Identifying Information
The client, Kyle Jones, is a 45-year-old professor working full-time at the Catholic University. He has taught English as a college professor for the past thirty years. Mr. Jones received his doctorate in English. The client is successful in his professional life as he is a popular teacher and has won several faculty awards (Kennedy & Harper, 2014). He identifies himself as a second-generation Italian American, and he is a Roman Catholic who actively practices his religion.
With his family, the client attends church every Sunday. Mr. Jones is heterosexual; he is married to a 30-year-old woman and has two adolescent children. The patient is right-handed and is involved in diverse social activities, including teaching, writing (and publishing) poems and different works, fishing with friends, and fixing motor engines. He also has several hobbies and keeps to a healthy lifestyle.
Reason for Referral
A neurologist referred Mr. Jones for a neuropsychological evaluation due to the persistence of some cognitive issues. The client’s cognitive functioning was impaired after a car accident that occurred in March 2009. Due to the deterioration of cognitive functioning, the assessment is necessary for the identification of the exact causes of the client’s psychological state. Based on the results of the assessment, the corresponding treatment will be developed for the patient.
Current Symptoms/Presenting Concerns
Mr. Jones is experiencing difficulties in generating ideas and planning, which is a considerable problem for his professional life. He has a decreased concentration during tests, which is another significant concern. Memory loss is another apparent difficulty as the client reported several episodes, including his inability to recall a conversation with a student after a class (Kennedy & Harper, 2014).
Other reported issues are decreased attention span, the loss of track of tasks, and disorganization. After the accident, as others note, the patient became more withdrawn. In addition, the client experiences headaches several times a day and neck pains. Mr. Jones has started physical therapy to treat his neck and head pain. The client reported reduced coordination when he tried to pick objects or when he walked. Mr. Jones has a history of depressive symptoms that started in his adolescence, but he reported having no depression at the moment although he mentioned sleep disturbance and reduced appetite.
Psychosocial History
Educational History
Mr. Jones was a successful student at school and college. He earned a doctorate in English and became a successful member of a college faculty. He did not report any academic problems at school or college. His children are also A-students and want to obtain degrees in the future.
Occupational History
As mentioned above, Mr. Jones has worked as a college professor for 30 years. The patient received several awards for teaching, and he is popular among students. He is a member of the institutional review board, so he reviews up to twenty grant applications each month (Kennedy & Harper, 2014). The client published several books, and he is proud of this accomplishment.
Medical History
The patient has a considerable history of hypercholesterolemia. Mr. Jones has a healthy lifestyle, so he is active, which contributes to his overall satisfactory physical state. The client reported that, as a child, he was dropped on his head and lost consciousness for several moments but regained consciousness soon (Kennedy & Harper, 2014). No cognitive or neurological consequences were reported, and no history of substance use or abuse was reported. The client admitted he could have a glass of wine at the end of the day to relax.
Psychiatric History
Mr. Jones also noted that he had had depressions since his childhood, but he started receiving treatment for this health condition in his adulthood. He reported that depressions could last for 3-6 months annually. The client denied any thoughts or ideas related to suicide. Mr. Jones reported that he had an accident when he was an adolescent, but he denied having fears or problems regarding driving.
The client noted that during the event, no one fastened seat belts, and the driver died in the accident. He stated that the last time he had depressive symptoms was after the school reunion when he saw the survivors of the accident. Mr. Jones had individual psychotherapy for years (he stopped and started again). His psychiatrist prescribed medications when needed. He described his current psychological state as stable although such issues as sleep disturbance and reduced appetite were reported.
Social History
As mentioned above, Mr. Jones is socially active, and he lives with his family and performs various duties (including managing finances and completing diverse household chores). In his free time, he does woodworking, fishes, repairs old cars, and has physical training three to five times a week. He also plays golf with his friends and attends church every Sunday. He goes to the church with his wife, father, and children, and he often meets other relatives there. He is proud of his achievements, including publishing a book and repairing an engine of an old car. He loves his children and proudly wears clothes his children present.
Interpretation of the Results
Mr. Jones completed the tests with precision and the necessary effort. He was quite cooperative and discussed all topics, but he was specifically animated when talking about his family or his teaching. Several tests were administered, and he performed well on them (Kennedy & Harper, 2014). His scores in effort tests were high, which is consistent with the overall impression of cooperativeness.
General Functioning
The general functioning construct was measured with the help of the Wechsler Adult Intelligence Scale (fourth edition) (WAIS-IV). The client’s results are high average in verbal comprehension, full-scale IQ, and perceptual reasoning.
Attention
When testing attention, certain impairment and lower scores as compared to the general functioning were observed. He scored high averaging in working memory assessment (measured with WAIS-IV). He displayed average results in processing speed, visual and auditory attention, task switching, measured with the help of WAIS-VI, FAS Test, Trail Making Tests, and PASAT. Semantic fluency tests revealed mild impairment, which was one of the symptoms and concerns mentioned by the client.
Visuospatial Tests
The patient displayed high average results on WAIS-IV Block Design, which means that he has appropriate visual-motor coordination, non-verbal reasoning, as well as considerable synthesis and analysis skills. The client showed average results on the cancellation test.
