ABNORMAL PSYCHOLOGY

Psychological Report
Name: Cindy Oakley
Age: 26
Gender: Female

Diagnosis: [309.81(F43.10)] Posttraumatic Stress Disorder with delayed expression

Reason for clients visit

The client is concerned of having flashbacks from the traumatic events that happened 10
years in the past after she had ended the extramarital affair which precipitated her of being
depressed for the last 3 months and that eventually prompts her in responding to a community
advertisement about a university-based research clinic that was conducting an evaluation
treatments for victims of sexual assault.

Problem / Symptoms

According to the DSM-5, the client is exhibiting characteristics matching that of a

Posttraumatic Stress Disorder with delayed expression. Essentially, the clinical presentation of
PTSD varies individually as others may have fear-based re-experiencing, emotional, and
behavioral symptoms. In this case, the client reported being in a direct experience of traumatic
events in particular to actual sexual violence. Additionally, the client has delayed the onset of an
intrusive and involuntary recollection of distressing memories. With the recent occurrence, the
client is concerned with having flashbacks of the traumatic events that centered on a series of
repeated rapes that had happened when she was 16 years old. During these times, she felt that as
if the past were occurring all over again. These episodes (flashbacks) trigger the client in prolonged
distress of being depressed for 3 months.

Psychosocial and Environmental Problem Areas

The client reported that after the incident, she had mostly having problems primarily in
their own house despite it was being recalled as safe haven for troubled kids in their neighborhood.
She felt that their house is not safe anymore and began to distance with her own brother who was
the best friend of her assailant; and caused a rare interaction with each other. The client also stated
that she had frequent fights with her mother. Consequently, she withdrew from the normal
activities in her school and began to lie often and drinking, and eventually became a total rebel in
the family. It is also notable to address that she had a serious trouble in making decisions in her
life since she became pregnant at a young age and agreed to her father to arrange an abortion which
she later on regret for relinquishing her right to decide.

In herself, the client felt being detached, numb, guilty and embarrassed from the incident
which resulted of not having self-confidence of going to college. Additionally, she was lacking of
social support which was evidently shown with her distant relationships in the family, and the
occasion when she had disclosed the incident to her best friends and completely received a negative
reactions. Lastly, the client’s marriage was also affected since she was having an extramarital
affair.

Precipitating Factor

In accordance to the traumatic events which was the main cause of her present actions,
notable reasons why the client behave or act the way she is may possibly be in relation to the
genetic factor. Increasing number of research studies show genetic influence in the development
of PTSD. For this reason, it was reported that the father of the client was diagnosed with PTSD as
a result of the traumatic events experience from the war. Apparently, according to the National
Center for PTSD about 7 or 8 out of every 100 people will experience PTSD at some point in their
lives. Women are more likely to develop PTSD than men, and genes may make some people more
likely to develop PTSD than others. While the study of Koenen, Nugent & Amstadter (2008),
suggests that Gene-Environment in PTSD is essential to understanding vulnerability and resilience
following exposure to a traumatic event.

Another reason is from the lack of social support, after the traumatic event, the need for
safe support resources is essential to help individuals process their experience in a healthy way
and to regain hope, confidence, courage and optimism through secure and safe emotional
connections, however the client wasn’t able to receive the support needed – she was ultimately
disregarded. Thus, some studies recommends to broaden and increased the access to social support
network from friends in patients with PTSD.

