GENERALIZED ANXIETY DISORDER (GAD)James’ case

BACKGROUND

James who is a doctor suffering from generalized anxiety disorder. At 31 years of age and living in New York, he is unemployed because of his constant anxiety, even at the thought of working. He now lives with his parents off a small trust fund set up for him by an uncle. Although he was an overachiever throughout his academic career, James is having a hard time keeping it together, while his parents are somewhat supportive but disappointed with his medical career.

IDENTIFICATION OF SICKNESS

The brain is a very fascinating and intricate part of who we are and if the brain is not functioning properly, then our reactions to certain situations are not in balance. This is why some people still believe that undeniable psychological disorders are said to be caused by biochemical imbalances. So in James' case, his brain was not functioning right and he was experiencing an unnatural balance of change within his various neurotransmitters, causing him to become anxious, easily irritated, distracted and quite tense. He also complained of headaches, body aches and pains and always feeling tired.

Some of the environmental influences that could lead to general anxiety are:

• Work. This would affect James immensely because his whole life has been based around his becoming a doctor. Even his father wanted him to follow in his footsteps and have a prestigious career.• School. Although James did not experience anxieties until after he graduated from medical school, I'm sure he still felt anxious with tests and schoolwork.• Relationships. This would be dealing with James' parents as they are somewhat supportive but disappointed that his career has not been progressing. He also lost his relationship with his girlfriend of three years because of the stress.• Health. Because James is dealing with this disorder, his health is rapidly declining. He is having headaches, body aches and pains and is always tired. His emotional health is affected as well with feelings of laziness and worthlessness.• Financial. James is realizing that if he cannot work, he cannot earn a paycheck. He is living off a small trust fund set up for him by his great uncle, but that won't last forever. All of these things are considered threats and can cause James to worry excessively which is interfering with his life.

Since James has generalized anxiety disorder, which has been called a 'free-floating' disorder because of his constant worrying and nervousness, as stated earlier, he would need a medication that treats low levels of GABA.

TREATMENT/ THERAPY

The textbook states that the drub benzodiazepine (minor tranquilizers) is the most frequently prescribed. The drug is used for short-term relief and can be hard to stop taking because of dependence issues. One such drug in particular is called Xanax, which is shown to enhance the function of GABA in the brain. It also slows down the central nervous system.

Another approach to treatment is to help James with therapy sessions to try to figure out why he is experiencing all this anxiety and worry. One session may include showing James pictures of things that may make him anxious and then teaching him how to relax deeply to fight his tension. It's called cognitive behavioral treatment, developed in the early 1990s, and is quite successful; however we need both medications and therapy to treat GAD. 

Source: http://www.theravive.com/research/Generalized-Anxiety-Disorder-Case-Study%3A-James

PANIC DISORDERSteve’s case

BACKGROUND

Steve was a 31-year-old sales manager who suffered from attacks of dizziness, blurred vision, and heart palpitations. The first panic attack occurred at work, in the presence of his coworkers, and began with feelings of weakness, nausea, and dizziness. Steve asked a colleague to call a doctor because he was afraid that he was having a heart attack since his father had recently died of one. In addition to this personal loss, Steve was dealing with a lot of stress at work. Several months before the first panic attack, there were times when Steve had been nervous and his writing had become shaky; but apart from that, he had never experienced anything like this before. After a thorough physical examination, his doctor told him that it was stress and anxiety. Nevertheless, the panics continued, mostly at work, and in trapped situations. Sometimes they were unexpected or “out of the blue,” particularly the ones that woke him out of deep sleep. Steve felt tense and anxious most of the time because he worried about having another panic attack. Since his third panic attack, Steve had begun to avoid being alone whenever possible. He also avoided places and situations, such as stores, shopping malls, crowds, theaters, and waiting in lines, where he feared being trapped and embarrassed if he panicked. Wherever he went, Steve carried a Bible, as well as chewing gum and cigarettes, because glancing at the Bible, chewing gum, or smoking cigarettes made him feel more comfortable and better able to cope. In addition, Steve took medication with him wherever he went to help deal with his panic attacks

IDENTIFICATION OF SICKNESS

Panic attacks occur as a part of many different anxiety problems. However, in other anxiety problems, panic attacks usually are not what the person is most worried about. In panic disorder, the panic attacks become the major source of concern and worry.

