Running Head: POST-TRAUMATIC STRESS DISORDER (PTSD)

Post-Traumatic Stress Disorder (PTSD)

A Special Topics Paper
Craig Canniff
Wake Forest University

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Post-Traumatic Stress Disorder (PTSD)
A Special Topic Paper
Post-Traumatic Stress Disorder (PTSD) was first added to the Diagnostic Manual of
Disorders (DSM) in 1980 in an attempt to categorize functional impairments of veterans
returning from the Vietnam Conflict (Richardson, et al., 2010). However, since its inclusion to
the DSM the disabling and debilitating effects of trauma related PTSD symptomology has had
far reaching effects well beyond the original veteran population. At risk groups with higher
incident rates now include: Adolescences and young adults, people in hazardous occupations,
sexual assaults, severe burn cases, psychiatric cases, and refugees (James & Gilliand, 2013).
PTSD is a treatable disorder that has a high comorbidity with other psychiatric and medical
disorders, including anxiety, depression, and substance use disorder (Richardson, et al., 2010).
The focus for this special interest paper encompasses: What is found in literature on
PTSD; a case study relevant to PTSD which includes both a conceptualization and treatment
formulation; and finally multicultural and legal/ethical considerations.
Summary of the Literature
Diagnoses Criteria
PTSD is defined by American Psychiatric Association (APA) in the fifth edition, text
revised Diagnostic and Statistical Manual of Mental Disorders (DSM-5, 2013). It is categorized
as an anxiety disorder with an essential feature of direct exposure or experience to an extreme
traumatic stressor followed by characteristic symptoms (APA, 2013). The traumatic experience
involves threat of injury or death to ones self coupled with the intense fear of helplessness. In
addition to substantiating direct exposure or experience, the APA, (2013) also established three
categories of symptoms; intrusive memories, avoidance and numbing, and increased anxiety and

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hyper-arousal. Furthermore, they established criteria (APA, 2013) within each of the three
categories that must be documented to obtain a clinical diagnosis of PTSD. A clinical diagnosis
of PTSD requires one or more of these symptoms are present. The second category, avoidance
and numbing, the APA (2013) categorizes individual behavior as a persistent avoidance of
thoughts, feelings, people, and places associated with the traumatic event. The individual may
become detached from others and may feel emotionally separated or demonstrates an inability to
maintain close personal and professional relationships (APA, 2013). The individual may also
develop a feeling of hopelessness and may suppress memories of the traumatic event out of the
conscious state of mind. A clinical diagnosis of PTSD requires three or more of these symptoms
are present. The third and final category is of symptoms, increased anxiety and hyper-arousal
encompass symptoms which have manifested themselves as extreme alertness, irritability, anger,
inflated startle reaction and inability to concentrate, irregular sleeping habits such as insomnia
(APA, 2013). A clinical diagnosis of PTSD requires two or more of these symptoms are present.
The APA (2013) further defined clinical diagnosis parameters by stating the symptoms
must last longer than a month and must cause impairment to an area of operational and social
functioning. Furthermore, they differentiated between: chronic PTSD, symptoms lasting less
than 3 months; delayed PTSD, onset of symptoms occurs six months or more after the traumatic
event; and acute PTSD, symptoms occurring for less than a month (APA 2013).
Prevalence Rates
The total numbers of individuals classified as having PTSD since 1980 is unknown, but it
has been estimated that U.S. combat veterans have been diagnosed with PTSD at a rate of two to
four times the rate of their U.S. civilian counterparts (Richardson, et al., 2010). In a 1984 study,
Jelinek and Williams estimated that approximately 4 million soldiers served in Southeast Asia

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between 1964 and 1975, of which 500,000 to 1.5 million had debilitating PTSD symptomology,
which if correct, civilian estimates would range between 250,00 to 750,00 during the same time
period. James and Gilliand (2013) estimated the chance of developing PTSD symptomology
after a trauma is relatively small, approximately 20 percent. The National Center for PTSD
(2016) reports that as many as 13 percent of women have experienced a sexual attack or trauma
during their lives with female childhood sexual abuse reported at 27 percent.
Treatment Available
Based on the literature review, the Department of Defense (DOD) currently utilizes three
PSTD treatment approaches.
First, a Group-Based Exposure Therapy (GBET) program which was developed by the
Atlanta VA which has been described as, A manualized, multifaceted, and cognitive-behavioral
treatment that synthesizes components of psychological education, psychosocial skill training,
and exposure to trauma memories to treat chronic combat-related PTSD and depressive
symptoms (Ready, Sylvers, Worley, Butt, Mascaro, & Bradley, 2012). The 16-week therapy
program utilizes cognitive behavior therapy, trauma focused therapy, interpersonal problem
solving, and relapse prevention (Ready, et al., 2012). Effectiveness rates are promising.
Second, a Prolonged Exposure Therapy (PE) which is an evidenced based manualized
protocol for treatment. PE is based in Emotional Processing Theory, which posits that PTSD
symptoms arise as a result of cognitive and behavioral avoidance of trauma-related thoughts,
reminders, activities and situations. PE uses vivo (repeatedly engaging in activities, situations,
or behaviors that are avoided because of the trauma) and imaginal exposure (repeatedly
revisiting the traumatic experience in memory describing the event aloud in detail) to help
clients interrupt and reverse the process of blocking cognitive and behavioral avoidance,