Language
Language tests showed quite differing results as the client’s performance was average on the Boston Naming Test. However, his results were superior on WAIS-IV Vocabulary.
Memory
Memory tests suggest that the client has several issues, but the overall cognitive abilities related to memory are age-appropriate. The results of the Wechsler Memory Scale-IV test were high average or superior. Logical memory and visual reproduction were measured with that test. However, the CVLT-II test displayed some problems or lower levels of memory. For instance, the patient displayed average abilities in recognition tests and delayed recalls. The results in learning and interference trials were worse. Mr. Jones showed certain memory (moderate) impairment in a learning trial.
Executive Functions
Mr. Jones performed well on executive functions tests showing high average or average results. This construct was measured with the help of WAIS-IV (Matrix Reasoning and Similarities) and WCST 64 cards.
Mood
Although the client denied having depressive symptoms, Beck Depression Inventory-II results suggest that the patient has moderate depression. These results are justified by the physical state of the client who has sleep disturbances and reduced appetite.
Diagnostic Impressions
Diagnosis
Based on the client’s history and test results, it is possible to provide a diagnosis for Mr. Jones. Posttraumatic stress disorder (PTSD) with depressive disorder is the most viable diagnosis. The criteria for PTSD the patient meets include exposure to a traumatic event (Criterion A1) and prolonged psychological distress at exposure to some cues related to the event (Criterion B4) (American Psychiatric Association, 2013). Other criteria that are apparent include feelings of detachment to others (Criterion D6), concentration issues (Criterion E5), sleep disturbance (E6) (American Psychiatric Association, 2013). It is necessary to note that a number of the criteria are not met as the client does not display negative emotions and continues to have an active life.
At that, the patient reported some of the most common symptoms immediately after the car accident although they disappeared soon after. For instance, Mr. Jones reported vague memories concerning the accident right after the car crash that took place in 2009. The loss of memory is Criterion D1, and it often occurs immediately after exposure to trauma, which was the case. The client also stated that he was quieter and less concentrated, which are symptoms associated with PTSD. Although such symptoms are common for brain injury, Mr. Jones had the corresponding tests, and no signs of brain or spinal injury were detected. Therefore, PTSD remains the most appropriate diagnosis.
Although the client does not experience all the symptoms related to PTSD, they occur and reoccur. According to the American Psychiatric Association (2013), the appearance of all criteria can take several months or even years. The delayed expression of symptoms is also quite common. At this point, it is important to note that Mr. Jones was exposed to a traumatic event at least three times in his life. He was dropped on his head in his childhood, he had a car accident that involved his friend’s death, and he had an accident being an adult person. All these incidents were similar and could be seen as triggers for the development of PTSD.
It has been found that early-life stress was a predictor of the development of PTSD in later life (Wang et al., 2018). Hence, the accident that took place in Mr. Jones’s childhood could be the primary trigger or, at least, the facilitator of the development of PTSD after the car accident in the client’s adolescence.
The recent deterioration of cognitive functioning and such issues as sleep disturbance and reduced appetite enhanced after the school reunion, which can be seen as the exposure to the traumatic experience. Mr. Jones reported that he had negative feelings after the reunion when he saw the survivors of the accident. These symptoms also suggest that the client has PSTD. It is necessary to note that one of the hobbies can seem unrelated to PTSD and the one that makes this diagnosis unsuitable. People with PTSD try to avoid any exposure or relation to cues or symbols related to the traumatic experience (American Psychiatric Association, 2013).
However, Mr. Jones loves fixing engines, but engines are a part of the motor vehicle and can be regarded as an embodiment of the threat related to or the major cause of car accidents. Nevertheless, the engine can be something other than a symbol of threat for Mr. Jones. For example, it can be a response to the accident and his desire to avoid any possible threats and risks for everyone, including himself.
It is also important to add that Mr. Jones is a devout Catholic who attends the church and is in close contact with his relatives and clergy people. It has been acknowledged that cultural peculiarities have a considerable impact on the development of the disorder and the occurrence and persistence of symptoms (American Psychiatric Association, 2013). The client’s religious beliefs could affect his behavior and the way he sees the situation.
The comorbidity of PTSD and major depressive disorder is common (Kostaras et al., 2017). Kostaras et al. (2017) note that PTSD, especially when it comes to prolonged PTSD, is a strong predictor of the development of depressive symptoms in patients. Mr. Jones experienced only symptoms related to Criteria A4, A5, A8, and Criterion B at the moment (American Psychiatric Association, 2013). However, the client reported that he had had a long history of depressive symptoms that started in his childhood. Therefore, it is possible to diagnose the major depressive disorder in the patient.
Differential Diagnosis
Acute stress disorder cannot be considered as a diagnosis as symptoms took place more than one month following the event. Personality disorders cannot be the diagnosis as well since interpersonal issues appeared after the exposure to trauma, which was noted by many people, including the patient’s wife and colleagues. Traumatic brain injury is differentiated from PTSD as in the latter case reexperiencing is common while the former is associated with confusion and disorientation.
