Abnormal Psych - Study Notes - Case studies PDF

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Case Study 5: Major Depressive Disorder Major Depressive Episode Symptoms 

Individual displays an increase in depressed mood for the majority of each day and/or a decrease in enjoyment or interest across most activities for the majority of each day (all over a two-week timeframe)

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During these two weeks, said individual must also experience 3-4 of the following symptoms:  Considerable weight change or appetite change  Daily insomnia or hypersomnia  Daily agitation or decrease in motor activity  Daily fatigue or lethargy  Daily feelings of worthlessness or excessive guilt  Daily reduction in concentration or decisiveness  Repeated focus on death or suicide, a suicide plan, or a suicide attempt

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Significant distress or impairment

Major Depressive Disorder Symptoms 

Presence of a major depressive episode

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No pattern of mania or hypomania

Quick Facts

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Most people with a mood disorder have unipolar depression

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Unipolar depression is when one has no history of mania, and when the depression subsides, their mood will return to (nearly) normal levels

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Of people with depression, 41% initially go to a physician with complaints of feeling a general sense of illness, 37% complain about pain, and 12% report that they are fatigued

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Around 8% of adults in the U.S. have a severe unipolar pattern of depression in any given year

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Another 5% have mild forms of unipolar depression

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At some point in their lives, about 19% of adults experience an episode of severe unipolar depression

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Around 60% of people with severe unipolar depression respond well to antidepressant medications

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A recent study suggests that the combination of pharmacotherapy and psychotherapy is more effective than either treatment on its own

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In mild to moderate cases of depression, exercise has been proven to compare favorably to antidepressant medication

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Approximately 40% of people with unipolar depression begin to recover within 3 months, with 80% recovering somewhat within a year

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About half of people with severe unipolar depression also have an anxiety disorder

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In most cases such as this, the anxiety symptoms precede the depressive symptoms (sometimes by years)

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Between 6% and 15% of people with severe unipolar depression commit suicide

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About 60% of people with severe unipolar depression respond successfully to cognitive therapy

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As many as 20% of the relatives of severely depressed people are themselves depressed

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Atypical antipsychotic medications (traditionally used to treat schizophrenia and other psychotic disorders) are often added to an antidepressant to augment its effectiveness in people with treatment resistant depression

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Studies have found that depressed subjects have a variety of biases in attention, interpretation, and memory for negative events. They recall unpleasant experiences more readily than positive ones, denigrate their performance on various tasks, and expect to fail in various situations

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When non-depressed subjects are manipulated into reading negative statements about themselves, they become increasingly depressed

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As many as half of depressed clients may have marital problems. In such cases, couple therapy may be as helpful as cognitive therapy

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People who repeatedly dwell on their moods without acting to change them (ruminate) are more likely to become clinically depressed than people who do not generally ruminate

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If people who respond to antidepressant medications stop taking the drugs immediately after obtaining relief, they run as much as a 50% risk of relapsing within a year

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The risk of relapse decreases considerably if they continue taking the drugs for 5 months or so after being free of depressive symptoms

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Studies that reveal depressed people who lack social support remain depressed longer than those who have a supportive spouse or warm friendships

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As many as 30% of depressed patients who respond to cognitive therapy may relapse within a few years after completing treatment. Symptoms such as increased anxiety, increased loss of appetite, and increased loss of libido are considered risk factors to relapse after 2 years

Assessment Questions 1. What are the first signs that a person might be depressed? Initial signs of depression include an increase in depressed mood/decrease in enjoyment and interest, weight or appetite change, insomnia or hypersomnia daily, agitation or decrease in motor activity, fatigue or lethargy, feelings of worthlessness or excessive guilt, reduction in concentration or decisiveness, focus on death or suicide/suicide plan/suicide attempt all happening over a two-week period. 2. Why did Carlos initially see his family physician?

