Running head: PROCESS RECORDING 1

Process Recording Number One

 PROCESS RECORDING 2

Date: 2/25/18 PR# 1

BSW & MSW Program Foundation Year Process Recording

I. Client Pseudonym Pablo Honcho

II. Basic Demographics

Pablo Honcho (not real name) is a 36-year old Caucasian male US army veteran

who served in the capacity of lieutenant in the 2nd infantry division (2ID). He was based

in Iraq where he served in various positions for three years before his promotion. Overall,

he served in the army for six years in Iraq and had been involved in countless battles.

Before joining the military, Pablo had a girlfriend, but they had issues that led to a nasty

breakup that left his girlfriend blinded in one eye. Following the breakup, he opted to

change his sexuality but was advised against the decision. As a result, Pablo chose to

become gay having lost love for all women except his mother. Currently, Pablo lives

with his partner, Fred McCoy, who he met during his stint in Iraq.

The couple is married with no kids, but Fred mentioned they planned to adopt two

children a few months ago but had to abandon the project due to Pablo’s health issues.

Fred is the only family Pablo knows having lost his parents and brother in a tragic road

accident. The loss, according to Fred, greatly tormented him leading to depression and

suicidal tendencies that seem never to end. Fred mentions that he takes Pablo to a local

Veterans hospital for a mental evaluation of his depression and PTSD. Besides the mental

problems, Pablo is disabled having lost both legs during a bombing. He also has
 PROCESS RECORDING 3

numerous wounds on his body and a patch on the left eye. In addition to the scars, he has

tattoos all over his body of his family, military friends, and events he says changed his

life.

Pablo is a highly talkative and jovial person, and despite his conditions, he can be

quite funny and charming. He speaks a lot; a thing that he mentions was rare before he

joined the military. He was shy and soft-spoken, but life in the military hardened him and

made him an assertive and outgoing person. Pablo spends most of his time at the local

veterans club and is a frequent drinker who is acquainted with almost all partygoers at the

local club scene. Despite his disability and sometimes depressive mood, the locals posit

that when in his right spirits, Pablo is the life of the party. Despite his charming nature, he

is quick tempered and has a tendency of being abusive and also when drunk. However,

Fred mentions that such incidents are infrequent. When not drinking or staying at home,

Fred and Pablo visit Pablo’s parents’ grave and veterans who served in the Iraqi war with

them. Pablo is unemployed, but Fred currently works as a cashier at the local bar during

the weekends and teaches during the other days. While he tries his best to care for Pablo,

he is not always around to provide emotional support to Pablo.

Fred’s family is highly religious and identify as Roman Catholics. The often

attend church services each Sunday and only miss when Pablo has a depressive episode.

According to Fred and Pablo, the church is a symbol of hope since it had supported them

when they had no one to help them. To them, the church was ready to help when Pablo’s

family died and during their wedding. Pablo reminisces about his past experiences with

the church, and a smile appears on his face as he recounts how the church has helped him

relieve any pains and worries due to his condition. The family intends to support Pablo to
 PROCESS RECORDING 4

live a rewarding life and overcome the previous painful experiences that damaged his

life. Fred mentions that he wants his partner back and is optimistic that one day, Pablo

will be able to live a healthy and fulfilling life free of depression, anxiety, PTSD, and

dementia, which he states he may not have thought it is in his file.

III. Purpose of Interview or Meeting and Participants

This meeting took place in the city of Orange, California at Pablo’s home in the

presence of Fred, his partner. The focus of the visit was to examine Pablo’s mental and

health state and give advice on what he ought to do to mitigate his PTSD, depression, and

anxiety problems. SWI intends to recommend to Pablo and Fred programs that might

help Pablo manage his conditions and live a fulfilling life. Besides, the SWI seeks to

enlighten Pablo and Fred on projects available for veterans that may assist them to find

employment and health services. Both Fred and Pablo were present during the visit

having been notified by the SWI in advance.

IV. Observations

Upon arriving, I found Pablo sitting on the porch listening to blues while basking

the morning sun. He was humming to Marvin Gaye’s ‘sexual healing’ and seemed to be

in a happy mood. Pablo let a big yawn and pretended to stand up when Pablo saw me

walking up the front stairs. We exchanged pleasantries, and he invited me to join him.

