Avondale University NURS20026 Case Study: PTSD Diagnosis and Care

This case study focuses on a 36-year-old male, Tom, presenting with symptoms of complex Post Traumatic Stress Disorder (PTSD) and erratic behavior. The assignment delves into diagnosing Tom based on DSM-5 criteria, specifically addressing the complexities of PTSD related to childhood neglect. It analyzes his legal status under the NSW Mental Health Act (2007), highlighting his mentally disordered status due to suicidal ideation. The essay explores the risks associated with his behavior, including hypomania and potential self-harm. It proposes a comprehensive treatment plan involving pharmacological interventions such as SSRIs and antidepressants, alongside non-pharmacological approaches like mindfulness-based stress reduction (MBSR) and psychotherapy. The importance of a multidisciplinary team, including nurses, psychiatrists, and counselors, is emphasized for effective care. The assignment also details a discharge plan, focusing on symptom monitoring, medication adherence, and community-based support, including referrals to social services. The overall goal is to ensure Tom's recovery and prevent rehospitalization, considering his spiritual and cultural needs.

Running head: MENTAL HEALTH
Mental health
Name of the Student
Name of the university
Author’s note

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Introduction:
The case study is about Tom, a 36 years old man who presented to the NSW mental
health service with symptoms of complex Post Traumatic Stress Disorder (PTSD). The current
risk that has been found is that police found Tom laughing hysterically and trying to jump from
the balcony. The main purpose of this essay is to confirm a mental health diagnosis for Tom
based on current symptoms and identify legal status of the client according to the NSW Mental
Health Act (2007). The essay will discuss about the risk associated with the behaviour, key
treatment and discharge plan for recovery of the client.
DSM-5 OR ICD-10 for PTSD symptoms for Tom
To make appropriate diagnosis of Tom according to his presenting symptoms, it is
necessary to compare his symptoms to those of the DSM-V criteria or ICD-10 for PTSD. His
symptoms have been defined as complex PTSD. The key difference between complex PTSD and
PTSD is that PTSD is mostly related to a single event, however complex PTSD is related to one
prolonged event or series of events. The traumatic episode may range from car accident to death
of loved one or sexual assault (Hyland et al., 2017). According to DSM-V criterion, there is no
separate criterion for diagnosing PTSD or complex PTSD. However, to be diagnosed with
PTSD according to the DSM-V, there is a need to meet criterion A (exposure to one of more
event), one or more symptoms from criterion B (strong and persistence distress, flashbacks,
strong bodily reaction, one symptoms from criterion C (avoidance of thoughts and people), three
symptoms from criterion D (negative evaluation of the world, negative emotional state, feeling
detached and loss of interest), three symptoms from criterion E (aggressive behaviour, poor
concentration and self-destructive behaviour) and criterion F to H. Criteria F is that all symptoms
must be present for more than one month , criterion G defines interference with daily life

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activities because of the symptoms and criterion H means occurrence of symptoms not due to
medical condition (Leonard, 2018).
In the context of Tom, one major trauma that has resulted in complex PTSD includes
experiencing childhood neglect in early life (Smith, Dalgleish & Meiser‐Stedman, 2019). This is
evidenced by Tom’s view on his life with PTSD where he reported that in his childhood, he had
to go through his father’s mania and he was not raised in normal manner unlike other children
(BBC Ideas, 2019). In addition, he had symptoms of harmful and aggressive behaviour, negative
evaluation, negative evaluation, distress and avoiding social situations. Presence of these
symptoms is relevant with the criterion defined above. Hence, Tom is diagnosed with PTSD
according to the DSM V criteria. The significance of diagnosing PTSD according to the DSM-V
criteria is that it rules out possibility of misdiagnosis and confusing the symptoms with that of
major depressive disorder.
NSW Mental Health Act:
The legal status of the client based on his behaviour can be ascertained according to the
NSW Mental Health Act (2007). The NSW Mental Health Act categorises individual into
voluntary and mentally disorder category based on different category. The significance of this
Act is that based on classifying the person into mentally ill or mentally disordered individual, it
is decided whether they can be given treatment or care against their will or not. A person can be
defined as mentally ill if they have a mental illness and it requires treatment and care to protect
the person from serious harm. One special requirement is that there must be reasonable grounds
for the person to receive immediate treatment. In addition, a mentally disordered person under
the act involves a person whose behaviour is so irrational that there are reasonable grounds for
providing them involuntary care. The main rational for this is the need to protect the patient from

