Case Study
Patient Demographic: Initial Intake: Age: 26 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual
Mental Status Exam: The client appears his stated age and is dressed appropriately for the circumstances in clean jeans and a t-shirt. He identifies his mood as “anxious but a little excited” because he “is hopeful that he can finally let his anger go.” He tells you he is tired because he has difficulty falling asleep and staying asleep most nights. His affect is pleasant with emotional lability evident. He demonstrates appropriate insight and judgment, memory, and orientation.  He reports never “seriously” having considered suicide but acknowledges that there were times when he wondered “if dying would make this pain go away.” He has never attempted suicide and states he would never consider harming himself or anyone else.
Presenting Problem: You are a counselor in a private practice setting.  Your client is a 26-year-old male who presents for counseling at the request of his family and his employer, with whom he is close and who knows his history. The client tells you that he has been angry for the past 15 years, beginning a year after the death of his father from a heart attack. He says that his anger is triggered very quickly when frustrated by people or situations and that his “fuse is very short these days.” He states that he has been in some “loud arguments” with his mother, and later his stepfather. He admits that there have been times in the past when he and his stepfather have “almost come to blows” but his mother stepped in and made them stop. He admits to having hit or kicked walls at times in his anger, but has never hit a person. He tells you that he doesn’t want to feel this way because it interferes with his relationships and his former girlfriends have never understood that when the anniversary of his dad’s death comes around, he just wants to be alone for a couple days and not have to talk to anyone. He tells you that he has never had a long-term relationship with a woman because either he gets “depressed” for a few days during certain times of the year (i.e., father’s birthdate and death date) or because he is too quick to get angry and then says things he doesn’t mean. He says that he has been in a relationship with a woman now for eight months and really wants to get himself together because he feels “she’s the one.”
Other Contexts: Family History:
The client reports a family history of being the youngest of three siblings born to his mother and father. He reports a “great life” with his family and that they regularly spent time together playing, camping, traveling, and “just being a family.” He tells you that he is sure there were occasional arguments but that he doesn’t remember anything significant, except that he had been mad at his dad the night he died because his dad wouldn’t let him stay up late, but that before the client went to bed, he had come down, apologized to his dad, and they had both said “I love you.”  He states his parents had been married for 15 years prior to his father’s death, which occurred when the client was 11 years old. He states his dad died of a heart attack while sleeping, so while he did not see it, he knew something had happened because his mother woke him and his siblings and rushed them over to the next door neighbors’ house. He said that his mother went to the hospital with his father in the ambulance and came home that night to tell him and his siblings that their father had died. He tells you that he and his siblings are still very close and that they now have three much younger siblings born after his mother married his stepfather. He says that he is very close to his mother and stepfather, although he lives three hours away from them. He tells you that he tries to get home for big family events, like birthdays. He states that his stepfather adopted him and his siblings after the wedding and the client loves him very much. He tells you that he and his stepfather have gotten in what the client thinks are “typical teenager/parent” conflicts but that they have often been made worse by the client’s anger that seems to always be inside and erupts quickly.

Question: Which of the following statements would best help the client understand his sadness and crying?
(A): The effects of trauma can prevent the client from experiencing normal grief.
(B): As the client tries to reduce his anger, his limbic system creates new defense mechanisms.
(C): As the client works on his trauma, he is beginning to showing symptoms of depression.
(D): Trauma is a neurological and emotional reaction and crying is an expected symptom.

Correct Answer: As the client tries to reduce his anger, his limbic system creates new defense mechanisms.
Explanation: The effects of trauma include the development of persistent negative emotional states including fear, guilt, anger, etc, (Criterion D4) and significant alterations in arousal and reactivity, including angry outbursts with little provocation (Criterion E1). As the client's symptoms of PTSD subside, he will be better able to connect with normal emotions of grief and loss. PTSD can be associated with MDD, however, the client has described not feeling sad most days, which is a requirement (Criterion A) for an MDD diagnosis. The limbic system is controlled by hormone release and as the client works through his anger, hormones that control "fight or flight" such as cortisol, will be released less often into the system inducing normal function, rather than creating new defense mechanisms. While crying can certainly be a reaction to trauma, this client has not experienced that reaction and is reporting crying more now that he is beginning to feel better and less angry. These facts suggest that crying is not a symptom of his PTSD and is occurring as a result of working through his trauma. Therefore, the correct answer is (C)
Competency: counseling skills and interventions