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Case Study: Diagnosis and Treatment of Susan

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This paper is a treatment recommendation for a patient Susan who suffers from major ...... More...
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Paper Abstract:
This paper is a treatment recommendation for a female patient who suffers from major depressive disorder and borderline personality disorder complicated by alcohol abuse and childhood sexual abuse. Two treatment options are offered, cognitive therapy and cognitive behavior therapy (CBT).

Paper Introduction:
Case Study Diagnosis and Treatment of Susan Laurie A Hicks Langston University Tulsa Oklahoma December Recurrent Major Depressive Disorder is characterized by periodic MajorDepressive Episodes that manifest in the form of a depressed or irritablemood or a loss of interest or pleasure in all or almost all activities that is relatively persistent occurring most of nearly every day withina two-week period DSM-III-R In Susan\'s case the depression isconcurrent with cocaine and alcohol dependence with Susan using anincreasing amount of cocaine to achieve

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The use of the SUD scale would be a helpful tool for Susan to use tobegin quantifying the level of distress she is feeling so that she candetermine appropriate responses. Both cognitive therapy and behavior therapy are good choices forSusan's condition, offering a variety of options from which to choose totailor her therapy precisely to her specific needs and situation. (2 2). The cognitivesymptom area is further broken down into deficits and bias; deficitsinclude confusion, short- and long-term memory deficits, and attentionaldeficits, while bias includes self-focused attention, negative memory bias,hopelessness, helplessness, and worthlessness (Westermeyer). Computer-assisted cognitive therapy would be a good treatment optionfor the depression, as there is consistent evidence that it promotes thedurability of treatment effects during the uncontrolled follow-up interval,with patients maintaining the ground they gained during treatment (Wrightet al., 1161). (1998). (1996). The association between theinvestigation by Child Protective Services and her own molestation islikely the key to her unresolved depression and the myriad symptoms she hascomplained of, since she has only recently begun remembering hermolestation. Engaging Susan in these types of "homework," or self-therapytechniques, would empower her to overcome some of the dependency that shehas evinced and give her more control over her own thoughts, words, andresponses. Journal of Counseling and Development, 8 (3).Practice Guideline for the Treatment of Patients with Borderline Personality Disorder . Patients like Susan who have losttheir jobs may conclude, "I'm a loser; I'm unemployable," and these self-statements will contribute to her emotional symptoms of sadness, guilt, anddepression, possibly manifesting in physical symptoms such as insomnia,behavioral symptoms such as staying in bed all day, and cognitive symptomssuch as difficulty with concentration (Westermeyer). Annual Review of Psychology, 47. Washington, DC: Author.Brewin, C.R. Cognitive Therapy for the Suicidal Patient: A Case Study. Retrieved on December 9, 2 5 from: mt=2&VInst=PROD&VType=PQD&RQT=3 9&VName=PQD&TS=11341716 9&clientId=1112 3Westermeyer, R.W. Emotional symptoms wouldbe such things as sadness, loneliness, guilt, shame, and anhedonia(Westermeyer). Homework also allows the patient to beginincorporating practical changes into her everyday life, taking her therapyout of the realm of the therapist's office and making it part of her ownlifestyle. Retrieved on December 1 , 2 5 from:, J.M. Computer-Assisted Cognitive Therapy for Depression: Maintaining Efficacy While Reducing Therapist Time. Retrieved on December 9, 2 5 from:, E. Although all of these options hold some promisefor use in Susan's case, as a literate patient-a former registered nurse-she is a good candidate for bibliotherapy, the use of the SUD scale, andthe keeping of a mood diary. Making Optimal Use of Homework to Enhance Your Therapeutic Effectiveness. A Primer on Suicidology: Implications for Counselors. Perspectives in Psychiatric Care, 34(4). CBT "for anxiety and depressive disorders is well established as apromising and frequently effective treatment" (Brewin, 33). Cognitive therapy works by breaking depression down into its fourgeneral symptom categories-physical, emotional, behavioral, and cognitive-so that its various aspects