Case 4 - Wally Graham

"The news is good," announced Wally Graham's clinician. "Your x-rays and the other tests show nothing wrong - no cancer, no ulcer, not even gastritis."

Wally Graham did not look pleased. "I don't understand it."

"I mean I don't understand why I'm still having the pain and why I'm throwing up nearly every morning." He slowly began to put on his shirt.

The clinician leafed through his chart. "I checked with your previous HMO. They said you'd had the same set of tests done there six months ago. And the year before that."

"Yes, I told you all about that, last time I was here. I haven't held anything back." Wally had begun to sound angry. "This has been going on for four or five years now. I don't like being this way, you know."

"No, of course not," said the clinician. "I didn't mean that. I meant that for years you've had stomach pains, nausea, vomiting, and diarrhea, and for years you've been afraid you have cancer. You've had at least four workups by excellent clinicians; they've all reassured you that nothing is wrong. Only you don't feel reassured. Last week you were even gastroscoped by our gastroenterologist. That's the most definitive test you can get. There weren't even enough findings to diagnose an upset stomach! I'm not saying you don't have pain, but I think your problem is somewhere besides your stomach. I'd like to check out some other possibilities, to see if we can get to the bottom of this."

"I hope so." Wally Graham was less angry, but he still sounded unconvinced. Fully dressed now in his tie and sports jacket, he looked somehow smaller than he had before. He was a 42-year-old, unmarried accountant who worked for a branch of one of the large national firms that advertised on TV. He liked his job (except during tax season, which nobody liked). but several days a month he had to stay in bed with abdominal pains. His supervisor was becoming restive.

Of course, Wally had been worried, maybe even a little depressed. He had felt this way occasionally throughout his ordeal of the past several years, but his concentration had been good and his interest in work and leisure activities had been high. Any problems with sleep or appetite had been due to the abdominal distress, which only lasted for a few days each time. He had never had suicidal ideas.

Wally had never tried street drugs; for years he avoided alcohol in any form. Except for his abdominal distress, his health was good. He denied everything on an impressively long list of symptoms that included headache, dizziness, chest pain, painful urination, and musculoskeletal and neurological complaints. Over the years he had quite a lot of anxiety about having cancer, but he never experienced a full-blown panic attack. He had never heard voices or seen visions, nor did he believe that people were plotting or talking about him behind his back.

The first few times a clinician told Wally that he did not have cancer, he felt relieved, but after a few days, the symptoms would start again and he would worry. "What if the lab had switched somebody else's tests with his?" "Suppose the radiologist had misread the film." "Or perhaps, I didn't have cancer then, but I've developed it since the last tests were made. How's anyone going to reassure me about that?"

*Note, You are looking for an Axis I diagnosis. Also, how is this case different from that of Jason Bird in Case 3?

Case 3 - Jason Bird

Jason Bird was a 47 year old man who was admitted to a cardiac intensive care unit despite having no health care card-- he claimed he had lost his billfold to a mugger a few hours earlier. He came to the emergency room of a Midwestern hospital late on Saturday night, complaining of crushing sub-sternal chest pain. Although his electrocardiogram (EKG) was markedly abnormal, it did not show the changes typical of an acute myocardial infarction (MI). The cardiologist on call, noting his ashen pallor and obvious distress, ordered him admitted and then waited for the cardiac enzyme results.

The following day, Jason's EKG was unchanged and the serum enzymes showed no evidence of heart muscle damage. His chest pain continued. He complained loudly that he was being ignored. The cardiologist urgently requested a mental health consultation. Jason was a slightly built man with a bright, shifting gaze an a four day growth of beard. He spoke with a nasal Boston accent. His right shoulder bore the tattoo of a boot and the legend "Born to Kick Ass". Throughout the interview he frequently complained of chest pain, but had no difficulty breathing or talking, and he showed no signs of anxiety about his medical condition.

He said he had grown up in Quincy, Massachusetts, the son of a physician. After high school, he attended college for several years, but found he was "too creative" for a profession or conventional job. Instead, he had turned to inventing medical devices, and numbered among his successes a positive-pressure respirator that bore his name. Although he had made several fortunes, he had lost nearly everything to his penchant for playing the stock market. He had been visiting in the area, relaxing, when the chest pain struck.

"And you've never had it before?" asked the interviewer, looking through the chart.
Jason denied that he'd had any previous heart trouble.
"Not even a twinge. I've always been blessed with good health."
"Ever been hospitalized?"
"Nope. Well, not since a tonsillectomy when I was a kid."
Further questioning was similarly unproductive. As the interviewer left, Jason was demanding an extra meal service. Playing a hunch, the interviewer began telephoning emergency room physicians in the Boston area to ask about a patient with Jason's name or peculiar tattoo. The third try struck pay dirt.

"Jason Bird? I wondered when we'd hear from him again. Hes been in and out of half the facilities in the state. His funny looking EKG-- probably an old MI looks pretty bad, so he always gets admitted, but there's never any evidence that anything acute is going on. I don't think that he's addicted. A couple of years ago he was admitted with genuine pneumonia and got through a week without pain medication and with no withdrawal symptoms. He'll stay in the ICU a couple of days and rag on the staff. Then he'll split. He seems to enjoy needling medical people."

