Example of Case Conceptualization
Description of the Problem
Emma is a 61-year-old black widow and retired accountant. Emma has a young family because she married very late. Her two children Joyce and Jared are 15 and 11 years. Her husband died five years ago in a vehicle accident. Since his death, Emma has been taking care of her two children alone. She has also adopted two other children belonging to her eldest sister who died of cancer seven years ago. Three years ago, Emma was diagnosed with lung cancer at stage II and started Chemotherapy treatment. However, Chemotherapy did not work as expected because cancer progressed to stage III. As a result, the treatment had to be upgraded to radiation therapy (Combs et al., 2015). Although this treatment worked for some time, after one year it was realized that cancer had spread to her liver. As a retired accountant, Emma did not have health insurance and hence was using the family savings for treatment. Considering the rate at which the family savings were being depleted, she started to worry about dying and leaving her children with nothing to support their education and other basic needs. Ever since she started to worry about the children, Emma has been feeling restless, easily fatigued, difficulties concentrating, and difficulty controlling her emotions and having sleeping problems. She often finds herself stranded when alone and starts imagining about her children and how they will turn into beggars shortly after she dies. Emma denies any thoughts of self-harm as well as visual and auditory hallucinations. However, she has a history of depression.
The Client’s Vulnerabilities
Emma is at the final stage of cancer where nothing much can be done in terms of treatment, apart from palliative care. Therefore, Emma is pretty sure that she is living her last days. Also, her husband died five years ago after getting involved in a road accident and since then, she has been the sole provider in her family of four (including her sister’s children whom she adopted after her death). According to Emma, she would not have been worried if her husband was alive because she could be assured that her children will be taken care of after her departure. According to her, she cannot entrust her children with the relatives because when her sister died, they all turned down the request to take care of the children. As a result, she accepted to take the burden and has been taking care of the children alone. According to her, she could be at peace if the family savings were enough to sustain the children until they become adults because she considered her firstborn daughter to be mature enough to take care of the rest. However, she was worried that the high cost of her treatment would exhaust the family savings before she dies. Example of Case Conceptualization
The Client’s Triggers
When Emma’s sister’s cancer condition reached stage III and was put under palliative care, she died after one year. According to Emma, her sister was much stronger compared to her because she was a military cadet. Emma’s cancer condition is already at stage III and has been put under palliative care. However, when she compares her current health state with that of her late sister when she was put under palliative care, she feels that she won’t make it past one year. She has been thinking of getting a job to supplement her treatment and medication but her condition does not allow it. Sometimes she skips appointments to cut the cost and ensure that she does not exhaust the family savings. Whenever it comes to paying her hospital bill after checkups, she feels that she is betraying her children who will be left without any shoulder to lean on. Excessive thinking about the issue has forced her to start taking alcohol and sleeping pills to help her get to sleep. She explains that her appetite has reduced because food seems unappealing. Sometimes she finds herself irritated out of the many negative thoughts crossing her mind “I am constantly worried about the future of my children because they will soon be forced to drop school and unable to take care of themselves, I have betrayed my children” Example of Case Conceptualization
Emma is afraid that the family savings will have been exhausted by the high cost of medical treatment for her condition before she dies “the treatment and medication for my current condition is very expensive and will exhaust the family savings, leaving my children with nothing”. She believes that she is living her last days and now it is a matter of time before she exhausts the family savings just like her sister. However, unlike her sister who could rely on her to take care of the kids when she dies, she has nobody to entrust with the children. She feels like she will never get a break from her negative thoughts. She states “I have failed my children, I have betrayed them, and like a mother, I will never forgive myself”. She states that the death of her sister who left two children and relatives distanced themselves is a reflection of what will happen when she dies. She considers her children to be unlucky that they will not have someone to sympathize with them as she did for her sister’s children. Example of Case Conceptualization
The Central Thoughts the Client is Avoiding
Since she was diagnosed with lung cancer, Emma has been using the family savings for her treatment because she has already retired and her health condition could not allow her to find a job. When she looks at the remaining savings, she does not see any hope for the children because it’s almost depleted yet she is still under treatment and medication. She feels that before she dies the family savings will have been exhausted and her children will not be able to continue with education due to a lack of school fees. Also, they will not be able to meet their basic needs and that will make them “beggars”. Memories about what happened when her sister died have also been disturbing her. She explains that none of her relatives was willing to take responsibility for her children’s needs, making her adopt both of them. According to her, that is a reflection of what will happen after she dies. The picture of her children sleeping hungry amid unconcerned relatives makes her regret to have been married in such a family.
