Post-Traumatic Stress Disorder

A Case Analysis Presented to The

Faculty of the Nursing Department
Mrs. Ma. Clarissa Yap, RN, MN

In Partial Fulfillment of
The Requirements in NCM 217 - RLE
MALADAPTIVE NURSING ROTATION

By:
Keyna Juliet N. Dizon, St. N
Keziah Marrie A. Magno, St. N
Karl Angelo Montano, St. N
Samcasell B. Ruedas, St. N BSN
3B – Group 2 Subgroup 3

May 9, 2021

1
TABLE OF CONTENTS

I. Rationale...............................................................................................................pp. 3-4

II. Objectives……………………………………………………………………. p. 5-6

III. Biographical/Clinical Data/Brief History………………………………… pp. 6-8

IV. Course in the Hospital………………………………………………………. p. 9-28

A. Mental Status Examination

V. Psychodynamics…………………………………………………………. pp. 27-58

A. Risk Factors

B. Signs and Symptoms

VI. Laboratory Exams…………………………………………………………. pp. 59

VII. Medical Management……………………………………………………. pp.59-71

A. Therapies…………………………………………………………….……. pp. 59-61

B. Drug Study…………………………………………………………… pp. 62-71

C. Nursing Care Plan…………………………………………………. pp. 72-88

VIII. Nursing Theory………………………………………………………….... pp. 89-99

IX. Recommendation……………………………………………………… pp. 100-104

Discharge Plan …………………………………………………………. pp. 105-115

X. Prognosis………………………………………………………………… pp. 116-125

XI. References………………………………………………………………... pp. 126-129

I. RATIONALE

Mental Health is defined as a state of well-being in which every individual realizes his or
her own potential, can cope with the normal stresses of life, can work productively and fruitfully,
and is able to make a contribution to her or his community. (World Health Organization ,2015).
In addition, mental health nursing also known as Maladaptive nursing or psychiatric nursing is
concerned with the prevention, treatment and nursing care of people of all ages who are suffering
from mental illness and its effects. Mental health nurses have advanced knowledge of the
assessment, diagnosis, and treatment of psychiatric disorders that provide specialized care. They
typically work alongside other health professionals in a medical team, intending to provide
optimal clinical outcomes for the patient. (Smith, Y. ,2019).
In relation with our Maladaptive Nursing rotation, our case is all about Post Traumatic
stress disorder (PTSD). According to the American Psychiatric Association (2021), Post
Traumatic stress disorder (PTSD) is a psychiatric disorder that may occur in people who have
experienced or witnessed a traumatic event such as a natural disaster, a serious accident, a
terrorist act, war/combat, or rape or who have been threatened with death, sexual violence or
serious injury. People with PTSD have intense, disturbing thoughts and feelings related to their
experience that last long after the traumatic event has ended. They may relive the event through
flashbacks or nightmares; they may feel sadness, fear or anger; and they may feel detached or
estranged from other people.

According to the British Journal of Psychiatry (2016), Canada has the highest rates of
PTSD of 24 countries studied. Nine percent of Canadians will suffer from PTSD in their lifetime.
Also, as stated by the Sidran Institute in the year 2018, statistics on the prevalence of PTSD in
the United States vary depending on the specific group or population being studied. Overall,
PTSD affects around 3.5% of the U.S. population, approximately 8 million Americans, in a given
year. PTSD statistics in children and teens reveal that up to more than 40% have endured at least
one traumatic event, resulting in the development of PTSD in up to 15% of girls and 6% of
boys. On average, 3%-6% of
high school students in the United States and as many as 30%-60% of children who have
survived specific disasters have PTSD. Up to 100% of children who have seen a parent killed or
endured sexual assault or abuse tend to develop PTSD, and more than
one-third of youths who are exposed to community violence (for example, a shooting, stabbing,
or other assault) will suffer from the disorder.

In the Philippines, during the aftermath of the devastation brought by Typhoons Ondoy
and Sendong, a large number of adults and children affected by these natural disasters were
found to be suffering from PTSD. As such, psychiatrists, psychologists, and special education
teachers were dispatched by the government and volunteer groups to the affected areas to
minister to adults and children suffering from PTSD. According to the Freedom of Information
Philippines, there are currently no extensive studies or statistics of the national level for PTSD.
However, in 1991, Filipinos experienced the wrath of Mt. Pinatubo eruption. Among the mental
problems observed from the victims according to the National Center for Biotechnology
Information (NCBI), PTSD was the top illness with a prevalence rate of 27.6%, followed by
depression (14%). A more recent event that caused a rise in PTSD cases in the Philippines is the
Typhoon Yolanda which hit the country in 2013.

For the nursing implications, primarily nursing education, the student nurses will be able
to acquire further knowledge regarding Post Traumatic Stress Disorder and broaden our
understanding of the disease and how it may affect a person, together with its proper treatments,
management, and interventions. It will also provide additional information relative to nursing
education on the possible complications and prognosis of the disease while strengthening the
comprehension regarding the topic. For nursing practice, it will help students accomplish proper
management and interventions, especially with patients with PTSD in the clinical area, aiding the
growth in terms of competence and critical thinking of the student nurses. Lastly, in nursing
research this case will serve as a reference for future research related to this subject and will
become an instrument in the furthering of quality nursing care.

II. OBJECTIVES
Within the nine weeks of Maladaptive Nursing Rotation, the student nurses will develop
and present a comprehensive case analysis about Posttraumatic Stress Disorder that will broaden
and enhance their knowledge and understanding of the how one reacts and responds to the
disorder, what symptoms and manifestations the patients show, and how it is treated; to enhance
skills in handling patients with this disorder, analyze situations with patients, make decisions and
apply appropriate nursing interventions to effectively understand PTSD.

Specific Objectives
To completely achieve the above-mentioned goal, the group specifically aims to;

a. Present a rationale of the case analysis which outlines the rotation, disease,
statistics based on global and national, and the significance of the study on nursing
education, practice and research;
b. formulate an objective that follows a specific, measurable, attainable, realistic and
time-bounded standard;
c. narrate the synopsis of the movie;
d. present the mental status examination in a tabular format;
e. tabulate the risk factors and signs and symptoms presented in the movie;
f. identify three differential diagnosis for PTSD;
g. distinguish the different therapies used in the movie;
h. explain two nursing theories that can be applied to PTSD;
i. formulate two nursing care plan for the client with PTSD;
j. enumerate an appropriate recommendation for individual, family, and
community using METHOD approach;
k. identify the prognosis of the patient suffering from PTSD; and
l. cite books, websites, and other references not later than 5 years from
publication used as sources of information.

III. BIOGRAPHICAL/ CLINICAL/BRIEF HISTORY

Name: Charlie Kelmeckis
Age: 15
 Gender: Male Birthday:
December 25
Educational Attainment: High School student

BRIEF HISTORY:
Past Medical and Psychiatric history:

Patient C. is a 15-year old male with a history of hospitalization due to an

occurrence of a traumatic event specifically suicidal event of his best friend and the
death of his aunt. Chief complaint was mainly seeing things or flashbacks as assumed
from the movie scenes wherein the contents are mainly about the traumatic events from
his past. He has been observed to have medications taken, unfortunately it is not
highlighted.

Present Health History:

As of his present condition, Patient C. came in due to recurrent flashbacks about
his aunt's death and the sexual abuse done to him. The triggers of symptoms started
when he witnessed his sister being slapped by her boyfriend followed by the occurrence
of his separation with his friends, and subsequent exposure to repeated upsetting
reminders. The patient experiences blackouts particularly during the occurrences of
flashbacks. Patient has a record of aggression and suicidal attempt as assumed when the
patient approached a knife during anxiety attacks. In addition, patient has been noted as
a substance user particularly drugs and alcohol.

Family History:
There was no family health history shown in the movie. Relationship with
significant others specifically his aunt. Noted that patient C. has been sexually abused
on his school age years.

SYNOPSIS:
 The movie opens with Charlie writing a letter to an anonymous pen pal, discussing his

upcoming first day in high school. On his first day, he is harassed by classmates but befriends his

English teacher, Mr. Anderson.

Charlie attends a school football game alone and notices the flamboyant Patrick , who is the

only senior in his freshman shop class. Patrick asks Charlie to sit with him. They are joined by

Patrick's step sister Sam, and Charlie immediately notices her beauty. Upon arriving home, he

witnesses Candace's boyfriend hitting her, something Charlie is especially sensitive about as his

Aunt Helen was also abused. Candace persuades him not to tell their parents. Charlie dances with

Sam and Patrick at homecoming and goes to a party with them afterwards. There, he meets their

other friends, Bob, Mary Elizabeth, and Alice. He also sees Sam with her boyfriend Craig, which

makes him jealous. He eats a pot brownie, and the group is amused by his observations. While in

the kitchen, Charlie tells Sam that his best friend Michael shot himself last May. He then goes

upstairs to the bathroom, leaving Sam shocked.

Upstairs, Charlie sees Patrick and Brad, the school's star football players, kissing. Patrick

tells Charlie that Brad doesn't want anyone to know about their relationship (as his father would

disapprove) and asks him to keep it a secret. Still high, Charlie agrees. Later, Sam
whispers to Patrick about what Charlie has gone through and they welcome him in their group of

friends.

While driving him home, Sam hears a song from the radio - David Bowie's Heroes - and

demands that Patrick drive through a tunnel. She stands up in the back of the pickup truck and

sways like she's dancing. Again, Charlie is stunned by her beauty.

As Christmas draws closer, Charlie helps Sam to study for her SATs and their friends

participate in a Secret Santa gift exchange. On the last night of the exchange, Sam takes Charlie

into her room and shows him her gift for him, a typewriter. The two start talking about first

kisses. Charlie says that he has never kissed a girl, and Sam reveals that her first kiss was from

her father's boss, who was molesting her. She tells Charlie that she wants his first kiss to be with

somebody who loves him, and the two kisses.

Charlie's Birthday (which is on Christmas Eve) arrives, and he remembers his Aunt Helen,

who died on the same night in a car accident after getting him a present. Later, at a New Year's

Eve party, he takes LSD and has more flashbacks to the night his aunt died. He is eventually

found passed out in the snow by the police.

Charlie attends the Sadie Hawkins dance with Mary Elizabeth. Afterwards, they go to her

house and make out. She then declares that he is her boyfriend. He has no interest in her but

continues the relationship because he doesn't know how to break up with her.

While playing truth or dare at a party, Patrick dares Charlie to kiss the prettiest girl in the

room, and he kisses Sam rather than Mary Elizabeth. Both girls are enraged, and Patrick tells

Charlie to stay away until things cool down.

 Weeks pass and his friends are still ignoring him. In addition, his flashbacks to the night his

aunt died are getting worse. Bob tells Charlie that Brad's father caught him and Patrick kissing.

Brad comes to school with a bruise on his face but claims he was jumped in a parking lot. Patrick

and Brad fight in the cafeteria after Brad calls him a "faggot." Brad's friends then begin to beat

up Patrick, until Charlie intervenes. Afterwards, he reconciles with his friends.

Patrick is upset after breaking up with Brad and he and Charlie become closer. One night,

Patrick kisses Charlie to no reaction, then breaks down because of his unhappiness. Sam breaks

up with Craig after finding out he has been cheating on her.

Graduation nears and Sam is accepted to Penn State. After her going away party, Charlie

helps her pack. Sam then asks Charlie why he never asked her out. After several heartfelt

confessions, they begin to kiss, but Charlie pulls away when Sam touches his inner thigh. She

asks him what's wrong, but he tells her that nothing's wrong and continues to kiss her.

The next day, Charlie is unnerved as he watches Sam leave for school. When he arrives at

his empty home, he begins to have a breakdown, flashing back to the memory of his Aunt Helen

touching his thigh. He calls Candace and tells her it's his fault their aunt died, and that maybe he

wanted her to die. Candace tells her friends to dispatch police to their house. Before Charlie can

hurt himself, the police arrive and he blacks out.

He wakes up in the hospital. His physician, Dr. Burton (Joan Cusack) explains to Charlie's

parents (Dylan McDermott and Kate Walsh) that his Aunt Helen was sexually abusing him, and

that Charlie repressed the memory because he blamed himself for her death.
 After Charlie is discharged from the hospital a few weeks later, Sam and Patrick visit him

and take him to their favorite restaurant.

They once again drive into the tunnel, and Sam tells Charlie that she finally found the song

that was playing the last time they were there. Charlie climbs into the back of the truck and

reminisces about life as whole. He kisses Sam, stands up and screams as they exit the tunnel.
• NAME: Charlie Kelmeckis
• AGE: 15
• CC: Traumatic Flashbacks
• Medical Diagnosis: PTSD
• Significant other:
• Educational attainment: Middle School

DESCRIPTION/VERBATIM QUOTES
I. PRESENTATION
A. General Appearance General Appearance: Grooming and dress
Interpretation: The patient was well - groomed and
dressed with a shaved beard and mustache and closed-
wearing clothes. He mostly wears a jacket when going out
of the house especially when he was at school which was
appropriate from the weather. The client’s lips are
symmetrical, pale to pinkish in color. There were no signs
of makeup used.
1. Grooming and dress
a. Note unusual modes of
dress
b. Evidence of soiled clothing
c. Neat, unkempt?
d. Use of make up?
2. Hygiene General Appearance: Hygiene
a. Note evidence of body or Interpretation:
breath odor
The client’s body and breath odor cannot be assessed. In
b. Condition of skin, addition, the client’s skin condition is normal since there
fingernails were no rashes, scar, wounds, hives, and other skin
abnormalities noted. His skin color is also uniform. The
c. Disheveled
client has clean, intact and well-trimmed fingernails.
d. untidy There are no discolorations and deformities being
observed.

3. Height and weight General Appearance: Height and Weight

a. Perform accurate Interpretation: Based on the movie, there were no
measurements information about the height and weight of the client.
Based on the group’s observation, the client has a body
build of a mesomorphic build.
4. Level of Eye contact General Appearance: Level of Eye Contact
a. Intermittent Interpretation Intermittent eye contact was observed
when the patient’s talk to his family and friends.
b. Occasional and fleeting
c. Sustained and intense
Sample Scene from the movie:
d. No eye contact?
On the time frame of 49:00 to 50:16, the client is having a
conversation with his older brother. They catch up with
each other and while talking, the client was able to
maintain an eye contact.
- I apil tung sa iyang sister after pagsagpa sa iyaha
-
At the time frame of 11:30 to 14:40, it is when the client
has met his new friends, Patrick and Sam. The client is
able to have an intermittent eye contact while having a
conversation with them.

5. Hair and color texture General Appearance: Hair and color texture
a. Is hair clean and healthy The patient’s black hair is clean and healthy looking. His
looking hair is also well brushed and equally distributed. Hair
texture and quality cannot be assessed.
b. Greasy, matted, tangled?

6. Evidence of scars, tattoos General Appearance: Evidence of scars, tattoos or

or other distinguishing skin other distinguishing skin marks
marks
Interpretation:
a. Note any evidence of
No evidences of scars, tattoos, or other distinguish skin
swelling or bruises
marks.
b. Birth marks
Sample Scene from the movie:
c. Rashes
At the time frame of 56:17 to 57:20, the client has
performed in a play with his friends where he only wears
underwear for the play. As per the group’s observation,
the patient has no presence of scars, tattoos, or skins
 marks in his body.
7. Evaluation of client’s Interpretation:
appearance compared with
The patient’s apparent age will be at 14 to 15 years old
chronological age,
since he is a high school freshman. Based on the group’s
deterioration of appearance,
evaluation, the patient’s looks and appearance is
client needs to be reminded
appropriate when compared to his apparent age
compared of 14 - 15 years old.

B. General Mobility B. General Mobility

1. Posture Interpretation: The client was in a good posture from the
start of the movie until the end. The client was standing
a. Note if standing upright,
comfortably erect. For the gait patterns, the client walks
rigid, slumped over
smoothly, even, and well-balanced associated with
b. Note for: symmetric arms swing.

Catatonia
Catatonic Stupor
Catatonic rigidity
Catatonic posturing
Waxy flexibility
Catalepsy
Cataplexy

2. Gait patterns
a. Any evidence of limping
b. Limitation of range of
motion
C. Ataxia
d. Shuffling

C. Motor Activity The client is a normoactive person. The client seemed to

appear normal in terms of his motor activity which is
Note for:
called as normoactivity. The client can stand and sit
Normoactivity properly.
Hyperactivity
Psychomotor retardation
Agitation
Tremors (hands, legs,
continuous, at specific time
Tics
Jerky or spastic movements
Stereotypical Movements
Mannerisms and Gestures
Aggressiveness
Echopraxia
Bradykinesia
Pacing and Rocking
Somnambulism
Anchoring
Anergia
Anhedonia
Regression
Compulsions
D. Behavior/ Nurse patient D. Behavior/Nurse patient Interaction
Interaction
Interpretation: The patient was cooperative with the
Cooperative psychiatrist. When he was admitted in Mayview Hospital,
the psychiatrist ask the client several questions and the
Cooperative (initially, all
client answered all the question. However during the
though out)
interview, the client is anxious about the remembering the
Uninterested/Apathetic flashbacks that he had.

