#fictional case study

Diagnostic Study: The Case of Luis Serra Navarro

Accurately diagnosing psychological disorders is a cornerstone of adequate mental health treatment, especially in cases of trauma-related conditions like Post Traumatic Stress Disorder (PTSD). Misdiagnosis or underdiagnosis can delay care, exacerbate symptoms, and reinforce stigma—primarily for individuals who mask distress behind humor or competence, as seen in high-functioning trauma survivors. This case study explores the psychological profile of Luis Serra Navarro, a character from Resident Evil 4, to better understand how PTSD manifests in complex sociocultural and moral contexts. Through clinical frameworks like the DSM-5 and Cultural Formulation Interview (CFI) and using evidence-based assessment tools, this paper examines the behavioral and cultural dimensions of Luis's trauma.

Character Description & Context

Character’s Role

Luis Serra Navarro is a prominent supporting character in Resident Evil 4 and its 2023 remake. Formerly employed by the Umbrella Corporation and later coerced into working for the Los Iluminados cult, Luis is a biologist with extensive knowledge of parasitology, notably the Las Plagas parasite. Throughout the game, he allies himself with protagonist Leon S. Kennedy to combat the bioterror threat and assist in rescuing Ashley Graham, the U.S. President’s daughter. His character arc centers around seeking redemption for his involvement in the creation and spread of the parasite.

Behavioral Overview

Luis is portrayed as intelligent, charming, and somewhat roguish, often using humor and flirtation to mask emotional concerns. Though initially mysterious and morally ambiguous, he reveals a strong sense of conscience and regret for his past actions. He demonstrates courage, loyalty, and a desire to protect others despite having once contributed to the very crisis he now seeks to resolve. His behavior includes occasional evasiveness and emotional distance, but he gives his life in the game to help Leon and Ashley, exhibiting his shift toward altruism.

Strengths & Challenges

Luis’s strengths lie in his scientific expertise, quick thinking, and interpersonal charm. He is resourceful under pressure and capable of forming alliances even with those initially suspicious of him. However, his past affiliations and internal guilt present psychological and moral challenges. He struggles with shame related to his scientific work with Umbrella and Los Iluminados, and his attempts to atone suggest an internal conflict between his past and present identity. His sense of isolation and the burden of responsibility shape many of his decisions, ultimately defining the emotional trajectory of his character.

Cultural Factors

Luis is a Spanish man from the rural village of Valdelobos, located in Spain. His heritage is rooted in European and Spanish traditions, which are reflected in the game's religious and cultural motifs. While the narrative does not explicitly explore his socioeconomic status, the setting of his hometown suggests a humble origin. His familiarity with both high-level scientific institutions and rural life implies a character who has navigated substantial cultural and social shifts. This duality adds complexity to his identity and motivations within the story.

Diagnostic Impressions & Conceptualization

Primary Diagnosis & Codes

The table below outlines the conditions Luis is experiencing, organized by primary diagnosis, ruled-out conditions, and relevant Z-codes indicating contextual and psychosocial factors.

Table 1 Diagnostic Codes for Luis Serra Navarro

Primary Diagnosis F43.10 – Posttraumatic Stress Disorder (PTSD) without Dissociation & without Delayed Expression Ruled Out Diagnoses F33.1 – Major Depressive Disorder, Recurrent, Moderate F41.1 – Generalized Anxiety Disorder F42.2 – Obsessive-Compulsive Disorder With Good or Fair Insight, Non-Tic Related (OCD) Z Codes Z60.4 – Social exclusion or rejection Z60.5 – Target of perceived adverse discrimination or persecution Z65.5 – Exposure to disaster, war, or other hostilities Z69.82 – Encounter for mental health services for perpetrator of non-spousal or non-partner adult abuse Z72.0 – Tobacco Use Disorder/ Mild Z91.49 – Personal history of psychological trauma

