CASE STUDY of Cindy

DON HONORIO VENTURA STATE UNIVERSITY COLLEGE OF SOCIAL
Cabambangan, Villa de Bacolor 2001, Pampanga, Philippines SCIENCESAND PHILOSOPHY

DHVSU ISO
Main9001:
Campus,
2015 Villa de Bacolor, Pampanga
Tel. No. (6345) 458 0021; Fax (6345) 458 0021 Local 211 ISO 9001: 2015 E-Mail Address: dhvsucssp@gmail.com
ISO 9001: 2015
CASE STUDY ANALYSIS
(Final Requirement)
Case 1: Cindy Oakley
I. Diagnosis
: 309.81 Posttraumatic Stress Disorder with delayed expression
: 296.21 Major depressive disorder, single episode, mild
: 305.20 Cannabis abuse
II. Justification of the Diagnosis
When reviewing the information provided about Cindy Oakley, a few psychological disorders
such as PTSD, MDD or clinical depression, and cannabis use disorder can be found. In Cindy's case,
she has more than one assigned diagnosis; however, based on the data gathered during the initial
interview, it can be concluded that her primary diagnosis is PTSD (posttraumatic stress disorder)
according to DSM-5. When an individual has more than one diagnosis, this is referred to as a
principal diagnosis. It is the diagnosis that has made the individual an inpatient and, for the most part,
in need of treatment at this time.
In DSM-V posttraumatic stress disorder is classified under the category of Trauma-and-

Stressor-Related Disorders and it defines as a development of certain symptoms (e.g. fear based
emotional behavioral symptoms, dysphonic mood states, development of arousal and reactive-
externalizing symptoms, and dissociative symptoms) due to exposure to a traumatic or stressful
event. Almost all the diagnostic criteria were met like a.) exposure to actual or threatened death,
serious injury, or sexual violence, in one (or more) of the following ways: (1) directly experienced the
events, the client reported that she experienced actual sexual violence and was subjected to several
sexual activities including oral, vaginal, and anal intercourse, (4) experienced repeated or extreme
exposure to aversive details of traumatic events (e.g., first responders to the aftermath of gruesome
crime scene); the client reported that she was repeatedly raped for over 5-week period which was
subjected to several sexual activities (including Oral, Vaginal, and Anal intercourse). Next is b.)
presence of one (or more) of the following intrusion symptoms associated with the traumatic events,
beginning after the traumatic events occurred: (1) recurrent, involuntary, and intrusive distressing
memories of the traumatic events; the client reported her experienced that within the course of the
affair she began to have flashbacks centered on a series of repeated rapes that had occurred when
she was 16 years old. The distressing images come into her mind out of nowhere. This criterion
merits the diagnosis since the flashbacks were recurrent, involuntary and intrusive within the time of
the affair. (2) dissociative reactions (flashbacks) in which the individual feels or acts as if the traumatic
events were recurring; in this the client reported that when she experienced the flashbacks she would
momentarily feels as if the past were occurring. (3) intense or prolonged psychological distress at
exposure to internal or external cues that symbolize or resemble an aspect of the traumatic events;
this criterion is present when the client was depressed for the last 3 months after she had ended the
affair. The duration of being depressed experienced is accounted as intense of prolonged. Then, (c)
persistent avoidance of stimuli associated with the traumatic events, beginning after the traumatic
events occurred, as evidenced by one or both of the following: (1) avoidance of or efforts to avoid
external reminders ( people, place, conversations, activities, objects, and situation) that arouse
distressing memories, thoughts or feelings about or closely associated with the traumatic events; in
this the client reported that after having the flashbacks triggered in the affair she then eventually
ended to suppress memories which was resulted to be depressed. In the treatment course, the
therapist pointed out how avoidance prevented her from recovering from the trauma. Additionally,
previous therapist labeled her marijuana use a form of avoidance. After, (d) negative alterations in
thoughts and mood associated with the traumatic events, (e.g., inability to recall important aspect of
event, feeling of detached or estranged from others, persistent inability to experienced positive
emotion), in this the client had an assignment to write a detailed account of the most traumatic raped
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she experienced from the incidents and instructed to

