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The patients background
The patient has a strained connection with her cocaine-addicted mother, who has been emotionally and physically abusive to her since she was three years old, along with her live-in partner. Moreover, the patient has had abandonment issues since she was an infant when her mother left her and her younger brothers at home alone for extended periods. She also does not have a relationship with her father since she does not know him.
The patient reports being raped since she was six by her adult neighbor, all the way through the age of thirteen. Furthermore, she was gang-raped by eight adult men at the age of fourteen. Presently, she experiences intrusive thoughts and feels physical pain during these flashbacks. Since being seven years old, she has had several suicide attempts and self-injurious behavior. The patient, moreover, presents that she has always had excessive nervousness, hopelessness, and mood swings characterized by aggression, irritability, and derealization.
Finally, Susie has a history of prostitution to support her marijuana and cocaine addictions. She also spent time in a youth correctional facility at age 13 for burglary, and while there, she had a history of getting into fights and received disciplinary infractions. She is currently on anti-depressants and reports that her greatest fear is managing the sudden and unpredictable flashbacks. Based on the signs and symptoms, a provisional diagnosis is reachable.
Provisional DSM-5 Diagnosis: Post-Traumatic Stress Disorder (PTSD)
Diagnostic Signs and Symptoms
The patient has clear signs and symptoms synonymous to PTSD. The development of distinctive symptoms after exposure to one or more traumatic incidents is known as Post-Traumatic Stress Disorder (PTSD) (Comer, 2012). Between ages six to fourteen, the patient was repeatedly exposed to unpleasant elements of the traumatic incident (rape). Also, she has dissociative reactionsflashbacksduring which she feels physical pain. The patient has a negative attitude towards school, implying feelings of detachment and diminished interest in significant activities. Finally, the patient exhibits alterations in arousal and reactivity associated with the sexual violence trauma. She is irritable and aggressive, for example, by engaging in multiple fights. She has been indulging in risky and self-destructive conduct, including marijuana and cocaine misuse, as well as prostitution.
The patient suffers from PTSD because she has experienced prolonged, repeated, and severe traumatic events like rape. Following prolonged exposure to the traumatic event, she has been experiencing difficulty regulating her emotions or maintaining stable interpersonal relationships or dissociative symptoms. Contextual variables such as family dysfunction and parental separation and peritraumatic factors such as the intensity of the trauma are risk and predictive factors for her PTSD.
Diagnostic Criteria
In contrast to DSM-IV, DSM-5 draws a stronger boundary between what constitutes a traumatic incident and when sexual assault is mentioned. The DSM-5 focuses on the behavioral symptoms associated with PTSD. The four unique criteria (arousal, re-experiencing, avoidance, and reduced responsiveness) are used to diagnose PTSD (American Psychiatric Association, 2022).
Re-experiencing
This criterion includes uncomfortable recollections of the traumatic experience, flashbacks, and other long-term psychological discomforts. The patient experiences flashbacks that are accompanied by physical pain, therefore, signifying trauma.
Reduced Responsiveness
This criterion indicates a wide variety of emotions, such as alienation from people or a dramatic decrease in interest in activities. The patient has a negative attitude towards school and often runs away from home and out of home facilities.
Avoidance and Numbing
Withdrawal, alienation, lack of interest or hopelessness are all symptoms of avoidance. The patient reports a history of excessive nervousness, feelings of suicidal ideation, and hopelessness. Moreover, she struggles with focusing her attention and often withdraws from reality.
Increased Arousal
Violent, risky, or self-destructive actions, as well as accompanying circumstances, define this criterion. The patient has a history of engaging in prostitution to support her drug addiction and, while in incarceration, engaged in multiple fights. Furthermore, her mood swings are characterized by being aggressive and irritable. According to the DSM-5, the disturbance should last more than a month to be diagnosed as PTSD (American Psychiatric Association, 2022). The patient has exhibited the disturbances for several years; therefore, she has PTSD.
References
American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders, Text Revision Dsm-5-tr (5th ed.). Amer Psychiatric Pub Inc.
Comer, R. J. (2012). Abnormal Psychology (Eighth ed.) [E-book]. Worth Publishers.
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