Anne, a 24-year-old female, arrived for her initial intake session reporting a complex array of symptoms rooted in traumatic childhood experiences. She currently suffers from significant distress, including sleep disturbances, mood lability, feelings of impostorism, and dissociative phenomena. This initial assessment aims to formulate differential diagnoses from her self-report and identify necessary further evaluations to reach a conclusive diagnosis and inform intervention strategies. Differential Diagnoses Posttraumatic Stress Disorder Anne meets many posttraumatic stress disorder (PTSD) criteria from the Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.; DSM-5-TR) including intrusive symptoms, emotional reactivity, avoidance, cognitive and mood alterations, arousal changes, and dissociation resulting from trauma exposure. Though she did not suffer direct physical harm, witnessing domestic violence and feeling emotionally unsafe fulfills Criterion A for trauma exposure (APA, 2022). Her mood instability, nightmares, dissociation, and avoidance of closeness are congruent with PTSD symptom clusters. However, key diagnostic components need further clarification. Criteria F and Gregarding the duration of symptoms and functional impairmentremain unverified. Additionally, she has not clearly indicated avoidance behaviors that meet Criterion C (APA, 2022). The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), a structured PTSD interview, should be administered to confirm diagnosis (Wojujutari et al., 2024). Borderline Personality Disorder Anne's symptoms align with borderline personality disorder (BPD) criteria outlined in the DSM-5-TR, including affective instability, emptiness, identity disturbance, suicidal ideation, and unstable relationships. Her idealization and devaluation of partners, fear of abandonment, and impulsive behaviors (such as past self-harm) also reflect classic BPD traits (Leichsenring, 2024; APA, 2022). According to the biosocial framework, early trauma combined with emotional dysregulation may lead to BPD development (Campbell et al., 2020). However, further evidence is needed for a definitive diagnosis. Specific examples of abandonment fears and unstable relationships (Criterion 1 and 2) are insufficient. Criteria involving identity disturbance, impulsivity, suicidal behavior, emotional reactivity, emptiness, intense anger, and stress-induced paranoia require deeper exploration (APA, 2022). The Structured Clinical Interview for DSM-5 Personality Disorders (SCID-5-PD) is recommended for comprehensive assessment (Heriot-Maitland, 2023; Fanti et al., 2023). Dissociative Identity Disorder Anne's derealization, disorientation, and imaginative coping during trauma raise the possibility of dissociative identity disorder (DID). DSM-5-TR defines DID as involving distinct personality states and amnesia for daily events or trauma (APA, 2022). While Anne doesn't report multiple identities, her dissociation may suggest unnoticed self-state shifts (Spiegel et al., 2021). Still, critical criteria are lacking. She has not confirmed distinct identities (Criterion A), significant memory gaps (Criterion B), or functional impairment (Criterion D). To determine DID, instruments like the Dissociative Experiences Scale (DES), SCID-D, or Multidimensional Inventory of Dissociation (MID) should be used to evaluate dissociative symptoms (Mychailyszyn et al., 2021). Domains of Functioning Relevant to Diagnosis Anne's statements about impostorism, confusion, and disorientation reflect disrupted self-concept, attentional deficits, and executive dysfunction. Trauma survivors often show cognitive deficits due to dysregulated emotional processing (Sanger et al., 2025). Maladaptive schemas like her fear of "becoming her mother" support BPD tendencies and unresolved attachment trauma (Haselgruber et al., 2020; APA, 2022). She demonstrates compromised social functioning, especially in intimate relationships. Her fear of becoming abusive, idealization, and distancing behavior reflect insecure attachment and abandonment trauma (Leichsenring, 2024). Her familial disconnection, particularly with her brother and deceased grandfather, illustrates unresolved loss and system disruption. Anne's childhood environment involved violence, parental substance use, and instability during key emotional development periods. Such adversity correlates with attachment issues, identity fragmentation, and emotional dysregulation (Tomoda et al., 2024). Her dissociative imagination as a child may have evolved into adult derealization (Kate et al., 2020). Anne has a biological predisposition to mental illness, with family history of substance abuse and suicide. Neurobiological changes from trauma affect brain regions linked to emotion and memory regulation (Yang et al., 2023). Chronic sleep issues and dissociation may result from hypothalamic-pituitary-adrenal (HPA) axis dysregulation, common among trauma survivors. Legal and Ethical Considerations Anne admits to passive suicidal thoughts recently. Hence, suicide risk must be assessed with standardized instruments and monitored for possible changes. Under legal and ethical mandates, if Anne presents with current danger to herself, therapists are obligated to intervene and provide safety planning, support systems, or involuntary hospitalization, depending on jurisdictional mental health law (Barnett et al., 2022). The therapist should engage Anne in informed consent processes that are sensitive to her truama. These processes include explaining the therapy process, confidentiality limits, and treatment options in an open, culturally sensitive, and emotionally responsive manner (Barnett et al., 2022). Due to Anne's history of powerlessness and domestic violence, collaborative consent helps her with autonomy and building trust (Aerts et al., 2023) Anne's case includes family therapy. The therapist should decide the limits of confidentiality when working with family members. This aspect involves getting Anne's explicit consent, laying down what can be disclosed, and maintaining confidentiality, particularly regarding her fear of becoming like her mother (Avasthi et al., 2022). Consultation and