Mrs. Seng is a 38 year old widow with a history of headaches and back pains, which could not have caused any medical condition. She has had these headaches for four years experiencing other pains and psychiatric symptoms. These include poor concentration, poor sleep and poor memory. According to her report, Mrs. Seng has had a depressed mood most of the day, and she feels persistent sadness. Additionally, she has had a lack of concentration in her environment in addition to a decreased energy level. She has had a significant weight loss of 20 pounds for the last three months.
Mrs. Seng also complains of feeling dizzy and losing balance. In addition, she often sees her mother’s ghost at night, though this is typical of the Cambodian culture. She has nightmares of being killed and intrusive thoughts about disasters, which she experienced during the war. These thoughts seem so real sometimes, that she feels she is experiencing the events all over again. She tries to avoid the past memories by thinking about other things, but it is not successful. She has also been very irritable towards her children for the past months, and this makes her feel hopeless.
Mrs. Seng was born in rural Cambodia, where her family members were farmers. She does not have a formal education. Her family members got separated during the Pol Pot regime, and later she heard that one of her brothers was executed. Her mother died of starvation several hours after they were re-united, and she was prevented from crying for her by death threats for being attached to the old ways. Mrs. Seng was forced to marry early, but she was separated from him when she was forced to a forced labor. At that time, she saw many people die of starvation or being killed. During the Vietnamese invasion in 1979, she felt that she was destined to die.
Mrs. Seng was re-united with her husband, but he died 3 years after it from multiple medical conditions. She has few friends. Mrs. Seng has got romantically involved with different men and has two children from these relationships. Apart from the physical pain, which she has been experiencing, irritability towards herself is her greatest concern.
5 Axis Diagnoses
Axis I: Post traumatic stress disorder comorbid with somatization disorder;
Axis II: No diagnosis;
Axis III: None;
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Axis IV: Relational issues, war experiences, the loss of family members, the anticipation of death;
Axis V: GAF= 25.
Mrs. Seng has clinically experienced significant distress and her anxiety has gone to the extent of inflicting upon her poor concentration, irritability and poor sleep. The feeling that she was destined to die during the war must have caused her immense fear. These symptoms have been ongoing for four years. Hence, I diagnosed Mrs. Seng with post-traumatic stress disorder. Mrs. Seng has had a depressed mood most of the time and reports that she feels persistent sadness. The criteria of suffering from PTSD are met, as she has had five or more symptoms of this illness for the past four years (American Psychiatric Association, 2000).
She has had a significant weight loss of 30 pounds for the last three months. Mrs. Seng is experiencing a lack of sleep, since she sleeps only for 2-3 hours a day. Additionally, she has a lack of interest in her environment in addition to a decreased energy level. The symptoms, which Mrs. Seng is experiencing, meet the criteria of post-traumatic stress disorder (PTSD), which is a physical change in the brain and in brain chemistry, which affects a person’s future response to stress and results from a past traumatic experience. PTSD is an emotional sickness that results from such life threatening, frightening or even highly unsafe experiences as Mrs. Seng’s ones during the war. This sickness could have resulted from exposure to a single experience or a repeating traumatic event or events.
Mrs. Seng has been exposed to different traumatic events in her life, such as separation from her family, forced labor, starvation and fearing for her life. She also lost her husband in addition to learning that her brother had been executed. Mrs. Seng’s exposure to a series of events has resulted in her long-lasting emotional and social problems. From her report, the death of her mother immediately after their re-union and the death threat relating to crying for her really affected her emotionally. These events overwhelm her ability to deal with ideas or emotions connected with that experience.
The other reason why I diagnosed Mrs. Seng with PTSD is because the effects of these traumatic events are usually delayed by months, years or even longer as an individual tries to deal with a situation immediately. Her problems are also related to past psychological trauma, and she is living her life for the purpose of reliving or warding of these traumatic memories and their effects. Mrs. Seng’s psychological trauma is caused by both experiencing and witnessing various forms of psychological and physical abuse. This is aggravated by the fact that her family members were separated, and she lived her life feeling frightened of both events and those surrounding her.
According to the American Psychiatric Association (2000), poor memory is the main characteristic of PTSD, since people, who have been exposed to trauma or extreme stress, have a smaller hippocampus (a region in the brain that plays a role in memory consolidation) than people, who have not been exposed to trauma. This is important for understanding the effects of trauma and the development of PTSD, especially because hippocampus plays a significant role in developing new memories about life experiences.
