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Case Study One
The case study evaluated represents Kristen, a 38-year-old, divorced mother of two teenagers. Kristen’s divorce was 4 years ago; however, she has been experiencing symptoms for the past 8 months including constant worry and negative thoughts associated with her job, her daughters and her parents. Kristen has reported feeling restless, tired, tense, having muscle aches, pacing in her office, losing track of what she was saying, her brain not shutting off at night and losing sleep. Kristen notes that there is no specific reason to worry about her daughters, parents or losing her job but still worries.
Kristen is a Methodist Christian, attends church regularly and states that church helps ease her concern and worry, but the thoughts come back when she is not there. She has a support system including her two daughters, parents and friends. She also noted that her divorce was friendly and that they co-parent well together. She currently has no desire for a romantic relationship because even that would cause her to worry (McIvor, n.
In the past eight months, 38-year-old female client, has been worrying constantly about losing her job (even though she has been there six years) and being unable to provide for her two teenage daughters. However, despite trying to get rid of her negative thoughts, she could not. She noted that she had no specific reason to worry about losing her job minus economic reasons and others losing their jobs/being laid off.
Since worrying, she has felt restless, tired, tense, having muscle aches, paces in her office when she is alone, several embarrassing moments when lost track of what she was trying to say, her brain will not shut off at night to sleep, mentally rehearses worst case scenarios and losing sleep only getting two to three hours a night.
She worries often about her two teenage daughters but reports they are good and have given her no reason to worry
Her thoughts go to worst case scenarios for her aging parents, no major health concerns, but still worries about what her parents will experience as they age.
She identifies as a Methodist Christian and attends church regularly; it does seem to assist with her concern and worry, but the worry returns when she is not at church.
She has a support system including her daughters, parents and friends.
The divorce was friendly and they co-parent well together.
She has no current desire for a romantic relationship and states that it would just give her something else to worry about; she also states that because she is irritable- no one would want to date her this way (McIvor, n.d.).
The first key issue represents the first insight into how long she has been experiencing constant worry (8 months), with two different situations including her job and children. This information is most important because it introduces the common theme of constant worrying, also known as anxiety. The diagnosis of anxiety requires persistent symptoms for six months or more, which is evident. I was also able to consider her age at 38, and how the beginning anxiety diagnoses are developmentally arranged. Therefore, I was able to eliminate other anxiety alternatives based on this information. Furthermore, she tried to cope but could not get rid of her negative thoughts on her own, even though she noted she had no reason to worry about losing her job in the first place. This constitutes that her worry was difficult to control. There was no specific reason for her worry which also eliminated other anxiety alternatives. Therefore, I was able to narrow it down to three potential options: Social Anxiety Disorder, Agoraphobia and Generalized Anxiety Disorder (American Psychiatric Association, 2013).
The second key issue is next in importance because it provides a list of physical symptoms. The losing track of what she was saying may have been part of the criteria for Social Anxiety Disorder, but she did not express concern for scrutiny, just embarrassment. Agoraphobia includes being anxious in two/more situations, which at first, I thought could be a potential option, but it did not include transportation, open spaces, being enclosed, in line/crowd and/or being alone outside the home. The list of symptoms took me straight to the diagnostic criteria for Generalized Anxiety Disorder (APA, 2013). Therefore, combining issue one and two was helpful in eliminating alternatives and coming to a diagnosis that best fit.
Key issue three is next because it grows on the theme of constant worry with no specific reason, strengthening the first issue. Key issue four is next because it is another example for the theme of constant worry with no specific reason, strengthening the first and third issue. Key issue five through eight are next in descending order as they represent the least threat and provide opportunity in future treatment. Key issue five is another example to the theme of constant worry (still strengthening the other preceding issues) and not being able to control her thoughts. However, provides a spiritual foundation that can be implemented for prevention and intervention in future treatment. Key issue six provides positive attributes for having a support system when it comes time for treatment. Key issue seven is another positive attribute, having a positive co-parenting relationship with her ex-husband, that could be beneficial in treatment. Key issue eight is last because not having a romantic relationship is a least concern. However, also provides another example of worry through irritability and avoidance of a romantic relationship. These issues, in order, provide reasoning for Generalized Anxiety Disorder and how it pertains to the diagnostic criteria. Based on her spiritual background, treatment should entail a spiritual aspect. Based on her negative thoughts, treatment should also entail cognitive behavior therapy (CBT) such as exposure therapy. My order of priority will contribute to a successful outcome because I was able to find the theme of worry quickly and the list of physical symptoms next led me to a potential diagnosis and ideas for treatment.