Friendly
Embarrassed Conversation from the Movie:

Seductive Psychiatrist: Ch*****? I’m Dr. Burton

Impulsive Client: Where am I?

Negativistic Psychiatrist: Mayview Hospital
Indifferent Client: You have to let me go. My dad can’t afford it.
Angry/hostile Psychiatrist: Don’t worry about that.
Evasive Client: No. I saw them when I was little and I don’t want to
be a Mayview kid. Just tell me how to stop it.
Withdrawn
Psychiatrist: Stop what?
Warm
Client: Seeing it. All their lives all the time. How do you
Distant
stop seeing it?
Guarded/Suspicious
Psychiatrist: Seeing what Ch*****?
Dependent
Client: There is so much pain. And I don’t know how to
Distracted not notice it.
Psychiatrist: What’s hurting you?
Client: No, not me. It’s them. It’s everyone. It never stops.
Do you understand?
Psychiatrist: (noods)
Timestamp: 1:31:22 – 1:32:25

II. STREAM OF TALK

A. Character A. Character
Note for: Interpretation: Character: At the most part of the movie,
the client talks in normal speed and in moderate volume
Slowness or rapidity
when he was having conversations towards his family,
Intonation friends and teachers. He was also spontaneous by
answering the questions that were being asked by the
Volume psychiatrist when he got admitted in Mayview Hospital.
Stuttering, hoarseness,
slurring
Spontaneous
Blocking
Deliberate
Pressured
Aphasia
B. Organization of B. Organization of Talk/Form of Thought: Mostly
Talk/Form of Thought Relevant
Relevant Interpretation: In the whole movie, the client was mostly
relevant in talking and has an organized talk or form of
Irrelevant
thought. He was able to communicate well towards his
Incorrect family, friends, teachers, and to the psychiatrist. In his
conversation with the psychiatrist, his thoughts and
Flight of Ideas verbalizations were relevant to the flashbacks the he was
Loose association experiencing with his aunt Helen.

Circumstantiality Conversation from the Movie:

Tangentiality Psychiatrist: What about your Aunt Helen?

Neologism Client: What about her?

Concrete Thinking Psychiatrist: Do you see her?

Clang Association Client: Yes. She had a terrible life. God what am I
supposed to..
Word Salad
Psychiatrist: You said some things about her on your
Perseveration sleep.
Echolalia Client: I don’t care.
Mutism Psychiatrist: If you want to get better, you have to.
Bradylalia Client: She… She was insane. I’m just saying.
Poverty of Speech Psychiatrist: Ch*****? You gonna let me help you here?
Glossolalia Client: (noods and cries) Okay
Coprolalia Psychiatrist: Do you remember anything before you
Verbigeration blacked out?

Condensation Client: I remember leaving Sam’s house. I was walking

home.

III. EMOTIONAL STATE

AND REACTIONS
A. Mood A. Mood:
Euthymic
Depression/despairing Interpretation: Joy/ happy and lonely
Euphoria Mostly, Charlie acts smart which leads him to good and
bad experiences. He sees things and understands that he
Elation
is lonely or even happy. One scene in school, he was
Fearful able to answer the questions asked by his English
teacher though not orally, but through his notes. He was
Irritable somehow seen smiling that he was able to have a good
Anxious conversation with his teacher. On the other hand, when
he went outside his classroom, a senior student grabbed
Guilty and tear his book. When he went home, he expressed
Labile what he felt through writing on his notebook.

Justification:
According to Videbeck, S. (2015), the mood of a person
with PTSD could be a wide range of emotions if possible.
Yale University psychology professor Laurie Santos, who
is teaching an extraordinarily popular course on how to be
happy, agreed it’s possible for people to feel both positive
and negative emotions at once. This is one of the reasons
that most scientific scales for emotion include a separate
dimension for positive emotion and negative emotion —
they're not a continuum. Our mind has the range to feel
both happy and sad at the same time to help us adapt,
psychologists believe. Human beings have the most
sophisticated minds in the history of the planet and we
have these complex minds, in part, because we live in a
complex world. Much as we might like stimuli and events
to come at us one at a time, that’s not how the world
works. Maybe you get good news and bad news within
the space of a minute.

Verbatim:
Charlie: “If my Aunt Helen were still here, I could talk to
her. And I know she would understand how I am both
happy and sad, and I'm still trying to figure out how that
could be. I just hope I make a friend soon. Love always,
Charlie.”
Interpretation: Anxious
One moment in Charlie and his friends has been
detached with each other due to the honesty of Charlie
when he was dared to kiss the prettiest girl in the room
and he kissed Sam instead of Mary Elizabeth that is his
girlfriend. With the mistake he did, all his friends went out
leaving him there feeling anxious on possibly how long his
friends won’t be talking to him.

Justification:
Separation anxiety isn’t only seen in children. It can also
be seen in adults. Adults with separation anxiety have
extreme fear that bad things will happen to important
people in their lives, such as friends, or family members.
In another study of the Journal of Traumatic Stress, it was
published that post-traumatic stress disorder (PTSD) is
related to separation anxiety disorder in adults.

Verbatim:
Charlie: "Dear friend, I have not seen my friends for 2
weeks now. I am starting to get bad again."

B. Affect
Interpretation: Appropriate
The Affect of Charlie has been observed to be in
congruence with his mood. It is not either blunted or even
flattened since his responses are not reduced in intensity
or delayed and there is no absence an emotional
 expression.

Interpretation: Anxious
As seen in the movie, Charlie was able to verbalize that
he has been talking to his family only for the whole
summer and thinking about the opening of the new school
year seemed like it made him socially anxious on what
could possibly be the occurrences that may happen.

Justification:
Aside from the fact that PTSD is an anxiety disorder that
B. Affect can develop after an individual experience or witnesses a
Congruence with mood traumatic event. According to the Mayo Foundation for
Medical Education and Research (2020), PTSD is known
Constricted/ Blunted to cause problems with communication and unreasonable
Flat fear surrounding certain situations or people. People who
have had a traumatic experience may develop social
Appropriate anxiety symptoms if they are not able to get effective
Inappropriate treatment and recover from their trauma.

Verbalization:
Charlie: “I hope it's okay for me to think that. You see, I
haven't really talked to anyone outside of my family all
summer. But tomorrow is my first day of high school ever,
and I really need to turn things around this year.”

Interpretation: Guilty
Charlie is a modest and caring person, but there is also a
lot of guilt in him subconsciously. Charlie’s repeated
flashbacks also cause him a great deal of distress. This is
evident when he remembers that his Aunt Helen sexually
abused him. When those memories resurfaced, the
intensity of the flashbacks increased and made him feel
 extremely guilty to the point of blaming himself and crying
uncontrollably.

Justification:
People who develop post-traumatic stress disorder
(PTSD) also commonly experience guilt. In particular,
individuals who have endured traumatic events may also
begin to feel what's known as trauma-related guilt.
Trauma-related guilt refers to the unpleasant feeling of
regret stemming from the belief that you could or should
have done something different at the time a traumatic
event occurred. (Tull, M. 2020)

Verbalization:
Charlie: "It's my fault. It's all my fault."

Charlie: “Candace, I killed Aunt Helen, didn't I? She died

getting my birthday present, so I guess I killed her, right?
I've tried to stop thinking that, but I can't. She keeps
driving away and dying over and over.”

IV. THOUGHT
CONTROL/PROCESSES
Content of Thought A. Delusions
There are none content of thought manifested by the
A. Delusions client from the start at the movie until end.
Persecutory
Grandiose
Reference/ideas of reference
Control/Influence (Thought
Broadcasting, Thought
Withdrawal, Thought
Insertion)
Somatic
Nihilistic
Erotomanic
Jealous
Religious

B. Suicidal Thought/ideation Interpretation: Present

Attempt Suicide Attempt
Threat At the later part of the movie, Charlie has an emotional
breakdown. He becomes detached from his friends when
Gestures
they went away for college. In the same setting, he went
home having no one inside his house. He starts feeling
guilty for the death of his aunt, Helen leading him to have
suicidal ideations. Charlie looks from the table to the
counter with the bread and the knife. In his flashback, he
saw his aunt’s wrist having scars. He even stared on the
knife just as the police came and breaks the door.

Justification:
In a survey of 5,877 people across the United States, it
was found that people who had experienced physical or
sexual assault in their life also had a high likelihood of
attempting to take their own life at some point. (Tull, M.
2020). According to Ramsawh HJ (2016), people with a
diagnosis of PTSD are also at greater risk to attempt
suicide. Among people who have had a diagnosis of
PTSD at some point in their lifetime, approximately 27%
have also attempted suicide. Another large-scale survey
found that 24% of military personnel diagnosed with
PTSD had experienced suicidal thinking within the past
year.

C. Obsessions
There are no obsessions, magical thinking, phobia, and
D. Magical Thinking poverty of content manifested by the client from the start
E. Phobia at the movie until end.

F. Poverty of Content

Perceptual Disturbances
1. Hallucinations There are no hallucinations manifested by the client from
Hypnagogic the start at the movie until end.
Hypnopompic
Visual
Auditory
Tactile
Olfactory
Gustatory
Trailing Phenomenon
Micropsia (lilliputian)
Marcopsia

2. Illusions
There are no illusions manifested by the client from the
Visual start at the movie until end.
Auditory
Tactile
Olfactory
Gustatory
3. Depersonalization There are no depersonalization and derealization
Derealization manifested by the client from the start at the movie until
end.

4. Preoccupation Interpretation: Rumination

Ruminations Charlie has given involuntary attention given to intrusive
thoughts. He has repetitive or continuous thinking about a
particular subject that interferes with other thought
process especially with regards to the death of her aunt
putting himself into blame.

Justification:
The exact reasons that people ruminate vary from person
to person. In clinical psychology, mental health
professionals attribute rumination to a variety of causes,
such as a misconception that obsessively thinking
about past trauma will give the individual new
perspective on these events. Also, continued
stressors that remind the individual of previous
trauma and predisposition toward negative thoughts
and negative self-image. Rumination can be a
detriment to healthy living in the context of
interrupting applicable and relevant thinking,
inhibiting healthy sleep patterns, causing appetite
disruptions, and interfering with basic life functions.
Ruminating over the traumatic event may actually
cause PTSD symptoms to become worse and longer
lasting. This is especially true when individuals begin
to blame themselves. In multiple studies, researchers
found a relationship between the severity of PTSD
symptoms and occurrence of rumination, indicating
that these are common features for trauma patients.
PTSD sufferers reported thoughts such as intrusive
 trauma memories, depressive rumination, self-
focused rumination, rumination as an emotion
regulation strategy, and the general tendency to
ruminate. These studies indicate that the way the
person processes these ruminations determines how
useful or dangerous this behavior is for their PTSD.

Verbatim:
Charlie: “Sam and Patrick left, and um, I just can't stop
thinking something. Candace, I killed Aunt Helen, didn't I?
She died getting my birthday present, so I guess I killed
her, right? I've tried to stop thinking that, but I can't. She
keeps driving away and dying over and over.”

5. Déjà vu There are no of Déjà vu and Jamais vu content

Jamais vu manifested by the client from the start at the movie until
end.

Impulse Control
Impulse Control
Ability to control impulses
Interpretation: Aggression
a. Aggression
Charlie has been exposed to different circumstances
b. Hostility including his relationship with his friends. He is not able to
c. Fear control his aggression especially during the time when
Patrick a friend of Charlie was in a fight inside the
d. Guilt cafeteria. Some boys were punching Patrick and there
e. Affection came Charlie and punched all of those who hurt his
friends. Charlie looks at his hand, clenched in a fist. It is
f. Sexual feelings already covered with blood. Charlie's confused until he
sees the Linebacker holding his broken, bloody nose.
Justification:
According to Tull, M. (2020), it is important to know that
 the anger of people with PTSD can become so intense
that it feels out of control. When that happens, the person
may become aggressive toward others or even harm
yourself. According to Tull, M. (2020), it is important to
know that the anger of people with PTSD can become so
intense that it feels out of control. When that happens, the
person may become aggressive toward others or even
harm yourself. According to the Developmental Task of
Erik Erickson, in accordance to the age of Charlie he
belonged to the Identity vs. Role Confusion stage wherein
it occurs during adolescence, from about 12-18 years.
During this stage, adolescents search for a sense of self
and personal identity, through an intense exploration of
personal values, beliefs, and goals. This is a major stage
of development where the child has to learn the roles he
will occupy as an adult. It is during this stage that the
adolescent will re-examine his identity and try to find out
exactly who he or she is. Teen behavior often seems
unpredictable and impulsive, but all of this is part of the
process of finding a sense of personal identity. Parents
and family members continue to exert an influence on
how teens feel about themselves, but outside forces also
become particularly important during this time. Friends,
social groups, schoolmates, societal trends, and even
popular culture all play a role in shaping and forming an
identity. Those who receive proper encouragement and
reinforcement through personal exploration will emerge
from this stage with a strong sense of self and a feeling of
independence and control with their feelings and
emotions. Those who remain unsure of their beliefs and
desires will remain insecure, confused about themselves,
and inability to stabilize their emotions and may loss
control of impulses.

Verbatim:
Patient: “If you touch my friends again, I'll blind you.”
V. NEUROVEGETATIVE
DYSFUNCTIONS
A. Sleep Interpretation: Normal
Normal Justification: In the movie, it was not shown that the
client had difficulty falling asleep or had any sleep
Hypersomnia
disturbances such as interrupted sleep, middle of the
MNA night awakening (MNA), early morning awakening (EMA)
and hypersomnia.
EMA
DFA
Interrupted

The client’s appetite was not observed in the entire

B. Appetite duration of the movie.
Poor/fair/good
Polyphagia
Voracious
Pica
Binge eating
Coprophagia

Diurnal variation, weight and libido was not observed and

C. Diurnal Variation assessed in the movie.

D. Weight
E. Libido
VI. GENERAL SENSORIUM
AND INTELLECTUAL
STATUS
Describe impaired or Interpretation: The client has impaired orientation about
unimpaired the place and time. He is disoriented about the place.
A. Orientation (place, time, Justification: In the later part of the movie, when he
person, situation) remembered that he was sexually abused by Aunt Helen,
he was anxious and had an emotional breakdown thus,
he called her sister and told her that the death of his aunt
was his fault. After that incident, he had a blackout and
was brought to the Mayview hospital.
Sample verbatim from the movie:

Psychiatrist: “Ch**, I’m Dr. Burton”

Patient: “Where am I?”
Psychiatrist: “Mayview Hospital”

Timestamp: 1: 31:15 – 1:31: 27

Interpretation: The client has an impaired memory. He

B. Memory was able to recall his recent memories however, he has a
Recent difficulty recalling his remote memory with emphasis on
the traumatic event. The client has dissociative amnesia.
Remote
Justification: In the movie, Charlie has an inability to
Immediate remember an important aspect of the traumatic event
Confabulation particularly when he was sexually abused by his aunt.
During the first part of the movie, when a flashback
Agnosia occurs, it only composes of some good memories with his
Apraxia aunt and the tragic car accident.

Amnesia According to Spiegel (2021), dissociative amnesia is a

type of dissociative disorder that involves inability to recall
important personal information that would not typically be
lost with ordinary forgetting. It is usually caused by trauma
or stress. The amnesia appears to be caused by
traumatic or stressful experiences endured or witnessed
such as physical or sexual abuse, rape, combat,
genocide, natural disasters, death of a loved one, serious
 financial troubles) or by tremendous internal conflict such
as turmoil over guilt-ridden impulses or actions,
apparently unresolvable interpersonal difficulties, criminal
behaviors).

C. Attention Span Interpretation: The client has good attention span. He

was able to elaborate his answers.
Justification: He is attentive to the questions being
raised at him by the psychiatrist and responds
immediately to the interviewer.