Diagnostic Justifications

Based on the Cultural Formulation Interview (CFI) and Luis’s results from the PTSD Checklist for DSM-5 (PCL-5) with Life Events Checklist for DSM-5 (LEC-5) and Criterion A, the most appropriate diagnosis is Posttraumatic Stress Disorder (PTSD), DSM-5 code F43.10. This diagnosis is supported by a combination of his subjective trauma narrative and objective symptom severity, specifically a PCL-5 total score of 56—well above the clinical threshold of 31–33 recommended for identifying probable PTSD (Bovin et al., 2016). Luis meets the DSM-5 symptom clusters required for a PTSD diagnosis, including intrusive re-experiencing (ex., distressing nightmares & flashbacks), persistent avoidance (of memories, conversations, and trauma reminders), negative alterations in cognition and mood (including guilt, shame, and emotional detachment), and changes in arousal and reactivity (ex., hypervigilance & disrupted sleep) (APA, 2022). The PCL-5’s reliability and validity, especially in trauma-exposed populations, lend strong psychometric support to this clinical formulation (Bovin et al., 2016).

Luis’s subjective experience of trauma is characterized not only by exposure to life-threatening events but also by moral injury or the psychological distress resulting from actions that violate greatly held moral beliefs. His distress is compounded by feelings of complicity in unethical scientific research and betrayal by the institutions he once trusted (Umbrella Corp. & Los Illuminados). These features are consistent with recent research demonstrating strong associations between betrayal trauma, emotional dysregulation, and moral injury in the development of PTSD symptoms (Mojallal et al., 2025). Luis’s self-reported shame, disconnection from cultural identity, and unresolved guilt reflect the internalized consequences of these moral violations. He describes ongoing emotional numbness, isolation, and self-alienation in both the CFI and LEC-5, all of which are consistent with trauma-related emotional dysregulation and identity disturbance.

The CFI further contextualizes these symptoms within Luis’s cultural background. He identifies as Spanish and was raised in a Catholic village with strong moral and communal expectations. His dislocation from this value system, combined with a persistent fear of retribution and estrangement from meaningful social ties, appears to exacerbate his psychological distress. While clinician-administered interviews and self-report measures remain the gold standard for PTSD diagnosis, research also supports the utility of physiological reactivity to trauma cues as a supplemental measure. For instance, Bauer et al. (2013) discuss how psychophysiological responses, such as heightened arousal to trauma-related imagery, can offer additional insight into PTSD’s neurobiological underpinnings, especially when subjective reporting is shaped by shame or avoidance.

Alternative diagnoses, such as Major Depressive Disorder (F33.1), Generalized Anxiety Disorder (F41.1), and Obsessive-Compulsive Disorder (F42.2), were considered but eventually ruled out. While Luis presents symptoms like low mood, persistent worry, and occasional rumination, these are better conceptualized as components of his trauma response rather than as primary disorders. His clinical picture is best explained by trauma-related mechanisms rather than by a mood, anxiety, or obsessive-compulsive disorder. There is no indication of manic episodes, psychosis, or substance-induced disturbances that would suggest other differential diagnoses.

Several Z-codes are relevant to Luis’s case, as they help contextualize his PTSD within a broader framework of psychosocial and cultural stressors. Z60.5 applies to his belief that he is being watched or hunted, stemming from both trauma-related hypervigilance and real-world fears linked to his past in unethical research. He perceives his identity as compromised and his safety as under constant threat, contributing to chronic anxiety and social detachment. Z65.5 is relevant due to his prolonged exposure to bioterrorism and violence while working within a corrupt scientific structure. His feelings of guilt over enabling harm (directly or indirectly) support the use of Z69.82, showing moral injury and persistent avoidance. Z60.4 captures his sense of cultural estrangement from his roots, colleagues, and community, resulting from both self-imposed exile and anticipated stigma. Z91.49 applies due to his cumulative exposure to life-threatening events, betrayal by institutions, and the loss of his grandfather. Lastly, although his smoking behavior is unclear, Luis disclosed past use as a coping mechanism, warranting consideration of Z72.0.

