CLINICIAN NAME: LEAH CLIENT NAME: GINA S.
DSM 5 Code Diagnostic Classification
309.81 (F43.10) Posttraumatic stress disorder (PSTD)
Medications: Prazosin and sertiline
Supports/Strengths: Prazosin would be appropriate for this patient because it has been shown to reduce insomnia and nightmares. Sertiline is also necessary since it is an anti-depressant hence will help in management of anxiety and depression. This agent also aids in improving the patient’s concentration and sleeping problems.
Presenting Problems: Leah presents with flashbacks and nightmares to an extent that she fear sleeping alone. She has disturbing thoughts, dreams as well as feelings related to the terror attack that occur at her school. Moreover, Leah develops distressing and repetitive images of the attack. The event has made it difficult for her to concentrate in class or even remember what was taught in previous classes.
Treatment Recommendations: a) Psychotherapy is the primary treatment for patients suffering from PSTD. Leah should therefore be subjected to exposure therapy, a form of psychotherapy, which helps a patient to safely face what they find frightening so that she can learn to cope with the negative thoughts that she has. This technique uses virtual reality programs that would help Leah to re-enter the setting similar to that of the attack. Cognitive therapy should also be used to help Leah change her ways of thinking.
b) Medications such as diazepam an anxiolytic agent or sertraline an anti-depressant can be used to manage Leah’s symptoms.
Desired Goals of Tx: The psychotherapy treatment will help Leah learn ways of coping with the symptoms of the attack that she witnessed. They drugs can help in relieving symptoms of fear, depression, and anxiety that Leah is going through. This will in turn improve Leah’s sleeping problems and concentration in class. Additionally, Leah is expected to start socializing with her classmates just like she used to.
Frequency of Tx: Treatment should be initiated immediately and maintained and the patient is stable enough. The initial dose of sertiline should be 10mg once daily and increased to 20 mg after one week. Adjustments should be made weekly based on patient presentation. However, the patient should be monitored since administered agents, that is, sertraline and diazepam are associated with severe side effects.
Project Length of Treatment: Approximately 2- 3months
Supportive Background Documentation for Diagnoses and Meds:
PSTD is the primary diagnosis in the case study presented. This is because the disorder occurs as a result traumatic events such as traffic collisions, sexual assault, or terror attacks. Patients suffering from PSTD present with nightmares, flashbacks as well as distressing and repetitive images (Williams et al., 2013). These findings are consistent to those presented in the case study, hence proving that the Leah has PSTD.
CLINICIAN NAME: LEAH CLIENT NAME: GINA S.
Long Term Goals:
– Exercise proper sleeping patterns
– Patient should demonstrate proper control and relaxation techniques
Short Term Goals:
– Patient should manage her feelings and fear.
– Improved social interaction
TREATMENT GOALS/PROBLEMS, STRENGTHS, BARRIERS, PERSON RESPONSIBLE
Goal #1: Leah should demonstrate control and relaxation techniques
OBJECTIVES: Distinguish between present and memory. She should also recognize environmental triggers and react to them appropriately.
INTERVENTIONS: Evaluate the patient’s symptoms, encourage her to identify terrors, use de-escalation techniques in her management, and use virtual programs to boost Leah’s courage.
Target Date: December 20th, 2016 |Review Date: |Completed ?yes, ?no | New Target Date: |Review Date: |Completed ?yes, ?no
TREATMENT GOALS/PROBLEMS STRENGTHS BARRIERS PERSON RESPONSIBLE
Goal #2: Improved social interaction
OBJECTIVES: Patient will interact effectively with her peers. Her concentration in class should also improve. Leah should also use proper skills when initiating and maintaining an interaction.
INTERVENTIONS: Enquire which symptoms she experiences when she starts feeling anxious. Leah should be trained on how to briefly remove herself when she feels agitated and engage in exercises that relief anxiety such as deep breathing. This will aid in improving her sense of control in public.
Target Date: January 7th, 2017 |Review Date: |Completed ?yes, ?no | New Target Date: |Review Date: |Completed ?yes, ?no
Signature of Client/Date Signature of Therapist/Date
Williams, A. M., Richardson, G., & Galovski, T. E. (2013). Posttraumatic Stress Disorder. Anxiety Disorders: A Guide for Integrating Psychopharmacology and Psychotherapy, 176.
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