Sample verbatim from the movie:

Psychiatrist: “What’s hurting you?”
Patient: “No, it’s not me. It’s them. Everyone. It never
stops. Do you understand?”
Psychiatrist: (nods) “What about your Aunt Helen?”
Patient: “What about her?”
Psychiatrist: “Do you see her?”
Patient: “Yes, she had a terrible life”
Timestamp: 1: 32: 12 – 1: 32: 45

D. General Information
The client is 15 years old, currently in his freshman year.
He experienced a traumatic event in his childhood which
was being sexually abused by his aunt. The client faces
difficulty in remembering incidents of his past most
especially with his aunt Helen. He often has flashbacks
when something upsetting occurs in his life such as when
his sister was being slapped by his boyfriend, it triggered
his childhood memories.
E. Abstract Thinking Ability Interpretation: The client has good abstract thinking
ability.
Justification: In the hospital setting, abstract thinking
ability can be assessed through letting the client interpret
proverbs or by asking the client to identify similarities
between pairs of objects. In the movie, there was a brief
contact with Dr. Burton, his psychiatrist thus it was not
seen that abstract thinking ability was assessed.
However, there was one scene that can be associated
with abstract thinking ability which was when he was able
to relate a concept to what he is currently feeling. During
their tunnel drive, he said, “I feel infinite.” Infinite can be
related to physics and mathematics since it refers to a
quantity which means that Charlie meant that he feels
free, rather than constrained by the constant pressures
and trauma of his past and his repressed memories.
Timestamp: 28:12-28:13

F. Judgment /Reasoning
1. Ability to solve
problems and make
decisions, make plans for the Interpretation: The client has good judgement/reasoning.
future Justification: In the movie, when he was brought to
Mayview Hospital and was being interviewed by the
psychiatrist there were no flight of ideas and
hallucinations observed in the person. He was able to
explain himself clearly to the psychiatrist.
Sample verbatim from the movie.

Patient: “You have to let me go. My dad can’t afford it”

Psychiatrist: “Don’t worry about that”
Patient: “No. I saw them when I was little. And I don’t
want to be a Mayview kid. Just tell me how to stop it.”
Psychiatrist: “Stop what?”
 Patient: “Seeing it. All their lives. All the time. Just… how
do you stop seeing it?”

VII. INSIGHT
Describe impaired or  In the beginning of the movie client has a poor
unimpaired insight regarding on how the trauma is affecting his
life. He has had blackouts where he does things
Knowledge about Self, and has no memory of them happening. He saw a
limitations series of flashbacks about his admired Aunt who
Awareness of illness died in a car crash on his seventh birthday. But
towards the end of the movie his insight about his
Ask: Do you think you illness becomes better because he realized that his
have a problem? aunt was molesting him when he was a child. this
justification is supported by the following
Do you think you verbatims:
need treatment?
Adaptive/Maladaptive use of Client: No. I saw them when I was little. And I don't want
coping mechanism to be a Mayview kid. Just tell me how to stop it.
Psychiatrist: Stop what?
Client: Seeing it. All their lives. All the time. Just... how do
you stop seeing it?
Psychiatrist: Seeing what, Charlie?
Client: There is so much pain. And I don't know how to
not notice it.
Psychiatrist: What's hurting you?
Client: No! Not me. It's them. It's everyone. It never stops.
Do you understand?
What about your Aunt Helen?
Client: What about her?
Psychiatrist: Can you see her?
Client: Yes, she had a terrible life. But... I mean, what
 am I...
Psychiatrist: You said some things about her in your
sleep.
Client: I don't care.
VIII. SUMMARY OF MSE
A. Disturbances in: At the start of the movie the mood of the client was
lonely but it all changed at the middle part of the
(X) Presentation movie where he meets his friends and he became
(X) Stream of Talk happy. He has a suicidal tendency because he felt
guilty that his aunt died because of him. At the time
(✓)Emotional State and when he is brought to the hospital he was
Reactions disoriented for he did not know where he was. At
sometime he doesn’t have any insight about his
(✓) Thought Processes illness but as the movie comes in the end he slowly
(X) Neurovegetative realizes the trauma that he has
Dysfunctions
(✓) Sensorium and
Intellectual Status
(✓) Insight The client’s condition was diagnosed as PTSD, it is
included in a new category in DSM-5, Trauma- and
Stressor-Related Disorders. He was traumatized for the
death of his aunt and his best friend where if affected his
life. Symptoms were present for more than 3 months
where he experienced flashbacks, anxiety, sleep
disturbance, low self-esteem and substance abuse. And
this symptoms falls under the criteria of diagnosing PTSD.
B. Diagnostic Category
(DSM IV : Diagnostic and
Statistical Manual of
Mental Disorders
V. Psychodynamics
A. Risk Factors
Pre- existing factors:
Factors Present/Absent Justification Rationale
Genetic Factors Absent It was not stated in Research continues
the movie that to explore the role of
client’s family genetics in the
members have development of
certain mental PTSD. There have
health conditions been studies showing
such as genetic influence on
schizophrenia, the development of
bipolar disorder, mental health
and major conditions such as
depressive schizophrenia,
disorder, and bipolar disorder, and
researchers are major depressive
finding genetic disorder, and
influence in the researchers are
development of finding genetic
PTSD as well. influence in the
development of
PTSD as well (Tull,
2021).
Sex Absent The patient in the Women are
movie is a male considered more
and a high school likely to develop
freshman. PTSD than men. The
prevalence of PTSD
over the lifespan has
been found to be 10
percent to 12 percent
 among women and 5
percent to 6 percent
in men. Researchers
have found among
European-American
females in particular,
close to one-third (29
percent) of the risk
for developing PTSD
after a traumatic
event was influenced
by genetic factors.
The genetic risk rate
was found to be
much lower in males
(Tull, 2021).
History of Abuse Present In the movie, it has People with a history
been shown from of physical,
the client’s emotional, or sexual
flashbacks on his abuse tend to be
memories that he more susceptible to
was sexually PTSD. Such
abused by his experiences
Aunt Helen when contributed to
he was just a previous trauma and
young boy. their effects may be
reinforced by any
additional trauma.
Lower Absent The patient is Studies have shown
Socioeconomic living in a 2-storey that lower
Status house with his socioeconomic status
family. His parents is associated with
have jobs to higher rate of PTSD
sustain their daily and depression
needs. Based on among trauma-
our assessment on exposed individuals
the movie, there (Ayazi, et.al, 2012).
family’s - SES was assessed
socioeconomic on the basis of
status will be community income,
middle class. education and
occupational status.
The study considered
economic stress as
one of several
possible explanations
for the correlation
between SES and
mental illness, and
this was determined
by how much the
local income income
was below the federal
poverty level, the rate
of unemployment,
and an index of rental
housing
unaffordability.

This study provides

strong evidence that
SES impacts the
development of
mental illness
 directly, as well as
indirectly through its
association with
adverse economic
stressful conditions
among lower income
groups, said Dr.
Hudson.
Less Education, Absent The client in the Two risk factors that
lower intelligence movie is a have been shown to
freshman in high possibly influence the
school. When his development of
teacher, Mr. PTSD after trauma
Anderson asked are IQ and
questions, he was neuroticism. Those
able to answer it who tend to score
but he does not lower on IQ tests
like to participate have been shown to
and state his be more susceptible
answer to the to developing PTSD.
class. The client (Tull, 2021).
also enjoys
reading and has a
goal to become a
writer someday.

Peritraumatic factors

Factors Present/Abse Justification Rationale

 nt
Severity and Present The patient was sexually abused The severity and nature
nature of by his aunt Helen when he was of the trauma can affect
trauma just a young boy. The traumatic treatment presentation,
experience of the patient engagement, and the
happened at their own house. outcome of behavioral
health services.
https://www.scielo.br/scielo.php? Moreover, it also affects
pid=S0101- the duration and onset
60832020000500135&script=sci_ of PTSD depending to
arttext the trauma’s nature and
severity that was
experienced by the
patient (Trauma-
Informed Care in
Behavioral Health
Services).
- In a study conducted
with a sample of 602
people in 2018, Guina
et al. compared the
trauma types with
PTSD severity. The
same study identified
more severe symptoms
in PTSD cases due to
post war period and
sexual traumas
9. Smith et al. also
compared severity of
trauma types with
PTSD symptoms, as
 well as comorbid
anxiety and depression.
They found that
symptom severity and
comorbid psychiatric
disorders were higher in
PTSD patients who
experienced sexual
trauma.
Interpersonal Present The patient punches three senior Interpersonal violence
violence students in his school in order to (IPV) is one of the most
Absent protect his friend Patrick who was frequent causes for the
being punched and bullied. development of
Based on the movie, the client posttraumatic stress
did not experience interpersonal disorder (PTSD).
violence which causes him to Trauma-related triggers
have a trauma that causes the have been proposed to
development of his PTSD evoke automatic
emotional responses in
PTSD (Neumeister,
2016). 
Dissociation Present In the movie, the patient only Dissociation commonly
at the time of remembered his memories with goes along with
the traumatic his aunt Helen when he was traumatic events and
event having flashbacks. In the one of PTSD. Dissociation as
the flashbacks, his aunt Helen avoidance coping
have whispered to him and said, usually happens
“It’s gonna be our little secret”. because of a traumatic
event. Being powerless
to do anything to
change or stop a
traumatic event may
 lead people to
disconnect from the
situation to cope with
feelings of
helplessness, fear or
pain (Washington State
University).

Post-traumatic Factors
Factors Present/Absent Justification Rationale
Development of Absent The patient In the weeks after a
Acute Stress experienced the traumatic event, you
Disorder trauma of being may develop an
sexually abused anxiety disorder
when he was just a called acute stress
young boy. It was disorder (ASD).
not shown in the ASD typically
movie that he occurs within one
experienced Acute month of a
Stress Disorder traumatic event. It
after 1 month of the lasts at least three
traumatic days and can
experience. persist for up to one
month. People with
ASD have
symptoms similar to
those seen in post-
traumatic stress
disorder (PTSD)
(Legg, 2018).
Subsequent Present When the patient’s A significant
adverse life events friend Sam left to proportion of trauma
pursue college, the survivors
patient started to experience an
have more additional critical life
flashbacks about his event in the
memories with his aftermath. These
aunt Helen. He renewed
remembered that he experiences of
was being sexually traumatic and
abused by his aunt. stressful life events
Moreover, with the may lead to an
flashbacks, he also increase in trauma-
knew that her aunt related mental
died on a car health symptoms.
accident in which
the patient blames
himself for his
aunt’s death.
Lack of social Present The client was not Social support, or
support able to show his lack of, is a critical
emotions and risk factor. Those
feelings towards his who are limited in
family. It is when he options for social
entered high school support can be at
when he was not greater risk for
able to express that PTSD. After the
he is both happy traumatic event, the
and sad when he need for safe
entered high school support resources is
since he does not essential to help
want to worry his individuals process
parents. their experience in a
 healthy way and to
regain hope through
secure and safe
emotional
connections.
Temperamental Present The client avoids Posttraumatic:
the sharing of These include
flashbacks when he negative appraisals,
was sexually inappropriate coping
abused by his aunt strategies,
Helen. Due to the and development of
intensity of the acute stress
trauma that was disorder.
experienced by the
client, the memory
where the patient
was being sexually
abused were
repressed.
Environmental Present The client is Posttraumatic:
exposed to the These include
environment where subsequent
he was sexually exposure to
abused by his aunt repeated upsetting
Helen. The client reminders,
was sexually subsequent adverse
abused in his own life events, and
house when he was financial or other
a young boy. The trauma-related
flashbacks of the losses. Social
client’s memories support (including
with his aunt Helen family stability, for
are revolving in the children) is a
client’s house such protective factor that
as the living room, moderates outcome
kitchen, entrance after trauma.
door, and outside of
the house.
VI. DIFFERENTIAL DIAGNOSIS
A. Diagnosis of the case
The client is diagnosed with Post Traumatic Stress Disorder with delayed
expression.
A. Duration
According to the Diagnostic and Statistical Manual of Disorders 5th edition, the
duration of PTSD criteria is more than a month. In the movie, Charlie encounters
his PTSD symptoms for several months. Although, he directly experienced the
traumatic event when he was still a child, his symptoms were first observed when
he was in freshman year. This was during he saw his sister being slapped by his
boyfriend which triggered his flashbacks until the time where his friends left for
college. For this reason, his diagnosis is Post-Traumatic Stress Disorder with
Delayed Expression.

C. Criteria
Major Depressive Disorder
A. Five or (more) of the following X
symptoms have been present during the
same 2-week period and represent a
change from previous functioning; at least
one of the symptoms is either (1)
depressed mood or (2) loss of interest or
pleasure
1. Depressed mood most of the day x
nearly every day as indicated by either
subjective report (e.g., feels sad, empty,
hopeless) or observation made by others
(e.g.,
appears tearful).
2. Markedly diminished interest or X
pleasure in all, or almost all activities
most of the day, nearly every day as
indicated by either subjective report (e.g.,
feels sad, empty, hopeless) or
observation made by others (e.g.,
appears tearful).
3. Significant weight loss when not dieting X
or weight gain (e.g., a change of more
than
5% of body weight in a month), or
decrease or increase in appetite nearly
every day.
4. Insomnia or hypersomnia nearly every X
day.

5. Psychomotor agitation or retardation /

nearly every day (observable by others,
not
merely subjective feelings of restlessness
or being slowed down).
6. Fatigue or loss of energy nearly every X
day.
7. Feelings of worthlessness or excessive /
or inappropriate guilt (which may be
delusional) nearly every day (not merely
self-reproach or guilt about being sick)
8. Diminished ability to think or X
concentrate, or indecisiveness, nearly
every day (either by subjective account or
as observed by others).
9. Recurrent thoughts of death (not just /
fear of dying), recurrent suicidal ideation
without a specific plan, or a suicide
attempt or a specific plan for committing
suicide.

B. The symptoms cause clinically /

significant distress or impairment in
social, occupational, or other important
areas of functioning.
C. The episode is not attributable to the /
physiological effects of a substance or to
another
medical condition.
D. The occurrence of the major /
depressive episode is not better
explained by schizoaffective disorder,
schizophrenia, schizophreniform disorder,
delusional disorder, or
other specified and unspecified
schizophrenia spectrum and other
psychotic disorders
E. There has never been a manic episode /
or a hypomanic episode.
Acute Stress Disorder
A. Exposure to actual or threatened /
death, serious injury, or sexual violation in
one or more of the following ways:
1. Directly experience the traumatic /
event(s)
2. Witnessing, in person, the event(s) as X
it occurred to others.
3. Learning that the traumatic event(s) X
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 X
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).
B. Presence of nine (or more) of the /
following symptoms of any of the five
categories of intrusion, negative mood,
dissociation, avoidance, and arousal,
beginning or worsening after the
traumatic event(s) occured

INTRUSION SYMPTOMS
1. Recurrent, involuntary, and intrusive /
distressing memories of the traumatic
event(s)
2. Recurrent distressing dreams in which /
the content and/or affect of the dream are
related to the traumatic event(s).
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.)
4. Intense or prolonged psychological /
distress at exposure to internal or
external cues
that symbolize or resemble an aspect of
the traumatic event(s).

NEGATIVE MOOD
5. Persistent inability to experience /
positive emotions
DISSOCIATIVE SYMPTOMS
6. An altered sense of the reality of one’s X
surroundings or oneself
7. Inability to remember an important /
aspect of the traumatic event
AVOIDANCE SYMPTOMS /
8. Efforts to avoid distressing memories, /
thoughts or feelings about or closely
associated with the traumatic event
9. 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).
AROUSAL SYMPTOMS
10. Sleep disturbance X
11. Irritable behavior and angry outbursts /
12. Hypervigilance X
13. Problems with concentration X
14. Exaggerated Startle Response X
C. Duration of the disturbance (symptoms X
in Criterion B) is 3 days to 1 month after
trauma
exposure.
D. The disturbance causes clinically /
significant distress or impairment in
social, occupational, or other important
areas of functioning.
E. The disturbance is not attributable to /
the physiological effects of a substance
(e.g.,
medication or alcohol) or another medical
condition (e.g., mild traumatic brain injury)
and is not better explained by brief
psychotic disorder.
Post-Traumatic Stress Disorder with Delayed Expression
A. Exposure to actual or threatened /
death, serious injury, or sexual violence in
one or more of the following ways:
1. Directly experience the traumatic /
event(s)
2. Witnessing, in person, the event(s) as X
it occurred to others.
3. Learning that the traumatic event(s) X
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 X
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).
B. 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)
2. Recurrent distressing dreams in which /
the content and/or affect of the dream are
related to the traumatic event(s).
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.)
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).
C. 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).
D. 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 X
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).
E. Marked alterations in arousal and X
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 & angry outbursts /
(with little or no provocation) typically
expressed as verbal or physical
aggression toward people or objects.
2. Reckless or self-destructive behavior. X
3. Hypervigilance X
4. Exaggerated Startle Response X
5. Problems with concentration X
6. Sleep disturbance X
F. Duration of the disturbance (Criteria B, /
C, D, and E) is more than 1 month.
G. The disturbance causes clinically /
significant distress or impairment in
social, occupational or other important
areas of functioning
H. The disturbance is not attributable to /
the physiological effects of a substance
(e.g.,
medication, alcohol) or another medical
condition.
Major Depressive Disorder
SIGNS & SYMPTOMS MARK JUSTIFICATION RATIONALE
Depressed mood X Depressed mood was not When someone
evident in Charlie during the experiences
whole duration of the movie. persistent and
Whenever he faces troubles intense feelings of
in his life, he is sad and sadness for
anxious however being in a extended periods of
depressed mood was not for time, then they may
a consistent duration or have a depressed
nearly every day. mood (Legg, 2018).

