PTSD Practicum Journal
People experience trauma at one point in their lives, and it is normal to feel afraid after traumatic situations. The fear experienced during the events causes a trigger in the fight and flight response of the body a mechanism meant to protect individuals from harm. Most people recover from this fears naturally, but some may continue experiencing the symptoms for a prolonged period. In extreme traumatic events, individuals can experience distress, upset, sleep disturbance and anger. According to Wheeler (2014), the most common outcome of traumatic events is post-traumatic stress disorder (PTSD). PTSD is a psychiatric condition that occurs in people who have witnessed or experienced life-threatening events like serious accidents, natural disasters, war events or violent occurrences like rape. Statistics indicate that about six of every ten men and five of every ten women in the world experience at least one episode of PTSD in their lives. I was part of the team that provided counseling to a client with PTSD, and this paper outlines the relevant history, criteria for diagnosis and the therapeutic approach used for management of the patient.
Description of the client: The patient is a 21-year old female of American origin currently staying in New York. She stays with her father in their home. Her mother and two other siblings are diseased as a result of a road accident. She is a Christian, and she goes to church often. Currently, the patient attends school at a nearby university.
Presenting complain: The patient states that “I feel like I am straddling a timeline where the past and the present are pulling each other. I experience sleepless nights, sometimes seeing flashes of images from the accident scene. My heart is not at peace, it sometimes races and fear covers my face. I experience episodes of anger, shouting and after the period I become depressed.”
Pertinent History: The patient reports that a year ago the family was involved in a car accident and unfortunately two of her siblings and her mother died. The patient and her father were the only survivors of the accident. The patient feels she is responsible for the accident because she was drunk. The patient was hospitalized for two months, and she was not able to attend for the burial because she was unconscious. Ever since she got out of the hospital, she has been experiencing the problem. Six months ago, she was diagnosed with PTSD, and after review, she was discharged home on medication.
It is six weeks now since she started experiencing flashbacks, upsetting memories of the accident, depression, and feeling of isolation, anger, and distress. The patient has been hospitalized once due to the accident, and she stayed in the hospital for two months. She was treated with a diagnosis of head injury at that time. Six months ago, the patient was treated for PTSD, and she was discharged home on Fluoxetine 40 mg PO once daily. The symptoms slowly subsided, and there has been no problem ever since. There is a family history of depression and substance abuse disorder. Her mother was depressive, and her grandfather currently is being treated for alcohol withdrawal syndrome.
Justification: PTSD is a psychiatric condition that occurs in people who have witnessed or experienced life-threatening events like serious accidents, natural disasters, war events or violent occurrences like rape. Traumatic events are shocking, dangerous and when it happens to patients, they always think their lives or other people’s lives are in danger. The diagnostic and statistical manual of mental illness provides the criteria for the diagnosis of PTSD (Ehlers, 2015). According to DSM-5, PTSD is diagnosed if the patient shows at least one re-experiencing symptom, at least one avoidance symptom, at least two arousal and reactivity symptoms and at least two cognition and mood symptoms for more than one month (American Psychiatric Association, 2013). In addition to the above criteria, dissociative specifications and delayed specifications aid in the diagnosis of the disorder. Depersonalization and derealization stimuli are used in this specification. Although symptoms of PTSD manifest almost immediately after trauma, full diagnostic criteria are not met until after six months.
Some of the symptoms that guide the diagnosis of PTSD include flashbacks, frightening thoughts, and avoidance of thoughts relating to the traumatic event, having difficulty in sleep, loss of interest and distorted feelings or blame. The patient has been experiencing flashbacks, sleep disturbances, change in moods, avoidance behavior and also feeling of the blame for the past incident leading to the diagnosis of PTSD.
Therapeutic Approach: The treatment approaches found to be effective in managing PTSD include pharmacotherapy and trauma-focused psychotherapies. According to Syros (2017), cognitive behavioral therapy is one of the best mechanisms used in the management of PTSD. The therapy focuses on the relationship between behavior, thoughts feelings and emotions that can improve the functioning of other domains (Syros, 2017). The main objective of using CBT is to restore the normal healthy behavior of the affected individual while improving emotional regulations. Cognitive behavioral therapy focuses on correcting the intrusive and painful patterns of behavior by teaching the affected individuals relaxation techniques through examining the mental processes affecting the person. Individual therapies are less effective than group therapies because people get to share more in group sessions.
