Post Traumatic Stress Disorder: A Case Study Media Communication
BASIC DATA (e.g., Age, sex, gender, sexual orientation, ethnic/cultural background, year at UWB, major):
He is a 21 years old single, Asian American, heterosexual male. He is a senior at UWB studying media communication.
PRESENTING CONCERN (Reason for seeking services and related history):
He presented with depressive mood, anxiety, fatigue, difficulties to concentrate, difficulties to fall and staying in asleep, and a diminished interest in daily activities. He noted that he is not motivated to do school work that he has been barely passing his classes for the last 2 years. He reported that he has failed some of his classes within the last 2 years. He mentioned that 2 of his professors suggested to seek counseling for depression. Robert stated …show more content…
that he is unsure that he has depression.
He reported that he has been struggling to cope with family members’ health issues. Both his paternal grandfather and father suffered from stroke in the recent years. His grandfather’s stroke was approx. 2 years ago and his father’s was approx. 1 year ago. He spoke about his own health concerns.
THERAPEUTIC IMPRESSIONS (e.g., Grooming, oriented X4, affect, insight, engagement):
He came to his appointment on time. He was oriented X4. He dressed appropriately for the weather. He was well groomed. His affect was depressed and anxious. His speech was rather blunted and quiet. He had a limited insight about his experience as well as other people’s observation of him. He was engaging and did not hesitate to answer any question.
ACADEMIC FUNCTIONING (e.g., Educational history, Current functioning, Employment):
He reported that he has not been doing well with his classes. His current cumulative GPA is 2.79. He noted that he has been struggling academically for the last 2 years. He has failed classes consecutively in the past few years. He indicated that he will fail one of his classes this quarter. He mentioned that he does not enjoy his major.
He indicated that he is scheduled to graduate in Spring; however, he does not have a job lined up for post-graduation at this time. He stated that he needs to work on finding a job but he has not been motivated.
He reported that he works at a grocery store in the area (12-14 hrs/wk). He stated that he enjoys his work that it is not very demanding work. He also stated that he likes his work because it is an indoor work.
SOCIAL SUPPORT (e.g., Current living situation, friends, recreation, hobbies):
He reported that he currently lives with his cousin and a roommate in Seattle. He indicated that he gets along with them fine but he does not see them as his support system. He reported that he has friends he meet up with periodically. He reported that he and his friends share interests in manga, anime, and pornography.
FAMILY HISTORY (e.g., Current contact/living situation, historical issues, current relationship):
He reported that his parents are divorced and only his father has remarried. He reported that he has one younger sister who is 16 y.o. and in high school, and one younger step-brother who is 7 y.o. He shared that his father calls him regularly and he sees his mother periodically.
MEDICAL, MENTAL HEALTH, MEDICINE (e.g., Historical and Current data):
He indicated that he is concerned about his health especially given that both is grandfather and father suffered from stroke. He reported that his mother tells him to take a better care of himself. He indicated that he is aware of risks of poor diet and a lack of exercise. Nevertheless, he stated that he is not very motivated to change his habits.
He reported that it is difficult for him to fall and stay in asleep.
SUBSTANCE USE (e.g., Historical, current, frequency, family history, client/family/friends concerned):
He reported that he consumes 2-3 alcoholic beverages a week and 2-5 caffeinated beverages such as espressos, sodas, and energy drinks a day. He denied any other substance use.
TRAUMA/ABUSE/SIGNIFICANT LOSS (recent and historical):
He did not report any trauma or abuse.
He presented with a sense of loss as he spoke about his grandfather and father's stroke.
RISK AND PROTECTIVE FACTORS (e.g., suicide history, SIB, harm to self or others, past and current):
He credibly denied having an active thought of suicide. He stated that due to his health concerns, he thinks about his mortality. He expressed having a feeling that consists of not caring if something were to happen to him. Nevertheless, he stated that he does not have any wish to commit suicide or harm himself. He also denied plan or intent of suicide. With regards to HI, he reported that he can become angry and have a thought about an impulsive act such as reckless driving or hitting others. However, he denied acting out on his thought. He did not indicate any history of violence toward others.
TREATMENT RECOMMENDATIONS (e.g., therapy modality, goals for therapy, therapeutic approach, referrals):
Due to being at the end of quarter and the level of depressed mood he displayed we agreed to meet sooner than one week interval. He would benefit from identifying his interests that would motivate him in life, a small step to begin to change some of his unhealthy habits (e.g., diet, excise, and sleep), and ways to cope with fear, depressed mood, and anxiety. A modified motivational interview may be
helpful.
