Case Study 1
Lillie Damen
Chapman University
Patient Information: Jack
· 14 year old adolescent male referred to the clinic by his parents.
· Decreased peer interaction
· Has abruptly quit the football team
· Grades have gone down from a “B” average
· Frequently leaves home without eating breakfast
· MMPI score 2-7-0
· Decreased interest in school and its purpose
· Parents recently found a joint in minor’s bedroom, which he denies knowing where it came from
Parents Information:
· Increased problems with employment
· Possibility of pay cuts and being laid off
· They would like us to do something fast to save their son
DIAGNOSIS:
The first step I will take towards a diagnosis is to perform, both, a psychosocial and clinical assessment. Since the adolescent was referred to the clinic by his parents, I will begin by performing an interview with them. After establishing their perspective, I will continue by interviewing the adolescent.
In this assessment process, my goal is to identify or rule out any biological or psychosocial causal factors. Also to determine the possibility for an Adjustment Disorder caused by life stressors, and to obtain an overall social and behavioral history. An extremely important consideration I must maintain throughout this process is the possibility for suicide ideation.
Biological Factors:
Hormonal imbalances are a contributory cause for abnormal behavior. Hormones are chemicals in our bodies that are released by the endocrine glands. These glands release their own set of hormones directly into the bloodstream. According to James N. Butcher, these hormones then travel to diverse parts of the body, including the brain, therefore stimulating different types of behavior such as fight-or-flight and other physical expressions of mental states (James N. Butcher, 2010).
A second biological factor to consider is that of temperament. Temperament refers to the way a person reacts to certain stimuli and their ability to self-regulate. It is considered to be strongly influenced by genetic disposition and can set the stage for development of psychopathology later on in life. Interviewing both the parents and Jack will give me some insight regarding both of these factors.
Psychosocial Factors:
If we consider the Behavioral Perspective, which is rooted in Pavlov’s Classical Conditioning or, as later named by Skinner, Operant Conditioning (James N. Butcher, 2010), people become reinforced and encouraged by those who surround them. Therefore, interviewing both Jack and his parents may provide useful information regarding the family dynamics and any behavioral patterns reinforced or enabled by these relationships.
Some of the psychosocial causal factors that I will be looking for during the assessments include:
1. Signs of early deprivation or trauma- certain things are very crucial during our childhood. Some people are resilient; others never seem to get over it. Obviously, a lot is dependent on the severity of the trauma.
2. Inadequate parenting styles- parents either too permissive or too authoritarian will cause a child to develop certain behavioral patterns that may become a part of their personality, particularly if dynamics occurred during crucial developmental years.
3. Marital discord and divorce- this is a factor that increases a person’s susceptibility to certain life stressors. This is a very important consideration in Jack’s case since his parents have admitted to certain discords due to employment and financial stressors.
4. Maladaptive peer relationships: Peer relationships are crucial in an adolescent’s life. Any conflict, such as bullying can cause a child to withdraw and feel lonely. Being either the bully or the person being bullied does not result in good mental health outcomes. In the case of Jack, it is important that we understand the cause for his withdrawal from friends and social activities such as the football team. This behavior could be a symptom of his disorder, or it could be another stressor contributing to it.
Adjustment Disorder:
The last possibility I would like to consider is that of Adjustment Disorder. This disorder is a reaction to common life stressors that have caused major disequilibrium to the individual. This disorder can be seen in children and adolescents and it can manifest itself through school-phobia or separation anxiety disorder in young children. It is a fairly mild disorder and therefore very responsive to treatment. If the disorder lasts more than six months a different diagnosis must be considered.
PSYCHOLOGICAL ASSESSMENT:
Psychological assessments give us some understanding about the nature and the degree of any given pathology. They can help us interpret the intensity, duration, and the quality of the symptoms. In Jack’s case, the assessment was done on an MMPI scale and the results were 2-7-0.
These results measured symptomatic depression along with anxiety and obsessive, worrying behavior. It also reports symptoms of social introversion. All of these symptoms are supported by his parent’s initial concerns.