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severe harm. In contrast, a mental health consumer is one who has mental disorder and the
person is receiving treatment either voluntarily or involuntarily (NSW Government, 2018).
Based on Tom’s case study, it has been found that due to PTSD symptoms, he is behaving
irrationally and trying to make harm to himself by trying to jump from the balcony. Hence, his
situation matches with mentally disordered status according to the NSW Mental Health Act
(2007) criteria for mental status. This is said because Tom’s behaviour is likely to increase risk
of suicide in the future. Hence, unless he is given proper treatment against his will, his
aggressive and irrational behaviour cannot improve.
Risk to PTSD patients and strategies to manage on the ward challenges:
Some of the risky behaviours of Tom include his erratic behaviour like hypomanic state
and his intention to jump from the balcony and negative evaluation of the worlds. Stevens et al.
(2013) supports PTSD as a vulnerability marker that increases the likelihood of maladaptive
response to traumatic event. PTSD is associated with symptoms of intrusive memories,
irritability and poor impulse control. Hence, due to the effect of these symptoms, suicide risk can
be higher too.
To manage patient in the ward, it will be necessary to identify the number of symptoms
that Tom is experiencing. This may include re-experiencing, avoidance, persistent negative
alterations and alterations in arousal and activity. Similar symptoms were seen in Tom too. To
manage this behaviour, it is necessary to constantly monitor Tom and never live him alone. This
is important because isolation can further increase the risk of harm. In addition, screening of
suicide risk with the use of suicide risk assessment tools is necessary to identify severity of
suicide risk (Suarez et al., 2015). In addition, use of restraint and monitoring may be required for
a temporary period until treatment is started (Chieze et al., 2019).

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Treatment plan:
To promote recovery of Tom and address hypomanic state, it is necessary to plan care
using recovery focussed approach. Recovery focussed care involves implementing a process of
change where individuals get the opportunity to improve their health and reach their full
potential. Hence, to ensure that Tom reaches his full potential, both pharmacological and non-
pharmacological interventions are necessary. The significance of pharmacological intervention is
that it will help in reducing key symptoms of PTSD such as hyper-arousal and neglect.
Medication like anti-depressants and selective serotonin re-uptake inhibitors (SSRIs) like
sertraline, paroxetine and fluoxetine can be provided to patient to reduce symptom severity and
prevent relapse of symptoms. The key advantage of using SSRIs is that it is safe and well-
tolerated by patients (Steckler & Risbrough, 2012). Ipser and Stein (2012) explain SSRIs as the
most first line of medication for PTSD associated with resolution of symptoms. In addition,
second line treatment with anti-depressants and anticonvulsants can be done to address other co-
morbidities. Antipsychotic may also be used as adjunctive drug to treat symptoms of PTSD for
Tom (Steckler & Risbrough, 2012).
Pharmacological therapy can be followed with non-pharmacological interventions such
as mindfulness based treatments or psychotherapy to increase coping mechanism and help Tom
achieve sense of control. Boyd, Lanius & McKinnon (2018) reports prolonged exposure therapy
and cognitive therapy as effective treatment options as it specifically addresses symptom of
avoidance which is most common in PTSD patients. However, as evidence has been found for
experience of residual symptoms after the therapy, considering the need for adjunctive treatment
such as mindfulness based stress reduction (MBSR) is important. The key feature of this
treatment is that it encourage acceptance of thoughts and emotions as they occur in the present

