Psychological Disorders and Treatments

PSYCHOLOGICAL CASE STUDIES 11

Psychological Disorders and Treatments

Paul Anthony Vitti

Kaplan University

A patient that is of 29 years old, we will call her Desirae to protect her identity as well as her right to confidentiality, walks into my office complaining of having problems for the last two months, in her life, to where she is having an identity crisis where she feels like she is a man trapped inside of a woman’s body. She does not know if she is considered a homosexual due to this problem. All that she knows is that she has a strong attraction to the same sex. This problem is causing her fear in her life because she is married to a man for ten years and has produced a child during her marriage to this man. She has yet to act upon her attraction to the same sex but feels a strong pulling towards experimenting with the attraction. Because she has yet tried to experiment with her attraction to the same sex, it is causing her stress in her life with her marriage because she has chosen to not have sexual intercourse with her husband and has refused him on several occasions. She is having trouble focusing on her everyday schedule due to the attraction to wanting to explore this new life style. She has even had times where she has seen a woman approach her and talk to her in a very seductive manner and then start to undress her, even though this felt real she knew that she was hallucinating this person. Due to these feelings she is having problems with dealing with here day to day habits such as eating, sleeping, and keeping up on her hygiene.

After listening to my patient, I realized that she could possibly have a comorbid diagnoses of Schizophrenia with an Anxiety Disorder, but I wanted to test here first to get a proper diagnosis. The DSM-IV T.R. states that a person who is exhibiting signs or symptoms of schizophrenia has hallucinations, delusions, gender identity problems, such as fears of being thought as a homosexual, and stress can worsen the symptoms she is exhibiting. The patient does not however exhibit or complain to having other symptoms which can be associated with schizophrenia disorder. These other symptoms are incoherence, loose associations, flat or grossly inappropriate affect, and catatonic or grossly disorganized behavior. I did ask the patient if she was having thoughts or plans of suicide, to which the patient denied any plans or thoughts of suicide.

The criteria in the DSM-IV T.R. states the following:

“Schizophrenia is a disorder that lasts for at least 6 months and includes at least

1 month of active-phase symptoms (i.e., two [or more] of the following: delusions,

hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative

symptoms). Definitions for the Schizophrenia 5ubt}'pes (Paranoid, Disorganized,

Catatonic, Undifferentiated, and Residual).” (American Psychiatric Association, 2000, pg. 325)

I then put my patient through the following testing to see if the results would be conclusive to my pre-determined diagnoses of an Axis I: Anxiety Disorder and an Axis II: Schizophrenia Disorder. The testing that I conducted was administrating a clinical diagnoses which would help to develop the historical information and a thorough mental status examination. Then I submitted a “laboratory test and a routine battery test which ruled out any possible organic etiologies, including CBC, urinalysis, liver function tests, thyroid function test, RPR, HIV test, serum ceruloplasmin (which rules out an inherited disease, Wilson’s disease, in which the body retains excessive amounts of copper), PET scan, CT scan, and MRI. Rating scale assessment: Scale for the assessment of negative symptoms. Scale for the assessment of positive symptoms. Brief psychiatric rating scale.” (Nurse labs, 2012, pg. 1) All of these tests where administered to determine that schizophrenia would be the proper diagnoses for this patient.

After concluding my testing and verifying my pre-diagnosis of an Axis I: Anxiety Disorder and an Axis II: Schizophrenia Disorder I decided to speak to my patient about here treatment options. I explained to my patient that there is currently no method for preventing schizophrenia and that there is no cure for it. Since we have caught the schizophrenia early we can minimize the impact of the disease with pharmacological and psychosocial treatments. I also explained to her that if one of her episodes is acute then she may need to be hospitalized to stabilize her, depending on the severity of course. I also told her that we would need to set up an outpatient treatment plan for counseling, this would help her to minimize her symptoms and to maximize her quality of life. The comprehensive treatment plan that I had produced consisted of an: “Antipsychotic medication Education & support, for both ill individuals and families Social skills training Rehabilitation to improve activities of daily living Vocational and recreational support Cognitive therapy Medication is one of the cornerstones of treatment.” (Nurse labs, 2012, pg. 1) I also explained to my patient that she would need to take her medication indefinitely, this is because “vulnerability to psychosis doesn’t go away, even though some or all of the symptoms do.” (Nurse labs, 2012, pg. 1) I also stressed to my patient the need of treatment in a psychosocial program and the initiatives combined with her medication which could be more effective in treating and managing her disorder.

I would have to say that the typical treatment therapy used for this type of disorder would be Behavioral Therapy but I have chosen to take the Humanistic approach in my treatment of this patient, The reason that I have chosen to use Humanistic Therapy is because it deals with the basis that “ people develop psychological problems when they are burdened by limits and expectations placed on them by themselves and others, and the treatment emphasizes the person’s capacity for self-realization and fulfillment.” (Stangor, 2010, pg. 405) The reason why I have chosen to use this form of therapy is because my patient has a gender identity problem. Even though she may feel like a man trapped in a woman’s body, I do not want to negatively influence her to make a decision on her sexual orientation. I would like to help her to come to terms what is good for her depending on her choices. Even if she chooses to leave her husband and pursue a relationship with a member of the same sex I would support her in this decision. The whole point is to provide guidance and understanding to the patient based upon her decision given. If I was to burden my patient by telling her that she should stay with her husband and lead a life that she is not happy with because of her sexual choices then I would be like everyone else she has been around who don’t support her decisions. If exploring the sexual fantasies that she is having will help her in her treatment to get better then, yes I would support her.