Fred was in the kitchen making breakfast and was still in his pajamas. Soon as he heard

my voice, he came to say hi before returning to his duties. A few minutes later Pablo was

back and set the table for breakfast. Pablo was full of praises for Fred, and he noted that

he was the best person he ever met. We shared a laugh and proceeded to eat our breakfast

in silence just as Pablo liked. From the veranda, we moved to the living room, which is
 PROCESS RECORDING 5

very well maintained. Fred handed me a photo album documenting their three-year

relationship and old pictures of them on the battlefield. Pablo was particularly nostalgic

about a photo of his parents and brother when he had just turned fourteen. The photo

showed Pablo held high by his father and his mother cheekily pinched his brother’s ears;

it was the perfect family. Grief-stricken, Pablo observed that he loved being around his

family and was sad he never got the chance to say goodbye. Fred gave me a glass of juice

as the mood drifted from jovial to slightly somber. We tried to laugh at a few pictures of

Fred and Pablo in awkward situations, but Pablo, who seemed lost in thought kept

yawning and tapping his chair nervously.

A few minutes elapsed before I asked Fred and Pablo about their battle encounters

and how they were faring. Pablo mumbles incoherently and stares blankly at the ceiling.

When I repeat the question, he gets frightened and quickly wheels off the room. Fred

reassures me that such incidents are usual and there is no cause for alarm. We talk for a

few minutes before Pablo enters the room with a beer saying he is doing fine and

focusing on becoming a better person. Pablo blames himself for enlisting in the army but

mentions that the experiences were a mix of very good and very bad. Taking a quick sip,

Pablo indicates that he is positive that he can cope with his conditions. Fred interjects

saying that Pablo sometimes gets upset over trivial matters and that he needs help. He

states that he frequently finds Pablo muttering things to him or traversing the house

without any clear sense of direction. Though slightly disturbed, Pablo tries to remain

calm but losses his composure and flees the room claiming he should not be perceived as

mentally unstable.
 PROCESS RECORDING 6

He seems gone for a long time but return with two cans of soda, which he hands

to Fred and I. Slightly relaxed, he relays his experience in the war and uses different

pictures to underscore his story. His narration is befuddled with incoherencies, but he

tries his best to remain captivating nonetheless. We share laughs and whine at the

horrible things that happened to them during their army time. The atmosphere becomes

almost electric until we hear a knock at the door. The knock startles Pablo, but he regains

his composure just in time. Fred gets the door and in comes one of the neighbors who

served with both Fred and Pablo in the same unit. He looks rough and unfriendly when he

sees me, but Pablo’s reassurance helps calm him. Soon we are back to the storytelling

episode with, Geoffrey, our visitor taking the pilot seat. The stories see never to end, but

two hours later, Geoffrey excuses himself and mentions that I should visit him someday.

We exchange contacts and leave. The day progresses fairly fast and my time to leave

reaches. Both Fred and Pablo implore me to stay for lunch, and I grudgingly oblige. We

eat roasted pork, salads, soda, and burgers, which seem weird to me, but it is enjoyable. It

is time to leave, and we part ways before promising Pablo and Fred that I would stop by

when not engaged somewhere.

V. Post-Interview or Post-Meeting Assessment

The blueprint for care and post-visit evaluation comprises of the following:

 SWI will counsel Pablo and Fred on different community programs that they can use

including the veteran disability claim

 SWI will continuously offer support for Pablo regarding the quality of his life

 SWI will scrutinize Pablo’s family’s basic needs and provide periodical evaluation of

Pablo and his household’s desire

 PROCESS RECORDING 7

 SWI will make monthly visitations to the family’s home to make sure Pablo gets the

help he deserves

 SWI will examine the impact of Pablo’s anxiety, PTSD, and depression on his

family’s functioning

 SWI will offer support on Fred’s behalf to ensure Pablo makes the required

rehabilitation and psychiatric visitations

 SWI will make sure Pablo accesses different supportive counseling groups once every

four months

 SWI will provide adequate information on alternative and complementary treatments.

SWI will additionally provide spousal support and recreational therapy to make sure

that Pablo’s family remains intact

 SWI will evaluate the efficiency of the prescribed interventions on a regular basis

 SWI will offer case management

 SWI will assess the necessity of emotional backing and craft a way through which

Pablo can get psychological help

 Pablo and Fred (his family) will receive physical, spiritual, and emotional support

 Pablo and his family will get unlimited and adequate access to communal resources

 Pablo will go to daily Alcoholics Anonymous meetings and therapy groups to

alleviate his PTSD

VI. Assessment of Social Worker’s Roles and Skills:

The SWK roles portrayed in this record include interviewer/assessor, case manager, and

educator.

