Case Formulation Assignment: Patient Case Study/History
“Sophia” is a windowed, African American woman in her late 50’s who came to the clinic and explained some of the symptoms she was experiencing such as hopelessness, lack of interest in most of the things she considered fun in the past, increased fatigue and sleeping problems, excessive worry, anxiety, irritability and uncontrollable emotions (Rotenstein et al., 2016). Eight years ago, Sophia reported that she had experienced similar symptoms when she lost both of her parents in a fatal road accident, although not severe and her provider recommended antidepressants whenever she experiences similar symptoms, but declined to take them because they are prohibited by her religion, Seventh Day Adventist (SDA). Over the short period she interacted with us in the clinic, Sophia reported a long history of recurrent depression-like symptoms since she was 21 years old, she estimated her current symptoms to be of 4 years duration. Our diagnostic interviews revealed that Sophia displayed Post Traumatic Stress Disorder related symptoms from an assault she had experienced at work 10 years ago. Some of the symptoms of PTSD included recurrent and unwanted memories of what had happened to her, upsetting dreams about the experience, and emotional distress when travelling past the workplace where she had been assaulted. She also displayed symptoms of generalized anxiety disorder such as difficulties concentrating, difficulties controlling her feelings and feeling restless. Case Formulation Assignment
Sophia was leading a happy life before her husband was killed mysteriously, five years ago. Before the death of her husband, Sophia explained that there was a sibling’s conflict following what her brothers in law considered to be unfairness on inheritance distribution. It had been alleged that her husband had grabbed a large portion of the family inheritance than the rest. As a lawyer, her husband had decided to settle the dispute in the court, a step that did not please the rest. At the initial stages of the case, her husband disappeared only to be found dead at the city dumpsite. It is at that moment that her struggle began. Her attempt to seek justice for her late husband was not successful. Instead, it led to the freezing of all the family bank accounts. Later on, the family property was grabbed.
The threats she was receiving pushed her to become alcohol dependent and felt that she was drinking too much. She was not receiving any treatment for her symptoms. However, she was taking codeine for the chronic pain affecting her muscles and joints, and which she described as diffuse. Despite her long history of the symptoms she presented, Sophia had received little treatment in the past. She had not taken the antidepressants she was given by her doctor but she had attended a few counseling sessions when her husband passed away, which was not helpful because she was not getting well with the therapy. She had resolved to work extra hours to meet the family demands as a sole breadwinner in the past, but she had started to reduce the working hours and was worried about debts. She lived with her sister’s daughter, who was blind, and for whom she was the main caregiver. Although she had two adult daughters, they lived away and did not see them frequently. Case Formulation Assignment
Several assessments were done on Sophia. They included the Baseline Questionnaire Assessment, Behavioural Activation for Depression Scale (BADS), Clinician-Administered PTSD Scale (CAPS), Hamilton Anxiety Scale (HAS) and Prospective Imagery Test (PIT). A Behavioural Activation for Depression Scale (BADS) is an assessment tool used to track weekly changes in behaviors hypothesized to underline depression especially those targeted for change by behavioral activation. The scale examines the changes in activation, rumination, social impairment and avoidance. BADS consists of 25 questions rated at a scale ranging from 0 to 6. A Clinician-Administered PTSD Scale (CAPS) is a structured interview that is designed to make a categorical PTSD diagnosis and measure symptom severity. Under this scale, symptoms are put into three categories: A, B and C based on intensity and frequency which are summed up to provide severity ratings. The Hamilton Anxiety Scale (HAS) is a 14-item test that measures the severity of the anxiety symptoms. For the 14 items in this scale, the values range from 0-4 where 0 indicates the absence of anxiety, 1 indicates mild anxiety, 2 indicate moderate anxiety, and 3 indicate severe anxiety while 4 indicates severe anxiety. The Prospective Imagery Test (PIT) is a measure of the ability to generate mental images about future events. Participants in this test are required to imagine at least 10 negative future scenarios and 10 positive future scenarios and rate the vividness of each image on a 5 point Likert scale where 1 denotes “no image at all” while 5 denotes “very vivid” (Ji et al., 2017). Participants are also required to rate the perceived “likelihood” of the occurrence of each in future on a scale of 1 to 5 before the average scores can be calculated. Baseline questionnaires are questionnaires administered in person bases to respondents with closed-ended answers for data collection purposes. Case Formulation Assignment
On the Prospective Imagery Test (PIT), Sophia rated the vividness of the positive events in her future as “vague and dim” on average. On the measure of negative interpretation bias under the Scrambled Sentences Test, she scored almost at the ceiling. On Behavioural Activation for Depression Scale (BADS) (Chartier & Provencher, 2013), her score indicated very low levels of behavioral activation, which was consistent with what she had reported “not doing much around the house” and that she was struggling to accomplish simple chores. On the baseline questionnaire, Sophia scored “severe” range for depression on Beck Depression Inventory (BDI), including anhedonic symptoms rating “I get very little pleasure from the things I used to enjoy” and “I am less interested in other people and things than I used before”. On the Clinician-Administered PTSD Scale (CAPS), most of the PTSD symptoms she was displaying had a frequency and intensity score of more than 2 indicating that she was undergoing a PTSD episode. Based on the 14 items of the Hamilton Anxiety Scale (anxious mood, tension, fear, insomnia, intellectual symptoms, cognitive symptoms, depressed mood, muscular symptoms, memory symptoms, cardiovascular, respiratory, genitourinary, and gastrointestinal symptoms), Sophia scored an average of 2 which was an indication of moderate anxiety.
