Psychological Disorder Case Analysis

The Patient

            Marla is a 42-year-old Hispanic female who comes to the mental health clinic complaining of having trouble sleeping, feeling “jumpy all of the time,” and experiencing an inability to concentrate. These symptoms are causing problems for her at work, where she is an accountant.

Marla’s Initial Interview

Marla: “Hello. Thank you for seeing me on such short notice today!”

Me: “No problem! I’m happy to help and to do that I need to ask you about 10 questions to gain a better perspective of your entire life. Okay…? Ready?”

Marla: “Yes sir!”

Me: “Do you have any grandparents, parents, or siblings that have been diagnosed with any type of psychological disorder, such as addiction, depression, anxiety, or mood disorders and do you have any addiction, severe depression, anxiety, or drastic mood swings that are interfering with any aspect of your life?”

Marla: “I really do not know for sure. They have never been diagnosed but I suspect they might. I do not have any drug addictions or drastic mood swings, but I have been feeling really jumpy all of the time.”

Me: “So you have been feeling on edge and anxious all the time?”

Marla: “Yes sir.”

Me: “Are there any other issues causing problems in your life?”

Marla: “Lately, I have been having trouble getting to sleep at night and trouble concentrating throughout the day, and most days are worse than others.”

Me: “My receptionist wrote down here that reason for emergency visit is that your job may be in jeopardy if someone does not help soon. I can understand why; the trouble sleeping is likely irritating you and further increases your levels of anxiousness the next day, causing that ‘jumpy’ feeling to get worse as the days progress. Anxiety floods the mind with uncontrollably constant negative evaluations toward yourself and everything around you. This causes your mind to become preoccupied with these repetitive thoughts, leading to increased jumpiness and difficulty concentrating on routine everyday tasks. If you do not mind me asking, how would you describe your childhood relationship with your parents?”

Marla: “I don’t mind. My father was really aggressive and he fought with my mother a lot, and I think that there were times when I heard him hit her. Mom and I always worried more as it grew closer to the time dad usually arrived home. I was always scared and worried when I was a kid.”

Me: “How would you describe your friendships (such as number of friends and the amount of self-disclosure and communicative openness between one another)?”

Marla: “I have maybe two really close friends and around five altogether.”

Me: “Do the two close friends know about your anxiety problems while the other three have not been told?”

Marla: “Yes!?! How did you know that?”

Me: “Those times when your ability to concentrate becomes extremely difficult and you feel more jumpy than usual, make me believe that you are experiencing panic attacks. Most people with panic attacks are not aware of when the next one may occur, therefore they usually consider friends as close when the friends know, assist, and are comfortable with them during the attacks; I made a guess!”

Marla: “Wow! I did not realize how much these problems were directing my choices and decisions, like who I consider close to me.”

Me: “Have you been or are you currently in a romantic relationship and how would you describe the quality of your past and/or current relationship?”

Marla: “I am not very good at approaching guys because I get too nervous and feel a strong urge to run away; then the urge to run away is all I can focus on, so I make up an excuse to myself as to why I should just go ahead and leave. I have not had any serious and lasting relationships; if I am not mistaken, I had around three boyfriends when I was around the age of 15 that all lasted close to two weeks. I guess I just assumed that I was not good with relationships after that because I do not seriously consider making attempts to establish romantic relationships.”

Me: “You said that you feel jumpy all the time; thinking back over the last six months, are there ever days that you do not feel anxious at all?”

Marla: “Hmmm… Very rarely I will feel hardly anxious for two or three days at the most. In the last six months this has happened maybe three times.”

Me: “I can imagine how much tension and stress you must feel. So, it was mentioned that your job is in jeopardy; can you explain your occupational situations further?”

Marla: “Well, sometimes when I begin to feel really jumpy I cannot concentrate at all on the financial figures on my screen, bringing me to become distressed about not being able to do my job. Then I begin to worry that the way I am feeling at that very moment is going to cause me to lose my job again and I panic to the point that I have to be sent home.”

Me: “So these symptoms have caused you to lose jobs in the past?”

Marla: “Well… I actually did not realize until just now that I may have lost my past jobs due to these symptoms.”

Me: “Do you have any goals you would like to accomplish in your future?”

Marla: “Honestly… I have not been thinking about the future as much as I have been thinking about not displaying my panic attacks in public.”

Me: “Have you been finding yourself avoiding most opportunities to get out in public from the fear of having an attack in public?”

Marla: “Now that you mention it, I just remembered that when I do not feel like going to my family’s to visit they have been telling me that I always have some excuse.”

Me: “Do you find yourself being mostly stressed, sad, angry, distrusting, or happy?”

Marla: “Well, that is a difficult question because my emotions always feel so mixed and unable to be identified. I can tell you that out of those emotions I spend less time happy in comparison to the others. I am always stressed and angry that I cannot just relax when I need to; I distrust myself because I cannot even be certain if I will act a certain way in public and then I become a little sad.”

Me: “That was a great analyzation of your feelings! You said it was difficult but described in detail with what seemed like ease. Based on the kind of person you would like to become or feel you should become, how do you currently feel about yourself overall?”

Marla: “Well I would like to be the kind of person that could go to work, do a great job, come home to a loving husband, and kids. Based on this person, I feel that I am not nowhere close to the person I would like to be.”