The SWK skills employed include:

 PROCESS RECORDING 8

 SWI provided and offered emotional support to Pablo and Fred using active listening

and empathy skills

 SWI will keep on making regular home visitations to evaluate the family’s progress

 SWI will strive to inspire positive communication between Fred, Pablo, and SWI

 SWI showed active listening skills when visiting Pablo and Fred

 SWI displayed support and empathy during the visit

 SWI gave insight and education with regards to Pablo’s health needs

 SWI evaluated and involved the family’s opinions on refining services (assessment

skills)

 SWI will keep on providing case management skills

 SWI stimulated Fred to support Pablo

VII. Plan for Next Session

While this session was highly rewarding and showed a lot of positivity, I believe

numerous aspects require reevaluating in Pablo’s life. As such in the following meeting

scheduled for next month, I will endeavor to establish whether Pablo is making the

needed life amendments such as low intake or abstinence from alcohol and drugs. I

would also like to check if he still engages in petty bar fights when he drinks and the

capacity to control his emotions and temper. I will also strive to look into the steps Pablo

has taken in improving his family’s finances, which is a significant contributor to

depression. What is more, I would like to build a lasting relationship with Pablo and Fred

to make sure they have someone to talk to whenever the need arises or, things get out of

control.
 PROCESS RECORDING 9

Dialogue Skills used Feelings Thoughts Course Instructor Comments

SWI: Hi. How are you, I am Remi Introduction Calm and Pablo looks
excited cheerful,
about the making me
encounter relaxed
Pablo: Hi there, welcome Hospitality Calm He has a
friendly
attitude.
Fred: I am Fred, Pablo’s partner Constructing At Ease Cordial
rapport
SWI: That is nice Rapport Relaxed Pablo is
building silent
Fred: Thanks, this is our third year together Rapport Comfortable He seems
building chatty and
has an open
character,
how nice
SWI: I see, you must be fortunate Rapport Relaxed I have a
building good feeling
about this
Fred: Are you married Rapport Welcome at He is such a
building ease pleasant
person
SWI: Very much so Rapport Calm He is very
building friendly.
Pablo is
immersed in
the song
Pablo: Please, do come in. I have something to Rapport Relaxed He will
 PROCESS RECORDING 10

show you building definitely

make this
easy for me
Fred: Would you like a drink? It’s quite warm Rapport Relaxed I am already
today building loving this
task
SWI: Sure, a glass of juice would do Creating Relaxed This will
communicati definitely
on links end well
Fred: Here you go Rapport Comfortable He really is a
building caring and
talkative guy
Pablo: Here you go Remi Rapport Relaxed They are a
building nice family
indeed
SWI: Cute and cheeky you were in these Monitoring Calm I think the
pictures, I love this body introduction
behavior went well

Dialogue Skills used Feelings Thoughts Course Instructor Comments

Pablo: Best memories I have Rapport Comfortable He adores
building his family
Fred: I agree Rapport Comfortable He has a
building really nice
personality
SWI: Agree Rapport Comfortable Calm
building
SWI: Pablo, can I ask a few personal questions if Monitoring Slightly I hope he is
you don’t mind body edgy amicable and
language answers
 PROCESS RECORDING 11

Pablo: No I don’t go ahead Monitoring Anxious He looks at

body Fred; I'm
language happy he is
present
SWI: You spent six years in the army, Checking Anxious I hope I was
unbelievable body not too direct
language
Pablo: It was amazing, reminded me of home all Monitoring Anxious That was a
the time body nice start
language
Fred: He looks amazing in uniform Direct Collected His input is
engagement highly
cherished
SWI: History of service in the family, Pablo? Direct Anxious I need to
engagement approach
this gently
Pablo: Yes, my dad was in the military Listening Collected Nice start

SWI: It must be a tremendous sacrifice, for your Involve Calm It’s time to
family and nation look into the
issue
Pablo: Leaving home was difficult, anything for Listening A bit tense He really
country and family cares about
his family
Fred: Had he not left home, I wouldn’t have met Listening Comfortable He has a
such a nice person supportive
and stable
family
 PROCESS RECORDING 12

