Unit 3 Case Studies Laura Laura is a 55-year-old Latina who is a former nurse. She has been married for 35 years to Raymond, who is 63. Raymond, who is also Latino, is a practicing physician who is nearing retirement. Laura met Raymond at a hospital when both were in training for their medical careers. They dated for less than a year and married when Laura was 20 years old. She continued to work as a nurse after graduation until their first child, a daughter, was born and Laura and Raymond agreed she should stay home to care for their child. Their son was born two years later. Laura did not return to her career as a nurse, and remained a homemaker and stay-at-home mother. Throughout the years, Laura and Raymond frequently socialized with other couples, although Laura did not form individual friendships with other women, stating she “just isn’t comfortable” with most women. Laura was an avid reader and an artist, and tended to enjoy quiet, solitary pursuits rather than joining group activities, so she resisted Raymond’s suggestions that she join women’s philanthropic groups or participate in volunteer activities. Laura and Raymond spent weekends with their children when Raymond was not working, and they always took family summer vacations and spent time on family activities. Laura’s parents live nearby and were very involved in the family activities as well. Laura is an only child. The family always considered themselves to be closely knit. Laura is in generally good health. Although she smoked cigarettes for 30 years, she quit seven years ago. She consumes alcohol daily and does not take any regular medications. She is sedentary and has gained 30 pounds over the past 15 years. Raymond does not smoke but he joins Laura in a nightly cocktail after work. He does not formally exercise but is on his feet most of the day at work. His weight is the same as it was when he was 25 years old. Raymond had prostate cancer five years ago; surgery and radiation treatments seem to have cured his cancer. Laura’s children are now adults. Both completed college, found successful careers, and married. Laura’s daughter has recently given birth to her first child, a son. In the past year, Laura has started to worry about her loved ones’ safety and well-being. She frequently becomes preoccupied with thoughts of injury or illness that could harm Raymond, her daughter or son, and now her infant grandson. Laura is unable to calm these fears or put them out of her mind. She often has trouble falling asleep because she “can’t shut down” her mind, and she wakes up in the middle of the night fearing something has happened to one of her loved ones. She is often fatigued during the day and is notably irritable. Lately, Laura has been calling her husband, daughter, and son several times a day, including when they are at work and cannot take her calls. She implores them to “be safe.” She has asked them not to drive or participate in social activities because they might have an accident or be infected with a disease by someone with whom they socialize. She is especially concerned that her infant grandson might contract a disease and die. She insists that her daughter not take the baby out or allow visitors. She has been known to drive to her daughter’s house at night to check whether the family is home, and if they have guests. Laura’s family members are beginning to be annoyed with her “meddling” behaviors and no amount of logical discussion seems to convince her that her fears are ungrounded. For this reason, her family is becoming upset with her and starting to avoid her.
• Conceptualization and Diagnosis of Laura.
You reviewed the cases of Laura in the study activities for this unit. You will respond to each of the questions below. Your initial post must be at least 250 words in length and include at least two references to a current article in the professional literature to support your ideas. Start by considering the broad category of the client’s presenting issues. What words would you use to describe the client’s presenting concerns and the types of thoughts, feelings, and behaviors the client is experiencing? What broad categories in the DSM-5 do these words relate to (i.e., depression, anxiety, trauma, et cetera).
Next, look at the case study and review the specific symptoms the client is reporting. Compare these symptoms to those listed in the broad categories you have considered. In what area of the DSM do the client’s symptoms seem to fit best? Select the DSM-5 diagnosis that you believe is the best match for the symptoms that the client is presenting and be sure to include the numeric ICD 10 code along with the name of the disorder. Support your choice of diagnosis by listing the diagnostic criteria in the DSM-5 and noting for each one how the client has expressed this. Does the client meet all criteria for this diagnosis or are there some areas that you are not fully sure about? If you do not have enough information about some symptoms that are required criteria for the diagnosis you have selected, what additional questions would you need to ask the client, or what other information would you need to obtain from other sources so that you could support an accurate diagnosis?
Response Guidelines Read the posts of your peers and respond to at least two. Try to choose those that have had the fewest responses thus far. For each response, discuss the DSM-5 diagnosis your peer applied to the case and the symptom criteria she or he noted as either present or absent. Were there additional criteria needed in order to make an accurate diagnosis?
