abnormal psychology, clinical psychology, Cognitive psychology, Cross-Cultural Psychology, Environmental Psychology, Maladaptive psychology, social psychology, Uncategorized

Case Study: Borderline Personality Disorder

Diagnosis:  Borderline Personality Disorder

Background

  • Outline the major symptoms of this disorder.
    • The DSM – V describes Borderline Personality Disorder (BPD) as a disorder that manifests in early adulthood as a pattern of instability in “relationships, self-image, and affects, and impulsivity” (p. 663).  Criteria for BPD includes, the individual portrays aggressive effort to avoid real or imagined abandonment, convey an identity disturbance, reveal suicidal ideation or self-mutilating behaviors, and maintain feelings of emptiness (American Psychiatric Association, 2013).  Additionally, an individual exhibits patterns of instability in interpersonal relationships via extreme devaluation and idealization, and affect due to reactivity of mood (American Psychiatric Association, 2013).  Individuals must portray two potentially self-damaging impulsive behaviors such as sex, spending, or substance abuse as well as exhibit intense anger or the inability to control anger (American Psychiatric Association, 2013).
  • Briefly outline the client’s background (age, race, occupations, etc.).
    • Becky is a 24-year-old college student who lives with her father, who was diagnosed with muscular dystrophy when she was three, in a one-bedroom apartment and sleeps in the dining room.  She lives with her father while trying to attain financial and emotional stability so she can support herself better.  She currently takes two medications (600mg/day) and has never thought of herself as mentally well. Becky is the oldest of five children born over six years.  Raised in a Mormon Church, she now repudiates, she left the church at 15 years old and began attending a Baptist church with her friends searching for a sense of belonging.  However, she claims she was not her “true self.” She expresses self-doubt and feels as if others are dishonestly praising her.  She also deals with a personal internal conflict which manifests through self-mutilation. Becky experiences severe panic attacks if she becomes the center of attention or separated from a person.  Upon uniting, she exhibits verbal rage.  However, she recognizes her irrational behavior and apologizes after she calms down (McGraw Hill Higher Education,  2007).
    • Becky experiences severe anxiety attacks relieved through “cutting”, self- mutilation practice that has progressively worsened over time.  Her first experience of cutting came about when she was left home alone for the weekend in the home she shared with a roommate.  The episode was triggered by a television program that made her cry due to sadness.  She attempted to distract herself and accidently sliced her arm which brought pain and further distraction.  She now uses the technique as a way to punish herself for irrational behavior.  Although Becky claims she is intelligent and possesses the good work ethic and empathy for others, her perception of self is negative as she views herself as unworthy of love and fake to society.  She fears if others find out her true self, they will abandon her (McGraw Hill Higher Education,  2007).

 

    • Becky has found peace with her therapist and views him as a positive and understanding support in her life.  She is proud to say she has had a male friend for five years, the longest ever, leading me to believe her friend is her therapist as she did not expose any further information about the friend or time in therapy. Becky maintains a negative view of the world claiming the human race is stupid, mean, horrible and cruel.  Due to this and biological factors, Becky does not want children (McGraw Hill Higher Education, 2007).

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    •  Although Becky claims to experience panic when she is in the limelight, she volunteered to do the interview to help her overcome her troubles, which seems contradictory.  She claims she wants to finish college and be free of medication and therapy and use her personal experience to help children like her (McGraw Hill Higher Education, 2007).

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  • Describe any factors in the client’s background that might predispose him or her to this disorder.
    • According to the DSM, premature parental loss, neglect, and violent conflict are two features associated with BPD (American Psychiatric Association, 2013). Although Becky has not experienced a parental loss, per se, she is coping with a father who is terminally ill and has been since she was only three years old.  She does not expose how ill her father is or if he suffers from limitations, but she has been living with the possibility of losing him.  Additionally, the violent altercations between her and her family members also support this feature of the DSM.  Becky shared that she did not receive the love and attention she needed in childhood.  She claims that she cried for attention and affection and even went to extreme measures to gain it, but she never received it which implies feelings of neglect.  Additionally, Becky claimed in the interview that mental health problems run in her family, which creates a predisposition to mental illness (Nolen-Hoeksema, 2013).  Another thing that stood out in the interview was Becky claiming that her mother would take all of her frustrations out on her and use her as her confidant even for inappropriate conversation.  Her mother’s behavior in conjunction with possible feelings of spousal abandonment or neglect, and dealing with childhood sexual abuse memories may be symptomatic of an undisclosed or undiagnosed mental health issue that predisposed Becky to her disorder.  In high school. Becky fell in love with a guy who made her feel as if here was potential in a relationship between them. However, he married her best friend.  The incident seems as if it reinforced her unworthiness of love she felt from her mother which holds the potential to cause Becky to exhibit the inability to maintain interpersonal relationships and continually “phase out” relationships she deems as having the potential to leave her feeling abandoned (McGraw Hill Higher Education, 2007).

