Nursing– Case formulation

FORMULATION:

51 y.o M with h/o anxiety, depression, panic d/o, AUD, h/o PE on eliquis who

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was transferred from OSA on a 5150 for DTS for SI with plan to either overdose

or crash his car into a lake in the setting of heavy alcohol intoxication.

Current presentation consistent with alcohol induced mood disorder, notable for

SI in the context of heavy drinking and resolution of SI with sobriety. Patient

seems to have an underlying anxiety disorder, likely social anxiety disorder,

notable for feeling anxious when talking to people and giving presentations that

hindered advancement in his career, which he tries to treat with alcohol. He

also has an unspecified depressive disorder, notable for amotivation and

hopelessness, but does not meet criteria for MDD at this time. There is no

concern for psychosis or mania given history.

 

Plan to admit to psychiatry to get patient’s anxiety and depression under

control prior to engagement with a substance use program given he has been

unsuccessful in such programs in the past due to his anxiety. Patient consented

to starting lexapro, as there is less chance of sexual dysfunction side effect

with this SSRI compared to his previous med, Paxil. Will also order gabapentin

PRN for anxiety/alcohol cravings, consider uptitrating and making standing.

Patient was given librium for alcohol withdrawal at the OSH and WLA ED. Will

contiue librium taper as detailed below. Consider discharging to the

Domicilliary.

 

Patient benefits from inpatient hospitalization for stabilization, medication

initiation, and appropriate disposition planning. Will continue LPS hold for DTS

given unable to gather collateral tonight to safety plan.

 

work (prefers 1:1 therapy rather than group therapy if available), and even

longer residential stay for substance use treatment and continued detox at the

. No withdrawal symptoms, just mild tremor, no hx of DT/sz confirmed.

 

Insightful into his drinking being a core issue, as well as anxiety and

depression. Denies current SI, plan, intent, or ideation. Doesn’t remember a lot

of what he said to his ex-wife or daughter when he was drunk and saying

everything. Has no recollection of the phrases from his 5150 hold but does admit

that this has happened before and he has been held a few times and hospitalized

briefly (he states 3-4 times). Patient again mentions that he would like to

leave once his hold expires but is open, especially since we are helping him

detox with librium taper and ativan, to stay for treatment and safer discharge

planning voluntarily and does understand that we may extend his hold if we are

concerned for him, but he could contest that if he disagrees and we would

advocate for him staying voluntarily since his SI is resolved, he did not have

any plan/act on a plan at this admission or historically (confirmed with

collateral), and is engaged with treatment. Communicate with RN staff to help

patient get access to his phone such that he can check emails regarding status

of declaration of bankruptcy, since financial stressor and housing issues are

the source of his anxiety right now. Patient ammenable to staying voluntarily

tomorrow and would be open to a DOM consult as well as outpatient mental health

treatment per our recommendations. Confirm he is ammenable to being on lexapro

5mg and will keep us updated if any SE.

 

Other notes about PPHX:

Med trials: paxil in the 90’s, anxiety was essentially treated (40mg) but then

stopped working a few decades later, had sexual side effects (ED). also tried

and failed celexa, venlafaxine, seroquel.

SHx: He notes that during that same time (2010-ish) when depression meds stopped

working, he began drinking heavily, business with brother (aerospace, describes

very interesting jobs such as helping folger coffee design their lids to

missile/defense work) was going well but then stopped going as well. job loss

early this year followed by evicion 1/1/21.

Fhx: some anxiety

Symptoms:

– social anxiety that is crippling since childhood, didn’t like school or pursue

higher education despite being very bright (aerospace engineer, business with

brother), failed group therapy and AA multiple times, very nervous being on

inpatient unit, can’t sleep well

– depression: +amotivation, +anhedonia, +poor motivation, +low energy, +poor

concentration. Appetite is okay. Sleep is impaired due to alcohol use.

– alcohol:

-military history: served in the army, persian gulf war, noncombat, ’88-92, no

trauma exposure

– denies childhood trauma, neglect, or sexual/emotional abuse though concedes,

“there were ups and downs”

 

– ex wife, , patient cleared us to speak with her. Ex-wife clarifies

she is a nurse, knows patient very well, married from 1995-2005, has been in

contact with good relationship ever since, their extended families also in good

contact with both of them. Main challenges were alcohol use which she

understands, has helped him detox many times prior. Unfortunately, his

escalating use since around 2010-2013 meant that they had to part ways which has

been a very challenging thing for both of them.