The death of a family

member, friend, or
pet sometimes goes
beyond normal grief
and leads to
depression. Other
difficult life events
such as when
parents’ divorce,
separate, or remarry
can trigger
depression (Lyness,
2016).

Diminished interest or X It was not seen during the People who

pleasure in all or entire duration of the movie. experience
almost all activities Instead, when Charlie anhedonia have lost
experiences a problem, such interest in activities
as having a they used to enjoy
misunderstanding with his and have a
friends, he still continues to decreased ability to
carry out the activities that feel pleasure. It's a
he enjoys such as writing core symptom of
and reading books. major depressive
disorder, but it can
also be a symptom
of other mental
health disorders
(Legg, 2018).

Depression causes
feelings of sadness
and/or a loss of
interest in activities a
person once enjoyed
 (American
Psychiatric
Association, 2019).
Significant weight loss X No significant weight loss or The Diagnostic and
or weight gain weight gain seen during the Statistical Manual of
entire duration of the movie. Mental Disorders
lists weight gain or
weight loss as a
symptom of
depression at all
ages. The relation
between physical
measures of weight
change and
depressive
symptoms varied
with age. These
relations were
explained by
individual differences
in body
dissatisfaction,
eating attitudes, and
behaviors, leading to
questions about
weight change as a
symptom of
depression in
adolescence (Felton
et al., 2014).
Insomnia X It was not observed or seen Depression and
in the movie. sleep problems are
closely linked.
People with
insomnia, for
example, may have
a tenfold higher risk
of developing
depression than
people who get a
good night's sleep.
And among people
with depression, 75
percent have trouble
falling asleep or
staying asleep (John
Hopkins Medicine,
 2019).
Psychomotor agitation X Psychomotor agitation was Psychomotor
not observed or seen in agitation is a
Charlie during the entire symptom related to a
duration of the movie. wide range of mood
disorders. It is
usually caused by
different conditions
also, such as
posttraumatic stress
disorder or
depression (Luo,
2017).

Fatigue or loss of X Fatigue or loss of energy People who have

energy was not observed during the chronic fatigue
entire duration of the movie. syndrome may
become depressed.
And while
depression doesn’t
cause chronic
fatigue syndrome, it
can certainly cause
increased fatigue
(Legg, 2020).

One of the most

common residual
symptoms of a
partially resolved
depression is
fatigue. Broadly
defined, symptoms
of fatigue can affect
physical, cognitive,
and emotional
function, impair
school and work
performance, disturb
social and family
relationships, and
increase healthcare
utilization.
Furthermore, some
of the medications
used to treat MDD
can induce
 symptoms of fatigue
as side effects
(Targum, et. al.,
2011).

People with
depression are more
likely to experience
fatigue, and chronic
fatigue can increase
the risk of
depression. This
bidirectional
relationship creates
a cycle that can be
hard to break.
Potential causes of
depression fatigue
include sleep
problems, diet,
stress, medications
which include some
for treating
depression (Litner,
2020).

Feelings of / This was seen when Charlie Feelings of

worthlessness was not able to help her inadequacy and
sister when she had a fight hopelessness were
with his boyfriend. In another part of the core
scene from the movie, depressive
Feelings of worthlessness syndrome, closely
was felt by Charlie was when co-occurring with
they had a misunderstanding depressed mood.
between his friends when he Self-blaming
kissed Sam in front of the emotions were highly
group. frequent and
bothering but not
restricted to guilt
(Zahn, 2015).
Diminished ability to / This behavior was seen Depression can
think or concentrate during the later part of the actually change a
movie when he remembered person’s ability to
that he was sexually abused think. It can impair
by Aunt Helen the attention and
memory, as well as
information
 processing and
decision-making
skills. It can also
lower the cognitive
flexibility and
executive functioning
(Cartreine, 2020).
Recurrent thoughts of / When Charlie remembered Although the majority
death that he was sexually abused of people who have
by his aunt, he had a depression do not
breakdown and repeatedly die by suicide,
uttered that Aunt Helen’s having major
death was his fault and went depression does
to the kitchen and tried to increase suicide risk
harm himself when he sees compared to people
a knife. without depression.
The risk of death by
suicide may, in part,
be related to the
severity of the
depression (National
Institutes of Metal
Health, 2019).

Acute Stress Disorder (ASD)

SIGNS & SYMPTOMS MARK JUSTIFICATION RATIONALE

Recurrent, involuntary, / On his way home after A distressing
and intrusive attending a house party, memory, image or
distressing memories Charlie suddenly lied down thought is something
of the traumatic event on the ground and recalled that you can't get out
his memories with his aunt of your head related
Helen. He also pictured out to trauma or stress.
his aunt driving and was hit Distressing
by a truck. Memories of the memories and
car accident of his aunt were images may occur
frequently recurring in the spontaneously, or
later part of the movie they may be
cued/triggered.
(Harmer, 2021)
Recurrent distressing / It was when the psychiatrist Many different
dreams in which the interviewed Charlie and she factors can
content and/or affect mentioned of him seeing her contribute to a higher
of the dream are aunt. The psychiatrist then risk of nightmares or
related to the event continued saying, “You said distressing dreams
some things about her in such as stress and
your sleep” which indicates anxiety: sad and
that Charlie had dreams traumatic events or
about her. worrisome situations
that induce stress
and fear may
provoke nightmares.
(Legg, 2020)
Dissociative reactions / He is often having This is due to an
(flashbacks) flashbacks of his Aunt Helen. abnormality in the
This behavior was observed circuit including the
when he saw his sister being amygdala and
slapped by his boyfriend it hippocampus. The
triggered his childhood amygdala is
memories of his aunt. responsible for
Another instance that this regulating anxiety
was seen was during and emotional
Christmas eve which also responses, while the
happens to be Charlie’s hippocampus
birthday. regulates stress
hormone as well as
playing an important
role in memory. The
two work together to
create emotional
parts of memory,
and when the two
structures do not
work properly,
repeated intrusive
and strong emotional
memories occur.
(Peterson, 2020)
Psychological distress / Charlie was observed to Traumatic
or marked have psychological distress experiences, such as
physiological reactions when he recalled the the death of a loved
in response to internal traumatic event in his one, sexual abuse,
or external cues childhood. This was when and violence are
Sam was caressing his causes of
thighs while kissing him psychological
which triggered his distress.
suppressed memories of her Psychological
sexually abusing him. The distress can be
morning after, he had thought of as a
flashbacks again which maladaptive
made him anxious and response to a
 agitated on his way home. stressful situation.
He is distressed on his way Psychological
home and had a breakdown. distress occurs when
external events or
stressors place
demands upon us
that we are unable to
cope with. (Marich,
2021)
Persistent inability to / In the movie, Charlie is The symptoms of
experience positive observed to be isolated since ASD may cause you
emotions he does not have friends and distress or disrupt
during his first days in important aspects of
school, her sister refuses to your life, such as
let him eat with them during your social or work
lunch. He is also bullied in settings. You may
school and lacks support have an inability to
system such as friends start or complete
which makes him difficult to necessary tasks, or
experience positive emotions an inability to tell
such as being happy and others about the
optimistic. Moreover, he is traumatic event.
perceived as a troubled (Legg, 2018)
person due to his flashbacks
about his past.
An altered sense of / This behavior was not Dissociation is a
the reality of one’ observed during the entire common feature of
surroundings or duration of the movie. Acute Stress
oneself Disorder (ASD)
which involves
disruptions in the
usually integrated
functions of
consciousness,
memory, identity,
and perception of the
self and the
environment.
(Lanius, 2016)

Inability to remember / His flashback contains only The impaired

an aspect of the some good memories of him voluntary memory, is
traumatic event and his aunt and the car caused by defense
accident. He was mechanisms serving
suppressing his memory of to protect against
his aunt sexually abusing reliving the
him which even led to emotional stress as
 consequences such as not well as by a poor
being able to cope up with cognitive match
the flashbacks. between the trauma
and preexisting
schema-structures,
which leads to faulty
encoding of the
event. (Bernsten,
2015)
Efforts to avoid / This was evident when his In acute stress
distressing memories, older brother confronted him disorder, there is a
thoughts or feelings about his condition and persistent attempt to
about or closely asked him if he is doing okay avoid situations,
associated with the then, Charlie replied “I’m not activities and
traumatic event picturing things anymore but sometimes even
if I do, I just shut it off”. people who might
evoke memories of
the trauma. These
efforts include trying
to avoid thoughts
and feelings related
to the event.
(Videbeck, 2020)
Efforts to avoid / It was seen when Charlie People with acute
external reminders was brought to the hospital stress disorder have
that arouse distressing and his psychiatrist talked to been exposed to a
memories, thoughts or him and he said that he just terrifying event. They
feelings about the wanted to stop seeing their may experience it
traumatic event lives. The psychiatrist directly or indirectly.
mentioned her aunt however, For example, direct
he refuses to disclose any exposure may
information about it. He involve experiencing
avoided situations in which serious injury,
he had to discuss the violence, or the
trauma. threat of death.
Indirect exposure
may involve
witnessing events
happening to others
or learning of events
that occurred to
close family
members or friends.
People mentally re-
experience the
traumatic event,
avoid things that
 remind them of it,
and have increased
anxiety. (Barnhill,
2020)
Sleep disturbance X It was not seen during the This is due to
entire duration of the movie. cortisol, a stress
hormone is one of
the key players
responsible for the
fight or flight
response, the energy
an individual gets
when he/she feel
stressed or
threatened enables
them to respond.
Unfortunately,
chronic stress can
lead to excessive
levels of cortisol, and
this can disrupt
healthy sleep
patterns. (Scott,
2020)
Irritable behavior and / Charlie had an angry Other criteria of ASD
angry outbursts outburst when he saw and PTSD include
Patrick being punched by a increased arousal,
group of men in the anxiety,
cafeteria, he was not able to restlessness,
control his emotions and irritability and
kept a calm nature instead, disturbances in
he was punching the group sleep. There might
of men and had a blackout. be occasional
outbursts of anger or
rage. (Videbeck,
2020)
Problems with X Charlie did not exhibit any Many people with
concentration problems with concentration PTSD report that
in the entire duration of the they have a hard
movie. time paying attention
or concentrating
while completing
daily tasks. This is
often the result of
being very anxious.
High anxiety levels
may also limit an
 individual’s ability to
notice things that are
going on around
them or interfere with
their ability to focus
on a task (Tull,
2020).
Exaggerated startle X It was not observed in the ASD symptoms like
response movie. hyperarousal
ultimately develop as
a result of the
overreaction of the
body's stress
response. In
addition,
hyperarousal can
persist long after the
trauma has passed,
leaving the individual
hyper-responsive to
anything that
reminds him/her of
the event (including
sights, smells,
sounds, or even
specific words of
passages of music)
(Tull, 2020)

Post-Traumatic Stress Disorder (PTSD)

SIGNS & PRESENT JUSTIFICATION RATIONALE

SYMPTOMS
Recurrent, / It was evident in the One explanation for
involuntary movie that the main the persistence of
distressing memories character, Charlie, was intrusive thoughts in
of the traumatic able to experience PTSD focuses on the
event recurrent, involuntary underlying automatic
distressing memories of neurocognitive
a certain traumatic event. processes involved in
Specifically, when he thought regulation. By
was on his way home this account, an
after attending a house inability of cognitive
party, Charlie suddenly control systems to
 lied down on the ground downregulate or inhibit
and recalled his information results in
memories with his aunt the occurrence and
Helen. He also pictured persistence of
out his aunt driving and unwanted intrusive
was hit by a truck. thoughts (Bomyea,
Memories of the car 2016)
accident of his aunt were
frequently recurring in
the later part of the
movie. Other than that,
pictures on his mind
flashed about some
certain details of how his
aunt molested him.
Hence, these traumatic
events were considered
to be recurring in the
mind of Charlie.
Recurrent distressing / In the whole duration of The exact relationship
dreams the movie, there was no between nightmares
certain scene wherein and PTSD is still
Charlie was having unknown but
nightmares or dreams. nightmares and PTSD
However, when he was are closely related, and
admitted in the hospital, both show altered
the psychiatrist activity in the same
mentioned to Charlie brain regions.
about him seeing her in However, a study
his sleep. As per suggests that
verbalization of the nightmares may be an
psychiatrist, “You said intense expression of
some things about her in the body working
your sleep” which through traumatic
indicates that Charlie experiences, so
had dreams about her. intense that the
nightmare causes the
person to wake up.
Nightmares may also
represent a breakdown
in the body’s ability to
process trauma.
Trauma-related
nightmares subside
after a few weeks or
months. (Dimitriu,
2020)
Dissociative / Charlie Kelmeckis is This is due to an
reactions experiencing flashbacks abnormality in the
(flashbacks) at different times, most circuit including the
especially when amygdala and
something of a familiar or hippocampus. The
similar event occurs. amygdala is
Most of the content of responsible for
Charlie’s flashbacks are regulating anxiety and
his memories with his emotional responses,
Aunt Helen. Particularly, while the hippocampus
when something regulates stress
upsetting happens to him hormone as well as
such as his sister getting playing an important
hit by her boyfriend or role in memory. The
when he had recalled a two work together to
memory of his aunt on create emotional parts
her way to get his of memory, and when
birthday present the two structures do
dissociative reactions not work properly,
and flashbacks occur. repeated intrusive and
strong emotional
memories occur.
(Pandya, 2017)
Psychological / It was when Charlie and Traumatic
distress related to Sam were kissing in the experiences, such as
symbols or room and Sam was the death of a loved
remembrance of the caressing his thighs one, sexual abuse, and
event which made Charlie violence are causes of
uncomfortable and was psychological distress.
hesitant to continue. The Psychological distress
day after Sam and can be thought of as a
Patrick was about to maladaptive response
leave for college, Charlie to a stressful situation.
was anxious as he Psychological distress
recalled that it was the occurs when external
same thing that events or stressors
happened to him in the place demands upon
past wherein Aunt Helen us that we are unable
was also caressing his to cope with. (Marich,
thighs and telling him not 2021)
to wake his sister up.
Avoidance of or / When his older brother Emotional avoidance
efforts to avoid confronted him about his may be effective in the
distressing condition and asked him short-term and can
memories, thoughts if he is doing okay then, provide some
or feelings Charlie replied “I’m not temporary relief. In the
picturing things anymore long run, it often
 but if I do, I just shut it causes more harm as
off”. avoidance behaviors
are associated with
increased severity of
PTSD symptoms. (Tull,
2020)
Avoidance of or / It was seen when Charlie Avoidance is another
efforts to avoid was brought to the cardinal symptom of
external reminders hospital and his PTSD. Sufferers avoid
(people, places, psychiatrist talked to him trauma-related
conversations, and he said that he just activities that reminds
activities, objects, wanted to stop seeing them of the past
situations) their lives. The experience or trauma
psychiatrist mentioned or reminiscent of the
her aunt however, he traumatic event.
refuses to disclose any (Videbeck, 2020)
information about it. He
avoided situations in
which he had to discuss
the trauma.
Inability to remember / Charlie has impaired The impaired voluntary
an important aspect memory of the traumatic memory, is caused by
of the traumatic event, where he could defense mechanisms
event not remember he was serving to protect
sexually abused and against reliving the
instead generally emotional stress as
admired Aunt Helen. In well as by a poor
the beginning of the cognitive match
movie, his flashbacks between the trauma
were just about the car and preexisting
accident and during his schema-structures,
birthday. which leads to faulty
encoding of the event.
(Bernsten, 2015)