Differential Diagnosis
Differential diagnosis is the process of distinguishing a certain disease or condition from others that present similar clinical features. Considering the symptoms of Emma, several conditions will need to be ruled out before her real health condition is determined
Panic Disorder
A panic disorder occurs when a person is experiencing recurring and unexpected attacks. The DSM-IV identifies it associates it with abrupt surges of intense fear and discomfort that peak within minutes (Walderhaug et al., 2019). A person is said to have the panic disorder if he/she experiences sudden and overwhelming terror that has no obvious cause. Based on these symptoms, the disease is ruled out because Emma’s anxiety is not sudden. Example of Case Conceptualization
Obsessive-Compulsive Disorder (OCD)
Obsessive-Compulsive Disorder is a mental disorder in which the affected person has repeated thoughts or obsessions and feels the need to perform certain routines repeatedly or compulsions to the extent of generating distress and impairing general functioning (Schubert et al., 2020). It is characterized by unwanted, repetitive and uncontrollable thoughts (obsessions) and repetitive actions (compulsions). In the case of Emma, Obsessive-Compulsive Disorder can be ruled out because she is neither experiencing any obsessions nor compulsions
Social Anxiety Disorder
Also known as Social Phobia, Social Anxiety Disorder is an anxiety disorder that causes extreme fear in social settings. People experiencing this disorder have trouble talking to people, meeting new people and attending social gatherings (Evren et al., 2017). The main symptoms of this disorder are fear and avoidance of public performance or situations where they may be judged. In the case of Emma, this can be ruled out because she is not experiencing any fear and avoidance of public performance or situations where they may be judged.
Post-Traumatic Stress Disorder (PTSD)
PTSD is a mental health condition that is triggered by terrifying events, either witnessed or experienced. They are characterized by severe anxiety and uncontrollable thoughts about the traumatic event (Dunn et al., 2017). A person affected by this disorder re-experiences the severe traumatic events through flashbacks, nightmares and intense emotions with increased arousal and avoidance of reminders of the event. This disorder can be ruled out in the case of Emma because her anxiety does not come from any traumatic event. Example of Case Conceptualization
Substance-Induced Anxiety Disorder
This is an anxiety disorder whose panic attacks and other anxiety symptoms are caused by the use or withdrawal from alcohol and other substances, medications and exposure to heavy metals or toxic substances (Blaney et al., 2019). The main symptoms of anxiety in this disorder are direct physiological consequences of drug abuse, toxin exposure or medications. In the case of Emma, this disorder can be ruled out because her anxiety symptoms do not have a direct connection with drug abuse. Example of Case Conceptualization
Diagnosis
Generalized Anxiety Disorder (GAD)
Generalized Anxiety Disorder (GAD) is a mental disorder that is characterized by uncontrollable worry about common occurrences and situations. The anxiety associated with this condition is different from the normal feelings of anxiousness because it is marked by excessive and exaggerated anxiety and worry about everyday life events. Emma appears to have Generalized Anxiety Disorder (GAD) because her symptoms meet the DSM-V criteria for the diagnosis of Generalized Anxiety Disorder. For instance, she has been experiencing fear and worries about most of her days since she was diagnosed with stage III lung cancer, more than a year ago (Stein & Sareen, 2015). She has been finding it difficult to control her anxiety and most of the time she finds herself stranded in a chain of thoughts. She expresses somatic complaints such as tension, fatigue and restlessness. She has also been experiencing impaired concentration at home, a condition that makes her brain go blank and lost in a chain of thoughts. She has been experiencing trouble falling asleep because her mind does not shut down easily while ruminating on the fate of her children after she dies. Her symptoms cannot be associated with direct effects of substance abuse or other mental disorders. Example of Case Conceptualization
Coping Strategies
Emma pointed out that she has been drinking alcohol to cope with her anxiety feelings. She explained that the strategy does not always work. She states that it worked at the beginning because she could sleep normally but it is no longer working because she does not want to become addicted (Schroder et al., 2017). She explains that she has also tried exercising but her breathing problems are an obstacle to this strategy. Sometime back, she tried morning runs but ended up fainting out of shortness of breathing. She has resulted into walking around her home but that does not help because she still keeps thinking about the future of her children. Example of Case Conceptualization
Treatment Plan
