Works Cited - Weebly



A Case Study of EmmaJessica StewartState University of New York at BuffaloCEP 695Emma is a patient at Amherst Pediatrics, her mother was concerned because she had “cut” and made an appointment to meet with the mental health counselor on staff at the medical practice. After a brief consultation, Emma was referred to Child and Adolescent Treatment Services but did not follow through with the referral. However, her mother was comfortable bringing Emma to see me at Amherst Pediatrics. Upon first meeting with Emma and her mother, I obtained informed consent, clearly explained confidentiality and the exceptions that I was required to report; both Emma and her mother understood what this meant.Within a short while after meeting with Emma it was clear that she was dealing with depression and anxiety. She explained her situation at both home and school and neither was a very supportive environment for her. With this information, I decided to meet with Emma alone for a few sessions before getting her family involved.Background and Medical AssessmentEmma is a 14 year old Caucasian female who comes from a middle class family. She is currently attending a local public high school and does not work yet. Her mother is currently unemployed and her father works full time.One of the benefits of working in a primary care practice is that I have access to each patient’s medical records. I was able to look through Emma’s records and saw that she has had no major medical issues. She is not currently having any problems with eating and sleeping, though she does choose to stay up late on a regular basis, as many teenagers do.There is also no family history of any major medical concerns. Psychological AssessmentAt every session I take note of the mental status of my patients. Emma is consistently well-presented; she is clean and well-groomed, made appropriate eye-contact and her speech is clear. Emma does not have any hallucinations or preoccupations and her thought process is well organized, she appears to be slightly above average in intelligence. Emma’s mood varies from session to session, though she is normally slightly depressed and anxious. This mood is not severe enough that she is unable to function and it does not interfere with her sharing in session.Emma’s mother’s main concern was the self-harm that Emma was engaged in. Upon further questioning, it was found that Emma had used an eraser to burn her forearm once, over a year ago. Emma explained that she tried it once after she saw a friend do it, but that the self-harm did not help her to feel any better and she has not engaged in any self-injurious behavior since then. An exam by a nurse practitioner confirmed that Emma did not have any more marks on her arms, legs or abdomen. It is interesting to note that this instance took place over a year ago and Emma’s mother is showing concern about it now.The issues of concern for Emma are her depression and anxiety which are affecting her functioning at home and at school. She reports struggling with both anxiety and depression for about a year. Both of these issues are ongoing and appear to be at a moderate level of intensity. Emma has not received any past treatment for her mental health.Emma’s family is the main source of stress in her life. She lives with her mother, father and 10 year old sister. In January of this year, Emma’s mother was hospitalized for mental health issues. She was admitted and stayed in an inpatient setting for several months. Emma has not opened up about the specific details of her mother’s mental health, but it is very possible that there was a suicide attempt. Emma’s mother is visibly depressed when she brings Emma for her appointments. Her walk, speech and body movements are extremely slow and lethargic. Emma reports that her mother does not work and spends all day sitting on the couch watching television. She is overly attached to her daughters and does not want them to leave her alone when they ask to visit with friends or to go to a social event. Emma’s mother is aware of her own mental illness and I believe that is why she is concerned for her daughter as well.Emma’s father and mother had been separated for years when Emma’s mother was hospitalized. In order to take care of the children, her father moved back into the house during her mother’s hospital stay; he has stayed in the home since then. Emma reports that her father dotes on her younger sister, but has very high standards for her. Even though Emma is doing well in school and has improved many of her grades, her father continues to be dissatisfied with her grades. Emma and her younger sister have a typical sibling relationship. They love each other but fight over everyday stuff. Emma feels that her father is more supportive of her sister as he helps her with her homework and spends more time with her in general. Emma reports that her father will not help her with her school work and expects much more of her which seems to have caused a little bit of sibling rivalry. Due to the family situation and her mother’s depression, Emma has had to step into a more parentified role; she has to care for her sister on a regular basis when her father is at work and her mother is unable to function. Overall there is very little family support available for