Additionally, Charlie was Dissociative amnesia

sexually abused by her is a type of dissociative
Aunt Helen when he was disorder that involves
a child and he is unable inability to recall
to recall the traumatic important personal
incident in his teenage information that would
years. He started having not typically be lost
flashbacks of his with ordinary
memories with his aunt forgetting. It is usually
during his freshman caused by trauma or
year. stress. The amnesia
appears to be caused
 by traumatic or
stressful experiences
endured or witnessed
such as physical or
sexual abuse.
(Spiegel, 2021)
Blaming self or / Charlie is blaming Posttraumatic stress
others for the trauma himself for the death of disorder (PTSD) is a
his aunt. Although, Aunt severe psychiatric
Helen sexually abused condition that can
Charlie, he is fond of manifest as a
Aunt Helen and combination of
developed an attachment debilitating symptoms,
for her. He is also seen one of which is a
banging his head distorted sense of
repeatedly while saying responsibility for the
“It’s my fault”. Then, traumatic event. The
Charlie called her sister, inclusion of DSM-5’s
he told her that he killed PTSD D3 criterion
his aunt and was (blaming self or others
constantly feeling at fault for the stressful
that she was in the car experience) has
and died in a car received little research
accident. attention in regard to
its relation to post-
trauma mental health
outcomes. (Forkus,
2020) 
Negative feelings / When his memory of An individual with
about self and the Aunt Helen sexually PTSD seeks comfort,
world abusing him resurfaced, safety, and security,
he viewed himself but can actually
extremely negatively, become increasingly
continuously blaming isolated over time,
himself for Aunt Helen’s which can heighten the
death, reasoning that he negative feelings he or
might have wanted her to she was trying to
die or she died because avoid. (Videbeck,
she went to get his 2020)
birthday present. Also,
he portrays a strong
sense of guilt over his
aunt’s death.
Feelings of / At the beginning of the It is common for
detachment or movie, Charlie spoke of people with PTSD to
estrangement from not having any friends isolate themselves.
others and not being a part of They may feel
 anything. In school, he overwhelmed or
often lacks the company unsafe in groups,
of friends and is seen quick to anger,
eating at the cafeteria misunderstood, or just
and refuses to participate uninterested in being
in class. around people.
However, isolation can
lead
to loneliness,
depression, and
anxiety. (Legg, 2018)
Inability to / When Charlie heard the PTSD can affect a
experience positive news of the suicide of his person's ability to work,
emotions best friend Michael, he perform day-to-day
was devastated and had activities or relate to
to undergo a counselling their family and friends.
season to help cope with A person with PTSD
Michael’s loss. During can often seem
his first days as a disinterested or distant
freshman student, he as they try not to think
does not have friends or feel in order to block
whom he can talk. He out painful memories.
prefers to be alone which Moreover, mood
makes it difficult to changes are common
experience positive in individuals with
emotions such as being PTSD, they may feel
optimistic and happy. hopeless, numb and
bad about themselves
or others.
(Desarkissian, 2019)
Hypervigilance X It was not shown in the Hypervigilance is a
movie. symptom of PTSD.
The condition may
cause the individual to
be tensed and may
result to constantly
scanning the area or
place for perceived
threats. (Legg, 2018)
Difficulty X It was not shown in the Many people with
concentrating movie. PTSD report that they
have a hard time
paying attention or
concentrating while
completing daily tasks.
This is often the result
of being very anxious.
 High anxiety levels
may also limit an
individual’s ability to
notice things that are
going on around them
or interfere with their
ability to focus on a
task (Tull, 2020).
Difficulty Sleeping X Difficulty sleeping was Sleep problems such
not observed during the as insomnia get in the
entire duration of the way of processing
movie. memories, which
increases vulnerability
to a traumatic event
when it occurs. In turn,
PTSD causes the brain
to become less able to
manage sleep, which
makes it more difficult
to process the trauma
memory and
distinguish between
safe and unsafe
environments. This
then maintains the
symptoms of PTSD.
And PTSD then
contributes to
continued sleep
problems. (Newsom,
2021)
Aggression or / Charlie manifested The trauma and shock
irritability aggression and irritability of early childhood
in the movie. It was when abuse often affects
Patrick was in a fight with how well the survivor
a group of boys together learns to control his or
with his boyfriend in the her emotions.
cafeteria. Patrick’s Problems in this area
boyfriend bullied him lead to frequent
thus, Charlie punched outbursts of extreme
him and had a fight. emotions, including
anger and rage.
(Center for Substance
Abuse Treatment,
2016)
Exaggerated Startle X Exaggerated startle PTSD symptoms like
Reflex response was not hyperarousal ultimately
evident in the entire develop as a result of
duration of the movie. the overreaction of the
body's stress
response. In addition,
hyperarousal can
persist long after the
trauma has passed,
leaving the individual
hyper-responsive to
anything that reminds
him/her of the event
(including sights,
smells, sounds, or
even specific words of
passages of music)
(Tull, 2020)

VI. LABORATORY TESTS

PTSD isn’t diagnosed until at least 1 month has passed since the traumatic event happened.

If symptoms of PTSD are present, the doctor will begin an evaluation by performing a complete

medical history and physical exam. Although there are no lab tests to specifically diagnose

PTSD, the doctor may use various tests to rule out physical illness as the cause of the symptoms.

If no physical illness is found, you may be referred to a psychiatrist, psychologist, or other

mental health professional who is specially trained to diagnose and treat mental illnesses.

Psychiatrists and psychologists use specially designed interview and assessment tools to evaluate

a person for the presence of PTSD or other psychiatric conditions. The doctor bases their

diagnosis of PTSD on reported symptoms, including any problems with functioning caused by

the symptoms. The doctor then determines if the symptoms and degree of dysfunction indicate

PTSD. PTSD is diagnosed if the person has symptoms of PTSD that last for more than one

month.

VII. MEDICAL MANAGEMENT

 A. Therapies

Cognitive Processing Therapy

CPT is a 12-week course of treatment, with weekly sessions of 60-90 minutes. At first,
you'll talk about the traumatic event with your therapist and how your thoughts related to it
have affected your life. Then you'll write in detail about what happened. This process helps
you examine how you think about your trauma and figure out new ways to live with it.

In so doing, the patient creates a new understanding and conceptualization of the

traumatic event so that it reduces its ongoing negative effects on current life.

For example, maybe you've been blaming yourself for something. Your therapist will help
you take into account all the things that were beyond your control, so you can move forward,
understanding and accepting that, deep down, it wasn't your fault, despite things you did or
didn't do.

Prolonged Exposure Therapy

Prolonged Exposure (PE) teaches you to gradually approach trauma-related

memories, feelings, and situations that you have been avoiding since your trauma. By
confronting these challenges, you can decrease your PTSD symptoms. If you've been
avoiding things that remind you of the traumatic event, PE will help you confront them. It
involves eight to 15 sessions, usually 90 minutes each.

Early on in treatment, your therapist will teach you breathing techniques to ease your anxiety

when you think about what happened. Later, you'll make a list of the things you've been avoiding

and learn how to face them, one by one. In another session, you'll recount the traumatic

experience to your therapist, then go home and listen to a recording of yourself. Doing this as

"homework" over time may help ease your symptoms.

 Eye Movement Desensitization and Reprocessing

EMDR therapy is a phased, focused approach to treating traumatic and other symptoms by

reconnecting the client in a safe and measured way to the images, self-thoughts, emotions,

and body sensations associated with the trauma, and allowing the natural healing powers of

the brain to move toward adaptive resolution.

With EMDR, you might not have to tell your therapist about your experience. Instead,

you concentrate on it while you watch or listen to something they're doing -- maybe moving a

hand, flashing a light, or making a sound.

The goal is to be able to think about something positive while you remember your trauma.

It takes about 3 months of weekly sessions.

Stress Inoculation Training

SIT is a type of CBT. You can do it by yourself or in a group. You won't have to go into

detail about what happened. The focus is more on changing how you deal with the stress from the

event.

You might learn massage and breathing techniques and other ways to stop negative

thoughts by relaxing your mind and body. After about 3 months, you should have the skills to

release the added stress from your life.

In the initial conceptualization phase, the therapist educates the patient about the general nature of

stress (offering much the same information as contained in the earlier sections of this document), and

explains important concepts such as appraisal and cognitive distortion that play a key role in shaping

stress reactions. The idea that people often and quite inadvertently make their stress worse through the

unconscious operation of bad coping habits is conveyed. Finally, the therapist works to develop a clear

understanding of the nature of the stressors the patient is facing.

 A key part of what needs to be communicated in the SIT conceptualization stage is the idea that

stressors are creative opportunities and puzzles to be solved, rather than mere obstacles. Patients are

helped to differentiate between aspects of their stressors and their stress-induced reactions that are

changeable and aspects that cannot change, so that coping efforts can be adjusted accordingly.

Acceptance-based coping is appropriate for aspects of situations that cannot be altered, while more

active interventions are appropriate for more changeable stressors.

The second phase of SIT focuses on skills acquisition and rehearsal. The particular choice of skills

taught is important, and must be individually tailored to the needs of individual patients and their

particular strengths and vulnerabilities if the procedure is to be effective. A variety of emotion

regulation, relaxation, cognitive appraisal, problem-solving, communication and socialization skills

may be selected and taught on the basis of the patient's unique needs.

In the final SIT phase, application and follow through, the therapist provides the patient with

opportunities to practice coping skills. The patient may be encouraged to use a variety of simulation

methods to help increase the realism of coping practice, including visualization exercises, modeling

and vicarious learning, role playing of feared or stressful situations, and simple repetitious behavioral

practice of coping routines until they become over-learned and easy to act out.
B. Drug Study

Generic Name: Sertraline Hydrochloride

Brand Name: Zoloft

Classification: SSRI Antidepressant

Mode of Action:

-Acts as antidepressant by inhibiting CNS neuronal uptake of serotonin; blocks uptake of

serotonin with little effect on norepinephrine, histaminergic, and alpha 1 – adrenergic receptors

Suggested Dose:

major depressive disorder and OCD: 50 mg PO daily. May be increased up to 200

mg/day.

Panic disorder: 25 mg PO daily. After one week increase to 50 mg once daily. PMDD: 50

mg/day PO daily. Or just during the luteal phase of menstrual cycle. Social anxiety disorder:

25 mg a day PO.
Indications:

· Major Depressive Disorder

· Obsessive-Compulsive Disorder

· Panic Disorder

· Premenstrual Dysphoric Disorder (PMDD)

· Social Anxiety Disorder

Contraindication:

All Dosage Forms of ZOLOFT:

Concomitant use in patients taking monoamine oxidase inhibitors (MAOIs) is

contraindicated). Concomitant use in patients taking pimozide is contraindicated

ZOLOFT is contraindicated in patients with hypersensitivity to sertraline or any of the inactive

ingredients in ZOLOFT.

Oral Concentrate:

ZOLOFT oral concentrate is contraindicated with ANTABUSE (disulfiram) due to the alcohol

content of the concentrate.

Adverse Effects:

· CNS: headache, nervousness, drowsiness, anxiety, insomnia, tremor, fatigue,

seizures, psychosis

· CV: hot flashes, palpitations, chest pains

· Dermatologic: sweating, rash, pruritus, acne

· GI: nausea, vomiting, diarrhea, dry mouth, dyspepsia, constipation, gingivitis

· GU: painful menstruation, frequency, cystitis, impotence, vaginitis

· Respiratory: URIs, cough, bronchitis, rhinitis, dyspnea

· Others: hot flashes, fever, pain, thirst

Drug Interactions:

● Sertraline is a moderate inhibitor of CYP2D6 and CYP2B6 in vitro.

● In a placebo-controlled study, the concomitant administration of sertraline and
methadone caused a 40% increase in blood levels of the latter, which is primarily
metabolized by CYP2B6.
● Sertraline had a slight inhibitory effect on the metabolism of diazepam (Valium),
tolbutamide (Orinase) and warfarin (Coumadin), which are CYP2C9 or CYP2C19
substrates; this effect was not considered to be clinically relevant.
● Sertraline had no effect on the actions of digoxin (Lanoxin) and atenolol
(Tenormin), which are not metabolized in the liver.
● Clinical reports indicate that interaction between sertraline and the MAOIs
isocarboxazid (Marplan) and tranylcypromine (Parnate) may cause serotonin
syndrome.

Nursing Interventions:
 1. Use lower dose in elderly patients and with hepatic or renal impairment.
2. Dilute oral concentrate in four ounce water, ginger, ale, lemon, lime soda,
lemonade, or orange juice only; administer immediately after diluting.
3. Establish suicide precautions for severely depressed patients, limit number of
tablets given at any time.
4. Give drug once a day, morning or evening.
5. Increase dosage at intervals of not less than one week
6. Counsel patients to use non-hormonal contraceptives; pregnancy should be
avoided due to risk to the fetus.
7. Take this drug once a day, morning or evening; do not exceed the prescribed dose,
it may take 4-6 weeks to see any improvement.
8. Consult your health care provider if you think that you are pregnant or wish to be
pregnant.
9. You may experience these side effects: dizziness, drowsiness, nervousness,
insomnia, nausea, and vomiting, dry mouth, excessive sweating.
10. Report rash, mania, seizures, edema, difficulty breathing, increased depression
and thoughts of suicide.

Generic Name: Risperidone

Brand Name: Risperdal, Risperdal Consta, Risperdal M-Tab

Classification: Antipsychotic

Mode of Action:

- Unknown; may be mediated through both DOPamine type 2 (D2) and sero-tonin type 2 (5-

HT2) antagonism

Suggested Dose:
Posttraumatic Stress Disorder (Off-label)

0.5-8 mg/day PO

Indications:

· Irritability associated with autism,

· Bipolar disorder,

· Mania

· Schizophrenia

Contraindication:

- Hypersensitivity
- Seizure

Precautions:

Pregnancy C, children, geriatric, cardiac/renal/hepatic disease, breast cancer, Parkinson’s disease,

CNS depression, brain tumor, dehydration, diabetes, hematologic disease, seizure disorders,
breastfeeding, abrupt discontinuation, suicidal ideation, phenylke-tonuria

Adverse Effects:

CNS: EPS (pseudoparkinsonism, akathisia, dystonia, tardive dyskinesia), drowsiness, insomnia,

agitation, anxiety, headache, neuroleptic malignant syndrome, dizziness, seizures, suicidal

ideation, head titubation (shaking)

CV: Orthostatic hypotension, tachycardia, heart failure, sudden death (geriatric), AV block

EENT: Blurred vision, tinnitus

GI: Nausea, vomiting, anorexia, constipation, jaundice, weight gain

GU: Hyperprolactinemia, gynecomastia, dysuria

HEMA: Neutropenia, Granulocytopenia

MS: Rhabdomyolysis

MISC: Renal artery disease; weight gain, hyperprolactinemia (child)

RESP: Rhinitis, sinusitis, upper respiratory infection, cough

INTERACTIONS

Alcohol: increased sedation

Carbamazepine: increased risperidone excretion

Chloroquine, clarithromycin, droperidol, erythromycin, haloperidol, methadone,

pentamidine, thioridazine, ziprasidone: increased QT prolongation

Furosemide: increased risk of death in dementia-related psychosis

Levodopa: decreased levodopa effect

Tramadol: increased seizures

Valproic acid, verapamil: increased risperidone levels

Nursing Interventions:

1. Suicidal thoughts, behaviors often occur when depression is lessened; assess mental
status: orientation, mood, behavior, presence and type of hallucinations before initial
administration, monthly; this product should significantly reduce psychotic behavior.

2. Monitor bilirubin, CBC, liver function tests monthly.

3. Assess affect, orientation, LOC, reflexes, gait, coordination, sleep pattern

disturbances.
4. QT prolongation: Monitor B/P with patient in sitting, standing, and lying positions;
take pulse and respirations q4hr during initial treatment; establish baseline before starting
treatment; report drops of 30 mm Hg; obtain baseline ECG and monitor Q- and T-wave
changes.
5. Check for dizziness, faintness, palpitations, tachycardia on rising; severe orthostatic
hypotension is common.

6. EPS: Assess for akathisia (inability to sit still, no pattern to movements), tardive
dyskinesia (bizarre movements of the jaw, mouth, tongue, extremities), pseudoparkinsonism
(rigidity, tremors, pill rolling, shuffling gait); an antiparkinsonian product should be
prescribed.

7. Assess for constipation, urinary retention daily; if these occur, increase bulk, water in
diet.

8. Assess for weight gain, hyperglycemia, metabolic changes in diabetes, increased lipids.

9. Assess for neuroleptic malignant syndrome: hyperpyrexia, muscle rigidity, increased

CPK, altered mental status; product should be discontinued.

10. Teach patient to use good oral hygiene; frequent rinsing of mouth, sugarless gum for dry
mouth.

Generic Name: Propranolol

Brand Name: Inderal, Inderal LA, InnoPran XL

Classification: Antihypertensive

Mode of Action:

- Nonselective b-blocker with negative inotropic, chronotropic, dromotropic

properties

Suggested Dose:

For acute heart attack:

Adults—180 to 240 milligrams (mg) per day, given in divided doses. Children—

Dose is based on body weight and must be determined by your doctor.

