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The client is a female, 45 years old with a child. She suffered two road accidents with no major physical traumas. The first accident happened years ago and claimed the life of her friend. The client went through a therapy that helped her cope with the trauma and live on. The second car crash was more recent but happened a month ago. That was possibly a trigger event that brought back the memories of the major one. The client claims that issues began 3 weeks ago while the major accident, which causes problems, happened several years ago. That allows to say that this specific PTSD has a delayed expression. As for the PTSD itself, the client meets criterion A because she reported car accident involving death of the other passenger. She meets criterion B because all five intrusion symptoms are reported. Criterion C is met because the client mentioned not feeling good about driving. Criterion D is met because the client said she feels “horrible things about herself” and feels detached from her husband. The client meets criterion E because the client reported exhibiting flashes of anger.
The client is working at school, has a normal relationship with sister and adult son. Health and weight problems are absent.
The client does not seem to exhibit enough symptoms to definitely match any personality disorder. She reports absence of desire to talk to anybody or being talked to for 3 weeks, which may suggest schizoid personality disorder, but there are no signs of a restricted range of emotions. Same symptom may also match avoidant personality disorder but there is no report on reacting harshly to critique.
The Client’s health condition based on self-reported data does not arouse suspicion of any medical condition. Weight and eating problems are absent which speaks further to normal medical condition.
Client Strengths:
- The client is a well-educated woman, which may give her the power to remain adequate in most situations.
- Despite having lived through two episodes of car crash and lose a friend she managed to keep adequate social connections so far, which speaks to her mental resilience.
- Being a churchgoer seems to benefit the client making her not abandoning the hope.
- The client acknowledges the problem and wishes to resolve it to restore mental health.
- Losing a person dear to her, she seems to begin caring more about lives of other people saying that she does not want to endanger other people’s lives.
- She does not hold back her emotions and talks to her sister in seeking comfort.
- The client does not let her mental problems affect her health condition through unhealthy eating
- She keeps good relationships with her son, despite he is a distance away.
This case is a vivid example of PTSD. Problems at work and in the family are not rare in people with such conditions. There are possible indications of insomnia disorder (G47.00) with comorbid nightmare disorder during sleep onset (F51.5) that are sometimes associated with PTSD cases (APA, 2013). The client reported trouble going to sleep. As for insomnia disorder, she meets criterion A, because the client complained about her sleeping trouble. She also meets criterion E, because she has an opportunity to sleep. The client meets criterion G, as she currently does not receive any medications nor has a history of receiving them. As for nightmare disorder, the client reported seeing nightmares of her accident while being asleep. She meets criteria A, and D because she receives no medications and the dreams reoccur in the multiple sleeping episodes. However, further research is needed to confirm the diagnoses.
Reference
American Psychiatric Association [APA]. (2013). Diagnostic and statistical manual of mental disorders. Arlington, TX: American Psychiatric Publishing.
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