1), 18-25.

Wagner, A.W., Zatzick, D.F., Ghesquiere, A., & Jurkovich, G.J. (2007). Behavioral activation as an early intervention for posttraumatic stress disorder and depression among physically injured trauma survivors. Cognitive and Behavioral Practice, 14(4), 341-349.

Wight, J.H., Basco, M.R., & Thase, M.E. (2006). Learning cognitive behaviour therapy: An illustrated guide. Arlington, VA: American Psychiatric Publishing.

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