As for the ethical obligations when it comes to selecting the best treatment, I would first follow the “10.01 Informed Consent to Therapy by (a) obtaining informed consent to therapy as required in Standard 3.10, Informed Consent, psychologists inform clients/patients as early as is feasible in the therapeutic relationship about the nature and anticipated course of therapy, fees, involvement of third parties, and limits of confidentiality and provide sufficient opportunity for the client/ patient to ask questions and receive answers. (See also Standards 4.02, Discussing the Limits of Confidentiality, and 6.04, Fees and Financial Arrangements.) (b) When obtaining informed consent for treatment for which generally recognized techniques and procedures have not been established, psychologists inform their clients/ patients of the developing nature of the treatment, the potential risks involved, alternative treatments that may be available, and the voluntary nature of their participation. (See also Standards 2.01e, Boundaries of Competence, and 3.10, Informed Consent.)” (American Psychological Association, 2010, pg. 13).

A second patient age 34, we will call him Thomas to protect his identity and his confidentiality, walked in to my office complaining of having problems with constantly checking the locks on his door, counting the many bricks that makes up his living room wall over and over, he has an extensive fear of germs to where he uses a handkerchief to touch object or to shake hands with a person, and he often repeatedly washes his hands to ward off infection.

After talking with this patient I made a pre-diagnosis that this patient was suffering from (OCD) Obsessive –Compulsive Disorder and Anxiety. I then looked up the symptoms inside of the DSM-IV T.R. to determine if I was correct to assume that this was his problem. The DSM-IV T.R. stated the following information:

“A. Either obsessions or compulsions:

Obsessions as defined by (1), (2), (3), and (4):

(1) recurrent and persistent thoughts, impulses, or images that are experienced, at

sometime during the disturbance, as intrusive and inappropriate and that cause

marked anxiety or distress

(2) the thoughts, impulses, or images are not simply excessive worries about real life

problems

(3) the person attempts to ignore or suppress such thoughts, impulses, or images,

or to neutralize them with some other thought or action

(4) the person recognizes that the obsessional thoughts, impulses, or images are

a product of his or her own mind (not imposed from without as in thought in section)

Compulsions as defined by (1) and (2):

(1) repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts

(e.g., praying, counting, repeating words silently) that the person feels driven

to perform in response to an obsession, or according to rules that must be applied

rigidly

(2) the behaviors or mental acts are aimed at preventing or reducing distress or preventing

some dreaded event or situation; however, these behaviors or mental

acts either are not connected in a realistic way with what they are designed to

neutralize or prevent or are clearly excessive

8. At some point during the course of the disorder, the person has recognized that the

obsessions or compulsions are excessive or unreasonable. Note: This does not apply

to children.

C. The obsessions or compulsions cause marked distress, are time consuming (take more

than 1 hour a day), or significantly interfere with the person's normal routine,

occupational (or academic) functioning, or usual social activities or relationships.

D. If another Axis I disorder is present, the content of the obsessions or compulsions is

not restricted to it (e.g. ... preoccupation with food in the presence of an Eating Disorder;

hair pulling in the presence of Trichotillomania; concern with appearance in the

presence of Body Dysmorphic Disorder; preoccupation with drugs in the presence of

a Substance Use Disorder; preoccupation with having a serious ill ness in the presence

of Hypochondriasis; preoccupation with sexual urges or fantasies in the presence of

a Paraphilia; or guilty ruminations in the presence of Major Depressive Disorder).

E. The disturbance is not due to the direct physiological effects of a substance (e.g... a

drug of abuse, a medication) or a general medical condition.” (American Psychiatric

Association, 2000, pg. 462-463)

I then decided to run some tests to determine if my pre-diagnosis was correct. The tests that I administered was a physical exam to rule out any physical causes, and a psychiatric evaluation of the Yale-Brown Obsessive Compulsive Scale (YBOCS) so that I can diagnose the pre-diagnosed OCD properly and track the progress of treatment at a later date. After running these tests my conclusion is that the patient is suffering from Obsessive Compulsion Disorder.

After concluding my testing and verifying my pre-diagnosis of an Axis I: Anxiety Disorder and an Axis I: Obsessive Compulsive Disorder I decided to speak to my patient about his treatment options. I then explained to my patient what Obsessive Compulsive Disorder is and that it can be treated with medication and therapy.

The therapy that I decided would help my patient best with his disorder is Psychodynamic Therapy. This therapy would help my patient to realize why he is acting the way he is and to make him aware of how to control his obsessions. “The Psychodynamic Therapy is a psychological treatment in which the therapist helps the patient explore the unconscious dynamics of personality.” (Stangor, 2010, pg. 404) This type of therapy will be most helpful for me, as well to find out what triggers the patient to be obsessive over a thing by listening to him explain everything in his own words about his condition.

As for the ethical obligations when it comes to selecting the best treatment, Again I would follow the “10.01 Informed Consent to Therapy by (a) obtaining informed consent to therapy as required in Standard 3.10, Informed Consent, psychologists inform clients/patients as early as is feasible in the therapeutic relationship about the nature and anticipated course of therapy, fees, involvement of third parties, and limits of confidentiality and provide sufficient opportunity for the client/ patient to ask questions and receive answers. (See also Standards 4.02, Discussing the Limits of Confidentiality, and 6.04, Fees and Financial Arrangements.) (b) When obtaining informed consent for treatment for which generally recognized techniques and procedures have not been established, psychologists inform their clients/ patients of the developing nature of the treatment, the potential risks involved, alternative treatments that may be available, and the voluntary nature of their participation. (See also Standards 2.01e, Boundaries of Competence, and 3.10, Informed Consent.)” (American Psychological Association, 2010, pg. 13)