These results, along with the other biological and psychosocial assessments will allow me to diagnose Jack. The results of the MMPI are helpful in determining the diagnosis, but the other assessments are helpful in understanding Jack’s biological and behavioral history. All of which, are important not only in determining the disorder, but also in determining treatment alternatives.
My biggest concern is the possibility of suicide. His loss of appetite, potential drug use, loss of interest in school, sports and connection with others are definitely red flags which support this concern.
It is important to pay attention to any clues that may be present. The following are four types of clues that are indicative of suicidal ideation:
1. Situational/Circumstances- any major situation going on in the home, i.e. parental discord due to finances
2. Depressive Symptoms and their intensity: drug use, loss of appetite, loss of interest in activities that use to be important
3. Verbal Clues- what the individual is saying
4. Behavioral Clues: is he hurting himself?
The best way to approach this concern is by being direct. Having an honest discussion with Jack is the best way to gage whether a suicidal concern is warranted. I will begin by asking him if he has any thoughts of hurting or harming himself.
TREATMENT:
The prognosis for stress disorders is better the earlier it is diagnosed and treated. In Jack’s case, I would start with psychotherapy, providing for him a safe environment in which he can share and talk about his feelings in regards to the experiences he is facing. A challenge may be the fact that Jack was referred to the clinic by his parents and he may not be willing or ready to undergo therapy. Treatments and outcomes depend on the patient’s willingness and motivation.
At the appropriate time, I would introduce some form of family therapy, working with the family as a unit on communication and mechanisms to cope with stress. In Adjustment Disorder the symptoms go away when the stressor ends, or when the person learns to cope with it (James N. Butcher, 2010).
Since drug abuse and dependency tends to run in families, it is important to address the possibility of drug use and addiction. Depending on the severity, rehabilitation therapy may also be necessary.
Common treatment for suicide ideation is chemical treatment with antidepressant medication. Unfortunately, studies show that in adolescents, suicide ideation increases with the use of antidepressant medications (James N. Butcher, 2010). Again, Family and Marital Therapy will be an effective treatment. Therapy will be directed at reducing any amount of stressors and hostility within the family. Also, focusing on any relationship issues and trying to help Jack and his parents understand and change any maladaptive interactions.
Most importantly, I recognize that my job is to not only address the symptoms, but also understand and treat the causes of the behavior. Therefore, throughout treatment, I will consider all the causal factors, including possible biological and psychosocial, and family dynamics in general.
James N. Butcher, S. M. (2010). The Biological Viewpoint and Biological Causal Factors. In S. M. James N. Butcher, Abnormal Psychology (pp. 63-65). Boston: Pearson Education, Inc.
Case Study 2
Lillie Damen
Chapman University
· 55-year-old, single, Caucasian male
· Complaints of anxiety and depression
· Divorced for the past three years, and has no contact with his ex-wife
· Has no significant other
· Limited contact with his two children who are married with children of their own
DIAGNOSIS: I must consider several factors before I can proceed with the differential diagnosis of Mood Disorders, including Depression and Adjustment Disorder with Depressed Mood. I must also consider the possibility for a diagnosis of Anxiety Disorder.
IMPORTANT FACTORS TO CONSIDER:
i. Psychosocial and Biological Factors
ii. Stress Adjustment Disorder
iii. Are there any specific age, gender, or race issues
iv. Social and behavioral history
v. Major Depressive Episode
vi. Substance abuse or dependency
vii. Suicide Ideation
viii. Identify sources of strength: friends, family, hobbies
ix. My role and potential biases
x. Treatment options
I would like to start by clearly identifying and describing the disorders being considered in this diagnosis. They are Depression, including Major Depressive Episode, Adjustment Disorder, and Anxiety Disorder.
DEPRESSION: is a mood disorder that affects the entire body. An individual who is suffering from depression may experience changes in their physical body, thoughts, and moods. It will affect the way the individual perceives himself and the world around them. Depression is characterized by overwhelming feelings of sadness and dejection (James N. Butcher, 2010). Some of the symptoms of depression may include, but are not limited to, memory loss, irritability, change in appetite and sleep patterns, chronic fatigue, helplessness and hopelessness, and loss in interest in things that were once pleasurable.