Emma. She does have a paternal aunt who she feels close with that she can talk to when she is feeling down. This aunt lives locally and is accessible for Emma via telephone.Emma reports that she has not used any drugs. As with all teenagers, I don’t assume that they are telling the truth about this topic. She does occasionally drink with a few of her friends, and has been honest about that. Because of the low frequency of these events, and the safe environment that they take place, I chose not to prioritize this issue too highly. There is no family history of substance abuse that Emma is aware of. Her mother is currently using prescription drugs for depression; because of the possibility of abuse by her daughters, she keeps the medication locked up. Emma’s social world is also not a very supportive place. She is often the target of bullying at school. Emma is on the cheerleading squad at school and is often outcast by the more popular girls on the squad. I feel that this environment is not really good for her, except that it provides an opportunity for Emma to be away from home and potentially interact with her peers. She doesn’t like her relationship with some squad members, but does value being on the team and looks forward to practices and competition. Emma is a little socially awkward and I believe that this is one of the reasons for her lack of friends. She is also constantly trying really hard to fit in, instead of just being herself, which is making her look desperate to her peers. Emma is not currently in a romantic relationship. She does have one good friend, Jenna, with whom she is able to talk; she has shared with Jenna about her mother’s depression and the stress she is dealing with at home. Aside from Jenna, Emma has little social support at all. Emma has a few coping skills that she has learned to use during this stressful time. She really enjoys listening to music and will often lock her bedroom door and listen to music on her headphones when she starts to get overwhelmed at home. While this is not the most efficient coping strategy, it does allow her to be removed from the situation and to calm down. Emma also enjoys being active and exercising. She reports feeling happier after physical activities and will often go for a walk or jog, practice her cheerleading or use the exercise bike to lift her mood. In spite of her lack of friends, Emma is surprisingly confident which is a great strength for a high school student. She has different interests than most of her peers, but for the most part, she is comfortable with who she is. Emma is also pretty self-aware which has helped her to learn a few coping strategies and to identify the times when she needs to use those strategies.Thankfully Emma has not had any serious thoughts of harming herself or others. It is likely that her mother attempted suicide, but aside from that, there are not lethality concerns for Emma.At our practice, we administer the Columbia Depression Scale and the Screen for Anxiety Related Disorders (SCARED) to each patient. In this case, both Emma and her mother completed these assessments. Emma scored “Moderately Likely” for depression on the Columbia Depression Scale. She also scored significant for Panic Disorder (or significant somatic symptoms), Anxiety Disorder and Social Anxiety Disorder. After a few months of treatment, I will re-administer these assessments to measure any improvement.DiagnosisAfter our first few sessions together, I decided on the following diagnoses for Emma:311 Other specified depressive disorder: depressive episode with insufficient symptoms – This category applies to presentations in which symptoms characteristic of a depressive disorder that cause clinically significant distress or impairment in social, occupational or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the depressive diagnosis class, CITATION Ame13 \l 1033 (American Psychiatric Association, 2013). There were two other options that were available for this diagnosis; the first being Major Depressive Disorder. However Emma did not fit the full criteria for a Major Depressive Disorder since she only met three of the required criteria when five are needed for diagnosis. The criteria she meets are: Depressed Mood most of the day, nearly everydayFeelings or worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)Diminished Ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) Another option could have been to use the Unspecified Depressive Disorder diagnosis. I chose to be more specific so that my notes would be clear for Emma’s medical doctor when they are reviewing her chart. This would also be more detailed for another counselor if Emma does decide to pursue outside counseling after we complete our sessions together.300.02 Generalized Anxiety DisorderExcessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).The individual finds it difficult to control the worry.The anxiety and worry are associated with three (or more) of the following symptoms (with at least some symptoms having been present for more days than not for the past 6 months). NOTE: Only one item is required in childrenRestlessness or feeling keyed up or on edge.Being easily fatigued.Difficulty concentrating or mind going blank.IrritabilityMuscle TensionSleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).The