Continuing with the technical definition of panic disorder, at least one of the panic attacks must be unexpected or occur for no real reason. In other words, the panic seems to occur from “out of the blue.” A good example of an unexpected panic attack is an attack that occurs when relaxing or when deeply asleep. For some people, panic attacks continue to occur unexpectedly, and for other people, the panic attacks eventually become tied to specific situations.

In Steve’s case, agoraphobia develops after panic attacks, resulting in panic disorder with agoraphobia.

THERAPY/TREATMENT

The kind of treatment that is described in this situation is called cognitive-behavioral therapy (CBT). CBT differs from traditional psychotherapies in several important ways.

Unlike traditional psychotherapies, CBT teaches skills to manage anxiety and panic. Specifically, you will be taught ways of slowing your breathing, ways of changing the way you think, and ways of facing the things that make you anxious so that they no longer bother you. For each set of skills, we begin with educational information and then outline exercises to be practiced. Then, we build on the previous practice by developing new skills. Finally, the skills are used to cope with panic and anxiety. Unlike traditional psychotherapies, you will be given homework assignments. Thus, CBT is much like attending class and continuing to learn on your own by further study between classes. In many ways, it is the self-study program that is the most essential to your success.

Unlike traditional psychotherapies, CBT do not emphasize your childhood memories and experiences (unless they are directly related to your panic attacks, as might occur if witnessing someone die of a heart attack when you were a child led you to fear that you will also die of a heart attack). Instead, CBT emphasizes interruption of the factors that currently contribute to your panic disorder and agoraphobia.

Source: http://global.oup.com/us/companion.websites/fdscontent/uscompanion/us/pdf/treatments/map4wkbkch1.pdf

OBSESSIVE –COMPULSIVE DISORDER

Ms. A’s case

BACKGROUND

Ms. A, an 18-year-old woman, presented to our hospital in November 2007 with an insidious onset, 6-month duration of illness characterized by repetitive acts such as cleaning; ritualized bathing, urination, and defecation; excessive need for symmetry in daily activities; and avoidance of morning duties. Nonperformance of proxy compulsions would make the patient aggressive.

IDENTIFICATION OF SICKNESS

A structured assessment was conducted at baseline and at subsequent follow-ups. The Mini-International Neuropsychiatric Interview,4 Wechsler Adult Intelligence Scale-Performance Scale (Indian adaptation),5Yale-Brown Obsessive Compulsive Scale Symptom Checklist,6,7 and a semi-structured clinical interview revealed that she had OCD, an intelligence quotient of 58 (mild mental retardation), contamination obsessions, and cleaning/washing compulsions.

THERAPY/TREATMENT

She was started on treatment with escitalopram 10 mg/day, which was increased to 20 mg over a period of 2 weeks. Differential positive reinforcement and performance-feedback procedures were initiated after family members were psychoeducated. By using differential positive reinforcement, exposure and response prevention was conducted. Initially, the patient received 20 sessions of inpatient behavior therapy on a daily basis and, later, 7 sessions on an outpatient basis.

Follow-up assessment at week 12 revealed that Ms. A was mildly ill on the OCD severity rating scale and on the Clinical Global Impressions-Severity of Illness scale. The patient's parents also reported 90% improvement in her symptoms.