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moment. Present-centred therapies compared to trauma-focused therapy are more effective for
PTSD patients (Zadeh, Yousefi & Farsani, 2016). In context of Tom too, implementing present-
centred therapy is most important compared to trauma-focused therapy because his trauma was a
life-long experience and it cannot be resolved now. However, controlling his present symptom is
most important. Therefore, mindfulness can help to unfold experience moment by moment and
address symptoms of negative avoidance, self-blame and guild. MBSR can cover activities like
mindfulness meditation, yoga, discussion about coping and daily activities to prevent relapse
(Azad & Hashemi, 2014).
Multi-disciplinary team in hospitals:
To ensure the above care plan is effectively implemented for TOM, the involvement of
multi-disciplinary team such as mental health counsellors, mental health nurse, psychiatrist,
physicians, dieticians and social care staff is necessary. Mental health nurse and physician and
physiatrist can plan and implement pharmacological treatment, whereas mental health
counsellors and social care staffs can help to implement MBSR therapy for client. Wallace and
Cooper (2015) supports inclusion of psychiatrist, social workers, nurses and counsellors as
important for multidisciplinary assessment. Mental health nurse can play a role in assessment of
Tom, taking care of his daily care needs, hygiene needs and managing his aggressive behaviour
throughout hospital stay. In addition, once his impulsive behaviour is resolved, the social case
staffs can guide Tom to take part in formal and informal groups, increase contact with families
and get support in preparing for job applications. The role of the mental health counsellor will be
crucial in providing behavioural intervention to Tom and helping client finally get control over
anxiety and pain through relaxation techniques. Effective collaboration and coordination with
member of the team is crucial for effective care and recovery of Tom.

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Discharge plan:
The above multi-disciplinary team can collaborate with each other to evaluate response to
treatment, identify improvement in symptoms and assess patient to ensure that Tom is ready for
discharge. To decide that Tom is ready for discharge, it will be necessary to monitor symptoms
of Tom regularly and ensure that all symptoms such as negative evaluation, hyper-arousal,
isolation and escaping are eliminated. No interference with daily life activities and optimal
functioning of client will make Tom ready for discharge. This is supported by research evidence
too as Lancaster et al. (2016) gives the evidence regarding the successful resolution of
hyperarousal behaviour to identify that patient is ready for discharge. The discharge plan can
give special instruction to Tom regarding the medications to be continued at home, the need to
visit counsellors as per sessions planned and getting in touch with social workers to increase
social contact and full functioning in life. The patient should be given instructions regarding self-
care and when to contact physicians to decrease chances of rehospitalisation. PTSD is a chronic
disorder and regular contact with health care team post discharge is critical for long-term
resolution of symptoms.
RN referral:
According to the NMBA code of conduct for nurse, it is necessary for nurse to engage in
effective communication and provide access to information necessary for continuity of care
(Nursing and Midwifery Board of Australia, 2018). The nurse can provide appropriate referral to
Tom to ensure that he receives adequate support to manage his symptoms and behaviour post
discharge. He can be referred to community based services and social support groups to manage
any recurrence of symptom and adhere with positive coping techniques. The main goal for
referral is to promote help-seeking behaviour in patient. In addition, RN can refer Tom to social

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support services in the community that can help him to interact with social groups and engage in
meaningful activities. Nurses also have the responsibility to follow-ups on referrals to ensure that
patient is kept involved in his recovery process. The above referral is like to improve outcomes
for Tom and reduce the need for hospital admission because of remission of previous symptoms.
Taking care to address spiritual and cultural needs during follow-up is critical too for complete
recovery (Bolduc et al., 2015).
Conclusion:
It can be concluded that symptoms of arousal, negative evaluation and avoidance are
some specific clinical presentations of PTSD that can increase behavioural risks and further harm
for Tom. In response to the issue of aggressive behaviour and suicide risk for Tom, interventions
like use of SSRI along with antidepressants has been identified as pharmacological treatment
option for the client. In addition, mindfulness based intervention has been identified as crucial
for recovery of Tom. The study gives the evidence that involvement of multi-disciplinary team is
important to provide effective and recovery focused care.

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References:
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BBC Ideas (2019). Living with complex PTSD: Comedian Tom Ward’s story | BBC Ideas.
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Leonard, J. (2018, August 28). Complex PTSD: Symptoms, behaviors, and recovery. Retrieved
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