anxiety, worry or physical symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning.The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder (social phobia), contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).Emma fits the full criteria for this diagnosis because children only have to meet one of symptoms in criteria C and she is irritable and has considerable muscle tension.V61.20 Parent-Child Relational Problem - This category should be used when the main focus of clinical attention is to address the quality of the parent-child relationship or when the quality of the parent-child relationship is affecting the course, prognosis or treatment of a mental or other medical disorder. Typically the parent-child relational problem is associated with impaired functioning in behavioral, cognitive or affective domains. Behavioral:Inadequate parental control, supervision and involvementParental overprotectionExcessive parental pressureArguments that escalate to threats of physical violenceAvoidance without resolution of problemsCognitive:Negative attributions of others’ intentionsHostility towards or scapegoating of the otherUnwarranted feelings of estrangementAffective:Feelings of sadness, apathy or anger about the otherBecause of the many different issues that are occurring at home, Emma and her family meet the criteria for this V-code. Mom’s depression keeps her from fulfilling her role as mother and has caused stress between her and Emma. Her mother is overly attached to both daughters, not allowing them to “leave” her to spend time in social settings (particularly on weekends). Emma regularly has explosive arguments with both parents. Emma’s father has rigidly high expectations for Emma and is very critical of her. Plus, Emma has had to step into a more parentified role during her family’s ongoing crisis which has shifted the family balance.V62.4 Social Exclusion or Rejection - This category should be used when there is an imbalance of social power such that there is a recurrent social exclusion or rejection by others. Examples of social rejection include bullying, teasing, and intimidation by others; being targeted by others for verbal abuse and humiliation; and being purposefully excluded from the activities of peers, workmates, or others in one’s social environment.Emma is dealing with rejection in several social areas. At school she is regularly picked on and bullied and at cheerleading she is outcast by the more popular girls on the squad.Biopsychosocial FormulationEmma has so much going on her in world right now that has contributed to her current state. First, she has a family history of major mental illness, specifically her mother’s major depression which resulted in a long-term hospitalization. Because of this illness, her family is going through so many dramatic changes and there is a lot of transitioning occurring, including her father moving back home and taking on a head-of-the-household role that he has not had in a few years. These transitions have also forced Emma into a parentified role in caring for her sister while her mother is unable to do so. All of these stressors at home combined with her social struggles at school and extra-curricular activities have really had a negative impact on Emma and have displayed themselves as anxiety and depression.Evidence-based Intervention PlanThere are many different treatment options for both anxiety and depression. The go-to option for many therapists is Cognitive Behavioral Therapy which usually focuses on finding distorted thought patterns that are keeping the client in a cycle of negative and inaccurate thoughts which feed their depression and anxiety. CBT has been found to be effective at treating depression CITATION Mad12 \l 1033 (Maddux & Winstead, 2012) and it has the strongest empirical support among the techniques for treating anxiety CITATION Mad12 \l 1033 (Maddux & Winstead, 2012) CITATION Lab99 \l 1033 (Labellarte, Ginsburg, Walkup, & Riddle, 1999). Research has found that in an adolescent population, the use of Cognitive Behavioral Therapy in addition to Selective Serotonin Reuptake Inhibitors (SSRIs) increased the global functioning of clients more than just the use of SSRIs alone CITATION Cal11 \l 1033 (Calati, et al., 2011) and that it is vital for treatment to not only reduce symptoms, but to improve the functioning of the patient CITATION Tho11 \l 1033 (Thomsen, 2011). In spite of the great evidence behind CBT, I did not think it was a good fit for this patient. Emma’s circumstances are considerably negative and her thought process related to her situation is not inaccurate, she seems to have a very clear and accurate picture of what is going on around her. I don’t feel that focusing on her thoughts would be effective because it is her situation, not her thoughts that are the problem.Being in a medical practice, the use of medication is an option for my patients. The first choice in medicating adolescents with anxiety and depression is SSRIs CITATION Mad12 \l 1033 (Maddux & Winstead, 2012). At our practice, we veer away from using benzodiazepines because they are easily abused and highly addictive. Emma would prefer not to use medication and since she is still able to function at school and at home, we did not pursue this course