Me: “Well… Marla, we are going to see if we cannot reduce the frequency and severity of your symptoms so that you can let that person inside of you out. With this antianxiety medication I’m prescribing, I promise that with some understanding and patience that this gradual and long process will find that person inside that I know is trapped in there. I will schedule an appointment for next week and if you need anything before then just give my office a call. Also, it would really be in your best interest to take 10 minutes to practice breathing deep and slowly while lying down and place your hand on your stomach so that your body will physically become aware of the proper rate to breathe. This will teach your body how to naturally relax and repeating this exercise three times a day for 10 minutes will lessen these anxious symptoms more quickly. Later, we will increase the length and frequency of the breathing exercises to teach your body more quickly.”

Marla: “Thank you so much! I already feel more optimistic and confident that this is something we will be able to work through. Bye!”

Me: “It is definitely something we can work out and I will see you next week, or sooner should a serious problem arise. Bye!”

Psychologically Diagnosing Marla

Marla’s suspicion of family psychological disorders and the abuse she witnessed caused traumatic family interactions that certainly contributed to her childhood anxiety expressed in her comment that she was always scared and worried. I suspect she may have even experienced abuse from her father but is not comfortable at this time to disclose such personal anguish that has never been resolved. She keeps a limited amount of intimate friendships due to negatively anticipated judgments about her condition and social rejection should she experience a panic attack. Marla’s level of daily anxiousness has been persistent for approximately six months with minor periods of absence and has suffered the loss of past jobs. Normal motivation to approach potential partners is the emotional arousal of excitability, but this exciting arousal in people with panic disorder is cognitively misinterpreted as a flight instead of fight response.

Psychologically healthy people usually maintain the confidence to convert the exciting arousal into a response overcoming initial nervous “butterflies” to fight for someone they want, whereas people with panic disorder lack social confidence from overly concerning themselves with potential panic attacks that may occur; to prevent the possibility of social rejection, they feel it is safer to just avoid, thereby likely contributing to the development of an avoidant personality disorder if the panic disorder is left untreated. The more situations Marla avoids the less productive her life will become from compounding stress left unresolved, such as avoiding paying the bills due to a lack of money or avoiding social situations to avoid the public embarrassment of having a panic attack.

Marla desires to lead a normally productive life of attending a job regularly and excelling, I expect more specifically she subconsciously desires excelling at life in general, evident from explaining that this productive life would also have a loving husband and kids to come home to. Marla’s loss of control over her behavior during panic attacks brings about a sense of hopelessness and negative expectations. Thinking the worse and feeling hopeless, she may even then begin to develop depression that will further exacerbate anxiety symptoms.

Strategy for Treating Marla

Socioculturally speaking, “Dysthymia, panic disorder, and phobia are somewhatmore prevalent among Mexican-American women over 40 years ofage compared with both non-Hispanic white women over and Mexican-Americanwomen under 40 years of age” (Karno, M., Hough, R., & Burname, A.,1986, para. 1). In light of her apparent symptoms and her increased risk of developing panic disorder with agoraphobia, “a fear of venturing into public places, especially when one is alone” (Comer, 2005, p. 108) and Dysthymia, “a longer-lasting but less disabling pattern of unipolar depression” (Comer, 2005, p. 197), I suggest using a moderate dose of anti-anxiety medication to reduce the progression of any depression she may have. I scheduled her next appointment in a week to assess her current emotional and psychological states and expectations, upon which I will assess the need for using anti-depressant medication. I instructed Marla to practice breathing deep and slowly while lying down and to place her hand on her stomach so that her body would physically become aware of the proper rate to breathe. I explained that this would teach her body how to naturally relax and how repeating this exercise three times a day for 10 minutes would lessen her anxious symptoms more quickly. In following sessions, exercises increase in length by five minutes and later increase in frequency to four times a day.

Since “people who are diagnosed with panic disorder experience dysfunctional changes in their thinking or behavior as a result of the attacks for a period of a month or more” (Comer, 2005, p. 117), cognitive restructuring will be applied to help Marla realize the thoughts exacerbating her anxiety immediately following a panic attack, recognize the irrationality behind those thoughts, and understand what environmental triggers increase panic by writing a list of the things that make her more anxious. Later, applying methods for coping with such triggers will reduce her social environments influence on her condition, making her gain a sense of control over her environments.

When Marla’s psychological and emotional states and expectations cease to be maladaptive to the point of an increased state of controllable concentration, we will discuss the many common bodily sensations that commonly get misinterpreted with proof of how normal body processes can cause such sensations. At this point, Marla will most likely be well on her way to being the kind of person she wants to be, which should be evident by her increased optimism, more controllable emotions, and developing future life expectations.

Reference

Comer, R. J. (2005). Fundamentals of abnormal psychology (4th ed.).New York: Worth.

 

Karno, M., Hough, R. L., & Burname, A. M. (1986). Lifetime Prevalence of Specific

Psychiatric Disorders Among Mexican Americans and Non-Hispanic Whites in

Los Angeles. Arch Gen Psychiatry, 44(8), 695-701.

Retrieved from http://archpsyc.ama-assn.org/cgi/content/abstract/44/8/695