For chest pain (angina):

Adults—At first, 80 milligrams (mg) once a day. Your doctor may increase your

dose if needed. The dose is usually not more than 320 mg per day.

Children—Use and dose must be determined by your doctor.

For high blood pressure (hypertension):

Adults—At first, 80 milligrams (mg) once a day, given at bedtime. Your doctor

may increase your dose if needed. However, the dose is usually not more than

120 mg per day.

Children—Use and dose must be determined by your doctor.

Indications:
Chronic stable angina pectoris, hypertension, supraventricular dysrhythmias, migraine
prophylaxis, pheochromocytoma, cyanotic spells related to hypertrophic subaortic stenosis,
essential tremor, acute MI

Unlabeled uses: Prevention of variceal bleeding caused by portal hypertension, akathisia induced
by antipsychotics, lithium-induced tremor

Contraindication:

Hypersensitivity to this product, cardiogenic shock, AV heart block, bronchospastic disease, sinus
bradycardia, bronchospasm, asthma, pregnancy C

Adverse Effects:

CNS: Depression, hallucinations, dizziness, fatigue, lethargy, paresthesia, bizarre dreams,

disorientation

CV: Bradycardia, hypotension, CHF, palpitations, AV block, peripheral vascular

insuffi•ciency, vasodilatation, pulmonary edema,

EENT: Sore throat, laryngospasm, blurred vision, dry eyes

GI: Nausea, vomiting, diarrhea, colitis, con•stipation, cramps, dry mouth, hepatomegaly, gastric
pain, acute pancreatitis

GU: Impotence, decreased libido, UTIs HEMA:

Agranulocytosis, thrombocytopenia

INTEG: Rash, pruritus, fever, Stevens-Johnson syndrome, toxic epidermal necrolysis META:

Hyperglycemia, hypoglycemia

MISC: Facial swelling, weight change, Raynaud’s phenomenon MS: Joint

pain, arthralgia, muscle cramps, pain

RESP: Dyspnea, respiratory dysfunction, bronchospasm, cough

INTERACTIONS

Cimetidine: increased b-blocking effect Disopyramide:

increased negative inotropic effects

Haloperidol, prazosin, quinidine: increased hypotension

Propafenone: increased propranolol levels

Smoking: decreased propranolol levels

Nursing Interventions:

Assessment
1. Monitor B/P during beginning treatment, periodically thereafter; pulse q4hr; note rate,
rhythm, quality; check apical/radial pulse before administration; notify prescriber of any
significant changes (pulse ,50 bpm or systolic B/P ,90 mm Hg)

2. Check for baselines in renal, liver function tests before therapy begins and periodically
thereafter
3. Assess for edema in feet, legs daily; monitor I&O, weight daily; check for jugular vein
distention, crackles bilaterally; dyspnea (CHF)
4. Monitor skin turgor, dryness of mucous membranes for hydration status, especially
geriatric patients.
5. Assess for headache, light-headedness, decreased B/P; may indicate need for decreased
dose; may aggravate symptoms of arterial insufficiency
6. Teach patient not to use OTC products containing a-adrenergic stimulants (such as nasal
decongestants, cold preparations); to avoid alcohol, smoking and to limit sodium intake as
prescribed; blood glucose (diabetes mellitus)
7. Teach patient how to take pulse and B/P at home; advise when to notify prescriber
8. Instruct patient to comply with weight control, dietary adjustments, modified exercise
program

9. Instruct patient to carry/wear emergency ID to identify product being taken, allergies; tell
patient product controls symptoms but does not cure
10. Caution patient to avoid hazardous activities if dizziness, drowsiness are present
Name of patient: C. K Age/sex: 15 years old/M
Chief Complaint: Recurr_e_n_t _F_la_s_h_b_a_cks Physician: Dr. Burton Diagnosis: Post-Traumatic Stress Disorder

Date/ Cues Ne Nursing Diagnosis Goal of Care Interventions Implement Evaluation

Time ed ation
A S Anxiety related to That within 2 weeks of Maintain a calm, non- 2
Subjective: E directly experiencing a my nursing intervention, threatening manner while
“Something’s wrong L traumatic event the patient will be able to conversing with the client. R: Keziah Magno
P with me” as evidenced by reduce anxiety attacks as Anxiety is contagious and may St.N
F
recurrent flashbacks of manifested by: be transferred from health care
R -
“Candace, I killed his childhood a. able to express and provider to client
I Aunt Helen, didn’t I? P memories, anxiety discuss emotions, or vice versa. Client develops
She died getting my E attacks and quivering triggers and thoughts; feeling of security in presence of
L
birthday present, so I R voice calm staff person.
2 guess I killed her, C b. able to learn and utilize
right? I’ve tried to E coping/relaxation Establish and maintain a trusting 1
0
stop thinking that but Rationale: Childhood strategies such as deep relationship by listening to the
P
I can’t. She keeps trauma is a major breathing exercises; and client; displaying warmth; being
driving away and T predisposing factor in available and respecting the
2 I
dying over and over” forming anxiety c. absence of feelings of client’s use of personal space. R:
0 O symptoms and guilt Therapeutic skills need to be
“Seeing it. All their N disorders in adulthood. directed toward putting the client
2
lives. All the time. Traumas can include at ease, because the nurse who is
1 Just, how do you S physical abuse, a stranger may pose a threat to
stop seeing it?” emotional the highly anxious client.
E
abuse, sexual abuse,
- Recurrent L neglect, exposure to Teach signs and symptoms of
F domestic violence, escalating anxiety and ways to
C parental substance interrupt its progression such as
@8am O abuse, and relaxation techniques, deep
N abandonment. 6
C Experiencing childhood

72
trauma can

72
 flashbacks of E predispose people to breathing exercises, brisk
his childhood P developing anxiety and walks and meditation.
memories T panic symptoms and R: Gives the client confidence in
with his aunt disorders in several having control over his anxiety.
ways. These are
- Directly related to Encourage to talk about the
experiencing a unpredictable traumatic experience under
traumatic childhood non-threatening conditions.
event such as environments, changes Help work through feelings of 3
being sexually in how one perceives guilt related to the traumatic
abused by his physical sensations, event.
aunt and changes in brain R: Verbalization of feelings in a
structure and function. non-threatening environment
may help client come to terms
Objective: Reference: with unresolved issues.
Binensztok, V.
Behavioral (2020). How Administer Selective Serotonin
- Diminished Childhood Trauma Reuptake Inhibitor (SSRIs) as
productivity Relates to Present- ordered.
during the time Day Anxiety and R: Selective serotonin reuptake
of attack Panic. Juno inhibitors (SSRIs) are usually the
- Self-blame Counselling and first choice of medication for
over his aunt’s Wellness. Retrieved treating social anxiety disorder 4
death May May 9, 2021 (SAD). SSRIs affect your brain
from chemistry by slowing re-
Cognitive https://junocounselin absorption of the
- Narrowing g.com/how- neurotransmitter serotonin, a
focus of childhood-trauma- chemical that we think helps to
attention relates-to-present- regulate mood and anxiety.
- Diminished day-anxiety-and-
ability of panic/
problem- 5
solving skills

73
 when he called
her sister,
Candace he
was in
emotional
distress and
unable to
process his
thoughts
Affective
- Guilt feelings
- Distress
- Irritability
- Helplessness

Physiological
- Trembling
during the
anxiety attack
(when he
recalled the
traumatic
event, he was
anxious and
panicky; he
was banging
his head on
the door
repeatedly)
- Quivering
voice during
their phone
call
conversation

73
with her sister

73
 Move the client to a quiet area
with minimal stimuli such as a
small room or area.
R: Anxious behavior escalates by
external stimuli. A smaller or
secluded area enhances a sense of
security as compared to a large
area which can make the client
feel lost and panicked.

Remain with the client at all 7

times when levels of anxiety
are high; reassure his safety
and security.
R: The client’s safety is utmost
priority. A highly anxious client
should not be left alone as his
anxiety will escalate.
8
Encourage the client’s
participation in relaxation
exercises such as deep breathing,
guided imagery and meditation.
R: Relaxation exercises are
effective nonchemical ways to
reduce anxiety.

Encourage to patient to use

positive self-talk such as 9
“anxiety won’t kill me”, “I can
do this one step at a time”,
“Right now, I need to pause to
breathe and stretch.”

[Type text] Page 76

 R: Cognitive therapies focus
on changing behaviors and
feelings by changing thoughts.
Replacing negative self-
statements with positive self-
statements aids to reduce
anxiety.

[Type text] Page 77

 NAME: Mr. C K AGE/ GENDER: 15 years old/ male
CC: Recurrent flashbacks DIAGNOSIS: Posttraumatic Stress Disorder AP: Dr. Uy
D/T CUES NE NSG DIAGNOSIS PT OUTCOME NSG INTERVENTION IMPL EVALUATION
ED EME
NTAT
ION

A Subjective: C Post-trauma Within the span of 2 1. Educate yourself about the 1

syndrome related to weeks on giving client’s experience and
Client: “I know I O experience of nursing interventions, about posttraumatic
P should have been
P distressing event as the patient will be able behavior.
honest, but I was evidenced by to improve the
R getting so mad, it I flashbacks,feelings sustained maladaptive R: Learning about the client’s
was starting to scare of guilt, nightmares, response to trauma as experience will help prepare you
me.” as verbalized N for the client’s feelings and the
I and dissociation or evidenced by:
by the patient. amnesia details of his or her experience.
G
(angry) a. verbalize
L / awareness of Keyna Juliet N. Dizon
psychological 2. When approaching the St,N.
S Rationale: symptom that 2
2 Client: "It's my fault. client, be non-threatening,
It's all my fault." as Post-trauma accompany non judgemental, and
T
verbalized by the syndrome is defined recollections of professional.
0
patient. (guilt) R as a sustained a past-traumatic
event R: The client’s fear may be Karl Montano. St,N.
maladaptive
, E triggered by authority figures of
response to a
traumatic, b. identify other characteristics such as
Client: “Well, um... I S
2 overwhelming event. situation/event/i gender or ethnicity.
was really tired, and
S This nursing mages that
uh… I was feeling
diagnosis addresses trigger
0 feverish. So, I went
the problems recollections 3. Examine and remain aware
outside for a walk,
experienced by and of your own feelings
76
2 just to get some cold T clients diagnosed accompanying regarding both the client’s 3
air. And I started with post-traumatic responses of traumatic experience and
seeing things. So, I O stress disorder. A past traumatic his feelings and behavior.
1
passed out.” as L nurse has been experiences;
verbalized by the caring for a client R: Traumatic events engender
patient. E diagnosed with post- c. demonstrate strong feelings in others and may
traumatic stress learned adaptive be quite threatening. A person
( dissociation or R may be reminded of a related
disorder. PTSD can cognitive-
amnesia) occur after a person behavioral experience or of your own
A
experiences a therapeutic vulnerability, or issues related to
N shocking, strategies to sexuality, morality, safety, or well-
unexpected event manage being. It is essential that you
- Recurrent
C remain aware of your feelings so
flashbacks of that is outside the symptoms of
range of usual emotional and that you do not unconsciously
the traumatic E
human experience. physical project feelings, avoid issues, or
event
The trauma is reactivity such be otherwise nontherapeutic with
usually so extreme as: the client.
that it can c1.) performing 4. Be consistent with the client
- Recurrent
overwhelm their deep breathing such as conveying
distressing
coping mechanisms and relaxation acceptance of him as a
dreams 4
and create intense exercises person while setting and
feelings of fear and maintaining limits regarding
helplessness. The c2.) join in a behaviors.
Objective: traumatic event may group treatment
be experienced by program R: The client may test limits or the
- Hesitant to the individual directly activity,cognitive therapeutic relationship. Problems
share his by observation or by therapy and with acceptance, trust, or authority
recurrent learning about a desensitization often occur with posttraumatic
memories to trauma affecting a behavior.
others close relative or c2.)
77
 friend. With this, communicate or
symptoms may arise talk with a staff
- low self- which may include for at least 30 5. Assess the client’s history
esteem flashbacks, minutes twice a of substance abuse. The
nightmares and day by a information of the significant
( In a scene inside a others might be helpful.
classroom, he is severe anxiety, specified date
Remember to be aware of
hesitant to Reference: the client’s use of or abuse 5
participate and of substances. If substance
instead wrote his American Academy use is a major problem,
answers in a of Child and d. verbalize ability
to control or refer the client to a
notebook. Most of Adolescent (2021). substance dependence
his classmates raise PsychiatryPosttraum manage
symptoms of treatment program.
their hands except atic stress disorder
Charlie's.) (PTSD). Retrieved emotional and R:  Client often use substances to
on May 8, 2021 from physical help repress or release emotions.
https://www.aacap.o reactivity that Substance use undermines
rg/AACAP/Families_ tend to occur therapy and may endanger the
- anxiety or
and_Youth/Facts_for during client’s health. Substance use
separation
_Families/FFF- recollections of must be dealt with because it may
anxiety
Guide/Posttraumatic the traumatic affect all other areas of the client’s
-Stress-Disorder- event. life.
PTSD-070.aspx
- substance use
particularly 6. Maintain the client’s safety
marijuana and integrity during a post
trauma episode, using
appropriate interventions 6
according to facility policy.
Such as securing the
environmental hazards and
78
 dangerous materials.

R: The nurse’s priority is to protect

the client and others from injury or
harm during a post trauma episode
since the client may experience
escalating anxiety, depression, or
suicidal thoughts.

7. Encourage the client to talk

about his experiences with
his consent. Be accepting
and non judgemental of the
client’s accounts and
perceptions. 7

R: Retelling the experience can

help the client to identify the reality
of what has happened and help to
identify and work through related
feelings.

8. Encourage the client to

identify and describe
specific areas surrounding
the traumatic event that are
most troubling and that elicit 8
powerlessness or loss of
79
 control (if part of the client’s
treatment plan).

R: “Talking it out” with a trusted

person helps the client bring the
details of the event into the open
during a safe, nonthreatening time.
It gives the client an opportunity to
gain some influence over the
traumatic event and decreases
apprehension about intrusive
recollection

9. Monitor the client’s anxiety

level.

R: Establishing the client’s anxiety

level prevents escalation of
symptoms through early
interventions. 9

10. Teach the client adaptive

cognitive-behavioral
strategies to manage
symptoms of emotional and
physical reactivity that
accompany intrusive
recollection such as deep
80
 breathing and relaxation
exercises, cognitive therapy
and desensitization. It may
also include communicating
or talking with a staff for at
least 30 minutes twice a 10
day by a specified date or
joining in a group treatment
program activity. After
these specified intervention,
the client must be able to
verbalize about his ability to
control or manage
symptoms of emotional and
physical reactivity that tend
to occur during recollections 11
of the traumatic event.

R: Deep breathing or relaxation

exercise provide slow, rhythmic,
controlled patterns that decrease
physical and emotional tension,
which reduce the effects of anxiety
and the threat of painful
recollection. Cognitive therapy
helps the client substitute irrational
thoughts, beliefs, or images for
more realistic ones and thus
promotes a greater understanding
of the client’s actual role in the

81
traumatic event, which may
decrease guilt and self-blame.

Systematic desensitization helps

the client gain mastery and control
over the past traumatic event by
progressive exposures to
situations and experiences that
resemble the original event, which
eventually desensitizes the client
and reduces painful stimuli.

11. Involve the patient in

decisions about the client’s
care and treatment.

R: This involvement helps foster

feelings of empowerment, control
and confidence in the client rather
than feelings of being a helpless
victim of external effects

12. Engage the client in group

therapy sessions with other
clients with PTSD when the
client is ready for the group
process.

82
R: The group process provides 12
additional support and
understanding through
involvement with others who may
have similar problems. Also,
seeing the success of others gives
hope to the client.

13. Provide realistic feedback

and praise whenever the
client attempts to use 13
learned strategies to
manage anxiety and reduce
post-traumatic stress
response.

R: Positive reinforcement
promotes self-esteem and gives
the client the confidence to
continue working on the treatment
plan.