He is a 21 years old single, Asian American, heterosexual male. He is a senior at UWB studying media communication.
PRESENTING CONCERN (Reason for seeking services and related history):
He presented with depressive mood, anxiety, fatigue, difficulties to concentrate, difficulties to fall and staying in asleep, and a diminished interest in daily activities. He noted that he is not motivated to do school work that he has been barely passing his classes for the last 2 years. He reported that he has failed some of his classes within the last 2 years. He mentioned that 2 of his professors suggested to seek counseling for depression. Robert stated …show more content…
that he is unsure that he has depression.
He reported that he has been struggling to cope with family members’ health issues. Both his paternal grandfather and father suffered from stroke in the recent years. His grandfather’s stroke was approx. 2 years ago and his father’s was approx. 1 year ago. He spoke about his own health concerns.
THERAPEUTIC IMPRESSIONS (e.g., Grooming, oriented X4, affect, insight, engagement):
He came to his appointment on time. He was oriented X4. He dressed appropriately for the weather. He was well groomed. His affect was depressed and anxious. His speech was rather blunted and quiet. He had a limited insight about his experience as well as other people’s observation of him. He was engaging and did not hesitate to answer any question.
ACADEMIC FUNCTIONING (e.g., Educational history, Current functioning, Employment):
He reported that he has not been doing well with his classes. His current cumulative GPA is 2.79. He noted that he has been struggling academically for the last 2 years. He has failed classes consecutively in the past few years. He indicated that he will fail one of his classes this quarter. He mentioned that he does not enjoy his major.
He indicated that he is scheduled to graduate in Spring; however, he does not have a job lined up for post-graduation at this time. He stated that he needs to work on finding a job but he has not been motivated.
He reported that he works at a grocery store in the area (12-14 hrs/wk). He stated that he enjoys his work that it is not very demanding work. He also stated that he likes his work because it is an indoor work.
SOCIAL SUPPORT (e.g., Current living situation, friends, recreation, hobbies):
He reported that he currently lives with his cousin and a roommate in Seattle. He indicated that he gets along with them fine but he does not see them as his support system. He reported that he has friends he meet up with periodically. He reported that he and his friends share interests in manga, anime, and pornography.
FAMILY HISTORY (e.g., Current contact/living situation, historical issues, current relationship):
He reported that his parents are divorced and only his father has remarried. He reported that he has one younger sister who is 16 y.o. and in high school, and one younger step-brother who is 7 y.o. He shared that his father calls him regularly and he sees his mother periodically.
MEDICAL, MENTAL HEALTH, MEDICINE (e.g., Historical and Current data):
He indicated that he is concerned about his health especially given that both is grandfather and father suffered from stroke. He reported that his mother tells him to take a better care of himself. He indicated that he is aware of risks of poor diet and a lack of exercise. Nevertheless, he stated that he is not very motivated to change his habits.
He reported that it is difficult for him to fall and stay in asleep.
SUBSTANCE USE (e.g., Historical, current, frequency, family history, client/family/friends concerned):
He reported that he consumes 2-3 alcoholic beverages a week and 2-5 caffeinated beverages such as espressos, sodas, and energy drinks a day. He denied any other substance use.
TRAUMA/ABUSE/SIGNIFICANT LOSS (recent and historical):
He did not report any trauma or abuse.
He presented with a sense of loss as he spoke about his grandfather and father's stroke.
RISK AND PROTECTIVE FACTORS (e.g., suicide history, SIB, harm to self or others, past and current):
He credibly denied having an active thought of suicide. He stated that due to his health concerns, he thinks about his mortality. He expressed having a feeling that consists of not caring if something were to happen to him. Nevertheless, he stated that he does not have any wish to commit suicide or harm himself. He also denied plan or intent of suicide. With regards to HI, he reported that he can become angry and have a thought about an impulsive act such as reckless driving or hitting others. However, he denied acting out on his thought. He did not indicate any history of violence toward others.
TREATMENT RECOMMENDATIONS (e.g., therapy modality, goals for therapy, therapeutic approach, referrals):
Due to being at the end of quarter and the level of depressed mood he displayed we agreed to meet sooner than one week interval. He would benefit from identifying his interests that would motivate him in life, a small step to begin to change some of his unhealthy habits (e.g., diet, excise, and sleep), and ways to cope with fear, depressed mood, and anxiety. A modified motivational interview may be
helpful.