Recommendations
Biological and Pharmacological Aspects
The primary concerns Mr. Jones wants to address (and that need to be managed) include his cognitive and interpersonal issues. The reoccurrence of depressive symptoms should also be minimized, and when the development of the depression is still problematic, the patient needs to be prepared to cope with the corresponding symptoms. In addition, the client’s neurovegetative symptoms should be treated. Clearly, the underlying cause of the problems mentioned above is PTSD, which needs to be addressed.
Based on the diagnoses and the specific symptoms mentioned above, it is possible to provide the following recommendations. The symptoms associated with the lack of concentration, sleep disturbances, and detachment are not severe, so it is possible to focus on the lifestyle of the client. Mr. Jones has an active lifestyle, but it is still important to discuss the most effective techniques contributing to high cognitive performance and the elimination of neurovegetative symptoms. The focus should be on the diet and the type of exercise chosen by the patient. There are chances that they are not age-appropriate or can be harmful in terms of cognitive and physical aspects. At this point, it is important to add that the patient can benefit from practicing yoga or similar types of physical activity to reduce pain.
Colvonen et al. (2017) state that biomarkers cannot be ignored as endocrine processes, genetics, brain structure, and brain activity predict the response to PTSD treatment. Based on the analysis of the cognitive capacity of the client, it is possible to note that a certain reduction of activity was noticed after the accident and has recently intensified. These changes can be related to biological aspects, as well as PTSD. By revisiting the client’s behaviors and diet, it is possible to detect possible areas for improvement. Some biomarkers can predict the potential efficacy of the chosen treatment.
However, if the analysis of these areas shows no visible concerns and potential factors contributing to the issues the patient is experiencing, it is necessary to consider the use of pharmacological treatment. Prior to prescribing medication, it is critical to consider the client’s previous prescriptions, especially related to his depression treatment. It is also necessary to know which drugs are used to treat pain. It can be effective to recommend several tests related to brain injury identification. Although no injury was detected immediately after the accident, certain changes could occur. Moreover, the medical error could take place, so additional tests can shed light on cognitive and neurovegetative symptoms. Based on these findings, it will be possible to prescribe the most effective medication.
Cognitive-Behavioral Therapy
Cognitive-behavioral therapy (CBT) is one of the most common strategies to address PTSD accompanied by depressive symptoms (Church et al., 2018). It is important to discuss both accidents with the client and the way he feels about them. Although he seems to have no negative emotions related to driving, his negative reactions and triggers related to the trauma may be related to other activities, emotions, or sensations. One of the most apparent responses to the accident that took place in Mr. Jones’s adolescence is his choice to wear a seatbelt when driving. More responses can be present, which is justified by the patient’s mood changes after the school reunion. Hence, it is important to pay attention to this area. It is important to identify possible triggers, which will help in creating effective strategies to mitigate their adverse impact.
In the case under study, CBT should be combined with clinical emotional freedom techniques (Church et al., 2018). This method implies the use of exposure elements and the stimulation of acupuncture points. Mr. Jones exhibits certain emotional distress that manifests itself in some alienation, so emotional aspects need to be addressed during sessions. During the sessions, the client will refer to the traumatic event by pronouncing a setup statement and will tap with his fingers on specific points (for example, eyebrows, the area under eyes, chin crease, or top of the head) (Church et al., 2018).
Church et al. (2018) claim that this approach has proved to lead to improved psychological state and biomarkers. Therefore, the client’s sleep disturbance and lack of appetite, as well as cognitive issues, may be addressed. The researchers add that depression, as a comorbid condition of PTSD, is also treated with the help of clinical emotional freedom techniques. In sum, a combination of CBT, clinical emotional techniques, and pharmacological treatment can be recommended.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association.
Church, D., Stapleton, P., Mollon, P., Feinstein, D., Boath, E., Mackay, D., & Sims, R. (2018). Guidelines for the treatment of PTSD using clinical EFT (Emotional Freedom Techniques). Healthcare, 6(4), 146-161. Web.
Colvonen, P. J., Glassman, L. H., Crocker, L. D., Buttner, M. M., Orff, H., Schiehser, D. M., Norman, S. B., & Afari, N. (2017). Pretreatment biomarkers predicting PTSD psychotherapy outcomes: A systematic review. Neuroscience & Biobehavioral Reviews, 75, 140-156. Web.
Kennedy, N. & Harper, Y. (2014). ABS 300 week five final paper adult male personal injury case study Mr. Jones. Web.
Kostaras, P., Bergiannaki, J. D., Psarros, C., Ploumbidis, D., & Papageorgiou, C. (2017). Posttraumatic stress disorder in outpatients with depression: Still a missed diagnosis. Journal of Trauma & Dissociation, 18(2), 233-247. Web.
Wang, Q., Shelton, R. C., & Dwivedi, Y. (2018). Interaction between early-life stress and FKBP5 gene variants in major depressive disorder and post-traumatic stress disorder: A systematic review and meta-analysis. Journal of Affective Disorders, 225, 422-428. Web.