Case of Jacob

Differential Diagnosis for Jacob

A differential diagnosis for Jacob will include Post Traumatic Stress Disorder, Obsessive Compulsive Disorder, and Delusional Disorder. Environmental and experiential factors will be considered, along with cultural influences. Research shows that African American males have a higher rate of traumatic incidences and up to 74% of those may have unmet mental health needs (Motley & Banks, 2018; Alim, et al., 2006). Jacob reports witnessing the shooting death of his uncle at the age of six. 

Since Jacob has not only been witness to the shooting death of his uncle but has also served in war zones for two tours of duty, trauma exposure is a huge factor in his diagnosis. While Jacob refutes being in direct combat situations, he is exposed to the gunfire and other sounds of combat and death. This is considered a peritraumatic factor for Post-Traumatic Stress Disorder (American Psychiatric Association, 2013). As research suggests a strong link between trauma and Post Traumatic Stress Disorder, such high exposure to traumatic experiences points strongly to this diagnosis (Motley & Banks, 2018). 

Being mindful of Jacob’s culture is also part of the differential diagnosis formulation.  Studies show that African Americans have a higher rate of Post-Traumatic Stress Disorder compared to other cultural groups. The prevalence of Post-Traumatic Stress Disorder in African American males is approximately 33% while the overall lifetime prevalence for Americans is 8.7% (Alim, et al., 2006; American Psychiatric Associaction, 2013). Jacob’s lack of social support and his socioeconomic status are also important to explore. Working with Jacob on his level of acculturation, past and present experience with discrimination and ethnic identity, will be explored. 

Obsessive Compulsive Disorder
        Post-Traumatic Stress Disorder is frequently comorbid with Obsessive Compulsive Disorder (Ray, 2018). Jacob reports checking his locks and his yard at least three times before he is able to leave. This suggests a compulsive behavior that may point to meeting criteria for Obsessive Compulsive Disorder (American Psychiatric Association, 2013). It is possible, however, that the hypervigilance is more likely due to Post Traumatic Stress Disorder as Jacob does not report obsessive thoughts other than flashbacks or nightmares. 

Delusional Disorder

African Americans are more likely to have nonschizophrenic psychosis as a comorbid diagnosis with Post Traumatic Stress Disorder (Schwartz, Bradley, Sexton, Sherry, & Ressler, 2005). Jacob’s report of people lurking in dark corners of his yard could meet diagnostic criteria for delusional disorder (American Psychiatric Associaction, 2013).  Given that Jacob’s delusions are of would be assailants, mirroring his trauma exposure, they would more likely fit the criteria of hypervigilance rather than delusional disorder (American Psychiatric Association, 2013).  

Provisional Diagnosis for Jacob

Post-Traumatic Stress Disorder 309.81 (F43.10) (American Psychiatric Association, 2013).

Diagnostic Criteria 

  1. Directly witnessing a traumatic event (shooting death of his uncle) and experiencing repeated exposure to aversive details of traumatic events (hearing sounds of combat and death).
  2. Recurrent memories of the traumatic event (thoughts of his uncle’s death), recurrent distressing dreams related to the traumatic event (nightmares of his uncle’s death) and dissociative reactions (flashbacks of his uncle’s death). Only recurrent memories are currently reported, flashbacks and nightmares reported to have stopped at some time in the recent past.
  3. Avoidance of distressing memories and thoughts of the traumatic event (compartmentalizing these in the past and wanting to move forward).
  4. Inability to remember important aspects of the traumatic event (not remembering his uncle’s death), persistent feeling of fear (not feeling safe), and feelings of detachment from others (not wanting a wife or children for fear of not being able to protect them).
  5. Hypervigilance and exaggerated startle response (checking door locks multiple times, checking for intruders).
  6. Duration of Criteria B-E is more than 1 month
  7. Disturbances are causing impairment in occupational functioning; will not be allowed on 3rd tour of duty.
  8. No report of medication or substance induced symptoms

Treatment

Cultural Considerations

Jacob is of African American descent; prejudice and discrimination are significant concerns within the African American community, even as they are underestimated by counselors (Walz & Bleuer, 2016). It is important to understand appropriate coping mechanisms in relations to the discrimination and prejudice experienced by the client rather than relying only on symptoms (Walz & Bleuer, 2016). This will be addressed with Jacob in the models of treatment discussed in a further section of this paper.