 

Observations

  • Throughout the course of the interview, Becky often looks away, making little eye contact, and many facial expressions. She also takes long pauses between thoughts.  Becky talks with her hands and smiles often.  When speaking of sleeping arrangements, she snickers as if embarrassed at having to admit her arrangement.  At the beginning of the interactive, the narrator stated his crew thought she was not genuine, but he disagreed.  The pauses imply that she had to think about a response, at some points, she paused for an extended period which seemed as if she was fabricating a scenario or thought.  However, other times she was clear and concise right to the point, leading one to believe she was speaking truth.  She rarely made eye contact specifically during the pauses; rather her eyes wandered, and she talked to the side.  Assuming the interviewer was in front of her, this implies dishonesty or simply shame of the events she recalled.  It was noted her thoughts remained mostly consistent and attentive to the question at hand.
  • Describe any symptoms that you have observed that support the diagnosis. You can include direct quotes or behaviors that you may have observed.
    • Becky recalled a trip to the grocery store in which she and her friend became separated.  The separation created a severe panic attack that caused her to lash out yelling at her friend.  Her behavior is consistent with avoiding abandonment criteria listed in the DSM.  Additionally, Becky disclosed she practices cutting to punish herself for irrational behaviors and rubs the scars as a reminder of the pain she endured from her behavior.  She views herself as worthless and fake to the general public and fears people will not like her if they learn who she is.  Her negative self-perception is evident when speaking interpersonal relationships.  Becky feels she needs to break up by two years because by then people will learn how she actually deals with life and it is better to be unhappy by losing a friend she chose to cut off than feeling abandoned because they discovered the “real” Becky.  Additionally, Becky disclosed she had had impulsive spending behaviors in the past (McGraw Hill Higher Education, 2007).

 

  • Describe any symptoms or behaviors that are inconsistent with the diagnosis.
    • Becky claims that she did not get mean towards her friends, rather would turn cold and phase them out of her life or just never talk to them again when she began to fear that the individual would learn her unmasked identity.  The behavior is inconsistent with the DSM claiming devaluation and idealization as the cause of the dissociation of relationships (American Psychiatric Association, 2013).  For Becky, I believe it was the fear of the potential outcome of abandonment.
  • Provide any information that you have about the development of this disorder.
    • According to the National Alliance on Mental Illness (NAMI) website, genetic factors such as first degree relatives support hereditary as a factor in the development of BPD (2016).  Although Becky did not disclose anyone in her family has the same illness, she did state that her family has a history of mental illness.  She also recalled hearing of her mother’s traumatic childhood, the dysfunction within her household as a child, her parent’s separation, and her father’s terminal disease.  The “NAMI” website claims childhood trauma increases the risk for developing BPD (2016).  Brain function, specifically the centers that control emotions and decision making may have a communication barrier that produces extreme behaviors and thoughts in individuals (“NAMI”, 2016).

Diagnosis

  • Did you observe any evidence of general medical conditions that might contribute to the development of this disorder?
    • Becky did not disclose any medical conditions that may contribute to the development of her disorder.  However, it seems as if her disorder is attributed to biological and environmental factors.
  • Did you observe any evidence of psychosocial and environmental problems that might contribute to this disorder?
    • Becky claims her manipulative mother is the root of her problem established through therapy. Becky’s mother learned of her childhood sexual abuse via flashbacks after a traumatic experience.  Her mother discussed in detail the sexual abuse her sisters endured from their father when Becky was a young child of 5 years. Additionally, Becky claims she was her mother’s confidant, and she would take her frustrations out on Becky.  In the interview, Becky often reverted to the conversation surrounding some sexual abuse which caused for questioning if she fabricated her experience from conversations shared with her mother or if she was genuine in her personal experience.  Her parents didn’t talk to each other.  However, the NIH website reports that individuals with BPD are more likely to subject themselves to violence and rape (“NIH”) causing one to believe that she is speaking from experience.  Additionally, Becky recalled physically violent altercations with family which resorted to her breaking dishes as she threw them screaming until she could calm down which implies that her family was dysfunctional and correlates with the National Institute of Mental Health’s report that she is at risk of developing BPD (“NIH”).
  • As per your observations, what is the client’s overall level of safety regarding the potential harm to self or others (suicidality or homicidality)?
    • Becky exhibits progressive self-mutilation.  She began on her arms, abdomen, and currently on her thighs as she has so much scarring from her actions.  Cutting is Becky’s coping skill for anxiety and panic triggered by minor experiences such as being called on in a class or a television program (McGraw Hill Higher Education, 2007).

According to the National Institute of Mental Health, eighty percent of individuals with BPD experience suicidal ideations and four to four percent commit suicide (“NIH”) placing Becky in a bracket of suicide risk.  Although she claims she is not suicidal, self-mutilation rituals have become a typical and expected behavior of Becky and the wounds created have potential to become life threatening.  Therefore, Becky’s safety should be regarded as highly at-risk to herself.