include as many sensory details as possible. Evidently, there are several parts that she wasn’t able to
remember and write it down. Also she has a negative belief which stemmed in response from the
incident. This type of cognitive error may be associated with the aftermath of the sexual assault.
Lastly, (e) marked alterations in arousal and reactivity associated with the traumatic events,
beginning or worsening after the traumatic events occurred as evidenced by two (or more) of the
following: (1) Reckless of self-destructive behaviour; after the incident, the client begin to lie often and
drinking and eventually become a total rebel in the family. Evidently, she got pregnant by a wild guy
who was totally bad news. (2) Hypervigilance; this criterion is present when the client began to
experienced the flashbacks which she had ended in order to protect herself from relieving the past
traumatic events.
III. Treatment Plan
Problem Presented Intervention/ Plan Objective Target Date Expected outcome

of action ( include
therapy and other
recommendation)
to assist the
Directly Cognitive individual in there are 5 to 20 She can now enable
experiencing the Behavioural enacting changes in sessions with, each to confront, rather
traumatic event Therapy thinking patterns lasting 30 to 60 than avoid, her
such sex assault and behaviors, minutes. distress in a
thereby improving controlled manner
quality of life by as well as he can
assisting the now know how to
individual in taking relax and what to
control of his or her do if there are
own perception of things that can
those trigger her
circumstances,
rather than by
changing the
circumstances in
which the person
lives.
to assist the
Recurrent, Cognitive individual in there are 5 to 20 She can now enable
involuntary and Behavioural enacting changes in sessions with, each to confront, rather
intrusive distressing Therapy thinking patterns lasting 30 to 60 than avoid, her
memories of the and behaviors, minutes distress in a
traumatic event thereby improving controlled manner
those trigger her
circumstances,
rather than by
changing the
circumstances in
which the person
lives.
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to assist the
Dissociative Cognitive individual in there are 5 to 20 She can now enable
reactions in which Behavioural enacting changes in sessions with, each to confront, rather
the individual feels Therapy thinking patterns lasting 30 to 60 than avoid, her
or acts as if the and behaviors, minutes distress in a
traumatic events are thereby improving controlled manner
recurring quality of life by as well as he can
those trigger her
circumstances,
rather than by
changing the
circumstances in
which the person
lives.
to assist the
prolonged Cognitive individual in there are 5 to 20 She can now enable
psychological Behavioural enacting changes in sessions with, each to confront, rather
distress at exposure Therapy thinking patterns lasting 30 to 60 than avoid, her
to internal or and behaviors, minutes distress in a
external cues that thereby improving controlled manner
symbolise or quality of life by as well as he can
resemble an aspect assisting the now know how to
of the traumatic individual in taking relax and what to
event control of his or her do if there are
those trigger her
circumstances,
rather than by
changing the
circumstances in
which the person
lives.
to assist the
Avoidance of or Cognitive individual in there are 5 to 20 She can now enable
effort to avoid Behavioural enacting changes in sessions with, each to confront, rather
external reminders Therapy thinking patterns lasting 30 to 60 than avoid, her
that arouse and behaviors, minutes distress in a
distressing thereby improving controlled manner
memories, quality of life by as well as he can
thoughts, or assisting the now know how to
feelings about or individual in taking relax and what to
closely associated control of his or her do if there are
with the traumatic own perception of things that can
events those trigger her
circumstances,
rather than by
changing the
circumstances in
which the person
lives.
to assist the
persistent, distorted Cognitive individual in there are 5 to 20 She can now enable
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enacting changes in
cognitions about the Behavioural thinking patterns sessions with, each to confront, rather
cause or Therapy and behaviors, lasting 30 to 60 than avoid, her
consequences of the thereby improving minutes distress in a
traumatic events quality of life by controlled manner
that lead the assisting the as well as he can
individual to blame individual in taking now know how to
herself control of his or her relax and what to
own perception of do if there are
those things that can
circumstances, trigger her
rather than by
changing the
circumstances in
which the person
lives.
to assist the
Persistent negative Cognitive individual in there are 5 to 20 She can now better
emotional state Behavioural enacting changes in sessions with, each manage things like
Therapy thinking patterns lasting 30 to 60 stress and anxiety
and behaviors, minutes that trigger her.
thereby improving
quality of life by
assisting the
individual in taking
control of his or her
own perception of
those
circumstances,
rather than by
changing the
circumstances in
which the person
lives.
to assist the
Markedly Cognitive individual in there are 5 to 20 She can now better
diminished interest Behavioural enacting changes in sessions with, each manage things like
or participation in Therapy thinking patterns lasting 30 to 60 stress and anxiety.
significant activity and behaviors, minutes And she can do
thereby improving some enjoyable
quality of life by activities or
assisting the exercise
own perception of
those
circumstances,
rather than by
changing the
circumstances in
which the person
lives.
to assist the
Feelings of Cognitive individual in there are 5 to 20 She can now better
detachment or Behavioural enacting changes in sessions with, each manage things like
estrangement from Therapy thinking patterns lasting 30 to 60 stress and anxiety
DHVSU ISO
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and behaviors,
others thereby improving minutes that trigger her.
quality of life by
assisting the
own perception of
those
circumstances,
rather than by
changing the
circumstances in
which the person
lives.
to assist the
persistent inability Cognitive individual in there are 5 to 20 She can now enable
to experience Behavioural enacting changes in sessions with, each to confront, rather
positive emotions Therapy thinking patterns lasting 30 to 60 than avoid, her
and behaviors, minutes distress in a
individual in taking relax.
own perception of
those
circumstances,
rather than by
changing the
circumstances in
which the person
lives.
to assist the