I. CASE OVERVIEW
In the past, the client recounted her childhood as a happy one and described their
house as a safe haven in the neighborhood. The client’s father was a Vietnam War
veteran whom diagnosed with PTSD as well in line with the events he had experienced
in the war and was emotionally shut off. While her mother was described as self-help
fanatic who have plenty of self-help books, and have a supportive relationship with her.
She has a brother which she was close to until the incidents happened. The client
reported that she had been repeatedly raped by a close friend in the family for over 5-
week period and was subjected to several sexual activities which includes oral, vaginal,
and anal intercourse and was verbally threatened, even though no weapons or physical
injuries were involved. Prior to the incident, the client was still a virgin and that she
had trusted the assailant since her family adopted him due to the abusive family. During
the time when the client was assaulted, her reactions were mainly feeling detached,
numb, guilty, and embarrassed. After the incident, she had particularly encountered
problems primarily in their own house despite that it was being recalled as a safe haven
for troubled kids in their neighborhood. She felt that their house is not safe anymore
and began to distance with her own brother who was the best friend of her assailant;
and caused a rare interaction with each other. The client also stated that she had
frequent fights with her mother. Consequently, she withdrew from the normal activities
in her school and began to lie often and drinking, and eventually got pregnant and had
an abortion which she later on regret for relinquishing her right to decide. Additionally,
the incidents were never reported to the authorities and she never received any medical
care. Despite the circumstances that happened, she fortunately got into a good sense
which resulted her to marry a fine man with whom she had two children. In the present,
The client is concerned with the delayed onset of traumatic event that she had in the
past which prompted her to respond the university-based research clinic that aimed to
evaluate treatments for victims of sexual assault. She reported that when she had an
extramarital affair she began to have flashbacks of the events from her past. These
episodes were the series of repeated rapes that had happened when she was 16 years
 old. She also specified that the images were vividly come into her mind out of nowhere
and briefly feel as if the past were happening all over again. Even though, her husband
is very supportive to her even after the affair, she wasn’t able to receive the support
needed – she was ultimately disregarded by her close friends and still relatively distant
with her family. Moreover, the client also stated that she often smoked weed (Cannabis
Sativa) and she was defensive about it and intended not to quit. She already sought
therapy three times where in the last therapist pointed that her main problem was the
marijuana which she profusely disagreed. All times had lasted only one session.

II. DSM-5 DIAGNOSIS

The following diagnostic criteria are from: American Psychiatric Association.
[309.81(F43.10)] Posttraumatic Stress Disorder with delayed expression. In:
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (APA, p. 271).
The symptoms italicized are the ones experienced by the client.
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) (APA, p. 271).

The client had a direct experience to actual sexual violence which was
subjected to several sexual activities (includes Oral, Vaginal, and Anal intercourse).

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) (APA, p.
271).

Note: Criterion A4 does not apply to exposure through electronic media,

television, movies, or pictures, unless this exposure is work related.

The client reported that she was repeatedly raped for over 5-week period
which was subjected to several sexual activities (includes Oral, Vaginal, and Anal
intercourse).
B. Presence of one (or more) of the following intrusion symptoms associated with
the traumatic event(s), beginning after the traumatic event(s) occurred:
1. Recurrent, involuntary, and intrusive distressing memories of the
traumatic event(s) (APA, p. 271).

Note: In children older than 6 years, repetitive play may occur in which
themes or aspects of the traumatic event(s) are expressed.

The client reported her experience that within the course of the affair she
began to have flashbacks centered on a series of repeated rapes that had occurred
when she was 16 years old. The distressing images come into her mind out of
nowhere. This criterion merits the diagnosis since the flashbacks were recurrent,
involuntary and intrusive within the time of the affair.

3. Dissociative reactions (e.g., flashbacks) in which the individual feels or

acts as if the traumatic event(s) were recurring. (Such reactions may
occur on a continuum, with the most extreme expression being a
complete loss of awareness of present surroundings.) (APA, p. 271).

Note: In children, trauma-specific reenactment may occur in play.

The client reported that when she experienced the flashbacks she would
momentarily feel as if the past were occurring all over again.

4. Intense or prolonged psychological distress at exposure to internal or

external cues that symbolize or resemble an aspect of the traumatic
event(s) (APA, p. 271).

This criterion is present when the client was depressed for the last 3 months
after she had ended the affair. The duration of being depressed experienced is
accounted as intense or prolonged.

C. Persistent avoidance of stimuli associated with the traumatic event(s),

beginning after the traumatic event(s) occurred, as evidenced by one or both of
the following:
 2. Avoidance of or efforts to avoid external reminders (people, places,
conversations, activities, objects, situations) that arouse distressing
memories, thoughts, or feelings about or closely associated with the
traumatic event(s) (APA, p. 271).

The client reported that after having the flashbacks triggered in the affair
she then eventually ended to suppress memories which was resulted to be
depressed. In the treatment course, the therapist pointed out how avoidance
prevented her from recovering from the trauma. Additionally, previous therapist
labeled her marijuana use a form of avoidance.

