Case Study

Case Study. Student’s Name: Institutional Affiliation: Course Name and Code: Instructor’s Name: Date Submitted:.

ASSESSMENT. Identifying Information Name: Mary Smith Age: 31 years Gender: Female Occupation: Lawyer Ethnicity: Caucasian Marital Status: Married Date of Service: April 23, 2024.

[Audio] A 31-years-old Caucasian female matching the stated age. Well-groomed and dressed appropriately with a composed stature. The patient is alert and responds to questions correctly and accurately. Clear, loud, and well-thought speech with normal volume and tone. Cooperative with no sudden movements and with the ability to maintain eye contact. Clear thought process with feelings of remorse when talking about her close family and friends. Cried when asked about her spouse due to overwhelming emotions. Long and short-term memory intact with no symptoms of dementia. The patient understands her current predicament and is seeking professional help to manage the condition. She is goal-oriented and prefers having a schedule for the entire session. Patient is aware of possible health issues related to depression and alcoholism and is ready to commence treatment to manage the condition and live healthily. The patient is determined to recover and gives clear indications and support materials needed in structuring appropriate interventions. No suicidal ideation is identified in her speech and answers indicating that she did not have any thoughts of self-harm. 296.3 - Major Depressive Disorder: The patient fits in the DSM-V tr criteria for MDD due to her symptoms including difficulty in concentration, fatigue, eating disorders, and feeling depressed and sad. 305.00 Alcohol abuse She also fits in the DSM-V tr criteria for alcohol abuse since she takes alcohol as a coping mechanism to deal with depression (American Psychiatric Association, 2022). The patient continues to drink despite knowing the consequences of her actions and has withdrawn from the social environment. Differential Diagnosis : 300.00 anxiety disorder NOS Differential diagnosis is anxiety disorder exhibited by social withdrawal and remorseful feeling of being a burden to immediate family and friends. These diagnoses were identified based on DSM-V criteria indicating universality and professionalism in developing appropriate treatment measures..

HPI. The patient is a 31-year-old Caucasian female named Mary. She is married with no children and works as a lawyer. She does not subscribe to any spiritual or religious organization and prefers doing good in society. Their highest education level is a Doctor of Juridical Science (SJD) and plans to utilize her expertise to serve others and bring justice to society. Mary presented as a new patient after being referred by a friend to seek support for depression and substance use management. She has come to the facility to get professional help since her condition continues to progress preventing her from accomplishing her goals. The patient states that her mother died eight months ago and did not have effective coping mechanisms. This led to an onset of depressive symptoms and several weeks of persistent sadness leading to alcohol intake as a coping (Kalin, 2020 Shao et al., 2020). However, the symptoms persisted and worsened over time since she did not seek external support to help her manage her condition. Mary began having difficulties maintaining social connections and would often miss out on cases harming her career. She reportedly had a low performance capacity caused by a lack of concentration and energy to work on various causes indicating the need to seek professional support in managing depression and substance usage. The patient's present goal is to get better and be in a better position to resume her work with limited interruptions..

History of Present Illness cont.. Physical appearance, patient statement, medical, and history report will help the subjective formulation process. This information provides clinicians with needed data for conducting an effective patient assessment to determine primary and differential diagnoses. The patient's current presentation is analyzed with a focus on personal and intersectionality aimed at building an effective review finding. Physical and mental examinations backed up by patient answers will provide detailed descriptions of patient information needed in the diagnostic process. Schoevers et al., 2021).Treatment regimens will incorporate existing subjective formulation and objective assessment findings in creating a tailored intervention for the respective patient..

Psychiatric ROS. Depression: Patient confirms depressed mood, diminished interest, weight/appetite changes, insomnia, fatigue, feelings of worthlessness/guilt/hopelessness, lack of concentration. Mania: Patient denies racing thoughts, pressured speech, distractibility, excessive involvement in pleasurable activities, or increase in goal-directed activity. Psychotic Disorder: Patient denies , paranoia, auditory/visual hallucinations, negative symptoms, or disorganized speech/behavior. Anxiety: Patient reports anxiety and worry occurring more days, feelings of restlessness, difficulty concentrating, and fatigue..