Irritable behaviour Cognitive individual in there are 5 to 20 She can now enable
and angry outburst Behavioural enacting changes in sessions with, each to confront, rather
typically expressed Therapy thinking patterns lasting 30 to 60 than avoid, her
as verbal or and behaviors, minutes distress in a
physical aggression thereby improving controlled manner
toward people or quality of life by as well as he can
object assisting the now know how to
own perception of
those
circumstances,
rather than by
changing the
circumstances in
which the person
lives.
to assist the
Reckless or self- Cognitive individual in there are 5 to 20 She can now enable
destructive Behavioural enacting changes in sessions with, each to confront, rather
behaviour Therapy thinking patterns lasting 30 to 60 than avoid, her
DHVSU ISO
Main9001:
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quality of life by
assisting the as well as he can
individual in taking now know how to
control of his or her relax.
own perception of
those
circumstances,
rather than by
changing the
circumstances in
which the person
lives.
Causes clinically Cognitive to assist the there are 5 to 20 She can now enable
significant distress Behavioural individual in sessions with, each to confront, rather
in social and Therapy enacting changes in lasting 30 to 60 than avoid, her
occupational thinking patterns minutes distress in a
functioning and behaviors, controlled manner
thereby improving as well as he can
quality of life by now know how to
assisting the relax.
own perception of
those
circumstances,
rather than by
changing the
circumstances in
which the person
lives.
Depressed mood Medication or to assist the 3 – 4 months She can now know
most of the day, Psychotherapy individual in manage the factors
nearly every day, as enacting changes in that contribute to
indicated by either thinking patterns his depression and
subjective report and behaviors, alter the behaviours
(e.g., feels sad, thereby improving that aggravate it.
empty, hopeless) or quality of life by Replace unhealthy,
observation made assisting the negative beliefs and
by others (e.g., individual in taking behaviours with
appears tearful). control of his or her healthy, positive
own perception of ones.
those
circumstances,
rather than by
changing the
circumstances in
which the person
lives.
to assist the
Markedly Medication or individual in 3 – 4 months She can now know
diminished interest Psychotherapy enacting changes in manage the factors
or pleasure in all, or thinking patterns that contribute to
almost all, activities and behaviors, his depression and
most of the day, thereby improving alter the behaviours
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quality of life by
nearly every day assisting the that aggravate it.
individual in taking Replace unhealthy,
control of his or her negative beliefs and
own perception of behaviours with
those healthy, positive
circumstances, ones.
rather than by
changing the
circumstances in
which the person
lives.
to assist the
Feelings of Medication or individual in 3 – 4 months She can now know
worthlessness or Psychotherapy enacting changes in manage the factors
excessive or thinking patterns that contribute to
inappropriate guilt and behaviors, his depression and
(which may be thereby improving alter the behaviours
delusional) nearly quality of life by that aggravate it.
every day (not assisting the Replace unhealthy,
merely self- individual in taking negative beliefs and
reproach or guilt control of his or her behaviours with
about being sick). own perception of healthy, positive
those ones.
circumstances,
rather than by
changing the
circumstances in
which the person
lives.
to assist the
Taking more or for Cognitive individual in there are 5 to 20 It has the potential
longer than Behavioural enacting changes in sessions with, each to reduce the
intended (substance Therapy or thinking patterns lasting 30 to 60 amount of
abuse) Pharmacological and behaviors, minutes substance used.
Treatment thereby improving
quality of life by
assisting the
own perception of
those
circumstances,
rather than by
changing the
circumstances in
which the person
lives.
to assist the
Unsuccessful Cognitive individual in there are 5 to 20 It has the potential
efforts to stop or cut Behavioural enacting changes in sessions with, each to reduce the
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thinking patterns
down use Therapy or and behaviors, lasting 30 to 60 amount of
(substance abuse) Pharmacological thereby improving minutes substance used.
Treatment quality of life by
assisting the
own perception of
those
circumstances,
rather than by
changing the
circumstances in
which the person
lives.
CASE STUDY ANALYSIS
(Final Requirement)
Case 2: Sonny Ford
I. Diagnosis
: 295.90 (F 20.9) Schizophrenia
II. Justification of the Diagnosis
In the case of Sonny Ford, who is a 21-year old Caucasian male. The diagnosis that should be given
according to his symptoms and the case evidence is the Schizophrenia spectrum disorder according to DSM-5
In the DSM-5 there are various criteria within in order to have the Schizophrenia disorder. Criterion A
states that the individual must have two (or more) of the following, where each of them are present for
significant portion of time during a period of one month (or less if treated successfully). At least one of these
following must be present; delusions, hallucination, or disorganized speech such as incoherence. Other
symptoms part of this criterion is if the person is grossly disorganized of have negative symptom.
Criterion B stated that a portion of the time of the onset of disturbance, level of functioning in one or more
of following areas; work, interpersonal relations, or self care is below the level achieved prior to onset.
Criterion C states that a continuous signs of the disturbance is persist for six months. During these six
months it must include at least one month of symptoms (or less if successfully treated) that meet Criterion A
(active phase) and may also include periods of prodromal symptoms. During these prodromal symptoms the
signs of distribution may only be manifested by negative symptoms or by two (or more) symptoms listed in
Criterion A.
Criterion D states that the schizoaffective disorder and depressive of bipolar disorder with psychotic
features have been ruled out because of the following one or two reasons. One being no major depressive or
manic episodes has occurred concurrently with the active phase symptoms. The second reason is if the mood
episodes started during the active phase of the illness and were only present for a small portion of the time
during the active and residual phases.
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Criterion E states that the disturbance is not attributed to

