Question

Just out of high school, Ron Kovic enlists in the Marines to serve in the Vietnam War. The trauma of battle leaves Ron not only paralyzed from the waist down, but also emotionally and mentally scared. His trauma continues during his recovery period in a veteran’s hospital where patient neglect is a daily occurrence. Upon returning home, Ron is further confused and alienated by the antiwar movement, which sharply contrasts with his deep sense of patriotism.

He spends the next decade living with the burdening trauma of combat memories, while adjusting to his disability and to a changing culture. His journey of emotional anguish takes him through many struggles, until eventually his political passions are reawakened.

Client name: Ron Kovic

Psychiatric diagnosis: Post Traumatic Stress Disorder (PTSD).

*For the criteria supporting this diagnosis, please refer to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, by the American Psychiatric Association, and/or your Wolters Kluwer mental-health nursing textbook.

Name of the client you are assessing: Ron Kovic

Name of the movie: Born on the Fourth of July

What is the chief complaint?

Response:

What questions would you raise during history taking? You might base your questions on the:

• History of your client’s present (and presenting) illness.
• Past psychiatric history, its treatment, and treatment outcomes.
• Psychosocial history.
• Past significant medical history.

Response:

     What observations do you have about the client’s behavior?

Response:

     In your opinion, is the diagnosis given above accurate?

Response:

     

What requirements does the client meet that support this diagnosis, based on the DSM-5 criteria?

Response:

     What treatment plan would you outline?

Response:

     With what expected outcomes?

Response:

     

Answer 1

Introduction

PTSD is an anxiety disorder that a person may develop after experiencing or witnessing an extreme, overwhelming traumatic event during which they felt intense fear, helplessness, or horror traumatic stress.PTSD is an anxiety disorder that a person may develop after experiencing or witnessing an extreme, overwhelming traumatic event during which they felt intense fear, helplessness, or horror traumatic stress.

DEFINITION

PTSD is characterized by repeated re-experiencing of highly traumatic events that involved actual or threatened death or serious injury to self or others, to which the individual respond with intense fear, hopelessness and horror.

                   (APA,2000)

PTSD is characterized by the development of the characteristic symptoms following exposure to an extreme traumatic stressor event involving a personal threat to physical integrity or to the physical integrity of others

DSM-5 Diagnostic Criteria for PTSD

Note: The following criteria apply to adults, adolescents, and children older than 6 years. For children 6 years and younger, see the DSM-5 section titled “Posttraumatic Stress Disorder for Children 6 Years and Younger” (APA, 2013a).

1. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

   1. Directly experiencing the traumatic event(s).

   2. Witnessing, in person, the event(s) as it occurred to others.

   3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.

   4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse). Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.

2. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:

   1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.

   2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Note: In children, there may be frightening dreams without recognizable content.

   3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Note: In children, trauma-specific reenactment may occur in play.

   4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

   5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

3. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:

   1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

   2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

4. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

   1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia, and not to other factors such as head injury, alcohol, or drugs).

   2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”).

   3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.

   4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).

   5. Markedly diminished interest or participation in significant activities.

   6. Feelings of detachment or estrangement from others.

   7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).

5. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

   1. Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects.

   2. Reckless or self-destructive behavior.

   3. Hypervigilance.

   4. Exaggerated startle response.

   5. Problems with concentration.

   6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

6. Duration of the disturbance (Criteria B, C, D and E) is more than 1 month.

7. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

8. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

HISTORY COLLECTION

Before taking the history of present illness, you should find the identification data of the patient , which incluses,

• Name :
• Age :
• Sex :
• Marital status:
• Religion:
• Education:
• Occupation :
• Income
• Address:
• Date of admission:
• Hospital No :
• Psychiatric ward :
• marital status
• And if the patient is not capable of providing the information, you can collect it from an informant. But make sure that you are having following information (sources of the information including Informant’s name ,The reliability of the sources • Relation to Patient: • Intimacy with the patient • Interest of the patient’ • Does the Informant live with the patient? • Duration of stay with the patient • Intellectual and observational ability)

HISTORY OF PRESENT ILLNESS

Provides a comprehensive and chronological picture of the events. Probably the most helpful in making an accurate diagnosis.It include,

• Duration- Weeks/months/years
• Mode of onset-Abrupt/acute/subacute/Insidious
• Course-( continuous / episodic/ fluctuating/ deteriorating/ improving/ unclear)
• Precipitating factors (death/ separation/ loss/ frightening experience/ any other)
• Aggravating and relieving factors, if any.
• if the information we are collecting from an informant, you should enquire about,
• When the patient was well the last time should be noted.
• The time of onset
• When the symptoms are first noticed by the patient or by the relatives.
• The symptoms of the illness from the earliest time at which a change was noticed until the present time should be narrated chronolo-gically, in a coherent manner.
• The presenting chief complaints should be expanded.
• Any disturbances in the physiological functions like sleep, appetite, and sexual functioning
• Always enquire about suicidal ideation
• Important negative history should be recorded(eg. no h/o head injury)
• Life chrt-valuable display of course of illness

PAST PSYCHIATRIC HISTORY

• Past psychiatric illness
• H/o alcohol/substance abuse/dependence
• Had the patient suffered from any mental illness and undergone psychiatric treatment
• Has the patient been hospitalized earlier for the treatment of mental illness
• What was the nature of treatment she or he had been getting; drugs or ECT
• Did the patient improve with the treatment
• Any similar or other psychiatric problems in the past?
• • Have you ever been admitted to a psychiatric hospital?
• • What treatments have you had?
• • Has there ever been a time that you felt completely well?