Peer 1 Post
James is a 43 year old Caucasian male that has reported that he feels awful and has no energy. He also reports that he’s married and his relationship is satisfactory but their sexual relationship has declined over the past two years. James is satisfied with his job but has a feeling that he is not able to move up in his profession at this time. James reports that he is in good health and takes no medications but has recently stopped going to the gym due to a strong loss of interest in it. James reports that his appetite has significantly increased and this explains his weight gain. James also admits that he has an issue with drinking and increased number of alcohol as often as four after work or before dinner. James is not suicidal at this time although he says that it would be nice not to wake up tomorrow but does not have a plan at this time to take his life. The client’s overall sense of discontentment can be categorized as depression if we were to consider the broad sense of the DSM-5. The client is reporting symptoms of feeling awful and having no energy. The client also is stating that there is a decline in his sexual relationship with his wife. The client also reports that he’s lost interest in exercising and taking care of his self physically. The client enjoys drinking alcoholic beverages several times a day. The client admits that the alcohol helps him to fall asleep. The client symptoms continue to fall in the Realms of depression although there is not enough information to make this conclusion due to his issue with drinking alcohol which is a depressant.. The client is exhibiting several symptoms that need further investigation. Measures for symptom severity, diagnosis, and problem behaviors may provide insight into client limitations, but typically neglect client strengths. (WILKINSON, 2015) Although the diagnosis could very well be duel with that of alcoholism and depression more investigation needs to be done because we do not know how long each was present. I would defer diagnosis until further evaluation. A physical examination would be beneficial in this case being that he has several physical issues that have not been examined by a physical doctor. The client continues to say that he is healthy while he has had a loss of interest in several activities including work and exercising and even in sexual activities with his wife. This could be several different physical diagnosis including thyroid ,diabetes, erectile dysfunction and so on. There are studies that indicate high false-positive rates of depression, with significant levels of diabetes-specific distress due to living with diabetes. This refers to the emotional distress associated with managing a long-term condition over time and is an area of greater concern, which requires more targeted interventions directed at the emotional side of diabetes. (Fosbury & Shaban, 2016) It would be best for the counselor to hold off on making a diagnosis by eliminating these external factors first. WILKINSON, B. D. (2015).
The Orientation Model: A Dual-Process Approach to Case Conceptualization. Journal Of Humanistic Counseling, 54(1), 23-40. doi:10.1002/j.2161-1939.2015.00062.x
Fosbury, J., & Shaban, C. (2016). Are we over-diagnosing depression in people with type 1 diabetes?. Journal Of Diabetes Nursing, 20(3), 108-109.
Peer 2 Post
The Case of Laura Presenting Issues: Preoccupied with negative thoughts; Ungrounded fears; Inability to remove thoughts from her mind; Anxiety; Trouble falling asleep; Fatigue; Irritability; Persistent behaviors aimed at preventing the ungrounded fears. Symptoms lasting for a year.
Broad DSM-5 Categories: Generalized Anxiety Disorder: Excessive anxiety and worry occurring more days then not for at least 6 months; Difficult to control the worry; Anxiety and worry are associated with fatigue, irritability, and sleep disturbance; Worry causes clinically significant distress or impairment in normal life functioning; The intensity of the anxiety and worry is out of proportion to the actual likelihood of the event; Difficult to control the worry, often worrying about the health of family members or misfortune of children (DSM-5). Obsessive Compulsive Disorder (OCD): Recurrent and persistent intrusive and unwanted thoughts that cause anxiety or distress; The individual attempts to neutralize intrusive and unwanted thoughts with some other thought or action; Repetitive behaviors or mental acts that the individual feels driven to perform in response to an obsession; Behaviors or mental acts are aimed at preventing some dreaded event or situation, however, these behaviors are not connected in a realistic way with what they are designed to prevent and are clearly excessive; The obsessions or compulsions cause impairment in social functioning (DSM-5).
Diagnosis: Obsessive Compulsive Disorder 300.3 (F42) with absent insight/delusional beliefs. At first look a Generalized Anxiety Disorder diagnosis appeared to be the accurate diagnosis for Laura. However, as I begun to read the differential diagnosis in the DSM-5, OCD was listed. Ellis, Hutman, and Diehl (2013) emphasize the importance of integrative case conceptualization and a key aspect of this is differentiating a diagnosis, or discriminating the most significant issues. The difference between Generalized Anxiety and OCD is that in Generalized Anxiety “the focus of the worry is about forthcoming problems, and it’s the excessiveness of the worry about the future event that is abnormal” (DSM-5). Whereas with OCD, “the obsessions are inappropriate ideas that take the form of intrusive and unwanted thoughts” (DSM-5). Laura’s symptoms are better matched with OCD criteria. Laura has become preoccupied with thoughts that her loved ones are going to become injured or ill; So much so that she has been calling her family members several times a day even when they cannot take calls, begging them to be safe and asking them not to drive or participate in social events because they could be in an accident or contract a deadly disease. She also drives to her daughter’s house at night to check whether the family is home safe or if they have guests that could pass on a disease. These actions fall within the OCD criteria of “excessive behaviors aimed at preventing some dreaded event or situation” that stem from” inappropriate ideas that take the form of intrusive thoughts”. The added diagnosis of absent insight/delusional beliefs is supported by the fact that logical discussions have not convinced Laura that her fears are ungrounded. Additional Information: More information is needed to pinpoint the underlying cause of Laura’s fear of loss. Information on her childhood and any traumatic situations in her life will help. Focusing on her developmental life stage is also important. In addition, Scott and Cervone (2016) emphasize the importance of one’s personality and self-schemata when conceptualizing a case; An assessment of self-schemata can highlight where Laura fits with valance, competence, rejection sensitivity, self-beliefs, competence, and self-efficacy (Scott & Cervone, 2016).
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Ellis, M. V., Hutman, H., & Deihl, L. M. (2013).
Chalkboard case conceptualization: A method for integrating clinical data. Training and Education in Professional Psychology, 7(4) 246–256.
Scott, W. D., & Cervone, D. (2016). Social cognitive personality assessment: A case conceptualization procedure and illustration. Cognitive and Behavioral Practice, 23(1), 79–98.