Download PSYCHOLOGICAL CASE STUDIES 1 Psychological Disorders and

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PSYCHOLOGICAL CASE STUDIES
Psychological Disorders and Treatments
Paul Anthony Vitti
Kaplan University
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A patient that is of 29 years old, we will call her Desirae to protect her identity as well as
her right to confidentiality, walks into my office complaining of having problems for the last two
months, in her life, to where she is having an identity crisis where she feels like she is a man
trapped inside of a woman’s body. She does not know if she is considered a homosexual due to
this problem. All that she knows is that she has a strong attraction to the same sex. This problem
is causing her fear in her life because she is married to a man for ten years and has produced a
child during her marriage to this man. She has yet to act upon her attraction to the same sex but
feels a strong pulling towards experimenting with the attraction. Because she has yet tried to
experiment with her attraction to the same sex, it is causing her stress in her life with her
marriage because she has chosen to not have sexual intercourse with her husband and has refused
him on several occasions. She is having trouble focusing on her everyday schedule due to the
attraction to wanting to explore this new life style. She has even had times where she has seen a
woman approach her and talk to her in a very seductive manner and then start to undress her,
even though this felt real she knew that she was hallucinating this person. Due to these feelings
she is having problems with dealing with here day to day habits such as eating, sleeping, and
keeping up on her hygiene.
After listening to my patient, I realized that she could possibly have a comorbid
diagnoses of Schizophrenia with an Anxiety Disorder, but I wanted to test here first to get a
proper diagnosis. The DSM-IV T.R. states that a person who is exhibiting signs or symptoms of
schizophrenia has hallucinations, delusions, gender identity problems, such as fears of being
thought as a homosexual, and stress can worsen the symptoms she is exhibiting. The patient does
not however exhibit or complain to having other symptoms which can be associated with
schizophrenia disorder. These other symptoms are incoherence, loose associations, flat or grossly
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inappropriate affect, and catatonic or grossly disorganized behavior. I did ask the patient if she
was having thoughts or plans of suicide, to which the patient denied any plans or thoughts of
suicide.
The criteria in the DSM-IV T.R. states the following:
“Schizophrenia is a disorder that lasts for at least 6 months and includes at least
1 month of active-phase symptoms (i.e., two [or more] of the following: delusions,
hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative
symptoms). Definitions for the Schizophrenia 5ubt}'pes (Paranoid, Disorganized,
Catatonic, Undifferentiated, and Residual).” (American Psychiatric Association, 2000,
pg. 325)
I then put my patient through the following testing to see if the results would be
conclusive to my pre-determined diagnoses of an Axis I: Anxiety Disorder and an Axis II:
Schizophrenia Disorder. The testing that I conducted was administrating a clinical diagnoses
which would help to develop the historical information and a thorough mental status
examination. Then I submitted a “laboratory test and a routine battery test which ruled out any
possible organic etiologies, including CBC, urinalysis, liver function tests, thyroid function test,
RPR, HIV test, serum ceruloplasmin (which rules out an inherited disease, Wilson’s disease, in
which the body retains excessive amounts of copper), PET scan, CT scan, and MRI. Rating scale
assessment: Scale for the assessment of negative symptoms. Scale for the assessment of positive
symptoms. Brief psychiatric rating scale.” (Nurse labs, 2012, pg. 1) All of these tests where
administered to determine that schizophrenia would be the proper diagnoses for this patient.
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After concluding my testing and verifying my pre-diagnosis of an Axis I: Anxiety
Disorder and an Axis II: Schizophrenia Disorder I decided to speak to my patient about here
treatment options. I explained to my patient that there is currently no method for preventing
schizophrenia and that there is no cure for it. Since we have caught the schizophrenia early we
can minimize the impact of the disease with pharmacological and psychosocial treatments. I also
explained to her that if one of her episodes is acute then she may need to be hospitalized to
stabilize her, depending on the severity of course. I also told her that we would need to set up an
outpatient treatment plan for counseling, this would help her to minimize her symptoms and to
maximize her quality of life. The comprehensive treatment plan that I had produced consisted of
an: “Antipsychotic medication Education & support, for both ill individuals and families Social
skills training Rehabilitation to improve activities of daily living Vocational and recreational
support Cognitive therapy Medication is one of the cornerstones of treatment.” (Nurse labs,
2012, pg. 1) I also explained to my patient that she would need to take her medication
indefinitely, this is because “vulnerability to psychosis doesn’t go away, even though some or all
of the symptoms do.” (Nurse labs, 2012, pg. 1) I also stressed to my patient the need of treatment
in a psychosocial program and the initiatives combined with her medication which could be more
effective in treating and managing her disorder.