After a traumatizing experience, PTSD sufferers re-experience the event either physically or mentally. This is the case of Mrs. Seng with her re-living memories and nightmares. People re-experiencing of traumatic events tend to avoid these triggers and are intensely sensitive to normal life experiences. Individuals may experience strong feelings of anger frequently or occasionally in inappropriate circumstances caused by a real or imagined fear resulting from the past events. This condition explains Mrs. Seng’s tendency to keep to herself and her irritability towards her children.
Distressing memories or flashbacks may disturb a person, and one may experience nightmares. Most relationships among individuals have been found to be dysfunctional. Mrs. Seng has been experiencing nightmares and disturbing thoughts, and she has not been able to maintain a long-term relationship or even make friends. Other problems, such as memory loss, poor health behaviors and other emotional problems are also characteristic of PTSD, similar to those symptoms that Mrs. Seng is exhibiting. People suffering from this condition are at a risk of having more medical problems, which could have caused Mrs. Seng’s numerous pains.
I also diagnosed Ms. Seng with somatization disorder because of the unexplained pain in her body. She has no known medical conditions, although she has been experiencing pains for four years. Ms. Seng also complains of dizziness and imbalance, headaches, back pain, and other numerous physical aches that have persisted for almost four years. The period of time that Ms. Seng has been experiencing these pains refers to somatization disorder.
Nothing indicates that Ms. Seng does not take care of herself and her children, so I ruled out major depressive disorder. This is also strengthened by the fact that she is concerned about her irritability towards her children. The other condition I have ruled out is bipolar, since Mrs. Seng has not reported about mania. In addition, she does not seem to be happy at any point in her life.
Mrs. Seng’s medical records have been not provided, and at this point, no medical condition is known. Therefore, there was nothing on Axis III. I did not diagnose Ms. Cooper with Axis II disorder. As far as her Axis IV was concerned, I recognized her war experiences and separation from her family issues as her environmental and psychosocial problems. She also appears to have relational issues, since she reports that she has had several relationships with men and has few friends. Mrs. Seng has feelings of sadness and difficulty in controlling her intense anger, and she is often irritated by her children. Taking into account the Assessment of Functioning Score (GAF) within the range of 21-30, her GAF score was 25 due to the fact that her problem was a result of two serious medical conditions.
Case 2 Ms. Cooper
Ms. Cooper is a 27 year old single lady from Rockland. She works as a hygienist and this is her first psychiatric hospitalization. She was referred by social workers and arrived saying “I don’t really need to be here.” Three months prior to this admission, Ms. Cooper had received news that her mother had gotten pregnant. She had started drinking extensively and often ended up with “one-night stands”. From her report, she has also had problems with sleeping and has been drinking to sleep at night.
Ms. Cooper had experienced panic two weeks before her admission and was caught wandering on a bridge at night. In one of such occasions, she also heard voices telling her to jump off the bridge the next day. Thus, she had to ask her supervisor for assistance. Noting her distress and cuts in her wrists, the supervisor sent her to a social worker, who recommended for her immediate hospitalization.
At the time of hospitalization, Ms. Cooper appeared weak, untidy and lost, though her appearance is generally appealing. She was coherent, cooperative and frightened. She supported the idea of assisting her in getting rid of her anxiety and depersonalization. She had a low concept of herself, and she acknowledged feeling lonely and inadequate. Ms. Cooper also had periods of anxiety and depressed mood, since her adolescence albeit for brief moments. She also reported about having fantasies of stabbing herself or being a little baby. She also complained of feeling “empty as a shell that is transparent for everyone to read.”
Ms. Cooper’s parents divorced when she was 3 and she had to live with her mother and maternal grandmother, who had a drinking problem. She had night terrors as a child, and she slept with her mother. Her grandmother died when she was 8, and this caused her a lot of grief. She lived with various relatives after this. Her mother was diagnosed with schizophrenia when she was 9 and was subsequently hospitalized.
Ms. Cooper lived with her aunt and uncle from the age of ten studying at college, though she had regular contact with her mother. She had regular relationships, though most of them usually ended abruptly because of her anger, when she got disappointed as a result of some minor causes. She also had several roommates, but this ended up in her losing them, when she became very possessive and manipulative, since she did not want to share her roommates with anyone else. Ms. Cooper currently lives alone, and works as a dental hygienist in a clinic.
5 Axis Diagnoses
Axis I: No diagnosis;
Axis II: Borderline personality disorder;
Axis III: None;
Axis IV: Familial changes, the past history of unstable family, which may have resulted in the feeling of neglect and problems related to the interaction with roommates;
Axis V: GAF= 20.
