Celia Vega: A Case Study. Kerrie Brown, Collin Kuoppala, Sarah Lehman, and Michael Way. Michigan Technological University

Transcription

1 Running head: CELIA VEGA: A CASE STUDY 1 Celia Vega: A Case Study Kerrie Brown, Collin Kuoppala, Sarah Lehman, and Michael Way Michigan Technological University

2 CELIA VEGA: A CASE STUDY 2 Celia Vega: A Case Study Three diagnoses were looked at when studying Celia Vega s life. These diagnoses are Posttraumatic Stress Disorder (309.81), Dissociative Identity Disorder (300.14), and Major Depressive Disorder (296.34) according to the DSM-5 diagnostic manual. They will be discussed as follows. Posttraumatic Stress Disorder The most likely diagnosis for Celia Vega is Posttraumatic Stress Disorder (PTSD), based on the DSM-5 Criteria A-H. In accordance with Criteria A, Ms. Vegas was directly exposed to sexual violence, as she was raped multiple times by her uncle when she was nine years old. She was also aware that her sister was raped by her uncle when they were picked up from school. While Ms. Vega has symptoms that make it difficult to differentiate between a few different disorders, PTSD seems like the most likely diagnosis. Before proceeding, a point that must be addressed is the amount of the time that has passed since the stimulus. Ms. Vega is now twenty-one years old and the rape happened when she was nine. Most survivors of rape have their symptoms subside within three months of the actual rape (Rothbaum et al., 1992). Despite the amount of time that had passed, it is possible for her symptoms to be present because the nature of symptoms is varied among individuals based on many factors (Kessler et al., 1995). For Criteria B of PTSD, at least one listed symptom must be present and Ms. Vega has three symptoms: recurrent distressing dreams, intense psychological distress at exposure to cues that resemble an aspect of the trauma, and dissociative reactions (DSM-5, 2013). This manifests itself in Ms. Vega s life as nightmares of her sister being raped that cause Ms. Vega to wake up

3 CELIA VEGA: A CASE STUDY 3 crying. Moreover, when Ms. Vega is asked questions about her uncle and the rape, she experiences intense psychological distress. She cries, covers her face with her hair, and becomes tense. These are typical behaviors of someone who has PTSD (DSM-5, 2013). Ms. Vega s dissociative reactions cause her to lose complete awareness of her present surroundings. She has episodes where she becomes wild: acting as if the traumatic event was recurring. During these reactions, she sees her uncle s face on the wall. Because her uncle was the one who raped her it can be inferred his face, and thus the rape, is more than likely connected with her dissociative reactions. In addition, Ms. Vega fulfills Criteria C as well by avoiding distressing memories, thoughts, and feelings that are closely associated with traumatic memories (DSM-5, 2013). When she is asked to discuss details of the rape, she forces the interviewer to probe for information about the event. During the interview, she reaches a point where she stops answering questions and starts crying. Avoidance of traumatic memories in any form is a hallmark characteristic of PTSD that Ms. Vega exemplifies (Brewin et al., 1996). Criteria D is based on negative alterations in cognition and mood associated with the traumatic event and two or more of the symptoms are necessary for a diagnosis of PTSD (DSM- 5, 2013). Ms. Vega has three of these symptoms: a persistent negative emotional state, a marked diminished participation in significant activities, and a persistent inability to experience positive emotions. Her negative emotional state and her inability to experience positive emotions are one in the same; she is constantly depressed and doesn t experience pleasure like an average person would. Ms. Vega is only able to enjoy intercourse when she is high on drugs. She also

4 CELIA VEGA: A CASE STUDY 4 no longer participates in normal activities as she has ceased attending school and is unable to hold a job. Furthermore, Ms. Vega s behavior fits Criteria E, which involves marked alterations in arousal levels and reactions. It is necessary for two aspects of Criteria E to be met for a diagnosis of PTSD and Ms. Vega meets three of these criteria (DSM-5, 2013). The criteria that she meets are irritable behavior and angry outbursts, reckless or self-destructive behavior, and sleep disturbance. Ms. Vega self-reported that she is frequently irritable and has trouble sleeping, as she often awakens from bad dreams. Also, when Ms. Vega experiences an episode of dissociative behavior, she engages in self-destructive behavior by attempting to cut herself. The Criteria s for A-E of PTSD have to do with individual behavioral, cognitive and social factors, while Criteria s F-H have to do with the symptoms from the previous criteria as a whole. Criteria F states that the symptoms in Criteria B-E have to have been present for more than a month and Ms. Vega has been experiencing episodes of acting out for the past four years (DSM-5, 2013). Criteria G states that the disturbances present in Ms. Vega s life must be significantly distressing to her and that they must cause impairment in social and occupational levels of functioning (DSM-5, 2013). The symptoms that she is experiencing cause her to wish that she was dead and are prevent her from attending school, holding a job, and spending time outside of her boyfriend s family s house. On the whole, Ms. Vega is experiencing a dysfunctional and distressing life due to PTSD. Criteria H states that the disturbance in behavior cannot be attributed to substance use/abuse or another medical condition (DSM-5, 2013). While Ms. Vega recreationally used