"He told me that he was the son of a physician and that he was a wealthy inventor."

The physician at the other end of the line chuckled. "The old respirator story. I checked into that one when he was admitted here for the third time. That was a different Bird altogether. I don't know that Jason's ever invented anything in his life. As for his father, I think he was a chiropractor." Returning to the ward to add a note to the chart, the interviewer discovered that Jason had discharged himself against medical advice and departed, leaving behind a complaining letter to the hospital administrator.

Case 2 - The Story of the Dizzy Electrician

A 27-year-old married electrician complains of dizziness, sweating palms, heart palpitations, and ringing in the ears of more than 18 months duration. He has also experienced dry mouth and throat, periods of extreme muscle tension, and a constant "edgy" and watchful feeling that has often interfered with his ability to concentrate. These feelings have been present most of the time over the previous 2 years; they have not been limited to discreet periods. Although these symptoms sometimes make him feel "discouraged," he denies feeling depressed and continues to enjoy activities with his family.

Because of these symptoms the patient has seen a family practitioner, a neurologist, a neurosurgeon, a chiropractor, and an ear-nose-throat specialist. He had been placed on a hypoglycemic diet, received physiotherapy for a pinched nerve, and told he might have "an inner ear problem."

He also has many worries. He constantly worries about the health of his parents. His father, in fact, had a myocardial infarction 2 years previously, but is now feeling well. He also worries about whether he is a "good father," and whether his wife will ever leave him (there is no indication that she is dissatisfied with the marriage), and whether he is liked by co-workers on the job. Although he recognizes that his worries are often unfounded, he can't stop worrying.

For the past 2 years the patient has had few social contacts because of his nervous symptoms. Although he has sometimes had to leave work when the symptoms become intolerable, he continues to work for the same company he joined for his apprenticeship following high school graduation. He tends to hide his symptoms from his wife and children, to whom he wants to appear "perfect," and reports few problems with them as a result of his nervousness.

(For those of you who prefer a directive approach)
Please give the Axis I diagnosis; defend your diagnosis with three to five characteristic
symptoms/situations; possible etiology, onset and prognosis; and suggest a treatment.

Online Diagnostic Resources

This link will take you to the ICD-10 online

Here is a specific link to the Mental and Behavioral Health Classifications.

Here is a link to psyweb.com which has assessments, flow charts, DSM classifications and more.

Here is a link to BehaveNet's extensive DSM resources.

Using www.turnitin.com

Here is the link to turnitin.com

This is where you will be sending your written assignments. Because, this is only now available, you may turn in assignments in person or via email to me. Thank you.

Evidence for Effective Treatment of PTSD

The Institute of Medicine (IOM) Committee on Treatment of Posttraumatic Stress Disorder (PTSD) was charged by the Department of Veterans Affairs (VA) to review and assess the evidence on the efficacy of pharmacologic and psychologic treatment modalities for PTSD
(see Box S-1 for the complete Statement of Task).

The committee was given five major tasks: review the scientific evidence and make conclusions regarding efficacy; note restrictions of the conclusions to certain settings, populations, and so on; comment on gaps and future research; answer several questions related to the goals, timing,
and length of treatment; and finally, note areas where the evidence base is limited by inadequate attention or poor quality.

This report contains the committee’s conclusions about the strength of the evidence regarding the efficacy of various treatment interventions.

http://www.nap.edu/catalog.php?record_id=11955

If you have any trouble getting this article post a comment.

Case 1 - The Story of Maggie

Maggie is a 22 year old lady who has been diagnosed with cerebral palsy and severe mental retardation. Over her life, she has made great improvements in her ability to communicate and understand the world around her. She was very social as a child and young adolescent. Her cognitive and social growth, however, stalled in early adulthood. She began having angry outbursts, violent nightmares, and appeared to be fearful of things that did not bother her in the past. Her willingness to socialize also reduced. Her mother later found out that a family member sexually assaulted her. She pressed charges and ensured that Maggie would never interact with him again. Maggie’s behaviors did not improved and, after the ceiling in her bedroom fell while she was sleeping, they worsened. It was difficult to get Maggie to go anywhere without her mother. She would have bouts of crying and throwing “tantrums”. She refused to sleep in her bedroom, even after repairs were made to the ceiling. Maggie’s mother took her to a psychologist who diagnosed her with PTSD in relation to the sexual assault and falling ceiling. She is now takes Zoloft, an SSRI. Her behaviors are slowly improving.

Does she meet the criteria for PTSD? Can you tell from this brief case study? If not, what is missing?