Legal and Ethical Issues
          Risk assessment and safety will be addressed at the onset of treatment. People with Post Traumatic Stress Disorder have an increased risk of suicide (American Psychiatric Association, 2013). Studies have found that persons with Post-Traumatic Stress Disorder have between 5.3 and 13 times the rate of death of those without this disorder, controlling for demographics and comorbidities (Gradus, 2017). For military personnel there is an 80 percent increase in suicide risk for people with Post-Traumatic Stress Disorder (Gradus, 2017).  While rate of suicide is lower for African American men, the risk of suicide is greater (Joe & Kaplan, 2001). Due to the Jacob’s status as both an African American male and an active member of the military, he will be referred to a psychiatrist for a complete medical and psychiatric evaluation to rule out suicidal ideation or other medical disorders. 

Polyvagal Model

Researchers have found that the vagal nerve system has a large role in our experience of threat and trauma. According to the polyvagal theory, our perceptions and cognitions are not always compatible with our threat response (Porges, 1995). When traumatic events happen and we lose our ability to fight or run away, we then trigger the dorsal vagal pathway that leads to the immobilization or freeze/faint reaction and this, according to polyvagal theory, is the root of trauma (Porges, 1995). Jacob’s inability to do anything to help his uncle and his inability to run from combat zones fits with this model of trauma.

In accordance with the polyvagal model, Jacob will be invited to move from immobilization to fight/flight. From here finding a sense of safety within the therapeutic alliance is necessary for Jacob to shift into the safe and social state (Dana, 2018). Somatic and embodied interventions, such as yoga, are indicated to facilitate these state shifts. Creating a safe and compassionate space during interventions is crucial to help Jacob regulate during his state shifts (Dana, 2018). 

The therapist will educate Jacob on polyvagal theory and the role that his neurobiology has on his Post-Traumatic Stress Disorder symptoms.  This may help Jacob understand why he feels unsafe even in safe situations (Porges, 1995). It is common for people with Post-Traumatic Stress Disorder, especially those who have experienced multiple and/or ongoing traumatic events to feel unsafe and be hypervigilant despite knowing, cognitively, they are in a safe space (American Psychiatric Associaction, 2013; Ray, 2018). Given potential misunderstanding associated with counselors and African Americans, this open, honest and empathic approach may facilitate a willingness to be compliant with treatment.

Facilitating state shifts will help Jacob become more adept and shifting from the safe and social state to the fight/flight state (Porges, 1995). This is necessary for Jacob as he will be returning to a 3rd tour of duty if his superiors allow. Learning to state shift depending on the situation requires that Jacob resolve his immobilization response—initiated in his first traumatic experience of witnessing his uncle’s death—in order to exist in either fight/flight or safe and social depending on his needs in the moment (Dana, 2018).  

Interpersonal Neurobiology Model
    Interpersonal Neurobiology characterizes disorders as a lack of neurobiological integration of differentiated parts of the brain (Siegel, Pocket Guide to Interpersonal Neurobiology: An Integrative Handbook of the Mind, 2012). Traumatic experience disrupts the brain’s ability to process incoming information and a key part of this disruption may be stress hormones that produce a deleterious effect on the functioning of the brain. Thus, trauma is seen as an impairment of the mind to integrate energy and information (Siegel, The Developing Mind and the Resolution of Trauma: Some Ideas about information processing and an interpersonal neurobiology of psychotherapy., 2002). 