– SOCIAL HISTORY/NATURE OF THIS EVENT OF SI: was texting wife that he just

wanted to die on the night that she called sherrif (texted her), drives truck

into lake, walk into freeway, and so forth. Family members have stopped

listening as this happens whenever he drinks. So far has never done it, but

family members also never know when he will do something. He also says some

hurtful things to family when drunk and ex-wife tells him “we’re not going to

see you until you’re sober”. Binge started on Friday (1/1/21), patient said “if

you don’t come see me I’ll take all my meds” and “am I so bad no one wants to

talk to me?” “I want to drive truck into lake”. Wife texting him, daughter

worried. Patient did not want suicide hotline to talk to him. Next step was to

do a welfare check. Sherrif then talked to family and evaluated patient which

took him to hospital. Per wife, this is usually how it goes, he drinks so much

no one will talk to him and then no one will talk to him anymore.

– SUICIDAL THOUGHTS: suicidal thoughts always come when he is bingeing on

alcohol, “not the first he has been on”

– DEPRESSION: mostly what patient describes, low motivation usually from

spiral/anxiety with worsening substance use.

– ANXIETY: anxiety is the major issue, has been anxious since childhood mostly

social, the alcohol helps to cope/self-medicating to tolerate anxiety,

depression in his 20-30’s, was stable and treated. Of note, patient spirals with

shame and embarassment when re-reading messages he sent while drunk. He has had

long standing anxiety ever since wife knows him, can get spiralled, embarassed.

Fails group therapy because he gets overhwhelmed listening to others’ problems

and hates sharing in front of groups to the point where he leaves. Has left AA

and other groups as a result.

– DEVELOPMENTAL/FORMATIVE HISTORY: very rough childhood growing up per wife,

mother had some emotional problems and took it out on the kids. Patient also has

a lot of guilt with not being involved in older child’s life (oldest daughter

from a previous relationship). Sensitive issue with him.

– SUICIDE ATTEMPTS: never per wife

– LETHAL MEANS: had shotgun when they were married but removed from house after

first hold. No knifes/opiates.

– ALCOHOL: drinking was heavy to begin with when they married 1 year of sobriety

around 4 years ago, major jump in drinking in 2013 which cause business started

to suffer. Also sober summer/thanksgiving-christmas, heavily drinking since

christmas eve with jack daniels bottles all over the place, over the last

weekend had to be out of his apartment due to the eviction, and he left

everything.

 

 

 

 

 

 

 

 

 

(beblow is an example of what is needed)

 

 

 

 

 

 

 

 

 

 

 

Case Conceptualization Paper

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Description of Problem

Jasmine is a 36 year old Caucasian female who presents to the clinic for psychotherapy. She states she has a successful, well-paying career for the past several years as a consultant for McKinsey & Company. Even though she has worked for the same, flourishing company for over 5 years, she’s found herself worrying constantly about losing her job and being unable to provide for her 2 toddler children. This worry has been troubling her for the past 7 months since her colleague and best friend was laid off from the same job. Despite her best efforts, she has not been able to shake the negative thoughts. Ever since the worry started, Jasmine has found herself feeling restless, tired, and tense. She often paces in her office when she is alone. She has even experienced several embarrassing moments in meetings where she has lost track of what she was trying to say. And when she goes to bed at night, it is as if her brain would not shut off and consequently she has trouble sleeping. She finds herself mentally rehearsing all the worse-case scenarios regarding losing her job, including ending up homeless and her children taken away from her. She is now agreeable to help, including medication, if necessary. She denies any thought of wanting to harm herself or others; and denies any visual and auditory hallucinations. Jasmine has psychiatric history of Generalized Anxiety Disorder.

The client’s vulnerabilities

Jasmine grew up with both parents in the house. She always felt she had to prove herself. Constantly seeking her father’s approval. She is the only child and always believed that her father wished he had a boy instead. She states “he always wanted me in sports and boyish activities. I never wanted to disappoint him which I guess created a lot of anxiety”. Jasmine states whenever she received praise from her daddy, her anxiety subsided. As she got older into her teens, education is more emphasized. Again, she wanted to please her parents so she spent less time with friends, and less time doing activity she enjoyed such as going out with friends. She states her parents were loving but she could not help but think they might not love her if she was not their “perfect” child. Jasmine was raised as a Christian Science which is the belief that prayers alone can cure all illnesses (mental or physical). They do not believe in labeling people with mental illness and/or taking psychiatric medication for extended period of time or even at all. She believes her mom suffered from anxiety but was never formally diagnosed. She remembers her mother worrying a lot and will talk about the same worse-case scenarios over and over. And when her mom was anxious, she had trouble concentrating and sleeping. Jasmine remembers when she was a senior in high school, her father lost his job as an administrator for a big company. As a result, her father became depressed. She states “he lost himself and I lost the strong father I knew”. She left for college and would drink alcohol to ease her anxiety. She never sought help. She did not want to be labeled as “crazy” and placed on medication for ‘crazy people” as sometimes she will often hear people say.

