Evaluation and intervention in a context adjustment disorder a single case study PDF

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The patient reports having depressive symptoms (constant tiredness, poor motivation, continuous crying, lack of concentration, trouble sleeping, ...), and problems with food....

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Evaluation and intervention in a context adjustment disorder: a single case study PATIENT HISTORY Description of the patient's demand The patient reports having depressive symptoms (constant tiredness, poor motivation, continuous crying, lack of concentration, trouble sleeping, ...), and problems with food. These symptoms appeared about a year ago, when he changed cities and came to study at the University. In addition to the personal discomfort experienced, there is interference in your activities of daily living and in your relationships with others. Past and current history of the problem SMJ is a 21 year old woman. It measures 1.56 meters and weighs 50-51 kilograms. She has had a partner for a year, has no children, and lives with her parents and older sister. She is the youngest of two sisters. He is not currently working and is pursuing a degree at the University About 3 years ago, SMJ asked a psychologist for help due to eating problems. She looked fat and would continually stop eating to lose weight. The psychologist focused on these eating problems and the body dissatisfaction problems she had. The patient was going to therapy for a year. After a year he was discharged, since he had improved a lot with the subject of food and was much better. The insecurities and problems with food appeared when the patient was in high school. SMJ had always been a girl with a few extra pounds, but she had never cared about her weight. He started to care when some classmates started messing with his physique. This caused him to start having insecurities. She started to feel bad about herself and didn't like herself physically, which

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that had never happened before. It was in 4th year of ESO when he decided to go on a diet. From this moment she began to feel thinner and became obsessed with not gaining weight. In order not to gain weight, he would stop eating radically and when he saw that he had already lost enough weight, he would eat abundantly again. She was thus until the 2nd year of high school, at which point the patient was so ill that she decided to ask a psychologist for help (mentioned above). When she started college, she hasn't been to the psychologist for 3 months and she was quite recovered. But the stress of arriving at the university with classes started (he entered the last session), of living in a new city, and of meeting other people, led to the appearance of some symptoms. It was from January-February 2017 that he started to feel bad again. She began to feel listless, tired, very sleepy, unconcentrated, in a bad mood, sad and wanting to cry continuously, especially at night. In addition, difficulties with feeding began to appear again. SMJ emphasizes that now the eating problems are not so much because of his physique, but that he believes that it is due more to the continued reluctance he has. To this is added that the patient has problems falling asleep and staying asleep, waking up continuously in the middle of the night. In addition, he has difficulties studying (due to his lack of concentration), and problems in his relationship with his family, friends and with his partner (as a result of his bad mood). These problems increase when you have to go out for lunch or dinner, since this generates a feeling of lack of control of the situation and what you eat, so you avoid meeting friends on many occasions so you do not have to go through for that situation. In addition, when she is with many people, she becomes overwhelmed, because she thinks that other people see her as fat or see some physical or personality defect. In relation to studies, it must be said that in the first year he only had one subject left. At that time he also had some concentration problems, but not as serious as those he reports having now. He is currently in second grade and has many difficulties studying. She says that when she begins to study, many thoughts come to her (related to the study or about other topics) that distract her and cause her to leave the study. In the first semester of this second year, he has failed four out of five subjects. During the academic year you live from Monday to Friday in a rental apartment