Clinical Challenges

Luis Specifically

Treating Luis would present a unique set of challenges due to his communication style, history of trauma, and internalized guilt. Luis tends to deflect serious conversations with humor or charm, which can make it challenging for a clinician to accurately assess his emotional state. He also exhibits avoidance behaviors and may be hesitant to disclose distressing details about his past, specifically regarding his involvement in bioweapon development and the deaths it caused. His trauma is further tested by a strong sense of moral injury (feeling responsible for harming others through his scientific work), which may result in low self-worth or resistance to self-forgiveness. Clinicians should avoid pressing him for disclosures too early and should be mindful of his tendency to mask vulnerability with wit or deflection. A trauma-informed approach that emphasizes safety, trust, and collaboration would be essential in building rapport.

Supporting Clients With PTSD: Application to Luis

Clients with PTSD often experience symptoms such as hypervigilance, avoidance, intrusive thoughts, and difficulty regulating emotions. A common challenge in treatment is that these clients may have learned to cope by detaching from or minimizing their own emotional needs, leading to underreporting symptoms or appearing “high-functioning” despite significant distress. It is crucial to avoid pathologizing coping mechanisms that have historically served as survival strategies. Providers must be especially mindful of not retraumatizing the client during assessment or treatment by pushing too quickly into trauma narratives (Kress & Paylo, 2019). Additionally, a common misconception is that PTSD only results from combat or violent assault; in reality, moral injury, betrayal, or prolonged exposure to systemic violence (as seen in Luis's role within Umbrella and Los Iluminados) can be equally debilitating. Treatment should focus on building emotional safety, encouraging resilience, and helping the client process trauma without shame.

Luis, as a Spanish man likely from a working-class background, may perceive a PTSD diagnosis with mixed feelings due to both personal and cultural factors. While he exhibits symptoms consistent with trauma, he may hesitate to acknowledge the depth of his distress due to cultural norms around emotional expression, particularly among men in traditional Spanish society. As noted by Gottlieb et al. (2018), although the general Spanish population has relatively low rates of formally diagnosed PTSD compared to other Western countries, individuals with severe psychiatric symptoms are often underdiagnosed, especially men. This suggests a larger cultural barrier to trauma acknowledgment and treatment, possibly due to stigma or lack of awareness within the mental health system.

Further, Luis might view the diagnosis as a sign of weakness or personal failure, given his guilt over past actions and his drive for redemption. He may downplay symptoms to maintain a sense of control or avoid being perceived as unstable, both in professional settings and in personal relationships. Friends (Leon Kennedy and Ashley Graham) or family (if any remain in contact) may react with disbelief, discomfort, or encouragement to simply "move on," reflecting broader societal minimization of psychological trauma. Additionally, due to limited systemic support and possible mistrust in institutions (a reasonable stance given his betrayal by influential organizations), Luis may encounter logistical or emotional barriers to seeking care.

It is worth noting that cultural strengths rooted in his Spanish identity may support Luis’s overall recovery. Values such as perseverance (aguantar), loyalty to one's community, and a strong sense of justice may help him remain engaged in treatment once trust is established. His intelligence, humor, and ability to form meaningful interpersonal bonds (as seen in his alliance with Leon and Ashley) can serve as protective factors and reinforce resilience. Treatment approaches that honor his need for autonomy while offering culturally sensitive trauma care may increase his receptiveness to help and improve outcomes.

Evidence-Based Treatment Recommendations

Individuals with complex trauma histories, like Luis, benefit from evidence-based, multimodal interventions that promote safety, narrative integration, and emotional regulation. The following are recommended treatment approaches based on current research literature.

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)

TF-CBT remains a gold-standard intervention for trauma-related symptoms, predominantly among children and adolescents, but its foundational principles are widely adapted for adults. This modality incorporates psychoeducation, cognitive restructuring, gradual exposure, and emotional regulation strategies. In a comprehensive review of ten randomized controlled trials (RCTs), TF-CBT was found to significantly reduce posttraumatic stress symptoms (de Arellano et al., 2014). Though some studies raised concerns about its efficacy for behavioral problems or depression, TF-CBT’s structured approach and emphasis on building coping skills make it a strong candidate for initial treatment planning with trauma-exposed individuals, such as Luis.

