In this article, we will present a case report of the therapy that is both psychodynamic and trauma-informed, of Mustafa1 a 10-year-old Afghani immigrant to Switzerland referred for psychotherapy in the context of being assigned to a therapeutic school because of scholastic and behavioral problems. His teachers wondered whether he suffered from Attention-Deficit/Hyperactivity disorder (ADHD). During his first session, his therapist noted a lot of anxiety, which appeared to trigger his externalizing symptoms. Mustafa displayed multiple fears of injury and aggression triggered by ordinary loud sounds (e.g., pencils rolled in their aluminum box) or by peers (e.g., anger outbursts), and when asked about his mental "absences" Mustafa said:believing he was asleep:"I had a nightmare." This curious symptom observed both in the classroom, in therapy sessions, and at home by his family contained elements of derealization (seems like a "nightmare") and depersonalization (Mustafa saw himself "sleeping" as if being outside himself and sleeping at the same time). Further history revealed that Mustafa who is of Hazara ethnicity was forced to leave Afghanistan with his family in 2015 at 4 years old due to persecution of the Hazara and the murder of his father by the Taliban. He was shot at close range as he attempted to protect Mustafa's older brother. Mustafa:who did not likely witness that:was in earshot, with his aunt rushing him to safety next door. After the murder, Mustafa, his mother, older brother, and sister left Afghanistan and arrived in Switzerland after a 3-month journey. His sister described their immigration as long, difficult, and triggering persistent fears of loss. It was fraught with the uncertainty of difficult passages in secret across mountainous regions in which there was a risk of further attacks within Afghanistan. They were unsure of whether they would have enough food and water, or if they would ever be able to return for their belongings as they were only able to take what they could carry in a small backpack. They did not know if they would ever again see the family whom they left behind. Subsequently, the family faced placement and resettlement in settlement camps where they feared illness, maltreatment, and met the uncertainty of not knowing where they would be sent next, if they would be able to stay together, and if they would be able to remain where they were sent and to thrive. Moreover, when the family finally arrived in Switzerland, they were left on their own, with very little information given about where they were, where they could get food, where they will be next and how long it would take to complete the immigration legal process.
During his first school year in Switzerland, the patient presented with motor restlessness, difficulty concentrating and impulsive behavior, emotional dysregulation, as well as recurrent disruptive behavior in class including aggression toward his peers. For that reason, he was transferred to a therapeutic school (with fewer students and more teaching staff). There, the patient presented additional, transient "absences" during which the patient did not seem to hear the adults speaking to him and appeared to stare and to be internally preoccupied. He also displayed startle responses to abrupt sounds or agitation by his peers. After being startled, he seemed disorganized. At that time, he admitted having intrusive, frightening images of faceless men fighting, holding weapons, women and children crying, and nightmares of intruders, monsters. The patient also exhibited avoidance and emotional numbing during verbal and physical conflicts between classmates as well as hypervigilance and irritability. He complained of fatigue due to awakening in the night, worries about his mother and other people in Afghanistan, and fears that something bad would happen again to him and his family. Re-experiencing, avoidance, hyperarousal, and negative cognition symptoms according to the DSM-5:strongly suggested a diagnosis of PTSD related to early experiences in civil war-torn Afghanistan. Moreover, the patient's symptoms involving the moments of absences:not consistent with any neurological difficulties, but rather feeling as if he was in a dream or movie and looking at himself and his classmates from afar (i.e., derealization and depersonalization), pointed toward the specific subtype of PTSD:called dissociative PTSD:which is characterized by abnormally high activation of several brain regions associated with emotional regulation and arousal modulation. We did not feel that Mustafa's dissociative symptoms were pervasive enough to say that he had a dissociative disorder independent of PTSD of a dissociative subtype.