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Running Head: VIGNETTE ONE 1 Vignette One: Steven Deborah J Vinall, MA California Southern University PSY 87506 September 22, 2016 Lori Aleknavicius, PsyD

Vignette One: Steven Steven exhibits symptoms of anxiety suggestive of Post-Traumatic Stress Disorder (PTSD), Generalized Anxiety Disorder, Panic Disorder, and / or Obsessive Compulsive Disorder (OCD). These disorders all share symptoms of anxiety, although they span three distinct diagnostic categories in the current Diagnostic and Statistical Manual (DSM) (American Psychiatric Association, 2013; Barnhill, 2014). We will examine the symptoms of each differential diagnosis toward formulation of an overall diagnostic impression. Steven’s background of growing up socialized to constant violence in an inner-city neighborhood, ostensibly lacking the protective factors of secure attachment due to the interference of both parents’ alcoholism, and experiencing constant fear as a self-described “scared little boy” who frequently observed domestic violence between his parents sets the backdrop of Post-Traumatic Stress Disorder of a complex type (Courtois & Ford, 2013). Either of these factors individually would be sufficient to qualify him for the first criteria of PTSD, “witnessing, in person, the event(s) as it occurred to others”. (American Psychiatric Association, 2013, p. 271). The current diagnostic criteria differ from the former in DSM-IV-TR in that we do not need to know his immediate reaction to the trauma, information not available to us in this vignette (Barnhill, 2014). Steven also exhibits intrusion symptoms as evidenced by recurrent, involuntary, distressing memories when he closes his eyes and can see his parents engaged in violence towards one another, as well as through his nightmares suggested by frequent waking with clenched fists and a felt sense of being at an earlier developmental stage with fearful emotions.

diagnostic interview might uncover difficulties with concentration, hypervigilance, or an exaggerated startle response (American Psychiatric Association, 2013). The disturbance appears to be longer than a month in duration, linked as it is to events from over a decade past. The disturbance does cause clinically significant distress, and does not appear to be associated with physiological effects of a substance, although a substance use assessment would be an important part of the diagnostic interview process. In these ways, Steven appears to meet criteria F, G, and H for the diagnosis (American Psychiatric Association, 2013). Based upon the symptoms presented, Steven might be given a provisional diagnosis of PTSD pending completion of the diagnostic interview. The specifier “with dissociative symptoms” might apply if the dizziness reported is related to feelings of detachment from reality and represent depersonalization, but more exploration of this sensation would be necessary to make such a diagnostic specification. “With delayed expression” might also apply as a specifier, and the diagnostic interview would illuminate this by determining whether the symptoms date back to the time or within six months of the time that he was immersed in the trauma (American Psychiatric Association, 2013). The dizziness Steven reports could, alternatively, be related to Panic Disorder. Steven exhibits two of the minimum four required symptoms of a panic episode; specifically his dizziness and difficulty breathing reported while at the mall with his wife. However, these symptoms appear to have occurred at disparate times and locations and without further information, do not appear to be accompanied by numerically sufficient symptoms to meet the threshold of panic (American Psychiatric Association, 2013). It would be important to refer Steven to his primary care physician to rule out possible physiological causes of these symptoms.

Steven also reports that his worry is chronic and spans multiple events or activities, such as fear of career failure and fear of failing his family. However, these are closely related fears that may actually be different facets of only one specific worry. His sleep disturbance, chronic worry, and any concentration impairment resulting from his ruminative thoughts could point toward a diagnosis of Generalized Anxiety Disorder, however, we are not presented with sufficient symptoms to make this diagnosis (American Psychiatric Association, 2013). Steven’s ruminative thoughts and difficulty leaving the house without making sure the door is locked, as well as his avoidance of odd-numbered streets are suggestive of Obsessive- Compulsive Disorder (American Psychiatric Association, 2013). His chronic worry is sharply contrasted with the realities of his life, in that he worries he will be unable to provide for his family despite his financial success, and so could be classified as obsessive thoughts. He also performs compulsive behaviors, specifically lock-checking and driving route alterations. In order to meet criteria for this diagnosis, there must be a link between the obsessive thoughts and compulsive behaviors (American Psychiatric Association, 2013). For example, perhaps Steven checks the locks compulsively due to a fear that someone might break in and steal what he has acquired to care for his family, and the behavior is done to alleviate this anxiety. Steven might focus on symmetry to avoid these intrusive thoughts, avoiding odd-numbered streets to suppress them and relieve his anxiety. These patterns must be time consuming or cause him social, occupational, or another form of distress, which with these examples would be foreseeable (American Psychiatric Association, 2013). He does not appear to be influenced by any substances, nor do these symptoms appear to be better attributable to another mental disorder. OCD and PTSD can be comorbid, with PTSD generally having an earlier onset. Both disorders