Psychiatric ROS cont.. Panic: Patient denies palpitations, discrete periods of intense fear/discomfort, trembling, sweating, shortness of breath, choking sensations, nausea, chest pain, dizziness. OCD: Patient denies recurrent intrusive thoughts/worries or repetitive rituals. PTSD: Patient confirms and flashbacks. Patient confirms emotional numbing, feelings of dissociation, and general responsiveness. Social Phobia: Patient confirms social discomfort. Somatoform: Patient denies unexplained medical symptoms. Eating Disorders: Patient denies behaviors such as binging and purging. Patient denies concerns with body image. Patient denies fears of weight gain. Cognitive Disorders: Patient denies , forgetfulness, memory impairment, disorganization, or altered consciousness. Learning Difficulties: Patient confirms issues with organization, attention, and impulsivity..

Past Psychiatric History:. Previous symptoms, past diagnoses, and current (if any) psychiatric diagnoses. Mary had her first diagnosis at 17 years with Single Episode Depressive Disorder through a medical diagnosis. She was taken to the hospital by her mother after episodes of isolation and social withdrawal. Mary had started becoming distant worrying her mother leading to seeking professional support. The symptoms persisted for several months reducing her appetite and ability to engage in normal activities. Additionally, Mary began showing these signs after her parents separated and lost interest in various activities including school work. Her grades dropped and she barely engaged in group activities..

Past Psychiatric History: cont.. History of psychiatric treatment: Outpatient: Patient states mother took her to see a psychiatrist who diagnosed her and began medicating her. Inpatient: There is no history of inpatient psychiatric treatment for the patient..

Past Psychiatric History: cont.. History of psychotropic medication use and reactions. Patient states mother took her to see a psychiatrist who diagnosed her and began medicating her. Substance Use Past and Current The patient states that she only takes alcohol on various occasions. However, the consumption has increased in the past months as a coping mechanism to deal with depressive symptoms. However, the patient denied the use of major substances like cocaine, methamphetamine, and ecstasy but has smoked marijuana on several occasions. She does not have any smoking or substance addiction issues and has, therefore, not been part of a detox program. Mary also denies having access to/being part of any support group to help in dealing with complications..

Lethality. History of suicide attempts and potential lethality. Current Ideation: Patient denies suicidal or homicidal ideation. Previous Ideation: Has never had suicidal or homicidal ideation Previous Attempt: None reported Risk Factors: Risk factors include male patient who has a history of clinical depression; major depressive disorder (MDD) Protective Factors: The patient is not a religious person even though she was brought up in a Christian household. Patient has a strong support system and believes that suicide is wrong..

Past Medical History:. The patient has not undergone any surgeries in her past life and does not have a surgery record. . Patient denies any current medical conditions. Allergies: The patient also denies having environmental allergens, allergies to latex, food, and medication Patient states he doesn’t take any medication over the counter. Patient reports exercising 1-4 x a week jogging 40 minutes a day. Pregnant: N/A Breastfeeding: N/A Height: 6’2 Weight: 208 BMI: 26.2.

Family History:. The patient reports paternal grandmother was diagnosed with T2DM and is currently under medication. Depression cases have also been recorded on the paternal side with at least two diagnoses indicating that the condition might be hereditary. The parents had no history of medical issues or substance abuse. The patient affirms that her parents lived healthy lives with minimal cases of illnesses, clinical visits, and hospital admissions. The patient denies a family history of substance abuse or severe mental illness. The patient's awareness and comprehension of the severity of mental disorders and substance abuse are not questionable. Her siblings have never been diagnosed with mental disorders and they do not take any illegal substances..

Personal History:. •Perinatal: Full-term birth, vaginal delivery, and well breastfed. •Childhood: The patient achieved his developmental milestones on time, with no history of attachment issues or significant childhood traumas. The patient had no learning disabilities, nightmares, phobias, bedwetting, or cruelty towards animals. •Adolescence: The patient was active in school days and underwent normal sexual development..

Social History. The patient is 31 years old and lives with her husband. She has lived in the United States all her life and states that she is surrounded by supportive people. She has an older sister, two brothers, and a deceased mother. The patient is not a religious person even though she was brought up in a Christian household. The patient believes in doing good instead of subscribing to religion and also supports science and modern advances made in the tech industry. She does not know where her father resides but believes he is still alive. The patient denies any history of abuse and no history of criminal offense or arrest. The patient complains of remorse feelings for living in a supportive environment and feels like a burden to her husband..

