1) What are your initial observations of the patient?
Include name, age, marital status, profession, behavior, etc. My clients name is Arleen Mc Coy. Arleen is a thirty eight year old female. She has been married for 15 years and has two sons ages five and twelve. Arleen is a police officer and has been so for ten years. She is currently on paid medical leave and has three weeks left before she is due back at work. Arleens parents have been divorced for sixteen years and her father is an alcoholic with history of physical abuse toward his children. Her profession as a police officer came about from her desire to serve and protect because she could not do so as a child. Arleen has two brothers, one that she keeps in contact with and one that she does not.
The day of our first visit my client seemed edgy and relayed to us that she has been feeling extremely stressed lately. Her husband and her have not been getting along because of her edginess. She says she has not been able to sleep, and does not want to go back to work or visit any of her fellow colleagues. My client has been having dreams and flashbacks about an incident that occurred while on the job. The incident occurred when she made a routine traffic stop and an altercation occurred between her and the suspect after one kilogram of cocaine was found during a routine search. The suspect then pulled out a gun and fired a shot wounding officer Mc Coy and ricocheting onto a car. By misfortune the car lost control and a five-year-old boy was killed as a result of the crash. Since the event my client has experienced feelings of helplessness, she feels if she could only go back and do something differently the child would not of had to die.
2) What is your diagnosis? Discuss the reasons for your diagnosis- the specific symptoms, social conditions etc that lead you to make your diagnosis.
The diagnosis that seems most appropriate for my client is Post-Traumatic Stress Disorder. PTSD is the response to an extremely traumatic event, which elicits fear, helplessness, or horror. Some of the characteristic symptoms for this disorder include the re-experiencing of the event in forms of dreams and flashbacks, which occur while awakening or intoxicated. Arleen claims that every time she closes her eyes the scene re-plays in her head time and time again, and she has been drinking to help her cope with this. She also relayed that she felt helpless at the time like if there was nothing else she could of done. Other symptoms include the physiological reactivity and increased arousal of the person, which was not there before trauma. In our case Arleen indicated that she had difficulty falling and staying asleep as well as feeling irritable and having outbursts of anger.
She has been very edgy and impulsively irritable towards her husband so he suggested she come and seek therapeutic aid. She also seemed very shaky and appeared to be hyper vigilant. Usually to qualify for PTSD these specific symptoms must persist for a period of one month or longer. The most evident symptom that Arleen displayed was probably the avoidance of disturbing stimuli. This is the main reason why she was seeking help. Arleen has exhibited symptoms of diminished interest in returning back to being a police officer, as well as even visiting or seeing any person from her job. This is because she may feel like it brings the situation all back again. She has declined invitations from her colleagues to go out or even visit. She is socially withdrawing herself.
3) Are there any physical, psychological, or social/ environmental conditions that might predispose a patient to getting this disorder?
P.T.S.D. can affect anyone who has been victimized or has witnessed a violent act or who has been repeatedly exposed to a life-threatening situation. Usually, survivors of domestic or intimate partner violence, rape, or physical assault experience PTSD. Also Survivors of unexpected events in everyday life, like car accidents or natural disasters also tend to suffer. In Arleens case she is a police officer and they are socially most likely to be diagnosed with PTSD. Professionals who respond to victims in trauma situations like Arleen have high incidence. There is really no set predisposition out there, but there are people in certain professions at risk such as the ones mentioned. Research I read earlier is looking into whether PTSD has anything to do with the way people perceive events. They are inquiring into whether those who report greater perceived threat or danger, suffering, upset, terror, and horror or fear are more likely to suffer. PTSD was first introduced to the DSM-IV in 1980 so it is a fairly new diagnosis of which is still the topic of many studies.
4) What other conditions might you need to rule out?
For Arleen, we found it necessary to rule out two other conditions. At first we believed our client was depressed or had general anxiety disorder. Both of the symptoms for these disorders seemed to be present. For depression everything seemed to fit, the depressed mood, the sleep patterns and even the withdrawals from others. She did not want to socialize in any way. She also seemed to have negative feelings of self worth. We also thought she might have GAD because she seemed uneasy around the company of others because of the incident and she seemed to not have the ability to relax. She was also shaky, and irritable as well as experiencing trembling and twitching that we witnessed. It seemed perfect.
The defining factor hit us when Arleen indicated that she had been experiencing flashbacks in forms or dreams and vivid memories often. She claimed she could not get the images out of her head. And she told us she felt like if she could change something things would be different. After our client told us this we realized she fit the criteria for Post-Traumatic stress disorder. Besides for GAD the symptoms would need to be present for six months or more and it had not been that long since the incident. It was a close match for another diagnosis but my partner Justin and myself feel confident in our ability to assess Arleen.