I would have to say that the typical treatment therapy used for this type of disorder would
be Behavioral Therapy but I have chosen to take the Humanistic approach in my treatment of this
patient, The reason that I have chosen to use Humanistic Therapy is because it deals with the
basis that “ people develop psychological problems when they are burdened by limits and
expectations placed on them by themselves and others, and the treatment emphasizes the
person’s capacity for self-realization and fulfillment.” (Stangor, 2010, pg. 405) The reason why I
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have chosen to use this form of therapy is because my patient has a gender identity problem.
Even though she may feel like a man trapped in a woman’s body, I do not want to negatively
influence her to make a decision on her sexual orientation. I would like to help her to come to
terms what is good for her depending on her choices. Even if she chooses to leave her husband
and pursue a relationship with a member of the same sex I would support her in this decision.
The whole point is to provide guidance and understanding to the patient based upon her decision
given. If I was to burden my patient by telling her that she should stay with her husband and lead
a life that she is not happy with because of her sexual choices then I would be like everyone else
she has been around who don’t support her decisions. If exploring the sexual fantasies that she is
having will help her in her treatment to get better then, yes I would support her.
As for the ethical obligations when it comes to selecting the best treatment, I would first
follow the “10.01 Informed Consent to Therapy by (a) obtaining informed consent to therapy as
required in Standard 3.10, Informed Consent, psychologists inform clients/patients as early as is
feasible in the therapeutic relationship about the nature and anticipated course of therapy, fees,
involvement of third parties, and limits of confidentiality and provide sufficient opportunity for
the client/ patient to ask questions and receive answers. (See also Standards 4.02, Discussing the
Limits of Confidentiality, and 6.04, Fees and Financial Arrangements.) (b) When obtaining
informed consent for treatment for which generally recognized techniques and procedures have
not been established, psychologists inform their clients/ patients of the developing nature of the
treatment, the potential risks involved, alternative treatments that may be available, and the
voluntary nature of their participation. (See also Standards 2.01e, Boundaries of Competence,
and 3.10, Informed Consent.)” (American Psychological Association, 2010, pg. 13).
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A second patient age 34, we will call him Thomas to protect his identity and his
confidentiality, walked in to my office complaining of having problems with constantly checking
the locks on his door, counting the many bricks that makes up his living room wall over and
over, he has an extensive fear of germs to where he uses a handkerchief to touch object or to
shake hands with a person, and he often repeatedly washes his hands to ward off infection.
After talking with this patient I made a pre-diagnosis that this patient was suffering from
(OCD) Obsessive –Compulsive Disorder and Anxiety. I then looked up the symptoms inside of
the DSM-IV T.R. to determine if I was correct to assume that this was his problem. The DSM-IV
T.R. stated the following information:
“A. Either obsessions or compulsions:
Obsessions as defined by (1), (2), (3), and (4):
(1) recurrent and persistent thoughts, impulses, or images that are experienced, at
sometime during the disturbance, as intrusive and inappropriate and that cause
marked anxiety or distress
(2) the thoughts, impulses, or images are not simply excessive worries about real life
problems
(3) the person attempts to ignore or suppress such thoughts, impulses, or images,
or to neutralize them with some other thought or action
(4) the person recognizes that the obsessional thoughts, impulses, or images are
a product of his or her own mind (not imposed from without as in thought in section)
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Compulsions as defined by (1) and (2):
(1) repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts
(e.g., praying, counting, repeating words silently) that the person feels driven
to perform in response to an obsession, or according to rules that must be applied
rigidly
(2) the behaviors or mental acts are aimed at preventing or reducing distress or preventing
some dreaded event or situation; however, these behaviors or mental
acts either are not connected in a realistic way with what they are designed to
neutralize or prevent or are clearly excessive
8. At some point during the course of the disorder, the person has recognized that the
obsessions or compulsions are excessive or unreasonable. Note: This does not apply
to children.