Based on the information provided in the case study, the common theme is worrying constantly and negative thoughts. The first area that I would go to is Anxiety Disorders. While looking through Anxiety Disorders you will see: Selective Mutism, Specific Phobia, Social Anxiety Disorder (Social Phobia), Panic Disorder, Agoraphobia, Generalized Anxiety Disorder, Substance/Medication-Induced Anxiety Disorder, Anxiety Disorder Due to Another Medical Condition, Other Specified Anxiety Disorder and Unspecified Disorder (American Psychiatric Association, 2013). Separation Anxiety Disorder is being fearful/anxious about separation from attachment figures (APA, 2013). This is not a match for this case because she has been divorced from her husband for four years and her symptoms are in the past eight months, therefore she is not experiencing separation anxiety. Also, her children and parents are not attachment figures. Selective mutism is a consistent failure to speak in social situations, therefore this situation does not match because social situations are not causing her anxiety (APA, 2013). Specific phobia is when a person is fearful/anxious about or avoid a specific object/situation (APA, 2013). This does not match because she expresses worry in various situations in her life, rather than one specific. Social anxiety disorder (social phobia) is fear/anxious or avoidance of social interactions/situations with the possibility of scrutiny (APA, 2013). Although she had several embarrassing moments in meetings where she lost track of what she was saying, she did not report being concerned with how others viewed her, only embarrassed. Therefore, this is not a match for this case study. Panic Disorder is recurrent panic attacks/worry about having more panic attacks, which does not match this case study because she is not experiencing panic attacks (APA, 2013). Agoraphobia is fear/anxious about two/more situations including using public transportation, being in open spaces, being enclosed in places, standing in line or in a crowd, being outside the home alone in other situations (APA, 2013). None of these situations match this case study. Substance/medication-induced anxiety involves anxiety from substance abuse or withdrawal (APA, 2013). This does not match the case study because no substance abuse was noted. According to the APA (2013), Generalized Anxiety Disorder (GAD) seems most appropriate because the case study description and key issues match the diagnostic criteria:
Excessive anxiety and worry, occurring more days than not for at least 6 months, about several events/activities (such as work or school performance)
She had excessive worry, lasting eight months about several events/activities including work performance, her daughters, her parents and a romantic relationship.
Individual finds it difficult to control the worry.
Despite her efforts, she can not get rid of her negative feelings. The situation with her job, daughters and parents said she had no reason to worry but did anyway.
The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months)
She was having trouble sleeping at night because her brain would not shut off. Therefore, she was only getting two to three hours of sleep a night.
From the two to three hours sleep a night, she was easily fatigued.
Difficulty concentrating/mind going blank
During her meetings, she mentioned having several embarrassing moments when she lost track of what she was saying.
She noted that as irritable as she had been for the past eight months, finding someone to date would be difficult and just something to worry about.
She noted that she has not worked out in months, but her muscles ached sometimes as though she had been working out.
Sleep disturbance (difficulty falling asleep/staying asleep, restless, unsatisfying sleep)
She noted that she finds herself mentally rehearsing worse case scenarios that causes her to lose sleep.
The anxiety, worry or physical symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning
She has been worrying constantly for the past eight months about losing her job and being unable to provide for her children. She also reports that as irritable as she has been for the past eight months, finding someone who would want to date her would be difficult. She seems avoidant when it comes to dating because she says it would just give her something else to worry about.
The disturbance is not attributable to physiological effects of substance or another medical condition.
No noted substance abuse or other medical conditions.
The disturbance is not better explained by another mental disorder.
Other mental disorders ruled out and explained more in detail in the following paragraphs, minus (p. 222-226).
Differential diagnoses included that are not applicable: anxiety disorder due to other medical condition because no medical conditions are reported; substance/medication-induced anxiety disorder because no substance or medical conditions are reported; social anxiety disorder because already eliminated; posttraumatic stress disorder and adjustment disorders because symptoms last longer than six months. However, other diagnoses to look at would be obsessive-compulsive disorder and depressive, bipolar and psychotic disorders. Obsessive-compulsive disorder is obsessing about inappropriate ideas, whereas generalized anxiety disorder suggests excessive worry about future events that are abnormal. Therefore, the case study still matches GAD (APA, 2013).