shared with two other student girls. If he does not have exams, he spends the weekends in his family home, together with his parents and sister with whom he has a good relationship. The patient indicates that she also has a very good relationship with her classmates and with friends from her hometown. However, although he gets along, he goes out less and less with them. She continually makes excuses to avoid going out and eating something out, since she knows that it can make her feel bad. She also comments that her boyfriend is a great support for her and that they hardly argue, since he is a very peaceful and understanding person (although lately they argue a bit more as a result of his bad mood). With him if he goes out more, although he tries to eat little and hide so that he does not suspect anything. There is no family history related to eating problems, depression, anxiety, or any other psychological disorder. Objectives of the evaluation In order to specify the patient's specific problem, and the factors that are related to it, a psychological evaluation process will be carried out to establish both a diagnosis and a possible intervention. Other data It indicates that no one knows anything about her current problems or how she is, since she does not want to worry them or that they are continuously aware of her. Despite this, she says she would like to tell someone because she thinks it would make her feel better. Specifically, she would like to tell her mother, her boyfriend, and her closest friends. Positive or adaptive functioning areas The patient is defined as an empathic person, who likes to help others. She also sees herself as a brave woman, since when she thinks she needs it, she is able to ask for help to solve her problems. It is observed that, in addition to the characteristics previously described, SMJ is a fairly responsible, educated and collaborative person. Behavior during the assessment SMJ was nervous and shy at the beginning of the evaluation. He was very bad emotionally, even breaking down and crying in the first session. Later, as the sessions progressed, she began to be very receptive and participatory at all times, demonstrating good comprehension and communication skills.

reflection during therapy. As a consequence of this, we have worked comfortably and all the required information has been obtained in a short period of time. HYPOTHESES EMERGED IN THE INTERVIEW Next, three types of hypothetical assumptions that can be formulated in Psychological Evaluation and the deduction of verifiable statements that are extracted from them are described, according to Fernández-Ballesteros (2004): -

Of similarity.The patient presents a symptomatology comparable to that

of people diagnosed with a context adjustment disorder with depressed mood. Therefore, SMJ should obtain a medium-high score on the Beck Depression Inventory (Vázquez and Sanz, 1997) and should meet the DSM-V diagnostic criteria for adjustment disorder with depressed mood. -

Of functional relationship.In the initial interview, the patient gives

information about some events that occurred in her adolescence (they insulted her and interfered with her physique), which generated many insecurities that are still present today. In addition, the change of city and the beginning of studies at the University have been able to lead to the onset of the symptoms that the patient currently presents. To all this we must add that SMJ is a person who does not see himself capable of achieving any objective or reaching any proposed goal. You perceive that you do not control anything, not your life or many situations or daily events. Also, she believes that she does nothing well and that others are better than her. All these thoughts could be contributing to worsen this ongoing discomfort that the patient presents. -

Predictive association.The diagnosis of an adjustment disorder with a

depressed mood is usually associated with an intense disproportionate discomfort in relation to the severity or intensity of the stressor, as well as a significant deterioration in social, occupational, or other important areas of personal functioning . In addition, low mood, apathy, the urge to cry, and / or the feeling of hopelessness predominate. Faced with this symptomatology, it is believed that the application of techniques such as behavioral activation, timing of eating, sleeping and studying, and the use of self-records (so that the patient can follow a control and become aware of some of her behaviors ), will reduce or make these symptoms disappear, improving

thus the quality of life and the daily functioning of the patient. In short, according to data collected from the interview, it seems that SMJ presents a set of emotional symptoms (sadness, apathy, reluctance, bad mood ...) and behavior (insomnia, loss of interest in many activities, crying, loss of energy almost every day, loss of appetite, concentration problems ...) as a consequence of one or more stressful events: in his case the change of city and the beginning of a new personal stage at the University. This stress has caused the patient to develop a series of depressive symptoms (already mentioned above), which suggest that SMJ may currently suffer from an adjustment disorder with a depressed mood. TECHNIQUES AND EVALUATION PROCEDURE In the first session, SMJ authorized that the data obtained from their participation in the sessions could be used for training and research purposes, guaranteeing the confidentiality of the data at all times in accordance with the provisions of the Code of Ethics for Psychologists. The evaluation was aimed fundamentally at evaluating the problem behaviors of SMJ It was carried out through interview, self-reports and self-registration. The application of the instruments was carried out mainly in the first, second, third, fourth and fifth sessions, although in more advanced sessions some self-registrations were also applied to see if some problem behaviors had been reduced. The order in which the instruments were administered was as follows: 

First, an interview was conducted: it was in the first session that more information was collected, although in the second and third sessions, the patient was also asked some more questions to complete the information.