Carlos went to see his doctor because he was seriously affected by his cousin’s death (from a heart attack). He became obsessed with taking his pulse and putting his hand to his chest to try to decide whether he could have symptoms of a heart attack as well. 3. What symptoms did Carlos present that prompted his family physician to suggest a psychologist? Carlos revisited his doctor not long after his first appointment and explained to him that his preoccupation with the idea of having a heart attack was getting out of hand. He then began to cry. 4. Why did his psychologist, Dr. Willard, recommend a psychiatrist? Upon hearing Carlos list his many symptoms (feelings of despair, poor concentration, difficulty sleeping, loss of interest in usual activities, and tearfulness), Carlos’s psychologist was able to diagnose him. He also told Carlos that he thought it would benefit him to see a psychiatrist because he would be able to better advise him on the benefits of antidepressant medication. 5. What was the initial antidepressant prescribed, and why did Carlos decide not to continue taking this medication? The psychiatrist prescribed 1-2 capsules of fluoxetine (Prozac) per day. Carlos followed his psychiatrist’s instructions for a few days but then decided that he didn’t like the side effects. Mainly the fact that he felt like he was about the jump out of his skin. 6. Why did the psychiatrist decide to hospitalize Carlos? He felt it would be best to hospitalize Carlos in order to find a better treatment plan for him. He realized that Carlos’s symptoms were increasing in intensity and frequency and he also noticed that Carlos was now refusing to go to work. 7. What concerns did Sonia, Carlos’s wife, have about her husband’s depression? She was concern for Carlos’s well-being primarily but also stressed her concerns over the fact that he could no longer act as a father or a husband. He stopped helping around the house, he wasn’t able to talk about finances any longer. It seemed as if he had become another child to her, only worse than the rest

because he would not comply and was never happy. She was also concerned that after her husband relapsed that he might be right in saying that he’d never recover and would never feel happy again. 8. What type of psychotherapy did Dr. Walden use with Carlos? Dr. Walden used cognitive psychotherapy with Carlos. 9. What were the criteria for Carlos’s diagnosis of major depressive disorder? Criteria include an increase in depressed mood/decrease in enjoyment and interest, weight or appetite change, insomnia or hypersomnia daily, agitation or decrease in motor activity, fatigue or lethargy, feelings of worthlessness or excessive guilt, reduction in concentration or decisiveness, focus on death or suicide/suicide plan/suicide attempt all happening over a two-week period, significant distress or impairment, and no pattern of mania or hypomania. 10. What are some of the concentrated methods that must be used to rid depressed persons of their cognitive bias? First off, one must record their emotional reactions for a period of time as well as record the thoughts or events that produce distress then rating the intensity. It may be required that a patient keep a record of their activities as well (like Carlos was). The patient and doctor must then engage in a type of Socratic dialogue which asks the patient why they may come to certain conclusions and ask them if they really think these to be true. The conversation overall helps them realize that their thoughts aren’t necessarily in line with reality and they help them realize their capabilities. 11. Carlos wanted to know how long it would be before he felt normal again. Why did Dr. Walton not want to give Carlos a definite timetable? Dr. Walton didn’t want Carlos to focus on the length of time that it might take him to recover because he wanted to avoid setting up expectations for improvement by specific dates. He thought that if these expectations were not met, Carlos’s negative view of the future would only get worse. 12. What was the first assignment Carlos was given for the first week of therapy?