Eye Movement Desensitization and Reprocessing (EMDR)

EMDR has been empirically validated in over two dozen RCTs and is effective for clients with trauma histories involving fragmented or overwhelming sensory memories. It offers a non-verbal, non-narrative pathway for integrating traumatic material, which may be especially beneficial for individuals like Luis, who may struggle to articulate or organize their past experiences coherently. EMDR has also been shown to achieve therapeutic gains in fewer sessions compared to cognitive behavioral modalities (such as TF-CBT), a notable benefit for clients ambivalent about treatment or skeptical of long-term therapy (Shapiro, 2014).

Narrative Therapy

Given Luis’s affinity for stories and characters like Don Quixote, Narrative Therapy offers an appropriate and culturally resonant treatment modality. This approach centers on the client's own storytelling and meaning-making processes, allowing individuals to re-author their experiences and identities beyond their trauma. Xu et al. (2025) identified that therapist behaviors promoting narrative-emotion shifts, such as deepening imaginal experiencing and facilitating reflective storytelling—can support the integration of complex trauma. Narrative therapy respects the client’s autonomy and inner world, which may align with Luis’s intellectual strengths and his need to construct a coherent sense of self following significant identity disruption.

Establishing Safety and Trust: Phase-Based Treatment

Experts in complex trauma endorse a phase-based model of care, which includes establishing safety and emotional regulation before trauma processing. Psychoeducation is often used in this early phase to enhance clients’ understanding of trauma symptoms and coping strategies. Although a recent meta-analysis found that psychoeducation alone does not quite reduce PTSD symptoms compared to treatment-as-usual, it holds promise as a foundation for building treatment readiness and engagement (Brouzos et al., 2022). Cloitre et al. (2011) emphasize the importance of a strong therapeutic alliance, the development of interpersonal skills, and emotion regulation in the early phases of treatment. This is critical for clients like Luis, who may feel exposed or destabilized by trauma-focused work without a secure relational foundation. Skills from modalities like DBT or mindfulness-based strategies may be helpful during this phase to build tolerance for affect and interpersonal closeness.

Psychotropic Medications

Selective serotonin reuptake inhibitors (SSRIs), such as sertraline or paroxetine, are frequently recommended as adjunctive treatments for PTSD and may help reduce hyperarousal, intrusive thoughts, and depressive symptoms (Kress & Paylo, 2019). However, in Spain and among men, cultural attitudes may skew toward viewing pharmacological interventions with suspicion or stigma (Gottlieb et al., 2018). Luis may resist medication if it conflicts with his self-image or values. Thus, any discussion around psychotropic medication must be collaborative and culturally attuned. Providers should validate Luis’s choices while transparently discussing potential benefits, risks, and side effects. Medication may serve best as a supportive element rather than a primary treatment, given Luis’s probable preference for insight-based approaches.

Summary

This case study explored the psychological functioning of Luis Serra Navarro using DSM-5 criteria and culturally informed assessment tools. Based on a comprehensive review of behavioral data, Cultural Formulation Interview responses, and a PCL-5 score of 56, the primary diagnosis is Posttraumatic Stress Disorder (F43.10). Luis meets the diagnostic criteria, including intrusive memories, avoidance, negative alterations in mood and cognition, and hyperarousal. His clinical presentation is further shaped by contextual stressors, as reflected in relevant Z-codes, including but not limited to Z60.5 (perceived persecution), Z65.5 (exposure to hostilities), and Z69.82 (perpetrator of non-partner abuse), which underline the influence of moral injury and sociocultural disruption.

Alternative diagnoses, including MDD, GAD, and OCD, were considered but ruled out due to the symptom pattern aligning more consistently with trauma-related etiology. Clinically, Luis demonstrates barriers to treatment engagement, including emotional avoidance, use of deflection, and possible minimization of psychological distress due to cultural or personal factors. Cultural aspects, such as masculine norms, potential stigma around mental health, and institutional mistrust, may further complicate engagement in care. However, Luis's intellectual insight, interpersonal capacity, and motivation for change indicate favorable prognostic factors. Evidence-based approaches, such as TF-CBT, EMDR, and Narrative Therapy, are recommended, supported by a phased treatment model that prioritizes safety, emotion regulation, and narrative integration.