Description of Decision-Making Process
Ms. Cooper’s diagnosis indicates a personality disorder rather than a serious clinical or medical condition. She exhibits poor social relationships. Ms. Cooper had intense relationships with men in the past. She broke up these brief relationships because of her quick temper, which lead to many disappointments. She convinced herself that those men were not good enough to start with. The possibility of diagnosing her with a personality disorder was also strengthened by physical altercations on her wrists that appeared to be self-inflicted. Despite her manipulative behavior in regard with her roommates and her quickly changing emotions, I ruled out histrionic personality disorder, because she also had self-destructive behaviors, chronic emptiness and disturbances in her relationships because of individual anger.
Ms. Cooper’s has a low concept of herself and feels that everyone else can see what she values. Therefore, I diagnosed her with borderline personality disorder. According to the American Psychiatric Association (2000), BPD is characterized by a “pervasive pattern of the instability of interpersonal relationships, self-image, and affects marked impulsivity beginning from early adulthood” (p.710).
Ms. Cooper has a poor concept of self, which is reinforced by self-mutilation (cutting). She does this to convert her psychic pain into physical pain, which she can deal with. As observed above, she has not maintained any long-term relationship before. Ms. Cooper has also reported hallucinations and trances, where she feels she is being removed from her body. She had auditory hallucinations, which propelled her to seek help. Ms. Cooper does not have a prior history of drug abuse. Her drinking problem began when she learnt that her mother was pregnant.
There are no known medical conditions provided by her, but Ms. Cooper feels definitely a lot of pain, but no real psychotic symptoms. She has a poor perception of herself and doesn't do well in interpersonal functioning. She has troubles with impulse control (cutting, drinking), and poor relationships with men and multiple roommates. She seems to repeat the same mistakes over and over in her relationships. Finally, her life situation causes her significant pain, but she continues the same behavior.
Ms. Cooper had a lot of caretaker interruptions in her childhood, and she could have suffered from the fear of abandonment. She tends to manipulate her roommates and dictate whom they can and cannot see. She is possessive of her friends and is not ready to share them with anyone else. This creates a problem in relationships. This problem could be associated with her fear of abandonment. Her feelings of inadequacy can be traced back to her adolescence. She also had periods of depression and anxiety. The onset of her problems is characterized by marked impulsivity, and her life seems to be at a risk with her hallucinations and fantasies of stabbing herself.
When Ms. Cooper learnt of her mother’s pregnancy, her presenting symptoms were a sudden start of auditory hallucinations and delusions. Ms. Cooper had delusions that she was being removed from her body, and in one of these trances wandering over a bridge at night she was stopped by the police. She was panicky and impulsively got involved with a series of men on a one night stand. She also had auditory hallucinations. Based on this, I diagnosed her with schizophrenia, schizoaffective disorder, brief psychotic disorder, and delusional disorder of the persecutory type. However, I ruled them out, since Ms. Cooper had only been experiencing delusions and auditory hallucinations for two weeks, and all of the criteria listed above resulted in providing a diagnosis outline based on the fact that psychotic symptoms need to be present for at least a month before a diagnosis can be put.
I also considered a possible diagnosis of panic attack disorder due to Ms. Cooper’s presentation in the hospital and her appearance to the supervisor, when she sought help. However, Ms. Cooper did not report about having panic attacks previously. However, one of the criteria of the disorder is recurrent panic attacks. Therefore, this diagnosis was ruled out. Ms. Cooper could not have suffered from major depressive disorder despite the characteristic two-week manifestation, because her behavior is impulsive resulting from earlier fears.
I did not diagnose Ms. Cooper with an Axis I clinical condition. There were no noted medical conditions. Hence, there was nothing on Axis III. Concerning Axis V, I gave Ms. Cooper the Global Assessment of Functioning Score (GAF) within the range of 18-20. I started at the top level and evaluated each range of the GAF scale in regards to Ms. Cooper’s symptom severity or the level of functioning, and decided it was at the level that had been indicated. Her GAF score is 20 because of the fact that her mutilation and impulsivity has been considerably influenced by delusions and hallucinations she is currently experiencing.
Case 3 Mr. Mclntyre
Mr. Mclntyre is a 38 year man, who has attempted to commit suicide by taking sleeping pills. He says nothing prompted the attempt, but admits to feeling depressed since he returned from the Operation Desert Storm in 1991. His childhood and adolescence were reasonably normal, and he says he has never felt such depressed before the operation. His school performance was average, and he was not in trouble with the law. He associated well with people and had many friends in school. He has also had many girlfriends, though he has never married.