D. Negative alterations in cognitions and mood associated with the traumatic

event(s), beginning or worsening after the traumatic event(st) occurred, as
evidenced by two (or more) of the following:
1. Inability to remember an important aspect of the traumatic event(s)
(typically due to dissociative amnesia and not to other factors such as
head injury, alcohol, or drugs) (APA, p. 271).

Within the course of treatment, the client had an assignment to write a

detailed account of the most traumatic rape she experienced from the incidents and
instructed to include as many sensory details as possible. Evidently, there are
several parts that she wasn’t able to remember and write it down. However, some
of the memories were somehow recounted as the treatment progresses.

2. Persistent and exaggerated negative beliefs or expectations about

oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,”
“The world is completely dangerous,” “My whole nervous system is
permanently ruined”) (APA, p. 271).

The client has negative beliefs which stemmed in response from the incident
(e.g., she believe that the world was an unsafe place reinforced by the news on
Television, and no successful people can be trusted). It was pointed out that she had
a faulty thinking pattern in particular to overgeneralization which means drawing a
broad conclusion on the basis of a single event. This type of cognitive error may be
associated with the aftermath of the sexual assault. The client tends to have a great
deal of anger and distrust from her assailant.

3. Persistent, distorted cognitions about the cause or consequences of the

traumatic event(s) that lead the individual to blame himself/herself or
others (APA, p. 272).

The client had a negative view because she felt that she was responsible for
what had happened to her.

4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or

shame) (APA, p. 272).

During the time when the client was assaulted, her reactions were mainly
feeling detached, numb, guilty, and embarrassed.

5. Markedly diminished interest or participation in significant activities

(APA, p. 272).

After the incidents, she withdrew from the normal activities in her school
and began to lie often and drinking.

6. Feelings of detachment or estrangement from others (APA, p. 272).

After the incidents, she felt that their house is not safe anymore and began
to distance with her own brother who was the best friend of her assailant; and
caused a rare interaction with each other. The client also stated that she had
frequent fights with her mother.

E. Marked alterations in arousal and reactivity associated with the traumatic

event(s), beginning or worsening after the traumatic event(s) occurred, as
evidenced by two (or more) of the following:
1. Reckless or self-destructive behavior (APA, p. 272).
 After the incidents, she began to lie often and drinking and eventually
became a total rebel in the family. Evidently, she got pregnant by a wild guy who
was totally bad news.

2. Hypervigilance (APA, p. 272).

This criterion is present when the client began to experience the flashbacks
which she had ended in order to protect herself from relieving the past traumatic
events.

F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month

(APA, p. 272).

This criterion meets the diagnosis since the period of disturbance presented
in the course of over a month to 10 years.

G. The disturbance causes clinically significant distress or impairment in social,

occupational, or other important areas of functioning (APA, p. 272).

The client reported that she was having trouble looking for jobs in several
occasions, experienced depression for 3 months, impaired decision making in
regards to relinquishing her right to decide about the pregnancy which was resulted
to abortion, being distant to her brother as well as the frequent fights with her
mother, and lastly, the extramarital affair she had.

H. The disturbance is not attributable to the physiological effects of a substance

(e.g., medication, alcohol) or another medical condition (APA, p. 272).

This criterion meets the diagnosis since the client was not seen to have any
physiological effects of a substance or another medical condition.
 Specify:

With delayed expression: If the full diagnostic criteria are not met until at
least 6 months after the event (although the onset and expression of some symptom may be
immediate) (APA, p. 272).

The client’s diagnosis was not fully meet the criteria B1 & B3 (flashbacks) until
the recent occurrence in the extramarital affair (It was deferred for 10 years).

III. ADDITIONAL INFORMATION (PREVALENCE/DEVELOPMENTAL

COURSE/ETIOLOGY/RISK AND PROGNOSTIC FACTORS/CULTURE
RELATED DIAGNOSTIC ISSUES/GENDER RELATED DIAGNOSTIC
ISSUES)