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Second, during the second session, the following psychometric tests were applied: State-Trait Anxiety Inventory (STAI) and Beck's Depression Inventory (BDI). Finally, in the last session (session 15), the Satisfaction with Treatment Questionnaire was passed to the patient.

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Third, the participant was given several self-registers that she had to fill out weekly:

a) Four self-registers of thoughts: one in the first session -which was never delivered-, another in the second session, another in the third session and another in the fourteenth session. b) Two self-records with information on daily activities, what he ate and his sleeping habits (in the second and fourth sessions). c) A specific sleep self-record (in the fifth session). d) A self-record of the social and leisure activities you do daily and your degree of satisfaction when doing them (in the fifth session). e) In more advanced sessions (tenth, eleventh, twelfth, thirteenth and fourteenth session) the patient also made four self-registrations - since the self-registration that was delivered in the thirteenth session was not filled in - with information on the number of times it is looked at to the mirror and / or weighed and the reason. The instruments used in the evaluation are explained in more detail below. 1. Interview A semi-structured interview has been carried out during three sessions, in order to obtain the necessary information to find and obtain a general idea about the patient's problem behaviors. In addition to everything related to the stressful situation that the patient has suffered since she arrived, information has also been collected on the intensity, frequency and duration of the depressive symptoms that she has had since then. Likewise, information was obtained on the thoughts they experience and on the behaviors they carry out on a daily basis. Finally, other areas of his life have been evaluated, such as family, friends, the relationship with his partner, study habits, time spent on leisure and social relationships, 2. Self-reports To delimit the problem, two questionnaires were used to complement the information obtained in the interview. These questionnaires were passed again

after the intervention, to see if there had been any improvement in this regard. These questionnaires were administered to the patient in session 2, in session 15 and in the follow-up session (one month after the end of the intervention). In addition, in the last intervention session (session 15), a Satisfaction with Treatment questionnaire was given to the patient. Before the patient filled them in, the instructions for their completion were clearly explained to her. State-Trait Anxiety Inventory (STAI; Spielberger, Gorsuch & Lushene, 1982). It is a self-evaluation test of anxiety as a transitory state (state anxiety) and as a latent trait (trait anxiety). It consists of two parts, with 20 items each, and four response alternatives. The response scale is Likert type, scoring from 0 (not at all) to 3 (very much). The first part evaluates the State Anxiety and the second part the Trait Anxiety. In the State form the patient answers how he / she feels at the moment and in the Trait form he / she answers in relation to their willingness to respond with anxiety to situations perceived as threatening. In population samples, it has an internal consistency that ranges between 0.90 and 0.93 for the State scale and between 0.84 and 0.87 for the trait scale (Spielberger et al., 1982). Beck Depression Inventory (Beck Depression Inventory, BDI; Vázquez and Sanz, 1997). This inventory consists of 21 items, with four response alternatives, from less to greater severity (0 to 3), the purpose of which is to assess the presence and severity of depressive symptoms, especially the cognitive and emotional aspects of the construct. The adapted questionnaire shows an internal consistency of 0.87 and a construct validity of 0.68 between the cognitive-affective and somatic-motivational factors (Sanz, Perdigón & Vázquez, 2003). Treatment Satisfaction Questionnaire (CSQ; Larsen, Attkisson, Hargreaves and Nguyen, 1979). At the end of the intervention (post-test evaluation), this questionnaire was also applied. It consists of 8 questions about the services the patient has received. These questions are answered by marking the chosen answer with a cross. Each question is evaluated between 1 and 4 points, satisfaction being directly related to the score. Therefore, the maximum score that can be obtained in this questionnaire is 32 points. Values for consistency range from 0.83 to 0.93; and its validity is around 0.6-0.8 (Larsen et al., 1979). The goal is to expand the