  • What cross-cultural issues, if any, affect the differential diagnosis?
    • According to the DSM, individuals exhibiting identity problems including existential dilemmas, emotional instability, and anxiety-provoked decisions, among others may mislead a diagnosis of BPD, especially when substance abuse is involved (American Psychiatric Association, 2013).  The three symptoms are identified in Becky. However, there is no evidence of substance abuse outside of her prescription medications.  Dependent Personality Disorder is clarified by the individual becoming submissive and appeasing and immediately seeks replacement relationships when things turn negative (American Psychiatric Association, 2013) is also consistent with Becky’s description of her abandonment dilemmas and therefore holds potential for co-occurring disorders.  However, the DSM also reports that BPD is established by a pattern of intense and unstable relationships (2013) indicative of Becky’s recorded history.

Therapeutic Intervention

  • In your opinion, what are the appropriate short-term goals of this intervention?
    • Self-mutilation seems to be overtaking Becky at this point.  It is imperative that she learn skills to cope with stressful events that cause anxiety and panic.  Self-mutilation can become deadly and should be the top priority.  Becky also needs to learn that she is worthy of positive relationships and should be treated as if she has a place in the world.  Additionally, Becky has only spoken of her therapist as a positive support.  She needs to develop a support system or reinstate her familial ties as they are not spoken about outside of childhood.  It seems as if she only has her father, but embracing her family in its entirety may prove beneficial in her circumstance.
  • In your opinion, what are the appropriate long-term goals of this intervention?
    • Becky appears to have unresolved issues with her mother.  It is important for Becky to acknowledge and work through these issues to achieve peace with her past and move on to live in the present.  Becky has a very negative worldview that needs to be turned around.  As she realizes her self-worth, she should also realize that it is good in the world.  Another long-term goal is to complete college and secure employment where she feels she does not have to mask herself.  This will allow her financial stability that will lead her to independence and having her bedroom door back.
  • Which therapeutic strategy seems the most appropriate in this case? Why?
    • Psychotherapy via Dialectical Behavior Therapy (DBT) seems to be the most promising in treating Becky.  DBT aims to help individuals better regulate emotional responses by accepting the issue they are facing (Johnson, Gentile, & Correll, 2010).  It is believed that self-harm is a way to reduce discomfort from affect (Johnson, Gentile, & Correll, 2010).  CBT begins by reducing the treatment-disruptive behavior, in Becky’s case, cutting, to effectively teach coping for emotional regulation and interpersonal relatedness skills (Johnson, et al., 2010). Additionally, talk therapy should be utilized to resolve the issues between Becky and her family.  Although the root cause is known at this time, talk therapy can help Becky effectively process her childhood experiences and grow from them.   According to the treatment section of the interactive, it is vital that therapists should “maintain open communication” to develop trust between themselves and the Becky.  Becky stated that she is fond of her therapist because he is open and honest and has shared personal experiences with her that relate to an experience she had.   However, a behavioral contract should be included to protect the therapist and Becky safety throughout the course of treatment.  It seems at this point; the self-mutilation has increased even with treatment implying Becky is in need of intensive therapeutic services.  The interactive also claimed it is beneficial for therapists to practice splitting during treatment.  This would allow Becky two therapists who swap out in the event Becky became angry with one.  Splitting would allow Becky to remain comfortable in sessions and also a collaborative approach to reconditioning negative thoughts and behavior.
  • Which therapeutic modality seems the most appropriate in this case? Why?
    • Pharmacotherapy such as serotonin reuptake inhibitors helps deter and regulate dangerous and impulsive behavior.  Becky exhibits increasing self-harm techniques and has admitted to impulsive behavior and major mood swings.  Additionally, she suffers panic and anxiety attacks in situations that bring focus to her.  The attacks are triggers for self-mutilation which in turn brings feelings of relief, but also emptiness and worthlessness.  Becky relates her mental state to others that result in death such as AIDs, which implies that she could be worse off by dying.  Becky’s ideations and professed feelings lead one to believe she would benefit from anxiety and depression medications as well.  Additionally, through DBT, Becky will learn healthy patterns of thinking about herself and the world, positive self-image, non-destructive coping skills and adaptive interpersonal skills.  Reversing the pessimism brings about a positive change necessary for Becky to establish a successful and independent life.

 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Dick, Ph. D., D. M., & Agrawal, Ph. D., A. (2008). The genetics of alcohol and other drug dependence. Alcohol Research and Health, 3(2), 111- 118. Retrieved from http://pubs.niaaa.nih.gov/publications/arh312/111-118.pdf

Johnson, A. B., Gentile, J. P., & Correll, T. L. (2010). Accurately diagnosing and treating borderline personality disorder: a psychotherapeutic case. Psychiatry (Edgmont)7(4), 21–30.

McGraw Hill Higher Education. (2007). Faces of abnormal psychology interactive [Multimedia]. Retrieved from McGraw Hill Higher Education, Maladaptive Behavior & Psychopathology | FP6005 A01 website.

