Chronic PTSD, Anxiety, and Depression: A Case Study

Task:

At the beginning of the session I introduced myself as an intern at Liberty University and what the purpose of the assignment was. I presented the client with the video informed consent asking if the client would be willing to acknowledge being video recorded for my assignment, I mentioned to the client that it is at her discretion to be visually present on the video recording. I reiterated that the client’s identity would be confidential, who would be viewing video and the timeframe for the video to be in existence. The client successfully signed the video informed consent.

Jill is a 28-year-old African American female who lives in Maryland with her boyfriend and 3 yr. old son from a prior relationship. She and her boyfriend have been together for over a year, and they have no children together. He has one son from a prior relationship as well.  Jill has four older brothers and four older sisters; one sister being her identical twin whom is fifteen minutes older.  Jill is currently employed fulltime as an office manager for a psychiatrist and is currently in school obtaining a bachelor’s degree for Business Management.  Jill says that she had no developmental delays while growing up and as far as she knew she reached all her major milestones at the appropriate timeframes as other children her age. She also states that she excelled in things like art and science while in school.  Jill stated she had one major surgery when she was younger to strengthen the muscles in her left eye. She has no past or previous military service or no known family psychiatric history. She is a Christian who attends service on occasion but would like to make it more consistent.

During the first session with Jill, she stated she was referred by her primary care physician due to concerns relating to chronic PTSD, anxiety, and depression. Jill explained that she feels she is “constantly walking on eggshells” in fear that her son’s father is following her and that he may abuse her again. She is highly depressed and anxious about the activities happening around her and does not feel she has family support anymore because of her child’s father constantly making threats to her family or lying to them about things going on with her. Jill stated she is unable to control her worry and always wonders when she takes her 3-yr. old son to his paternal grandmother’s house for visits that he may retaliate and take it out on her son. She feels that her constant anxiety prevents her from living a full, happy life with her son and boyfriend. Jill states that she is reluctant to share her feelings of depression and anxiety with anyone including her boyfriend because she feels her feelings will be disregarded or ignored and she will not be taken seriously. Jill states when she is anxious or worried, she will not eat and only wants to sleep.

Presenting Concerns

During the first session with Jill she was very reluctant on speaking and sat with a nervous posture. As the session progressed, and she became more engaged in the conversation and she became more relaxed and that is when she stated she felt comfortable speaking with me.  She explained feeling guilty, constant anxiety, and like a failure because she is not where she needs to be financially. Her insight seems to be within normal limits. No abnormal or psychotic thoughts. Cognitive skills within normal limits; aware of current events, good vocabulary use, good recent memory, and motor skills. Jill also displays intact abstract reasoning, able to complete computation, gives clear organized content. Jane is oriented to time, place, and person. Attention span and concentration are also within normal limits. Overall, the client is neatly dressed and well groomed. She gives direct eye contact most of the time and is well coordinated. She speaks with a normal tone and volume. Jill is very articulate, coherent, and speaks English fluently. She is also cooperative, appropriate and sociable. Jill’s mental status revealed no suicidal ideations or intent to harm herself.

During her childhood, Jill lived with her mother, father and twin sister. Her older siblings did not live in the home with her. She went through school as an average student making decent grades mainly B’s and C’s. She also had an average teenage social life. Her mother was typically not home even though she made sure her, and her twin sister had food, was well groomed, went to school every day, attended doctor’s appointments and school events. She and her twin sister were mainly in the care of their maternal grandparents who had been there since birth. Her mother who had two sons from a previous marriage was abused physically by her then husband which she later divorced. During this time her mother was struggling with a drug problem, until she met Jill’s father who helped her get clean along with her paternal grandmother who she never got to know.