the physiological effects of a substance (drug abuse) or another medical condition.
Criterion F states that if there is a history of autism spectrum disorder or communication disorder of
childhood onset, then the additional diagnosis of schizophrenia is made only if prominent delusions or
hallucinations are present. In additional to the other required symptoms of schizophrenia, the symptoms must be
present for at least one month (or less if treated successfully).
In the case of Sonny, he meets majority of the criteria in order to be diagnosed with schizophrenia. Within
Criterion A, Sonny has dealt with his symptoms of delusional and hallucinations for more than one month,
especially after partaking in marijuana. Some of these delusional were thinking that people were coming after
him or authorities are trying to catch him in homosexual acts. The hallucinations that Sonny was having were
voices in his head. He knew they were in his head but he could not make out what they were telling him that the
authorities were out for him. As Criterion B stated, before the time of onset the individual must have
disturbance in functioning prior to the onset symptoms. Sonny in fact did have this; he was struggling with part
time jobs of keeping one and also problems within his own family, mostly his mother who was not accepting of
him and his homosexual orientation. Sonny does meet Criterion C; he has dealt with his symptoms for more
than six months in fact Sonny has dealt with symptoms of hallucinations and delusions persisting past six
months after smoking marijuana. More so Sonny also holds prodomal phases which his symptoms slowly and
gradually developed, and then eventually moved into the active phase. The schizoaffective disorder and
depressive or bipolar disorder has been ruled out because Sonny has it suffered from and manic episodes nor
depressive episodes have occurred while the active phase was in effect, which is stated in Criterion D. within
Criterion E, Sonny did smoke marijuana which may in fact develop his symptoms more severely. He would
meet this criterion because the marijuana is not attribution to physiological effects now was the marijuana
abused by Sonny. In Criterion F, Sonny does have a history of being distant from others in society, but not
officially diagnosed with communication disorder. Sonny does hold schizophrenic symptoms lasting more than
one month.
III. Treatment Plan
Problem Presented Intervention/ Plan Objective Target Date Expected outcome