This patient with mild mental retardation and OCD responded to escitalopram and behavior therapy. The improvements attained at week 4 included a 33% decrease (based on a clinical significance formula11) in severity of symptoms; clinically significant reduction in proxy compulsions; and a 50% overall improvement of symptoms, which was reported by the patient's parents and was visible on the Clinical Global Impressions-Improvement scale. Another important issue that requires attention is the substantial decrease in OCD symptom severity and proxy compulsions, which occurred within the first 2 weeks of treatment. This improvement at week 4 (within the initial few weeks) would be attributed primarily to behavior therapy and not

to serotonin reuptake inhibitor (SRI) medication, as it is well known that an SRI would take at least 8 weeks to demonstrate its benefits.

Source: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2708014/

POST-TRAUMATIC STRESS DISORDER (PTSD)Dick’s case

BACKGROUND

Dick is 57 years old, single but in a committed relationship. He resides in southern California and currently lives alone, with plans to co-habitat with his girlfriend in the near future. He is retired from the military after twenty years of service and has also retired this past year from his civilian job. He is in overall good health with recurring kidney stones and general age maladies, but is physically fit. He has no criminal history or addictions to alcohol or other substances. Dick spends the majority of his time alone and does not openly share his PTSD situation with others. His girlfriend is fully aware of his issues with the PTSD flashbacks and bad memories and has shown tremendous support and encouragement. His biological family is spread out, but Dick is in fairly regular contact with them. Overall he reports having good relations with his mother and three sisters. Dick is a retired military man, in his late fifties, suffering from DSM-IV-TR chronic military-related posttraumatic stress disorder (PTSD). He stated that he had served in Vietnam, Panama, Grenada, the Gulf War, and several other armed conflicts. Dick explained that being in the military for twenty years he has been exposed to a wide variety of cultures and environments. He described tours as taking place across the globe and that he had fought in jungles, deserts, and urban settings. He emphasized the most painful wounds that he had sustained could not be seen by the naked eye. He served from late 1970 until mid-1972 in Vietnam and was assigned to rescue missions via river patrol boats and Special Operations. The client was a civilian for a few years, and then re-entered the armed forces and completed his twenty-year career serving in Special Operations, or as he termed it Special Ops. According to Dick, although it has been over thirty years since the Vietnam War, the majority of his problems stem from that time with varying levels of intensity.

IDENTIFICATION OF SICKNESS

Dick is currently concerned with the unexpected onslaught of flashbacks that last from a few hours to a few days. During these times he isolates, shutting himself off from his girlfriend and everything else. This has caused some problems between him and his girlfriend. He behaves in a very clandestine fashion; his behavior is secretive and deceptive. He is a chronic liar about everything for no apparent reason. He has life-long bouts of suddenly becoming distant, withdrawn, non-communicative and flat emotionally (Marshall, Schell & Miles, 2010). He runs from any type of confrontation or emotional outburst and then disappears for great lengths of time. He becomes very agitated and angry then almost comatose and sits and stares blankly for hours on end. During these times, he does not shower or change his clothes for days on

end. He describes feeling in a zombie-like trance. He feels worthless, weak, and powerless against the vivid memories that he describes as being burned into his soul forever

Dick reports that he did not experience any of his current PTSD symptoms during his active duty time. He recalls that a few years after his 1995 retirement, he started to experience outbursts of anger, heightened startle response, survivor’s guilt, extreme difficultly in relationships, especially male-female ones, and frequent, overpowering flashbacks. Dick stated there have been brief spans of time when he was unaware of any prominent symptoms, yet reports that he could not feel regular emotions and mostly just suffered through these times in silence. Dick says he has just made a major geographic relocation this past year and feels very good about the move, but this has triggered some intense flashbacks and other symptoms. Dick decided to seek treatment in the hopes of laying some of his ghosts to rest once and for all. He feels he is in a good stable position emotionally and mentally, as well as very motivated to take a more aggressive treatment approach.

THERAPY/TREATMENT

The client and therapist have agreed on the benefits of using a holistic approach and treating. Dick as a whole person, rather than a man diagnosed with PTSD. Studies done on the effects of trauma have shown that the whole person needs to be explored in depth to understand the totality of trauma memories. The therapist (Yvonne) and the client (Dick) have established a respectful relationship, where both actively contribute to the ongoing treatment plan and willingness to explore whatever options feel like they may work. Both have agreed that the treatment should remain dynamic and what works stays and what does not, goes.

