Substance Abuse Disorder

Case Study 2

Diagnosis:  Substance Abuse Disorder

Background

• Outline the major symptoms of this disorder.
  • Substance Abuse Disorder is signified through psychological, cognitive, and behavioral indicating the individual continued use despite problems associated with substance use (American Psychiatric Association, 2013).   Changes in brain circuits, persistent after detoxification which manifests through repeated relapse and substance cravings triggered by environmental cues (American Psychiatric Association, 2013).  Substance abuse disorder is diagnosed based on some categorical criteria.  The first group of criteria, impaired control, explains the individual may increase usage over a longer period of and be unable to cut down usage even though expressing a desire (American Psychiatric Association, 2013).   Additionally, a great deal of time is spent attaining the substance which may cause the individual to incorporate activities around the substance and develop cravings for the substance (American Psychiatric Association, 2013). The second group, social impairments, identifies recurrent use is hindering daily life such as work, school and home combined with continued use despite deficits in interpersonal relationships (American Psychiatric Association, 2013).  Important and enjoyable activities may be given up for the substance as well as familial withdraw for the use of the substance (American Psychiatric Association, 2013).

The third group, risky use, includes the failure to abstain from the substance despite, physical or psychological impairments caused by the substance (American Psychiatric Association, 2013).  The fourth group, pharmacological criteria, is defined as a marked tolerance for the substance and the presence of withdrawal syndrome (American Psychiatric Association, 2013).  At this point, the individual likely no longer continues use for the effect of the substance, rather avoid the effects of withdrawing as the body has now become dependent on the substance for the feeling of normality (American Psychiatric Association, 2013).  However, according to the DSM-V, individuals who use and become dependent on a substance solely for medical treatment should not be diagnosed with substance abuse disorder (2013).  Additionally, Substance Abuse disorders are diagnosed by severity according to specific coding for a specific substance (American Psychiatric Association, 2013).

• Briefly outline the client’s background (age, race, occupations, etc.).
  • Bobby is a thirty-one-year-old female who claims sobriety for ten years.  She lives in an apartment with her five-year-old son, Tyler and her boyfriend.  April 10, 1989, Bobby was diagnosed with HIV although she does not know how she contracted the virus.  She does continue to work a part-time job at this point.  Bobby established that her issue began at nine years old when she desperately desired her mother who was inconsistent in her life.  Her mother was an addict and very sporadic.  She remembers being sexually abused by her stepbrother from the age of nine to fifteen.  At the age of nine, she began doing things for attention from her father such as attempting suicide.  She recalls the attention she received from her father was a “slap in the face” or “a knee in the stomach.”  However, later in the interview, she claimed not to have experienced abuse from her father, rather witness domestic violence towards her mother by her father.  By twelve she was smoking cigarettes and drinking alcohol.  Her father moved her three times in Tucson, assuming this gave her a sense of instability, her acting out progressed.  By thirteen she was smoking pot and at fourteen was drinking vodka daily.  At fifteen, Bobby dropped out of school, and her life revolved around, “partying” and sex (McGraw Hill Higher Education, 2007).

At sixteen Bobby ran away from her father’s home hitchhiking to Iowa and experienced her first rape and began using cocaine, speed, and acid. She started living with her mother, in Portland, who introduced her to heroin through a cotton ball as a chew for a mouth infection.  Her mother was busy with her life, so Bobby took to the streets and began prostituting, shooting up, and went through an abusive relationship.  By twenty, Bobby was using 2.5grams of heroin and 1gram of cocaine a day, was prostituting in the street almost twenty-four hours a day, and entertaining bisexual relationships.  She felt consumed by her substance abuse and would turn tricks with a partner to make more money (McGraw Hill Higher Education, 2007).

When Bobby was twenty-one, she was sent to prison for the second time.  A diagnosis of HIV soon followed which brought her to the realization she was going to die yielding her to sobriety.  Although she maintains sobriety from her adolescent lifestyle, Bobby admits to smoking pot to alleviate side effects of her medications, occasionally drink and have a methadone dependency which allows her to get out of bed each day.  However, she said choosing to smoke pot was difficult because it crosses the line of addiction.  Bonny maintains she is fearful of returning to addiction even though she has no desire.  It is a battle each day for her, but she is adamant on helping others turn their life around or prevent addiction in potential users.  She has returned to school for medical office assisting (McGraw Hill Higher Education, 2007).

