Case report essay

Case report

This report contains privileged and confidential patient information and may not be copied.  Any unauthorized disclosure is a federal offense.

Patient Name: Janet Lake                                                   Gender: female
Age: 43                                                                     Birth date: September 30, 1952
Marital Status: Single           Occupation: Secretary currently on disability from work

Information was received for this report from face to face meeting with the client, and her two sisters who attended two sessions. Written history was received from the previous treating agencies as well as the employers Employee Assistance Program. The client was cooperative and came to therapeutic sessions voluntarily, though it was also a required by her employer if she wished to return to work.

Based on the initial evaluation, assessment, and 8 individual therapy sessions with Jane Doe, it is my opinion that the information contained in this report is reliable and is likely to be a valid reflection of her current level of functioning outside of the examination setting. Collateral information was obtained from the clients sister’s, with the required release of information paperwork signed by the client. Referral information was also obtained from the client’s employer. Records were obtained on prior treatment from the community mental health center, with release of information forms signed by client.

SOURCE AND REASON FOR REFERRAL

Janet Lake is a 43 year old single white female of Irish descent. She was referred by her employers Employee Assistance Program  as a result of problems at work. The employer reoported that clients behavior became bizarre and  manic. Client was making bizarre statements to coworkers. She was sending notes to cowokers which reference religiona nd smoking cessation programs. Coworkers found the notes distressing and odd, as well as difficult to understand. Client began dressing inappropraitly in formal evening attire with exagerrated make-up. Client became loud and disruptive at work. She  was required to seek treatment via the  Employee Assistance Program.

Clinet had been employed for a period of six months prior to referral, as a secretary for  a large company. Co-workers reported to supervisors that Janet’s behavior became bizarre and unpredicatable. Client was referred to the company EAP program who met with client once and referred her to this office for evaluation and treatment services. Client is agreeable to services and must follow through with treatment if she wishes to return to her job. The employer reports that client had a positive work performance  for the first five month in her position as a secretarial assistant. During the past month, her behavior and work began to decompensate. Client is currently on disability from her job.

Client reports a history of depression and difficulty maintaining employment. She has a history of wraparound/case management services but has been noncolmpliant with these services in the past. Historically, client clears relativly quickly with treatmetn and is able to maintain stability on medication. Eventually, client discontinues medication and symptoms reapear. . Client is easily frustrated and admits to feeling overwhlemed and disorganized. She reports that her troble at work is casued by  a boring and picky supervisor who is not willing to look at different ways of doing things. Client feels that she can improve the flow of work at the organization. She has comlicated ideas of how to improve the work flow in her office which are difficult to follow and of no interest to those who superviosr her at work. She jumps from one idea to the next , without completing thoughts or sentences. Her  thoughts could be decibed as having flight of ideas and her speech is pressure.

Client has a supportive family and several close friends.  Client is very well aware of her past mental health history though she minimizes the need to follow through with treatment protocol. Her past diagnosis included Bipolar Disorder and Major Depression. Client has also had an Axis II. Diagnosis of Borderline Personality Disorder.  Client has no history of suicide attempt but does have a history of self-abuse. Client reports mood swings, difficulty sleeping and poor eating habits. Client is very thin, appears well groomed, and is very talkative with excessive make-up, racing thoughts and, tangential thinking. She explains her work isues as being in part, due to her need to take frequent smoking breaks.  Client reports that she is a heavy smoker and needs to smoke frequently. She claims that her employer found the smoking breaks disruptive and complained that she was not getting her work done. Clinet feels that if she can quit smoking, she can return to work.

PYCHO-SOCIAL HISTORY

Janet Lake is the youngest of three children. Both parents were alcoholics and are now deceased. She has two sisters, who are married and live in the areas. Both sisters are supportive and available to assist Janet. She has lived with both sisters from time to time. Client has had two brief, voluntary psychiatric hospitalizations in the past. Her most recent hospitalization was five years ago and followed the death of her mother with whom she lived. Client’s mother died suddenly of a heart attack. Client’s father died five years earlier as the result of an automobile accident. These two sudden and traumatic events resulted in decompensation of client’s mental status which resulted in the need for intensive treatment.

