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Emily ShieldsCEP 695 – Psychopathology & Evidence-Based InterventionsUniversity at BuffaloCase Study of Daniel JohnsCase Study of Daniel Johns: Assessment, Diagnosis and Evidence-Based TreatmentThis study will investigate Daniel Johns, a musician and public figure, and his presenting psychological, emotional, and physical issues. Daniel is now 34 years old, a Caucasian male, and the former lead singer of the alternative rock band, Silverchair. I chose Daniel for my case study because of his complex array of mental health disturbances and unusual symptomology. Although he has widely acknowledged his mental illness in public, I found his case challenging to diagnose according to the current standards of the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (2013). I focused on the years between 1997 and 2003, during which Daniel was experiencing the most severe of symptoms. Since he is a public figure and has spoken at length about his issues, I did not receive informed consent to study him. I evaluated him based on biographical information and personal interviews, and assessed him using the DSM-5. To briefly summarize his presenting issues, Daniel experienced severe social anxiety, depression, restricted eating patterns, paranoia, substance use, and chronic pain beginning in 1997. These issues were deeply entwined and related to his rise to international fame at age 15. In this analysis, I will outline his personal and family medical history, a psychological assessment, and supplementary data that lead me to his diagnoses, biopsychosocial formulation, and evidence-based intervention plan. Background & Medical AssessmentTo my knowledge, Daniel had no remarkable developmental or medical issues during childhood. He began to restrict caloric intake in 1997, following several years of intense pressure due to his sudden rise to fame with Silverchair. This also coincided with Daniel’s other emotional and mental problems, which I will discuss further in his psychological assessment. In 2001, Daniel began experiencing pain in his joints, which spread to his whole body and impaired him so severely that he had trouble moving and walking. He was diagnosed with reactive arthritis, also known as Reiter Syndrome in 2002. Reiter Syndrome can be caused by bacterial infection in the body or by genetic predisposition, so it is possible that Daniel inherited genetic marker for this disease. I have little knowledge of Daniel’s family medical history, but he has acknowledged that his younger brother, Greg, has also battled severe depression in the past. Psychological AssessmentThrough interviews with Daniel, I observed that his affect was quite flat. He appeared unkempt at most times, with subdued mood. He did not display any sign of hallucinations, but was significantly preoccupied with socially-focused fears. During most interviews, Daniel appeared anxious but not antagonistic, and answered questions clearly but with poor eye contact. He appeared to be of at least average intelligence and extremely creative. Daniel had several major presenting issues. First, his anxiety about public places, social interaction, and judgment of others was severe enough to keep him from leaving his home. This anxiety was persistent, caused marked distress, and was out of proportion to the realistic threat at hand (American Psychological Association, 2013). He feared being attacked, poisoned, or ridiculed by others, and leaving his home would cause him panic attacks. These symptoms persisted for at least one year and kept Daniel from communicating with friends and family. Second, Daniel showed many signs of restrictive eating patterns. He lost a significant amount of weight due to (self-reported) starvation, with his lowest estimated weight at 110 pounds (a BMI of 15 for a 5’11” male). This behavior was an attempt to control his environment during a chaotic time, and not directly linked to any body image or weight concerns, according to Daniel. Third, his depressive symptoms became debilitating to the point of suicidal ideation and planning. Daniel experienced a depressed mood almost daily, had little interest in formerly enjoyable activities, significant weight loss, fatigue, feelings of worthlessness, and recurrent thoughts of ending his own life. He also reported abusing the controlled substance Valium as a way of coping with persistent anxiety and reducing hunger. Beginning in 2001, Daniel’s medical condition (Reiter Syndrome) seemed to deepen his depression and disturbed eating patterns. It was during this time of painful illness and social isolation that Daniel planned to end his life. Daniel’s family consists of his parents, Julie and Greg, a brother Heath (two years younger) and sister Chelsea (nine years younger). In an interview (with Bryony Gordon of The Telegraph, 2003) Daniel explained making a suicide pact with his brother, who was unemployed at the time. It is important to note a history of trauma in Daniel’s life. During his youth, he was attacked by a group of his peers and beaten. After this assault, he began experiencing heightened social anxiety and desire to protect himself by avoiding social situations entirely. He has said that this experience also encouraged his distorted thoughts about food and weight. He imagined that by becoming thinner, he would not be targeted by others. Although I believe that his restrictive eating was mostly an attempt at controlling his environment, it is important to include the social anxiety element alongside the eating disorder. Daniel perceived little to no cultural or social support during these years, fearing the criticism of the press and ridicule of peers. Due to his fame and wealth, he could afford to seclude himself in a rented house in Sydney. During his lowest points, Daniel withdrew from friends and family and wrote poetry. However, he met and married Australian singer Natalie Imbruglia in 2003. He credits her with encouraging him to seek treatment for his medical and psychological issues and helping