Session #: 1

Patient: William Russo

Relevant History:

  • Marine background and special ops training
  • Hx of violence; involuntary status due to assault of FBI officer
  • Coma post-trauma of Traumatic Brain Injury (TBI)
  • Posttraumatic amnesia (memory loss of approx. 1-3 year prior)
  • Facial disfiguration, pain from injuries

Diagnosis: (G31.84) Mild neurocognitive disorder due to TBI

Client Presentation

Cognitive Functioning: Intact overall

  • No improvement to persistent retrograde amnesia (1-3 years)
  • Insufficient sleep & nightmares potential cause for lack of improvement, no progress in autobiographical memory recall

Affect: Low affect; medium agitation

Mood: Anxious, depressive, dark

Pain: Client responds 3 out of 10 Likert scale (assess validity: marine training may influence lower rating response)

Interpersonal: Resistant; defiant; hostile – cooperation in therapy sessions

Functional Status: Daily functioning skills intact; physical skills and coordination improving

 

Safety Issues: Nightmares potentially indicative of increased suicide risk

  • Suicide Assessment completed: Patient denies thoughts of self- or other-harm
  • Lack of sleep may lead to increased impulsivity, inability to control agitations

 

Medications: Painkillers (Opioid – Rx from MD). Sleeping medication prescribed PRN – patient doesn’t take despite trouble sleeping through night; reports sleeping meds increase severity of nightmares

 

Symptoms and Subjective Report:

  • Isolation and loneliness contributing to hostility. Yearns for family, place of belonging – formerly felt those when in military unit overseas. Difficulty adjusting to civilian life.
  • Denial, repression, and projection of blame. Denial observed in William’s avoidance of practicing coping mechanisms
  • Pre-trauma, patient self-esteem based on achievements, appearance and physical capabilities. Sense of self-worth shattered upon discovery of permanent facial disfiguration along with loss of strength due to coma / muscle atrophy and injuries.
  • Grudgingly accepts therapist analysis of improving physical skills; impatient for 100% physical recovery.

Relevant Content:

  • Core wound of childhood abandonment
  • Continued nightmares - patient expresses hopelessness and that he is resigned to avoiding these persistent nightmares
  • Nightmare imagery: Skull, blood (see sketch note in patient file)

  

Treatment Plan Progress

Objectives (short-term):

  • Build upon therapist-patient rapport
  • Reduce anxiety and hopelessness
  • Confront underlying issues of nightmares and amnesia
  • Gain coping skills; increase hope and positive affect
  • Reduce agitation; increase concentration capabilities

 

Objectives (long-term): Regain memories, cultivate memory cohesion, self-identity and self-acceptance, and improved sleep patterns.

 

Prescribed Frequency of Tx: 2-3x/week

Session Intervention(s):

History was reviewed to address which specific events or problems for which he was feeling severe guilt. Patient unable to identify, expressed frustration. Therapist shifted to art therapy techniques. Therapist building out more of an understanding and adaptation to patient triggers, creating deeper trust between Billy and therapist.

Psychoanalytic free-association; progressive muscle relaxation for anxiety reduction.

Art therapy along with psychodynamic exploration utilized to explore metaphorical imagery for memory recall.

Response:

Patient currently reports rumination and obsessive thinking, causing him anxious, depressed mood and lowered affect. Pain and anger interfere with ability to effectively engage with all interventions.

William demonstrates acceptance of therapist empathy and support; expresses difficulty internalizing to apply to himself. Continues to challenge therapist suggestions, uses humor to deflect some aspects of deeper exploration with art interventions (e.g., comparing to pre-school activities of finger-painting) – yet demonstrated willingness to engage in conceptualization art-based interventions.

William resistant to suggestions around sleep, nightmares.


Session #: 2

Patient: William Russo

Relevant History:

  • Marine background and special ops training
  • Hx of violence; involuntary status due to assault of FBI officer
  • Coma post-trauma of Traumatic Brain Injury (TBI)
  • Posttraumatic amnesia (memory loss of approx. 1-3 year prior)
  • Facial disfiguration, pain from injuries

Diagnosis: (G31.84) Mild neurocognitive disorder due to TBI

Differential Dx: Dissociative amnesia

Client Presentation

Cognitive Functioning: Intact overall

  • No improvement to persistent retrograde amnesia (1-3 years)
  • Insufficient sleep & nightmares potential cause for lack of improvement, no progress in autobiographical memory recall
  • Patient presents with scattered recall of recent events (incident with staff)

Affect: Increased agitation from last week; lethargy decreased

Mood: Anxious, irritable

Pain: Client responds 2 out of 10 Likert scale, Marine training may be hiding higher level

Interpersonal: Resistant; defiant; hostile with other staff; willingness displayed when working with therapist

Functional Status: Daily functioning skills intact

 

Safety Issues: Nightmares potentially indicative of increased suicide risk

  • Suicide Assessment completed: Patient denies thoughts of self- or other-harm
  • Lack of sleep may lead to increased impulsivity, inability to control agitations
  • Unlikely return to group units

 

Medications: Painkillers (Opioid – Rx from MD). Sleeping medication prescribed PRN – patient doesn’t take despite trouble sleeping through night; reports sleeping meds increase severity of nightmares

Symptoms and Subjective Report: Increased expression of separation and frustration stemming from memory loss and lack of familial grounding.

Obsessive thinking re: military family & “brother” in conjunction with memory loss and recent incident leading to his coma and facial disfiguration.

Internalizing blame, contributing to increased hostility with others → stemming from underlying self-hatred / guilt he cannot explain due to amnesiac symptomology.

 

Relevant Content:

  • Recent confrontation with staff when challenged with rule compliance
  • Core wound of childhood abandonment
  • Fragmented sense of self; lacks cohesive self-identity
  • Ongoing nightmares – could be expressing what conscious brain is repressing from recent years (contributing to differential Dx of dissociative amnesia)
  • Imagery: Skull, blood (see sketch note in patient file)

 

Treatment Plan Progress

Objectives (short-term):

  • Reduce hostile interactions with staff
  • Strengthen therapist-patient rapport; continue building trust
  • Reduce observed and reported agitation and anxiety
  • Reduce reported hopelessness
  • Confront underlying issues of nightmares and amnesia
  • Gain coping skills; increase hope and positive affect
  • Despite resistance to Tx, William displays trust within therapeutic holding environment; increased rapport with therapist

 

Objectives (long-term): Regain memories, cultivate memory cohesion, self-acceptance, and improved sleep patterns. Gain insight and awareness into root of hostility.

 

Prescribed Frequency of Tx: 2-3x/week

Session Interventions:

Psychoeducation continued in this session: Thought-identification techniques and substitution (e.g., turning from obsessive thinking to journaling, utilizing memory skills books to help with cognitive recall improvement)

Art therapy along with psychodynamic exploration to explore metaphorical imagery for memory recall. Conceptualization: piecing together fragmented self-identity and corresponding autobiographical memories through visual representation of jigsaw puzzle.

Self-identity was underlying thread of CBT and journal analysis. Suggested mask personalization to patient as a way of determining his own identity, what he wishes to portray to the world.

Response:

William embraced metaphor of piecing together pre-trauma memories as a jigsaw puzzle. Difficulty identifying concrete recollections from amnesiac time period.

Patient expressed self-judgment around improving physical skills and inability to recover memories.

Patient open to conceptualization of his self-identity post-trauma as the assembler of jigsaw pieces, providing a potential sense of purpose during time in facility vs. perception of lockup for punishment.

Patient # 9873456