Client K.M is an an18-year-old Hispanic teen in the 12th grade with a history of domestic violence exposure. She lives with her family – a bio-mother, stepfather, and four siblings – in a family house in Los Angeles. The presenting concern entails symptoms of heavy breathing and incoherent speech triggered by an exercise in theater class.
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Client K.M has no history of medical problems and no biological predisposition to chronic illnesses or allergies. She has no sensory/motor impairment but wears glasses. She has no reported medical issues except weight or appetite change. Client K.M has no developmental issues. However, she has a history of social withdrawal in latency and anxiety attacks in adolescence. She reports no unusual reproductive or physical health issues.
K.M’s psychological health was affected by a traumatic event – sexual abuse by a maternal uncle at the age of six. She also witnessed chronic domestic violence between her parents as a child. Client K.M suffers severe anxiety that is affecting her sleeping and eating patterns. She has maladaptive coping skills (cutting) and persistent avoidance associated with trauma (dissociative amnesia). The client could not remember parts of the events. She is easily distracted, is unable to communicate her feelings, and reports poor social skills and isolation. The trigger factor appears to be the exposure to theater class exercises. Her depressive symptoms are sleep disturbances, distraction, sadness, and altered eating patterns.
Client K.M is an 18-year-old Hispanic female with a normal developmental history. The client stays with her mother, a stepfather, and four younger siblings – two brothers and two sisters. The client was temporarily placed in foster care after a case of sexual abuse at age 6. Her bio-father was deported when she was 11. Client K.M isolates from family members and friends. She seems to be attached to the bio – mother, but a lack of communication between them makes the client anxious as well. The client claims to be Christian but does not consider church a support system.
The client’s coping mechanisms seemed sufficient until the recent repetitive symptoms of anxiety, sadness, distraction, and poor social skills, which appear to indicate delayed expression of traumatic stress. Family dynamics and social withdrawal do not seem to have affected the client’s academic history; her grades are good and she has no history of behavioral problems.
Mental Status Exam
- Appearance: Age-appropriate, well-groomed
- Affect: Constricted
- Mood: Depressed/Anxious
- Thought Content: Fears for her future
- Thought Process: Easily distracted
- Speech: Normal
- Motor: Limited activity
- Intellect: Average
- Insight: Cooperative and motivated
- Judgment: Limited
- Impulse Control: Uncontrollable hand rubbing
- Memory: Intact
- Concentration: Normal
- Attention: Normal
- Behavior: Cooperative
- Thought Disorder: None identified
This 18-year-old female displays depressive episodes and anxiety as seen in her symptoms of sleep disturbance, sadness, difficulty concentrating, and socialization difficulties. The chosen DSM-V diagnosis, in this case, is F43.10 – posttraumatic stress disorder (PTSD) with delayed expression. The reasons for arriving at this diagnosis relate to histories of trauma exposure and evidence of intrusion symptoms.
Trauma exposures in childhood could explain the client’s symptoms at this stage in her life. As specified in Criteria A1 and A2 of the F43.10 diagnosis, traumatic stress could result from either directly experiencing trauma or witnessing violence as a child. A maternal uncle sexually assaulted client K.M at the age of six. She also witnessed repetitive domestic violence in her childhood.
Criteria B, C, D, and E also match with the symptoms identified through the biopsychosocial assessment. Client K.M presents with intense physiological distress or reactions – heavy breathing and speech difficulty – to a traumatic event, consistent with Criteria B4 and B5. In this case, the trigger factor or external cue symbolic of the trauma is the theater class exercise.
Trauma survivors demonstrate avoidance of reminders of the traumatic event. Based on Criterion C2, such stimuli may include people, locations, or situations that remind the victim of the event. Client K.M’s poor social/family relationships could be seen as an attempt to avoid reminders (kin perpetrators) of her history of sexual abuse. The client also displays trauma-related negative cognitions (Criteria D6 and D7) as demonstrated by two symptoms of detachment from friends and family (except the mother) and feelings of sadness. Her introverted nature and episodes of heavy breathing and incoherence indicate a benign inability to feel positive emotions due to her traumatic experiences.