him recover. She was his primary emotional support through his treatment. Valium was Daniel’s method of self-soothing through his emotional and physical issues. He reported using it continuously to reduce his anxiety and repress hunger. It has been mentioned in the press that Daniel used to drink alcohol, but I could not confirm any addiction or serious abuse of it. Throughout his illness, Daniel seemed to rely on music and poetry as coping mechanisms. Writing poetry and songs was therapeutic and helped him express his emotions. An example of this is “Ana’s Song,” an honest musical account of the pain and suffering of his eating disorder, which appeared on Silverchair’s 1999 album Neon Ballroom. Daniel’s strengths were his love of music, support of his bandmates, insight to his illness, and desire to change. Although he felt hopeless and planned to end his life at one time, he was too concerned about hurting his mother to carry out his plan. These few special social connections were most likely essential to Daniel’s eventual decision to seek help. Daniel has never mentioned publicly the method he planned to use to end his own life. He has no prior history or family history of violence. Daniel was arrested once in Santa Monica, California for test driving a vehicle on the beach (without an American permit) for a magazine shoot. However, the factors that made him a high risk for suicide were his “pact” with his brother to end their lives together, his socioeconomic status, and nearly complete isolation from friends and family. With plenty of money and resources available as a famous musician, I believe he could have easily found a way to kill himself. There is little information available as far as supplementary data from family, friends, or physicians, but Daniel’s wife Natalie acknowledged his absence at several public functions because of illness.Diagnoses and Biopsychosocial FormulationWith all of the data at my disposal considered, I formulated the following diagnoses according to the standards of the DSM-5 (2013).Diagnoses300.23 Social Anxiety Disorder307.59 Avoidant/Restrictive Food Intake Disorder296.23 (F32.2) Major Depressive Disorder, Severe, Single episodeNotationsZ60.5 Target of (perceived) adverse discrimination or persecutionZ65.4 Victim of a crimeMedical ConditionsReactive Arthritis, also called Reiter SyndromePublicly, Daniel Johns has acknowledged his primary diagnosis as anorexia nervosa. During the time he was seeking treatment (the late 1990s and early 2000s), this was probably an accurate diagnosis. With the changes in the DSM-5, I think Daniel’s symptoms fit better with the diagnosis of avoidant/restrictive food intake disorder (ARFID) due to the lack of intense fear of gaining weight or becoming fat (APA, 2013, p. 338). ARFID often co-occurs with anxiety disorders, and Daniel fits the criteria for social anxiety disorder as well. I also settled on Major Depressive Disorder (MDD) instead of Depressive Disorder Due to Another Medical Condition because Daniel’s persistent depressive symptoms began long before his problems with reactive arthritis, though his depression did worsen considerably with his declining medical condition. I completed the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) based on the answers I though Daniel might select if he had taken it, as a tool for diagnosis in this project. The answers are fictional, but I believe that his mock General Disability Score of 105/180 and average domain scores indicate that he was moderately disabled in 4 out of 6 domains of functioning. Biopsychosocial formulation. Daniel Johns suffers from debilitating social anxiety, stemming from his experiences with international fame beginning in adolescence. These issues have also fueled his desire to control his environment by restricting food intake, which has in turn exacerbated his depression, feelings of hopelessness, and thoughts of suicide. Daniel becomes more isolated and depressed when his medical condition (Reiter Syndrome) worsens and his physical pain intensifies.Evidence-Based Intervention PlanBecause of Daniel’s multiple diagnoses and array of symptoms, I propose that a multidisciplinary approach incorporating cognitive-behavioral therapy (CBT) and dialectical behavior therapy (DBT) would be most beneficial for him. Plenty of empirical support for CBT with social anxiety disorder (SAD) exists, due to its efficacy in eliminating avoidant behaviors and fear responses and establishing new thought patterns. Directive relaxation training, gradual exposure to the feared stimulus (social situations), and extinction of avoidance are the primary CBT techniques with this population (Rodebaugh & Heimberg, 2005). Some research suggests the efficacy of CBT combined with pharmacological drugs (such as SSRIs) in treating anxiety disorders, which I think is promising if more research is conducted with specific drugs (Rodebaugh & Heimberg, 2005). A longitudinal study of Resource-Oriented Cognitive Behavioral Therapy (ROCBT) showed that patients experienced significant symptom reduction following treatment at the 2-year and 10-year marks (Willutzki, Teismann, & Schulte, 2012). I like the approach of ROCBT in this study because it includes safety behavior training, restructuring of disturbing thoughts and images, utilization of resources, and reframing of distorted self-image. I think this approach would be a promising avenue for Daniel. I believe much of Daniel’s depression occurred because of his intense fear of social ridicule, so targeting the anxiety around social interaction first would likely reduce his depressive symptoms overall. CBT and ROCBT also address negative self-image and feelings of worthlessness and hopelessness, so it seems to be an appropriate treatment for his co-occurring issues.In addition to addressing his social fears and anxiety, treatment must also target Daniel’s eating disorder, suicidal ideation, and depression. There is new research in the field regarding the use of Dialectical Behavior Therapy (DBT) with eating disorders, particularly