14

83
84
DATE/ Need Imple-
Cues Nursing Diagnosis Goal of Care Nursing Interventions Evaluation
TIME mentation

A Subjective: C Ineffective coping related to After 1 week of nursing 1. Assess vital signs and perform the necessary 1
P - “No. I saw them O recurrent thoughts about the intervention, the patient will be nursing assessment. Samcasell B.
R when I was little P traumatic event and multiple able to identify ineffective coping Ruedas St.N
and I don’t want Rationale: To determine the vital sign baseline
I I stressors as evidenced by behaviors and consequences as and underlying medical conditions.
to be a
L Mayview kid. N suicidal ideations, feelings of manifested by:
Just tell me how G guilt and avoiding distressing a. Verbalize awareness of 2. Assess client’s level of anxiety and coping.
27, to stop (seeing) memories. own coping abilities; Investigate the types of situations that increase 2
it” as verbalized anxiety.
& b. Expression of feelings
2 by the patient. Rationale: and utilize positive coping Rationale: Helping the client recognize the
0 - Anxious S Trauma, including one-time, mechanisms such as: precipitating factors is the first step in teaching
- Recurrent the client to interrupt the escalating anxiety.
2 T multiple, or long-lasting b.1. Practice relaxation
flashbacks of the
1 traumatic event R repetitive events, affects techniques (deep
3. Set a working relationship with the patient
- Stressful E everyone differently. Traumatic breathing and through continuity of care.
@ events (The S stress tends to evoke two mindfulness)
client was being S emotional extremes: feeling b.2. self-monitoring and Rationale: An ongoing relationship establishes 3
7AM excluded from either too much journaling trust, reduces the feeling of isolation, and may
his group of T (overwhelmed) or too little b.3. establishing social facilitate coping.
friends and
O (numb) emotion. support 4. Determine previous methods of dealing with
client’s friends 4
are leaving for L Overwhelming emotional b.4. Behavioral activation; life problems.
college) E extremes includes c. and absence of feeling of
R anxiousness, guilt, and guilt, suicidal ideations, Rationale: To identify successful techniques that
can be used in the current situation.
A suicidal ideation. There are and avoiding distressing
N several diverse ways of coping memories. 5. Assist patient set realistic goals and identify
Objective: C with stress. Positive coping personal skills and knowledge. 5
- Suicidal
E mechanisms include seeking
ideations Rationale: Involving patients in decision making
- Feelings of guilt help from supportive people,
helps them move toward independence. This
towards his P such as a counselor or friend. can be done through journaling and self-

85
aunt’s death A Other positive ways to cope monitoring.
- Recurrent T include meditation, journaling, 6
distressing 6. Provide chances to express concerns, fears,
T and exercising. A negative
dreams feeling, and expectations.
E coping mechanism includes
- Hesitant to
share his R stress in which a person Rationale. Verbalization of actual or perceived
recurrent N attacks others and makes threats can help reduce anxiety and open doors
memories to them uncomfortable. Or, to for ongoing communication.
others avoid the person, place or 7. Use empathetic communication. 7
- History of thing that causes us stress.
sexual abuse Some choose to become Rationale: Acknowledging and empathizing
defensive or even find ways to creates a supportive environment that enhances
coping.
harm themselves. Treatment 8
can help the client find the 8. Convey feelings of acceptance and
optimal level of emotion and understanding. Avoid false reassurances.
assist him or her with
Rationale: An honest relationship facilitates
appropriately experiencing and
problem-solving and successful coping. False
regulating difficult emotions. In reassurances are never helpful to the patient
treatment, the goal is to help and only may serve to relieve the discomfort of
clients learn to regulate their the care provide.
emotions without the use of 9
substances or other unsafe 9. Encourage the patient to recognize his or her
own strengths and abilities.
behavior. This will likely
require learning new coping Rationale: During crises, patients may not be
skills and how to tolerate able to recognize their strengths. Fostering
distressing emotions; some awareness can expedite use of these strengths.
clients may benefit from
10. Consider mental and physical activities
mindfulness practices, within the patient’s ability (e.g., reading, 10
cognitive restructuring, and television, outings, movies, radio, crafts,
trauma-specific desensitization exercise, sports, games, dinners out, and social
approaches, such as exposure gatherings).
therapy and eye movement
Rationale: Interventions that improve body
desensitization and awareness such as exercise, proper nutrition,
reprocessing
86
 and muscular relaxation may be helpful for
Reference: treating anxiety and depression.
Tull, M. (2020). Coping With
11. Assist patients with accurately evaluating the 11
PTSD. Retrieved May 8, 2021 situation and their own accomplishments.
from
https://www.verywellmind.com/ Rationale: It can be helpful for the patient to
coping-with-ptsd-2797536 recognize that he or she has the skills and
reserves of strength to effectively manage the
Vantage Point behavioral
situation. The patient may need help coming to
Health and Trauma Healing a realistic perspective of the situation.
(2020). What is Adaptive and
Maladaptive Coping? 12. Assist the patient with problem-solving in a
constructive manner. 12
Retrieved May 9, 2021 from
https://vantagepointrecovery.c Rationale: Constructive problem solving can
om/adaptive-maladaptive- promote independence and sense of autonomy.
coping/
13. Provide outlets that foster feelings of
personal achievement and self-esteem. 13

Rationale: Opportunities to role-play or rehearse

appropriate actions can increase confidence for
behavior in actual situations.

14. Use distraction techniques during

14
procedures that cause patient to be fearful.

Rationale: Distraction is used to direct attention

toward a pleasurable experience and block the
attention of the feared procedure.

15. Encourage use of cognitive behavioral

relaxation (e.g. music therapy, guided imagery,
deep breathing, and mindfulness). 15

Rationale: Relaxation techniques,

desensitization, and guided imagery can help
patients cope, increase their sense of control,

87
and allay anxiety.

References:

Doenges, M. E., Moorhouse, M., & Murr, A. C.

(2016). Nursing care plans guidelines for
individualizing client care across the life span
(9th ed.). Philadelphia: F.A. Davis Company.

Wayne, G. (2019). Ineffective Coping Nursing

Care Plan. Retrieved May 8, 2021 from
https://nurseslabs.com/ineffective-coping/

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89
 VI. Nursing Theory

Middle- Ranged Caring Theory by Kristen Swanson

This theory states that caring proceeds in a sequence of five categories: knowing, being
with, doing for, enabling, and maintaining belief. When applied to nursing practice, each of
these five stages stimulates the caregiver’s attitude and improves the overall patient well-
being. The theory aims at helping nursing personnel to deliver care that promotes dignity,
respect, and empowerment. This model was framed to ensure consistent caring behaviors
which would, in turn, improve patient satisfaction.

In the case of our patient, Post traumatic Stress Disorder results in intense, disturbing
thoughts and feelings related to their experience that last long after the traumatic event has
ended. Having this type of condition comes with different problems occurring to the patient
not only mentally but holistically. With that, it's common for people with PTSD to isolate
themselves due to the fact that they may feel overwhelmed or unsafe in groups, quick to
anger, misunderstood, or just uninterested in being around people which concludes that
these persons may truly need to have someone care about them.

It is already given that care is one of the prioritized responsibilities of a nurse hence,
this theory would fit the case of the patient since the structure of caring in ‘Swanson’s

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Middle Range Caring Theory’ enlightens nursing caregivers on the significance of
Caring process and its observable and practical criterion are distinguishing
humanitarian behaviors which are mandatory in nursing. The highly significant
qualities that were highlighted were those of compassion, knowledge, optimism,
reflection, concern and commitment, communication skills, focus on the others'
experience, respect for individual dignity/worth and being present to the other. We
need to utilize the different traits aforementioned in this theory to maximize patient
centered care. If this theory could effectively be used to guide clinical practice, the
nurses can ensure a personal approach to care because effective maladaptive nursing
management involves a continuous and coordinated action by the patient and the
healthcare team.

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 Ida Jean Orlando: Deliberative Nursing Process Theory

Ida Jean Orlando was a first-generation Irish American born in 1926. She received her
nursing diploma from New York Medical College at the Lower Fifth Avenue Hospital School of
Nursing. Ida Jean Orlando’s Deliberative Nursing Process is set in motion by the behavior of the
patient. According to the theory, all patient behavior can be a cry for help, both verbal and non-
verbal, and it is up to the nurse to interpret the behavior and determine the needs of the patient.
The Deliberative Nursing Process has five stages: assessment, diagnosis, planning,
implementation, and evaluation.

Ida Jean Orlando’s Deliberative Nursing Process is set in motion by the behavior of the patient.
According to the theory, all patient behavior can be a cry for help, both verbal and non-verbal,
and it is up to the nurse to interpret the behavior and determine the needs of the patient. The
Deliberative Nursing Process has five stages: assessment, diagnosis, planning, implementation,
and evaluation.
In the assessment stage, the nurse completes a holistic assessment of the patient’s needs.
This is done without taking the reason for the encounter into consideration. The diagnosis stage
uses the nurse’s clinical judgment about health problems. The diagnosis can then be confirmed
using links to defining characteristics, related factors, and risk factors found in the patient’s
assessment. The planning stage addresses each of the problems identified in the diagnosis. Each
problem is given a specific goal or outcome, and each goal or outcome is given nursing
interventions to help achieve the goal. By the end of this stage, the nurse will have a nursing care

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plan. In the implementation stage, the nurse begins using the nursing care plan. Finally, in the
evaluation stage, the nurse looks at the progress of the patient toward the goals set in the nursing
care plan. Changes can be made to the nursing care plan based on how well or poorly the patient
is progressing toward the goals.
Her Deliberative Nursing Process Theory focuses on the interaction between the nurse
and patient, perception validation, and the use of the nursing process to produce positive
outcomes or patient improvement. Orlando's key focus was to define the function of nursing.
This author's purpose is to acquaint nurses with Orlando's theory and to encourage the use of the
deliberative process to bring about patient improvement. The goal of this model is for a nurse to
act deliberately rather than automatically. This way, a nurse will have a meaning behind the
action which means the patient gets care geared specifically toward his or her needs at that time.
This theory fits our client because it has a maladaptive behavior because it has a direct
function that initiates the process of helping the patient express the specific meaning of his
behavior in order for us to ascertain his distress and helps the patient to feel relieved. It also has
an indirect function that is calling for help from others whatever help the patient may require for
his/her need to be met. It also has disciplined and professional activities of verbal and non-verbal
responses, validation of perceptions, matching of thoughts and feelings with action. Knowing
that our patient suffers from a maladaptive problem or disorder that would really affect the well-
being of a person. It has an impact on creating the best interventions that can be applied to
the patient most especially that this theory highlights the interaction and deliberation between
the nurse as well as the patient.

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VIII. RECOMMENDATIONS

For the individual.

Following a traumatic event such as a natural disaster, traffic accident, terrorist attack, or
assault, almost everyone experiences at least some of the symptoms of PTSD. When a person’s
sense of safety and trust are shattered, it’s normal to feel unbalanced, disconnected, or numb. It’s
very common to have bad dreams, feel fearful, and find it difficult to stop thinking about what
happened. These are normal reactions to abnormal events. For most people, however, these
symptoms are short-lived. They may last for several days or even weeks, but they gradually lift.
But if a person has post-traumatic stress disorder, the symptoms don’t decrease and they don’t
feel a little better each day. In fact, they may start to feel worse.

As the statement given by the Mayo Foundation for Medical Education and Research
(2020), PTSD can affect people who personally experience the traumatic event, those who
witness the event, or those who pick up the pieces afterwards, such as emergency workers and
law enforcement officers. It can even occur in the friends or family members of those who went
through the actual trauma. Whatever the cause for a person’s PTSD, by seeking treatment,
reaching out for support, and developing new coping skills, they can learn to manage the
symptoms, reduce painful memories, and move on with their life.

According to the National Center for PTSD (2020), recovery from PTSD is a gradual,
ongoing process. Healing doesn’t happen overnight, nor do the memories of the trauma ever
disappear completely. This can make life seem difficult at times. But there are many steps you
can take to cope with the residual symptoms and reduce your anxiety and fear. Overcoming your
sense of helplessness is key to overcoming PTSD. Trauma

93
leaves you feeling powerless and vulnerable. It’s important to remind yourself that you have
strengths and coping skills that can get you through tough times.

When you’re suffering from PTSD, exercise can do more than release endorphins and
improve your mood and outlook. By really focusing on your body and how it feels as you move,
exercise can actually help your nervous system become “unstuck” and begin to move out of the
immobilization stress response.

PTSD can make you feel disconnected from others. You may be tempted to withdraw
from social activities and your loved ones. But it’s important to stay connected to life and the
people who care about you. You don’t have to talk about the trauma if you don’t want to, but the
caring support and companionship of others is vital to your recovery. Reach out to someone you
can connect with for an uninterrupted period of time, someone who will listen when you want to
talk without judging, criticizing, or continually getting distracted. That person may be your
significant other, a family member, a friend, or a professional therapist.

The symptoms of PTSD can be hard on your body so it’s important to take care of
yourself and develop some healthy lifestyle habits. Take time to relax since relaxation techniques
such as meditation, deep breathing, massage, or yoga can activate the body’s relaxation response
and ease symptoms of PTSD. Avoid alcohol and drugs. When you’re struggling with difficult
emotions and traumatic memories, you may be tempted to self- medicate with alcohol or drugs.
But substance use worsens many symptoms of PTSD, interferes with treatment, and can add to
problems in your relationships. Also, you need to start and maintain a healthy diet as well as
getting enough sleep.

All in all, the very important thing to remember and to do is to seek professional help.
This will give them an opportunity to understand themselves better, along with the disorder that
they have. Better quality of life, proper coping strategies, and appropriate treatments and
therapies await them. Early treatment is better most especially that symptoms of PTSD may get
worse. Dealing with it immediately might help stop them from getting worse in the future.
Finding out more about what treatments work, where to look for help, and what kind of
questions to ask can make it easier to get help and lead to

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better outcomes. Getting help for your PTSD can help improve your family life knowing that
PTSD symptoms can change family life. PTSD symptoms can get in the way of your family life.
You may find that you pull away from loved ones, are not able to get along with people, or that
you are angry or even violent.
For the family.

Coping with post-traumatic stress disorder (PTSD) in family members can be difficult
because the effect of PTSD on the family can be great. Studies have shown that families in which
a parent has PTSD are characterized by more anxiety, unhappiness, marital problems and
behavioral problems among children in the family as compared to families where a parent does
not have PTSD. This finding is not entirely surprising. PTSD symptoms can cause a person to act
in ways that may be hard for family members to understand. Their behavior may appear erratic
and strange or be upsetting.

According to the Mayo Foundation for Medical Education and Research, the role of the
family can either positively or negatively impact a loved one's PTSD symptoms. The first step in
living with and helping a loved one with PTSD is learning about the symptoms of PTSD and
understanding how these symptoms may influence behavior.

It is important to understand that behavior does not necessarily equal true feelings. Your
loved one may want to go out with friends and family but is too afraid of running into upsetting
thoughts and memories. It is important for family members to understand their loved one's
symptoms and the impact of those symptoms on behavior. Also, the family members should
know the triggers. A family also needs to be aware of their loved one's triggers. Being
knowledgeable about the triggers contributes to controlling the occurrences of those memories so
there is no way that your loved one will experience that particular trigger. Another thing is about
considering changes in routines. Family members may also need to change their routines based
on a loved one's symptoms. For example, if your loved one tends to have nightmares, try to
figure out a way to wake him up without touching him. Some people with PTSD may respond as
though they are being

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attacked. Lastly is to get help. Support groups and/or couples counseling may be a good way to
learn how to communicate with your loved one, as well as cope with PTSD symptoms. They may
also help you find the best way to encourage your loved one to get help if he or she hasn't
already. If you suspect that you or a loved one has post-traumatic stress disorder, it’s important to
seek help right away. The sooner PTSD is treated, the easier it is to overcome. If you’re reluctant
to seek help, keep in mind that PTSD is not a sign of weakness, and the only way to overcome it
is to confront what happened to you and learn to accept it as a part of your past. This process is
much easier with the guidance and support of an experienced therapist or doctor. ( Tull, M. 2020)

All in all, awareness and education about PTSD is highly recommended. This will enable
understanding about the disorder which then lessens the discrimination, fear, and misconceptions
about it. Patients with PTSD, in return, will experience a normal life as their community, peers,
and family help them to cope up with their struggles every time the symptoms hit up.

For the community

Trauma survivors with PTSD may have trouble with their close family relationships or
friendships. The symptoms of PTSD can cause problems with trust, closeness, communication,
and problem solving. These problems may affect the way the survivor acts with others. In turn,
the way a loved one responds to him or her affects the trauma survivor. A circular pattern can
develop that may sometimes harm relationships.