5) What specific areas of the brain might be affected and how might they be affected?
Specific areas that might be affected from this disorder vary. Sensory input, memory formation and stress response mechanisms are affected in patients with post-traumatic stress disorder (PTSD). The regions of the brain involved in memory processing that are implicated in PTSD include the hippocampus, amygdala and frontal cortex. While the heightened stress response is likely to involve the thalamus, hypothalamus and locus coeruleus. The amygdala is located in the limbic system, and connects the cortex with the hypothalamus. It is really small and shaped like an almond. This tiny little object integrates the behavioral, autonomic, and hormonal components of emotion. The hippocampus of the brain is the learning and memory center for storing raw information from our senses.
A PTSD patient may have a damaged or reduced size hippocampus because of the stress induced cortizol levels. There is also consistent evidence from MRI volumetric studies that hippocampal volume is reduced in posttraumatic stress disorder (PTSD). This atrophy of the hippocampus is thought to represent decreased neuronal density. However, other studies suggest that hippocampal changes are explained by whole brain atrophy and people with PTSD exhibit generalized white matter atrophy. In adults such as my client there is a reduction in hippocampal volume. The BNST or better known as the Bed Nucleus of the Stria Terminals perpetuates fear response causing long-term unease such as anxiety.
6) What neurotransmitters might be involved in this condition and what evidence supports this?
There are many chemical alterations involved with this condition. Serotonin, Dopamine, Norepinephrine and Cortizol are definitely involved. Recent findings show that amino acid transmitters, glutamate and GABA, are intimately involved in the process of factual memory registration, and suggest that amine neurotransmitters, norepinephrine and serotonin, are involved in encoding emotional memory. In addition, research suggests that 5-HT neurons have direct effects on both adrenergic and HPA function.
There is a dysregulation of neurotransmitters in the brain. Serotonin is altered. Serotonin is involved in many processes. It helps regulate sleep, aggression, and respiratory activity. It also helps us regulate anxiety, mood and motor output. Because Serotonin controls all of these, it may be related to various PTSD symptoms. The main ones include the persons hypervigilence, exaggerated startle, irritability, impulsivity, aggression, intrusive memories and depression. Both what serotonin helps regulate and the symptoms of PTSD are comparable. Cortizol is also very involved in this condition because low levels of cortizol are correlated with stress.
7) How might this condition be treated? How do these treatments work to address the specific physical and psychological conditions? What side effects are associated with your treatments? If appropriate, be sure to include different types of treatments.
Post-traumatic stress disorder can be treated both in a therapeutic and pharmacological method or using both of those methods to create a multi-modality method. There is no documented tested cure for PTSD but different forms of treatments have yielded several positive results. Certain prescription drugs will work on certain symptoms of the disorder. For example, select serotonin reuptake inhibitors or better known as SSRIs such as Zoloft, Prozac and Paxil, will help with intrusive recollections. They will also help by regulating some of the flashbacks, Get rid of the insomnia, and regulate irritability. These have also been approved by the FDA, for use by PTSD clients. SSRIs do have side effects, the main one being sexual side effects but this is not as alarming as other side effects such as those of MAOIs.
Another class of prescription drugs used is the benzodiazepines. These include mainly Valium and Xanax, as the most widely used. These drugs are supposed to help with basic symptoms of PTSD like hypervigilence, hyper arousal, and nightmares, to name a few. However benzodiazepines are widely prescribed and not very effective or specific. They also produce dependency issues and withdrawal symptoms. The last categories of prescription drugs used to treat PTSD are MAO inhibitors. These are not used too often but work on relieving invasive thoughts, depression, insomnia and flashbacks. The reason MAOs are not used widely is because they have way too many food and alcohol restrictions. A person would have to specifically watch their diet and make sure they cannot have wine and cheese products, because the interaction with the drugs and chemicals would have aversive side effects.
They also do not mesh too well with many other drugs. People who do not wish to begin a medicine treatment for their disorder also have the psychological approach. In the psychological approach there are many goals. For example a counselor would want to teach the client healthy skills such as, problem solving and decision-making skills. This would be the best approach for my client, Arleen seeing as she does not wish to take pills. Other things my client would learn is boundaries, emotional and physical and self-care strategies. These are very useful methods the psychological approach uses and in some cases has been proven just as effective if not more that medication.
On a final note it is my recommendation that Arleen attempt a multi- modality approach to getting better. She can try going to therapy session conjoined with some medication to help settle her hypervigilence and edginess. In the end, I feel a client has to want to get better in order for these methods to be successful.