C. The obsessions or compulsions cause marked distress, are time consuming (take more
than 1 hour a day), or significantly interfere with the person's normal routine,
occupational (or academic) functioning, or usual social activities or relationships.
D. If another Axis I disorder is present, the content of the obsessions or compulsions is
not restricted to it (e.g. ... preoccupation with food in the presence of an Eating Disorder;
hair pulling in the presence of Trichotillomania; concern with appearance in the
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presence of Body Dysmorphic Disorder; preoccupation with drugs in the presence of
a Substance Use Disorder; preoccupation with having a serious ill ness in the presence
of Hypochondriasis; preoccupation with sexual urges or fantasies in the presence of
a Paraphilia; or guilty ruminations in the presence of Major Depressive Disorder).
E. The disturbance is not due to the direct physiological effects of a substance (e.g... a
drug of abuse, a medication) or a general medical condition.” (American Psychiatric
Association, 2000, pg. 462-463)
I then decided to run some tests to determine if my pre-diagnosis was correct. The tests
that I administered was a physical exam to rule out any physical causes, and a psychiatric
evaluation of the Yale-Brown Obsessive Compulsive Scale (YBOCS) so that I can diagnose the
pre-diagnosed OCD properly and track the progress of treatment at a later date. After running
these tests my conclusion is that the patient is suffering from Obsessive Compulsion Disorder.
After concluding my testing and verifying my pre-diagnosis of an Axis I: Anxiety
Disorder and an Axis I: Obsessive Compulsive Disorder I decided to speak to my patient about
his treatment options. I then explained to my patient what Obsessive Compulsive Disorder is and
that it can be treated with medication and therapy.
The therapy that I decided would help my patient best with his disorder is
Psychodynamic Therapy. This therapy would help my patient to realize why he is acting the way
he is and to make him aware of how to control his obsessions. “The Psychodynamic Therapy is a
psychological treatment in which the therapist helps the patient explore the unconscious
dynamics of personality.” (Stangor, 2010, pg. 404) This type of therapy will be most helpful for
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me, as well to find out what triggers the patient to be obsessive over a thing by listening to him
explain everything in his own words about his condition.
As for the ethical obligations when it comes to selecting the best treatment, Again I
would follow the “10.01 Informed Consent to Therapy by (a) obtaining informed consent to
therapy as required in Standard 3.10, Informed Consent, psychologists inform clients/patients as
early as is feasible in the therapeutic relationship about the nature and anticipated course of
therapy, fees, involvement of third parties, and limits of confidentiality and provide sufficient
opportunity for the client/ patient to ask questions and receive answers. (See also Standards 4.02,
Discussing the Limits of Confidentiality, and 6.04, Fees and Financial Arrangements.) (b) When
obtaining informed consent for treatment for which generally recognized techniques and
procedures have not been established, psychologists inform their clients/ patients of the
developing nature of the treatment, the potential risks involved, alternative treatments that may
be available, and the voluntary nature of their participation. (See also Standards 2.01e,
Boundaries of Competence, and 3.10, Informed Consent.)” (American Psychological
Association, 2010, pg. 13)
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References:
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders:
fourth edition text revision.
Washington, D.C.: American Psychiatric Association.
American Psychological Association. (2010). Ethical principles of psychologists and code of
conduct.
Washington, D.C.: American Psychological Association.
Nurse Labs. (2012). Schizophrenia case study: types, diagnosis, interventions & treatment.
Retrieved from.
http://nurseslabs.com/schizophrenia-case-study-types-diagnosis-interventionstreatment/#_
Stangor, C. (2010). Introduction to psychology.
Irvington, NY.: Flat World Knowledge, Inc.
The New York Times. (2013). Obsessive-compulsive disorder. Retrieved from.
http://health.nytimes.com/health/guides/disease/obsessive-compulsivedisorder/overview.html
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