subjective or clinical information on the efficacy of the intervention. For this, the patient is asked to give his / her opinion in a sincere way, be it positive or negative. 3. Self-records The patient was also asked to fill out several self-records (in different sessions), which are explained below. You were asked to spend approximately 30 minutes each day filling out these self-records. Self-registration of thoughts The self-registration of thoughts administered to the patient included the evaluation of the following aspects: what is she doing at that moment, what she is thinking, how she feels and the degree to which she believes it (Annex 2). The patient was asked to fill out this self-record four times, but she only did it three times. The first time he was asked to do it was in session 1 (this was not delivered, since it says he was traveling and I can't do it), the second time in session 2, the third time in session 3 and the last time in session 14. On the first and second occasions he was asked to do it for a week, Self-recording of what you do each day, what you eat and your sleeping habits On the same page, to make it easier for her and to take as little time as possible, the patient was asked to make a weekly record in which a list of what she does each day appears (time spent studying, if whether or not you start studying, if you go out with friends or your partner ...), a list of things you eat every day (breakfast, lunch, snack and dinner ...) and a list of your sleep habits (hours of sleep, if you have trouble sleeping, if you feel tired…). This self-registration (Annex 3) was sent to you in order to have subjective information on these aspects. It was filled for a week and on two occasions (sessions 2 and 4). Sleep self-recording After the information collected in the previous self-registration regarding sleep habits, it was considered necessary to obtain more detailed information about it. In this registry (Annex 4), the patient took note of the quality and duration of her sleep. It included the time you go to bed, the time you get up, if you

you wake up during the night and if it takes a long time to fall asleep (at the beginning and when you wake up). This self-record was only requested once (in session 5) and the patient completed it for one week. Self-registration of social and leisure activities As in the previous self-registration, given the information collected in the selfregistration of what she does each day, what she eats and sleeping habits, it was considered necessary to delve deeper into the patient's social relationships and activities that makes. This self-registration (Annex 5) included the following aspects: activities carried out daily, for how long they were carried out, with whom and degree of satisfaction with them. Session 5 was when the patient was asked to carry out this record for a week. Self-recording of the times you look in the mirror and / or weigh yourself In sessions 7, 8 and 9 the patient began to report that she looks in the mirror many times to continually check that she has not gained weight. Given this information, they were asked to fill in a self-registration in session 10 and 11 (Annex 6), indicating whether they looked at the mirror more than 5 times and the reason (5 was the number agreed upon by both and that number was agreed upon because it was considered to be the number of times justified for personal hygiene). In session 13 the patient commented that, in addition to looking in the mirror a lot, she is also beginning to weigh herself many times throughout the day. Therefore, in sessions 13 and 14, he was asked to also record the times he weighed and the reason. It was agreed that one could not weigh more than 1 time in two weeks. RESULTS OF THE EVALUATION AND INTERVENTION PROPOSAL Interview The data obtained through the SMJ interview indicate that he has depressive symptoms (sadness, insomnia, loss of interest in many activities, crying, loss of energy almost every day, bad mood, loss of appetite, concentration problems ...) that affect him in many areas of your life. Problems have also been found with eating (which may be related to that reluctance and continuous depressive symptoms) and with how he looks physically. On the other hand, it also presents

cognitive manifestations related to studies (such as: “I am not going to finish my degree”, “I am going to fail the exams”, “what I study is useless”), or related to their physical or discomfort (such as, for example: “I have eaten a lot”, “I am fatter”, “I don't feel like anything”), which affect their academic performance. In relation to studies, there is a marked lack of motivation to study and great difficulty in passing subjects and achieving other goals in life. He does not seem capable of achieving anything. In addition, his study habits do not seem to be adequate to pass the exams, since it is difficult for him to concentrate and he ends up leaving the study or studying very few hours a da...