This paper will introduce the case study of Kyle and his presenting issues. I will provide any contextual considerations that need to be taken into account with Kyle. A diagnosis will be provided along with a justification for the diagnosis. I will provide a theoretical orientation, and I will discuss how this orientation explains the presenting issues of the client. Finally, I will provide and discuss a treatment plan created for Kyle. Kyle is a married 40-year-old male. He is Caucasian and a reserve in the U.S. Marines. Kyle has been sent twice to Iraq by the U.S. Marines and during his second leave he experienced a traumatic event. He was in the market place with fellow soldiers when a bomb exploded and killed several people including one of his fellow soldiers. Kyle was not injured but did help those who were seriously injured.
Kyle has been home for 10 months and is abnormally withdrawn along with instantly becoming irritated when asked about his leave. He will not speak to his family or friends about the event. Kyle’s wife reports he constantly has nightmares where he yells out or weeps when he is asleep. She also has observed he appears incapable of sitting still to watch a movie.
Last month Kyle was frequently staying up all night, pacing the floor a lot and was obsessed with keeping his family and home safe due to robberies that occurred in his neighborhood at night.
Kyle feels disconnected from his family and is aware that his behavior is impacting his marriage, but Kyle is under the assumption that "there is nothing he can do about it." Kyle's current primary care physician is presently treating him for Gastro esophageal with Tagamet and dietary change.
Client Concerns: Constant nightmares in which he yells out or weeps
Client Concerns: Abnormally withdrawn, irritated and feels disconnected from family and friends.
Clinical Concerns: False beliefs about his behavior stating "there is nothing he can do about it."
Clinical Concerns: Kyle was exposed to a traumatic event during his second leave in the U.S, Marines.
Granted that Kyle’s wife was a contributing factor to him coming to therapy it would seem she might be a patronage source in Kyle’s treatment.
Kyle’s military background provides him awareness of the impact his behavior is having on his family, it appears Kyle could have that ability for insight, capability to maintain and motive for change.
Axis I: 309.81 post traumatic stress disorder
Axis II: V71.09 no diagnosis
Axis III: ICD-10-CM- 530.81 (K21.9) - Gastro esophageal reflux disease.
Axis IV: problems with primary support group- disruption of family by separation Kyle has been deported twice.
Problems with primary support group- death or loss of a friend and adjustment to life-cycle transition.
Other psychosocial and environmental problems- exposure to war.
Axis V: GAF= 51
1. PTSD: Exposure to war resulting in constant nightmares and faulty cogitates about his behavior.
2. Problems with primary support group: client is feeling unusually withdrawn, irritated a lot and feels disconnected from family and friends.
Kyle is experiencing constant nightmares and unusually withdrawn may be rooted in unconscious beliefs, emotions and cogitated.
As a result, beliefs about behavior may have been damaged, early damaged may have led to "stuck points," problematical cogitates, closeness, value.
Because of the long-standing and deep-rooted nature of the damage that appears to have impacted most areas of the individual’s life, awareness and understanding of PTSD and the connection between experiences cogitates and emotions would appear to be the most suitable goal for Kyle.
Taking into account Kyle has external support, the client/ therapist relation might be viewed as educating and teaching the