Carlos was required to record his emotional reactions, take note of the thoughts or events that produced distress, and then rate the intensity of the distress. 13. Why did Dr. Walton want Carlos on medication as well as the cognitive therapy approach? Dr. Walton and the psychologist (Dr. Hsu), had discussed it and together decided that it would be safe to add a small dose of aripiprazole (abilify) to Carlos’s daily regimen. 14. What was the homework assignment given in Session 2? What was the purpose of this assignment? Carlos was instructed to continue keeping track of his emotions and triggers. In addition, he was told to try to produce alternative, more realistic thoughts by considering whether his initial thoughts were truly a reflection of all the evidence. He also was required to leave for work at 8 am as he once did, as well as read a book to his children every night before bed. 15. Why was it important to get Carlos to set up an evening routine of activity? This would help Carlos recognize the capabilities that he did have, and realize how he wasn’t a basket case as he believed. 16. This case study mentions that about half of depressed clients may have marital problems. What factors led Sonia to become frustrated with Carlos’s behaviour? He stopped being a father and a husband. She was also upset by the fact that he would worry about everything and anything, and was only concerned for himself. 17. Why is it suggested that clients continue to take their medication for several months rather than quitting once they begin to feel better? Because if he were to stop, he would run a 50% chance of relapsing within the next year. 18. At approximately what point in treatment did Carlos return to full function?

It said that by sessions 10-14, Carlos had returned to full functioning and was in good spirits most of the time.

Case Study 6: Bipolar Disorder Manic Episode Symptoms 

For a week or more, a person displays a continually abnormal inflated, unrestrained, or irritable mood as well as continually heightened energy or activity, for most of every day

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Person also experiences at least 3 of the following symptoms:  Grandiosity or overblown self-esteem  Reduced sleep need  Increased talkativeness, or drive to continue talking  Rapidly shifting ideas or the sense that one’s thoughts are moving very fast  Attention pulled in many directions  Heightened activity or agitated movements  Excessive pursuit of risky and potentially problematic activities

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Significant distress or impairment

Bipolar I Disorder

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Occurrence of a manic episode

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Hypomanic or major depressive episodes may precede or follow the manic episode

Quick Facts 

The mean age of onset for bipolar I disorder is approximately 18 years olf

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Bipolar disorders are about equally common in women and men (ratio of 1.1:1)

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Antidepressant drugs can trigger a manic episode for some people who have bipolar disorder. Thus, clinicians must carefully monitor the impact of these drugs when prescribing them for people with such a disorder

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Most people with bipolar disorder tend to have depressive episodes more often than manic episodes. Depressive episodes may even occur three times as often as manic episodes

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Like depressive episodes, some manic episodes include psychotic symptoms. Some persons with mania, for example, may hold delusions of grandeur. They believe that they have special powers or that they are especially important beings, even a deity

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Many states have established procedures by which physicians can temporarily commit patients to a psychiatric hospital in an emergency. The procedure is usually called a physician emergency certificate

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Between 1-2.6% of adults around the world have bipolar disorder at any given time

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Bipolar disorder appears to be more prevalent in lower socioeconomic groups. Specifically, a negative association has been found between the number of days spent in a manic or hypomanic state and income level

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Various genetic studies have linked bipolar disorders to possible gene abnormalities on chromosomes 1, 4, 6, 10, 11, 12, 13, 15, 18, 21, and 22

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A hypomanic episode is an abnormally elevated mood state that is not as severe as a manic episode (it produces little impairment)

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In bipolar I disorder, full manic episodes alternate or intermix with major depressive episodes. In bipolar II disorder, hypomanic episodes alternate or intermix with major depressive episodes

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Because lithium and other mood-stabilizing drugs help prevent bipolar mood episodes, clinicians usually continue to prescribe these drugs even after a mood episode subsides

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Identical twins of persons with a bipolar disorder have a 40% likelihood of developing a similar disorder, whereas fraternal twins and other siblings have a 5-10% likelihood

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If people with bipolar disorder have four or more mood episodes within a year, their disorder is further classified as rapid cycling

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The cause of bipolar disorders is not clear. However, some theorists point to improper transport of sodium and potassium ions between the inside and the outside of a person’s neuron membranes

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Many bipolar treatment programs now include individual, group, or family therapy as an adjunct to medication. The adjunctive therapies focus on the need for proper management of medications, psychoeducation, improving social and relationship skills, and solving disorder-related problems

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More than 60% of patients with bipolar disorder improve while taking lithium or another mood stabilizer

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Two anticonvulsant drugs, carbamazepine (Tegretol) and valproate (Depakote), are also used in the treatment of bipolar disorder. They are about as effective as lithium and often have fewer side effects

Assessment Questions 1. What event prompted Gina’s first symptoms of bipolar disorder? Gina’s first symptoms arose in her senior year of high school when she got a minor acting role in a school play production. Gina became very absorbed in her work, was increasingly theatrical in her performances, and more involved in her costuming and makeup. 2. What events may have turned her mania into depression?