Client grew up in a small neighborhood in a rural area where she attended public school. She was classified with learning disabilities as a young child and received some special education services. While reports are not available, her sisters report that she was overactive and was a behavior problem in schools. She also had trouble concentrating and remembering. She was told by teachers that she was an underachiever, meaning that she was bright but did not apply herself to her schoolwork. At age 15 Janet became sexually involved with a school employee, an event which was well publicized. She was sent to a special education school for emotionally disturbed children following this event and completed high school. Client was involved in therapy as a result of the incident with her teacher. Client has a history of several brief romantic relationships. She is not currently involved with anyone romantically.

Client reports a chaotic family life with frequent volatile fights between her parents. The police were called to the house regularly. There was little guidance or supervision in the home. Client and her sisters were free to come and go as they pleased. While the older sisters were good students and took on much of the responsibility for household duties including cooking and cleaning, Janet was not required to help with the house. Her sisters report that they were attempting to shield their young sister and let her have a childhood. She had a very active social life and dated frequently. Janet had a very outgoing personality, though she was very moody. Her sisters were proud of her vibrant and effervescent personality. Janet enjoyed painting and was very artistic as a teenager. Client had a distant relationship with both parents as a child. The parents were reported to be preoccupied with work and their own personal life’s and spent little time with the children. As the youngest child, Janet received the least amount of attention as her parents alcohol problems were significant at by the time she was born. . Her parents both worked full time. Her mother was a nursing assistant in a hospital and her father worked for the post office. Her parents spent evenings and weekends watching television, drinking or socializing with neighbors. Client’s mother is described as loud, and extremely social. Her behavior while drinking was at times “out of control” and the source of much laughter. Clients sister describe there mother as the neighborhood clown. There father, a quiet man, though also heavy drinker would become angry at his wife’s behavior and that was the source of frequent fighting in the family.  Client describes her father as very quiet and unhappy. She claims that her father hated his job and would come home each evening and drink heavily.

 Following high school, client attended community college, earned an associates degree in Business and began working in a local bank. She was fired by the bank after two years of employment as a result of numerous errors. Client reports that she has great difficulty maintaining her personal finances and frequently overdrew her checking account. She says that this was against the rules for bank employees so she has been unable to secure employment in a bank.  Over the next ten years, client held a series of jobs in retail and small businesses. She reports that she would become bored after holding the same job of more than one year and so quit, to move onto a new job. Client has attempted to love independently several times. Her success into his areas is generally short lived. She has been evicted from several apartments due to her inability to consistently pay her rent. so has lived alternately with family members.

Client was first hospitalized at the age of 28 in the local hospital voluntary inpatient mental health unit. At the time, she was not eating, had many superficial cuts to her arms and reported feeling extremely depressed. Following that hospitalization, client received therapy and medication monitoring at the local mental health center. She discontinued treatment after one year. Her second hospitalization was at the age of 35 following her mother’s death. Client’s behavior at that time became bizarre and delusional. She followed treatment again with the mental health center as well as a case management service for a period of one year and then discontinued treatment. Client claims she was doing quite well at the time. She inherited over $50,000 following her mother’s death and lived in a nice apartment for two years, working at a department store. When the money was depleted, client was evicted from the apartment and moved in with her oldest sister.

There is some indication in the research, that mood disorders have genetic underpinnings so a thorough family history was completed. The family history indicates that both of Janet’s parents have a history of alcohol abuse. Her mother may have suffered form manic episode, given he historical description for Janet and her sisters. Her father may have suffered some depression, also given the description and example fro m client and siblings.  Janet has a close relationship with her sister, who is both supportive and have always functioned in a more parental ole with Janet.

OBSERVATIONS

A)    Behavioral

Janet Lake came to the initial session’s appearing well groomed, dressed in formal wear, with a great deal of make up.  She arrived early and paced in the waiting area, frequently stepping outside to smoke a cigarette. She was very animated, friendly, and anxious to begin the session. Her speech was somewhat pressured.  . Client was wearing a long, sleeveless lavender dress and high heels. Her hair had obviously been curled and was pulled up on her head. While she had obviously made an effort on her appearance and was clean and well groomed, her appearance was over done and her mannerisms were exaggerated.
During the initial assessment client was grandiose, euphoric. She was irritable when questioned about her large-scale plans for social events, activates and addressing her problems at work. For example, client reported making several calls to her supervisor home late at night to discs her employment. Client was upset that the supervisor was not willing to discuss the problems at home or at that hour of the night.  Client reports that she sleeps very little and frequently forgets to eat.
Client was not observed in a period of depression, but history from client and siblings, in addition to past medical history does indicate a history of depressive symptoms that have lasted several weeks and required hospitalization.
During the course of treatment, client’s behavior became less exaggerated and dress become more appropriate.

