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The Client, a 20-year-old single woman, was a sophomore at a Midwestern university. She had always been a good student, but her grades had fallen...
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The Client, a 20-year-old single woman, was a sophomore at a Midwestern

university. She had always been a good student, but her grades had fallen recently, and she was having trouble studying. Her academic difficulties, coupled with some problems with relationships and with sleeping, had finally led The Client to see a therapist for the first time. Although she was afraid of being alone, she had no interest in her current friends or boyfriend. She told the therapist that when she was doing everyday things like reading a book, she sometimes was overcome by vivid images of violent events in which she was the victim of a mugging or an assault. These symptoms had begun rather suddenly, and together they made her afraid that she was losing her mind. Most of The Client's symptoms had begun about two months before she visited the university's counseling service. Since then, she had been having nightmares almost every night about unfamiliar men in dark clothing trying to harm her. She was not having trouble falling asleep, but she was trying to stay awake to avoid the nightmares. During the day, if someone walked up behind her and tapped her unexpectedly on the shoulder, she would be extremely startled, to the point that her friends became offended by her reactions. When she was studying, especially if she was reading her English textbook, images of physical brutality would intrude on her thoughts and distract her. She had a great deal of difficulty concentrating on her schoolwork.
The Client also reported problems with interpersonal relationships. She and her boyfriend had argued frequently in recent weeks, even though she could not identify any specific problems in their relationship. "I just get so angry at him," she told the therapist. Her boyfriend had complained that she was not emotionally invested in the relationship. He had also accused her of cheating on him, which she denied. These problems were understandably causing her boyfriend to distance himself from her. Unfortunately, his reaction made The Client feel abandoned. The Client was afraid to walk alone to the library at night. She could not bring herself to ask anyone to walk with her because she didn't know if she could feel safe with anyone. Her inability to study in the library intensified her academic problems.
The Client's roommates had begun to complain that she was unusually sensitive to their teasing. They noticed that she cried frequently and at unexpected times. In the course of the first few therapy sessions, the psychologist asked a number of questions about The Client's life just prior to entering therapy. Because the symptoms had such a rapid onset, the therapist was looking for a specific stressful event that might have caused her symptoms. During these first few sessions, The Client reported that she had begun to feel more and more dissociated from herself. She would catch a glimpse of herself in the mirror and think, "Is that me?" She would walk around in the winter weather with no gloves on and be relieved when her hands hurt from the cold, because "at least it's an indication that I'm alive."
After several sessions, The Client mentioned to her therapist that she had been raped by the teaching assistant in her English literature course. The rape occurred 2 months before she entered therapy. The Client seemed surprised when the therapist was interested in the event, saying "Oh, well, that's already taken care of. It didn't really affect me much at all." The therapist explained that serious trauma such as rape is rarely resolved by itself, and especially not quickly.
When it became apparent that The Client had not previously reported the rape to anyone else, her therapist strongly advised her to contact the police. She refused, citing a number of reasons, ranging from her conviction that no one would believe her (especially 2 months after the incident) to the fear of facing cross examination and further humiliation. Without The Client's consent, the therapist could not report the rape because the information she had obtained from The Client was protected by confidentiality (the ethical obligation not to reveal private communications, in this case, between psychologist and client). There are some rare exceptions to this ethical principle. State laws require mental-health professionals
to break confidentiality and report cases of child abuse. Psychologists are also required to report clients who are imminently dangerous to themselves or others. These exceptions did not apply to The Client's situation.
The Client gradually revealed the story of the rape over the next few sessions. She had needed help writing an English paper, and her T.A. had invited her to his house one night so that he could tutor her. When she arrived at the house, which he shared with several male graduate students, he was busy working. He left her alone in his room to study her English textbook. When he returned, he approached her from behind while she was reading and grabbed her. The T.A. forced her onto his bed and raped her. The Client said that she had not struggled or fought physically because she was terrified and stunned at what was happening to her. She had protested verbally, saying, "No!" and, "Don't do this to me!" several times, but he ignored her earnest objections. She had been afraid to yell loudly because there were only other men in the house, and she was not sure whether or not they would help her. After the rape, the T.A. walked The Client back to her dorm and warned her not to tell anyone. She agreed at the time, thinking that if she never told anyone what had happened, she could effectively erase the event and prevent it from having a negative effect on her life. She went up to her dorm room and took an hour-long hot shower, trying to scrub away the effects of the rape.
While describing these events to the therapist, The Client shook and her voice was breathy. She kept saying, "You believe me, don't you?" For several days after the rape occurred, The Client believed that she had been able to keep it from affecting her everyday life. The more she tried not to think about it, however, the more times it came to mind. She began to feel stupid and guilty for having gone to a T.A.'s house in the first place, and because she had not been able to anticipate the rape, The Client wondered whether her own behavior had contributed to the rape: Had she dressed in some way or said something that indicated a sexual invitation to him? She was ashamed that she was not strong enough to have prevented the rape or its negative consequences.
The Client had initially believed that only one aspect of her life changed after the rape; she no longer attended discussion sections for her English course. Unfortunately, several other problems soon became evident. Her exaggerated startle response became more and more of a problem because her friends were puzzled by her intense reactions to their casual, friendly gestures. Frequent nightmares prevented her from getting any real sleep, and she was having trouble functioning academically. She had no further contact with her T.A. unless she saw him while walking across campus. When that happened, she would duck into a doorway to avoid him. She also began to withdraw from relationships with other people, especially her boyfriend. He responded to this retreat by pressuring her sexually. She no longer had any interest in sex and repeatedly rejected his physical advances. All these problems finally made The Client believe that she was losing control of her feelings, and she decided to seek professional help.
Social History: The Client had grown up in a small midwestern town 100 miles away from the university. She was the oldest of three children. Both of her parents were successful in their professional occupations, and they were involved in the community and their children's schools. The Client had attended public schools and was mostly an A student. She was involved in several extracurricular activities. In high school, she had some trouble making friends, both because she was shy and because it was considered "nerdy" to be an A student. It wasn't until she enrolled at the university that she was able to form a relatively large peer group. The Client's parents were strict about dating and curfews. She had not been interested in attending large parties or drinking when she was in high school.
She did have a boyfriend during her junior and senior years. They began dating when they were both 16 years old and became sexually involved a year later. That relationship had ended when they left their hometown to attend different colleges.
The Client recalled that her high school boyfriend had occasionally pressured her into having sex when she thought it was too risky or when she was not interested. She denied having previously been a victim of sexual assault, although one incident she described did sound abusive to the therapist. When she was about 13 years old, The Client went to a summer music camp to play the trombone, an instrument not usually played by a female. One day after rehearsal, the boys in her section ganged up on her, teasing her that "girls can't play trombones!" One boy began to wrestle with her and, in the melee, placed a finger inside her shorts into her vagina. The Client remembered yelling at him. The boy let her go, and then all the boys ran away. The Client had never viewed that event as being assaultive until she thought about it in reference to being raped. The Client's adjustment to college had been good; she made several friends, and most of her grades were good. She had never before sought psychological help. The Client felt as if she had the world under control until she was raped by someone she knew.
Q1. Kindly give the tentative diagnosis of the patient and also write presenting complaints.
Q2. Critically explain the possible etiological factors according to different psychological perspectives (par

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