Treatment Plan for PTSD
...e sleeps fitfully and in bursts until around seven in the morning when she “gives up” and starts her day. She works at a local firm as a receptionist. She says she is usually fine at work, but since it has been getting dark earlier she has had to cut her hours short. She has been unable to leave the house alone after dark since the rape, and she has been unable to leave the house after dark at all for the past three to four weeks. As soon as the sun goes down she says she gets moody. She cries “at the drop of a hat”, for instance she spilled a bowl of soup and cleaning it up while sobbing. She says she is frightened easily, if someone knocks on the door and they weren’t expecting company, she jumps. If any of the appliances makes a loud noise, she jumps. Sometimes these little startles escalate into a pounding heart and shortness of breath. Axis 2: Developmental/Personality Disorders Kelly is a very bright individual; she is halfway to her associate’s degree in business management at the County College of Morris. She had a three point seven grade point average her last semester. She does not have any learning disabilities. When Kelly described her life growing up, although not in detail, and her relationship with her parents one did not get the impression that she suffers from a personality disorder. She seems to have developed good methods for dealing with those around her as well. And up until this recent crisis she has dealt with obstacles in her life with great stride. Axis 3: Physical Conditions Kelly is for the most part in good physical condition. That is to say she does not suffer from any disabilities or disease. Lack of sleep is evident in her face; she has dark circles under her eyes. Also she has lost about fifteen pounds since the assault. She complains of fatigue throughout the day which she attributes to only getting four hours of restless sleep a night. She also states a loss of appetite after an “episode”, when she has a panic attack. Axis 4: Psychosocial Stressors Kelly got engaged to her fiancé about a year ago after living together for about four months. They have been together for three years; she says they have been very happy. Six months ago Kelly was coming home from an outing with a friend when she was attacked on the way to her car. A large man wearing a ski mask physically assaulted her and raped her. It happened in a dark alley around eleven at night. She suffered from a broken collar bone, nose, and an orbital fracture as well. She drove herself to the hospital and reported the crime. She was treated and also questioned by the police. The local domestic abuse and rape crisis team was sent to speak with her as well. Unfortunately her assailant has not been arrested or identified yet. At the time of the attack Kelly was emotionally numb. She refused all counseling, stating she would be ok once she worked it all out in her head. She says she was coping well for about a month. That she wasn’t having nightmares, but she was uncomfortable leaving the house alone after dark. She says that to her it has become obvious that her attacker will not come to justice, that he is free out there. While she says she is not afraid that he will come after her again just knowing he, and guys like him are out there, scares her. She says she did not realize he was going to get away right off the bat. She said she had faith in the system. She pointed out that her symptoms did not get bad until she came to the conclusion he would get away with it. She has also isolated herself from her mother, and friends. She reports friction between herself and her fi...