Dialogue Skills used Feelings Thoughts Course Instructor Comments

Pablo: It is my duty, my honor Listening Collected He loves his
family and it
comes first
to him
SWI: That is an amazing thing to do, Pablo, I Communicat Uneasy I need this to
would love if we talked about your encounters in ion strategies happen, it is
the war extremely
important
Pablo: Alright, what would you like to know? Listening Uneasy My approach
will make or
break this
SWI: Thanks, Pablo, I need to know about the Building A bit I need to
encounter, from news and stories, I believe that rapport nervous monitor his
being in the war is extremely risky. Many lives reaction not
are lost and families traumatized. It is a big just oral but
sacrifice that only a few individuals can attain; I also body
perceive acts as yours heroic. Owing to what you movement
do, we are secure but lack time to thank you.
How would you explain your encounter in
explosive areas such as Iraq in the past six years
since you spent a large portion of your life in
direct combat
SWI: Please, put it any way you want Listening Calm I would love
if he talks, it
is vital to his
wellbeing
Pablo: That’s a nice question, all I can say is Listening Comfortable I am starting
there were very bad days, good and some risky. to like the
Such outcomes are typical in such locations flow
 PROCESS RECORDING 13

SWI: Can we begin with the good days or you Listening Calm I should not
have a different approach? cut the
communicati
on link
Pablo: Alright, the good days were lackluster. Listening Collected This is
Old films at the station, dusting equipment, progressing
playing poker and Russian roulette with the fine, he has
squad. Taking the rare hot bath, ringing family no issue
when the signal was good. Sometimes playing recounting
soccer, the list of activities was restricted. the good
However, it was alright, strong women and men ones
in the camps knew what needed doing and did as
required. Or the times we would win battles,
liberate women and kids. We did not lose any
battles; they were the good
Fred: I loved when he had time for each other Listening Calm His
telling old jokes and spending time together. contribution
Days were long, but with him by my side, I felt is highly
courageous valued. He
makes me
feel
comfortable
SWI: Now, what about the bad ones? The Listening Anxious, The most
extreme and bad interested vital part of
the meeting
Pablo: They were just the contradictory to the Listening Edgy It seems
nice ones those elicit a
lot of trauma
Fred: You can share with him, there is no need Listening Uneasy I will
holding onto past pain. You’re my hero and I involve him
think what you have done is much more than frequently to
 PROCESS RECORDING 14

anyone could. break any

deadlocks
whenever he
stops
communicati
on
SWI: Share what you feel comfortable with, Reassuring, Uneasy I need to
please. Narrate as much as you can about without gauging reestablish
any fears. That is all you need right now body the
behavior communicati
on lines. I
cannot allow
him to shut
me out
Pablo: Well, since you asked, there is nothing I Listening Calm, That was
can’t talk about. The bad days involved those interested, awesome; it
when we visited small boroughs, supplying food thrilled was what I
and cargo to units and infirmaries or on guard was hoping
duty to ensure the towns did not get hit by for. I hope to
mutineers. In one out of four trips, there would get more out
be an incident or accident and a person would be of such
wounded. Everything from RPGs or the direct
procession comes under enemy fire, or we responses
uncover during the tour what remains after
detonations have ripped apart people, vehicles,
and buildings. For me, the worst part was not
knowing who would be next, maybe your troop,
colleague, or you. You had to accept such
ambiguity after you acknowledge that this is the
typical way of life in the environment. You have
serenity.
 PROCESS RECORDING 15

Dialogue Skills used Feelings Thoughts Course Instructor Comments

Fred: It was extremely exhilarating and Listening Eager I want to
depressing in equal measure hear Pablo’s
response to
that
Pablo: Yeah, you just never knew when your Listening Composed He seems to
luck would run out have
experienced
a lot
SWI: Lastly, to conclude this part, what about Direct Composed It is nearly
the extreme days? engagement, time for the
Sympathizin ensuing
g, Probing stage
Pablo: Well, the worst days saw death. Listening Relaxed Such
Bereavement was always the last encounter. encounters
Landmines and improvised explosives killed a might have
dozen members of my cavalry. You saw your life lasting
flash before you, and it was like a nightmare impacts on
replaying over and over. You never know if you people’s
are next, you just admit there’s nothing you can mental
do health
SWI: How is the home experience, Pablo? I Instinctive Anxious I need to
know you have a drinking issue and often get and curious know
into fights when tipsy. What is at home that whether he
makes you cheerful, something you look forward has issues
to each day blending into
the home
atmosphere
 PROCESS RECORDING 16

