Psychotherapy with Individuals

PSYCHOTHERAPY WITH INDIVIDUALS 6

Psychotherapy with Individuals

Name

Institutional Affiliation

Date

Comprehensive Client Family Assessment

Demographic information: a 28-year-old male Hispanic and working-class (from home due to COVID-19). Works in a warehouse as a call center representative

Presenting Problem: the patient is experiencing reduced ADLs and hygiene and has not been sleeping nor eating for the past few days before the admission to the facility. The patient is also lacking a motive to live, and having suicidal ideation with no plan. These problems have been linked to the recent anxiety and depression which has occurred as a result of working from home due to COVID.

Medical History: the patient states that she is having anxiety and depression that has been caused by working from home due to the emergence of COVID-19. The patient is distracted and showing signs of depression. He has been hospitalized for a mental problem even though he was anxious.

Substance use History: the patient admits to being using alcohol and has been taking marijuana six months ago.

Developmental history:

Family psychiatric history: Father is deceased, diagnosed with Attention deficit hyperactivity disorder. The mother having a personality disorder.

Psychosocial History: He has been hospitalized for a mental problem even though he stated that he was anxious. He has a history of depression, PTSD, paranoia, anxiety, and pseudo-seizures.

History of the abuse or trauma: the patient stated that he has been sexually abused at the age of 5 years old by their maid. Nevertheless, she never shared the story with another person. She also has a history of post-traumatic stress disorder (PTSD).

Review of the system

Psychiatric: Depression, unspecified bipolar disorder and other related behavior, trauma

Constitutional: No fever nor chills.

Respiratory: No breathing difficulty. No orthopnea.

Cardiovascular: absence of edema.

Gastrointestinal: denies vomiting, nausea, abdominal pain, and constipation

Physical Assessment

Height: 5’8”; weight: 125 pounds; BMI: 18.2 kg/m2; B/P: 110/70; Temperature: 97.8; p 80 R 22

Abdomen: No distension of the abdomen with no axillary and the inguinal lymphadenopathy; non-tender; bowel sounds + × 4 quadrants. No organomegaly. No palpable masses.

Neurological: Cranial nerve is intact i.e. A & O × 3

Cardiovascular: the S1 and S2 rhythm are regular and stable.

Musculoskeletal: the patient is having stable gait

Respiratory: there is a normal chest when percussion is performed. There is bilateral expiratory wheezing.

Mental status examination: the patient is cooperative and is redirectable even though he is having some thoughts. He easily loses attention when he is distracted. He is depressed and having anxiety as a result of working from home. The situation is made worse since he is having some marital issues which increase his level of stress. He admits to being having some suicidal ideation even though he has no plan to implement it. This patient seems to be having some psychosis and this is evident by the fact that he is having auditory and visual hallucinations.

Differential Diagnosis

Anxiety Disorder: this is a condition that is characterized by anxiety or fear that interferes with daily activities. An example of an anxiety disorder is a post-traumatic stress disorder. In this case study, the patient has neglected his ADLs and hygiene. He is also not eating and he is having no motivation in life. The patient is also having a history of the post-traumatic disorder (Karlson et al., 2016).

Suicidal Ideation: this is a mental disorder that has the characteristic of persistent depressed mood and the loss of interest in activities. In this case, the patient is depressed and he has neglected the ADLs and hygiene, not eating, and not sleeping.

Post-traumatic stress disorder: this is a condition that is related to the triggers that can bring memories of the trauma that is characterized by the intense emotional and physical reactions. In this case, the patient has been abused while at the age of five years. She is currently having marital stress which might be the trigger to his current condition. The patient is also not sleeping and having some depressed moods or anxiety as some of the chiefs complain while reporting to the facility.

Schizophrenia: This is a severe mental disorder whereby the victim abnormally interprets the events. It leads to hallucination, delusions, and severely disordered thinking and behaviors that impair functioning and disabling. In the case study, the patient is having both auditory and visual hallucinations. He is neglecting his ADLs, not observing his hygienic condition at the moment, and getting easily distracted. (Chakhssi et al., 2017)

Case formulation

Based on the symptoms presented in the case study, it is clear that the patient might be suffering from the anxiety disorder which is also characterized by the post-traumatic disorder that is being triggered by the marital stress. The anxiety disorder is caused by the fact that he is unable to attend to his jobs in the organization as a result of the COVID-19. He is forced to work from home, something he finds not comfortable with. The problem has forced him not to be further attentive to his ADLs and hygiene. He is losing a focus in his life and he is no longer feeling motivated to live.

The Treatment Plan

The patient is having some issues to be addressed to help him deal with his situation. The patient is currently dealing with issues related to suicidal ideation with no plan of fulfilling it and anxiety. The patient is also having sleeping and eating problem, therefore, the goal of therapeutic approaches, in this case, is to help in the reduction of anxiety, help in addressing the sleeping problem, and to deal with suicidal ideation. Therefore, the therapeutic approach will involve the use of medication and therapy.

Therefore, the treatment will involve the initiation of Seroquel 50 mg at HS for the mania and Prazosin 1 mg at HS for the trauma. The patient is also put under activity therapy by engaging him in a group focus therapy. Activity therapy is also aimed at improving coping skills and managing the moods of the patient.

Part 2: Family Genogram

According to the familial history of the patient, his father is still alive while the mother is deceased. His father died three years ago after being found in a borehole, something that was linked to suicide. Before his death, his father was diagnosed with attention deficit hyperactivity disorder (ADHD). His mother is having a personality disorder and she is always and she is showing some strange behaviors which makes the family to be much worried. The family has always found a hard time while explaining to her about some events in the family. She always faces the challenge of perceiving and relating to the circumstance and people.

References

Chakhssi, F., Schaap, G., Bohlmeijer, E., & Westerholf, J. G. (2017). Well-being in psychotherapy for individuals with personality disorders. Society for the Advancement of Psychotherapy. Karlson, B., Johnell, K., Sigstrom, R., & Sjoberg, L. (2016). Depression and depression treatment in a population-based study of individuals over 60 years old without dementia. The American Journal of Geriatric Psychiatry, 24(8), 615-623.

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