Introduction
After completing his third tour of service in the army, Roberto has come home to his spouse Lora, a 29-year-old White lady of Swedish and Irish ancestry, and their 6-year-old son Michael. Roberto, a 30-year-old Mexican American, spent his past two deployments in Afghanistan. Up until now, Roberto has been a sociable, friendly, and empathetic man, a devoted spouse who routinely used the Internet from his tours abroad. He also enjoyed hosting salsa soirees for friends and other relatives at his home. When Roberto hears abrupt noises, such as Michael dumping a metallic toy on the floor, a helicopter flying in the sky, or a car or motorbike driving noisily by their house, he becomes startled. When he is eventually able to fall asleep, he experiences nightmares (which he describes as “night sweats”) many times a week.
Roberto, however, declines to talk about what he saw in Afghanistan, claiming that these are only dreams and that nobody can understand him. He avoids discussion with his close and extended relatives and friends by spending too much time watching television and old films, as well as putting off going to bed. He used to enjoy playing the guitar, but it has been six months since he last picked it up.
Differential Diagnoses
Hence, there are several crucial systemic considerations allowing to determine the number of appropriate diagnoses. Roberto has a visible mental trauma – that he got during the military tour in Afghanistan – that he avoids revealing and discussing with his family and friends. This is visible from his remoteness from society – particularly, Roberto is sure that nobody will understand and be able to help in his struggle. Then, the mentioned trauma follows Roberto in his dreams and his daily routine, hindering the way of his normal life. This is expressed in his reactions to various sounds – starting from one of the fallen toys and ending with one of the passing cars.
Moreover, Roberto’s personality changes can also be considered important concerns in the framework of the case. His relatives and friends note that prior to the tour, Roberto was a gregarious and warm person. For now, he demonstrates a great extent of anxiety and does not show any interest in the things and aspects of life that he used to enjoy. Particularly, it is said that Roberto has not played the guitar for six months. The final point in this vein is that he delays his dreams by watching TV late at night, which, again, indicates Roberto’s non-desire to fall asleep; he fears what he will see there.
Given the explored considerations, Roberto can have one of the following diagnoses. The emergence of recognizable symptoms after an encounter with one or more traumatic experiences is the key component of posttraumatic stress disorder (PTSD). PTSD can manifest clinically in several ways. Some people may have a predominance of psychological, behavioral, and fear-based re-experience symptoms (American Psychiatric Association, 2013). Others may find that morbidly depressed or dysphoric mood states and unpleasant thoughts are the most upsetting.
However, it seems reasonable to notice that symptoms of PTSD may arise when a traumatic brain injury (TBI) takes place in the setting of a stressful experience. An incident that results in brain trauma may also be seen as a psychologically traumatic experience, and neuropsychological symptoms associated with TBI may also appear simultaneously (American Psychiatric Association, 2013). People with PTSD, as well as people without brain injuries, might have symptoms once referred to as postconcussive. Treatment options between PTSD and cognitive disorder symptoms attributed to TBI may be achievable depending on the existence of symptoms that are specific to each manifestation since the symptoms of PTSD and TBI-related neuropsychological issues might overlap.
Recurrent intrusive ideas are common in obsessive-compulsive disorder (OCD), but these fit the criteria for an obsession. Furthermore, impulses are frequently present, and other signs of PTSD or acute stress disorder are normally missing (American Psychiatric Association, 2013). The obsessive thoughts are also not connected to a traumatic experience that has been experienced. Both the aversion, anger, and anxiety of severe anxiety and the excitation and dissociation episodes of panic disorder are not connected to a particularly traumatic incident.
In order to define a precise diagnosis for Roberto, it is essential to appeal to a number of significant assessment tools that are likely to alleviate the process. It should be noted that the described considerations allow assuming that Roberto is likely to have PTSD. Hence, the related evaluation instruments are to be used here. For instance, Blevins et al. (2015) provide the posttraumatic stress disorder checklist for DSM-5. Then, Murphy et al. (2017) show optimum cut-off scores to screen for probable PTSD. Such tools give the opportunity to utilize the list of specific questions and procedures that reveal the real degree of probability for PTSD. They should be utilized during the initial meeting with Roberto as a client.