 

 

• Describe any factors in the client’s background that might predispose him or her to this disorder.
  • Evidence suggests that genetic factors influence the risk of substance abuse disorders with inheritability at fifty percent or more ((Dick, Ph. D. & Agrawal, Ph. D., 2008). Additionally, twin studies suggest dependence is determined by a combination of genetic and environmental factors (Dick, Ph. D. & Agrawal, Ph. D., 2008).  Both facts imply Bobby has a genetic predisposition for the development of substance abuse disorder.  According to an article found on the NIDA website, females who were sexually abused as children were three times more likely to develop a substance dependence as adults (Zickler, 2002), supports the effect of the sexual abuse and intercourse experienced by Bobby via her step brother from age nine to fifteen.  Additionally, Bobby exposed that she believed she felt worthless, unloved, and unwanted.  To attempt to receive what she desired and needed, she began to reach out in the world and gain acceptance from anyone who would oblige it.  She found comfort in using drugs and drinking and felt as if she knew everything which directed her toward leaving to her mother.  Her mother then exposed her to other drugs building upon the dependence she had already influenced herself which is consistent with the environmental factors discussed in twin studies earlier (McGraw Hill Higher Education,  2007).

Observations

• Describe any symptoms that you have observed that support the diagnosis. You can include direct quotes or behaviors that you may have observed.
  • Bobby exhibited impaired control through her behaviors such as prostitution and the evolution of her experimentation with drugs into dependence.  Social impairments were evident in her abusive relationship, separating herself from her father, and dropping out of school after planning her future as an astronaut for the Air Force.  Shooting up, prostitution, and bisexual relations identify with risky behavior as explained by the DSM-V as she exposed herself to sexually transmitted diseases and contracted HIV.  She met the fourth criteria due to the high dosages she needed at the time she chose sobriety.  Additionally, Bobby currently has an addiction to methadone, claiming she takes it to get out of bed in the morning.  She also exposed that she currently smokes marijuana, although she uses it for medicinal purposes, it was understood she obtained it illegally and became defensive when explaining herself.  She also admitted to drinking socially from time to time which implies that she is still triggered in the environment.  She fears to relapse in her addiction, but the implication is that she has not completely broken the addiction, rather substitutes through prescription and medicinal purposes.
• Describe any symptoms or behaviors that are inconsistent with the diagnosis.
  • The DSM states that an individual should not be diagnosed with a substance abuse disorder if the dependency evolved directly from medical treatment (American Psychiatry Association, 2013).  Due to the methadone being prescribed for the pain she endures from neuropathy caused by HIV drugs, currently, she would not fall under the substance dependence criteria.  However, she did not distinguish if the methadone was originally prescribed as a detoxification tool or for medical treatment.
• Provide any information that you have about the development of this disorder.
  • Bobby claims she was desperate for love and attention which prompted her negative behavior.  In her mind, at the time, any attention was good attention, and she sought it at all extremes.  She was genetically predisposed through her mother who also fought heroin addiction.  She moved three times in a short period which implies an unstable lifestyle in childhood which is stressful and holds potential to ignite negative behavior.  Additionally, she endured sexual abuse heightening her risk for developing a substance dependence in adulthood (McGraw Hill Higher Education, 2007).

Diagnosis

• Did you observe any evidence of general medical conditions that might contribute to the development of this disorder?
  • Bobby’s current usage is due to the pain and sickness she endures while battling HIV.  However, it appears that childhood depression caused by family dysfunction and abuse led her to develop the disorder.  She was desperately looking for a place in the world to fit in and be loved.
• Did you observe any evidence of psychosocial and environmental problems that might contribute to this disorder?
  • Bobby claimed as a child she just wanted to be loved.  However, looking back she believed she was unhappy due to an absent mother and feelings of abandonment brought on by her father who fostered more attention toward his stepdaughter.  She chose the crowd of people who accepted her with her flaws and had ways to make her feel better through the use of alcohol and illicit drugs.  At sixteen she was raped and at that point, it seems her dependence heightened as she claimed using heroin dulled the emotional pain she experienced (McGraw Hill Higher Education, 2007).
• As per your observations, what is the client’s overall level of safety regarding the potential harm to self or others (suicidality or homicidality)?
  • Bobby attempted suicide twice seeking attention and love from her father.  She was scared by the death sentence she received being diagnosed with HIV and decided to change her lifestyle.  She claims she does no want to die because she wants to watch her son grow and be a mother to him, so he does not experience what she did (McGraw Hill Higher Education, 2007).  However, it is imperative to use caution.  Bobby has a terminal disease that makes life difficult and painful for her.  As she recalls memories of her past, she becomes very emotional especially memories about her health status.  If she falls ill again, she holds potential for harming herself because she may fear her son watching her die from AIDs.

Therapeutic Intervention

• In your opinion, what are the appropriate short-term goals of this intervention?
  • Bobby needs to focus on healing from living with HIV.  She fears the future or the thought of the future because she feels doomed to death.  If Bobby can view the future in a positive manner, she will have more success at battling her health and raising her son.  The development of a goal plan will give her a reason to keep fighting.  The plan should include medical, personal, educational, and her son’s milestones.  Once Bobby is able to accept her past and view the future, she can begin a full recovery.