MAJOR DEPRESSIVE EPISODE: In order to consider a diagnosis for this disorder, the individual must be experiencing three or four other symptoms, in addition to those of depression. These symptoms include:
i. Cognitive: Feelings of worthlessness or guilt
Thoughts of suicide
ii. Behavioral: Fatigue
Physical agitation
iii. Physical Symptoms: Changes in appetite
Changes in sleep pattern
I must also consider the severity and duration of such symptoms.
ADUSTMENT DISORDER: is a reaction to common life stressors that have caused major disequilibrium to the individual. The experiences we have to face may be on an emotional, mental, or physical level. It is a mild disorder and therefore very responsive to treatment.
ANXIETY DISORDER: The most obvious manifestation of an anxiety disorder is the presence of unrealistic and irrational fears or anxieties that will disable the individual’s ability to function (James N. Butcher, 2010). Several symptoms must be present in order to consider this disorder. These include, excessive amounts of anxiety and worrying occurring during most days than not, individual unable to control the worry, anxiety and worry must be associated with three or more of the following symptoms on most days than not: (James N. Butcher, 2010)
· restlessness or feeling wound up
· easily fatigued
· experiences difficulty concentrating
· irritable
· muscle tension
· sleep pattern disturbance
· symptoms severely affect functioning
HYPOTHESIS: At this point, my hypothesis is that Bob is suffering from Major Depressive Episode. I will take into consideration that there may be a precedent for Generalized Anxiety Disorder. Stressful events in life are known to be causal factors involved in the onset of a variety of mood disorders. According to Monroe & Hadiyannakis, separations such as divorce are strongly correlated with depression, also known to precede generalized anxiety (James N. Butcher, 2010).
The process by which I will prove or disprove my hypothesis will involve many steps. I will focus on ruling out those disorders that I have considered as possibilities.
PSYCHOSOCIAL FACTORS: I will attempt to determine the underlying issues. Is there a trend in the way the patient views and deals with the world around him? He has suffered a great deal of losses recently in his life. Since how we think about things has a lot to do with how we feel and act, I have to condider whether these stressful life events have been generated by the Bob’s behavior or personality. In other words, does he have a negative view of himself and the world around him? Determining all these factors and their causality is also detrimental in establishing proper treatment.
BIOLOGICAL FACTORS: Hormonal imbalances are a major contributory cause for abnormal behavior. Hormones are chemicals in our bodies that are released by the endocrine glands. These glands release their own set of hormones directly into the bloodstream. According to James N. Butcher, these hormones then travel to diverse parts of the body, including the brain, therefore stimulating different types of behavior such as fight-or-flight and other physical expressions of mental states (James N. Butcher, 2010).
A second biological factor to consider is that of temperament. Temperament refers to the way a person reacts to certain stimuli and their ability to self-regulate. It is considered to be strongly influenced by genetic disposition and can set the stage for development of psychopathology later on in life.
The best way to identify any psychosocial or biological factors is by administering a series of assessments. The following are some of the assessments I would consider performing:
i. Assessment Interviews: Asking the client the day, time, year, and who the president is can give me an idea if this individual is really oriented. It can also help me determine how aware he is of his environment. I will also utilize this interview to determine social and behavioral histories.
ii. Clinical Observations of Behavior: How does the person look? Do they look depressed, tathered, unkept? This might help me determine the severity of their disorder by establishing their level of functioning.
iii. Psychological Tests: There are several psychological tests I can administer and evaluate in relationship to established norms. These tests can give me an understanding about the nature and degree of pathology by establishing the intenstity, duration, and quality of symptoms. I will consider three of these tests.
a. MMPI: This test can be used as a diagnostic standard by evaluating an individual’s personality characteristics and clinical tribulations (James N. Butcher, 2010). An elevated score of “2” will indicate depression, “7” anxiety, and “10” social isolation. All of which are under consideration for diagnosis.
b. RIT: This is a good perception test. It is a very tedious task but it is very helpful in understanding how an individual looks at their environment
c. TAT: This test involves thematic content. The individual is asked to look at cards with pictures and tell a story, based on these, including beginning, middle, and end. The result can be very indicative of what is going on in this person’s life.
