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  • Axis I: The acute symptoms that need to be treated. These symptoms are the most familiar and widely recognized.Axis II: Personality disorders and intellectual disabilities. Life-long problems.Axis III: Medical condition(s) that may influence psychological problem.Axis IV: Psychosocial Stressors-primary-family separation Social- loner, no contract with the “outside world”Work- temporarily been signed off from workAxis V: over 50-serious symptoms (suicidal ideation but low risk, for example); serious impairment in one area.Axis III: Medical condition that may influence the psychiatric problem. - Alcohol abuse and depression (that was previously diagnosed)Axis IV: Psychosocial Stressors.
  • CBT targets emotions by changing thoughts and behaviors that are contributing to the distressing emotions. CBT: enables an individual to be aware of their thoughts and emotions*Helps identify how situation, thoughts, and behaviors INFLUENCE our emotions.Improves our feelings by changing dysfunctional thoughts and behaviors.
  • Both strategies implement Socratic dialogue, or a style of questioning that helps uncover the patients view’s and examines his or her adaptive and maladaptive features.Three major approaches to treating dysfunctional modes:Deactivating themModifying their content and structureAnd constructing more adaptive modes to neutralize them.
  • Rapport will be build by demonstrating: empathy, being genuine (authentic, eye contact, full attention/nodding, ect), active listening, and clarification. Orient Patient to CBT: Describe cog.-behav. model and answer any questions the patient may have.(Thoughts we have about situations give rise to our emotions) Assess Concerns: Thought (I am responsible for the accident)  Situation (was the accident)=Emotion/Feeling (Depressed/Guilt)PTSD will be explained to the patient and how CBT will directly address their problem.Depression: thoughts of inadequacy have led him to distance himself from the “world” resulting in self medicating with alcohol. Goals:Because the alcohol abuse has been a result of the PTSD and depression, it will be addressed first. 1st Goal: Alcohol Abuse- stop alcoholism all togetherDepression-improve relationships at work and communication with friends and family.PTSD- learn how to cope with feelings of guilt and sadness. Maladaptive thoughts.Homework Assignment:1.Keep a running list of questions you may have about the therapeutic process, and bring it with you to the next session. 2. Think about our agreed-upon treatment plan, and consider any adjustments it might need. SASSI – Substance Abuse Subtle Screening Inventory
  • Begin/Continue Intervention Techniques:CBT- identify thoughts that are making the patient feel afraid or upset. -Teach patient to replace these thoughts with more accurate and less distressing thoughts. -Teach patient ways to cope with feelings such as anger, guilt, and fearEye Movement Desensitization and Reprocessing- help change how the patient reacts to memories of the trauma. -helps the patient focus on other stimuli (eye movements, hand taps, sounds) while thinking or talking about their memoriesFor example, the therapist will move his or her hand near the patients face, while the patient follows this movement with their eyes.Depression: Cognitive restructuring-change thinking patterns-automatic thoughts (often unaware of these thoughts, but are very familiar with the emotions that they create within us. )Behavioral Activation-teach patient to overcome obstacles and encourage patient to participate in “enjoyable” activities Homework- Keep a notepad with you and attempt to list automatic thoughts you have during the day. We will go over these thoughts are reconstruct maladaptive thinking into a functional thoughts.
  • Maintain Changes
  • Failure: psychosocial problems

PTSD Presentation Transcript

  • 1. Dydrek
  • 2. Dydrek is a 48 year old married man on sick leave from his job as a foreman in a food processing factory, a position he has held for some five years followinga redundancy from a previous employer. Nearly 2 1/2 years ago, Dydrek was in charge of a production line and witnessed one of his fellow workers, a young manof 16 years of age, fall into a piece of machinery resulting in horrible injuries. Dydrek accompanied the injured man to hospital, but was prevented fromentering the treatment room, where he later died. Immediately after the incident, Dydrek took the train home, but missed his station stop. He appears to havespent a number of hours wandering the street in the dark, disorientated, eventually being picked up by the police and taken home. He was signed off from hiswork for a couple of weeks and has little recall of the period following the accident.Dydrek returned to his work two weeks later, fearing reprisals from his employers. He was telling himself to "pull himself together", neither understanding whyhe was feeling so bad, nor believing that there was any justifiable reason for taking more time off work. He regarded failure to cope as a sign of weaknesswhich would not be looked well upon by his colleagues. The incident which had occurred at work was not discussed, and Dydrek perceived that he was beingostracized by his work colleagues. He believed that they must blame him for the death, and he feared that the parents of the young man, who lived in the samecommunity, would