NAMI. (2016). Retrieved from https://www.nami.org/Learn-More/Mental-Health-Conditions/Borderline-Personality-Disorder

NIH. (2012). Retrieved from https://www.drugabuse.gov/publications/principles-drug-addiction-treatment/evidence-based-approaches-to-drug-addiction-treatment/behavioral-therapiesNIH. Retrieved from http://www.nimh.nih.gov/health/topics/borderline-personality-disorder/index.shtml

Nolen-Hoeksema, Susan. (12/2013). Abnormal psychology, 6th edition. [VitalSource Bookshelf Online]. Retrieved fromhttps://digitalbookshelf.argosy.edu/#/books/1259316335/

Zickler, P. (2002, April). Childhood sex abuse increases risk for drug dependence in adult women. NIDA, 17(1),. Retrieved from http://archives.drugabuse.gov/NIDA_Notes/NNVol17N1/Childhood.html

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abnormal psychology, clinical psychology, Cognitive psychology, Cross-Cultural Psychology, Environmental Psychology, Maladaptive psychology, social psychology, Uncategorized

Case Study: Paranoid Schizophrenia

Case 2:  Paranoid Schizophrenia

Background

  • Outline the major symptoms of this disorder.
  • According to the DSM-5, the overall symptoms of Schizophrenia include positive symptoms such as delusions (surreal beliefs), hallucinations (seeing or hearing things which are nonexistent), disorganized speech (impaired communication or answers to questions are unrelated), or catatonic or grossly disorganized behavior (a range of silliness to agitation and may include abnormal motor behavior) (American Psychiatric Association, 2013).  Schizophrenia also includes negative symptoms such as avolition which includes diminished emotional expression, lack of eye contact, monotone speech, neglecting personal hygiene, and social withdraw among other symptoms (American Psychiatric Association, 2013).    The DSM-5 declares two or more symptoms must be present for the majority of a one-month period and one of the symptoms must be delusions, hallucinations, or disorganized speech (American Psychiatric Association, 2013). Level of functioning in one or more areas of life must have a marked decrease that lasts for at least six months and during one month symptoms must be present (American Psychiatric Association, 2013).

In this specific case study, it is important to note the prominent feature is delusions.  Delusions are fixed beliefs that are not amendable despite evidence and manifest in six types:  Persecutory delusions (belief that the individual will be harmed by someone or something), referential delusions (gestures, comments, or environmental cues are directed toward the individual), grandiose delusions (the individual is exceptional and above others), erotomanic delusions (false belief someone is in love with them), nihilistic delusions (belief a catastrophe will happen), and somatic delusions (preoccupation of health and organ functioning) (American Psychiatric Association, 2013).  Delusions can be classified as bizarre (belief that one has loss of control over mind or body) or nonbizarre (external influence brings about conviction such as police have the individual under surveillance) (American Psychiatric Association, 2013).  Delusions can be difficult to separate from strongly held ideology and therefore is dependent upon the degree of conviction despite proposed evidence of its surrealism (American Psychiatric Association, 2013).

  • Client’s background
    • Valerie is a middle-aged Caucasian female who resides with her parents and maintains a full time position working with mentally ill individuals (McGraw Hill Higher Education, 2007).  Valerie loves her work and finds solitude within her working structure.  Her childhood consisted of many moves in several states due to her parents teaching church school. Valerie experienced a normal childhood close to her parents (McGraw Hill Higher Education, 2007).   Although she felt like a social outcast, she did well in school and even went on college and graduate school.  In college she dated a little and married in her, mid-twenties.  However, her marriage was unstable and she began manifesting symptoms of delusions of persecution and grandeur around twenty-eight years old(McGraw Hill Higher Education, 2007).  Her husband had her involuntarily committed to the psych ward where her delusional state led her to believe doctors were performing experiments on her for several months.  Once medications took effect and reduced the delusional symptoms, Valerie was released, however, due to the side effects she experienced, she refused the medications which would increasingly exacerbate the symptoms and she would be reinstitutionalized (McGraw Hill Higher Education, 2007).    Over an eight-year period, she was able to accept her diagnosis, remain medicated, and symptoms have subsided.

Throughout the interview, Valerie was coherent and answered questions accordingly.  However, she exhibited little emotion, with only a couple smiles and giggles throughout the interview which seemed to occur during her recollection of times she stood up for herself (McGraw Hill Higher Education, 2007).  She appeared comfortable in the setting and did not usher much movement, rather arms were raised and rested on back of furniture.  When explaining her illness, she resorted to using her hands to speak as if to get the point across it was a gradual onset not recognizable until she told about the infiltration she had been hiding in her diary (McGraw Hill Higher Education, 2007).

  • Predisposition to disorder
    • Valerie indicated herself as the only individual suffering from mental health issues within her family leading to the belief that there is no direct genetic link or predisposition to the illness (McGraw Hill Higher Education, 2007).  According to the “National Institute of Mental Health”, there tends to be a link between chronic substance use affects interpersonal relationships and other areas of daily functioning (2016), but there is no evidence of substance usage among Valerie, her ex-husband, or other family members.  It is believed that unspecified psychosocial factors may have a part in the development of Schizophrenia (“National Institute of Mental Health”, 2016).  Therefore, it is possible that during her travels, Valerie may have been exposed to a virus that may have inflicted the development, but Valerie herself attributes the development to her marriage (McGraw Hill Higher Education, 2007).  According to Valerie, she chose to remain in her marriage despite the indifferences that arose (McGraw Hill Higher Education, 2007).  During this time, she engulfed herself in religion and soon developed delusions based in the church that led to hospitalization causing her to fear she would be a martyr of religion for exposing the individuals she believed were infiltrating the church (McGraw Hill Higher Education, 2007).  When she turned to the individuals she trusted and they committed her to the psychiatric ward, she probably began feeling abandoned which led to delusions that caused her to fear for her life and the lives of her family (McGraw Hill Higher Education, 2007).  Ultimately it was difficult to pinpoint a definitive cause outside of speculation from her unhappy environment.