Developmental History. Raised where: lived in the United States all her life. By whom: Parents Siblings: has an older sister, two brothers Childhood description: Reported being a good student in high school with friends and activities. Performance at school: Good student High School Friends: Had a friend group. High School Activities: Participated in chess team throughout high school. Current Hobbies: Spends time at home with family..

Mental Status Exam. A 31-years-old Caucasian female matching the stated age. Well-groomed and dressed appropriately with a composed stature. The patient is alert and responds to questions correctly and accurately. Clear, loud, and well-thought speech with normal volume and tone. Cooperative with no sudden movements and with the ability to maintain eye contact. Clear thought process with feelings of remorse when talking about her close family and friends. Cried when asked about her spouse due to overwhelming emotions. Long and short-term memory intact with no symptoms of dementia. The patient understands her current predicament and is seeking professional help to manage the condition. She is goal-oriented and prefers having a schedule for the entire session. Patient is aware of possible health issues related to depression and alcoholism and is ready to commence treatment to manage the condition and live healthily. The patient is determined to recover and gives clear indications and support materials needed in structuring appropriate interventions. No suicidal ideation is identified in her speech and answers indicating that she did not have any thoughts of self-harm..

Cognitive Examination. The patient is alert, and conscious, and demonstrates full orientation to place, time, and person. The patient has, however, presented herself to the clinic seeking professional support to manage her condition and this would include therapy and support group interventions to deal with her current situation enabling her to regain social presence and connection and complete her tasks confidently. Sound judgment with recognition of the consequences of behavior and appropriate judgment in hypothetical situations. Impulse control is observed to be good, both during the evaluation and as reported in recent history..

Formulation/Impression: Diagnosis:. 296.3 - Major Depressive Disorder: The patient fits in the DSM-V tr criteria for MDD due to her symptoms including difficulty in concentration, fatigue, eating disorders, and feeling depressed and sad. 305.00 Alcohol abuse She also fits in the DSM-V tr criteria for alcohol abuse since she takes alcohol as a coping mechanism to deal with depression (American Psychiatric Association, 2022). The patient continues to drink despite knowing the consequences of her actions and has withdrawn from the social environment. Differential Diagnosis : 300.00 anxiety disorder NOS Differential diagnosis is anxiety disorder exhibited by social withdrawal and remorseful feeling of being a burden to immediate family and friends. These diagnoses were identified based on DSM-V criteria indicating universality and professionalism in developing appropriate treatment measures..

Neurobiology of Stimulant Use Disorder. Alcohol consumption leads to relaxation and sedation caused by GABA's enhanced inhibitory effects. Abuse also leads to withdrawal and tolerance symptoms because of downregulating GABA receptors. Heightened release of glutamate with chronic alcohol abuse leads to dependence. Alcohol consumption increases the release of dopamine caused by the brain's stimulation in the reward pathway. This reinforcement leads to addiction and dependency as the body feels the urge to indulge in the "satisfying" behavior (Mumba & Davis, 2023). Alcohol consumption interferes with the functioning of the amygdala and hippocampus leading to disrupted memory and emotions altering existing thought processes. External factors like peer influence, trauma, and stress contribute to enhanced alcohol intake and may develop alcohol use disorder if the problem is not addressed early enough. Pharmacotherapy is effective when combining medication targeting glutamate and GABA neurotransmission to minimize craving and withdrawal symptoms. CBT also helps individuals use coping mechanisms to reduce and manage drinking behavior and solve psychological factors..

Formulating the Diagnosis:. •Diagnosis: Major Depressive Disorder Alcohol abuse Anxiety •Rationale: The patient exhibited persistent and severe depressive symptoms, as evidenced by fatigue, overwhelming sadness, lack of concentration when doing various activities, and persistent feelings of isolation; these meet the diagnostic criteria for MDD..

Formulating the Treatment Plan:. Treatment Plan: Cognitive-Behavioral Therapy (CBT) to address depressive symptoms. Rationale: CBT is an evidence-based psychotherapy effective in treating MDD. Psychoeducation and ongoing monitoring should be integral as part of the treatment..

