Has Wayne been exposed to trauma in his past? Could his symptom pattern be indicative of PTSD?

Question

DSM Diagnosis
309.28 Adjustment Disorder with Mixed Anxiety and Depressed Mood.
314.01 Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type, Mild
995.81 Spouse or Partner Violence, Physical, Confirmed

Rationale
An adjustment disorder provides a least restrictive diagnosis that accommodates the fact that Wayne’s responses could be considered “normal” for someone going through a breakup with a significant other (a week prior). Wayne’s anxiety manifests through constantly recurring thoughts about Wendy, and his depression can be indicated by insomnia and an irritable mood. Wayne copes with the breakup by staying as busy as possible.
The V code Spouse or Partner Violence, Physical, was added because of Wayne admitting to being physically violent with his previous girlfriend. Also of concern was his violence to his ex-girlfriend’s child. When the social worker inquired about this, Wayne was vague, but sounded regretful about hitting the child. The social worker notes that this will be something to explore in further sessions, as it relates to the experience of Wayne’s own physical abuse and watching the physical abuse of his mother by his father.
Wayne was also diagnosed with Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type. Wayne meets six of the symptoms of inattention:

1. Often has difficulty sustaining attention in tasks or play: Wayne admitted to having a hard time concentrating on anything other than watching television.
2. Difficulty organizing tasks and activities: Wayne said he became easily frustrated if he had to deal with too many things at once, such as a lot of work orders.
3. Avoids, dislikes, reluctant to engage in tasks that require sustained mental effort: The client typically avoids activities that require him to do a lot of thinking, and typically spends his time watching television. Wayne chose his current occupation because he is able to move around a lot, through the apartment units.
4. Loses things: Wayne leaves his tools in different apartment units and wastes time at work searching for them.
5. Easily distracted: If Wayne is cleaning the kitchen, he will sometimes leave the tap water running as his attention becomes diverted on something else.
6. Forgetful: Wayne will forget instructions that have been given to him at work.

Wayne does not seem to meet enough criteria to meet the hyperactivity-impulsivity subtype. He does leave situations in which remaining seated is expected. For instance, during the counseling session, Wayne jumped out of his seat to go to the water fountain without announcing his departure. He is also restless and impatient when faced with traffic.
Wendy states his mother found him to be an “exhausting” child. He ran around constantly, was easily distracted, and acted on every whim he had. Although he did not receive a diagnosis as a child, we can assume that he met criteria for ADHD before age twelve. Wayne’s symptoms cause both social (relationship problems) and occupational impairment (he is unable to hold jobs for long periods of time).

Additional Information Required
The social worker would like to explore Wayne’s background and current symptoms in more detail to rule out several other possible diagnoses. Specifically, she would like to inquire further about possible PTSD symptoms, including re-experiencing, avoidance, and numbing of general responsiveness.

Risk and Resilience Assessment
Onset
Many of Wayne’s risks for ADHD are unknown as they are theorized to involve neuropsychological factors. Very little is also known about his biological father and his history of mental illness, although he was said to have an alcohol problem and was physically abusive. On the protective side, Wayne’s mother did not smoke or use substances during pregnancy.

Course
From the information provided, it does not appear that Wayne developed ODD or CD in his youth, which bodes well for the course of ADHD. However, the past physical abuse of his ex-girlfriend and her child is troubling. With the help of his girlfriend, Wayne has some insight into his behaviors and seems determined to get better, if only to get her back. Wayne suffers financially, which puts him at risk; he is in debt, earns little, and does not receive health insurance benefits. This means that treatment might be difficult to pay for.

What techniques could be used to elicit additional strengths?
Wayne has many strengths. It is known, for example, that he is well liked by his co-workers, does well on the job, and has an attractive personality to some women. Further, he always feels remorse for his angry outbursts. His strengths could be further assessed by asking Wayne to recount the various successes he has experienced throughout his life, asking him to make a list of his personal qualities, asking how he learned to be such a good repairman, and how he has been able to implement the organizational tasks suggested by his girlfriend. Other techniques could include:
1. Exception-finding
Attention: When are you able to focus your attention on what you need to get done, even for a little while? What are you doing differently? Who is there? What is going on?
Frustration and anger: When was a time you started to feel mad but was able to stop yourself from letting it take over? What did you do?
2. Future without the problem: When you are able to control your anger and focus yourself, what will you be doing differently? How will you be responding to others?
What will they be saying towards you? Talk about times this happens now.
When you have the kind of relationship you want towards your girlfriend, how will you be acting? How will she be responding to you? What will you be doing together?

Treatment
Medical
Goal: To receive a comprehensive assessment for ADHD and appropriate biological interventions for that disorder.
Plan: Wayne will receive a medical exam to determine if there is a physical basis to his irritability and angry outbursts. He will also complete a series of rating scales for further assessment of his ADHD. He will be referred for a psychiatric evaluation to determine a need for medication.

Psychological
Goal: To become educated about ADHD and its management.
Plan: Wayne will attend a psychoeducational group on ADHD at agency.
Goal: To increase quality of social and occupational functioning.
Plan: Wayne will receive cognitive-behavioral interventions concentrating on anger management, frustration tolerance, time management, problem-solving skills, and communication skills. The social worker will continue to support and guide Wayne’s efforts to increase structure in life, including budget schedules, increased usage of dry erase board and memos, and files for important documents.
Goal: To resolve the nature of romantic current relationship.
Plan: Wayne and Wendy will attend couples counseling and problem-solve about the nature of their relationship.

Social
Goal: To resolve financial concerns.
Plan: The social worker will refer Wayne to a legal aid agency to determine whether he has a basis for not being liable for the student loans. He will also be helped to inquire about health insurance options through his current place of employment, and possible to inquire about other places of employment that provide such benefits.
Critical Perspective
Wayne’s case highlights some of the problems in applying the ADHD DSM diagnostic criteria for adults, although improvements have been made in DSM-5. Wayne suffers from such symptoms as overreacting to frustration, poor motivation, and difficulty with time management, although these are not listed in the DSM. As it is, he only met criteria for the “Predominantly Inattentive Type” of ADHD, but many of his symptoms involve impulsivity, and these are not captured in the diagnosis.

Answer 1

Wayne has experienced trauma in the past, although the nature and extent of that trauma needs to be more fully evaluated. Wayne experienced physical abuse by his father, as well as witnessing the abuse of his mother. These experiences may have provoked fear, helplessness, or horror in Wayne. Further, Wayne and Wendy both describe a variety of situations where Wayne becomes intensely angry at normal life occurrences. His outbursts of anger could represent physiological reactivity but whether it is in reaction to cues of trauma is questionable. Wayne spoke primarily of the breakup and only briefly and vaguely of his past experiences with his father. This could represent his efforts to avoid thoughts, feelings, or conversations associated with the trauma. Wayne did not appear to exhibit signs of numbing. Therefore, without additional information, the social worker would be unable to consider further a diagnosis of PTSD.