5 CELIA VEGA: A CASE STUDY 5 drugs at one point in her life, it is unknown whether or not she is still taking drugs. The knowledge of whether or not she is still taking drugs is crucial knowledge to obtain, because part of her symptoms could be due to excessive drug usage, which would make a diagnosis of PTSD incorrect. For Criteria H to be applied, it is also necessary to know whether or not Ms. Vega s depression was present before her abortion a few months ago. If her constant negative mood and inability to experience positive emotions hadn t been present, she would only have one symptom from Criteria D. This would make the diagnosis of PTSD incorrect, because at least two symptoms from Criteria D are necessary for a diagnosis of PTSD (DSM-5, 2013). Dissociative Identity Disorder Another possible but less likely diagnosis for Celia Vega is Dissociative Identity Disorder (DID). DID is the presence of two or more distinct personality states that is diagnosed by Criteria A-E in the DSM-5. While Ms. Vega fulfills most of the criteria for this diagnosis, her symptoms better align with the criteria for PTSD. Criteria A for DID states that an individual must have two or more distinct personality states. These personality states are distinctly different in behavior, memory, consciousness, perception, cognition, and/or sensorimotor functioning (DSM-5, 2013). Ms. Vega has two different personality states: her normal self and her violent self. Her normal self is what dominates her life, while her violent self only started appearing about four years ago and lasts for abrupt two hour spells. During these spells she sees her uncle s face on the wall, engages in self-destructive behavior, and attempts to bite people. The

6 CELIA VEGA: A CASE STUDY 6 last time this happened to her, she woke up restrained in chains in the emergency room because her boyfriend called the police out of fear. Ms. Vega also fulfills Criteria B for DID. Criteria B states that there are recurrent gaps in recall of everyday events, important personal information, and/or traumatic events that are inconsistent with everyday forgetting (DSM-5, 2013). Ms. Vega has no recollection of what she did as her violent self when she is her normal self. However, she has no problem remembering important personal information and her personal information does not seem to change. She can also recollect traumatic memories of her uncle raping her, which she told a social worker. Overall, her memory is interrupted while she is in her violent state, but she otherwise appears to have perfect memory recall. Despite the fact that Ms. Vega can remember the majority of her actions, her symptoms cause distress and impairment in social and occupational areas of functioning, which is necessary via Criteria C for a diagnosis of DID (DSM-5, 2013). Her violent self has impaired her social life because her boyfriend needed to call the police to restrain her and she seldom leaves the house. She can also no longer hold a job, but it is unknown whether or not this is due to outbursts from her violent self or other factors. Information that tells what the cause is for this is would be beneficial in aiding or abetting a diagnosis of DID. Criteria D goes to on to require that the disturbances are not a cause of a broadly accepted cultural or religious practice (DSM-5, 2013). In this case, it is unknown whether or not Ms. Vega s dissociative state can be attributed to religious practices due to the timing of the onset of her violent self. After Ms. Vega s husband was sent to prison, her mother blamed her, telling her that she would pay for it via brujeria (witchcraft). Ms. Vega s dissociative states started shortly

7 CELIA VEGA: A CASE STUDY 7 after this occurred. Therefore, a further understanding of brujeria is necessary to know whether or not Criteria D applies to Ms. Vega. Criteria E of DID is the same as Criteria H of PTSD. Criteria E states that the symptoms are not attributable to the physiological effects of a substance or other medical condition (DSM- 5, 2013). For Criteria E to be applied, it is necessary to look at Ms. Vega s current drug use and onset of depression after her abortion for the same reasons it was necessary to look at these two factors to determine whether or not Criteria H should be applied for PTSD. PTSD and DID can appear in concert in individuals who are subjected to trauma as a child (Courtois, 2004). This is especially true when the trauma is repetitive and the victim is forced to keep silent about the trauma (Bentovim, 2002). Ms. Vega fits both of these criteria as she was raped multiple times and her mother refused to believe her when Ms. Vega voiced her pain. Despite the fact that Ms. Vega has dissociated states, they are fueled by stressors related to her childhood trauma. Stressors and stress responses are the two main characteristics of stress disorders (Comer, 2013) and Ms. Vega s behaviors appear to be dominated by them. Because of this, it is suggested that the main diagnosis be PTSD for Ms. Vega. It can be difficult to distinguish between PTSD and DID when both seem to be at play. However, it is usually the PTSD that invokes symptoms of DID and thus the PTSD should be at the forefront of treatment (Lowenstein, 2007). There is only a small number of people who experience symptoms of PTSD and DID where the two diagnosis exist for separate reasons (Bentovin, 2002). Because PTSD appears to be the main cause and is recommended to be at the forefront of treatment, PTSD is a better diagnosis than DID.