Conclusion

Luis Serra Navarro’s case illustrates the complexity of diagnosing PTSD when symptoms are shaped by moral injury, institutional betrayal, and cultural dislocation. Through the use of standardized diagnostic tools and culturally informed frameworks, this study emphasizes the importance of considering both clinical symptoms and contextual factors in trauma assessment. Luis’s presentation reflects a trauma profile complicated by guilt and identity disruption. His case reinforces the value of holistic, individualized evaluation in understanding trauma responses and supports the need for trauma-informed, culturally responsive care tailored to the client’s lived experience.

Citations

American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.; DSM-5-TR). American Psychiatric Association.

Bauer, M. R., Ruef, A. M., Pineles, S. L., Japuntich, S. J., Macklin, M. L., Lasko, N. B., & Orr, S. P. (2013). Psychophysiological assessment of PTSD: A potential research domain criteria construct. Psychological Assessment, 25(3), 1037–1043. https://doi.org/10.1037/a0033432

Bovin, M. J., Marx, B. P., Weathers, F. W., Gallagher, M. W., Rodriguez, P., Schnurr, P. P., & Keane, T. M. (2016). Psychometric properties of the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders–Fifth Edition (PCL-5) in veterans. Psychological Assessment, 28(11), 1379–1391. https://doi.org/10.1037/pas0000254

Brouzos, A., Vatkali, E., Mavridis, D., Vassilopoulos, S. P., & Baourda, V. C. (2022). Psychoeducation for adults with post-traumatic stress symptomatology: A systematic review and meta-analysis. Journal of Contemporary Psychotherapy: On the Cutting Edge of Modern Developments in Psychotherapy, 52(2), 155–164. https://doi.org/10.1007/s10879-021-09526-3

Cloitre, M., Courtois, C. A., Charuvastra, A., Carapezza, R., Stolbach, B. C., & Green, B. L. (2011). Treatment of complex PTSD: results of the ISTSS expert clinician survey on best practices. Journal of Traumatic Stress, 24(6), 615–627. https://doi.org/10.1002/jts.20697

de Arellano, M. A., Lyman, D. R., Jobe-Shields, L., George, P., Dougherty, R. H., Daniels, A. S., Ghose, S. S., Huang, L., & Delphin-Rittmon, M. E. (2014). Trauma-focused cognitive-behavioral therapy for children and adolescents: assessing the evidence. Psychiatric Services (Washington, D.C.), 65(5), 591–602. https://doi.org/10.1176/appi.ps.201300255

Gottlieb, J. D., Poyato, N., Valiente, C., Perdigón, A., & Vázquez, C. (2018). Trauma and posttraumatic stress disorder in Spanish public mental health system clients with severe psychiatric conditions: Clinical and demographic correlates. Psychiatric Rehabilitation Journal, 41(3), 234–242. https://doi.org/10.1037/prj0000318

Kress, V. E., & Paylo, M. J. (2019). Treating those with mental disorders: A comprehensive approach to case conceptualization and treatment (2nd Edition). Pearson.

Mojallal, M., Simons, R. M., Simons, J. S., & Swaminath, S. (2025). Betrayal trauma, mindfulness, and emotional dysregulation: Associations with moral injury and posttraumatic stress disorder. Traumatology, 31(2), 212–226. https://doi.org/10.1037/trm0000528

Shapiro, F. (2014). The role of eye movement desensitization and reprocessing (EMDR) therapy in medicine: addressing the psychological and physical symptoms stemming from adverse life experiences. The Permanente Journal, 18(1), 71–77. https://doi.org/10.7812/TPP/13-098

VA: US Department of Veteran Affairs. (2025, May 9). PTSD Checklist for DSM-5 (PCL-5). PTSD: National Center for PTSD. https://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp

Weathers, F. W., Litz, B. T., Keane, T. M., Palmieri, P. A., Marx, B. P., & Schnurr, P. P. (2013). The PTSD Checklist for DSM-5 (PCL-5) – LEC-5 and Extended Criterion A [Measurement instrument]. Available from: https://www.ptsd.va.gov/ https://www.ptsd.va.gov/professional/assessment/documents/PCL5_LEC_criterionA.PDF

Xu, M., Friedlander, M. L., Angus, L., Paivio, S. C., & Carpenter, N. (2025). The weaving of therapist responses with client storytelling to promote narrative and emotional integration of complex trauma. Journal of Psychotherapy Integration, 35(1), 3–20. https://doi.org/10.1037/int0000346

I CAN START Clinical Formulation – Luis Serra Navarro

I – Individual (Counselor)

As Luis’s counselor, I’ll stay mindful of my biases around redemption stories and avoid over-identifying with his guilt. His charm and humor are protective, not resistance. I’ll also be aware of cultural dynamics around masculinity, emotion, and moral injury.