DSM-5 Diagnosis
Socio-psychological adaptation in peacetime of participants in hostilities (local armed conflicts, counter-terrorist operations) remains an extremely urgent problem today. The factors of the combat situation caused the development of adverse mental consequences in 25% of those who fought and were not injured during the war in Afghanistan. Among those involved, the number of those suffering from posttraumatic stress disorder reaches 40% (Turgoose et al., 2018).
Roberto is likely to be affected by delayed reactions that occur after a strong traumatic event when the situation has already ended, but psychologically the person continues to experience it. There are complexes of changes in the emotional and mental sphere in behavior. The reaction to anthropogenic (social) catastrophes, terrorist acts, and military operations is more intense and prolonged. The higher the degree of threat to life or health, the greater the likelihood of posttraumatic stress disorder. In addition, there is a proportional relationship between the occurrence of mental and psychosomatic disorders and the number (multiplicity) of trips to the zones of armed conflicts.
The dynamics of experiencing a traumatic situation seem to include the following stages. The initial phase is denial or shock (immediately after the action of a traumatic factor, a person cannot accept what happened on an emotional level). The second phase is aggression and guilt; a person tries to blame those who directly or indirectly had a relationship with the event for what happened and then turns aggression on himself and experiences an intense feeling of guilt.
The third phase is depression; it is the realization that circumstances are stronger than him, accompanied by feelings of helplessness and loss of purpose. At this stage, the unobtrusive support of the closest ones is crucial. However, an individual experiencing trauma gets this support rarely, given that people do not want to “infect” the person’s state. Interest in communication is steadily lost, and the feeling of loneliness increases. The fourth stage is the healing phase – conscious and emotional acceptance of one’s past and finding new meaning in life. A person is able to extract useful life experiences from what happened.
This sequence is a constructive development of the situation that may be inherent to Roberto’s experiences. If the victim does not go through these phases of experiencing a traumatic situation, or the stages are too long and do not come to a logical conclusion, then symptom complexes appear, which he can no longer cope with on their own. In such a case, PTSD develops, and among differential diagnoses, this option seems the most relevant.
PTSD is a delayed or prolonged response to a stressful event (brief or prolonged) of an exceptionally threatening or catastrophic nature that can cause general distress in a person (ICD-10: F43.1). Symptoms include repetitive and vivid intrusive memories of a traumatic situation, etc., and flashback effects. Moreover, the stress experienced by a soldier will be stronger than that which they felt at the time of the traumatic event (usually it is intense and causes thoughts of suicide in order to stop the attack). The symptom complex also includes: difficulty falling asleep and nightmares, emotional instability, emptiness, explosive reaction, fits of rage, unmotivated vigilance, and expectation of a threat, addictive behavior. These states have certain dynamics and are often complicated by somatic disorders and diseases.
Diagnostic criteria for PTSD in accordance with DSM-5 can be presented as follows. Criterion A – the presence of a traumatic event (participant, witness to the event; experienced helplessness, fear, or horror). Criteria B: Constantly experiencing the traumatic incident as evidenced by at least one of the following: intrusive memories, recurrent migraines, nightmares about the incident, or symptoms of dissociation states. These include sensations of the past “reviving” itself through delusions, hallucinations, and flashbacks. A chronic avoidance drive that was unnoticed prior to the injury is criterion C. A continuous sign of elevated psychophysiological sensitivity is criterion D. Criteria E: The condition has existed for more than one month. Criterion F: Severe emotional instability or a significant decline in essential aspects of one’s social, professional, or personal life (American Psychiatric Association, 2013). The presented criteria are inherent to Roberto’s case; hence, his diagnosis is PTSD.
Treatment
Various authors emphasize that there is no universal therapeutic method for the treatment of PTSD. Recovery from PTSD is, first of all, complex, which proves that the selected interventions should not be carried out one-sidedly but affect different aspects of the client’s life. In the process of psychotherapy, it is necessary to compare the components of treatment and methods to best address the specific symptoms of PTSD present in a person.