B)  Affective

Janet generally appeared happy and goal oriented in therapy, though she was initially insistent that her only goal was to stop smoking. She engaged in conversation easily and appeared interested in developing a treatment plan goal which would resolve her issue very quickly. Janet has a history of depression. Evidence of this was not seen during the interviews or course of treatment.

B)    Cognitive

 Janet stated that she was required to attend therapy to quit smoking. She believed that her employer would allow her to return to her job if she stopped taking smoking breaks. Janet appears to be of at least average intelligence. Her functioning in the work world is not indicative of her apparent intelligence. Client has a great deal of difficulty organizing and maintaining finances in her personal life and this has caused much difficulty in her life. The client has been able to maintain employment for relatively long periods of time which indicates a successful treatment history.

DSM-IV DIAGNOSIS

Axis I              296.44 Bipolar Disorder I. with most recent episode hypomanic and hx of psychotic features
Axis II                        301.83 Borderline Personality Disorder rule out
Axis III           Asthma
Axis IV           Interpersonal problems, Occupational problems, Daily/Routine Functioning problem
Axis V             Current Initial 30

DSM-IV-TR criteria
Axis I Bipolar I Disorder – Per the DSM-IV-TR, requires one or more manic or mixed episodes. A depressive episode is not required for the diagnosis of Bipolar I disorder but it frequently occurs. Janet had experienced several episodes of mania and depression. Client’s symptoms, consistent with the diagnosis of BPD include those following symptoms of mania:
High level of energy, activity. Client is restless and unable to sit still during sessions.
Client quickly becomes irritable when questioned about unrealistic, grandiose thinking ad plans.
Client shows evidence of racing thoughts, pressure speech and flight of ides.
Client is easily distracted and has difficulty concentrating.
Poor sleeping and eating habits.
Poor judgment
Financial difficulties as a result of poor financial management and impulsive spending.

Client’s symptoms consistent with the diagnosis of BPD include the following symptoms of depressions:
Client has had lasting periods of  sadness and thought of hopelessness
Clients have experienced prolonged periods helplessness and anxiety.
Loss of interest or pleasure in activities once enjoyed, including sex
Client has self-injurious behavior.
Axis II Borderline Personality Disorder – Per the DSM-IV-TR. Borderline Personality Disorder (BPD) is a in a number of areas with a wide variety of related symptoms.  Janet’s history included symptoms associated with BPD including; impulsivity, self-abuse, and unstable moods.

Axis III Asthma – Client has a history of asthma since childhood and uses an inhaler as needed.

Axis IV Interpersonal problems, Occupational problems, Daily/Routine Functioning
Problems – Client has a history of occupational problems in addition to interpersonal and
Financial difficulties which are the result of her problematic behaviors.

Axis V – GAF was initially rated as 30. The means that the clients behavior was considerably influenced by delusions or hallucinations OR serious impairment in communications or judgment OR inability to function in all areas. In Janet’s case, her behavior was influenced by delusions and there was significant impairment in judgment and functioning as evidenced by her employment, interpersonal and financial problems.

Axis V – GAF was rated as 65 at the time of this report. This indicates that there are some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, has some meaningful interpersonal relationships. At the time of this report Janet was preparing to return to work. She had reestablished a treatment protocol, was reestablishing health social relationships and working towards recovery.
MODALITY

Cognitive-Behavioral Therapy

Treatment utilized with Janet was Cognitive-Behavioral Theory. This therapeutic technique allows the client to participate and engage in treatment and allows the therapist to educate and guide actively towards the goals of treatment.

Cognitive therapy can be beneficial for clients with Bipolar Disorder as it focused on helping clients recognize their negative thoughts and problem behavior patterns Cognitive therapy, in addition to medication to stabilize mood, can prevent relapse and improve overall functioning. As Janet has a positive history of stability when on medication, therapy will focus on recognizing the signs that lead her to discontinuing medication and treatment. Therapy will focus on the following three goals.
•           Recognizing and tracking mood changes, from depression to mania. Recognize these changes early on in the continuum of behavior can prevent a full-blown episode, deterioration and hospitalization.
•           Learn how to establish and monitor a structured daily routine that assures daily compliance to treatment protocols.
•           Establish and utilize support systems early on when mood changes become evident.
To help the patients recognize a pending episode, a technique called Monitoring
And Grading Mood was utilized. This technique is done with a graph and a diary which involves recording and grading various behaviors that reflect the client’s mental status. For Janet, recording energy level, activity, sleep was used. Janet was instructed to use the ratings of -5 through +5 and the indicators can graph both manic and depressive symptoms. In this case, Janet’s sisters were asked to assist in the completion of this test, particularly while Janet is at either end of the rating scale.