Mr. Mclntyre joined technical school and was trained as an electrician after his graduation from high school. He hated violence, but he felt a need to join the Army due to a long family history in the military. During his service in the Gulf, Mr. Mclntyre killed a civilian for fun. He felt that this was completely out of his character. He still feels guilty of this incident, and memories about the act continue to haunt him. He was discharged from the army and he has never worked since then. He lives on government assistance.
Mr. Mclntyre began using drugs he could get, mostly abusing them. For the last few years, he has turned almost exclusively to alcohol. He has been drinking heavily for the last ten years, and it mostly ends in blackouts. He has been arrested several times for public intoxication and getting involved into drunken fights. He feels very depressed when he is sober. It is a similar case when he drinks. He has attempted to commit suicide four times for the last six years. The longest time he has ever been sober is the month prior to his suicide attempt, when he lived in an alcohol treatment residence. He turns out to be a very sad, thoughtful and introspective man, and he appears to be of at least average intelligence in an informal conversation.
Mr. Mclntyre confides that he has lost interest in everything, and he gets intensely jealous when he sees people enjoying themselves. This urge is concealed by his otherwise courteous behavior. He has never experienced delusions or hallucinations, and his appetite and sex drive are normal. His psychomotor skills are normal, though he complains of absentmindedness. Mr. Mclntyre has not responded to antidepressant medications, and he feels that if he does he will not get better and he definitely wants to die.
5 Axis Diagnoses
Axis I: PTSD with comorbid substance abuse;
Axis II: No diagnosis;
Axis III: None;
Axis IV: Group attitude during the army operation, the lack of friends, the lack of occupation;
Axis V: GAF = 25.
Description of Decision-Making Process
Mr. Mcltyre’s indicated that his problems started, when he got back from Iraq. The memories about the case of him having killed a civilian have been still haunting him and he feels guilty. His drug and alcohol problems also started around this time. His real problem is post traumatic stress, hence treating it as major depression with antidepressants does not help him. He feels guilty of killing a civilian for fun, self medicates and is depressed. He seems to be very sad, depressed and introverted.
Mr. Mclntyre is disturbed by his past action, because he have always viewed himself as a dignified person. He is currently on a downward trend with four suicide attempts. Before his problems, Mr. Mclntyre had been a social person with many friends. After his return from Iraq, he reports that he does not have any friends, he only has acquaintances. He also does not enjoy anything, including sex.
The other concern that comes out in the Mr. Mclntyre’s case is that he cannot sleep without medications: he is depressed and lacks interest in activities. He also has recurrent suicidal ideation and is easily distracted. These symptoms led to an earlier misdiagnosis of major depression. However, I ruled out major depression based on the period of time when the symptoms were present and their onset after his army service in Iraq. This indicates his post traumatic stress.
At the same time, Mr. Mclntyre is involved in substance abuse. He has gone to the extent that he feels depressed whenever he is sober and whenever he drinks. His attempts to stop or cut down drinking have all failed, except when he was in an alcohol treatment residence. After a traumatizing experience, PTSD sufferers re-experience the event either physically or mentally. Many victims tend to use psychoactive substances, such as alcohol and drugs to ward off the pain and escape these experiences. That is what Mr. Mclntyre tries to do.
Mr. Mclntyre’s symptoms also present the case of substance induced mood disorder. He feels jealous of people when he sees them enjoying themselves and even feels compelled to hit them. Prior to his problems, Mr. Mclntyre has never had problems with the law. Since then he has been arrested several times due to intoxication and injuries during drunken brawls. Despite having these interpersonal problems, he cannot quit his drinking. Though he has never had any hallucinations, at one time Mr. Mclntyre experienced alcohol withdrawal delirium.
According to the above findings, Mr. Mclntyre needs the treatment of substance abuse, while the treatment of the trauma is going on. Mr. Mclntyre could also have been dependent, since the report shows alcohol withdrawal delirium.
There is no Axis II diagnosis at this time. In regards to Axis III, Mclntyre does not suffer from any other medical condition. Concerning Axis IV, I recognized his psychosocial and environmental problems based on the group attitude during the army operation, the lack of friends and the lack of occupation. Relating to Axis V, I gave him a Global Assessment of Functioning Score (GAF) of 25. I placed his level of functioning in between the range of 21-30 because of his recurrent suicide attempts, since he definitely wants to die if things do not improve. Additionally, he has been drinking alcohol and has had problems with the law. The final GAF score, which I have given to Mr. Mclntyre, is 25.