Treatment goals:

Goal #1 Decrease the client's frequency and intensity of flashbacks.a. Keep a daily written journal on thoughts, feelings, and everyday activities.b. Start training three times a week for upcoming bicycle marathon in three months.c. Attend weekly counseling session. d. Learn and practice Eye Movement Desensitization and Reprocessing (EMDR) four times a week for two weeks, increasing two session each week for three months.e. Attend weekly biofeedback sessions for six months.

Goal #2 Increase the client's social network.a. Participate in a veteran's group weekly. b. Make friends with neighbors by going for daily walks of at least thirty minutes a day.c. Dine out at a public facility once a week and greet someone each time.d. Initiate social functions with girlfriend and friends a minimum of once monthly.e. Join a bowling team that meets every week.

Goal #3 Build a happy healthy whole life with his girlfriend.a. Initiate plans to move and be an active participant. b. Daily say or do something nice or complimentary.c. Be as honest as possible, even about the inability to be honest. Practice telling the truth one hour a day, for one week, then two hours a day for one week and continue until the 24-hour goal is reached. (Being silent or not communicating does not count). Keep a schedule of times and dates and work to break each day's record.d. Invite family members of new friends to meet your girlfriend.e. Practice being happy and being in love in a new way every week.f. Learn to want to do the dishes

Three-month time frames have been set for evaluation of each section of the plan with options for extensions, add-ons, extinction, replacement or time-out periods in that one area. The client has a time-out option on all segments of the treatment plan and may use a seven-day time out without reason. After seven days he has agreed to continue or talk it out and process what was not working for him and together they will decide where to go from there. Due to the nature of this particular treatment and the intensity of it, a safety valve of time-outs will be employed. The greatest intervention at the onset is Dick’s enthusiasm and determination along with his open willingness to try a variety of new things. In this sense Solution-Focused Therapy is actively implemented. Dick feels strongly that what he has been doing does not work, even to the point that it is now the problem.

Dick wants to continue building a happy, healthy, whole relationship with his girlfriend. He wants to move in together to a new home that they can share equally. He has expressed strong motivation to improve his interpersonal skills and to be able to feel emotions of any kind. He is ready to try to experience a full life and actually make future plans. He wants to work on being able to open himself up more in a personal manner. He wants to stop lying all the time and being abrupt and sullen. He wants the vivid memories to at least fade to some degree. He wants to leave Vietnam and to be present in his own life.

Source: http://www.academia.edu/2498356/Post_Traumatic_Stress_Disorder_PTSD_Case_Study_One_Mans_Journey

SOMATOFORM DISORDERSAngel’s case

BACKGROUND

The patient, an 11-year-old Caucasian girl, presented with a 5-month history of whole body pain that eventually lead to paralysis of her extremities. She had become non-ambulatory and totally dependent on her parents for all self-care activities over the prior 2 months. Because of the extensive immobility, there were concerns about progressive muscle wasting and contractures.

The onset of symptoms followed a documented viral infection (with evidence of Epstein-Barr viral infection). The diagnostic work-up for this patient involved pediatric office visits and subspecialty pediatric evaluation by immunology, neurology, rheumatology, and physical therapy. Results of ordered diagnostic procedures (e.g., blood work, MRI) were negative. Because the patient's functioning continued to deteriorate, a second neurologist was consulted who recommended an acute psychiatric hospitalization. After 3 days of medical and psychiatric evaluation, the patient was discharged from the psychiatric facility with a diagnosis of severe fibromyalgia. Discharge recommendations included weekly counseling with a licensed social worker and evaluation at an adult pain center. During this time, the patient's functioning had deteriorated to complete immobility and she was using a wheelchair. The family was directed to a third pediatric neurologist (MS), who confirmed a somatoform disorder and recommended treatment with an inpatient pediatric admission.