Sessions 1-3: The Initial Phase
The goal for these three sessions was to examine the current depressive symptoms experienced by Sophia and explore their relevance. Her current interpersonal relationships and difficulties will also be examined and linked to the depressive symptoms experienced. Lastly, the main area of focus that best reflects the above patterns will be selected and the remaining contract negotiated. First, we will explain the interpersonal therapy (IPT) approach to Sophia and make sure she acknowledges the interpersonal challenges she is currently facing and express her willingness to work on changing her behavior (Mufson et al., 2015). We will then review Sophia’s current depressive symptoms. Sophia’s hopeless feeling was associated with the fact that everything her family and her had tried in the past did not seem to work at all and it ended up as a disappointment. For instance, when her husband had tried to pursue the case of the sibling’s conflicts in the extended family, he ended up being killed. Consequently, when she tried to seek justice for her late husband, the family bank accounts ended up being frozen and could not afford to pursue the case. Also, the family property that her husband had died defending was later taken away by the two brothers. Although she could report the threats she was receiving from unknown sources to the police, she was not getting the help she anticipated. Based on the chain of these events, Sophia’s feeling of helplessness was linked to fact that most of the things she tried to do were not working out as she expected. Case Formulation Assignment
Her loss of interest in activities she considered fun before was associated with the difficulties she was undergoing, which deprived her ability to enjoy and feel pleasure. Sophia was facing so many challenges at the same. Right from losing her husband mysteriously, she had also lost the family property that her husband had died pursuing. As if that was not enough trouble, the family savings in the bank accounts which could have enabled her to seek justice for her late husband had been lost. The fact that she was facing different challenges and none of her solutions were working had taken away her feeling of joy and pleasure. All through, she was trying to get a solution for her problems and that increased her fatigue and caused sleeping problems (Smarr & Keefer, 2011). The anxiety symptoms were linked with the threats Sophia was receiving. She felt worried, nervous and unease about the threats because she was not sure about what was going to happen to her. Besides, she did not know who was threatening her since she had not gotten any help from the police even after reporting. Her irritability and uncontrollable emotions were associated with a low level of tolerance because things were not working in her way.
Sophia admitted to being feeling lonely now that she was living with her sister’s daughter with whom she could not socialize fully because she was blind. She also confessed that she felt insecure because of the ill relationship between her family and the two brothers’ in law. She was also worried about the fate of her two daughters who were living away from her. She felt that family rivalry could be extended to them. She was also worried about what was going to happen to her following the threats she was getting from unknown sources.