of action ( include
therapy and other
recommendation)
to assist the
Concentration Cognitive individual in there are 5 to 20 He can now better
difficulties Anxiety Behavioral Therapy enacting changes in sessions with, each manage things like
thinking patterns lasting 30 to 60 stress and anxiety.
and behaviors, minutes
thereby improving
quality of life by
assisting the
own perception of
those
circumstances,
rather than by
changing the
circumstances in
which the person
lives.
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to assist the
Considerable Cognitive individual in there are 5 to 20 He can now enable
distress and Behavioral Therapy enacting changes in sessions with, each to confront, rather
frustration thinking patterns lasting 30 to 60 than avoid, his
own perception of
those
circumstances,
rather than by
changing the
circumstances in
which the person
lives.
to assist the
Discomfort in Cognitive individual in there are 5 to 20 He can now better
social situations Behavioral Therapy enacting changes in sessions with, each manage things like
thinking patterns lasting 30 to 60 stress and anxiety.
and behaviors, minutes
thereby improving
quality of life by
assisting the
own perception of
those
circumstances,
rather than by
changing the
circumstances in
which the person
lives.
Separation anxiety Cognitive This therapy There are 5 to 20 He can now better
Behavioral Therapy teaches you how to sessions with, each manage things like
or Medication relax and breathe to lasting 30 to 60 stress and anxiety.
control anxiety, as minutes.
well as how to
replace negative
thoughts with
positive ones.
to assist the
Obsessional Cognitive individual in There are 5 to 20 He can now better
thinking Behavioral Therapy enacting changes in sessions with, each manage things like
or Medication thinking patterns lasting 30 to 60 stress and anxiety.
and behaviors, And he can do
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thereby improving
quality of life by minutes. some enjoyable
assisting the activities or
individual in taking exercise to avoid
control of his or her his obdessional
own perception of thinking.
those
circumstances,
rather than by
changing the
circumstances in
which the person
lives.
Hallucinations Cognitive The goal is to make There are 5 to 20 No more

( hearing voices) Behavioral Therapy them less sessions with, each hallucination he
distressing and less lasting 30 to 60 and he can be relax
impairing in day-to- minutes and do his daily life
day life. routine without
worry.
Can't make out Cognitive The goal is to make There are 5 to 20 He can now better
what they're saying Behavioral Therapy them less sessions with, each manage things like
but knows they're distressing and less lasting 30 to 60 stress and anxiety
angry impairing in day-to- minutes that trigger his
day life. delusional.
Believes mind has Cognitive The goal is to make There are 5 to 20 He can now better
gone "numb" from Behavioral Therapy them less sessions with, each manage things like
marijuana distressing and less lasting 30 to 60 stress and anxiety
impairing in day-to- minutes that trigger his
day life. delusional.
References:
https://www.healthline.com/health/clinical-depression#treatment
DSM-5: https://cdn.websiteeditor.net/30f11123991548a0af708722d458e476/files/uploaded/DSM
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DON HONORIO VENTURA STATE UNIVERSITY COLLEGE OF SOCIAL

Cabambangan, Villa de Bacolor 2001, Pampanga, Philippines SCIENCESAND PHILOSOPHY

CASE STUDY ANALYSIS

Case 1: Cindy Oakley

: 309.81 Posttraumatic Stress Disorder with delayed expression

: 296.21 Major depressive disorder, single episode, mild

: 305.20 Cannabis abuse

II. Justification of the Diagnosis

In DSM-V posttraumatic stress disorder is classified under the category of Trauma-and-

she experienced from the incidents and instructed to

III. Treatment Plan

Problem Presented Intervention/ Plan Objective Target Date Expected outcome

CASE STUDY ANALYSIS

Case 2: Sonny Ford

: 295.90 (F 20.9) Schizophrenia

II. Justification of the Diagnosis

Criterion E states that the disturbance is not attributed to

III. Treatment Plan

Problem Presented Intervention/ Plan Objective Target Date Expected outcome

Hallucinations Cognitive The goal is to make There are 5 to 20 No more

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