Observations

  • Symptoms that  support the diagnosis.
    • Valerie spoke of many examples of typical delusion classifications.  Her delusions actually took over her mind and caused her to isolate herself in front of the television and drive for hours (McGraw Hill Higher Education, 2007).  At one point she believed doctors were using poison so they could take her breasts and use her body for experimental research (McGraw Hill Higher Education, 2007).  Throughout the course of the interview, Valerie remained monotone and had very little expression consistent with avolition, a negative symptom of Schizophrenia (American Psychiatric Association, 2013).  She spoke of experiencing only two hallucinations, both of which were of religious basis implying the possibility of grandiosity.  In the couple segments she did have emotion, it was noted these were during her recollection of times she came off as winning or seemed to view herself as “superior” to others, giving the perception of her experiencing grandiose delusions in the moment.
  • Symptoms or behaviors inconsistent with the diagnosis
    • The manifestation of Schizophrenia altogether appears to be void of the diagnosis.  There is no directly linked disposition, only environmental factors.  This may be due to lack of research or unproven environmental factors.
  • Development of this disorder.
    • There was no familial connection to mental illness.  However, Valerie stayed in her unhappy marriage due to her religious background (McGraw Hill Higher Education, 2007).  After being married a few short years, her husband abandoned the notion of moving out of California and having children which is something she looked forward.  Upon realization that her dreams were not going to come true, she was no longer happy and lost faith in her husband (McGraw Hill Higher Education, 2007).  The stress of living in an unhappy, stressful environment may have cued the onset of delusions as she attempted to hide her emotions.  As her illness continued, her husband abandoned her altogether and they divorced rendering her victim to having to move into her parents’ home.

Diagnosis

  • Medical conditions
    • No observation of medical conditions that may contribute to Schizophrenia nor any medical conditions exposed in the interview.  However, Valerie has done quite a bit of traveling opening her to the potential of contracting a virus that may have led to the development of Schizophrenia (American Psychiatric Association, 2013).  Additionally, Valerie had mentioned a gradual onset of symptoms that had caused her to question if she was mentally ill before her initial major episode (McGraw Hill Higher Education, 2007).
  • Psychosocial and environmental
    • Valerie described an unstable marriage that eventually led to her spouse abandoning her in her illness (McGraw Hill Higher Education, 2007).  After a few years into the marriage, the things they decided on as a couple were abandoned such as having children and moving to a different state which made her lose faith in her husband and created a resentment within her (McGraw Hill Higher Education, 2007).  Having been raised in a religious household, turning to religion in her time of trouble with her husband, seemed to trigger the first major Schizophrenic episode (McGraw Hill Higher Education, 2007).
  • Client’s overall level of safety regarding potential harm to self or others (suicidality or homicidality)
    • Although Valerie does not present with suicidal ideations during the interview, she should be recognized as potential risk especially if symptoms come out of remission.  According to the DSM-5, five percent of individuals diagnosed with Schizophrenia commit suicide, twenty percent attempt suicide, and many more have frequent suicidal ideations (American Psychiatry Association, 2013).  Statistics implicate a high risk for those suffering from Schizophrenia, therefore best practice wold be to have an alert, especially is symptoms recur.
  • Cross-cultural issues that affect the differential diagnosis
    • Valerie’s manifested in her late twenties as consistent with the average of women developing the order (McGraw Hill Higher Education, 2007).  The duration of Valerie’s illness has been more than eight years allowing the definitive diagnosis of Schizophrenia to hold true (McGraw Hill Higher Education, 2007).    Statistically, individuals with schizophrenia have the potential to be readmitted to the hospital within two years of release such as Valerie experienced in the beginning of the symptoms onset (McGraw Hill Higher Education, 2007).  Due to Valerie’s residing with her parents, she appears to satisfy the supportive environment necessary for recovery as paranoid schizophrenia tends to have a higher recovery rate from other subtypes (McGraw Hill Higher Education, 2007).