PSYCHOSOCIAL ASSESSSMENT

Based on Psychosocial theory, the PTSD subjected to 3 factors, so the history collection should be based on,

Traumatic experience (Sevearity and duration of the stressor,Degree of anticipatory p[reparation for the event,Exposure to death,Numbers affected by the life threat,Amount of the control over the occurance,Location where the trauma experienced ,recovery environment)

Individual (Degree of the ego strenth,Effectiveness of the coping resources,Presence of the pre existing pathology,Outcomes of the previous experiences with the stress or trauma,Behavioural tendencies,Current psychosocial developmental stage,Demographic factors)

The recovery environment (Avilability of the social support,The cohesiveness and protectiveness of the family and the friends,The attitude of the society regarding the experience,Cultural and socio cultural influences)

OBSERVATIONS ON CLIENTS BEHAVIOUR

• Mr.Ron has experienced,   witnessed,   or   was   confronted with the event or events in the war, that involved death and serious injury
• He has response involved intense fear, help lessness, or horror and he couldnt save the only lone survivor, a crying baby from the battle field
• He has recurrent and intrusive distressing recollections of the event, including images, thoughts,and recurrent dreams that leads to disturbed sleep.
• feelings of detachment from others
• restricted range of affect
• Fatigue
• Difficulty in concentration
• Forgetfullness
• Irritability
• Anger
• Guilt
• Alcohol abuse

Based on the above observation, The diagnosis is accurate.

Diagnosis Based on DSM criteria the client ( Mr.Ron is suffered from PTSD)

TREATMENT PLAN

MEDICATIONS

1.Antidepressants SSRIs – Sertraline, FluoxetineSSRIs – Sertraline, Fluoxetine TCAs- Imipremine

2. Antianxiety drugs - Lorazepam

TRAUMA-FOCUSED COGNITIVE-BEHAVIORAL THERAPY

• It involves carefully and gradually “exposing” patient to thoughts, feelings, and situations that remind you of the trauma.remind you of the trauma.
• Teaching the patient specific techniques within a limited number of sessions (with “homework exercises” between sessions).
• Identifying upsetting thoughts about the traumatic event

Exposure therapy

• It involves gradually facing the thoughts and memories of the traumatic event or situations (places where the event occurred) that make one anxious.
• This can be done by using imaging techniques or by actually returning to the place where one had anactually returning to the place where one had an accident.
• Exposure should be gradual and done with the help of an experienced clinician.

Cognitive restructuring therapy

• Cognitive restructuring involves identifying irrational (but understandable) patterns of thought, feeling and behavior that emerge after a traumatic event.
• Cognitive restructuring aims at replacing dysfunctionalCognitive restructuring aims at replacing dysfunctional thoughts with more realistic & helpful ones.

Eye movement desensitization and reprocessing (EMDR)

• The patient is asked to concentrate on an image connected to the traumatic event and the related negative emotions, sensations and thoughts, At that time usually the therapist’s fingers moving fromAt that time usually the therapist’s fingers moving from side to side in front of your eyes.
• After each set of eye movements (about 20 seconds), the patient is encouraged to let go of the memories and discuss the images and emotions he experienced during the eye movements.
• This process is repeated, this time with a focus on any difficult, persisting memories. Once HE feel less distressed about the image, should be asked to concentrate on it while having a positive thought relating to it.having a positive thought relating to it.
• It is hoped that through EMDR the aptient can have more positive emotions, thoughts and behavior in the future.

Family therapy

• Family therapy can help the patients loved ones understand what you’re going through.
• It can also help everyone in the family communicate better and work through relationship problems caused by PTSD symptoms.

Group Psychotherapy

• Through group therapy, They often feel more confident and able to trust.
• Telling one’s story (the “trauma narrative”) and directly facing the grief, anxiety and guilt related todirectly facing the grief, anxiety and guilt related to trauma enables many survivors to go on with their lives rather than getting stuck in unspoken despair and helplessness.

Nursing Diagnosis

1. Post trauma syndrome related to distressing event considered to be out side the range of the usual human experience as evidenced by night mares.
2. Dysfunctional grieving related to loss of self as perceived prior to the trauma or the other related events as evidenced by verbalization of the survival guilt