exact revenge. The incident report at the food processing factory had apparently concluded that the accident had occurred as a result ofmachinery failure. DYDREK, who has been unable to attend the inquiry, nonetheless continued to believe that he must have been responsible, and that he couldhave done more to prevent the risk of the accident occurring.Two months later, following a period of increasing time off work, because of poor time-keeping and increased alcohol consumption, Dydrek was sent home as unfitfor his duties. Dydrek did not easily talk about his difficulties, but his GP managed to learn that Dydrek had been unable to sleep since the incident, and hadtaken to self-medicating with alcohol. Dydrek complained of having no energy and of increased irritability with his wife and children. His manner waswithdrawn, and Dydrek appeared to be consumed with self-hatred. The GP signed him off his work as suffering from depression. He has not since returned to work.Dydreks GP prescribed a short course of benzodiazepines to help him to withdraw from alcohol, but this was unsuccessful. He was then prescribed lofepramine75mg (a low dose of antidepressant medication), but still did not improve. After a further 4 months, his wife dragged him to the GP, complaining that hisdrinking had worsened and that he was verbally aggressive to her and their children. The GP made a referral to the Alcohol Problems Clinic. It later emergedthat Dydrek had failed to attend and was discharged in his absence. Meanwhile, his wife and the children had moved out.One night, Dydrek had gone to his wifes new address, shouting and throwing stone up at the windows, demanding to see the children. A neighbour called thepolice, and Dydrek was charged with breach of the peace. A duty psychiatrist was called to the cells, where Dydrek reported that he had taken an overdose ofhis stored-up medication, lofepramine. His knuckles were bleeding, resulting from Dydrek hitting his right fist against the wall, something which he saidhelped him to stop his mind from racing. He expressed thoughts of hopelessness and despair and that he couldnt guarantee his safety. He was transferred to theInfirmary overnight. On admission, he became acutely disturbed and required heavy sedation.Dydrek told the duty psychiatrist that he was suffering from unbearable involuntary memories of the workplace accident. He was unable to sleep, unless drunk,for fear of the nightmares which tormented him. He believed that he was being blamed by his work colleagues, and avoided his place of work, ignoring the phoneand any mail which could relate to work. He had, until now, managed to avoid the Infirmary, where the young man had died, and had experienced a severe panicattack the night before, when brought into the hospital. Dydrek presented with guilt and self-blame. He had isolated himself from his work-mates and hisfriends. He reported no current social contacts, only the strained contact with his wife, who forbade him to see their children unless he was sober.Dydrek reported extreme levels of stress and edginess, he was noticeably jumpy in the consultation. He was vague about his daily life, and it transpired thathe was spending much of the day at home. His self-care was impoverished and he described that he couldnt account for the time, finding that he was spending SYNOPSIS"long hours staring into space or feeling "out of it". The psychiatrist asked about the sores on his right fist, and Dydrek said that when things get too muchfor him, he hits his hand against the wall. He said that he deserves it because his life is "shit", and that it helps him to forget for a while. Sometimes hesays that he gets upset and is not aware that he is hitting his hand. He feared that his marriage was over, and that he will lose contact with his children. Itwas his second marriage, the first was ended with divorce, 15 years ago, because of his alcohol problems at the time. He had, until recently, been abstinent ofalcohol in this 9 year long marriage.The duty psychiatrist referred Dydrek to the Rivers Centre with a diagnosis of PTSD and secondary depression. She requests an urgent appointment - the waitinglist for treatment is over 6 months. When Dydrek is sent an appointment for assessment, he fails to attend. He attends for a second appointment with hisseparated wife. He does not smell of alcohol, but is twitchy. He is subdued and monosyllabic. His wife is angry and complains, "This shouldnt have beenallowed to happen. Something should have been done about him months ago".Dydrek was born and brought up in a working-class area of Edinburgh. His mother is now elderly and physically infirm. She has lived for the past 5 years withDydreks sister in Canada. Dydreks father, a hard-drinking, heavy-smoking stonemason, died of a sudden heart-attack in his forties, when Dydrek was 9. Hedescribes that he hadnt ever cried since his fathers death, believing that, as the oldest son, he was expected to be brave and to look after his grievingmother. After the death, his mother "went to pieces", and didnt manage to return to paid work for a number of years. Dydrek has hazy, idealised memories ofhis father.Following his death, Dydrek got in with a crowd of older boys, truanting from school, smoking, drinking and stealing. He left school at 15, working at variousodd jobs, until at 21, he married his childhood sweetheart. He found work