The client’s triggers

One of Jasmine’s colleagues at work, who happens to be her best friend was laid off “improper conduct” 7 months ago. She states no one saw it coming and it caught everyone by surprise. Since that particular incident, work has been more stressful. She feels as if all eyes are on her. She feels as though she has to work harder or else she would lose her job. Furthermore, because of her anxiety, she is not able to perform at a confident level resulting to performance anxiety. She has been drinking more caffeine than usual about 4 cups daily to stay awake. Consequently, the increase caffeine use result to jittery hands, palpitation and inability to get sound sleep. She then uses alcohol and over the counter sleep medication, Nyquil which does not help her stay asleep. Jasmine states she has decreased appetite and food seems unappealing. “I’m constantly worrying, thinking negative thoughts about losing my job, my kids and being homeless. And then I worry about my worries”.

Core Beliefs

Jasmine is afraid of success because she believes that “what goes up must come down. It is the rule of life”. She believes she is at the height of her career perhaps and now it is only a matter of time that she “drops” just like her best friend at work and others she believes has had the same fatal outcome. Jasmine believes there is “something wrong with me”. She feels like she can never get a break from her negative thought process. She states “I am flawed. It seems like I can never been happy or make others happy”. She states she has always felt this way since childhood believing that her father always wished she was a boy. She believes she suffers from low self-esteem. She has trouble developing close intimate relationship. For example, she states the reason why her 3 year old married failed was because it was easier to her not to connect fully to him than to connect and he see how really flawed she is. She believes he saw that “flaw” in her anyway. Jasmine believes “you have to be happy to be liked”. She believes having negative thoughts makes her “unlovable” and “nobody likes a worry wart”

The most central thoughts client is avoiding

Since her childhood, she has never felt that she was not good enough. She believed she was born the wrong sex because her father’s dream was to have a boy and her mother could not have more children. She constantly sought the approval of her father and others. She never fully was validated and therefore would worry a lot thinking others did not like her or see her as good enough. She remembers having to work extra hard at her current job. She states she has to struggle for everything in her life. And even she has to work extra hard to relate to others. She remembers having a decent childhood and her dad having success career, marriage until her father lost his job.

 

Differential Diagnosis

Social Anxiety Disorder

According to the DSM-5, (Diagnostic and Statistical Manual of Mental Disorders, fifth edition), there are a total of ten diagnostic criteria for Social Anxiety disorder:

The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.

 

Adjustment Disorder with anxiety DSM 5 criteria (Adjustment Disorder, 2019)

A. The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s).

B. These symptoms or behaviors are clinically significant, as evidenced by one or both of the following:

Marked distress that is out of proportion to the severity or intensity of the stressor, taking into account the external context and the cultural factors that might influence symptom severity and presentation.
Significant impairment in social, occupational, or other important areas of functioning.

C. The stress-related disturbance does not meet the criteria for another mental disorder and is not merely an exacerbation of a preexisting mental disorder.

D. The symptoms do not represent normal bereavement.

E. Once the stressor or its consequences have terminated, the symptoms do not persist for more than an additional 6 months.

 

Diagnosis

Generalized Anxiety Disorder

Patient appears to have Generalized Anxiety Disorder (GAD) as evidenced by persistent excessive anxiety about many aspects of her life and having difficulty controlling her worrying for 8 months about losing her job and ability to care for her children. There is no specific threat present and it is disproportionate to the actual risk. She is anxious most of her waking hours. She has at least 3 of the symptoms associated with GAD affecting her physically and cognitively. She expresses somatic complaints such as restlessness, tense and fatigue. She experiences impaired concentration at work, her mind going blank and losing her train of thought. She has trouble falling sleeping because she is unable to shut her mind down at night ruminating on the worse as scenario of losing her job. As a result she is more fatigued than usual.

Her symptoms are not caused by a direct effect of a substance or another mental disorder or medical condition. Her symptoms cause significant social and occupational dysfunction.

Coping strategies

Jasmine states she drinks beer to cope with her anxiety. She states it has been a habit to drink a minimal of one or two beers before going to bed. She states it worked for a while, at least she could sleep. But now, drinking is not working anymore and I don’t want to go to work drunk. She states she has tried to be responsible with her drinking. She never drinks in front of the kids and never let alcohol affect her job. She mentioned walking, doing some deep breathing activities, and guided imagery she discovered on the internet but does not find any of them beneficial anymore.