with patients who have other co-occurring psychiatric issues. Although DBT is most widely used with borderline personality disorder and bulimia, I discovered some promising research for its use with clients like Daniel. Federici, Wisniewski, & Ben-Porath (2012) found that DBT techniques tailored to address disordered eating and self-harm behaviors were effective with multidiagnostic clients. Furthermore, their approach in this study is congruent with my suggestion of multidisciplinary treatment for Daniel, incorporating his physician and nutritional counseling. Though there is more research to be done on this particular treatment method, I hypothesize that it will be useful with clients like Daniel in the future. A major limitation comes to mind regarding treatment for Daniel. His intense fear of leaving his home might impede his ability to participate in treatment at a mental health agency or facility. Any group-based interventions such as social skills training, psychoeducation, or group psychotherapy would have to be integrated very slowly and cautiously. I think he would be more likely to adhere to outpatient treatment because his level of functioning around others in an unfamiliar setting at the time of his illness was extremely poor. However, he has/had the financial means to seek high-quality medical and mental health treatment. Daniel’s occupation might present some difficulties for him in regard to relapse. The nomadic life of a musician and the constant scrutiny of the media and fans are serious risk factors for him. It would be important for Daniel and his clinicians to define his boundaries and develop a plan for him to stay healthy upon completing treatment. As Daniel’s clinician, I would prepare for future complications by establishing a pattern of consistent communication and opportunities to “check in” and practice some of the skills he learned in therapy. I would also encourage him to maintain a few close, personal supports that he could rely on in times of high stress, when he might feel inclined to withdraw and stop eating. In terms of evaluation, I would keep a detailed record of Daniel’s body weight and monitor his progress toward a healthy body mass index (BMI). A food journal would be particularly helpful for him during the early times of treatment (and perhaps indefinitely) to keep him accountable and allow me to make sure he is nourishing himself appropriately. For his social and cognitive functioning, it would be helpful for him to take a few follow-up assessments after treatment completion. Private interviews and self-report questionnaires could be used together to monitor Daniel’s recovery in the following months and years. Research regarding follow-up assessment of disordered eating patterns suggests that similar results are achieved regardless of the methodology of self-report assessments or clinician-conducted interviews (Fairburn & Beglin, 1994). Evaluation of the treatment method should also include reports from Daniel on his level of social interaction, occurrence of panic attacks, and other anxiety-related responses. I propose the use of the Social Phobia and Anxiety Inventory (SPAI [Turner, Beidel, & Dancu, 1996)]) to assess Daniel’s social anxiety symptomology during follow-up assessments due to its superior validity compared to other measures (Peters, 2000). Daniel is now 34 years old and functioning much better than he was from 1997-2003. To my knowledge, he no longer suffers from reactive arthritis and appears to be at a healthy body weight. He is writing and performing music again and is photographed in public regularly. If I had been predicting Daniel’s prognosis during his most troubled time, I would have said he had a challenging road ahead but would likely succeed in recovering. My reasons for this are that despite his crippling illness, depression, anxiety, and isolation, he maintained a few crucial supports in his life: music and his relationships with his mother and wife. Also, he had the means to seek treatment once he was ready and never lost the concern of hurting his mother if he had chosen to kill himself. I believe the imbalance of his life due to the rapid pace of fame was the critical incident that spawned his downward mental health spiral. With a skilled team of counselors, physicians, and nutrition experts, I think he could make an excellent recovery. Although many individuals with eating disorders struggle with relapse throughout their lives, he could learn to prevent those occurrences with the proper emotional support and coping skills.ReferencesAmerican Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: Author. Bryant-Waugh, R. (2013). Avoidant restrictive food intake disorder: An illustrative case example. International Journal of Eating Disorders, 46(5), 420-423. doi:10.1002/eat.22093Fairburn, C., & Beglin, S. (1994). Assessment of eating disorders: Interview or self-report questionnaire?. The International Journal of Eating Disorders, 16(4), 363-370.Federici, A., Wisniewski, L., & Ben-Porath, D. (2012). Description of an intensive dialectical behavior therapy program for multidiagnostic clients with eating disorders. Journal of Counseling & Development, 90(3), 330-338. doi:10.1002/j.1556-6676.2012.00041.xJancin, B. (2006). Data show that DBT reduces suicidal behavior. Clinical Psychiatry News, 7(01), 48. Peters, L. (2000). Discriminant validity of the Social Phobia and Anxiety Inventory (SPAI), the Social Phobia Scale (SPS) and the Social Interaction Anxiety Scale (SIAS). Behaviour Research & Therapy, 38(9), 943.Rodebaugh, T. L., & Heimberg, R. G. (2005). Combined treatment for social anxiety disorder. Journal of Cognitive Psychotherapy, 19(4), 331-345.Willutzki, U., Teismann, T., & Schulte, D. (2012). Psychotherapy for social anxiety disorder: Long-term effectiveness of resource-oriented cognitive-behavioral therapy and cognitive therapy in social anxiety disorder. Journal of Clinical Psychology, 68(6), 581-591. doi:10.1002/jclp.21842 ................
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