However, GAD may be diagnosed comorbidly with depressive, bipolar and psychotic disorders if the anxiety/worry is sufficiently severe to warrant clinical attention. Furthermore, when an individual meets criterion for GAD, they may meet criteria for unipolar depressive disorder. Comorbidity with psychotic disorders is less common, therefore no diagnosis of bipolar disorder. One-third of those experiencing GAD is genetic and these factors may overlap with neuroticism and mood disorders such as major depressive disorder. There are not enough symptoms present from the diagnostic criteria for major depressive disorder to diagnose: no reports of feeling sad, diminished interest in activities, no reported significant weight loss, no thoughts of dying and no reported feelings of worthlessness or inappropriate guilt. Her physical symptoms are tailored to worry, anxiety. No environmental factors have been identified specific to generalized anxiety disorder (APA, 2013).
According to Kring et al. (2018), “worry is the core feature of GAD·associated with negative affect·with modest increases in psychophysiological arousal·distressed” (p. 184). Those with GAD are uncontrollably worried about minor things, in excess, that turn into long term. Their threats involve relationships, health, finances and daily hassles. It is a cognitive inclination to focus on a problem and incapable of letting go. GAD is strongly related to marital distress. Considering three-quarters of people with an anxiety disorder might one day have the potential of being diagnosed with another psychological disorder, that would be something to pay close attention to in future sessions. This may alter future treatments and will need to be re-assessed if new information is revealed (Kring et al., 2018).
It is normal to feel strong emotions but being overwhelmed by intense emotions is an abnormal response. Also, having persistent thoughts that interfere with usual functioning is an abnormal response. Furthermore, having temporary physical symptoms are normal but strong persistent bodily reactions are abnormal. Long-term problems pertaining to work and love is abnormal as well (Sarason, I. G., & Sarason, B. R., 2002). The possible impact of GAD could result from early lifetime events, trauma or insecure attachment style, and may persist into adulthood. Those with GAD do not have the appropriate resources to cope with uncertain events. Worry may be reinforced by those with GAD if they have positive beliefs about worry. Furthermore, those with GAD believe that worry is a distraction to avoid emotional processing (Behar, DiMarco, Hekler, Mohlman & Staples, 2009). A reduction in intolerance of uncertainty is important for outcomes of cognitive behavior therapy. There is increased activation within parts of limbic system (amygdala) and reduced in the prefrontal cortex, diminished functional connectivity between these regions in neuroimaging studies relating to GAD (Stein & Sareen, 2015).
Follow up with their primary care physician, for a physical, to rule out any treatable physical medical conditions such as thyroid or cardiac problems, considering no medical information was reported (Stein & Sareen, 2015). This would address the biological aspect.
Use the GAD 7-item Questionnaire to gauge severity and to track progress (Stein & Sareen, 2015). This would address the psychological aspect.
Provide and explain unbiased psychoeducation on Anxiety Disorders and GAD: high quality sites including self-help, books, educational groups (Stein & Sareen, 2015). This would address the psychological and social aspect.
Educate client about lifestyle changes to reduce symptoms: exercise and diet (avoiding caffeine, alcohol, nicotine, drugs and sugar) Also, strategies for improving quality of sleep. Examples: yoga, meditation, relaxation and breathing techniques, avoiding light emitted electronics before bedtime (Stein & Sareen, 2015). This would address the psychological aspect.
CBT (mindfulness) by targeting worry, to only worry during scheduled time. Homework: keep diary/journal of the outcomes of worrying. Focus thoughts on present moment instead of worrying, address core fears (Kring et al., 2018). This would address the psychological aspect.
CBT by identifying anxiety triggers. This will help challenge misconceptions that maintain worry and test validity of irrational beliefs. Furthermore, using desensitization methods like imaginal exposure to evoke fear/anxiety then working on skills to manage worry and develop more adaptive ways of responding to situations (Szkodny, Newman & Goldfried, 2013; 2014). Homework for example may include a list of anxiety triggers, worksheets that challenge irrational thoughts; writing self-statements to counteract negative thoughts by writing down the reality of the situation versus automatic negative thoughts; visualizing positive aspects of each day to shift focus from negative to positive. This would address the psychological aspect.
Discuss spiritual practices such as prayer, meditation, gratitude, forgiveness, self-acceptance and how it can decrease anxiety (Koszycki, Raab, Aldosary & Bradwein, 2010). This would address the psychological and spiritual aspect. Some examples include the power in forgiveness and self-acceptance releasing emotional pain from the past and renouncing blame; gratitude enables positive emotions, scripture references to cultivate spiritual intelligence and seek silence/solitude for re?ection (Koszycki, Raab, Aldosary & Bradwein, 2010).
Pharmacotherapy: reduce symptoms and improve health-related quality of life; referral needed to psychiatrist because we do not have the ability to prescribe medication. They can address biological aspects of disorder client is dealing with. However, discontinuance of medicine will bring back symptoms (Stein & Sareen, 2015). This would address the biological aspect.
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