Therapeutic Intervention

  • Short-term goals of intervention
    • Valerie should maintain her current status through the utilization of medication and therapy.  Throughout her journey with mental illness, stability seems to be a major aggressor in the development of the disorder.  She depended on those who love her to support her, but she was abandoned in her time of need and during those stressful periods, she regressed and opted out of treatment (McGraw Hill Higher Education, 2007).  Additionally, Valerie should seek out external sources of support.  Her support system is reportedly her parents and those who work with her which is great.  However, it may benefit her to incorporate others into her life as a more rounded support team.  Additionally, it appears that Valerie has unresolved issues from her marriage and these should be addressed and dealt with as soon as possible to help her rehabilitate.
  • Long-term goals of intervention
    • Valerie was happy at one point in her life.  She described high lights such as traveling to Europe.  If Valerie were able to travel she may feel a sense of freedom and “normalcy” as she does something she has enjoyed since she was a little girl.  It may benefit Valerie to pursue her Ph.  D. or even a second degree in mental health as she originally wanted.  Attaining that goal will edify her self-worth and in turn create a sense of accomplishment that lets her know she is still capable of achieving her goals and dreams.
  • Therapeutic strategy
    • An article on the APA website explains new hope for Schizophrenia which integrates psychosocial rehabilitation, or a model consisting of the combination of medication, maintenance, and stabilization, to teach those with schizophrenia self-sufficiency via work skills, social integration via coping techniques that lead them to rehabilitation in their illness (MacGuire, 2000).  Valerie should continue using antipsychotic medications.  Pharmacological treatments block the dopamine D2 receptor which reduces psychotic symptoms such as hallucinations and delusions as well as potential relapse (Chien & Yip, 2013).  Psycho-social interventions are utilized for ongoing treatment (Chien & Yip, 2013).  Psycho-social interventions enhance functioning, reduce relapse and hospitalizations and facilitates rehabilitation and recovery (Chien & Yip, 2013).  Psycho-social interventions are found in Cognitive Behavior Therapy which teaches the individual coping skills and diversion plans in the event of an “episode” (Chien & Yip, 2013).  Additionally, psycho-social interventions include patient and family pseud- education increasing the knowledge of the illness allowing a reduction of stigma that may be experienced from the diagnosis (Chien & Yip, 2013).
  • Therapeutic modality
    • In the video, The Answered Patient:  Schizophrenia Overview, posted in Dr. Cronin’s conclusion segment, Anthony Zipple, Sc. D.  states that the “biggest misconception is that people don’t recover” from schizophrenia (2015).  He goes on to claim looking at the data for over a five to twenty-year period, most people “do recover quite well” and others claim that the proper use of psychotherapy, medication, and group support systems increases the likelihood of positive relationships and independent life (The Answered Patient, 2015).  The Clubhouse Model is a community program designed to create an atmosphere that helps individuals with mental illness find hope and opportunities to reach their maximum potential (“Clubhouse International”, 2016).  Although Valerie works within the community of the mentally ill, it appears that should would benefit greatly if a Clubhouse was incorporated into her treatment.  Valerie wanted to ern her Ph.  D., but her illness caused her to abandon that goal.  However, with the support of the model and education potential, external support may be what Valerie needs to attain her goal.

 

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Brinkman, W. B., & Epstein, J. N. (2011). Treatment planning for children with attention-deficit/hyperactivity disorder: treatment utilization and family preferences. Patient Preference and Adherence5, 45–56. http://doi.org/10.2147/PPA.S10647

Centers for Disease Control and Prevention. (2016). Retrieved from http://www.cdc.gov/ncbddd/adhd/diagnosis.html

Chien, W. T., & Yip, A. L. (2013). Current approaches to treatments for schizophrenia spectrum disorders, part I: an overview and medical treatments.  Neuropsychiatric Disease and Treatment9, 1311–1332. http://doi.org/10.2147/NDT.S37485

Clubhouse International. (2016). Retrieved from http://www.iccd.org/whatis.html

McGraw Hill Higher Education. (2007). Faces of Abnormal Psychology Interactive [Multimedia]. Retrieved from McGraw Hill Higher Education, Maladaptive Behavior & Psychopathology | FP6005 A01 website.

MacGuire, P. A. (2000, February). New hope for people with schizophrenia. American Psychological Association, 31(2), 24. http://www.apa.org/monitor/feb00/schizophrenia.aspx

 

 

The Answered Patient (2015).  Schizophrenia overview [Video file]. Retrieved from BehaveNet.com website: http://behavenet.com/schizophrenia

 

 

 

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abnormal psychology, clinical psychology, Cognitive psychology, Cross-Cultural Psychology, Environmental Psychology, Maladaptive psychology, Personality Psychology, Uncategorized

Case Study: Attention Deficit Hyperactivity Disorder

Case 1:  Attention Deficit Hyperactivity Disorder (ADHD)

