Cilinical overview and assessment of PTSD Case and Intervention Plan (fictional case for

1. PTSD ASSESSMENT
JUAN L. ROSADO
ESTEBAN MARRERO
ANIRAM TREJO DR. BILLY B. SANTIAGO
FRANCES RIVERA CNSL 526

2. AGENDA
• Case Summary
• Subject Mental Status
• Diagnosis and Axis
• Treatment Plan
– Objectives
• Short Term
• Long Term
– Treatment
• Short Term
• Long Term

3. CASE SUMMARY
J suffers Posttraumatic Stress Disorder with Primary Insomnia characteristics from
war deployment to Iraq for 15 months. He presents avoidance of multitude events or
places; nevertheless, it is not Avoidance Personality Disorder due to this attitude is
not in avoidance of jobs or activities by fear of criticism, disapproval or mocking. It is
not avoidance due to embarrassment or fear of being ridiculous. J also presents
Primary Insomnia characteristics; for over two years he does not sleep more than
four hours, if he sleeps. There is no evidence of physical deterioration, eliminating
Narcolepsy Disorder. J feels anxiety in his job due to many responsibilities, but this
feeling appeared after his experience during Iraqi Freedom deployment in 2009-2010;
he’s been working in the same factory for 13 years. J presents anger outbursts,
although he has not hurt or physically attacked anyone. His relationship with friends
and family has diminished and deteriorated. He spends more time alone; prior his
deployment he expressed participating in sports activities with friends (basketball
and golf). J describes forgetting simple tasks like remembering what he would buy
upon arrival to the grocery store. Also describes remembering traumatic situation in
combat but completely forgetting activities on-post activities during deployment.
Although his nightmares have decreased, J describes still waking up dramatically
after a combat memory during sleep. No physical illnesses are present or detected.

4. SUBJECT MENTAL STATUS
Subject was neatly dressed (clean ironed slacks, clean
ironed short sleeve shirt, clean shoes). Hair neatly
trimmed and neatly shaved. He wore his wedding
ring. His conversation was normal and coherent.
During a specific episode he cried but in a calm
manner. During a specific moment J expressed anger
towards a specific person, but remained under control
and maintained a moderate tone of voice. His
vocabulary was clean and non-offensive.

5. DIAGNOSIS: PTSD
• Posttraumatic Stress Disorder 309.81
• AXIS I: Posttraumatic Stress Disorder with Primary
Insomnia traits.
• AXIS II: Differed
• AXIS III: Palpitations
• AXIS IV: Family situations, labor situations,
avoidance of crowded places
• AXIS V: 61-65%; some moderate symptoms or
difficulty in social, labor or school activities, but can
work, has some significant interpersonal
relationships.

6. Treatment Plan: Objectives (Short Term)
• Diminish stressors associated with
traumatic event
• Monitor stress level
• Reduce nightmares
• Anger management

7. Treatment Plan: Objectives (Long Term)
• Return client to premorbid level of
functioning
• Prevent recurrence of symptoms
• Restore regular sleep patterns
• Eliminate stressors associated with traumatic
events
• Restore healthy interpersonal relationships

8. Short Term Treatment
• Determine level of anxiety
• Report to sleep clinic for testing
• Understand and confront contributing factors of
sleep problems
• Explore underlying problems with therapist
• Use bed for sleep and sex only
• Relate and help interpret dreams
• Improve family interaction
• Complete homework assignments

9. Short Term Treatment (cont.)
• Maintain daily journal
• Recognize situational triggers
• Teach client “time out”
• Teach client assertiveness principles
• Learn relaxation techniques
• Follow through with psychiatric referral
• Attend self-help therapy sessions

10. Long Term Treatment
• Re-evaluate sleep through test
• Use relaxation audio at home
• Re-determine level of anxiety
• Replace exaggerated reactions
• Learn new breathing techniques
• Maintain assertiveness

11. Long Term Treatment (cont.)
• Use relaxation techniques or hypnosis
• Practice coping skills with real life situations
• Encourage client to practice old activities
• Maintain family interaction
• Family sculpturing

12. QUOTE
“
Dream as if you'll live forever, live as if y
”
James Dean

13. QUESTIONS?