can be identified (Westermeyer). The Language of Feeling and the Feeling of Anxiety: Contributions of the Behaviorisms toward Understanding the Function-Altering Effects of Language. In Susan's case, the depression isconcurrent with cocaine and alcohol dependence, with Susan using anincreasing amount of cocaine to achieve numbness "so that nothing matters.Comorbidity of other disorders such as mood and substance-related disordersis typical with Borderline Personality Disorder, Susan's Axis IIclassification ("Practice Guideline for the Treatment of Patients withBorderline Personality Disorder"). (2 ). Brewin'sCBT approach empowers the therapist to "directly alter the contents challenging automatic thoughts or instructing patientsto distract themselves-disrupt the feedback loop whereby upsetting(automatic) thoughts and images constantly pervade consciousness,reactivate situational memories and maintain depressed mood (33). Retrieved on December 1 , 2 5 from:, G.H. New Cognitive Therapy Successful With ADHD. Journal of Rational-Emotive & Cognitive- Behavior Therapy, 18(1), Spring. The Psychological Record, 46(4). Works CitedAmerican Psychiatric Association. Susan's chronic self-destructive behavior in the form of suicide attempts is typical ofBorderline Personality Disorder, as are her substance abuse and theantisocial behavior evinced during her recent hospital stay, where sheprovoked racial tensions ("Practice Guideline for the Treatment of Patientswith Borderline Personality Disorder"). The computer-assisted cognitive therapy was found to be "asefficacious as standard cognitive therapy" as well as less expensive, whichis a consideration for Susan due to her long-term lack of employment(Wright et al., 1161). CBT hasdeveloped "pragmatically to deal with often difficult and refractoryproblems," which makes it an appropriate treatment method for Susan, sinceshe has recurrent substance abuse and depression problems (Brewin, 33).CBT is also considered an effective suicide prevention treatment strategy,a significant factor given Susan's past suicide attempts (Laux, 38 ). This adds ameasure of self-awareness that can help Susan achieve self-control. Behavioral symptoms would be inactivity, withdrawal,reduced socialization, reduction in pleasurable activities, social skilldeficits, crying, and self-injury/suicide (Westermeyer). Diagnostic and statistical manual of mental disorders (3rd ed.). The Cognitive Model of Depression. Retrieved on December 1 , 2 5 from:, M.S. Theoretical Foundations of Cognitive-Behavior Therapy for Anxiety and Depression. Retrieved on December 1 , 2 5 from:, J.R.; Clark, L.A.; Kraft, D., et al. Forsyth, J.P. Roche describes the theory behind this type of behavioraltherapy as "disputing irrational beliefs and displacing them with rational,realistic, and positive statements" that effect behavior change (Taylor).Roche offers the A-B-C model, a simple model that she credits to AlbertEllis, in which "A" is an activating event, "B" is a belief, and "C" is aconsequence of an emotional and behavioral nature (Taylor). Cognitive therapy is especially effective withregard to Susan's depression and suicide attempts, as it helps patientsidentify destructive thoughts and their impact on feelings and behaviorsand then substitute constructive thoughts that reduce the feeling ofhopelessness (Reilly, 26). Therapy can reveal negativevisualizations that she has been engaging in, and these can be replaced bypositive visualization of things as she would like them to be. Broder identifies similar techniques that he refers to as"disputation" (1 ), "thought-stopping techniques" (16), and "affirmation"(11). Hicks Langston University Tulsa, Oklahoma December 2 5Recurrent Major Depressive Disorder is characterized by periodic MajorDepressive Episodes that manifest in the form of a depressed or irritablemood, or "a loss of interest or pleasure in all, or almost all activities"that is "relatively persistent," occurring most of nearly every day withina two-week period (DSM-III-R). Now that Susan remembers her sexual molestation as a child, thesememories coupled with the molestation of her own daughter create asituation where her unpleasant memories of the past can be continuallyreactivated by "situationally accessible memories" (Brewin, 33). Visualization might also be extremely helpful as an adjunct to thethought-stopping, disputation, and affirmation techniques, to enable Susanto redirect and reframe her thoughts. Thistechnique can redirect Susan's thought processes, helping her to see thepast and her current situation from a new perspective that