Case Study
Patient Demographic: Name: Ella Clinical Issues: Seeking help after experiencing a trauma Diagnostic Category: Trauma and Stressor Related Disorders Provisional Diagnosis: F43.0 Acute Stress Disorder Age: 35 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: White Marital Status: Married Modality: Individual Therapy Location of Therapy : Private Practice  
Mental Status Exam: The client is a 35-year-old white female with a slender build. She is wearing jeans and a t-shirt and appears to be clean and well groomed. Her posture is slumped, her facial expression is flat, her eyes are downcast, and she has been displaying signs of crying. She speaks softly in a monotone voice. The client appears depressed and anxious, with tearfulness and trembling. She seems overwhelmed by her current situation and is unable to control her emotions. She reports difficulty concentrating on day-to-day activities. Her thoughts are logical and organized with tangential moments. She reports feeling as if she is living in a dream-like state since the trauma occurred. She experiences frequent nightmares about people she loves being killed. She is able to recall her personal history accurately. She is able to understand and follow your instructions and questions. She recognizes that she needs help. She denies suicidal ideation or intent.
Presenting Problem: First session You are a mental health counselor working in a private practice setting while under supervision. The client is a 35-year-old white female who presents for therapy following a trauma. When you ask the client why she made an appointment to see you, she begins to cry and shake uncontrollably. She tells you that her friend was shot two weeks ago and the client saw it happen. Her friend is in the intensive care unit at the hospital. She cannot consciously recall the actual shooting. Since the assault, she cannot concentrate and feels anxious all the time. She does not want to talk to her friends, and she has been withdrawing from her family. The client tearfully tells you that "life has no meaning." She is seeking your help to find some relief.    You validate the client's emotions and begin processing her subjective experience. You help her to understand that witnessing such a traumatic event can lead to the physical and emotional symptoms that she is experiencing. She appears receptive to what you are saying and nods her head. You emphasize that she has taken a courageous step by seeking professional help. As you continue with the initial session, you focus on providing an empathetic space where she can explore her feelings without fear of being judged. You provide her with information about resources she can access for further help. You also discuss the principles of cognitive-behavioral therapy as a method to begin to process her traumatic experience. Before the session ends, you present relaxation exercises that she can practice at home in order to reduce distress and tell her that learning healthy coping skills will be an important part of her recovery.    Following the session with your client, your supervisor tells you that she has worked extensively with the client’s parents in the past and offers to give you their files so that you can understand more of the client's family history.
Other Contexts: The client's family has a long history of living in the Bronx, New York, as her great-great-grandparents immigrated from Italy. She currently lives with her parents in a house that has been in her family for generations. Her entire life she has always felt safe and secure living in her Italian neighborhood. The client has one older brother who is married and works as a paramedic. She is close to her parents and describes them as supportive, hardworking, and loving. Her father was diagnosed with cancer several years ago and she has tried to be there for him in every way possible. Stressors & Trauma: The client witnessed her friend being shot during a robbery. Since then, she cannot stop thinking about the event. As a result, she has insomnia and frequent nightmares about people she loves being killed. She is unable to stop shaking and crying when discussing the nightmares. In addition, the event has left the client feeling angry, confused, ashamed, depressed, and highly anxious in her day-to-day activities.  

Question: What information precludes you from diagnosing this client with Posttraumatic Stress Disorder (PTSD)?
(A): The disorder does not cause enough significant dysfunction in the client’s life.
(B): The client does meet the criteria for PTSD.
(C): The traumatic event is too recent.
(D): The client’s family issues seem to be part of the problem; a diagnosis is not needed.

Correct Answer: The traumatic event is too recent.
Explanation: The traumatic event occurred within the past two weeks. For a diagnosis of PTSD, the symptoms must last at least one month. Because the event is recent, the client's prognosis is better than having a PTSD diagnosis. Intervening soon after a traumatic event is important and can lead to better treatment outcomes. Therefore, the correct answer is (C)
Competency: intake, assessment, and diagnosis