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introducing corrective information, and facilitating organization and processing of the trauma
memory and associated thoughts and beliefs (Center for Deployment Psychology, 2016).
Third, a Cognitive Processing Therapy (CPT) for PTSD. CPT for PTSD is 12-session
individual or group therapy program with the goal of improving PTSD symptoms, and associated
symptoms such as depression, anxiety, guilt, and shame (Resick, Monson, & Chard, 2014). Its
aim is to identify and explore how the clients trauma(s) has changed their thoughts and beliefs,
and how some of these ways of thinking may keep them stuck in their symptoms (Resick,
Monson, & Chard, 2014). Patients write about their trauma experiences in order to understand
how they have affected their thoughts, feelings, and behaviors. Effectiveness rates are
promising.
Case Study
Conceptualization
The patient is a 53-year-old African American divorced female, domiciled, and
employed, who was voluntarily admitted to Emerald Coast Behavioral Hospital (ECBH) with the
presenting conditions of depression and suicidal ideation. Presenting conditions were
triggered by her inability to deal with the murder of her son in April of this year. Patient has a
significant history of depression over the past 20 years and has been hospitalized at Peachford in
Atlanta just following the death of her son, and twice at ECBH in June and November 2013 for
depression accompanied by auditory hallucinations of a derogatory nature telling her she
shouldnt be here. Hospitalizations in 2013 were in response to the death of her brother. Patient
was subjected to childhood maltreatment due to parental abandonment and sexual abuse both
within and outside the immediate family. Patient has experienced a tremendous amount of
trauma both within her childhood and adult life. Patient significant losses are: father was

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murdered while answering the door, mother died of cancer, brother committed suicide, her close
childhood female friend died, and her son was recently murdered. Patient was a victim of
childhood sexual molestation by her cousin, mothers partner, and she became pregnant by her
mothers ex-boyfriend. Patient stated that she had planned to get a hotel room and consume a lot
of sleeping pills. Although she had not identified a time and date, she had written her final letters
to her children. Patient exhibits a tremendous amount of self-blame, has low self-esteem, and
states that everybody that loves her dies. Upon arriving home after church one Sunday, she
learned that her brother had gotten in trouble with the law and committed suicide. Patients son
was murdered 5 months ago; was drug related. Patient has assumed most if not all of the
responsibility for her sons murder because in 2003 she wanted her son, age 14, to have a father
figure so she sent him to live with her mothers ex-boyfriend. During his 1 year stay, he was
introduced to illegal drugs that continued until his death. Patient is suffering from both grief and
guilt for the death of her son and is experiencing a tremendous amount of self-blame. Patient
says she is expected to be a pillar of strength outwardly and is unwilling to share her story or
display emotions because its a sign of weakness; afraid people will judge or ridicule her. Im
an emotional wreck inside. The patient has also rationalized that she is responsible for the
deaths because of things she either did or didnt do. Patient denies previous suicide attempts or
homicide ideation and denies history of tobacco, alcohol, or substance abuse.
The challenge for the patient is to function more effectively, and to feel safe while she
interacts and relates to others and within her external world. The initial goal was to use a personcentered approach to help the client with her depression and suicidal ideation. However, due to
the complexity, scope, and nature of the patents childhood and adult trauma issues, increases in
her occupational and social levels of functioning required a switch from a person-centered

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approach to a more structured treatment approach, CPT for PTSD. The treatment goals were to
address her PTSD symptomology and associated symptoms such as depression, anxiety, guilt,
and shame, with the aim of improving her day-to-day living. The 12 session format focused on:
Meaning of the event; identification of thoughts and feelings using A-B-C worksheets;
identification of stuck points; challenging questions; patterns of problematic thinking;
challenging beliefs; safety issues; trust issues; power/control; self-esteem; and intimacy issues.
The therapeutic strategy was to identify and explore how the patients trauma(s) has changed her
thoughts and beliefs, and how some of these ways of thinking may kept her stuck in her
symptomology.
DBT group therapy focused on the following areas: First, the reduction and stabilization
of her depressive symptomology through use of mood stabilizing pharmaceuticals. Second, the
identification and recognition of both early warning signs and triggers. Third, identification and
use of breathing techniques, positive coping and grounding skills to promote further stabilization.
Fourth, social skills training in a group therapy setting emphasizing assertive communication,
trust, and friendship. Fifth, since the patient had not been previously able to verbalize her
trauma, she will be encouraged to begin journaling her emotions and feelings as a means of
validating and acknowledging their existence. Sixth, the use of confidence targets where she
was required to perform tasks with gradual increases in risks which promoted her confidence to
effectively work through her PTSD triggering situations.
Some obstacles and challenges to post discharge treatment are anticipated. Given her
propensity to avoid verbalization of her experiences with loved ones and her psychiatrist,
avoidance will likely continue unless a safe and secure environment is fostered for self-

