This is the final written assignment in this course. Throughout the course, you should work to infuse information about your couple and identified patient (Jasmine) in each section. This template is

Jasmine’s Diagnosis Part I

2021 ICD-10-CM Diagnosis Code F43.10: Post-traumatic stress disorder, unspecified

Diagnosis #1

A class of traumatic stress disorders with symptoms that last more than one month. There are various forms of post-traumatic stress disorder, depending on the time of onset and the duration of these stress symptoms. In the acute form, the duration of the symptoms is between 1 to 3 months. In the chronic form, symptoms last more than 3 months. With delayed onset, symptoms develop more than 6 months after the traumatic event. In Jasmine’s case her reported symptoms have lasted more than 3 months with delayed onset and currently affecting her ability to form healthy relationships with family and intimate.

Clinical Information

• Acute, chronic, or delayed reactions to traumatic events such as military combat, assault, or natural disaster. In Jasmin’s case it would be physical, emotional and mental abuse occurred over a period of time with different partners and family members (mother/sister).

• An anxiety disorder precipitated by an experience of intense fear or horror while exposed to a traumatic (especially life-threatening) event. The disorder is characterized by intrusive recurring thoughts or images of the traumatic event; avoidance of anything associated with the event; a state of hyper-arousal and diminished emotional responsiveness. These symptoms are present for at least one month and the disorder is usually long-term. In Jasmin’s case she has reportedly experienced intense fear of being alone, intrusive reoccurring thoughts only when faced or reminded of trauma, avoidance associated with her trauma (avoiding one-way in/one-way out environments & looking for exits), and hyper-arousal emotional responses (i.e uncontrollable anger-outburst, easily irritated/aggravated, and easily scared or startled).

• An anxiety disorder that develops in reaction to physical injury or severe mental or emotional distress, such as military combat, violent assault, natural disaster, or other life-threatening events. Symptoms interfere with day-to-day living and include reliving the event in nightmares or flashbacks; avoiding people, places, and things connected to the event; feeling alone and losing interest in daily activities; and having trouble concentrating and sleeping. In Jasmin’s case it would be the physical injury and severe mental or emotional distress caused by her mother/sister and past abusive relationships.

• Post-traumatic stress disorder (PTSD) is a real illness. You can get PTSD after living through or seeing a traumatic event, such as war, a hurricane, rape, physical abuse or a bad accident. PTSD makes you feel stressed and afraid after the danger is over. It affects your life and the people around you. PTSD can cause problems like

  • flashbacks, or feeling like the event is happening again

  • trouble sleeping or nightmares

  • feeling alone

  • angry outbursts

  • feeling worried, guilty or sad

PTSD starts at different times for different people. Signs of PTSD may start soon after a frightening event and then continue. Other people develop new or more severe signs months or even years later. PTSD can happen to anyone, even children. Medicines can help you feel less afraid and tense. It might take a few weeks for them to work. Talking to a specially trained doctor or counselor also helps many people with PTSD. This is called talk therapy.

Diagnosis #2

F 41.1: Generalized Anxiety Disorder/ ICDM 10: F34.9 Persistent moods [affective] disorder, unspecified. V-Codes: 61.20 (Parent-Child Relational Problem); V-Code 61.8 (Sibling Relational Problem); V-Code 61.10 (Relationship Distress with Spouse or Intimate Partner).

Theory of Practice

Chapter 5- Systemic Therapies: MRI and Milan Chapter 9- Symbolic-Experiential and Internal Family Systems & Anxiety Disorders DSM-5: Pages 189-234

Chapter 15- Evidence-Based Treatments in Couple and Family Therapy: Emotionally Focused Therapy and Functional Family Therapy & Chapter 7: Trauma and stress related disorders DSM-5: Pages 265-290

Part II

What I’ve learned about treatment planning after reviewing this rubric is that I’ve been watering down my treatment plans for years. This is a very detailed plan of action for treatment that includes the theory of practice, therapeutic relationship, and what assessment tool used. All the other components I’m familiar with and have used in previous plans for my client. This plan has influenced by ideologies by simply expanding my work. I’ve already completed the work, but never credited myself in this format maybe in a progress note, but still not to this extent.

IP vs. Family Plan

One obvious difference I notice is that family is not addressed on the IP version. The IP version is focused more on individualized goals/objectives whereas the family version addresses individualized as well as family goals/objectives. What I also noticed is that on IP version medication is not addressed like it is on family plan and on family plan theory of practice and therapeutic relationship is not addressed.

References:

ICD-10-CM Diagnosis Codes (n.d.). In Find A Code. Retrieved from https://www.findacode.com/code-

set.php?set=icd10cm&i=9574

Post-traumatic stress disorder, unspecified (n.d.). In ICD10Data.Com. Retrieved from

https://www.icd10data.com/ICD10CM/Codes/F01-F99/F40-F48/F43-/F43.10