Goals of Treatment. Psychotherapy Approach - Cognitive Behavioral Therapy (CBT). Psychotherapy typically provides alternative reinforcement, enhancement of motivation, and social support. Treatment regimen Factors to consider; external and environmental factors. Medication management. To manage the condition within the stipulated period. Bi-monthly follow-up sessions..

Pharmacotherapy:. With the approval from the Food and Drug Administration, Starting with sertraline 50 mg once daily is the recommended beginning dose for major depressive disorder for treating MDD. Sertraline (Zoloft) a selective serotonin reuptake inhibitor (SSRI), has shown efficacy in treating both depression and anxiety. 75 mg imipramine (Tofranil) once daily 15 mg Aripiprazole daily Targeted symptoms for using the drugs include social anxiety, depressed mood, and anhedonia. Side effects include nausea, vomiting, diarrhea, dry mouth, insomnia, and dizziness. The drug's function is preventing the reuptake of serotonin ensuring that adequate measures are available to help in mood regulation..

Psychotherapy:. The treatment plan will incorporate medication and psychotherapy to attain the goal of ensuring Mary improves functional status by eliminating depressive symptoms (Pavkovic et al., 2018). The treatment will consider other factors like spiritual, cultural, environmental, and pertinent family by using all alternatives needed to support Mary after giving her consent to proceed with the treatments. Patient will be educated on how to manage her medication with help from her husband, friends, and family. A safety plan with emergency contacts will be developed to help in managing the condition within a given period. Social support is essential in enabling Mary to adopt a health-seeking behavior to effectively manage the condition with minimal liabilities and complications. Bi-monthly patient check-ups are encouraged to facilitate a faster transition into normalcy. A crisis management plan will incorporate coping strategies and early identification of warning signs to effectively handle the condition before escalating..

Interventions:. The treatment plan will incorporate medication and psychotherapy to attain the goal of ensuring Mary improves functional status by eliminating depressive symptoms (Pavkovic et al., 2018). The treatment will consider other factors like spiritual, cultural, environmental, and pertinent family by using all alternatives needed to support Mary after giving her consent to proceed with the treatments. Mary will be educated on how to manage her medication with help from her husband, friends, and family. A safety plan with emergency contacts will be developed to help in managing the condition within a given period. Social support is essential in enabling Mary to adopt a health-seeking behavior to effectively manage the condition with minimal liabilities and complications. Bi-monthly patient check-ups are encouraged to facilitate a faster transition into normalcy. A crisis management plan will incorporate coping strategies and early identification of warning signs to effectively handle the condition before escalating..

Medication:. Selective Serotonin Reuptake Inhibitor (SSRI) antidepressant - Sertraline (Zoloft) 50mg daily Neurotransmitters - Serotonin Antidepressant - imipramine (Tofranil) Antipsychotic - Aripiprazole.

Consent. Informed Consent: For every medication and therapy, informed consent was acquired. The patient participated in the planning of their care and decision-making process. Signature: Date:.

References. Kalin, N. H. (2020). The critical relationship between anxiety and depression. American Journal of Psychiatry, 177(5), 365-367. Mumba, M. N., & Davis, L. L. (2023). Are We Witnessing a New Wave of Substance Use Disorders?: A Spotlight on Stimulant Use Disorders. Journal of Psychosocial Nursing and Mental Health Services, 61(3), 13-18. Pavkovic, B., Zaric, M., Markovic, M., Klacar, M., Huljic, A., & Caricic, A. (2018). Double screening for dual disorder, alcoholism, and depression. Psychiatry Research, 270, 483-489. Schoevers, R. A., Van Borkulo, C. D., Lamers, F., Servaas, M. N., Bastiaansen, J. A., Beekman, A. T. F., ... & Riese, H. (2021). Affect fluctuations examined with ecological momentary assessment in patients with current or remitted depression and anxiety disorders. Psychological Medicine, 51(11), 1906-1915. Shao, R., He, P., Ling, B., Tan, L., Xu, L., Hou, Y., ... & Yang, Y. (2020). Prevalence of depression and anxiety and correlations between depression, anxiety, family functioning, social support and coping styles among Chinese medical students. BMC psychology, 8, 1-19..