Case Study: Post Traumatic Stress Disorder (PTSD)

Case Study: Post Traumatic Stress Disorder

Jada Toledo
William Paterson University

Abnormal Psychology
Dr. Masia
May 1st, 2014

Case Study: Post Traumatic Stress Disorder (PTSD)

Jada Toledo
Abnormal Psych
PTSD Case Study Outline
May 1st, 2014
Presenting Complaint
42-year-old female patient was in Motor vehicle accident 2 months ago and is contemplating
quitting her job due to the fact that she cannot concentrate while on the job. Her husband
wants her to be checked out by a doctor before she makes a final decision of quitting her job.
Once seen by her primary care physician, she was referred to a psychologist for further
evaluation.

Symptoms
Patient exhibits 10 of the 14 needed symptoms of a valid diagnosis of PTSD. She was in a
motor vehicle accident about 3 months ago in which she sustained multiple injuries. Her
reason for being referred to a psychologist in the first place is due to her lack of
concentration at work and wanting to quit. Patient reported having distressing and recurrent
flashbacks of the accident, especially in her dreams, disturbing her sleep by waking her up.
She stays awake for the remainder of the night avoiding the memories and dream. Patient
avoids external reminders of the accident by not driving a motor vehicle alone, and will not
drive on the highway in which the accident occurred. Patient exhibits an inability to feel
happiness by stating that she feels it is hard to put on a happy face and that she no longer
feels the love she has for her family, although she knows she loves them. Patients hyper
vigilance is experienced while in a motor vehicle, patient cannot relax and constantly looks

Case Study: Post Traumatic Stress Disorder (PTSD)

around to be sure no one is crashing into them. Patient reported having amnesia after the
accident and cannot recall any specific details of the accident.

Diagnosis
I believe that the patient, Anna, is suffering from PTSD. The symptoms mentioned above
account for 10 of the 14 associated symptoms, and only 9 are needed to diagnose PTSD.

Other Possible Diagnoses

Other possible diagnoses I considered were: Acute Stress Disorder (ASD), Anna exhibits 12
of the 14 symptoms and only needs 8. This diagnosis, however, cannot be valid due to the
fact that it has been more than 1 month since the accident; which leads me to believe she
may have had ASD in the past that developed into PTSD. Another diagnosis I considered
was major depressive disorder (MDD), as she meets 7 out of the 9 symptoms, and only 5
symptoms are needed for a MDD diagnosis. Diagnosing this patient with MDD would not
be valid due to the fact that the depressive symptoms shes experiencing are better explained
with a PTSD diagnosis. The last diagnosis I considered was a specific phobia of driving,
being on the highway, or getting into a motor vehicle accident. For this diagnosis I would
need more information such as: how she felt about driving and how she felt being on the
highway before her accident.

Treatment
The treatment I would recommend for this patient would be exposure therapy to slowly ease
her back into the normal routine of driving on the highway and being able to feel safe while

Case Study: Post Traumatic Stress Disorder (PTSD)

doing so. In conjunction with exposure therapy I would strongly suggest family therapy
sessions to re-establish the connection Anna feels she has lost with her family in addition to
educating her family on how to help her.

Summary
42-year-old patient was in motor vehicle accident 2 months ago. In the accident, she
witnessed a fatality and has since been experiencing a number of distressingly intrusive
symptoms affecting her family, occupation, and personal well-being. Patient feels that she
cannot function normally due to a lack of sleep and wants to quit her current job. After
interviewing and assessing the patient, I feel confident in diagnosing her with posttraumatic
stress disorder. My recommended course of treatment is exposure therapy driving a motor
vehicle and slowly easing her back onto the road and eventually the highway. In addition to
the exposure therapy, I recommend family therapy with her children and husband to regain
the lack of unity and connection Anna is feeling towards her family.