Bobby should continue working with inmates.  Telling her story to others is part of the healing process and will allow her to see clearly what was void to her before.  It serves, in a sense, as a group therapy.  Walking into the prison is a reminder of the potential behind relapse and telling her story can reach someone else fulfilling her desire to help others.

• In your opinion, what are the appropriate long-term goals of this intervention?
  • Bobby admits to continued use of Marijuana, alcohol, and an addiction to methadone.  Although she explains, the above are used for medicinal purpose, she appears emotional to her past.  When speaking of the past, one should be able to do so with confidence that emanates the pleasure and peacefulness of the change.  I don’t think Becky is there yet, hence her continued usage, and possibly replacement addiction.  Bobby should ween off the methadone and replace with a healthier pain management strategy.  Additionally, Bobby needs to come to terms and accept the mistakes that she made in order to have a positive future.  A healthy psyche leads to biological health.

It is also important that Bobby continue her education goal.  She desires to be needed, wanted, and make a difference in someone else’s life.  Continuing her education will give her a sense of accomplishment and boost her self-esteem and allow her to set the positive example she wants for her son.  Additionally, helping in the HIV/AIDs field as she desires will help her better accept her life in its current state, despite the hardship.

• Which therapeutic strategy seems the most appropriate in this case? Why?
  • A behavioral therapeutic approach would allow Bobby incentives to maintain sobriety.  That incentive is a longer, healthier life for her son.  Currently, Bobby suffers from HIV which has led her to a drastic life change.  However, Bobby still has addictive tendencies as seen with her current usage.  Although she has eliminated the lifestyle and the addiction that led her to HIV, she dabbles with other drugs and alcohol and has developed a new addiction to a prescription.  Behavioral therapy aims to modify attitude and behavior (“NIH”, 2012), such as the thought of using is okay because it alleviates medical symptoms.  Additionally, Bobby will learn coping skills for times of stress or environments that trigger cravings (“NIH”, 2012), such as drinking in social settings.
• Which therapeutic modality seems the most appropriate in this case? Why?
  • The harm reduction model discussed in the treatment section of the interactive seems to be the most appealing for Bobby.  In the Harm-Reduction Model, the individual is taught that relapse is not a personal weakness, rather caused by the situation (McGraw Hill Higher Education, 2007).  When an individual is led to believe their fall is from a personal deficit, it may cause them to believe they are not able to conquer their demon which triggers the addictive behaviors to reignite.  In the Harm-Reduction model, the experience of relapse is examined to identified what caused the slip and coping skills for the scenario are developed to avoid repeat relapse in the future (McGraw Hill Higher Education, 2007).  However, there is a drawback, relapse rate is higher (McGraw Hill Higher Education, 2007).  However, as found in conditioning, repetitive negative reinforcement deters the behavior and eventually the individual is strong enough to beat the addiction.  Using this model can help Bobby recover from her methadone addiction and permanently release her from marijuana and alcohol use.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

 

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

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).

.

•  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).

.

 

• 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

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 Adherence, 5, 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 Treatment, 9, 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

 

 

 

Who are we?

The relationship between what we are and what we do:

What we are should be defined through our actions.   We are our beliefs, feelings, emotions, thoughts and morals.  These beliefs that make us what we are should be proven through our actions.  Our actions should, therefore define us.  Our actions should portray our private beliefs and feelings.  However, this is not always the case.  Sometimes people tend to act adversely to their beliefs, morals, and other emotions because they may become unaligned with their true self which causes confusion about what they are.  Humans all have core needs, the most basic being survival.  When one becomes unaligned, they may lose sight  of their core needs and act on impulse.  Acting on impulse may result in a negative action which causes another person to perceive us as “wrong”.  When we are aligned with our true self, we know what our needs are and act accordingly to fulfill those needs. 
Outsiders perceive us based on our actions.  People have a tendency to behave in a manner that is socially acceptable which may or may not be acceptable to our true self.  Behaving outside the social norm may create a negative perception from our peers therefore we may unalign ourselves and behave in a manner that is unacceptable to our true self.  When we act on impulse, we are acting based on feelings thoughts and emotions which serve as a reason for denial or wrong doing (doing wrong for good).  We may also feel we are behaving in an acceptable manner because the majority at the time was doing the same (bargaining for acceptance of a negative action).  Then there are those who truly feel no remorse because their true self feels as if they are not doing wrong. 
There should be a direct relationship between what we are and what we do, but as we face moral dilemmas and social acceptance issues, that relationship may disconnect and cause a clouded perception of who we truly are from our peers.  If we stay aligned with our true self and do not quiver or hesitate to do what we truly feel is morally acceptable, we will not disconnect and society perceives us as we perceive ourselves.