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disclosure. Once trust is established with the therapist and she begins gaining confidence she
will likely cling to the therapist as a support system which may elicit problems during the
termination stage of the therapeutic alliance. The feasibility exits for some level of patient
transference. The therapist should consider utilization of group sessions and community support
groups as continued support mechanisms to aide and assist in the post discharge treatment
planning. Due to the patients reliance on her religious beliefs, it would be essential to
incorporate her religious beliefs and her family support systems into post discharge planning.
Assuming the patient is able to continue stabilization of her symptomology and is able to
achieve increased levels of occupational and social levels of functioning, she will be able to
achieve what she described as a normal life again. If she is unable to gain self-confidence,
relational skills, and social contacts both in and outside therapy, it will promote further isolation
and reinforcement of her symptomology.
Treatment Plan
Diagnosis: 309.81 (F43.10) PTSD, depersonalization
Short Term Goals and Objectives:
Goal 1: Identification and recognition of early warning signs and triggers mechanisms
associated with the PTSD symptomology.
Objective 1: Patient will become familiar with and will be able to identify early warning
signs and triggers mechanisms associated with her PTSD symptomology and identify appropriate
coping and grounding skills.
Objective 2: Patient will participate in at least two complete DBT groups or activities per
day.

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Objective 3: Patient will identify feared situations and discuss at least one such situation
in the daily individual session.
Goal 2: Patient will be able to decrease her reactivity to PTSD symptomology through
emotional regulation. Patients reported self-assessed PCL rating will begin to decrease after the
4th PTSD session.
Objective 1: Practice cognitive restructuring and use of positive self-talk when faced with
trauma producing situations.
Objective 2: Patient will identify at least three each new coping and grounding skills
(soothing, mental, and physical) that can be utilized to reduce PTSD producing symptomology.
Goal 3: Identification, recognition, and resolution of stuck points enabling the patient to
move forward in resolution of depression, anxiety, guilt, and shame symptomology with the aim
of improving her day-to-day living.
Objective 1: Patient will participate in at least three PTSD session per week.
Objective 2: Patient will develop her trauma account, identifying the primary trauma
incident, based on her five senses of what occurred.
Objective 3: Patient will complete 10-12 ea. A-B-C worksheets, understanding the
relationships between the triggering event, what she thinks, and the emotions and feeling she
experiences.
Long Term Goals and Objectives:
Goal 1: Patient will achieve a reduction in PTSD symptomology; PCL less than 38 no later
than session 12; threshold for further PTSD assessment/evaluation.
Objective 1: Patient will develop confidence in used of emotional de-escalation skills
and will be able to confronted her most feared situations.

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Objective 2: Patient will not have suicidal thoughts or thoughts of harming herself for a
period of 1 week.
Assessment:
PCL PSTD Symptomology Severity self- assessment; completed prior to each session.
PHQ-9 Depression Severity Scale
Clinical Characteristics:
Location of Treatment: Patient was admitted to ECBH for observation and will attend
individual and group sessions for the next 30 days and upon discharge will be wrapped in post
discharge services; individual therapy and community mutual support groups.
Interventions: Individualized Cognitive-Processing Therapy for PTSD and group
Dialectic Behavioral Therapy (DBT) and Mindfulness Therapy.
Emphasis:
Patients primary motivation: The reduction of major depressive symptomology and
suicidal ideation. Prognosis is good that the patient can achieve all identified goals and
objectives which will promote improvement in her current occupational and social levels of
functioning.
Defectiveness continuum: The therapist will use a structured and more directive CPT
PTSD program with established session goals and objectives for accomplishment.
Past vs. present focus: Given the present-moment nature of the patients presenting
concern, the majority of counseling will remain present focused, but improving her occupational
and social levels of functioning with regard to past trauma.
Numbers: Concurrent treatment for individualized PTSD and group DBT and
Mindfulness sessions for the identification of both early warning signs and trigger mechanisms