The common approaches to CBT include exposure therapy and cognitive restructuring. The exposure therapy helps the individual to control and face their fears. The therapist introduces the fears of the person gradually, and it can involve going to the scene where the accident took place or the use of mental imagery to remind the individual of the traumatic event (Wheeler, 2014). A literature review search conducted by researchers on the effectiveness of CBT strongly suggests that CBT is safe and effective for the management of both acute and chronic PTSD. However, the research also found that nonresponse rate to the therapeutic approach is as high as 50 percent (Yehuda et al., 2015). Another recent research conducted in the United States on the effectiveness of CBT in managing PTSD suggests that CBT has clinical improvement significance and follow-up programmes indicate that the progress is impressive after six months, one year and two years post-treatment.
Pharmacotherapy is the second recommended approach in the management of PTSD symptoms, and the commonly used drugs are the selective serotonin reuptake inhibitors (SSRIs). Research indicates that neurotransmitters like serotonin have a role in the experience of mood and anxiety. The drugs are prescribed when the patient shows signs of depression or difficulty in sleeping and the patient should be monitored for any side effects. The main objective of using pharmacotherapy is to stabilize the patient’s condition through symptomatic management to pave the way for other therapies (Cusack et al., 2016). Pharmacotherapy is therefore used in combination with other therapies such as CBT. The common antidepressants recommended by FDA in the management of PTSD include Sertraline, Paroxetine, Fluoxetine, and Venlafaxine.
Legal and Ethical Considerations: Ethical considerations in client counseling are applied to give a guide to the nature of the relationship between the therapist and the patient. The therapists understand that patients have rights that should be adhered to during therapy sessions. The ethical considerations in counseling are guided by the ethical principles of autonomy, beneficence, nonmaleficence, and justice (Gunn and Taylor, 2014). Informed consent is a consideration during therapy sessions which ensures that patients are fully aware of the benefits and risks involved in treatment. The patients must be given options for the treatment and if the client is incapacitated the next of kin is informed.
Confidentiality is an ethical consideration used in counseling sessions especially CBT that involves keeping the patient’s information between the brackets of the patient and the therapist. The patient has the right to sue the health practitioner f their confidential information is breached. The patient has the right to dictate who should be given information concerning treatment or the diagnosis (Gunn and Taylor, 2014). In some cases, the therapist uses privileged notes to keep off the hospital record confidential information regarding the patient’s treatment. Protection and safety of the patient’s information is a legal consideration. According to HIPAA, the patient’s information should remain within the healthcare settings for security purposes.
Conclusion: Every individual experience traumatic events at one point in their lives and post-traumatic stress disorder is one of the outcomes of trauma. The diagnosis of the condition is based on a cluster of symptoms including stressors, intrusion symptoms, avoidance symptoms, negative alterations in cognition, alterations in arousal and functional significance symptoms. The management of PTSD uses two main approaches, psychotherapy and pharmacotherapy. Research indicates that a combination of pharmacotherapy and psychotherapy brings better outcomes than individualized therapy. Therapists should be aware the legal and ethical considerations in counseling like confidentiality and informed consent so that ethical issues are avoided.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Bruce, T., &Jongsma, A. (2010b). Evidence-based treatment planning for post-traumatic stress disorder [Video file]. Mill Valley, CA: Psychotherapy.net.
Cusack, K., Jonas, D. E., Forneris, C. A., Wines, C., Sonis, J., Middleton, J. C., … & Weil, A. (2016). Psychological treatments for adults with posttraumatic stress disorder: A systematic review and meta-analysis. Clinical Psychology Review, 43, 128-141.
Ehlers, A. (2015). Understanding and treating unwanted trauma memories in posttraumatic stress disorder. Zeitschrift für Psychologie/Journal of Psychology.
Gunn, J., & Taylor, P. (2014). Forensic psychiatry: clinical, legal and ethical issues. CRC Press.
Syros, I. (2017). Cognitive behavioral therapy for the treatment of PTSD. European Journal of Psychotraumatology, 8(sup4), 1351219. Retrieved from http://www.tandfonline.com/doi/abs/10.1080/20008198.2017.1351219
Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.
Yehuda, R., Hoge, C. W., McFarlane, A. C., Vermetten, E., Lanius, R. A., Nievergelt, C. M., … & Hyman, S. E. (2015). Post-traumatic stress disorder. Nature Reviews Disease Primers, 1, 15057.