Therefore, with all the effects PTSD may cause, it is very important to provide awareness
with regards to the details of having this condition. They need much understanding, care, as well
as avoidance of discrimination. Unfortunately, public awareness of the causes, symptoms, and
cure of PTSD remains low in most countries. A PTSD awareness and prevention health program
are especially crucial given the recent tide of natural and man-made disasters affecting large
populations of people in this country. In accordance with a bill introduced by Senator Miriam
Defensor Santiago last

96
January 19, 2012 this seeks to find ways to help victims cope with the detrimental effects of post-
traumatic stress disorder. By knowing the causes of this disorder and providing awareness and
prevention programs, those suffering from PTSD can be reintegrated into mainstream society. It
is also the policy of the State to promote and protect the physical, moral, spiritual, intellectual,
and social well-being of the youth recognizing their vital role in nation-building. The Department
of Health shall craft programs to improve the identification of patients with post-traumatic stress
disorders (PTSD), increase awareness of such disorders with the public, and train educators (such
as teachers, nurses, social workers, coaches, counselors, and school administrators) on effective
PTSD assistance methods. Also in Public Service Announcements, it has been stated that the
Secretary of Education, in consultation with the Secretary of Health, shall carry out a program to
develop, distribute, and promote the broadcasting of public service announcements to improve
public awareness, and to promote the identification and prevention of PTSD.

All in all, it is not beneficial to the community and the society to disregard persons with
PTSD. It is still the awareness and education about PTSD that is highly recommended. Spreading
awareness is much more of a help since this will not only lessen discrimination but it will always
be considered to be a bridge towards the improvement on coping abilities and mechanisms of the
persons with this condition.

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DISCHARGE PLAN

M Rationale:

Medication 1. Instruct the patient and the - This will help in continuing
significant others about taking therapy and facilitate
the prescribed medication progress towards wellness,
regularly as ordered. to avoid remissions.

2. Remember to note and keep a - This will help avoid missed

list of all the medicines that or skipped doses.
should be taken. Medications According to the Mayo
might include Foundation for Medical
antidepressants, anti-anxiety Education and Research,
medications and Prazosin. antidepressants are
medications that can help
symptoms of depression
and anxiety. They can also
help improve sleep
problems and
concentration. The
selective serotonin
reuptake inhibitor (SSRI)
medications sertraline
(Zoloft) and paroxetine
(Paxil) are approved by the
Food and Drug

98
 Administration (FDA) for
PTSD treatment. On the
other hand, anti- anxiety
medications are drugs that
can relieve severe anxiety
and related problems. Some
anti- anxiety medications
have the potential for
abuse, so they are generally
used only for a short time.
Lastly, Prazosin while
several studies indicated
this may reduce or
suppress nightmares in
some people with PTSD, a
more recent study showed
no benefit over placebo.
But participants in the
recent study differed from
others in ways that
potentially could impact the
results. Individuals who are
considering prazosin should
speak with a doctor to
determine whether or not
their

3. If any adverse reactions occur,

instruct the client to contact the
physician immediately.

99
 particular situation might
merit a trial of this drug.

- This will avoid further

complications that may
occur on the patient that
will also help with the
immediate management to
be provided by the
physician.

100
 E 1. Do some regular low-intensity - The absence of a cure
workouts such as stretching, makes PTSD treatment a
Exercise
walking, and passive range of multifaceted challenge.
motion, such as arm circling, There is emerging
and leg raises. Also, mind- body evidence that exercise
low- intensity aerobic exercises can be a valuable
can be component of a
recommended as studies have comprehensive PTSD
shown positive results in treatment plan. Low-to-
patients with PTSD. These are moderate intensity
Pilates, Yoga, Nia, Therapeutic exercise can elevate
Dance, Tai Chi, or Qigong mood, reduce anxiety
which are also considered to be and act as an overall
Meditative exercises. stress-buffer. More
specifically, exercise,
particularly mind-body
and low-intensity aerobic
exercise, has been
shown to have a positive
impact on the symptoms of
depression and PTSD.
Because the needs of each
client with PTSD can be
very different, it is
important to individualize
instruction and
emphasize communication.
One of the key
considerations in designing
an exercise

101
 program for clients with
PTSD is to include low- to-
moderate intensity body
awareness
movement activities (e.g.,
Pilates, Yoga, Nia,
Therapeutic Dance, Tai
2. Advise to rest whenever Chi, or Qigong), which are
needed. known for their
effectiveness in reducing
symptoms of anxiety and
depression and have shown
positive results in PTSD
sufferers .

- This will help provide

relaxation and prevent
exhaustion.

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 T 1. Advise to have a clean, - This will help avoid stress
nurturing, quiet environment. and to facilitate treatment
Treatment
properly.

2. Encourage them to attend and

comply with therapy schedules - Aside from the fact that
such as Psychotherapy sessions. each schedule is important
for a client's progress
towards
wellness, therapies
develop stress
management skills to help
the patient better handle
stressful
situations and cope with
stress in his/ her life. All
these approaches can help
the patient gain control of
lasting fear after a
traumatic event. The
patient and the mental
health
professional can discuss
what type of therapy or
combination of therapies
may best meet the patient’s
needs. During
psychotherapy, learn about
the condition and the
moods, feelings,

103
 thoughts and behaviors.
Psychotherapy helps learn
how to take control of life
and respond to challenging
situations with healthy
coping skills. This will
enable them to resolve
conflicts, relieve major life
changes, learn to manage
unhealthy reactions and
cope with sexual problems.

H 1. Maintain good and proper - This will promote cleanliness

personal hygiene such as taking of the patient physically
Hygiene
a bath, brushing the teeth, and also to maintain
wearing clean clothes, and integrity of skin, nails, etc.
more.

Outpatient

1. Attend follow-up checkups at attending psychiatrist or physician’s clinics, as scheduled.

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2. Bring necessary documents needed.

3. Encourage Coping and Support with family members.

- This will help monitor the progress of the patient by also being able to attend the needs of
the client given and provided by the doctor.

- Certain documents such as tests and even journals will help update the doctor about the
condition’s progress and other necessary information.

- The person you love may seem like a different person than you knew before the trauma —
angry and irritable, for example, or withdrawn and depressed. PTSD can significantly
strain the emotional and mental health of loved ones and friends. Hearing about the trauma
that led to

your loved one's PTSD may be painful for you and even cause you to relive difficult
events. You may find yourself avoiding his or her attempts to talk about the trauma or
feeling hopeless that your loved one will get better. At the same time, you may feel guilty
that you can't fix your loved one or hurry up the process of healing.

105
 Diet

1. Avoid alcohol and drugs.

2. Eat a healthy diet and maintain eating nutritious

- When a person is struggling with difficult emotions and traumatic memories, you may be
tempted to self-medicate with alcohol or drugs. But substance use worsens many
symptoms of PTSD, interferes with treatment, and can add to problems in your
relationships.

foods. Start the day right with breakfast, and keep the energy up and the
mind clear with balanced, nutritious meals throughout the day. Also,
include Omega-3s which play a vital role in emotional health so
incorporate foods such as fatty fish, flaxseed, and walnuts into your diet.

106
 3. Limit processed food, fried food, refined starches, and sugars.

- By recommending 3 meals per day and 1-2 snacks per day with a wide variety of nutrients
and consistent carbohydrate intake in the mix to help promote overall
nutritional balance and stable blood sugars. Omega-3 fatty acids are
essential for the maintenance of brain health and for the prevention of cognitive
dysfunction. Getting in 2 servings of Omega-3 Fatty acids per week (EPA & DHA in
particular) can help preserve the
maintenance and function of the brain, in addition to cognition.

- Processed, fried, and refined

food is unhealthy which
can also exacerbate mood
swings and cause
fluctuations in your energy.

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IX. Prognosis
CRITERIA POOR FAIR GOOD JUSTIFICATION AND RATIONALE
1. Onset of ✓ Justification:
Illness The onset of illness is at the night when the
patient saw his older sister Candace being
slapped by her boyfriend Derek. At that
night, the patient have started seeing
flashback about his memories with her aunt
Helen, specifically the time when he was a
young boy with his older siblings, standing
on the stairs to welcome their aunt Helen.
Rationale:
The development of PTSD is somewhat
unpredictable and can occur at any age.
The severity and timing of PTSD symptoms
differ with each individual; while symptoms
usually begin within the first 3 months after
the trauma, there can be a delay of months
or even years before a person meets criteria
to be diagnosed with PTSD. PTSD typically
develops immediately after the trauma.
108
 Nonetheless, in some cases symptoms may
not emerge until years have passed since
the event. Additionally, a traumatic incident
may cause mild PTSD symptoms in one
individual while chronically debilitating
another. PTSD can be successfully treated,
even when it develops many years after a
traumatic event. Any treatment depends on
the severity of symptoms and how soon
they occur after the traumatic event
(University of Pennsylvania, 2020).
2. Duration of ✓ Justification:
Illness The client’s duration of illness is about
several months. It started from the day his
older sister Candace was slapped by his
boyfriend to the time in which his friend Sam
left for college.

Rationale:
Duration of symptoms also varies, with
some people recovering from trauma
naturally in the first 3 months, and others
experiencing symptoms for months or
years. (University of Pennsylvania, 2020).

3. Mood & ✓ Justification:

Affect/Premor The client’s mood is congruent with its
bid affect. When the patient felt happy and sad
Personality on his first day of class in high school, his
feelings can also be seen through his
actions especially when he smiled when
he answered the question of his English
teacher, Mr. Anderson. He also has a sad
face especially when he was being bullied
by his classmates and when a senior
student grabbed and tore his book. The
client also felt anxious when his friends
were leaving and excluding him due to his
mistake of kissing his friend Sam instead
of her girlfriend Mary Elizabeth. He also
felt anxious when his friend Sam left to go
to college.

Rationale:
Affect is the patient's immediate

109
 expression of emotion while the mood
refers to the more sustained emotional
makeup of the patient's personality.
Patients display a range of affect that may
be described as broad, restricted, labile, or
flat. Affect is inappropriate when there is
no consonance between what the patient
is experiencing or describing and the
emotion he is showing at the same time
(e.g., laughing when relating the recent
death of a loved one). Both affect and
mood can be described as dysphoric
(depression, anxiety, guilt), euthymic
(normal), or euphoric (implying a
pathologically elevated sense of well-
being) (Walker, Hall, & Hurst, 1990).

4. Willingness ✓ Justification:
to take In the scene from the movie, specifically
Medication with a timestamp of 9:52 to 10:00, it was
shown that the patient is taking a
medication.

Rationale:
The willingness of the patient to take
medications helps in the treatment of
PTSD. Prescribed medications play a key
role in the treatment of co-occurring
disorders. They can reduce symptoms
and prevent relapses of a psychiatric
disorder. In order to get the most out of
medication, patients must make an
informed choice about taking
medications, and understand the
potential benefits and costs associated
with medication use. In addition, they
must take the medication as prescribed

110
 by a mental health professional
(Behavioral Health Evolution, 2016).

5. Any ✓ Justification:
depressive In the movie, after his friend Sam left to
features go to college, the patient experiences
various flashbacks on his memories with
his Aunt Helen. The client became
anxious, paranoid, and also started
crying. He even started to have suicidal
ideations when saw the knife in their
kitchen in which he is feeling guilty for the
death of her aunt Helen.

Rationale:
The presence of depressive features to a
patient with Post Traumatic Stress
Disorder may develop another disorder
which is the Major Depressive Disorder.
These two disorders may co-occur in
which PTSD is characterized by
symptoms of anxiety, flashbacks, and
reliving traumatic experiences. The
condition develops after a person
experiences some sort of traumatic event
such as a natural disaster, car accident,
attack, abuse, or combat. On the other
hand, depression is characterized by low
mood, loss of interest and pleasure, and
changes in energy levels. In order to
prevent the development of depression
towards a patient with PTSD, it is highly
recommended to seek medical attention
to a psychiatrist and undergo the needed
therapy for PTSD patient (Tull, 2020).
6. Factors ✓ Justification:
There are various factors that lead for the
patient to have Post Traumatic Stress
Disorder. Some of these risk factors that
can be seen in the movie include lack of
social support since the patient was not
able to show his feelings of being happy
and sad about his first day in high school.
The patient has also a history of abuse in
which he was sexually abused by his aunt

111
 Helen when he was young. The patient’s
environment and his temperamental is
also a risk factor that triggers the
flashbacks.

Rationale:
Factors such as previous traumatic
experiences, history of abuse, family
history, history of substance abuse, poor
coping skills, lack of social support, and
ongoing stress are some of the factors
that increase the risk for a person to have
Post Traumatic Stress Disorder.
However, with proper psychotherapies
such as Evidence-based therapies for
PTSD include Trauma Focused Cognitive
Behavioral Therapy (TF-CBT) Prolonged
Exposure (PE), Cognitive Processing
Therapy, and Eye Movement
Desensitization and Reprocessing
(EMDR), it will to alleviate the symptoms
and helps for the recovery of the patient.
Moreover, giving psychotherapy to
patients with PTSD is clearly more
effective than giving medication
(University of Pennsylvania, 2020).

7. Family ✓ Justification:
Support The client’s family is supportive especially
when the client is being admitted in
Mayview Hospital. His older brother and
sister visited him. His parents also
provided for the treatment even though
according to the patient that his father
can’t afford the hospital.

Rationale:
When family relationships are stable and
supportive, a person suffering from
mental health issues or disorders may be
more responsive to treatment.
Companionship, emotional support and
often even economic support can have a
positive impact on someone coping with a
mental health problem. While some who

112
 suffer from mental health issues may
require intense familial support, others
may simply need help with transportation
to get to treatment or the day-to-day
companionship that most people require
in times of need. (Mental Health Center,
2020)

Summary

In post-traumatic stress disorder (PTSD), distressing symptoms occur after one or more
frightening incidents. For the most part, a person with this disorder must have experienced the
event with him or herself, or witnessed the event in person. The person may also have learned
about violence to a close loved one which may have involved serious physical injury or the threat
of serious injury or death.

The long-term outlook for PTSD varies widely and depends on many factors, such as your ability
to cope with stress, your personality or temperament, a history of depression, the use of
substances, the nature of social support, your level of ongoing stress and your ability to stay in
treatment. Overall, about 30% of people eventually recover completely with proper treatment,
and another 40% get better, even though less-intense symptoms may remain. Treatment with
psychotherapy and/or medications, such as SSRIs, has been very helpful. Even without formal
treatment, many people receive the support they need to make a successful adjustment as time
puts distance between them and the traumatic event.

Based on the movie, the patient has an onset of illness when he was at his first days in
high school when he saw her older sister Candace to be slapped by Derek, her boyfriend. It took
several years for the patient to remember through flashbacks his memories with his aunt Helen
when he was young. The occurrence of PTSD is somewhat unpredictable and can occur to
anyone that experienced trauma at any age since the severity and timing of PTSD symptoms
differ with each individual. On the patient’s duration of illness, it is about several months, can be
7 to 8 months since it started from the patient’s first days in high school to the time in which his
friend Sam left for college where he was hospitalized after it. The duration of the symptoms also

113
varies from each person. Thus, both the onset and the duration of the illness is good in attaining a
good prognosis.

For the mood and affect/Premorbid Personality, the client’s mood is congruent with its
affect. Affect is the patient's immediate expression of emotion while the mood refers to the
more sustained emotional makeup of the patient's personality. Patients display a range of
affect that may be described as broad, restricted, labile, or flat. Affect is inappropriate when there
is no consonance between what the patient is experiencing or describing and the emotion he is
showing at the same time. With this, the mood and affect of the patient is also good. In the
category of willingness to take medication, there was a scene in the movie where the patient was
taking his medicine. With this, as a group, we can conclude that the patient has the willingness to
take medications. Thus, the group rated this category as good.

In the category about depressive features, In the movie, after his friend Sam left to go to
college, the patient experiences various flashbacks on his memories with his Aunt Helen. The
client became anxious, paranoid, and also started crying. He even started to have suicidal
ideations when saw the knife in their kitchen in which he is feeling guilty for the death of her
aunt Helen. The group rated it as fair since although the condition of the patient is still treatable,
the patient’s family must be very careful and observant towards the patient in order to ensure his
safety and to prevent possible suicide attempts or violence towards self. Moving on to the
category of factors, there were various factors that affect the patient that leads to developing his
PTSD. The group rated it as good since by knowing the factors that affect the patient, we can
develop therapies that will help him to overcome his difficulties and to treat the symptoms.

Lastly, on the family support, the client’s family is very supportive to him especially
when he was being admitted in Mayview Hospital. His older brother and sister visited him. His
parents also provided for the treatment even though according to the patient that his father can’t
afford the hospital. The group rated it as good since a supportive family helps the patient to have
companionship, emotional support, and even economic support can have a positive impact on
someone coping with a mental health problem. In totality, the prognosis of the patient of the
movie is good as he was able to be discharged in the Mayview Hospital. He will still be also
having follow-up check-ups with his psychiatrist in order to monitor his progress.
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