does not includeupsetting automatic thoughts (Brewin, 33). (2 5). Theymight even be used in combination, to utilize the best of both. American Psychiatric Association. The American Journal of Psychiatry, 162(6). Multiple measures, methods, and moments: a factor-analytic investigation of change in depressive symptoms during acute-phase cognitive therapy for depression. The keeping of a mood diary would be helpful in identifying triggersand patterns for anxiety, anger, and depression (Broder, 12). Case Study: Diagnosis and Treatment of Susan Laurie A. (2 ). This, in addition to her other Axis IV profile stressors-unemployment and living in a dangerous neighborhood- as well as her currentGAF of 3 establish her circumstances and environment as potential factorsthat can precipitate or aggravate her condition. Susan would be capable of fairly advancedreading where this would be helpful to her in understanding how to furtherunderstand and implement the concepts she has learned in therapy.Bibliotherapy also provides a link from one therapy session to the nextthat could keep Susan on track so that the therapist does not have to coverold ground again but can keep moving forward, keeping Susan in sync withthe sessions. Duringher recent hospitalization, Susan admitted having flashbacks of sexualabuse by her father that began when she was age 7 and continued until shewas age 12, when she began menstruating. Broder suggests other homework options, including bibliotherapy-"assigned reading that is specific to the issue that you are working on intreatment" (5), audiotherapy-"listening to appropriate audio tapes thatreinforce the material covered in your session between sessions" (5), goalsetting, use of the SUD scale that measures intensity of a feeling orreaction (8), the keeping of a mood diary (12), list making 12), guidedimagery (13), visualization (14), relaxation techniques (14), meditation(14), and exposure (15). Depressionbecomes ongoing because "depressive symptoms feed one another, and this iswhat prolongs the state" (Westermeyer). Physicalsymptoms include low energy, fatigue, agitation, diminished libido,insomnia, and changes in appetite (Westermeyer). Broder recommends customizing this toolwith the patient so that it shows the trigger for "each level of anxietythey could feel" (8). Retrieved on December 9, 2 5 from:, C.E. Another treatment option for Susan is cognitive behavior theory (CBT). Psychological Medicine, 35(5). (1996). Retrieved on December 1 , 2 5 from:, J.H., Wright, A.S., Albano, A.M. The patient's ability to reframe negative experiences by monitoringthoughts and breaking the cycle of replaying negative thoughts is enhancedby teaching the patient to use different language, as well: Recognizing the importance of language and emotion in human affairs, cognitive psychologists have emphasized the inextricable relation between language and emotive functions, that is, how language-symbolic processes convey emotional meaning and how emotions depend on such processes (Eifert & Forsyth, 6 7).An approach for changing negative "self talk" was developed by researcherKim Roche and Dr. Eldon Taylor for use with sufferers of ADHD, based on thephilosophy of cognitive engineering originally conceived in the mid 195 's(Taylor). The increased drug usage wasprecipitated by an investigation by Child Protective Services followingcharges of sexual molestation against Susan's live-in boyfriend. Susan's treatment could be approached from the perspective ofcognitive therapy, and in that event it should be augmented by anassessment of her depressive symptoms according to one of the clinicianreports such as the 17-item Hamilton Rating Scale for Depression (HRSD-17),the 3 -item Inventory for Depressive Symptomatology-Clinician Report (IDS-C-3 ), or patient reports such as the Beck Depression Inventory (BDI) and the3 -item Inventory for Depressive Symptomatology-Self Report (IDS-SR-3 ),all of which "reflect essentially the same symptom severity and changeconstructs during acute-phase cognitive therapy" (Vittengl et al., 693). (2 5). Roche andTaylor argue that the belief can be changed by subliminal statements thatbypass critical or conscious awareness, becoming internalized as self talkor "semantic priming" that results in "a different interpretation of theevent" (Taylor). The advantages of homework are that it maintains and increasesthe value of psychotherapy, enables the patient to achieve focus andprogress in a self-paced manner, and adds a dimension of depth to therapythat costs the patient nothing.

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