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Psych 515 - Posttraumatic Stress Disorder Case Report

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Case Report: PTSD

Team A


January 28, 2013

Rachel Stein, Psy. D

University of Phoenix Material

Case Report

Background Information

1. Outline the major symptoms of the disorder discussed in the case.

Posttraumatic Stress Disorder (PTSD) is an anxiety disorder that can occur after an individual has seen or experienced a traumatic event that involved the threat of injury or death. Examples of events that PTSD follows are flood, fire, assault, domestic abuse, prison stay, rape, terrorism, and war. PTSD can occur at any age. The cause of Posttraumatic Stress Disorder is unknown. Psychological, genetic, physical, and social factors are involved. The disorder changes the body's response to stress. Symptoms of the disorder include involuntary flashbacks, emotional detachment, and hyper-vigilance (unalert). When individuals suffer from flashbacks, they relive the events that occurred and may have nightmares. They tend to detach themselves emotionally and are unable to remember important aspects of the trauma. The individuals suffer from arousal. They have difficulty concentrating, are startled easily, and have trouble sleeping. They also suffer depression, anxiety, and tension. Fifty percent of people experience trauma and only eight percent experience PTSD. PTSD may arise from severe, prolonged trauma, pre-existing anxiety, poor coping techniques, and lack of support network. The diagnostic features of this disorder are fear, helplessness, and horror. There are no tests to be done to diagnose PTSD. Complications of PTSD include alcohol or drug abuse, depression, and panic attacks.

2. Briefly describe the client's background.

The client being evaluated is Carl. Carl is an elder American Indian with a ponytail. Carl came from a lower socioeconomic background. Carl was 17 years old when he joined the army. He joined the military for the GI Bill because his family could not afford to send him to college. He is a Vietnam veteran. His first assignment was to assign individuals in divisions to combat zones. He was also an air traffic controller. He worked the night shift. Carl later volunteered for combat. He killed people in combat. He witnessed a friend getting killed one night while checking on things before going to sleep. He then began to operate machine guns off the side of patrol helicopters. His psychological problems began after he returned to the United States. He stated that he felt different when returning home on a 30 day leave. Carl's PTSD symptoms began two years after returning home. He suffered from the symptoms flashback, hyper vigilance, and emotional detachment. Carl stated that being shot at was a traumatic experience. He felt guilty for putting people in harm's way. With his job, he put people in the field. He tried to stay unemotionally involved during combat. Carl avoided crowds and people before receiving treatment. Alcohol is what caused his flashbacks to occur. When viewing Vietnam photos, Carl admitted to getting excited and somewhat relaxed. Carl stated that when he hears helicopters, his hair stands up on his neck and he protects the soft spot on his neck. Carl claims that his dreams became worse after therapy. Carl began therapy after police had a gun on him and he wanted to take the police's gun and kill him. Carl stated that PTSD affects him on a daily basis. He gets agitated and disturbed when going to the mall with his wife and kids. He says that it is difficult to keep up with and protect them from harm. Carl is detached and overprotective of his kids. Carl is a social worker who works with other veterans helping them to cope with their own PTSD challenges. Vietnam left Carl with permanent emotional scars. Carl used his American Indian tradition for his own survival.

3. Describe any factors in the client's background that might predispose him or her to the disorder.

Some factors that may predispose Carl to Post Traumatic Stress Disorder (PTSD) are his young age, he was only 17 going into Vietnam. Although age does not have a major factor on PTSD, Carl's training before being deployed does. According to Butcher, Mineka, and Hooley (2010), people who have an idea or who have been trained for combat are at a lower risk for developing PTSD. In Carl's interview he elaborated on the feeling of not fully knowing or having that training to prepare him. He also indicated that he believes no matter how much training a person receives they can never be fully prepared for the affects and sights they will see in combat. Carl came from a lower socioeconomic family and PTSD is found to be higher in individuals who come from low income families. He is American Indian and although they have a strong sense of pride for their culture and country, many American's look down on them. When Carl returned home for his first visit, he stated that the seen all his buddies from high school and how they were happy and enjoying life. He began to feel angry and robbed of his youth. The stated "they were still kids and I wasn't". He had to grow up much faster than his peers. While in Vietnam, Carl also stated that they did not talk about their feelings or have emotions because if you had emotions you would not survive long. Carl began drinking and smoking marijuana to take relax, this in turn caused him to start having flashbacks of men being killed and things he had done to others. When Carl returned home for good he had a hard time adjusting to life as it was. He did not want to talk to people about what he did while in Vietnam and would often times get very angry when people asked him if he killed anybody.


1. Describe symptoms that you observed that support the diagnosis of the individual.

Some symptoms that I observed with Carl that will support a diagnosis of PTSD are uncontrolled emotions, mood changes, flashbacks that he has, and his inability to communicate with others. At the beginning of the interview Carl is very tensed and unresponsive. He was looking at the interviewer as if he was chasing him to see if he was the good guy or the enemy (much like combat). Once Carl realized that the interviewer was on his side he became more calm, relaxed, and opened up to him. Trauma of military combat brings in constant fear, unpredictability, and many incontrollable circumstances (Butcher, et al., 2010, pg.162) Carl had become familiar with the



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