Case Study 3. DSM Symptoms Present: [DSM criteria as evidenced by (with evidence from case study)]

Transcription

1 Case Study 3 DSM Symptoms Present: [DSM criteria as evidenced by (with evidence from case study)] Insomnia Related to Generalized Anxiety Disorder A. The predominant complaint is difficulty initiating or maintaining sleep, or non-restorative sleep, for at least 1 month that is associated with daytime fatigue or impaired daytime functioning. As evidence by: Although Ms. D. has had sleep problems intermittently since her college years, she has developed more persistent problems over the past year and a half. She claims that she does not sleep at all some nights and is concerned that her sleeplessness will impair her ability to take care of her children and otherwise function during the day. Ms. D reveals that, although her sleep problem is the biggest difficulty she is having at the moment, it is only one of many symptoms that have been bothering her. B. The sleep disturbance (or daytime sequel) causes clinically significant distress or impairment in social, occupational or other important areas of functioning. As evidence by: Ms. D. claims that she does not sleep at all some nights and is concerned that her sleeplessness will impair her ability to take care of her children and otherwise function during the day. Ms. D reports great interest and enthusiasm for her daily activities, although her energy is adversely affected by her sleep disturbance. C. The insomnia is judged to be related to another Axis I or Axis II disorder, but is sufficiently severe to warrant independent clinical attention. Generalized Anxiety Disorder: A. Excessive anxiety or worry, occurring more days than not for at least 6 months, about a number of events or activities. As evidence by: Although she has had sleep problems intermittently since her college years, she has developed more persistent problems over the past year and a half. This worsening coincided with several stresses, including a move to a new house, a change of jobs for her husband, her own decision to quit working, and her elderly and ill father s moving in with her family. Ms. D. says that she can t stop herself from worrying about everything : the health and safety of her family, their financial situation, the security of her husband s job, the possibility that their old furnace may explode, the state of the tires on the family car, the quality of her children s schools, filling out her tax forms, and so on. B. The person finds it difficult to control the worry. As evidence by: Ms. D. says that she can t stop herself from worrying about everything : the health and safety of her family, their financial situation, the security of her husband s job, the possibility that their old furnace may explode, the state of the tires on the family car, the quality of her children s schools, filling out her tax forms, and so on. C. The anxiety and worry are associated with three (or more) of the six symptoms (with at least one symptom present for more days than not for the past 6 months).

2 (1) Restlessness or feeling keyed up or on edge: As evidence by: Ms. D. constantly ruminates on her concerns and suffers from somatic tension manifested by tenseness in her neck, shoulder, and jaw muscles; digestive troubles; and general jumpiness. (2) Muscle tension: As evidence by: Ms. D. denies abrupt episodes of panic but says that she does have intermittent episodes of severe anxiety that are characterized by palpitations, sweating, increased muscle tension, difficulty breathing, and a fear that she is losing her mind. (3) Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep): As evidence by: She claims that she does not sleep at all some nights and is concerned that her sleeplessness will impair her ability to take care of her children and otherwise function during the day. D. The focus of the anxiety and worry is not confined to features of an Axis I disorder: As evidence by: Ms. D. did not state that her worry was due to anything other than concerns regarding: the health and safety of her family, their financial situation, the security of her husband s job, the possibility that their old furnace may explode, the state of the tires on the family car, the quality of her children s schools, filling out her tax forms, and so on. Ms. D. does not worry about having panic attacks, being embarrassed in public, being contaminated, being away from home, having multiple physical complaints, having a serious illness, or her worry does not occur exclusively during Posttraumatic Stress Disorder. E. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. As evidence by: She claims that she does not sleep at all some nights and is concerned that her sleeplessness will impair her ability to take care of her children and otherwise function during the day. F. The disturbance is not due to direct physiological effects of a substance or general medical condition. As evidence by: Ms. D. reported using alcohol and other substances to medicate her insomnia and it would not seem likely that her anxiety would be a symptoms of her endometriosis. D. The disturbance is not better accounted for by another Sleep Disorder or by an inadequate amount of sleep. As evidence by: Ms. D also notes an increased heart rate and sweating on occasion at night but denies depersonalization or parenthesis (numbness or tingling). She denies other unusual behavior during sleep and daytime sleepiness, and she only rarely takes a daytime nap. E. The disturbance is not due to the direct physiological effects of a substance or a general medical condition. As evidence by: Ms. D uses alcohol and other medications to treat her insomnia, but the use of those substances do not seem to be the etiology of her insomnia. It is also unlikely that her insomnia would be a symptom of her endometriosis.