A. According to the National Center for PTSD about 7 or 8 out of every 100 people
will experience PTSD at some point in their lives. Women are more likely to
develop PTSD than men. At least some of the increased risk for PTSD in females
appears to be attributable to a greater likelihood of exposure to traumatic events,
such as rape, and other forms of interpersonal violence (APA, p. 278). In this case,
she experienced difficulties in maintaining stable interpersonal relationships. It is
evident to his lack of social support from her friends and the distant relationships
with her family. In the United State, projected lifetime risk for PTSD using DSM-
IV criteria at age 75 years is 8.7%. 12 month prevalence among U.S adults is about
3.5% (APA, p. 276). The Development of PTSD can take place at any age,
beginning after the first year of life. In the client’s case, she is 26 years old before
completely diagnosed of PTSD with delayed expression since some symptoms
appeared late, in her situation the criteria B1 & B3 was delayed. As she had not
experienced the episodes until 10 years have later after the incidents. Additionally,
she judged herself as coward and harbor beliefs of being changed in ways that she
was feeling estranged and distant to others. (APA, p. 277). The prognostic factors
that the client experienced includes: “Environmental Pretraumatic factors – she
 had lower education which stemmed from the absence of self-confidence going to
college & the result of being withdrawn to her high school activities, and childhood
adversity such as the family dysfunction. Another risk is that of Temperamental
and Environmental Posttraumatic Factor – at present, the client is having a
negative beliefs in life in a sense of overgeneralization, while continually
experiencing subsequent adverse life events and the lack of support” (APA, p. 278).
In terms of culture-related diagnostic issues – the risk of onset and severity of PTSD
may differ across cultural groups as a result to the ongoing sociocultural context as
the client is experiencing (e.g., residing among unpunished perpetrators in post-
conflict settings). With this regards, it may be the reason for the client’s severity of
PTSD that it took over 10 years to completely diagnose and intensified the
significance of the events on her life (APA, p. 278).

B. FUNCTIONAL CONSEQUENCES OF THE DISORDER

“Functional consequences of PTSD to the client had greatly affected her
interpersonal, social & family relationships, and lower educational & occupational
success” (APA, p. 279).

C. DIFFERENTIAL DIAGNOSIS
a. Depressive Disorder – The client may have symptoms that wasn’t fully
reported in the case based on the fact the she had stated experiencing
prolonged depression for the last 3 months after ending the affair.
b. Substance Use Disorder – The client reported that she often smoke
marijuana and admittedly does not want to quit. For this reason, it may be a
comorbidity to the preliminary diagnosis of PTSD with delayed expression.
Further information with regard to this matter would be beneficial to
examine the overall effects of her marijuana usage.

IV. THEORETICAL ANALYSIS OF THE CASE

The case can use a holistic approach in treating the client as a whole person,
rather than as an individual being diagnosed with PTSD. Effects of trauma have shown
 that the whole person needs to be explored in depth to understand the totality of trauma
memories. The treatment should remain dynamic and what works stays and what does
not, goes.
V. EVIDENCE BASED TREATMENT FOR THE DISORDER

Individuals experiencing Posttraumatic Stress Disorder have several options in

using psychotherapeutic treatments. These treatments differs accordingly and may
need a required levels of psychological stability to attain its effectiveness. The most
notable evidence for remission of symptoms is trauma related therapies such as
exposure therapy – which involves the patients to graded exposure of the situations
causing the fear response, and cognitive behavioral therapy (CBT) – it engages the
patient to challenge dysfunctional beliefs about the world or themselves while
simultaneously engaging them in more healthy behaviors such as social activation.
There also supportive ego-strengthening, or motivational treatment that can be
incorporated or used prior to the 2 aforementioned effective treatments. Additionally,
the one used in the case merits as a good evidence in treating PTSD. It is called the
Cognitive Processing Therapy wherein it includes information processing therapy in
the form of education, exposure, and cognitive components that challenge the
cognitive errors or dysfunctional thoughts and modify beliefs related to the trauma
events (Kirkpatrick & Heller, 2014).
 Reference

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders

(5th ed.). Arlington, VA: Author.

Gradus, J. (2019, July). PTSD: National Center for PTSD. Retrieved from

https://www.ptsd.va.gov/professional/treat/essentials/epidemiology.asp=

Kirkpatrick, H., & Heller, G. (2014). Post-Traumatic Stress Disorder: Theory and

Treatment Update. International journal of psychiatry in medicine. 47. 337-346.

10.2190/PM.47.4.h.

Koenen, K. C., Nugent, N. R., & Amstadter, A. B. (2008). Gene-environment interaction in

posttraumatic stress disorder: review, strategy and new directions for future research.

European archives of psychiatry and clinical neuroscience, 258(2), 82–96.

doi:10.1007/s00406-007-0787-2