NURS 6640: Psychotherapy with Individuals
Week 10: Case Study
IDENTIFICATION: The patient is a 69-year-old, widowed African American male who is the father of one adult child and grandfather of six grandchildren. The patient is self-referred to a psychiatric outpatient clinic.
CHIEF COMPLAINT: “I need help with depression and anxiety.
HISTORY OF CHIEF COMPLAINT: The patient reports that his father is dying, and he has been experiencing worsening of depression and anxiety symptoms over the past few months. He is seeking a psychiatric evaluation at his son’s advice. The patient does not enjoy being with his family.
He has difficulty falling asleep, but then spends the day lying on the couch and reports feeling like he is “moving in slow motion.” He reports feeling tired all the time. He has also stopped going to his volunteer job at the nursing home.
He responded to the practitioner’s question of “why depressed now?” by saying that with the imminent death of his father, he is losing his main support. In addition to his father’s illness, the patient was diagnosed and treated for prostate cancer this year. He received psychotherapy at that time which focused on his anxiety about the diagnosis, his denial of its severity, his wish to “not know what he knew,” and, ultimately, end-of-life issues.
PAST PSYCHIATRIC HISTORY: The patient was never hospitalized for psychiatric reasons. He has no history of suicidal thoughts, gestures, or attempts. The patient described either a partial or negative response from several medications he had been prescribed from his primary care provider (PCP) over the course of a several years, including Effexor, Prozac, Zoloft Lexapro and Duloxetine.
He is currently prescribed Lorazeapm 1 mg BID by his PCP which he has been taking for several years.
MEDICAL HISTORY: GERD, HTN and hyperlipidemia. History of prostate cancer.
HISTORY OF DRUG OR ALCOHOL ABUSE: The patient denies history of drug and alcohol abuse.
FAMILY PSYCHIATRIC HISTORY: Patient reports that his mother had depression. He is an only child and does not recall any emotional difficulties in grandparents or other relatives.
Perinatal: No known perinatal complications.
TRAUMA/ABUSE HISTORY: Denies
Mental Status Examination
Appearance: Well-groomed, appropriately dressed, older Gentleman who is obese
Behavior and psychomotor activity: Good eye contact, pleasant, cooperative. Slightly unsteady gait uses walker.
Consciousness: Alert and able to answer all questions appropriately.
Orientation: Oriented to person, place, time, and situation.
Memory: Intact. Good recent and remote memory.
Concentration and attention: Appears to have good concentration during the interview but reports that he has recently had trouble concentrating while reading.
Visuospatial ability: Not formally assessed.
Abstract thought: Within normal limits, appropriate use of metaphors.
Intellectual functioning: Patient has master’s degree
Speech and language: Normal rate and rhythm.
Perceptions: No abnormalities present.
Thought processes: Goal directed, but evidence of guilt and rumination consistent with depressive symptomatology.
Thought content: Patient is highly anxious and expresses thoughts of sadness, frustration. He is preoccupied with thoughts about the anticipated loss of his father.
Mood: Depressed and anxious.
Affect: Congruent with mood.
Impulse control: Good.
Discussion: Therapy with Older Adults
Clients who are older have often times been dealing with their mental health disorder their entire lives, whiles other disorders may be brought on through the aging process or the trauma of losing a lifelong partner. Treatment can be challenging for both the client and the therapist. For this Discussion, you will focus on therapeutic approaches for an older adult presented in a case study.
• Assess clients presenting with depression
• Analyze therapeutic approaches for treating clients presenting with depression
• Evaluate outcomes for clients presenting with depression
To prepare: •
• Download and review the Week 10: Case Study from this week’s Learning Resources.
• Review this week’s Learning Resources and reflect on the insights they provide.
Post a treatment plan for the older adult client in the Week 10: Case Study found in this week’s Learning Resources. Be sure to address the following in your post:
• Which diagnosis should be considered?
• What is the DSM-V Coding for the diagnosis you are considering?
• What is your rationale for the diagnosis? Be sure and link the client’s signs and symptoms to the DSM-V diagnostic criteria to support your diagnosis.
• What tests or tools should be considered to help identify the correct diagnosis?
• What differential diagnosis should be considered?
• What Treatment Strategy would you recommend?
• What treatment would you prescribe and what is the rationale?
• Diagnostic Tests
• What standard guidelines would you use to treat or assess this patient?
• Clinical Note: Is depression a normal part of aging?
Support your approach with evidence-based literature.
APA 7th Edition Note
NOTE: Walden University currently uses the seventh edition of the Publication Manual of the American Psychological Association (APA) as the accepted standard for citations, references, and writing style guidelines. This course was developed when APA’s sixth edition was the standard, and we are in the process of making any necessary updates to the course content. Please be sure to consult the seventh edition of the APA manual, as well as the Walden Writing Center’s APA resources, for all your written assignments.