Background

  • Major symptoms of this disorder.
    • According to the DSM 5, ADHD is a pattern of “inattention and / impulsivity” that affects day to day functioning (p. 59).  Inattentiveness manifests through failure to follow or focus on tasks and exhibiting disorganization (American Psychiatric Association, 2013).  Hyperactive behavior manifests as excessive motor activity such as fidgeting, talking, or the inability to sit still when inappropriate (American Psychiatric Association, 2013).  Excessive impulsivity refers to actions made without forethought that may risk safety as a way to gain a reward or the inability to delay personal gratification (American Psychiatric Association, 2013).   Impulsive behaviors may be perceived as socially intrusive and void of long term considerations (American Psychiatric Association, 2013).  However, it is important to note that all symptoms must not manifest due to defiance or lack of comprehension, must be inconsistent with the development level of the individual, have a manifestation before the age of twelve, and be present in two or more settings (American Psychiatric Association, 2013).
  • Client’s background
    • David is a sixteen-year-old, Caucasian, high school sophomore.  He lives in a single parent household and is raised by his mother.  David presented as a “regular” teen who likes sports and video games.  He claims to have a girlfriend he enjoys spending time with her.  Additionally, David takes Wellbutrin and Ritalin throughout the course of the school year, but during the summer he remains medication free.  David claims to have always been hyperactive which led to teacher complaints in elementary school.  David’s mother loves him, but has allowed his negative behaviors to continue their evolution through her lack of discipline and failing to enforce the vitality of passing grades.  David seems to have no schedules or daily routine chores set in play, rather spends hours playing video games and watching television.  His mother asks little of him and when she does, he has no consequences for not doing what was asked.  When medicated, David tends to do better in school and retains some focus, however, he does not like that the pills make him “lazy and anti-social” (McGraw Hill Higher Education, 2007).
  • Possible Predispositions
    • Although genetic factors, especially inheritable traits from the father, play a part in the development of ADHD (McGraw Hill Higher Education, 2007)., there was no information disclosed on medical history, therefore a predisposition cannot be acclaimed in David’s case.

Observations

  • Symptoms
    • Throughout the course of the interview David was in constant movement.  He spoke with hands and fidget in and with his chair.  His thoughts were unaligned as he began with one topic and moved to the next and back to the original topic (McGraw Hill Higher Education, 2007).  Consistent with the DSM-5 development and course, David claimed to be hyperactive as far as his memory would allow him to recall.  David admits that he has difficulty focusing on tasks or schoolwork demonstrating symptoms of inattentiveness as the DSM-5 reports as a primary symptom (American Psychiatric Association, 2013).  ADHD inhibits individuals in school performance, and social relationships which may letter cause the development of antisocial personality disorder in adulthood (American Psychiatric Association, 2013) which solidifies David’s struggles in school and his lack of friendships.
  • Symptoms or behaviors that are inconsistent with the diagnosis.
    • David plays several hours of video games implicating that a video game can hold his attention.  He actually claimed that he can beat and entire game in one sitting by the time his mother woke up in the morning (McGraw Hill Higher Education, 2007).  This fact is inconsistent with the DSM-5 criterial symptoms which claim a very short attention span and easy distractibility in addition to the inability to quietly indulge in leisure activity for a period of time (“Centers for Disease Control and Prevention”, 2016).   The “Center for Disease Control and Prevention” website claims individuals are often unable to listen when spoken to (2016), however, David followed along in the conversation and answered questions promptly.  Although he tended to lose track of his thoughts throughout his answers, he often jumped topics, but ultimately returned to his initial thought (McGraw Hill Higher Education, 2007).  Another aspect that seemed odd was David’s claim that when reading, words would begin jumping around the page and become blurry causing him to lose focus and attention, but this was not relatable to the DSM-5 criteria (McGraw Hill Higher Education, 2007).
  • Development of this disorder.
    • The DSM-5 clarifies that ADHD is most identifiable in elementary school as inattention becomes more prominent (American Psychiatric Association, 2013) resulting in educational impairment and teachers identifying behavioral issues to parents as David discussed in the interview. However, it would be interesting to l earn the mother and father’s medical and mental health history.  The DSM-5 also explains family interaction has no bearing on the development of ADHD, but may influence the disorders course or development of secondary conduct disorders (American Psychiatry Association, 2013).   There is little family time for David and his mother and the void is filled through gaming and lack of discipline and reasonable expectations from the mother.  It is possible that the lacks and void filling encouraged the course of ADHD to heighten and possibly lead to worse symptoms of the disorder.

Diagnosis

  • Medical History
    • There was no medical history exposed in the interview to validate a contribution to David’s ADHD.
  • Psychosocial and environmental problems
    • David is being raised by a single, overwhelmed mother who has little time for him.  However, the interview revealed “most of the time” he lives with his mother, implying there is another figure involved in David’s upbringing that is not disclosed in the interview (McGraw Hill Higher Education, 2007).  His mother tends to give him tasks, but fails to follow through with any type of recourse for his negative actions or failure to complete a task (McGraw Hill Higher Education, 2007).  This was evident when she accepted his failing math and directed him to focus on another subject rather than seek help to aid in him learning the material (McGraw Hill Higher Education, 2007).  She does not ask him to do much giving the persona that she reinforces the negative behavior and inability to focus on a task or topic.   According to the narrator, it is common to see children from single parent households present with ADHD (McGraw Hill Higher Education, 2007).  It is a typical routine for David to play video games which appears to be a distraction from other aspects of life such as schoolwork and chores (McGraw Hill Higher Education, 2007).  Additionally, David feels as if many teachers just give up on him rather than attempt to help him improve in learning (McGraw Hill Higher Education, 2007).
  • Client’s overall level of safety regarding potential harm to self or others (suicidality or homicidality)
    • Regarding David’s safety, he appears stable.  However, in the course of the interview, he admitted to being taunted by other kids and seemed to have little knowledge about ADHD (McGraw Hill Higher Education, 2007).  He claimed to have friends and a girlfriend, but appeared to be socially awkward and compared himself to another male who was “worse off” than himself (McGraw Hill Higher Education, 2007).  Due to his comparisons and the reactions of others to his demeanor, it is essential to closely monitor his self-esteem.  Additionally, he does not always make the best choices and his impulsive behavior holds potential for harm even if he does not intend hurting himself (McGraw Hill Higher Education, 2007).  According to the DSM-5, as individuals enter early adulthood the risk of suicide attempt increases especially when comorbid with mood, conduct, or substance abuse arises (American Psychiatric Association, 2013).  David will soon be entering adulthood and he claims irritation and frustration with certain aspects of his life.  Early intervention of possible suicide ideations would reduce the likelihood of David developing suicidal potential.
  • Cross-cultural issues that may affect the differential diagnosis?
    • According to the interview, ADHD occurs in about five percent of the population and although it occurs across all cultures, it is most prevalent in the United States (McGraw Hill Higher Education, 2007). Additionally, David is male and statistically more prone to a diagnosis of ADHD than female (American Psychiatric Association, 2013).