 

Treatment plan

The most effective treatment approach combines psychotherapy and pharmacotherapy. Cognitive Behavioral Therapy (CBT) is the gold standard of psychotherapy and one of the most popular treatments for Generalized Anxiety Disorder (GAD). The overall goal is to frequency, intensity, and duration of the anxiety so that daily functioning is not impaired. With 12 weeks, there are numerous objectives alongside interventions developed to aid Jasmine in reducing or alleviating her anxiety. She will learn and implement coping skills that result in a reduction of anxiety and worry, and improved daily functioning. This will be achieved by teaching calming and relaxation skills such as applied relaxation, progressive muscle relaxation, cue-controlled relaxation; mindful breathing; biofeedback and how to discriminate better between relaxation and tension. With the advent of smartphone technology and the rising popularity of interactive applications, Jasmine can benefit from the electronic self-help options that deliver programs informed by evidence-based GAD treatment. There are also applications available with circumscribed, do-it-yourself anxiety-busting tools, like relaxation techniques and mindfulness meditation exercises. She will be taught how to apply these skills to her daily life. To measure progress, Jasmine will be assigned homework each session in which she will practice relaxation exercises daily, gradually applying them progressively from non-anxiety provoking to anxiety-provoking situations. The staff will then review and reinforce success while providing corrective feedback toward improvement.

Jasmine will learn and implement a strategy to limit the association between various environmental settings and worry, delaying the worry until a designated “worry time. She will be taught how to recognize, stop, and postpone worry to the agreed-upon worry time using skills such as thought stopping, relaxation, and redirecting attention. Jasmine will be encouraged to use this skill in daily life. The staff review and reinforce success while providing corrective feedback toward improvement. Jasmine will be able to verbalize an understanding of the role that cognitive biases play in excessive irrational worry and persistent anxiety symptoms. The staff will assist Jasmine in analyzing her worries by examining potential biases such as the probability of the negative expectation occurring, the real consequences of it occurring, her ability to control the outcome, the worst possible outcome, and her ability to accept it. Jasmine will be taught to identify, challenge, and replace biased, fearful self-talk with positive, realistic, and empowering self-talk. Staff will explore jasmine schema and self-talk that mediate her fear response; and assist her in challenging the biases; and replacing the distorted messages with reality-based alternatives and positive, realistic self-talk that will increase her self confidence in coping with irrational fears. Jasmine will be assigned a homework exercise in which she identifies fearful self-talk, identifies biases in the self-talk, generates alternatives, and tests through behavioral experiments.

Other Modality of therapy will explored such as Acceptance and Commitment Therapy (ACT) which is another present- and problem-focused talk therapy used to treat GAD. Although similar to CBT, the goal of ACT is to reduce the struggle to control anxious thoughts or uncomfortable sensations and increase involvement in meaningful activities that align with chosen life value. Psychodynamic psychotherapy, also known as insight-oriented therapy is another modality that can be explored. It is based on the idea that thoughts and emotions that are outside of our consciousness (i.e., outside of our awareness) can lead to internal conflict and manifest as anxiety. Psychopharmacology works will with psychotherapy. Jasmine is agreeable to medication and will be prescribed Lexapro 10 mg daily. Lexapro is a SSRI. SSRI stands for Selective Serotonin Reuptake Inhibitor. SSRI antidepressants are a type of antidepressant that work by increasing levels of serotonin within the brain. Serotonin is a neurotransmitter that is often referred to as the “feel good hormone”. It carries messages between brain cells and contributes to well-being, good mood, appetite, as well as helping to regulate the body’s sleep-wake cycle and internal clock. SSRIs increase levels of serotonin in the brain by preventing the reuptake of serotonin by nerves. Having more serotonin available in the nerve synapse means that it can transmit messages easier (Fookes, 2018). Jasmine will return weekly for treatment assessment and effectiveness.

 

 

 

 

 

 

 

 

 

 

 

 

 

References

 

Adjustment Disorders (2019). Traumadissociation.com. Retrieved from:

http://traumadissociation.com/adjustment.

American Psychiatric Association. (2013). Social Anxiety Disorder. Diagnostic and Statistical

Manual of Mental Disorders. (5th Edition). Washington, DC.

Generalized Anxiety Disorder Treatment (2019). Retrieved from:

https://www.verywellmind.com/generalized-anxiety-disorder-treatment-4157244

Fookes, C. (2018). Selective Serotonin reuptake inhibitor. Retrieved from:

https://www.drugs.com/drug-class/ssri-antidepressants.html

SAMPLE TREATMENT PLAN ANXIETY. Retrieved from

https://kapost-files-prod.s3.amazonaws.com/published/554a8479b20fa4d878000078/sample-treatment-plan.pdf

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