All references require creditable sources, nothing less than 5 years. References require APA 7th edition http. Please add conclusion.
Therapy with Older Adults
Older adults are at risk of depression and anxiety disorders, although it is not a normal part of the aging process. The case study indicates that the patient is worried about his father’s imminent death, who is the main source of support. The diagnosis for the condition is GAD, whose symptoms rhymes with the conditions the client is experiencing. The condition for the condition is DSM-5 300.02 (F41.1). Diagnosis of the condition involves screening tools, including GAD-7 and GADQ-IV (Gottschalk & Domschke, 2017). The differential diagnosis for the patient is GAD, MDD, and panic disorders. The treatment strategy will involve both pharmacological and non-pharmacological approaches. The best medication for GAD is Zoloft, while cognitive behavior therapy will help reduce anxiety levels. Educating the patient about the condition will improve compliance and help them cope with the illness. The paper aims to examine the case study of a 69-year-old, widowed African American male and prescribe effective treatment.
The information presented about the patient shows the elderly adult patient is suffering from Generalized Anxiety Disorder (GAD).
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) coding for GAD is DSM-5 300.02 (F41.1) (Gottschalk & Domschke, 2017).
Rationale for Diagnosis
The rationale for the diagnosis is the similarity of the symptoms and the DSM-5 criteria for GAD. The symptoms include anticipating disaster, constant worry, restlessness, and trouble sleeping (Gottschalk & Domschke, 2017). People with GAD also experience massive thoughts about their future that affects their ability to participate in daily lives or enjoy social relationships (Boehlen et al., 2020). The elderly patient is worried about losing his father, who is the main support system. The worry also occupies him until he cannot sleep well and spends the day lying on the couch. He stopped going to a nursing home where he was volunteering. The anxiety is hindering him from participating in daily activities. Additionally, the patient is not interested in spending time with the family. The symptom shows his preoccupation with his father’s anticipated loss leads to poor social relations with family members.
Tests and Tools for Diagnosis
Different diagnostic tests and tools are effective in examining patients for GAD. Some of the screening tools include GAD-7 and GADQ-IV (Boehlen et al., 2020). The tools contain a list of questions that help determine the severity of the symptoms of patients. The detailed psychological questionnaires focus on the symptoms and medical history (Boehlen et al., 2020). Psychotherapists should also utilize the DSM-5 criteria to check for similarities of the symptoms and the screening tool.
GAD – The mental health problem occurs due to persistent worry about various elements of life. Patients also anticipate danger or loss that will significantly impact their lives (Domènech-Abella et al., 2019). They are also preoccupied with worry leading to a lack of interest in daily activities. Patients also experience trouble sleeping. In some cases, patients experience fatigue, nausea, diarrhea, irritability, trembling, and nervousness (Domènech-Abella et al., 2019). The major cause is persistent worry about personal life or family issues. The condition is common among older adults leading to memory problems and poor quality of life. The condition can occur with other health conditions.
Major Depressive Disorder (MDD) – It involves a feeling of sadness when a person passes away, or a life-changing event occurs. The condition is also referred to as clinical depression, which can affect multiple areas of life (Domènech-Abella et al., 2019). For example, it affects individuals’ mood and behavior, including sadness, despair, and low moods due to the inability to maintain mood stability. Although the causes are not clear, stress and genetic factors can affect brain chemistry (Hoge et al., 2018). People with MDD feel hopeless, frustrated, irritable, lose interest in daily activities, and have poor sleep patterns.
Panic Disorder – People with panic disorder experience fear of loss or impending groom, sweating, rapid heart rate, shortness of breath, and chills. Some of the major causes are losing a loved one, job loss, or diagnosis with a major health condition (Hoge et al., 2018). Other causes include significant changes in life or major events such as divorce or sexual assault. It affects personal lives and undermines the ability to participate in daily activities such as working or socializing (Hoge et al., 2018). Family history can also increase the risk of panic disorder.
The treatment strategy will involve both pharmacological and non-pharmacological approaches. The non-pharmacological approach involves psychological counseling that involves talking to a counselor to reduce anxiety (Gottschalk & Domschke, 2017). For instance, cognitive behavior therapy is an important approach since it helps patients change their thinking patterns. Changing the patterns and emotions reduces worry.
The patient also requires medication, including Zoloft, under the category of Selective serotonin reuptake inhibitors. The drugs are effective in reducing worry among elderly patients. The patient should take Zoloft 25mg during breakfast (Boehlen et al., 2020). The patient should avoid combining the drug with other medications.
A combination of pharmacological and non-pharmacological approaches is effective in addressing mental health disorders. Evidence-based practice shows that patients have better results when utilizing both methods (Boehlen et al., 2020). Cognitive behavior therapy is effective for the elderly patient who needs to restructure their thinking patterns.
The patient should start taking Zoloft 25mg during breakfast. The provider may increase the dose in the next clinic, depending on the outcomes (Boehlen et al., 2020). The patient should not take the medication alongside other mental health drugs to avoid adverse reactions.
