Psy 241 Case Study Template Updated 8-2021 PDF

Preview

Summary

assign...

Description

PSY 241 CASE STUDY TEMPLATE Name: Kyla Ralston Date of Birth: March 12, 2002 Age: 19 years old Date of Report: November 22, 2021 COMPLETE THE SECTIONS BELOW IN COMPLETE SENTENCES. REMOVE THE “BULLETS” AFTER YOU TYPE IN YOUR INFORMATION Reason for Seeking Treatment:  How did client decide to enter treatment?  Was the client referred? Whom by? Kyla was taken to the family doctor by her mother when expressing severe difficulty breathing, chest pains, light-headiness when the bus was running late for her final exam at 8:30am. The first time she expressed these symptoms was at a school field trip to another city where she got lost, the second was when her computer mysterious shut off while she was writing a zoom mid-term, because this presence of severe anxiety didn’t seem to be going away, and in fact has heighted since the initial incident, her mother took her to her family practitioner. Her mother also noticed a heightened worrisome behavior than her usual since the incident. Background Information:  Identifying information including age, gender, ethnocultural identity, marital status, and occupation or academic role.  Presenting complaint Kyla is a 19-year-old girl white female who lives with her biological mother. Elizabeth is entering her first year of University at the University of British Columbia. Kyla was always a rather type A, organized person, she would be overcome of distress over any negative or unexpected event in her life. Kyla is rather introverted and keeps to herself, she does not have many friends and is rarely present at social gatherings. History of the presenting complaint:  Symptoms: Age or time of onset, duration, course (times when it’s better or worse) o Be sure symptoms match DSM-5 criteria and be very specific in describing the symptoms  Prior treatment efforts and success of these.  Prior psychological assessment (if any)  Client's understanding or level of insight of the problem  Client’s motivation for change Mom reports that when Kyla was around 12 years old, she went on a class field trip to New Orleans and got lost in the middle of the French Quarter. During this experience, she became short of breath, dizzy and feel faint. Following this incident when she returned home, Kyla began to express desire of not wanting to be alone, and since then she has started to overthink everything, she was doing, was on edge over even the slightest uncertainty. Initially, her mother thought this was a phase, some type of PTSD from the incident that will gradually smooth over time, but according to mom, Kyla slowly started restricting her presence in any social gatherings and events (e.g., school, church groups, sports games, etc.) that had uncertainty. Kyla stated she currently is choosing to remove herself from situations that she 1

PSY 241 CASE STUDY TEMPLATE feels uncomfortable and unwelcomed in. Mom reports that Kyla has become more and more worrisome about many aspects of her life since the “lost incident”. She loses sleep over many things in her life. Kyla stated that this worrisome behavior is to “worry in advance, I will be less disappointed if something serious occurs.” (Dozois, 2019). Kyla must do an in-class oral presentation, is mandatory worth 40% of her final grade and right now there is a BC Transit strike, and all transit buses are not working, Kyla gets to school by transit and has not alternative method of getting to school, and this thought is keeping her up at night, and she has difficulty concentrating on anything except this overwhelming fear of powerlessness and uncertainty. Due to this lack of sleep, she feels very tired and her body aches. Kyla has never been assessed or treated for any anxiety disorder or any other mental health problems. Kyla’s mother dates that this issue has been occurring since the beginning of the school year in 12th grade and has progressively inclined in severity and continued since then and has been occurring for around 16-months. Other pertinent information  Personal, academic, work, medical, social, or family history relevant to the referral question, presenting complaints, or diagnoses under consideration.  Other psychological/ psychiatric problems in the family history.  Reports of substance abuse: what, how recently, how often, how long.  Medication use: what medication, dose, when last dose was taken, what it is for. Kyla’s father passed away when she was 5 years old from suicide after severing two tours in Afghanistan and suffering from severe PTSD. Her mother has been diagnosed with obsessive compulsive disorder and her maternal grandmother suffered from bipolar disorder and anorexia. Kyla was always quite anxious as a child; had trouble sitting still for long period and when she was younger, she would insist that she would have to go to school one hour before needing to be there. Mother described Elizabeth as a “perfectionist” and stated that she is very hard on herself at school. Kyla has a very good relationship with her mother and the absence of her father never seemed to affect her in a noticeably negatively symptomatic way. Kyla is on birth control and has never had any issues with substance abuse and has never had anything more than an occasional celebratory drink or smoke with friends. Diagnosis: DSM-5 name: Rationale for diagnosis:  How does the case study meet the specifiers or subtypes of the diagnosis?  Describe the symptoms that lead you to the diagnosis. o Be very specific on how the symptoms meet the DSM-5 criteria for the disorder o With each DSM criteria you discuss, match it to a symptom from the “History of presenting complaint” by discussing how that symptom meets the DSM criteria. Based on the symptoms reported by mother and Kyla as well as her family history, it appears to meet the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) (American Psychiatric Association, 2013) for generalized anxiety disorder. To meet the diagnostic criteria for generalized anxiety disorder, she must experience “excessive anxiety and worry, occurring more days than not for at least 6 months, about a number of events or activities” (American Psychiatric Association, 2013). She is restless and on edge, as she has difficulty sleeping due to her excessive worrying, she has become easily tired. Kyla often would get really worked up and anxious over what most people would think was nothing. For instance, if the bus was one minute behind schedule, her mind 2

PSY 241 CASE STUDY TEMPLATE would automatically race all over multiple things at once; “what if the bus is canceled, what if I can’t go to school, what if I miss didn’t lock the door to my house, what if I’m late, etc., she thinks of an endless amount of “what ifs”. She suffers from a severe case of Intolerance of uncertainty (IU). This worrying makes he rlose sleep, be on edge, and causes difficulties in concentration. The worry that she is feeling over everyday situations is consistent with this diagnosis and was at an all-time high when the situations were more unpredictable. The DSM-IV for GAD requires at least three of six criteria be met for a successful diagnosis of GAD Kyla meets enough criteria for GAD. Kyla’s reports of fatigue, irritability, sleep disturbance, concentration troubles and restlessness. Recommendations for Treatment:  Discuss in detail what types of treatment would most benefit the client based on research.  Base your recommendations for treatment on empirical evidence from research on treatment for your disorder.  Provide an A.P.A. style in-text citation and a reference for the research article you cite in this section. Based on the research, it appears that Cognitive-behavioral treatment (CBT) would be the first treatment recommended for Kyla. This is an effective long-term GAD management treatment that aims to change pathological worries into normal worries (Borza, 2017). It will initially try to help patients detach themselves from their automatic tendencies for anxious thoughts and disconnect from the worries (Borza, 2017). The therapy is meant to modify thought contents for a more objective prespective of situations and minimize cognitive biases feeding the worrisome beliefs (Borza, 2017). Research believes that an improvement in the tolerance of uncertainties will effectively alleviating symptoms of anxiety as it will reduce worriment (Dozois, 2019). Although antidepressants such as venlafaxine hydrochloride and Benzodiazepines are common and effective pharmacotherapy treatments used for GAD, these medications are more often used as short-term treatments for GAD as patients can be desensitized to the benefits or dependent on the drug (Dozois, 2019). References: American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.) Arlington, VA: American Psychiatric Publishing. Borza L. (2017). Cognitive-behavioral therapy for generalized anxiety. Dialogues in clinical neuroscience, 19(2), 203–208. https://doi.org/10.31887/DCNS.2017.19.2/lborza

(Textbook) ADD THE REFERENCE FOR ANY OTHER SOURCES YOU USED INCLUDING THE TEXTBOOK AND THE SEARCH ARTICLE.

3...