CASE STUDY SAMPLE

Name: Cindy Oakley

Age: 26

Gender: Female

Diagnosis: Posttraumatic Stress Disorder with delayed expression.

Reason for clients visit

The client is concerned about having flashbacks of traumatic events from 10 years in the
past. These events centered around a series of repeated rapes that had occurred when she was 16
years old. The surfacing memories made the client depressed for about 3 months which
prompted her to respond to a community advertisement for a university-based research clinic that
was evaluating treatments for victims of sexual assault.

Problem / Symptoms

According to DSM-5, the client is manifesting characteristics of PTSD but with delayed
expression. The client is having flashbacks of events that centered around a series of repeated
rapes that occurred to her when she was 16 years old. Aside from the distressing images about
the events, the flashbacks include times when the client would momentarily feel as if the past
were occurring all over again. As more memories from the past surfaces, the client became more
depressed and agitated.

Psychosocial and Environmental Problem Areas

The client revealed that after the incident, a lot of things changed. She became a total
rebel and started to hang out with troubled kids. She often lied and began drinking. She rarely
interacted with her brother whom she was close to before the incident and frequently fought with
her mother. She dated a wild guy who was totally bad news and got pregnant. Knowing not to
do, she consulted her father who decided to abort the child. The client reported that although she
might have made the same decision, she now regretted relinquishing her right to decide.
 The client also mentioned how she lacked the self-confidence to go to college. Also, her
social support was poor that she received negative reactions to her disclosure about the assault
from her closest friends. One of her best friends for instance responded by telling her to get over
the incident.

Precipitating Factor

Aside from the traumatic events that the client experienced, one of the factors that may
have caused the development of PTSD would be genetic factors. It is noted that the client’s
father who was a Vietnam veteran experienced symptom of PTSD from events he had
experienced during the war. This is supported by research (Watson et al.,1995) who found that a
trauma survivor’s risk for PTSD may be related to his/her family's history for PTSD.
Furthermore, researchers (Tolin & Foa, 2006; Tekin et al.,2016; Ainamani et al., 2020) suggests
that women are more likely to develop symptoms of PTSD than women.

In addition, the client lacked social support. According to Lazarus & Folkman (1984), the
presence of social support is seen as one of the best protective factors against the development of
PTSD. But what happened to the client was that she got disregarded by her close friends when
she disclosed what occurred to her. One of them simply told her to get over it. Thrasher et al.
(2010) said that social support is a predictor of better treatment outcomes for PTSD and thus
recommends the increase of access to social support from friends and families for patients with
PTSD.

I. CASE OVERVIEW

The client recounted that her childhood was a happy one and characterized her house as a
safe house in their neighborhood. Her father was a Vietnam veteran who is suffering from
PTSD from events he experienced during the war and her mother was a fanatic self-help
book who filled the house with them. She described her father as emotionally shut off yet
spoke very fondly for him. She had a close and supportive relationship with her mother. She
was also close to her older brother until the incident happened. The client disclosed that she
had been repeatedly raped by a close friend in the family for over a 5-week period and was
subjected to several sexual activities which included oral, vaginal, and anal intercourse and
was verbally threatened although no weapons or physical injuries were involved. Before the
incident, the client was still a virgin and had trusted the assailant as her family adopted him
due to his abusive family. During the assault, she mainly felt detached, numb, guilty, and
embarrassed. The incident only stopped when the client told her mother that the assailant was
trying to flirt with her and that she needed him to stop. The client’s mother then told the
assailant to stay away from her although she never told her mother that she had been raped.
Thus, the incident was not reported to the police and she never received medical care.

After the incident, the client began to change. She withdrew from her normal high school
activities and began to hang out with troubled kids. She lied often and began drinking. She
fought frequently with her mother and rarely interacted with her older brother who was best
friend with her assailant. She became a total rebel and dated a wild guy who was bad news
and got pregnant. Not knowing what to do, she consulted her father who took over and
arranged for an abortion. The client added that although she may have possibly made the
same decision, she regrets relinquishing her right to decide. The client lacked the self-
confidence to attend college so her mother talked her into taking classes at a business school
for secretarial training. She had worked as an executive secretary until the current year where
she was unemployed for 6 months.

Fortunately, she had a good sense 5 years ago and was able to marry a fine man with
whom she had 2 kids. She began having flashbacks about the traumatic events from the past
while she was having an extramarital affair. Aside from the distressing images of the events
that seem to come into her mind out of nowhere, the flashbacks included times when the
client would feel as if the past were occurring all over again. When she realized that the affair
coincided with the exact time of the year that she had been raped, she broke off the affair.
Even so, she became more depressed and agitated as more memories surfaced. The recurrent
flashbacks made the client depressed for about 3 months which prompted her to respond to a
community advertisement for a university-based research clinic that was evaluating
treatments for victims of sexual assault. Although she had an extramarital affair, her husband
did not give up on her and is even supportive of her efforts to receive therapy.
 II. DSM-5 DIAGNOSIS

The following diagnostic criteria are from the Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition. The symptoms italicized are the ones experienced by the client.