matrix (Comer, 2015). As a bi-racial Hispanic and African-American male raised in the gang- saturated culture of East Los Angeles, Steven faced specific pressures and potentially competing values that contributed to the formation of his personality and behavior. We can assume, based upon the location of his home, that his family was economically disadvantaged, and that he also attended under-funded schools. We know that people of low socio-economic status have a higher risk factor for a variety of mental illnesses, with the PTSD occurring four percent more frequently (Comer, 2015). Additionally, minorities, subject to frequent racial discrimination and prejudice, experience serious psychological disturbance at higher rates, with African Americans experiencing mental health problems 0.9% more often and Hispanic Americans experiencing mental health problems 0.5% more often than Caucasian Americans (Comer, 2015). Due to the higher attrition rate in therapy of minority clients and the identified role of culture in creating the psychological difficulties, the multicultural model advocates for culture- sensitive therapies (Comer, 2015). This includes cultural sensitivity training for therapists, and increasing therapists’ awareness of culturally based values and mores as well as of the stresses, hardships, and prejudices faced by minority clients and the children of immigrants. Therapists help clients become aware of the impact of both their own culture and the dominant culture on their behavior and understanding of self, help them to become aware of and express suppressed pain and anger, help client to achieve a bicultural balance that feels congruent to them, and help clients raise their self-esteem which is assumed to have been damaged by years of cultural oppression (Comer, 2015). In Steven’s treatment, the prepared, culturally sensitive and aware therapist might engage Steven in examination and processing of his experience as a biracial man, how the conflicts between the two minority groups influenced his self-esteem, sense of affiliation, and self-concept, as well as his sense of safety due to the racial wars between gangs of

different ethnicities. The therapist might go a generation further in exploring with Steven his perception of the impact of these tensions on his parents and the possible role in their frequent violent conflicts. Moving forward, the therapist could support Steven in exploring what it means to him to find a grounded sense of affiliation with his minority background and his place in the dominant culture in the Caucasian-dominated world of architecture and upper-middle class suburban or urban life, while validating his strengths and guiding Steven to gain a greater appreciation and respect for himself as a complex whole. These divergent approaches could be complementary in Steven’s treatment. For example, the psychodynamic emphases on cathartic release and working through are congruent with the multicultural therapy goals of increasing awareness and releasing repressed pain and anger. Psychodynamic approaches have traditionally failed where they have overlooked cultural factors, making multicultural therapy an essential adjunct. At the same time, while the multicultural model brings a key element to treatment, it is not able to sufficiently account for discrepancies in diagnostic rates and thus cannot be a comprehensive explanatory model, thus needing a relationship with another model, such as the tenants of psychodynamic therapy (Comer, 2015). When a child has experienced trauma, there is a higher likelihood that the legal mandates for child abuse reporting may come into play. From what we know, Steven does not report having been the direct victim of child abuse, although exposure to domestic violence would constitute a discretionary report in most states. However, unless one of Steven’s younger brothers is yet a minor and the unsafe home environment ongoing, it is unlikely that there is a justification for breaching confidentiality. As such, maintaining confidentiality and providing informed consent are the major legal and ethical considerations in this vignette (American Psychological Association, 2010).

References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th^ ed.). Arlington, VA: American Psychiatric Association. American Psychological Association (2010). Ethical principles of psychologists and code of conduct. Washington, DC: American Psychological Association. Retrieved from: https://www.apa.org/ethics/code/principles.pdf Barnhill, J. W. (2014). DSM-5 clinical cases. Arlington, VA: American Psychiatric Association. Comer, R. J. (2015). Abnormal psychology. (9th^ ed.). New York, NY: Worth Publishers. Courtois, C.A. & Ford, J.D. (2013). Treatment of complex trauma: A sequenced, relationship- based approach. New York, NY: The Guilford Press.