Referral Anne may benefit from psychiatric consultation for mood and sleep symptom management (Samuels, 2024). Referral to trauma specialists for eye movement desensitization and reprocessing (EMDR) or trauma-focused cognitive behavioral therapy (TF-CBT) is advisable. Social skills training and support groups for trauma survivors or adult children of alcoholics (ACOAs) could reduce isolation and enhance relational confidence (Browne et al., 2020; Kirkland, 2022). Integrative, Collaborative, and Evidence-Based Treatment Plan Trauma-Focused Cognitive Behavioral Therapy Trauma-focused cognitive behavioral therapy (TF-CBT) is an evidence-based psychotherapy adapted to help individuals, including adults, recover from trauma's emotional and psychological effects (Medical News Today, 2023; Kliethermes et al., 2025). Though developed for children and adolescents, its principles are highly effective for adult survivors of childhood trauma with PTSD symptoms (Kliethermes et al., 2025). TF-CBT typically follows a phased approach. Phase 1 (Weeks 1-4): Stabilization and Skill-Building Psychoeducation, Relaxation and Stress Management. Educate Anne on trauma's neurobiological effects, including the "fight, flight, or freeze" response and how domestic violence contributes to symptoms like mood swings and nightmares (Walton, 2021; Ghosh et al., 2024). This normalizes reactions and reduces self-blame. Teach deep breathing, progressive muscle relaxation, and visualization to manage anxiety and mood swings (Medical News Today, 2023). Trust-building is essential through empathy, validation, and psychoeducation (Black & Flynn, 2021; Beck & Dozois, 2020). Address sleep hygiene and emotion regulation (Logan et al., 2023). Use genograms and family meetings to promote shared goals (McGoldrick et al., 2020; Stolper et al., 2024). Emotional Regulation, Cognitive Coping, and Safety Planning. Focus on identifying and expressing emotions healthily. Introduce self-soothing strategies to manage intense feelings and prevent maladaptive behaviors (Mayo Clinic, n.d.). Challenge distorted beliefs about self and relationships stemming from trauma (Medical News Today, 2023). Monitor passive suicidal ideation and develop a robust safety plan, including identifying triggers and coping strategies (Daglas et al., 2024). Phase 2 (Weeks 5-12): Trauma Narration and Processing Trauma Narrative, Gradual Exposure and Cognitive Restructuring. Once coping skills are in place, Anne creates a trauma narrative of her parents' violence and its impact in a supportive setting (Medical News Today, 2023). Use imaginal and in vivo exposure to desensitize trauma reminders and reduce nightmares and intrusive thoughts (Idaho Youth Ranch, n.d.; TherapyGroupDC, n.d.). Re-evaluate trauma-related beliefs, challenge self-blame, and develop adaptive understandings of past experiences (Medical News Today, 2023). Phase 3 (Weeks 13-20): Integration and Consolidation Enhancing Safety and Development, Grief Processing & Relapse Prevention. The therapist will help Anne through this final phase to apply skills to daily life, develop assertiveness, improve communication, and set boundaries (Medical News Today, 2023). Address grief from childhood losses and familial silence about suicide to foster closure. Identify triggers and prepare to use coping strategies to maintain progress. Multifamily Therapy The therapist should incorporate multifamily therapy (MFT) as a family intervention strategy. (MFT) brings together families with similar issues to promote collective healing using systemic, psychodynamic, and cognitive-behavioral approaches (Paganin, 2024). It has been effective in addressing trauma and relationship disorders (Corominas Daz & BalcellsOliver, 2023). MFT fosters mentalization, crucial in families with disrupted emotional awareness and attachment. Substance abuse and emotional turbulence have likely impaired Anne's family's emotional functioning. MFT uses role-playing and feedback to improve empathy and emotional interpretation (Marschall, 2024). MFT provides a safe environment to build self-regulation and prevent emotional escalation. This promotes psychological safety and healthier interactions, reducing conflict and improving emotional stability. MFT encourages shared learning and support. Group sessions provide both guidance and peer learning. This process normalizes struggles, reduces stigma, and builds resilience. For emotionally fragmented families like Anne's, mutual support counters isolation. MFT restores relational connections and fosters long-term resilience (Lo & Ma, 2023). Conclusion Anne's symptoms align with DSM-5-TR criteria for emotional lability, interpersonal distress, and dissociation (APA, 2022). Her conflicting desire for closeness and fear of upheaval reflect attachment disruptions and early trauma (Briere & Scott, 2020). Evidence-based therapies provide a structured framework to process trauma and integrate personality. These models enhance regulation and healing through a strong therapeutic alliance (Schwartz & Sweezy, 2022; Jensen et al., 2022). With an integrative and collaborative approach, Anne has a hopeful path toward self-integration and healthy relationships (Haselgruber et al., 2020). Based on this vignette analysis of Anne, 1. Clarify Duration and Impairment (PTSD Criterion F & G). These are unverified but consider adding an example of how to assess functional impairment (e.g., in work, school, or relationships) during intake. 2. Expand on Impulsivity and Self-Harm in BPD: Anne's impulsivity and self-harming behaviors were noted but could be further exploredwhat forms did self-harm take? Were substances involved? This could help solidify Criterion 4 and support differential clarity. 3. Clarify Why DID is Less Likely. Anne doesn't meet DID Criteria A or B. Strengthen this by stating whether amnestic gaps, voices, or out-of-body experiences were explicitly denied. This strengthens the ruling out process. 4. Treatment Customization. With regards to TF-CBT outline, briefly acknowledging potential adaptations if Anne exhibits avoidant tendencies or dissociation during narrative work, as these may affect her capacity for trauma narration in Phase 2.