Posttraumatic Stress Disorder with delayed expression [309.81 (F43.10)]

A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of
the following ways:

1. Directly experiencing the traumatic event(s)

The client reported that she experienced actual sexual violence and was subjected to
several sexual activities including oral, vaginal, and anal intercourse.

4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s)

(e.g., first responders collecting human remains: police officers repeatedly exposed to details of
child abuse).

The client reported that she was repeatedly raped for an over 5-week period and was
subjected to several activities including oral, vaginal, and anal intercourse.

B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic
event(s), beginning after the traumatic event(s) occurred:

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).

The client reported that during the course of the extramarital affair, she began to have
flashbacks about the series of repeated rapes that occurred when she was 16 years old. The
intrusive images of these events would come into her mind out of nowhere causes distress to the
client.
 3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the
traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the
most extreme expression being a complete loss of awareness of present surroundings.)
The client reported that the flashbacks cause her to momentarily feel as if the past were
occurring all over again.

4. Intense or prolonged psychological distress at exposure to internal or external cues that

symbolize or resemble an aspect of the traumatic event(s).

The client became more depressed and agitated as more memories surfaced. For the last 3
months, the client felt depressed which merits the criteria as the duration of feeling depressed is
accounted as intense or prolonged.

C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the
traumatic event(s) occurred, as evidenced by one or both of the following:

2. Avoidance of or efforts to avoid external reminders (people, places, conversations,

activities, objects, situations) that arouse distressing memories, thoughts, or feelings
about or closely associated with the traumatic event(s).

The client reported that she began to have flashbacks about the series of repeated rapes
that occurred to her when she was 16 years old during an extramarital affair. When she realized
that the affair coincided with the exact time of the year that she had been raped, she broke off the
affair.

D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning
or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the
following:

1. Inability to remember an important aspect of the traumatic event(s) (typically due to

dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).
 During the first interview, the client only gave a sketchy account of the incident although
it became clearer as more memories surfaced. This implies that the client wasn’t able to
remember a lot of aspects of the traumatic event in the beginning.

4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).

The client reported that when she was repeatedly raped, she mainly felt detached, numb,
guilty, and embarrassed. It is also noted that when she began to have flashbacks about the
incident, she became increasingly depressed and agitated as more memories surfaced.

5. Markedly diminished interest or participation in significant activities.

After the incident, the client withdrew from her normal activities in high school.

6. Feelings of detachment or estrangement from others.

The client reported that after the incident, she began to distance from her older brother
who was best friend with her assailant. She also had frequent fights with her mother.

E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning
or worsening after the traumatic event(s) occurred, as evidenced by two (or
more) of the following:

2. Reckless or self-destructive behavior.

After the incident, the client lied often and began drinking. The client began to hang out with
troubled kids and got in a car accident due to a friend’s reckless driving. In the end, she got
pregnant by a wild guy who was totally bad news.
 3. Hypervigilance.

The client reported that as more memories resurface about the incident, she felt more
depressed and agitated.

F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.

This criterion meets the diagnosis since the period of disturbances has started when the
incident has occurred and had been in progress for 10 years. The client had been disturbed by
Criterion A and B for more than 1 month.

G. The disturbance causes clinically significant distress or impairment in social, occupational,

or other important areas of functioning.

The client reported that after the incident, she began to distance from her older brother
and had frequent fights with her mother. She also withdrew from her normal high school
activities and became a total rebel. She got pregnant by a wild guy she dated and relinquished her
right to decide about the pregnancy which resulted in abortion. She lacked the self-confidence to
attend college and had been unemployed for 6 months. In addition, she had an extramarital affair.

H. The disturbance is not attributable to the physiological effects of a substance (e.g.,

medication, alcohol) or another medical condition.

This criterion meets the diagnosis since the client was not seen to have any physiological
effects of a substance or another medical condition.

Specify if:

With delayed expression: If the full diagnostic criteria are not met until at least 6 months after
the event (although the onset and expression of some symptoms may be immediate).
 The client’s diagnosis has not fully met the criteria B1 & B3 (flashbacks) until the
flashbacks started to appear during the extramarital affair. The period of disturbance started 10
years ago.