Post Traumatic Stress Disorder

by Erika Donaldson

Abstract

Posttraumatic stress disorder (PTSD) begins with exposure to a traumatic event. The disorder is marked by reexperiencing, avoidance of reminiscent stimuli, numbing of responsiveness, and increased arousal associated with the traumatic event. Traumatic events can be experienced directly, witnessed, or learned about. In addition, as with all mental disorders, the symptoms must also cause distress or impairment in areas of functioning to meet the diagnostic criteria. The prevalence of PTSD in adults is 8% over a lifetime (American Psychological Association, 2000). Many psychological, biological, and social factors appear to contribute the development of this disorder (Barlow & Durand, 2009). Other factors, such as the intensity and source (human design vs. nature) of the traumatic effect appear to affect the likelihood of PTSD development (American Psychological Association, 2000). Treatments for PTSD are relatively effective and include cognitive-behavioral therapy, eye movement desensitization and reprocessing (EMDR), and serotonin reuptake inhibitors (SSRIs) (National Center for PTSD, 2008). Special attention for this research review will be given to the experience of PTSD for individuals with developmental disabilities as it relates to the case study.

Diagnostic criteria for 309.81 Posttraumatic Stress Disorder

The person has been exposed to a traumatic event in which both of the following are present:

• the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
• the person’s response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior

The traumatic event is persistently reexperienced in one (or more) of the following ways:

• recurrent and intrusive recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed
• recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable context
• acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur
• intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
• physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
  

Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:

• efforts to avoid thoughts, feelings, or conversations associated with the trauma
• efforts to avoid actual activities, places, or people that arouse recollections of the trauma
• inability to recall an important aspect of the trauma
• markedly diminished interest or participation in significant activities
• feeling of detachment or estrangement from others
• restricted range of affect (e.g., unable to have loving feelings)
• sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:

• difficulty falling or staying asleep
• irritability or outbursts of anger
• difficulty concentrating
• hypervigilance
• exaggerated startle response
  

Duration of disturbance (symptoms in Criteria B, C, and D) is more than 1 month.

The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

Specify if:
Acute: if duration of symptoms is less than 3 months
Chronic: if duration of symptoms is 3 months or more

Specify if:
With Delayed Onset: if onset of symptoms is at least 6 months after the stressor.

Related Links

The Center for Trauma Recovery (CTR) www.umsl.edu/divisions/artscience/psychology/ctr/index.html
The National Institute of Mental Health (NIMH)
http://www.nimh.nih.gov/
US Department of Veteran Affairs
http://www.ncptsd.va.gov/

Know Your ABCs: Behavioral Assessment Basics

Behavioral assessment takes the mental status exam a step further by using direct observation to formally assess an individual’s thoughts, feelings, and overt behaviors in specific situations or contexts. This information is used to explain the maintenance of present problems in the here and now. Observations may occur in the therapy context, in the home, schools, the workplace, or in other real life situations.

The purpose of behavioral assessment is to identify target behaviors (problematic behaviors) and environmental events that may become targets of therapeutic intervention. This is accomplished via a functional analysis of antecedents, behaviors, and consequences (i.e., the ABCs of observation) following the behavior.

Observational assessment is usually focused on the here and now. Therefore, the clinician's attention is usually directed to the immediate behavior, its antecedents (what happened just before the behavior), and its consequences (what happened afterward) (Hersen 2006)

Behavioral observation may be either formal or informal. In formal observation, the observation procedures are usually structured and systematic, and involve behavior rating scales or checklists (such as the Brief Psychiatric Rating Scale) and clear operational definitions of target behaviors. Informal observation is less standardized and systematic.

People may also be asked to observe their own behavior using a technique called self-monitoring or self-observation (e.g., recording the number of cigarettes smoked per day). Self-monitoring may be formal (e.g., using scales, coding sheets, checklists) or informal (e.g., recording overall mood each day).

Reactivity can distort observational data, and refers to changes in behavior as a result of knowing that one is being observed. Anytime you observe how people behave, the mere fact of your presence may cause them to change their behavior (Hersen 2006) Reactivity can occur while being observed by others or when self-monitoring. Behaviors tend to shift in the desired direction with reactivity.

The Importance of Empathy

The Importance of Empathy in the Therapeutic Alliance.
by Candi P. Feller , R. Rocco Cottone

In this investigation of the construct of empathy, the authors report that the literature reflects strong evidence that empathy is an essential component of the therapeutic alliance across theories and that empathy is necessary in the counseling process. The concept of empathy continues to be a central component of new forms of counseling and therapy.
Rogers (1957) conceptualized and specified six conditions that he considered to be both necessary and sufficient for therapeutic client change to occur. Rogers hypothesized that these six conditions apply to all psychotherapy, not just to client-centered therapy. These conditions require counselor congruence or genuineness in the therapeutic relationship, unconditional positive regard for the client (warmth), the ability of the counselor to empathize with the client in this relationship, and communication of empathy and unconditional positive regard to the client. Of the conditions defined by Rogers as both necessary and sufficient, empathy is the construct that has evoked the most attention from psychotherapy theorists and researchers.

An exerpt from The Importance of Empathy in the Therapeutic Alliance. Journal article by Candi P. Feller, R. Rocco Cottone; Journal of Humanistic Counseling, Education and Development, Vol. 42, 2003