The treatment option should observe safety guidelines since the patient is elderly. The initial dose will be Zoloft 25mg since it is recommended as the lowest dose patients can take (Domènech-Abella et al., 2019). Depending on the outcomes in the subsequent clinic, a higher dose may be recommended.
Zoloft is in the category of drugs called Selective Serotonin Reuptake Inhibitors (SSRIs). They prevent serotonin’s uptake, thus increasing serotonin concentration within the nerve synapse (Domènech-Abella et al., 2019). The action improves mood, appetite, sleep quality, and interest in daily activities. It also makes a person less afraid.
Therapists diagnose GAD with mental health screening. The screening involves asking questions to examine medical history (Hoge et al., 2018). For instance, Generalised Anxiety Disorder Assessment (GAD-7) is a seven-item instrument used to examine the severity of symptoms. The tool has quality results that depict reliability, factorial and procedural validity (Hoge et al., 2018). The scoring involves 0-21. People with 0-5 have mild or moderate symptoms, while those with over 10 scores require further evaluation.
Cognitive behavior therapy is the best medication for GAD. The patient will meet a therapist for several sessions to address the mental disorder (Gottschalk & Domschke, 2017). The provider should refer the patient to counseling.
Psychoeducation is essential for mental health patients to help them cope with the illness and enhance treatment adherence. It will provide skills and resources in an emphatic and supportive environment (Gottschalk & Domschke, 2017). It will comprise briefing the patient about the illness, communication, problem-solving, and self-assertiveness training.
Standard Guidelines for Treatment
The first line of treatment for GAD is selective serotonin reuptake inhibitors. Evidence-based practice shows that SSRIs are effective in addressing anxiety problems. The medication should also be combined with cognitive behavior therapy to increase recovery chances (Boehlen et al., 2020). The pharmacological and non-pharmacological approaches also address multiple problems that occur as a result of anxiety disorder. Psychoeducation
Psychoeducation is critical for mental health patients to help them cope with their illness and adhere to treatment. It will provide skills and resources in a positive and encouraging environment (Gottschalk & Domschke, 2017). It will include informing the patient about the illness, as well as communication, problem-solving, and self-esteem training.
Standard Treatment Guidelines
Selective serotonin reuptake inhibitors are the first-line treatment for GAD. Evidence-based practice indicates that SSRIs are effective in treating anxiety disorders. To improve recovery chances, the medication should be combined with cognitive behavioral therapy (Boehlen et al., 2020). The pharmacological and non-pharmacological approaches address a variety of issues that arise as a result of anxiety disorder.
Depression and Aging
Although older adults are at risk of depression, it is not a normal part of aging. According to the Center for Disease Control (CDC), it is not automatic for older adults to suffer from depression (Boehlen et al., 2020). Older adults should get a comprehensive medical check to ensure any mental condition is identified early before it severely undermines life quality.
Anxiety is a common mental disorder among patients due to the fear of negative occurrences in their lives. Worrying leads to the negative thoughts of how life will change if a close relative dies or loses their jobs. Although depression is not a normal part of aging, the CDC indicates that high depression cases occur among older adults. The case study of the 69-year-old, widowed African American male shows he is suffering from GAD. The condition presents various symptoms, including persistent worry and lack of interest in daily activities. Diagnosis of the condition involves screening tools, including GAD-7 and GADQ-IV. Treatment involves pharmacological and non-pharmacological approaches, including Zoloft and cognitive behavior therapy, respectively. Patient education is essential to improve compliance, coping skills, and prevent future mental conditions from reoccurring.
Boehlen, F. H., Herzog, W., Schellberg, D., Maatouk, I., Schoettker, B., Brenner, H., & Wild, B. (2020). Gender-specific predictors of generalized anxiety disorder symptoms in older adults: Results of a large population-based study. Journal of Affective Disorders, 262, 174-181. https://doi.org/10.1016/j.jad.2019.10.025
Domènech-Abella, J., Mundó, J., Haro, J. M., & Rubio-Valera, M. (2019). Anxiety, depression, loneliness and social network in the elderly: Longitudinal associations from The Irish Longitudinal Study on Ageing (TILDA). Journal of Affective Disorders, 246, 82-88. https://doi.org/10.1016/j.jad.2018.12.043
Gottschalk, M. G., & Domschke, K. (2017). Genetics of generalized anxiety disorder and related traits. Dialogues in Clinical Neuroscience, 19(2), 159. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5573560/
Hoge, E. A., Bui, E., Palitz, S. A., Schwarz, N. R., Owens, M. E., Johnston, J. M., … & Simon, N. M. (2018). The effect of mindfulness meditation training on biological acute stress responses in generalized anxiety disorder. Psychiatry Research, 262, 328-332. https://doi.org/10.1016/j.psychres.2017.01.006
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