Case Conceptualization and Treatment Plan: Extremely Loud and Incredibly Close

Case Conceptualization #2
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Oscar from Extremely Loud and Incredibly Close
The novel Extremely Loud and Incredibly Close by Jonathan Safran Foer narrates the story of a nine-year-old boy who loses his father, Thomas Schell, in the 9/11 terrorist attacks in 2001 (Glazebrook, 2005). Oscar Schell is incredibly close to his father, and the loss devastates him. The novel is told from Oscar's point of view, and his innocence and childlike perspective of the world make the story more poignant. To deal with his grief, he travels on a journey to find a lock that could fit his father's hidden key. His coping mechanism takes him all over New York City and gets him into contact with various people who have their own stories regarding 9/11. In his journey, he gradually realizes that the lock is not the only thing he is looking for but also a way to cope with his loss and accept the happenings and lack of closure of what occurred on that fateful day. The book explores the themes of loss, grief, and love and how Oscar came to terms with his father's death.
Behaviors, Thoughts, Emotions, Relationship Changes, and Spiritual Alterations the Character is Experiencing.
Oscar's thoughts shift from chapter to chapter, but deep down, he tries to come to terms with his dad's demise. In this regard, he feels safe dealing with death as an imaginary concept rather than facing the reality behind it. His non-stop activity when he talks about rapid-fire speed and cracks jokes on the limousine ride to the cemetery for the funeral is a way of showing grief. He later describes the letters he began to write after his father's death to connect to people. In the second chapter, the book describes a letter by Oscar's grandfather, who grieves differently from the lack of communication. He has the words "Yes" and "NO" tattooed on his palms and carries a day book.
Losses Incurred by Oscar
Oscar is experiencing the loss of his father, hope of closure, part of his identity, and love and affection from his dad. Additionally, he has lost support, someone to joke and perform activities with, potential loss of financial security, the illusion of safety, and loss of control over how to grieve and adjust to the losses.
How Oscar Is Responding to the Loss
In the third chapter, Oscar describes the bracelet he made for his mother using the different colored beads that depicted his father's last voice message in Morse code. Since his father's death, he had trouble with several things that triggered him, like crossing suspension bridges, showers, and being around Arab people. Oscar also frequently bruises himself due to guilt as a way of punishing himself physically. For instance, when he falls asleep on the floor, and his mom pulls off his shirt to get him into pajamas, he is afraid that her mom will notice the forty-one self-inflicted bruises on his chest. One of his rules is only to wear white clothes. Oscar's relationship with his mother changed, for he started hiding things from her to protect her, such as the calls that dad made before his death.
Oscar has insomnia, and he calls his grandmother using a walkie-talkie because both are afraid of being abandoned again. When rummaging through his dad's closet, he finds a letter with the initials Black with a key inside. Towards his journey, Oscar packs his cell phone, flashlight, and Hamlet's script, which symbolizes that he is trying to cope with his father's death just as hamlet is doing. He later met Mr. Black, who never left his apartment for 24 years due to his wife's death whereby; by helping him move out of it, he was helping himself escape from some of the guilt that kept him locked inside his head. Magical thinking is a component of how characters in the novel relate to death, whereby grandpa writes letters to his unborn son while Mr. Black nails a nail on a tree every day to commemorate his wife. Oscar keeps his father's voice on the answering machine in his closet.
Relevance of any DSM-5-TR Diagnosis
Grief and depression have similar symptoms but are distinct from each other. The difference is that the former decreases over time and occurs in waves triggered by reminders or causative thoughts. Comparatively, depression presents itself regardless of the circumstance. Prolonged Grief Disorder -DSM-5-TR diagnosis is relevant in Oscar's case, for six months have elapsed since his father's death. Prolonged grief disorder is an extended maladaptive grief reaction that can be diagnosed after a year has elapsed since the demise of a loved one and at least six months for children and adolescents for criteria A (Haneveld et al., 2022). The diagnostic criterion B is the development of an endless grief reaction present most days to a clinically substantial level. Oscar has a strong desire for her deceased dad, and his mind is preoccupied with thoughts and memories of his father. Criteria C for diagnosis of prolonged grief disorder is at least three symptoms since the death that has been present to a clinically significant degree occurring nearly every day.
Oscar presents intense loneliness due to his father's death, difficulty reintegrating into his regular activities after the loss, a sense of disbelief about the demise, and severe emotional pain. Criteria D entails the death causing significant clinical distress in social, occupational, and other areas of functioning. Criteria E is the duration of the grieving process exceeding the expected period following an individual's cultural and religious norms. Lastly, criterion F is the symptoms of the condition are not similar to other mental disorders, such as PTSD or major depressive disorder, that are not attributed to substance abuse or medication. In Oscar's case, the diagnosis is fully met for Prolonged Grief Disorder.
Biopsychosocial Factors Influencing the Etiology and Development of Prolonged Grief Disorder
There is a particular way each individual perceives loss and death and deals with grief. In this regard, various risk factors influence the etiology and development of prolonged grief disorder. Culture impacts the manifestation of the disorder as collective beliefs about the grieving process, psychological healing, and beliefs surrounding death varies between cultures (McGoldrick et al., 1991). Family values, systemic processes, and dynamics can also impact the concept of loss and grief. Risk factors for developing complicated grief entail a history of depression, post-traumatic stress disorder, and anxiety. Another factor is unexpected or violent death which is evident in Oscar's father, whose death is unplanned and caused by the 9/11 bombing.
Social loss or isolation is another risk factor for developing complicated grief due to losing a friendship or a support system. Oscar had a close relationship with his father compared to his mother; therefore, his dad's loss of social support can contribute to prolonged grief disorder. Other factors include life stressors such as financial hardships, a child's loss, a history of previous losses, physical health, mental health history, and traumatic childhood experi...