Client K.M shows significant alterations in arousal specified in criterion E. Her sleeping patterns are not consistent, she lacks focus, and she is easily distracted. The criterion identifies problems with concentration and sleeps disturbance as evidence of alterations in arousal. Further, the client’s recent episodes in the theater class and socializing difficulty will have a significant impact on her social and academic functioning (Criterion G). Her symptoms are not attributable to substance use (Criterion H).
Possible Differential Diagnosis
A possible differential diagnosis for client K.M is an anxiety disorder or obsessive-compulsive disorder (OCD). In general, people diagnosed with OCD display intrusive obsessive or compulsive actions. Unlike PTSD, OCD is linked with other psychiatric co-occurring illnesses. Although both disorders involve persistent intrusive thoughts, OCD involves a more heightened obsessive symptom severity than PTSD. OCD is characterized by repetitive actions or mental acts, which constitute stress responses to obsessions, as opposed to a traumatic event. The obsessions and compulsions that are the prominent symptoms of OCD diagnosis are lacking in client K.M. She had intrusive symptoms – marked physiological reactions to a trigger – but not recurrent obsessive or compulsive episodes; hence, the PTSD diagnosis.
Generalized anxiety disorders are also ruled out because they involve no relation to traumatic experiences. A panic disorder diagnosis is made when the individual shows dissociative responses (flashbacks) and alterations in reactivity or hyper-arousal. Although client K.M displays symptoms of arousal (lack of concentration and sleep disturbance), she lacks marked dissociative symptoms that could support a panic disorder diagnosis. The diagnosis of a generalized anxiety disorder is also not feasible. Client M.K shows symptoms of sadness and anxiety, but not irritability. Since she lives with her mother and siblings, the separation anxiety disorder is ruled out. Therefore, it is not possible to make an OCD or anxiety disorder diagnosis for client M.K since their etiology does not involve recurrent exposure to a traumatic event.
Cultural and/or Social Justice Issues
Hispanic Americans, being a minority group in the US, are prone to stress-related disorders, which could be attributed to economic marginalization and racism. Further, Hispanic cultural characteristics seem to affect health-seeking behavior, symptom severity, and coping practices. Hispanics are not open to mental health services. In most cases, they do not seek help or report abuse, especially if the perpetrator is a family member. The cultural attributes may promote avoidance and self-harm coping behavior. The underreporting of abuse cases can be attributed to the Hispanic culture’s emphasis on family relationships. Family is an important part of the Hispanic culture. Client M.K may show discomfort discussing her history of sexual abuse or domestic violence with the therapist since it involves family members. An approach that builds therapeutic trust can promote self-disclosure. Family (mother) involvement can also lead to better therapeutic outcomes since client M.K identifies her as a support system.
Another cultural aspect that pertains to client M.K is the inclination to normalize stress. This behavior may be due to the cultural belief that people who seek mental health services are emotionally weak. The client only sought help after experiencing repetitive distress symptoms/episodes for weeks. Thus, Hispanics will only look for aid in emergency/crisis situations due to cultural attitudes and socio-economic hardships. Hispanics express their spirituality in the context of cultural beliefs. Although client M.K professes to be a Catholic, she does not identify the church as a support system. This shows that personal ideologies are critical in developing individualized therapy for Hispanic patients.
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The risk of PTSD exposure in Hispanics could be higher owing to the economic difficulties often faced by minorities in the US. Client M.K belongs to the second generation of Hispanic immigrants. She admits that her family needs financial support. These factors could limit her ability to access to affordable mental health services and remain in treatment for long. Stress-related cultural concepts, such as ‘Ataque de nervios’, in the Hispanic culture can affect PTSD expression. In this case, a panic attack is a predominant symptom; hence, an accurate diagnosis based on the DSM-V criteria may be a challenge.