of treatment. If, in the future, Emma’s functioning declined and she wanted to try a medication, we would do so in addition to therapy, not in place of it. Another interesting therapeutic approach that I found is Interpersonal Therapy for Adolescents (IPT-A) where the goal is to reduce depressive symptoms by improving interpersonal functioning of the patient CITATION Mad12 \l 1033 (Maddux & Winstead, 2012) CITATION Tho11 \l 1033 (Thomsen, 2011). Again, I chose not to use this treatment plan because I believe that given her circumstances, Emma is functioning well. My chosen approach is to use a Rogerian Person-Centered therapy. According to Haimerl, Finke and Luderer (2009) Person-centered therapy has been proven to be as effective as Cognitive Behavioral Therapy. I chose this approach because more than anything, Emma needed someone to just be there for her and to listen to her. I believe that in providing Emma with unconditional positive regard and empathic understanding she will start to see improvement in her moods. I do believe that a family is a system and that when a change is made in one part of that system it will unavoidably influence the other parts of the system. In Emma’s situation we can observe how much has changed because of her mother’s mental illness and hospitalization. If Emma starts to improve with her depression and anxiety, I believe that the whole family will in reaction start to change for the better.I am also teaching Emma about a few relaxation techniques. I believe that these are great coping strategies for any patient with anxiety, especially with somatic symptoms like Emma. I have walked her through progressive muscle relaxation, deep breathing and a few calming yoga poses. (When doing the research for this, I found a few empirical articles, however UB did not own them and I could not locate them elsewhere – the articles looked promising).I would love to be able to work with the entire family, which is not a possibility right now. If I can arrange this in the future, I would like to implement an Attachment-based Family Therapy where the goal is to improve relationships, repair relational wounds and increase empathy among family members. A study of this approach saw a 63% improvement rate, which is similar to the results for using the tried-and-true CBT approach CITATION Dia02 \l 1033 (Diamond, Reis, Diamond, Siqueland, & Isaacs, 2002). This is a manualized treatment based on the idea that there are family factors that are linked to the development, maintenance, and relapse of child and adolescent depression including: disengagement or weak attachment bond, high levels of criticism and hostility, parental psychopathology and ineffective parenting. Since there is dysfunction in all of these areas of Emma’s family, this seems like a good fit. There are five tasks in this approach and the first is to shift the focus away from the adolescent and onto improving family relationships. Since the entire family is under considerable stress and they are not relating well with each other and supporting each other, I think this would be a great focus for therapy. It would also shift the focus off of Emma’s mother a bit and allow the family to start functioning as a whole. Unfortunately working with the entire family is not possible right now, so I will continue to meet with Emma and help her to navigate through this situation. Overall I believe that Emma’s prognosis is fair to good. Emma herself is actively involved in her treatment and has had great attendance so far. I am afraid that transportation may be a problem in the future due to Emma’s mother’s depression and lack of motivation. I also believe that to have the most impact with Emma the best approach will be to work with the family; without her family’s involvement in treatment, the results will be less effective. Hopefully they will see the benefit to Emma and start to support her in her therapy and maybe even be open to meeting as a family. Working with Emma has been a great experience and I hope to see her truly thrive in her social and home life. With the support of her family and continued therapy, I believe that she will do wonderfully.Works Cited BIBLIOGRAPHY American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.Calati, R., Pedrini, L., Alighieri, S., Alvarez, M., Desideri, L., Durante, D., et al. (2011). Is cognitive behavioral therapy an effective complement to antidepressants in adolescents? A meta-analysis. Acta Neuropsychiatrica, 23(6), 263-271.Diamond, G. S., Reis, B. F., Diamond, G. M., Siqueland, L., & Isaacs, L. (2002). Attachment-based family therapy for depressed adolescents: A treatment development study. Journal of American Academy Of Child and Adolescent Psychiatry, 41(10), 1190-1196.Labellarte, M. J., Ginsburg, G. S., Walkup, J. T., & Riddle, M. A. (1999). The treatment of anxiety disorders in children and adolescents. Biological Psychiatry, 46, 1567-1578.Maddux, J. E., & Winstead, B. A. (2012). Psychopathology: Foundations for a contemporary understanding (3rd ed.). New York: Routledge.Thomsen, P. (2011). Treating adolescents with depression and anxiety disorders, also looking at global functioning and general improvement. Acta Neuropsychiatrica, 23(6), 261-262. ................
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