For the treatment of Emma’s health condition to be effective, a combination of medication and therapy approach will be utilized. Medication will be useful for alleviating the symptoms of GAD she is experienced and will be prescribed in conjunction with other therapies (Kehoe, 2017). Among the medications to be used will be the antidepressants, particularly the Selective Serotonin Reuptake Inhibitors (SSRIs). Examples of these medications include Celexa, Prozac, Paxil, Zoloft and Effexor. Antihistamines and beta-blockers will also be considered because Emma’s anxiety condition is mild-moderate. The antidepressants will need to be taken daily, whether she is experiencing anxiety on that particular day or not. On the other hand, antihistamines or beta-blockers will only be taken when the anxiety levels are too high (Locke et al., 2015). Emma’s anxiety has reached the acute and hence will need to take anti-anxiety medicine as well. The most effective anti-anxiety drugs for her case will be the benzodiazepines for purposes of immediate relief. However, Emma should expect some side effects such as drowsiness, dizziness and irritability after taking this medication. Example of Case Conceptualization
Regarding therapy, Emma will be taken through psychotherapy which is the most preferred therapy for generalized anxiety disorder. Although there are different forms of psychotherapy such as psychodynamic and supportive-expressive therapy which consider anxiety as an outgrowth of feeling about important relationships, Cognitive Behavioral Therapy (CBT) which exposes the patient to behavioral relaxation techniques to reconstruct patterns of thinking will be used (Hall et al., 2016). The CBT process will involve four steps. In the first step, Emma will be guided by the therapist to identify the troubling condition in her life. The second step will entail familiarizing her with the thoughts, emotions and beliefs about the problems identified in the first step. At this step, a therapist will encourage her to share her thoughts about the identified problems (Westra et al., 2016). In the third step, Emma will be guided by her therapist to identify negative and inaccurate thinking. This will entail being asked to pay attention to her physical, emotional and behavioral responses whenever she is experiencing severe anxiety. The last step will entail guidance and counselling sessions to reshape any negative and inaccurate thinking. Example of Case Conceptualization
References
Blaney, D., Jackson, A. K., Toy, O., Fitzgerald, A., & Piechniczek-Buczek, J. (2019). Substance- Induced Anxiety and Co-occurring Anxiety Disorders. In Substance Use and the Acute Psychiatric Patient (pp. 125-144). Humana, Cham.
Combs, S. E., Hancock, J. G., Boffa, D. J., Decker, R. H., Detterbeck, F. C., & Kim, A. W. (2015). Bolstering the case for lobectomy in stages I, II, and IIIA small-cell lung cancer using the National Cancer Data Base. Journal of Thoracic Oncology, 10(2), 316-323.
Dunn, E. C., Nishimi, K., Powers, A., & Bradley, B. (2017). Is developmental timing of trauma exposure associated with depressive and post-traumatic stress disorder symptoms in adulthood?. Journal of psychiatric research, 84, 119-127.
Evren, C., Dalbudak, E., Ozen, S., & Evren, B. (2017). The relationship of social anxiety disorder symptoms with probable attention deficit hyperactivity disorder in Turkish university students; impact of negative affect and personality traits of neuroticism and extraversion. Psychiatry research, 254, 158-163.
Hall, J., Kellett, S., Berrios, R., Bains, M. K., & Scott, S. (2016). Efficacy of cognitive behavioral therapy for generalized anxiety disorder in older adults: systematic review, meta-analysis, and meta-regression. The American Journal of Geriatric Psychiatry, 24(11), 1063-1073.
Kehoe, W. A. (2017). Generalized anxiety disorder. Ambulatory Care Pharmacy Self-Assessment Program, 1-21.
Locke, A., Kirst, N., & Shultz, C. G. (2015). Diagnosis and management of generalized anxiety disorder and panic disorder in adults. American family physician, 91(9), 617-624.
Schroder, H. S., Yalch, M. M., Dawood, S., Callahan, C. P., Donnellan, M. B., & Moser, J. S. (2017). Growth mindset of anxiety buffers the link between stressful life events and psychological distress and coping strategies. Personality and Individual Differences, 110, 23-26.
Schubert, J. R., Stewart, E., & Coles, M. E. (2020). Later bedtimes predict prospective increases in symptom severity in individuals with Obsessive Compulsive Disorder (OCD): An initial study. Behavioral sleep medicine, 18(4), 500-512.
Stein, M. B., & Sareen, J. (2015). Generalized anxiety disorder. New England Journal of Medicine, 373(21), 2059-2068.
Walderhaug, E. P., Gjestad, R., Egeland, J., Havik, O. E., & Nordgreen, T. (2019). Relationships between depressive symptoms and panic disorder symptoms during guided internet- delivered cognitive behavior therapy for panic disorder. Nordic journal of psychiatry, 73(7), 417-424.
Westra, H. A., Constantino, M. J., & Antony, M. M. (2016). Integrating motivational interviewing with cognitive-behavioral therapy for severe generalized anxiety disorder: An allegiance-controlled randomized clinical trial. Journal of Consulting and Clinical Psychology, 84(9), 768.