Case Presentation Bae Intake Date July 6, 2019 Identifying D

Case Presentation Baeintake Date July 6 2019identifyingdemographi

Provide a full DSM-5 diagnosis for the client, including disorder name, ICD-10-CM code, severity, specifiers, and Z codes for other conditions that may be clinical focuses, considering the most recent 12 months.

Explain the diagnosis by matching symptoms from the case to specific DSM-5 criteria.

Identify the first area of focus as the client’s social worker and explain specific treatment recommendations supported by research.

Describe how to manage the client’s diverse needs, including co-occurring disorders.

Develop a treatment plan for the client, including methods to evaluate treatment progress, supported by relevant resources and evidence-based practices.

Sample Paper For Above instruction

Introduction

Trauma-related disorders represent a broad spectrum of mental health conditions that can arise after exposure to traumatic events. This case study explores Bae, a 22-year-old college student who experienced a traumatic incident involving witnessing a stabbing, resulting in significant psychological distress. Accurate diagnosis, targeted intervention, and culturally sensitive treatment planning are crucial for the effective management of her condition.

Diagnosis and Rationale

Based on the DSM-5 criteria and the details provided, Bae most appropriately fits the diagnosis of Posttraumatic Stress Disorder (PTSD). Her symptoms—persistent intrusive thoughts about the incident, hyperarousal, sleep disturbances, avoidance behaviors, and emotional numbing—align with DSM-5 criteria for PTSD (American Psychiatric Association, 2013). Specifically, Bae reports reliving the trauma through intrusive thoughts and flashbacks, difficulty sleeping, irritability, anxiety, and hypervigilance. Her avoidance of situations reminiscent of the event and emotional numbing further support this diagnosis.

ICD-10-CM coding identifies PTSD as F43.10, with severity likely moderate to severe given her impairment in functioning, ongoing distress, and symptoms of hyperarousal and intrusion (World Health Organization, 2016). Z-codes such as Z63.0 (problems related to primary support group) and Z60.0 (social environment issues) might also be relevant given her family and social stressors.

Treatment Focus and Recommendations

The initial focus as a social worker should be on safety and stabilization, addressing Bae’s acute anxiety, sleep disturbances, and trauma-related symptoms (Schnyder et al., 2015). Cognitive-Behavioral Therapy (CBT) with a trauma-focused approach, particularly Prolonged Exposure (PE) therapy, is supported by evidence as a frontline treatment for PTSD (Powers et al., 2016). Additionally, integrating techniques such as stress management, relaxation training, and psychoeducation can empower Bae to manage symptoms effectively.

Culturally competent care must consider her Korean heritage and familial expectations, which can influence her engagement and recovery process. Incorporating culturally sensitive interventions and possibly involving family in psychoeducation may enhance treatment adherence and outcomes (Maercker & Hecker, 2016).

Managing Co-occurring Disorders

Bae displays comorbid anxiety symptoms and alcohol use, which complicate her clinical picture. Addressing her substance use is critical, as it serves as a maladaptive coping mechanism for sleep and anxiety issues. A combined treatment plan of trauma-focused therapy with motivational interviewing for substance use is recommended (McHugh et al., 2017). Incorporating pharmacotherapy, such as prazosin for nightmares, might also be considered, in line with current evidence (Vale et al., 2018).

Treatment Plan and Evaluation

The comprehensive treatment plan involves multiple phases: initial stabilization, trauma processing, and relapse prevention. Initial interventions focus on psychoeducation, sleep hygiene, and managing safety concerns. Once stabilization is achieved, trauma processing using PE or Cognitive Processing Therapy (CPT) can be implemented. Progress will be monitored through standardized assessments like the PTSD Checklist for DSM-5 (PCL-5) (Weathers et al., 2013). Regular follow-ups will assess symptom reduction, functional improvement, and treatment adherence.

Conclusion

Accurate diagnosis and tailored, culturally sensitive intervention are vital in treating Bae's trauma-related symptoms. Employing evidence-based therapies such as trauma-focused CBT, addressing co-occurring substance use, and involving her support system will promote recovery. Ongoing evaluation and flexibility in treatment modalities will ensure that her needs are met effectively, fostering resilience and healing.

References

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing.
  • Maercker, A., & Hecker, T. (2016). Broadening perspectives on trauma and recovery: A socio-interpersonal view of PTSD. European Journal of Psychotraumatology, 7(1), 29303.
  • McHugh, R. K., Gratz, K. L., & Tull, M. T. (2017). The role of anxiety sensitivity in reactivity to trauma cues in treatment-seeking adults with substance use disorders. Comprehensive Psychiatry, 78, 107-114.
  • Powers, A., Fani, N., Cross, D., Ressler, K. J., & Bradley, B. (2016). Childhood trauma, PTSD, and psychosis: Findings from a highly traumatized, minority sample. Child Abuse & Neglect, 58, 111–118.
  • American Psychiatric Association. (2013). Dissociative disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books..dsm08
  • Schnyder, U., Ehlers, A., Elbert, T., et al. (2015). Psychotherapies for PTSD: What do they have in common? European Journal of Psychotraumatology, 6(1), 281–286. doi:10.3402/ejpt.v6.28186
  • Vale, O., Murphy, E., & McFarlane, A. (2018). Pharmacological approaches to PTSD. Expert Opinion on Pharmacotherapy, 19(16), 1765–1773.
  • Weathers, F. W., Litz, B. T., Keane, T. M., et al. (2013). The PTSD Checklist for DSM-5 (PCL-5). Scale available from the National Center for PTSD.
  • World Health Organization. (2016). International statistical classification of diseases and related health problems (10th revision). WHO.
  • Goral, A., Lahad, M., & Aharonson-Daniel, L. (2017). Differences in posttraumatic stress characteristics by duration of exposure to trauma. Psychiatry Research, 258, 101–107.

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