Coordination of Services
Client will need to be monitored by a psychiatrist for medication managements. Coordination and collaboration with the treating psychiatrist will be necessary. In the past, client has been successful for the longest period of time when followed by a case management program. Coordination with this service will be necessary to obtain feedback on client’s progress and identify any potential problems early, prior to crisis situation.
.

TREATMENT PLAN & INTERVENTIONS

Early Phase Goals
Maintain a sense of respect for Janet while establishing a therapeutic relationship.
Model communication, such as reflecting what was heard and asking questions. Model slow, deliberate speech and listening skills
Positively reinforce desired functioning.
Begin process of shaping desired behaviors.
Provide information on medication management
Educate Janet on wellness and recovery from a mental illness

Middle Phase Goals
Identify problem and obtain a baseline of individual functioning, highlighting baseline for daily functioning.
Work with Janet to behaviorally and measurably define depression and mania, including duration and frequency.
Have Janet track baseline functioning by using a daily chart of behavior, including triggers, intensity and frequency.
Build support systems with friends, family and case management services
Educate family and friends on Janet’s illness as permitted by Janet per confidentiality agreements.

Late Phase Goals
Decrease anxiety/dysfunctional thinking and behavior while increasing acceptable functioning.
Continue to use Psycho education to provide awareness about Bipolar Disorder, and treatment to Janet and her family and friends as confidentiality permits.
Identify ways personal schema’s needed to be changed or has changed; identify irrational beliefs that trigger non-compliance with treatment.

LEGAL & ETHICAL ISSUES:

Janet was referred for treatment by her employer.  Parameters will need to be established regarding the information that will be reloaded to the employer from his evaluator. Appropriate releases of information will need to be signed. Because of Jane’s history of depression and impulsivity, I will review the legal issues regarding suicide and criminal activity in terms of required reporting to police. Because of Janet’s history of sexual promiscuity and relationships with those in positions of authority, issues related to transference will need to be evaluated regularly and addressed as appropriate. This case will be reviewed regularly in my supervision to assure that all issues are identified and addressed.

Janet’s only other legal concerns involve personal financial matters. These problems will be addressed as treatment issues in n effort to prevent these ongoing problems for this client.

DIVERSITY ISSUES:

Janet is Irish with strong ties to her sisters and her heritage.  The family reports a history of depression and alcohol abuse in parents as well as several aunts, uncles and cousins on both side of the family. The family understands the problem with alcohol in certain cases, but in general downplays the problem of alcohol. The explain the use of alcohol as a social norm in their family and humorously explain that as the result of their Irish heritage.
Working with this client will require and understanding of the family heritage as well as social and cultural norms. While client has not had an issue with alcohol or drugs to date, prevention oriented education is a necessary component of treatment.

PERSONAL REFLECTION

Janet is a bright, articulate likable person with many strengths. When she is following the prescribed treatment regimes, she clears quickly and does very well. She has had positive work experience. She has family and friends support. Her illness at times leads her to poor decisions that result in decompensate. Her strengths and likeability keep her in touch with the supports in her life. Janet will need to understand her illness and learn to use her strengths and support to maintain wellness and recovery. Janet’s prognosis is positive, though guarded. She has had enough success in her life to establish a pattern of well being. However, the severity of her illness makes recovery and stability difficult to maintain without compliance and support. Working with Janet will need to include building a strong support system and building on her intelligence and strengths to empower recovery.

Working with this client was a rewarding experience as the clients was motivated and interested in therapy, though her symptom logy made id difficult for her to fully understand the illness and need for treatment at times.

References

“301.83 Borderline Personality Disorder” in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. DOI: 10.1176/appi.books.9780890423349.3831. Retrieved on 2007-09-21.
(2004). Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR (Text Revision). Washington, DC: American Psychiatric Association. ISBN 0890420246. DSM-IV & DSM-IV-TR Borderline Personality Disorder criteria. BehaveNet.com. Retrieved on 2007-09-21.
“Borderline Personality Disorder DSM IV Criteria”. BPD Today. Retrieved on 2007-09-21.
http://en.wikipedia.org
 

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