III. ADDITIONAL INFORMATION (PREVALENCE/DEVELOPMENTAL

COURSE/ETIOLOGY/RISK AND PROGNOSTIC FACTORS/CULTURE
RELATED DIAGNOSTIC ISSUES/GENDER RELATED DIAGNOSTIC ISSUES)

A. Women have been found to have greater exposure to sexual assault throughout their lifespan
(Pratchett et al., 2010). Across all female age groups, girls from the ages of 16 to 20 have been
found to have the highest risk of traumatic exposure (Breslau, 2009). And studies show that,
compared to other types of traumas (e.g., physical assault or combat), rape exposure is most
strongly associated with PTSD (Norris et al., 2003). In this case, the client was 16 years old
when she was exposed to sexual assault and 10 years later, she experienced symptoms that fully
meet the criteria for a PTSD diagnosis.

Delayed disclosure of rape has been associated with mental health. Research has found that
victims of rape who disclosed the incident after 1 month have a higher prevalence to PTSD than
those who disclosed the incident within 1 month. In the client’s case, she never told her mother
and her family about the rape so they were never able to help and support her. They weren’t able
to understand why she changed, why she chose to hang out with troubled kids, and why she
lacked the self-confidence to go to college. Furthermore, the client received negative reactions
from her close friends when she disclosed about the traumatic event that occurred to her. As
Ullman and Filipas (2001) have found, negative reactions to a woman’s experience of
victimization can lead to more psychological harm.

Although the client’s social support is rather poor, it is good to note that she still has her husband
who did not give up on her despite her extramarital affair. Research has shown that having strong
social support in times of crisis can help reduce the consequences of trauma-induced disorders
including PTSD (Gros et al., 2016). Her husband would be her source of support, empathy, and
motivation.
B. Differential Diagnosis

a) Depressive Disorder – The client may have symptoms that weren’t fully investigated in
the case because the client reported that she felt depressed for the last 3 months after
ending the extramarital affair.
b) Substance Use Disorder – The client stated that she often smoked marijuana during the
initial interview. She was defensive about her use of it and said that she did not want to
quit. Further investigation regarding this matter would be beneficial as this may be
comorbidity to the preliminary diagnosis of PTSD with delayed expression.

IV. ASSESSMENT AND EVALUATION PROCEDURES/TOOLS

To assess the client, I would first let the client answer a self-report measure designed to
identify whether she is likely to have PTSD. I would use the PTSD Checklist for DSM-5 (PCL-
5) that aims to screen individuals for PTSD, aid in diagnostic assessment for PTSD, and to
monitor change in symptoms of PTSD. Specifically, I would use the PCL-S (specific) version
that asks about symptoms concerning an identified “stressful experience” and ensuring that the
index event met the PTSD Criteria A. The PCL-5 has been evaluated by researchers to be a
psychometrically sound measure of PTSD symptoms (Blevins et al., 2015; Bovin et. al, 2016;
Wortmann et al., 2016).

After determining that the client is likely to have PTSD using the PCL-5 self-report
measure, I would conduct a clinical interview using the Clinician-Administered PTSD Scale for
DSM-5 (CAPS-5) to make a current diagnosis of PTSD, make a lifetime diagnosis of PTSD and
assess PTSD symptoms over the past week. The CAPS-5 has been evaluated to be a
psychometrically sound measure of DSM-5 diagnosis and symptom severity (Weathers et al.,
2018).
 V. EVIDENCE-BASED TREATMENT FOR THE DISORDER

Fortunately, there are many well-validated psychotherapies available to address PTSD-

related problems across the lifespan (Foa et al., 2009). Among these, Cognitive behavioral
therapy (CBT) is the most common approach for the treatment of PTSD. The idea is to change
thought patterns that causes distress to people by talking about the trauma and concentrating on
where fears come from. A lot of studies have been conducted to investigate the efficacy of CBT
and have found it effective for the treatment of PTSD (Smith et al., 2007; Mendes et al., 2008;
Levi et al., 2016). Of these, prolonged exposure (PE) and cognitive processing therapy (CPT)
were primarily used as an approach to the treatment of PTSD cases. PE aims to teach patients
how to gradually approach their trauma-related memories and make them realize that trauma-
related memories and cues are not dangerous so they don’t need to avoid them. Meanwhile, CPT
helps patients learn how to modify and challenge unhelpful beliefs related to the trauma.

In addition, researchers have found that anti-depressants are an effective treatment for PTSD
(De Boer et al., 1992; Pearlstein, 2000; Stein et al., 2006). These medications can help symptoms
of depression and anxiety and can help improve sleep problems and concentration. The selective
serotonin reuptake inhibitor (SSRI) medications sertraline (Zoloft) and paroxetine (Paxil) are
approved by the Food and Drug Administration (FDA) for PTSD treatment.
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