C – Contextual Assessment

Luis is a Spanish biologist formerly involved with Umbrella and later coerced by Los Iluminados. His trauma includes moral injury from past unethical scientific work, religious and cultural conflict, and community disconnection. He presents with symptoms consistent with complex trauma.

A – Assessment and Diagnosis

Primary Diagnosis: PTSD (F43.10)

Luis meets DSM-5 PTSD criteria with symptoms including:

Intrusive thoughts and nightmares

Avoidance of trauma reminders

Guilt, emotional numbing, detachment

Hypervigilance and sleep disturbance

Rule-Out Diagnoses:

MDD, GAD, and OCD traits are present but tied to trauma and don’t meet full criteria.

Assessment Tools Used:

PCL-5 (Score: 56), LEC-5, Criterion A

Relevant Z-Codes:

Social exclusion, discrimination, war exposure, trauma history, mild tobacco use, perpetration-related distress.

N – Necessary Level of Care

Outpatient trauma therapy (weekly individual sessions). IOP may be considered if functioning worsens. No current need for inpatient care. Optional referral to psychiatry for SSRIs, approached with cultural sensitivity.

S – Strength-Based Lens

Luis’s recovery is supported by:

Intelligence and scientific insight

Humor and interpersonal skill

Courage and loyalty

Cultural values like perseverance and justice

Motivation to make amends and form connections

T – Treatment Approach

Psychotherapy:

TF-CBT: Manage intrusive thoughts, reduce avoidance, address guilt.

EMDR: Process overwhelming trauma memories nonverbally.

Narrative Therapy: Re-author his story with values like honor and redemption.

Phase-Based Trauma Care: Prioritize emotional regulation and safety before trauma processing.

Optional Pharmacotherapy:

SSRIs (e.g., Sertraline, Paxil) for sleep, hyperarousal, or persistent distress if needed.

Psychoeducation:

PTSD and trauma impacts, moral injury, mindfulness/DBT skills.

A – Aims and Objectives

Short-Term Goals (within 20 days):

Build rapport and reduce defensive humor in session.

Decrease PCL-5 scores by 25%.

Increase insight into avoidance with psychoeducation.

Begin constructing a trauma timeline and identifying values.

Long-Term Goals:

Rebuild a compassionate self-narrative.

Find purpose through prosocial activities.

Reconnect with supportive, value-aligned communities.

R – Research-Based Interventions

TF-CBT for trauma-related thoughts (de Arellano et al., 2014)

EMDR for nonverbal memory integration (Shapiro, 2014)

Narrative Therapy for identity rebuilding (Xu et al., 2025)

Phase-based care for safety and trust (Cloitre et al., 2011)

SSRIs as culturally-sensitive adjunctive support (Gottlieb et al., 2018)

T – Therapeutic Support Services

Individual Therapy: Weekly trauma processing

Group Therapy: Moral injury and PTSD support

Peer Support: Shared experience of ethical conflict

Community Engagement: Purposeful reconnection

Disclaimer

This case conceptualization was created for academic and narrative purposes only. Luis Serra Navarro is a fictional character owned by Capcom, and part of the Resident Evil franchise. This essay is not intended to be used as a diagnostic tool for real individuals, nor is it representative of any official clinical stance. The treatment plan and analysis reflect a speculative, trauma-informed lens and are shared for educational, creative, and fandom-based exploration. Any assessments referenced (e.g., PCL-5, LEC-5) were completed “in character” and will not be shared in full to preserve academic integrity and prevent potential misuse. Reblogging, commenting, and discussing are welcome and encouraged. However, please do not repost, rehost, or cite this work outside of Tumblr without explicit permission.