Therapeutic Intervention

  • Short-term goals of this intervention
    • It is essential to reduce David’s video game activity and increase his number of chores.  Setting up a chore chart or goal plan with David will help him remember what needs to be completed and by when.  The chart and schedule can be utilized for schoolwork, chores, and recreation as it will clearly define expectations.  Another short term goal would be to improve grades in school by incorporating a daily homework schedule and seeking out external tutoring programs to help accommodate his problem areas such as math.  Additionally, David should join sports team’s year round as this will help him focus his energy in an area he loves and build social skills and develop a teamwork effort.
  • Long-term goals of this intervention
    • David needs behavior modification to address his impulsive behaviors and replace them with thought out actions and reactions.  As a minor, his mother has a major role in David’s life.  His mother needs to learn techniques of proper discipline and basic parenting skills that provide an environment that includes rewards for positive behavior and consequence to negative behavior.
  • Therapeutic strategy
    • The psychosocial approach to ADHD includes Direct Contingency Management focuses on a direct approach for rewarding desired behavior (Brinkman & Epstein, 2007).  David has not experienced consequences for his behaviors, instead his mother just accepted whatever he did.  Encouraging good grades and completion of homework assignments and chores with a reward would allow David to perceive that good behavior and deeds earns positive feedback and he carries potential to do good.  Clinical Behavior Therapy will allow David’s mother to learn basic parenting skills to help manage ADHD in day to day activity and settings (Brinkman & Epstein, 2007).  Teaching David’s mother the proper skills will allow her to create an environment that rewards desired behavior hopefully implanting a drive in David to take on responsibility that will allow him to use some of the excess energy he fights (Brinkman & Epstein, 2007).  Additionally, David should continue his medications as they allow him to focus and have proven an improvement in school.  However, it may be necessary to alter medications as he may have built up a tolerance and the medication is not as effective as it once was.
  • Therapeutic modality
    • A multimodal approach of Psychotherapy in conjunction with medications seems to be the most appropriate modalities in David’s case.  A study of the Multimodal Treatment approaches conducted by Brinkman and Epstein which included only direct contingency management and Cognitive Behavioral Therapy reported 34% of the children reported a remission of symptoms (Brinkman & Epstein, 2007).  The study concluded that 56% of the children who were treated only with medication reported positive benefits to the medication, although 50% reported mild side effects (Brinkman & Epstein, 2007).  In a combination treatment of both medication and therapeutic services, 68% of the children reported remission of symptoms after fourteen months (Brinkman & Epstein, 2007).  However, it is important to note that although these statistics have a wonderful turnaround, both patient and parent, must choose goals that align with both desires of outcome as well as both must be willing to stick to the regimen to have the most effective results (Brinkman & Epstein, 2007).

References:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Brinkman, W. B., & Epstein, J. N. (2011). Treatment planning for children with attention-deficit/hyperactivity disorder: treatment utilization and family preferences. Patient Preference and Adherence5, 45–56. http://doi.org/10.2147/PPA.S10647

Centers for Disease Control and Prevention. (2016). Retrieved from http://www.cdc.gov/ncbddd/adhd/diagnosis.html

Chien, W. T., & Yip, A. L. (2013). Current approaches to treatments for schizophrenia spectrum disorders, part I: an overview and medical treatments.  Neuropsychiatric Disease and Treatment9, 1311–1332. http://doi.org/10.2147/NDT.S37485

Clubhouse International. (2016). Retrieved from http://www.iccd.org/whatis.html

McGraw Hill Higher Education. (2007). Faces of Abnormal Psychology Interactive [Multimedia]. Retrieved from McGraw Hill Higher Education, Maladaptive Behavior & Psychopathology | FP6005 A01 website.

MacGuire, P. A. (2000, February). New hope for people with schizophrenia. American Psychological Association, 31(2), 24. http://www.apa.org/monitor/feb00/schizophrenia.aspx

 

 

The Answered Patient (2015).  Schizophrenia overview [Video file]. Retrieved from BehaveNet.com website: http://behavenet.com/schizophrenia

 

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