Pablo: Fred and my buddies, they make me Listening Collected This is a

happy good
response
even if he is
overlooking
the alcohol
issue
Fred: Thanks a lot, I love you so much Listening Calm Hope he
makes him
talk about
the alcohol
issue
Fred: However, I am worried you are drinking Listening Nervous This is direct
excessively and might get injured in those bar altercation
brawls. We got a great life and I cannot stand to but his
lose. You hear me Pablo, the world and I still contribution
need you so much, healthy and intact is the right
stimuli I
need
SWI: Pablo, what do you say regarding the Inquest Anxious I really need
brawls and drinking? Do you feel incapable of a frank
managing some issues; rage, feelings, human response but
clashes in a tavern? You might not be under he appears
attack, but Fred is worried. hesitant
Pablo: The bar visits are to grab a few drinks, Listening Calm He tries to
clear my mind, and meet my pals. I have healthy keep his
thoughts and strong emotionally and mentally. emotions
The brawns are just disagreements often over hidden. I
trivial matters. have to pry
and get
better
 PROCESS RECORDING 17

responses
SWI: Your drinking has increased compared to Tackling the Edgy, I need to
the previous years. issues anxious engage the
issue
Pablo: Feeling a little bit rundown Listening Composed I trust he
approves my
recommenda
tions
SWI: Your file mentions that you visited a Investigating Relaxed He denies,
therapist after returning home and had PTSD which is
diagnosis. You also go to counseling groups at expected
the veterans hospice
Pablo: Yeah, it’s part of the arrangement after Listening Collected He would
leaving the service not do it
voluntarily

Dialogue Skills used Feelings Thoughts Course Instructor Comments

SWI: Have you spoken with the therapist Reassurance, A bit I trust he
regarding the depression, anxiety, and rage Probing anxious will agree
bursts? Do you think you need to? In my view, and move
the PTSD diagnosis is true. Nonetheless, it is an past the
issue you can conquer if you become more frank refutation
about it. Your encounter during the service might
have instigated them. Would you love to
overcome the alcohol, brawls, and depression at
least for your family? Fred is worried about what
all this might bring
Pablo: I informed the counselor of the anxiety Listening Composed I love the
and not alcohol and brawls. I would love Fred to course this
 PROCESS RECORDING 18

be blissful, I would do anything for him has taken

Fred: Thank you, I am pleased to hear that, Listening Relaxed I think I
there’s someone at the door need to get
him onboard
with the
program
SWI: I may recommend an Alcohol Anonymous Stressing Tense This was the
session and addiction clinic. The sessions and goal of the
involve veterans who overcame alcohol and reassuring visitation. I
learned to control their tempers. I might also hope he
refer you to my supervisor, he was in the army agrees
and has wide experience of dealing with post-
war issues; I can reassure you that he will assist
you. You can rise above the rage and alcohol, I
saw in your file that you a strong character and
determination. These traits can assist you to
become mentally strong. By the time you
complete the projects, you will be a new person,
which is good for you and Fred. What do you
think? Should I go ahead and start the
preparations?
Pablo: Yeah, sure. For Fred, there is nothing I Listening Anxious That went
won’t do. So go ahead and make the necessary well and I’m
arrangements, I will not let you down happy, it’s a
worthy start
Fred: Geoffrey is here, look, it’s almost past one Listening Composed He seems
encouraging,
what he says
matches his
body
language
 PROCESS RECORDING 19

SWI: Thank you very much for having me and Analyzing Collected Hoping to
the good time we had. Be sure that our body follow-up, I
conversation will be held with extreme language wanted to be
discretion. Pablo, the AA sessions commence in genuine and
two weeks, I will give the counselor your name I hope he
and inform you of the schedule. I’m positive takes the
they will be of help to you treatment
Pablo: I appreciate that, I look forward to it Checking Composed He seems
body resolute
language about
keeping his
word
SWI: Before you start the sessions, you can cut Assessing Comfortable I hope this
your drinking and time spent in the tavern. I body works, Fred
believe it will help you avoid brawls and rage language, forms a solid
bursts. It will also help you concentrate on stressing, support base
mitigating the alcohol issue reassuring.
SWI: Lastly, Pablo and Fred, you got yourself a Checking Calm It’s time to
nice family. I appreciate the generosity, it made body end the
me feel at home language meeting, and
make sure
the stage is
set for
subsequent
sessions
Pablo: Am lucky and blessed Listening Undisturbed He is
collected. I
think war
pain and
PTSD
greatly
 PROCESS RECORDING 20

affected him
Fred: Thanks for stopping by, our doors are Listening Calm He has been
always open for you, anytime accommodat
ing
SWI: I appreciate that. Bye for now, I look Checking Relaxed That went
forward to many lovely meetings and progress body far much
language better than I
thought it
would; I was
nervous
 PROCESS RECORDING 21

Summary

I have never had an interview with two veterans before and, I believe the visit to

Pablo’s home was highly rewarding. Based on his file, I anticipated the meeting was

going to be very difficult owing to his quick temper and tendency to lose control.