Going into adulthood Jill graduated from high school in 2008 and immediately began working thereafter. She took a year off from school and returned entering a massage therapy program and had graduated in 2010. During this time, she was living with her maternal aunt. She continued to work varies jobs outside of her trade until she met a mentor who took her under his wing. She started working in his massage spa that same year. Over the course of the next two years he helped her build cliental, helped her to make enough to be able to afford her first apartment in the summer of 2012.  That is where she met her sons’ father, shortly after meeting him in March of 2013 he began to abuse her physically breaking her nose in three places and fracturing her eye socket leaving multiple lesions and bruises. He would make threats if she wanted to leave. She felt so trapped and scared. She was at a crossroads of what to do because of the things he did to her, she knew what he was capable of so she stayed thinking the situation would get better but it did not. In the midst of losing her first apartment, they had then begun to stay at his apartment for a short while; during this time, she found out she was pregnant with their first child. In August of 2014 he had gotten extremely drunk and started hitting her causing her to longer feel the baby moving causing her to have a miscarriage while she was at work. He would come to her place of employment and start trouble causing her to get fired in December of 2014. A few weeks later she fled from their apartment while he was sleeping and never looked back. At that time, she didn’t know she was pregnant again with their current child.

Initial Session

Prior to seeking counseling currently, Jill had just learned to deal with what was going on instead of talking to someone or seeking help. Jill reported she has a support system from her boyfriend’s mother and a few people she met through church who check on her from time to time. Jill stated she feels her worry and anxiety would not make sense to others and feel they may not support her thoughts and feelings. She states that even though she feels her boyfriend may not listen to her sometimes when she needs to vent she doesn’t know what she would do without him because ever since she met him he always promised to protect her and never put his hands on her in a violent way. Jill mentioned her interests and hobbies include playing with her two dogs, doing art work in her free time.

During the initial intake with Jill, she sated she has a medical prescription for Xanax and she uses it to help with her anxiety and uplift her mood. During our first session and after evaluating Jill she poses no risk of self-harm or harm towards others. A thorough risk assessment was completed due to Jill’s previous history with the crying spells, not having the energy to want to do anything, and sleeping a lot. Jill did not express any desire or intent to harm anyone. No evidence of homicidal ideations past or current, therefore, no further risk assessment.

Diagnosis

After fully evaluating Jane during our first session I have diagnosed her with the following:
300.02 (F41.1): Generalized anxiety disorder.
296.21 (F32.0) Major Depressive Disorder, mild, single episode
307.50 (F50.9) Post Traumatic Stress Disorder

Problem List:

1. Anxiety related frustration, worry, and depression
2. Cognitive impairment, low self-esteem, depressed mood
3.  Psychological distress, persistent thoughts of traumatic event Medications:

Case Conceptualization Summary Statement

While writing a Case Conceptualization Summary Statement an expert first presents the conditions associated with the findings of a clinician and discuss the social aspects, psychosocial aspects and biological traits of the subject. In general, this discussion revolves around the self-presentation of the subject, predisposition, habit to perpetuate and precipitation. This discussion helps a reader in understanding a pattern associated with various factors of the case (Berman, 2018).

When we put the case of Jill on the same scale, we find that prima facie her symptoms give us an indication about the presence of anxiety, low self-esteem and lack of confidence. Her presentation prior to the ice breaking session gives us this idea.  The disturbance in her family life and her isolation from the society forced her to think negative about life this absence of a social circle can also be termed as a strong reason behind her depression that can be considered as the root cause of major conditions that she is facing now (Ehde, Dillworth & Turner, 2014). Her condition perpetuated because of the cycling nature of her life, the repetition of supervised visits can be termed as a major reason behind her Post-traumatic stress disorder (Trauer, 2015). 

Theoretical Orientation and Research/Evidence-based treatment

Cognitive behavioral therapy can be an answer to Jill’s problem, the scope of CBT is not confined to counseling alone, and the list of associated goals can help an expert to fix the right course of action.  In the case of Jill, she can become a part of various social circles and observe other individuals how they are coping with the difficulties of life. The role of associated goals in a CBT is of utmost importance because it can guide an expert in administering other behavioral interventions (Ehde, Dillworth & Turner, 2014).