She likely transitioned from mania to depression due to the fact that students began to distance themselves from her. This made her think that other students might be plotting against her and her role in the play so she became more guarded and withdrawn from her activities. 3. What was the reason for her second hospitalization? The second time Gina found herself in a psychiatric hospital was due to the fact that she had become so absorbed in her astronomy coursework that she had stopped attending classes and was staying up night and day. Thankfully, her RA noticed something was amiss and decided to contact the dean of students’ office for help. 4. What medications were used in the beginning of her treatment and then several years later to assist in reducing Gina’s symptoms? She first started on an antipsychotic drug called paliperidone (Invega), but this gave Gina some extrapyrimidal side effects, so her doctor switched her to lithium carbonate (Lithium) in combination with eszopiclone (Lunesta) for sleep. 5. Why did Gina decide to stop taking her medications, and what was the result? Gina decided to stop taking her medications because she felt “straightjacketed” by them, saying that she lost her spark and her emotions felt dulled. Short term, she became more vulnerable to manic episodes and the depression that often followed. Over the years, her life was greatly hampered by periodic bipolar episodes. Because of this, she was unable to finish her bachelor’s degree on time. 6. Which of her manic behaviours became a concern to her parents? Her parents became concerned when Gina shared with them that she planned to open her own interior design business and had already started re-designing her parents home. She had purchased several thousand dollars’ worth of strange furniture and interesting wallpaper. 7. Gina suffered from delusions of grandeur. What was her specific grandiose idea?

She believed that she would be a successful interior designer and insisted that her parents’ home would be featured in her portfolio. 8. Explain the concept of the physician emergency certificate. Why was this necessary in Gina’s case? A physician emergency certificate allows a hospital to hold a patient for 3 days without a court order if the case is deemed an emergency. This was necessary in Gina’s case because she had experienced many prior episodes and was refusing treatment this time because she was so deeply enthralled in her manic episode. 9. Why do friendships suffer when an individual is bipolar? Friendships suffer because oftentimes, they may not know of the individual’s diagnosis and they may become very confused throughout the switching of moods, traits, and behaviours (manic and depressive episodes). It becomes difficult to know who the true person might be and is hard to know what to do in the situation. 10. Genetic studies have linked bipolar disorder with gene abnormalities on which chromosomes? Chromosomes 1, 4, 6, 10, 11, 12, 13, 15, 18, 21, and 22 have been linked to possible gene abnormalities in bipolar disorder. 11. Why did Gina decide to begin therapy with Dr. Rabb? At the time of her decision to see Dr. Rabb, her emotions were fairly stable, however, she knew that this stability would change unpredictably. These changes were a result of either changes in her reactions to her medications or a change in heart about taking them. She had heard of Dr. Rabb from a friend who previously had success in managing their mood disorder. 12. Why did Dr. Rabb choose the diagnosis of bipolar I?

Doctor Rabb chose the diagnosis of bipolar I because Gina experienced full manic episodes intermixed with major depressive episodes. This is rather than experiencing hypomanic episodes mixed with major depressive episodes as in bipolar II. 13. Why did Dr. Rabb want to increase Gina’s lithium level? Dr. Rabb wished to increase Gina’s lithium level in order to raise her blood-level to the higher end of the therapeutic range. 14. What is meant by the term rapid cycling? Rapid cycling refers to people wi...