However, the warm welcome I received made e change my mind and I must say, I had a

wonderful time. However, I think the meeting would not have been so successful without

Fred’s involvement; he seemed to have an optimistic attitude and was compromising in

most cases. Overall, the encounter was extraordinary and ended well, which was a good

start point. However, I have a feeling that since it was my first visit, there is little I could

have changed.

For this meeting, I utilized the cognitive behavior theory to help Pablo conquer

his anxiety, anger, and alcohol dependency and take charge of his life. By definition,

cognitive behavior therapy is a concept that underscores moods, opinions, and physical

awareness and actions that emanate from incapacity to regulate these emotions and

feelings. Cognitive behavior therapy is a temporary therapy model, which assists people

to break down issues into small pieces and tackle them. For instance, Pablo ought to

break down his alcohol addictions to money problems and handle it. Secondly, the fights

and temper are indications of trauma, mental suffering, and a lopsided way of managing

conflicts after being involved in a dispute. Therefore, Pablo needs to learn to deal with

his moods and emotions, which are his primary problems and cognitive behavior therapy

is one of the best treatment methods.

I also used a problem-solving model during the home visit. Pablo has four

significant issues including PTSD, anger management, depression, and alcohol addiction.
 PROCESS RECORDING 22

I believe that Pablo is running away from his problems instead of facing them. Alcohol is

just one of the tactics he is employing to show his frustration of returning home a

different person than the way he left. Anger might be an upshot of uncontrolled mental

distress and growth of severe PTSD, which is trailed by erratic behavior. As a result, the

goal was to espouse a framework to help Pablo tackle the pain, financial difficulties, and

other challenges he faces and live a better and confident life.

VIII. Provisional DSM-5 Diagnosis

ICD-9: 309.81 Posttraumatic Stress Disorder (provisional)

Short Description: Posttraumatic stress dis 

Long Description: Posttraumatic stress disorder 

This diagnosis is being assigned to Pablo Honcho because he meets the main

DSM-5 criteria for diagnosing acute PTSD. These, according to the American Psychiatric

Association (2013), include:

Criterion A: Stressor

Pablo has a history of exposure to death (death of his mother and brother in a

tragic road accident). He has been threatened by death (lost both legs in a bomb

explosion) during his service in Iraq. He has also experienced sexual violence with his

girlfriend.

Criterion B: Intrusion symptom

He experiences intense distress and gets frightened when reminded of the

battlefield making him to even wheel off. His physical reactivity shows he re-experiences

traumatic events.
 PROCESS RECORDING 23

Criterion C: Avoidance

Pablo avoids trauma-related stimuli, thoughts or feelings. When Pablo sees a

photo of them on the battlefield, he turns nostalgic and grief-stricken. When asked about

their encounters on the battlefield, he stares blankly at the ceiling, gets frightened and

quickly wheels off.

Criterion D: Negative alteration in mood

He shows negative feelings that began after the experienced trauma. He blames

himself for enlisting in the army but mentions that the experiences were a mix of very

good and very bad (guilt). Fred is also not always around to take care of Pablo and hence

Pablo feels a bit isolated.

Criterion E: Altered arousal and reactivity

He is irritable, quick-tempered, and has a tendency of being abusive particularly

when drunk. The fights and temper are indications of trauma and mental suffering. Anger

might be an upshot of uncontrolled mental distress and growth of severe PTSD.

Criterion F: Duration

Pablo’s symptoms have lasted more than a month

Code Classification
 Mental disorders (290–319)
o Personality disorders, neurotic disorders, and other non-psychotic mental
disorders (300-316)
 309 Adjustment reaction
 Alcohol abuse (305.0x)

309.81 Excludes 
 acute stress disorder (308.3)
 posttraumatic brain syndrome – non psychotic (310.2)

But applies to

- Post-Traumatic Stress Disorder (PTSD)

PROCESS RECORDING 24
 PROCESS RECORDING 25

Reference

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

disorders, Fifth Edition. American Psychiatric Publishing, Arlington, VA.