as a minicab driver, and the couple moved to Fife. Their first child was stillborn,and shortly after this, Dydrek was charged with drunk-driving and lost his license. There were growing arguments at home, mostly about his drinking, and theensuing financial difficulties. They had separated, after the birth of their son, and Dydrek had returned to Edinburgh, living at first with his mother, andlater in a solitary bed-sit.Dydreks second marriage had marked the most stable period of his life. He had found stable employment, within which he had acquired a position of someresponsibility. Despite a temporary hitch in coping at the time of his redundancy, Dydrek had done well in acquiring a foremans position in the local foodreprocessing factory, where his wife worked as a secretary. He had friends among his colleagues, and with his wifes income, they had managed to create acomfortable home. The stable environment enabled Dydrek to build a relationship with his 15 year old son from the first marriage, and they soon had two girlsof their own. Dydrek described his second wife, 8 years his junior, as bossy and in charge of family life. She was a devoted mother and house-keeper, in chargeof the family finances and decision making regarding the children and house-hold affairs. Dydrek appeared to have taken a passive role, saying that she tendedto mother him and that he couldnt have coped without her. She had been tolerant of his apparent withdrawal into himself at the time of his redundancy andduring episodes of stress regarding access to his oldest son. Nonetheless, their relationship had deteriorated substantially since the incident at work. Aftera long period of waiting for him to return to normal, she had started to lose patience.She had become watchful of his movements and was extremely angry and resentful of his growing alcohol problem, and the ways in which he was destroying all thatthey had worked so hard to build. She had gradually begun to restrict his access to the children, by arranging for them to be at her parents when he had beendrinking, and following the ensuing arguments. She was aware that he was unwell, and that he had started hitting his hand and forehead against the walls. She,however, felt unable to reach him. He would not talk to her and appeared not to care. She eventually chose to move in with her parents.Dydrek is reluctant to discuss details of the trauma, but agrees fairly readily to meet for 6 individual sessions to address "here and now" issues. He appearspre-occupied with the separation from his wife, and his feelings of failure as a husband and father. He starts fluoxetine (Prozac), prescribed by his GP, anddispensed on a weekly basis. He tolerates a fairly high dose, though without clear benefit. He fails to appear for the 3rd session, but arrives at your clinic3 days later, smelling of alcohol, weeping, begging for help, saying that he "cant stand it any longer". He says that he has been having recurrent images ofthe accident, and increasing episodes of lost time. He is despairing and hopeless, saying that he is "a wreck", and that his wife and family would be betteroff without him. He refuses to see his GP, whom he says is unable to help him any more.
  • 3. Multi-Axial 
 Assessment"•  Axis I – PTSD (Severe), Depression (Secondary Type) (Moderate), Alcoholism (Residual), Suicidal Ideations•  Axis II – Deferred•  Axis III – Deferred•  Axis IV – Primary, Social, Work•  Axis V – <50
  • 4. •  UnbearablePrimary Issues 
 involuntaryor Problems" memories of the accident. •  Unable to sleep unless drunk for fear of nightmares. •  Extreme levels of stress and edginess. •  Despairing and hopeless.
  • 5. Cognitive Behavioral Therapy "The basic premise of CBT is that emotions are difficultto change directly, so CBT targets emotions by changing thoughts and behaviors that are contributing to the distressing emotions.
  • 6. Core Concepts" Behavioral" Cognitive "•  Applied Behavior •  Strategies Analysis –  Schemas –  Cognitive Shift•  Neobehavioristic –  Cognitive Meditational Vulnerabilities Stimulus-Response •  Techniques   Model –  Collaborative•  Social-Cognitive Empiricism –  Guided Discovery Theory
  • 7. Therapy Sessions"
  • 8. 1st Session"•  Obtain Consent•  Build Rapport•  Orient Patient to CBT•  Assess Concern –(Self Report Inventory)•  Set Initial Treatment Plan/Goal•  SASSI•  Medical Referral
  • 9. 2 nd Session"
  • 10. Inpatient"•  Detox•  Group Therapy•  Individual Therapy    
  • 11. 28 days later…
  • 12. 3 rd Session"
  • 13. Individual
 Therapy"•  Bridging Session•  CBT•  EMDR•  Cognitive Restructuring•  Behavioral Activation
  • 14. 4 th Session"
  • 15. Group
 Therapy"•  Review HW•  Continued AA•  Family
  • 16. Continued Therapy" •  AA •  Individual •  Family •  Depression •  Weekly Check-Ups
  • 17. Final Session?"
  • 18. Comments and Statements"•  Believes that co-workers blame him for his colleague’s death.•  Feared parents of the young man killed would exact revenge.•  Appears to be consumed with self hatred.•  Has guilt and self blame.•  Losing track of time staring into space.•  Unaware he is physically hurting himself.•  Seems pre-occupied with the separation from his wife.•  Feelings of failure as a husband and father.
  • 19. Success and Failures"•  Completes Rehab Program•  Cognitive Distortions•  Managing Mood•  Emotional/Social/Relationship Problems•  Marital Stress•  Family Stress