    Early trauma such as the death of a loved one, like Jacob experienced, can lead to a perpetual state of dis-integration. Thanks to neuroplasticity, this adaptation has made it easier for Jacob to cope with other traumatic events, such as his combat experiences (Siegel, Pocket Guide to Interpersonal Neurobiology: An Integrative Handbook of the Mind, 2012). However, now that he is no longer in a traumatic situation, these adaptations have become maladaptive and Jacob is unable to integrate successfully into civilian life. Helping Jacob distinguish between the skills and integrations needed to process information in combat zones versus civilian life will be the focus of psychotherapy (Siegel, The Developing Mind and the Resolution of Trauma: Some Ideas about information processing and an interpersonal neurobiology of psychotherapy., 2002). This is especially important as Jacob’s goal is to enter into a 3rd tour of duty and will still need his combat zone adaptations. 

    Attachment and interactive regulation are important aspects of Interpersonal Neurobiology. The therapist will invite Jacob to engage in collaborative communication (Siegel, The Developing Mind and the Resolution of Trauma: Some Ideas about information processing and an interpersonal neurobiology of psychotherapy., 2002).  Therapeutic trust is also crucial given cultural implications in the African American community. It is important that Jacob feel safe while reexperiencing and communicating his trauma from childhood and from his military service (Siegel, Pocket Guide to Interpersonal Neurobiology: An Integrative Handbook of the Mind, 2012).  Normalization of his experiences and his symptoms as adaptive and protective can help build the therapeutic alliance and begin the process of integration. 

    Mindfulness interventions are also indicated in the resolution of trauma in order to reintegrate parts of the brain that may have dis-associated. (Siegel, The Developing Mind and the Resolution of Trauma: Some Ideas about information processing and an interpersonal neurobiology of psychotherapy., 2002). Helping Jacob be mindful while in the presence of a safe and trusted person to help him stay regulated throughout the psychotherapeutic process. 

References

American Psychiatric Association. (2013). Diagnositic and statistical manual of mental disorders (5 ed.).

Motley, R., & Banks, A. (2018). Black Males, Trauma, and Mental Health Service Use: A Systematic Review. Perspectives in Social Work (Houst), 4(1), 4–19.

Alim, T. N., Graves, E., Thomas, M. A., Aigbogun, N., Gray, E., Lawson, W., & Charney, D. S. (2006, October). Trauma exposure, posttraumatic stress disorder and depression in an African-American primary care population. Journal of the National Medical Association, 98(10), 1630-1636.

Schwartz, A. C., Bradley, R. L., Sexton, M., Sherry, A., & Ressler, K. J. (2005). Posttraumatic Stress Disorder Among African Americans in an Inner City Mental Health Clinic. PSYCHIATRIC SERVICES, 56(2), 212-215.

Ray, W. (2018). Abnormal psychology (2 ed.). SAGE.

Gradus, J. L. (2017). PTSD and Death from Suicide. PTSD Research Quarterly, 28(4), 1050-1835.

Joe, S., & Kaplan, M. S. (2001). Suicide Among African American Men. Suicide and Life-Threatening Behavior, 31, 106-121.

Walz, F. R., & Bleuer, J. C. (2016). The Invisible Client: Ramifications of Neglecting the Impact of Race and Culture in Professional Counseling. VISTAS, 38.

Porges, S. W. (1995). Orienting in a defensive world: Mammalian modifications of our evolutionary heritage. A Polyvagal Theory. Psychophysiology, 32, 301-318.

Dana, D. A. (2018). The Polyvagal Theory in Therapy: Engaging the Rhythm of Regulation. New York: W.W. Norton & Company.

Siegel, D. J. (2012). Pocket Guide to Interpersonal Neurobiology: An Integrative Handbook of the Mind. New York: W.W. Norton & Company.Siegel, D. J. (2002). The Developing Mind and the Resolution of Trauma: Some Ideas about information processing and an interpersonal neurobiology of psychotherapy. In F. Shapiro, EMDR as an Integrative Psychotherapy Approach: Experts of Diverse Orientations Explore the Paradigm Prism (p. 357). APA Press.

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