Assessment Of Laurel: Steps, Methods, And Preliminary Diagno

Assessment of Laurel: Steps, Methods, and Preliminary Diagnosis

In conducting an intake session with Laurel, establishing a warm, empathetic, and nonjudgmental environment is essential to facilitate her comfort in sharing her story. The initial steps include a clear explanation of the purpose of the assessment, confidentiality limits, and the structure of the session. Building rapport involves active listening, demonstrating genuine concern, and ensuring her understanding that her experiences are valid and will be handled with sensitivity. Employing open-ended questions allows her to narrate her story at her own pace, while reflective listening affirms her feelings and encourages further disclosure. Ensuring privacy, maintaining a calm demeanor, and using non-threatening language all contribute to creating a safe space for her to open up. It is crucial to observe her emotional state and validate her feelings, especially given the traumatic nature of her experience, which can involve feelings of guilt, shame, and fear.

Continued assessment will involve multiple sessions, ideally three to four, to gather comprehensive information. To facilitate this process systematically, I will employ a combination of structured clinical interviews and standardized assessment tools. Instruments such as the Clinician-Administered PTSD Scale (CAPS) or the PTSD Checklist for DSM-5 (PCL-5) are appropriate for evaluating trauma-related symptoms, including intrusive thoughts, hyperarousal, and avoidance behaviors, which are relevant given her history of sexual assault and subsequent distress. The rationale for using these questionnaires lies in their established reliability and validity in assessing trauma-related symptoms, providing quantifiable data that can guide diagnosis and treatment planning. Additionally, I may utilize the Beck Depression Inventory-II (BDI-II) to assess severity of depressive symptoms, especially considering her recent history of depression. Combining qualitative data from narrative input with quantitative measures ensures a comprehensive understanding of her psychological state and allows tracking of symptom progression over time.

Given the current information, a provisional diagnosis for Laurel may be Post-Traumatic Stress Disorder (PTSD), based on her recounting of the traumatic event and subsequent symptoms such as hypervigilance, flashbacks, sleep disturbances, and emotional numbing. According to DSM-5 criteria, these symptoms have persisted for more than one month and cause significant impairment. Specifically, her re-experiencing symptoms, avoidance behaviors, hyperarousal, and emotional numbing align with Criterion B (Intrusion), Criterion C (Avoidance), and Criterion D (Negative alterations in mood and cognition). Her avoidance of talking about the event and her emotional withdrawal are characteristic signs supporting this diagnosis. Additionally, her depressive symptoms and difficulties with interpersonal relationships could suggest comorbid Major Depressive Disorder (MDD), which may be secondary to her PTSD or developmental factors. However, for the purposes of this assessment, PTSD remains the primary provisional diagnosis, pending further evaluation.

References

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
  • Foa, E. B., & Rothbaum, B. O. (1998). Treating the trauma of rape: Cognitive-behavioral therapy for PTSD. Guilford Press.
  • Weathers, F. W., Blake, D. D., Schnurr, P. P., et al. (2013). The PTSD Checklist for DSM-5 (PCL-5). National Center for PTSD.
  • Blow, A. J., & Hartog, S. (2009). Clinical interview and assessment tools for trauma. In R. J. Prat (Ed.), Handbook of trauma assessment and therapy (pp. 117-132). Guilford Press.
  • Herman, J. L. (1992). Trauma and recovery: The aftermath of violence—from domestic abuse to political terror. Basic Books.
  • Schwarz-Bucholer, M., & Mott, M. (2020). Assessing trauma and PTSD in clinical practice. Journal of Contemporary Psychology, 29(4), 254-269.
  • Resick, P. A., & Monson, C. M. (2017). Cognitive processing therapy for PTSD: A comprehensive manual. Guilford Publications.
  • Resnik, H. L., & Chen, M. (2019). The impact of trauma on emotional regulation: An assessment perspective. Psychology, 10(6), 612-626.
  • Keane, T. M., & Barlow, D. H. (2014). Trauma assessment and diagnosis. In E. B. Foa, T. M. Keane, & M. J. Friedman (Eds.), Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies (pp. 269-293). Guilford Press.
  • Najmi, S., & Amir, N. (2018). Using assessment tools in trauma-focused psychotherapy. Clinical Psychology Review, 65, 28-36.

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