Cognitive behavioral therapy (CBT) helps in replacing distorted or distressing thoughts with more accurate and positive beliefs. Two methods of cognitive behavioral therapy are often used for psychotherapy: exposure therapy and cognitive process therapy (Hoffart et al., 2018). Exposure therapy involves desensitization (desensitization) to psychic trauma by repeatedly reciting traumatic memories. This method also uses relaxation techniques and breathing exercises (Pearce et al., 2018). Cognitive Process Therapy reduces the power of fearful memories by activating the fearful memory while providing new information that is inconsistent with the beliefs associated with the memory. Cognitive process therapy involves psychological education about the symptoms of PTSD; helps to develop an awareness of thoughts and feelings; promotes the adoption of new, more positive beliefs; encourages the practice of new skills that lead to actionable insights.
Then, a number of researchers agree that trauma-focused individual therapy is more effective than group therapy. Gianluca et al. (2018), based on their observations, say that subjects with posttraumatic stress disorder that began in childhood almost certainly needed a more individualized approach to treatment. As an argument, it is claimed that different types of trauma cause differences in the severity and complexity of the symptoms experienced and thus lead us to the conclusion that therapy requires an individual approach to each individual case.
Further, researchers believe that a combination of methods and forms of therapy may be effective in reducing the symptoms of PTSD. Intensive treatment included exposure-based treatment (long-term exposure), acceptance and responsibility therapy, and functional analytic therapy (Turgoose et al., 2018). Yoga, art therapy, individual therapy, group therapy, psychoeducation, and physical education can be applied. Thus, the data obtained support the idea that interventions should be complex, combining different types and methods of psychotherapy, which increases the chance of therapy success.
In the end, it should be noted that a soldier cannot return to their former self, to things that they previously considered important, to their former perception of the world under no circumstances, and if they try, they will not succeed. In this case, they undergo a transformation; social support and emotional connection from family members and friends play an important role here (Contractor et al., 2022). The military family also needs to create a new type of relationship and understanding. If they can get through this, then such families become stronger and stronger than they once were.
Conclusion
To conclude, Roberto’s case was analyzed through the prism of DSM-5 essentials and evidence-based research. It was found that his diagnosis is PTSD, which is supported by the related disorder criteria. The suggested treatment includes cognitive behavioral therapy, trauma-focused individual therapy, and a combination of methods such as yoga, psychoeducation, etc. It is also important for Robert to get social support from his family and friends.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing.
Blevins, C. A., Weathers, F. W., Davis, M. T., Witte, T. K., & Domino, J. L. (2015). The posttraumatic stress disorder checklist for DSM-5 (PCL-5): Development and initial psychometric evaluation. Journal of Traumatic Stress, 28(6), 489–498.
Contractor, A. A., Weiss, N. H., Forkus, S. R., & Keegan, F. (2022). Positive internal experiences in PTSD interventions: A critical review. Trauma, Violence, & Abuse, 23(1), 101–116.
Gianluca L., Giuseppe M., Laura S., Veronica O., Carla D., Gabriele P., & Salvatore G. (2018). The Italian version of the inventory of interpersonal problems (IIP-32): Psychometric properties and factor structure in clinical and non-clinical groups. Frontiers in psychology, 9(341), 1–12.
Hoffart, A., Johnson, S. U., Nordahl, H. M., & Wells, A. (2018). Mechanisms of change in metacognitive and cognitive behavioral therapy for treatment-resistant anxiety: The role of metacognitive beliefs and coping strategies. Journal of Experimental Psychopathology. Web.
Murphy, D., Ross, J., Ashwick, R., Armour, C., & Busuttil, W. (2017). Exploring optimum cut-off scores to screen for probable posttraumatic stress disorder within a sample of UK treatment-seeking veterans. European Journal of Psychotraumatology, 8(1), 1–9.
Pearce, M., Haynes, K., Rivera, N. R., & Koenig, H. G. (2018). Spiritually integrated cognitive processing therapy: A new treatment for post-traumatic stress disorder that targets moral injury. Global Advances in Health and Medicine. Web.
Turgoose, D., Ashwick, R., & Murphy, D. (2018). Systematic review of lessons learned from delivering tele-therapy to veterans with post-traumatic stress disorder. Journal of Telemedicine and Telecare, 24(9), 575–585.