3 Other factors given by the DSM-IV which support the diagnosis of Insomnia Related to Generalized Anxiety Disorder As stated by the DSM-IV individuals with Generalized Anxiety Disorder often have trouble falling asleep and experience anxious ruminations in the middle of the night. MS. D. reported that she constantly ruminates on her concerns, which can account for her inability to fall and remain asleep. The DSM-IV also states that individuals with Insomnia Related to Another Mental Disorder will experience conditional arousal and negative conditioning which individuals with Primary Insomnia display. Ms. D. acknowledges feeling physically and mentally tense about her sleep difficulty and notes that sometimes she clenches her jaw, grips her hands, or feels panicky at night. The DSM-IV also reports that individuals with Insomnia Related to Another Mental Disorder will demonstrate inappropriate medication for treatment of their symptoms of Insomnia. Ms. D has used Diphenhydramine (Benadryl) and alcohol to help with her sleep problems.

4 Axis I: Generalized Anxiety Disorder Insomnia Related to Generalized Anxiety Disorder Axis II: No Diagnosis Axis III: Endometriosis Axis IV: A move to a new house A change of jobs for her husband Ms. D s own decision to quit working Ms. D s elderly and ill father s move into the home with her family Axis V: GAF: 74

5 Treatment Plan: 1 Problem and Goal; 2 Objectives with minimum of 2 Intervention each. Problem: Due to symptoms of Insomnia Related to Generalized Anxiety Disorder, Ms. D. is experiencing sleeplessness due to worry which is causing impaired functioning in her everyday living. Goal: Ms. D will regain control of her worry and anxiety and increase the amount of restorative sleep. Objective #1: Ms. D will be prescribed Alprazolam Xanax to help with symptoms due to Insomnia related to Generalized Anxiety Disorder. Intervention #1: Client will meet with medical treatment personnel to learn about prescribed medication(s) including medication symptoms and possible side effects. Intervention #2: Client will take medication as prescribed continuously, until otherwise instructed. Intervention #3: Client will meet with medical personnel as determined by medical treatment personnel to reassess medication management including symptom improvement and medication side effects. Intervention #4: Client will not use other non-prescribed substances as a means to treat symptoms due to Insomnia Related to Generalized Anxiety Disorder. Objective #2: Ms. D will begin a counseling regimen with the local community agency for exploration and reduction of worry related to Anxiety in order to understand and acknowledge concerns regarding life events. Intervention #1: Client will schedule appointment for an initial assessment with local community counseling center. Intervention #2: Once the assessment is completed, client will schedule weekly individual counseling sessions consisting of exploration of worry through Cognitive Behavioral Techniques. Intervention #3: Client will meet with counselor on a weekly basis and comply with behavioral provider s requests. Intervention # 4: Client will explore irrational thinking regarding self-evaluation in relation to her beliefs regarding her worry.

6 Objective #3: Ms. D. will learn and utilize Cognitive Behavioral Therapy techniques as a means to cope with her worry and anxiety. Intervention #1: Ms. D will explore the idea of revisiting progressive relaxation techniques as a means to immediately deal with her uncontrollable worry, anxiety and panic attacks. Intervention #2: Ms. D. will explore the idea incorporating thought-stopping techniques as a means to assist her with uncontrollable thoughts and worry. Intervention #3: Ms. D will explore the idea of using self-talk as a means to confront internalized expectations and irrational thoughts and beliefs.