My next step is ruling out Stress Adjustment Disorder. As I stated earlier, this disorder is a reaction to common life stressors. This disorder will manifest itself within three months of the onset of causal factors. Therefore, I must determine the timing of Bob’s symptoms. If they have been present for six months or longer, than I can rule out this disorder. Otherwise, this disorder is relatively easy to treat. It responds well to counseling.
I will also consider any age, gender, and race issues that may be present. According to the DSM-IV TR, melancholic features in Major Depressive Episodes are more common in older depressed people. This concurs with Erikson’s Maturity and Old Age Stage which is an age when there is an increasing amount of looking back at one’s life with either happy resignation about one’s accomplishments and willingness to continue to live a happy life, or a great amount of despair. In Bob’s case, this would definitely be a contributory factor since he has experienced several losses and failed relationships in the last few years.
Substance abuse or dependency is always a concern and must be considered when diagnosing a patient with mood disorders. It may include excessive use of tranquilizing drugs, sleeping aides, street drugs, and alcohol, usually complicating the clinical picture. If present, and depending on the severity, rehabilitation therapy may also be necessary.
In conclusion, if I am able to prove my hypothesis, my biggest concern will then be that of suicide ideation. The criteria necessary to prove my hypothesis of a diagnosis of Major Depresseive Episode with a precursor to Anxiety Disorder are:
1. Bob must exhibit three or four cognitive, behavioral, or physical symptoms indicated in the description of Major Depressive Episode above, in addition to the other emotional symptoms of Depression.
2. The duration of the symptoms must be longer than six months,
3. MMPI scores should indicate elevated levels of 2-7-10.
4. Clinical Observations and Assessment Interviews are indicative of disorder
CONSIDERATIONS FOR SUICIDE IDEATION:
This is a gradual wearing down process. In Bob’s case the initial stressors have been occuring within the past few years. Paying attention to certain clues will help determine this possibility. The following are four types of clues:
1. Situational/Circumstances: Divorce and recent job loss
2. Depressive Symptoms and their intensity: One of the red flags in Bob’s case is the lack of social interactions. He has limited contact with his family and no significant other. Studies have shown that people who lack support or are socially isolated are more likely to become depressed. Furthermore, depressed individuals tend to have smaller, less supportive social networks.
3. Verbal Clues: What is Bob saying especially during interviews and other assessments.
4. Behavioral Clues: How does he look? Is he functioning? Is he already hurting himself?
Also consider his level of perturbation, or the degree to which he is upset.
MY ROLE: It is important for the therapist to be direct and honest whenever suicide suspicion is present. The best way is to directly ask him is he is hurting himself. Then consider the method, its availability and lethality.
It is also crucial that I establish a trusting therapist-client relationship with Bob. This will help me identify the major issues and assess available resources to him. Including type of therapy, and his personal resources such as faith, family, friends. These resources need to be mobilize and made available to him if possible.
My attitude must remain professional, positive, calm, and understanding. I must establish his trust by not sounding shocked, but rather demonstrating him that I am in control and know exactly what to do.
TREATMENT: I believe that Cognitive Therapy is very helpful in dealing with these disorders. This therapy provides the environment to talk about cognitions and how the individual handles himself under given circumstances. How we look at things has a lot to do with how we feel and act. Changing the way we look at things will change how we feel about them and, therefore, how we act.
Finally, in regards to Bob’s treatment, it is important that I consider working in tandem with a psychiatrist if biological causal factors have been established, and with family or other social network, especially if dealing with suicide ideation. Antidepressant drugs act on the nervous system. This will cause Bob to feel more energetic, alert, and increase his stamina. If it’s necessary to treat Anxiety Disorder chemically, antianxiety drugs will alleviate levels of anxiety. The downside of these is their addictive traits. It is important to advice client on what to expect when taking these drugs.