8 CELIA VEGA: A CASE STUDY 8 Major Depressive Disorder Another disorder that should be considered is Major Depressive Disorder. There are three criteria for this. Criteria A states that there must be two or more major depressive episodes present and will be discussed further shortly. Criteria B states that the depressive episodes aren t better accounted for by other diagnosis such as schizophrenia, delusional disorder or psychotic disorder not otherwise specified which applies to Ms. Vega. Criteria C states that there has never been a manic episode, mixed episode, or hypomanic episode (DSM-5, 2013). While Ms. Vegas does have periods of time where she experiences different thoughts and feelings, these feelings are not euphoric and thus do not represent maniac or mixed episodes. A major depressive episode is diagnosed via Criteria A-E. Criteria A deals with symptoms and states that five or more symptoms must be present during the same two week period and that one of the symptoms is depressed mood or a loss of interest or pleasure (DSM-5, 2013). Ms. Vega exhibits both of these symptoms along with three additional symptoms, which supports the diagnosis of a major depressive disorder. The three additional symptoms that fulfill Criteria A that Ms. Vega displays are insomnia, diminished ability to concentrate, and recurrent thoughts of death (DSM-5, 2013). Ms. Vega reported that she has a hard time sleeping and awakens from bad dreams often. Her diminished ability to concentrate is seen in her inability to hold a job and finish her schooling, and her recurrent thoughts of death commenced after the abortion of her child several months ago. Criteria B for a major depressive episode is the same as Criteria B for major depressive disorder, which Ms. Vega adequately met (DSM-5, 2013). Criteria C for a major depressive

9 CELIA VEGA: A CASE STUDY 9 disorder says that the symptoms cause clinically significant distress or impairment in social, occupational, or other areas of functioning. This is also the same as Criteria G for PTSD and Criteria C for DID, which Ms. Vega fulfilled (DSM-5, 2013). Criteria D states that the symptoms are not due to the direct physiological effects of a substance or due to a general medical condition, which is also the same as Criteria H for PTSD and Criteria E for DID (DSM- 5, 2013). Ms. Vega satisfied both these criteria as well. Criteria E for a major depressive episode requires that the symptoms that the individual is experiencing are not better accounted for by bereavement. It is necessary for the symptoms to persist longer than two months and to be characterized with marked functional impairment, a preoccupation with their own worthlessness, suicidal thoughts and psychotic symptoms (DSM-5, 2013). While Ms. Vega did experience the loss of a child several months ago in an abortion that coincided with the commencement of her suicidal thoughts, her general disinterest and depressed mood were present before her loss. The extent of which her symptoms worsened after aborting her child would be beneficial to know so that the extent to which Criteria E applies can be known. Since the abortion of her child did not significantly further impair her functioning and since the symptoms that were present before her loss were more indicative of depression than the symptoms that she acquired after her loss, it was decided that Ms. Vega fulfilled Criteria E (DSM-5, 2013). While Ms. Vega fulfills Criteria A-E for a major depressive episode, Criteria A for a major depressive disorder states that she must have experienced two or more depressive episodes where there were at least two months where criteria were not met for a major depressive episode (DSM-5, 2013). Despite the fact that Ms. Vega fulfills Criteria B and C for a major depressive

10 CELIA VEGA: A CASE STUDY 10 disorder, she has not experienced a two month window where her symptoms subsided. Therefore, the diagnosis of a major depressive disorder does not apply to Ms. Vega. Conclusion Overall, Ms. Vega s complicated life and symptoms can point to many different diagnoses if the DSM isn t carefully attended to. Posttraumatic Stress Disorder (309.81), Dissociative Identity Disorder (300.14), and Major Depressive Disorder ( ) are all diagnosis that should be looked at. However, Posttraumatic Stress Disorder best aligns with Ms. Vega s condition for the reasons discussed above.

11 CELIA VEGA: A CASE STUDY 11 References Bentovim, A. (2002). Dissociative Identity Disorder: A developmental perspective. In V. Sinason (Eds.), Attachment, trauma, and multiplicity: working with dissociative identity disorder (pp ). New York, NY: Taylor & Francis Incorporated. Brewin, C., Dalgleish, T. & Joseph, S. (1996). A dual representation theory of posttraumatic stress disorder. Psychological Review 103(4), Retrieved from %20PTSD/A%20dual%20representat.%20Brewin.pdf Comer, Ronald J. (2013). Abnormal Psychology (8 th ed.). New York, NY: Worth Publishers. Courtois, C. (2004). Complex trauma, complex reactions: assessment and treatment. Psychotherapy Theory, Research, Practice, Training 41, Kessler, R., Sonnega, A., Bromet, E., Hughes, M. & Nelson, C. (1995). Posttraumatic stress disorder in the national comorbidity survey. Archives of General Psychiatry 52(12), Retrieved from Lowenstein, R. (2007). Dissociative Identity Disorder: Issues in the Iatrogenesis Controversy. In E. Vermeeten, M. Dorahy, & D. Spiegel (Eds.), Traumatic dissociation: neurobiology and treatment (pp ). Washington, DC: American Psychiatric Publishing Incorporated. Rothbaum, B., Foa, E., Riggs, D., Murdock, T. & Walsh, W. (1992). A prospective examination of post-traumatic stress disorder in rape victims. Journal of Traumatic Stress 5(3), Retrieved from