Sophia explained that her problems were overwhelming and needed help to handle them. As a staunch SDA follower, she explained that she was not ready to take antidepressants because they were prohibited but would appreciate any other help. She believed that counseling and spirituality would be of much help to her. Her objective was to get back to live her normal life. However, she considered it impossible before getting into good terms with her two brother’s in law, to whom she linked with all her miseries. Sophia agreed to therapy to help her deal with the challenges she was facing. Case Formulation Assignment
Session 4-9: Middle Phase
After Sophia agreed to cooperate and play her role in the transition, we entered the middle phase of the IPT. Sophia had now understood that her clinical symptoms were related to depression, which was not her fault but the challenges she was going through. The main goal of this phase was to monitor her depressive symptoms and work towards resolution and active engagement to support and facilitate change. She would learn how to detect and monitor her symptoms in the course of the therapy. She would also learn to control the symptoms and feel better. In her role transition, she would learn how to face her challenges without affecting her normal life. We introduced her to the tactics of emotional controls and guided her on how to respond to different emotions (Treasure et al., 2012). We also supported Sophia in confronting and overcoming some of the negative thoughts and feelings she was experiencing at the moment. Sophia needs to learn how to intellectualize her emotional feelings and block the unpleasant moods that further complicated her ability to change. Case Formulation Assignment
In this phase, Sophia would learn to examine her emotions and properly control them. In every session, the emotional challenges she was facing would be examined to enable her to learn how to elicit some of the feelings and behaviors before giving her a chance to practice on how to improve the coping mechanisms for her feelings. We persisted in weekly probing, to guide Sophia on how to cope with different situations and stir her away from some of her negative experiences. Although she seemed to be improving on her coping mechanisms, she was still facing emotional challenges. For example, after her recent efforts to get the family bank accounts activated had distorted her emotions to the extent of spending a whole day in the bed (Cuijpers et al., 2016). Case Formulation Assignment
The first two sessions of this phase were disappointing because Sophia did not seem to change from her old emotional behaviors. For example, she would confess that she can handle any emotional challenges successfully but when faced with one, she could respond the way she used to respond. That made us feels as if we were doing nothing. Sophia was undoubtedly weak in emotional response. However, by session 7, Sophia was more equipped and could respond to emotional challenges in a better way. This was confirmed through a threat she had received but did to distort and well-being like it used to be. However, she was still hesitant to communicate her challenges. As a result, we introduced a role play to improve her ability to communicate and share her emotional challenges. Acknowledging her feelings with intense emotions was the most challenging task for Sophia (Rotenstein et al., 2016). In session 8, a profound shift of thinking and behavior was apparent because Sophia was able to acknowledge negative moods without affecting her badly, which was very useful as it socially revealed her feelings. She could come to the sessions more willing to discuss her recent challenges and resultant feelings. She had realized the advantages of trying and was more peaceful. Case Formulation Assignment
Session 10-12: Termination Phase
The main goals of this phase were to discuss the ending and associated effects of the therapy explicitly, review and evaluate the treatment, and provide support for continued use of interpersonal strategies when faced with potential symptomatic relapse. Sophia had made some progress regarding her interpersonal strategies and response to negative emotions and feelings. We understood and acknowledged that Sophia was facing a difficult situation regarding the loss of almost everything that the family-owned. We focused on the improvement she had made and highlighted the areas in which Sophia felt she needed additional support before the therapy was over. Sophia as well as the therapist anticipated the difficulties thought to appear post-treatment and proposed potential ways to solve them such as exercising, visiting friends and sharing her difficulties with confidants. Sophia recognized her progress but expressed her disappointment that the treatment was ending and would wish it to continue. She was worried that the end of the therapy would get her back to where she was initially (Mufson et al., 2015). However, we assured Sophia that the skills she had acquired were enough to overcome any challenges she may face in future. We shared our contact information with Sophia and encouraged her to always feel free to contact us whenever she needs help. Case Formulation Assignment
There are several complications identified in the course of Sophia’s 12-week therapy. It was difficult for her to commit fully and attend all sessions because of job commitments. There are other times when she could arrive late for sessions because she had to perform house chores, including preparing her niece for school. It was also a challenge for Sophia to recover because the sources of her depression had not disappeared. The 12-week therapy was successful and improved Sophia’s response to emotions. She learned how to cope with emotional feelings without adverse effects to her general health and well-being. By the end of the session, Sophia was emotionally expressive and her interpersonal relationship had greatly improved. Case Formulation Assignment
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Rotenstein, L. S., Ramos, M. A., Torre, M., Segal, J. B., Peluso, M. J., Guille, C., … & Mata, D. A. (2016). Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: a systematic review and meta-analysis. Jama, 316(21), 2214-2236.
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Treasure, J., Corfield, F., & Cardi, V. (2012). A three‐phase model of the social emotional functioning in eating disorders. European Eating Disorders Review, 20(6), 431-438.