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and the development of coping and grounding skills. The patient will also be evaluated for
community mutual support group attendance as part of her post discharge plan.
Timing: Three individual PTSD sessions per week for 4 weeks for a total of 12 sessions,
then re-evaluate benefit of additional sessions. Additionally, there will be two group DBT
sessions (psychoeducational and process) per day, 7 days a week.
Medication: Although the patient has seen a therapist, there is no indication that the
patient has been has placed on mood stabilization pharmaceuticals. Therefore, a recommended
will be made for mood stabilization pharmaceuticals for stabilization of her depressive
symptomology.
Adjunct Services: A review will be conducted to determine the nearest location of
various PTSD support groups that the patient may benefit from.
Prognosis: Prognosis is good that the patient can in fact achieve all identified goals and
objectives which will restore her previous occupational and social levels of functioning.
Advocacy, Multicultural, and Legal/Ethical Considerations
Advocacy Strategies. Due to the vast number of at risk groups (adolescences and young adults,
people, in hazardous occupations, sexual assaults, severe burn cases, psychiatric cases, and
refugees), perhaps one of the most effective strategy would be increasing public awareness,
through the recognition and understanding and debilitating effects of PTSD (psychoeducation).
A second strategy would be the education of loved ones and other support personnel about the
symptomology, treatment modalities, and locations of community support groups.
Cultural Considerations.

Due to the structured nature of CPT for PTSD, the therapy may

either be culturally offensive and/or may not be useful for certain cultural groups. Additionally,
knowledge of and exhibiting culturally relevant considerations will be essential to forming a

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therapeutic alliance with this patient. Being culturally (female African American) aware of the
relative importance of both the role of the family and her religious support systems is critical to
establishing a therapeutic alliance with the patient. One of the major stuck points was her
inability to forgive herself. Having a strong belief in God, I once summarize, what Im hearing
is that you have a strong religious belief in God and that you believe that God will forgive you
for your sins, no matter what they are, as long as you ask for forgiveness. Knowing God can
forgive you for any sins that you may have committed, can you help me understand your
inability to forgive yourself? This served as a major point of self-awareness for and enabled her
to move past the stuck point.
Legal and Ethical Issues. PTSD is a treatable disorder that has a high comorbidity with other
psychiatric and medical disorders, including anxiety, depression, and SUD (Richardson, et al.,
2010). However, due to the high comorbidity between PTSD and other mental health issues,
accurately diagnosis of all symptomology is an ethical concern. With a dual diagnosis, ethical
decisions must then be made in terms of concurrent or sequential treatments of the mental health
issues. Some primary ethical considerations spelled out in ACA (2104) ethical code are relevant
here: The primary responsibility of counselors is to respect the dignity and promote the welfare
of the client (ACA 2005, p. 4). Section A.4.b. states, Counselors are aware of and avoid
imposing their own values, attitudes, beliefs, and behaviors. Section A.1.d. Support Network
Involvement, the therapist is charged with enlisting the support and involvement of others
(people, organizations, etc.,) when appropriate.

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References
American Counseling Association (2014). ACA code of ethics. Alexandria, VA: Author.
American Psychiatric Association (2013). Diagnostic and Statistical Manual of
Mental Disorders (5th ed., Text Revision). Washington, DC: Author.
Center for Deployment Psychology (2016). Prolonged exposure therapy for PTSD (PE).
Retrieved from: http://deploymentpsych.org/treatments/prolonged-exposure-therapy-ptsd-pe.
Gilliland, B., & James, R. (2013). Crisis intervention strategies (7th ed.). Belmont, CA:
Brooks/Cole. 978-1111186777
Jelinek, J. M., & Williams, T. (1984). Post-traumatic stress disorder and substance abuse in
Vietnam combat veterans: Treatment problems, strategies and recommendations. Journal of
Substance Abuse Treatment, 1(2), 87-97. doi:10.1016/0740-5472(84)90031-X
Ready, D. J., Sylvers, P., Worley, V., Butt, J., Mascaro, N., & Bradley, B. (2012). The impact of
group-based exposure therapy on the PTSD and depression of 30 combat veterans.
Psychological Trauma: Theory, Research, Practices, and Policy, 4(1), 84-93.
Resick, P. A, Monson, C. M., & Chard, K. M. (2014). Cognitive processing therapy:
Veteran/military version: Therapist and patient material. Washington, DC: Department of
Veteran Affairs.
Richardson, L. K., Frueh, B. C., & Aciero, R. (2010). Prevalence estimates of
combat-related PTSD: A critical review. Australian and New Zealand
Journal of Psychiatry, 44(1), 4-19. doi: 10.3109/00048670903393597
U.S. Department of Veteran Affairs (2013). 38 CFR Book C, Schedule for Rating Disabilities.
Retrieved from: http://www.benefits.va.gov/warms/bookc.asp

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