James N. Butcher, S. M. (2010). The Biological Viewpoint and Biological Causal Factors. In S. M. James N. Butcher, Abnormal Psychology. Boston
Case Study 3
Lillie Damen
As a school counselor I am faced with a bicultural, 13 year old adolescent whose steady decline in her functioning for the last three months may be indicative of a potentially harmful situation at home. At this point, and with limited information, including hearsay, my hypothesis is that Maria Sangria is potentially a victim of sexual molestation. The reasons I believe this to be a possibility include the fact there has been a change at home by having her family from Mexico stay with them, and Maria has expressed anger at her parents for allowing this; secondly, her functioning has declined in the last 3 months, including her grades and the way she dresses, along with suspicion from her friends that she may be cutting herself; and lastly, her friends express concern that she may be throwing up after meals, which indicates the possibility of Bulimia.
At this point, and before I examine the evidence to support my hypothesis, there are several things I must consider. It is important to investigate Maria’s academic and social history at school. This will help me understand how drastically her functioning has changed, but may also give me some insight as to her dynamics at home previous to her uncle’s family coming to stay with them. In other words, did there appear to be any issues at home before, and did the onset of the symptoms she is expressing begin when her uncle came to stay with them? Another important point that I must not ignore is her family’s culture. Based on personal experience, I understand the dynamics of a Latino family. Not only is there a lot of pride and secrecy when it comes to any family situation, but also the importance of the male hierarchy. Therefore, it is important for me to understand this in order to know the steps to take in approaching Maria and her family, and to know what steps I can take to help this adolescent.
The major factor to consider is, regardless what Maria’s family dynamics were at home, they have now drastically changed by having her uncle’s family come stay with them. Not only is she now sharing a room with her cousins, but Maria has also tried to reach out to her best friend about something her uncle did, but quickly lost the courage. Her best friend has met her uncle and states that he “creeps her out”. Maria’s steady decline in functioning is too drastic to attribute it to being upset about having to share her space with another family.
Her friends express concern that she may be cutting herself. Her look has changed and she is mainly wearing black clothes and long sleeves. According to Dr. Bruce Jacobs from the State University of New Mexico, one of the warning signs of cutting is wearing long pants and long-sleeve shirts (even in warm weather). He also states that cutting is done primarily as a means to cope with painful emotions. The person who cuts will do so in order to escape the feeling of being trapped in an intolerable psychological and emotional situation that they can’t control and are unable to cope with. As discussed in class, cutting can provide temporary stimulation out of emotional “numbness” and hopelessness. Also reported is the feeling of gaining some sense of control over an otherwise uncontrollable situation. It provides an unhealthy, but immediate sense of control, since it gives the person an escape from depressive thoughts and feelings.
The third point that I must consider in backing up my hypothesis is the fact that her friends have also expressed concern that she may be throwing up after meals. As defined by Santrock, Bulimia Nervosa is an eating disorder in which the individual follows a binge-and-purge eating pattern. As with cutting, the act of binging-and purging may make you feel in control of an otherwise uncontrollable situation. According to Loma Linda Health.org, a person may feel that purging temporarily alleviates self-loathing and feelings of vulnerability. Sexually abused children are tormented by shame or guilt. Dr. Carol Boulware from Helpguide.org stated that they may feel as though they brought this upon themselves. This belief can lead to self-loathing.
Taking all these concerns and the facts that support them into consideration, along with Maria’s family culture, the first step I would take is talk to her best friend. Since she has met the uncle I can assume that she could possibly give me some insight on Maria’s family. Based on this information, I would approach Maria, making it clear that my job is to provide her with confidentiality and support in a safe environment. It is important that she feels in control of the next steps to take involving her family. I would also explain to her the importance of getting her help. The different options include individual therapy and family therapy, provided that talking to the family would not pose any danger to her.
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