Case Study
Case Study
Barbara Torres is a 36 year-old Hispanic married women and the mother of male twins of seven years old. She lives in Kalamazoo, in the state of Michigan. She has a very challenging, high stress occupation as a Chief Executive Officer (CEO) in Stryker, a multi-billion manufacture corporation that develop medical devices and medical equipment.
Ms. Torres has always been a hard worker and high achiever. She graduated from Harvard University with top honors in both college and graduate school. She has very high principles for herself and can be very self-critical when she fails to meet a goal.
Barbara Torres arrives to the Pan-American Mental Health Center seeking for psychological services for possible symptoms of depression. Before the intake interview began, the psychologist introduced herself to Ms. Torres, explained the mission, values and services provided in the mental health center, the purpose, form and time of the interview, the information that it will be gathered, and the basis for a good working client/therapeutic relationship, among others.
The client complete and signed the consent for treatment form, authorization to contact form, release of information, and other necessary or relevant paperwork. Once the documents were signed, it was proceeded to explain confidentiality and its limits.
Presenting Problem
During the initial interview, the client was inquired about information about the present problem, the symptomatology, when did it start, how often does it occur, how long does the symptom last, how it affected her everyday life, any incidents that precipitated the symptomatology, and if this mood episodes occurred previously.
The client chief complaint was symptoms of depression and excessive distress that started about three months ago with daily depressed moods, decrease of interest or pleasure in everyday activities, difficulty in sleeping, decreased of energy, weight loss and lack of concentration because of worry. Then the symptoms just get worse. There was no incident or psychosocial stressor that could precipitated the symptomatology.
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Ms. Torres was asked what motivated her to look for help at this point, and she explained that after much deliberation with her family, friends, primary medical doctor and pastoral counseling, she decided to look for help, because the symptoms she was and still experiencing, are deteriorating the relationship with her husband and kids, with her ability to accomplish her work, and were interfering with her daily functioning.
The client explained that in her job she has struggled with significant emotions of worthlessness, embarrassment and guilt due to her inability to perform as well as she always has in the past. The client described that she’s having a lot of stress and preoccupation that she cannot handle the situation or that something awful may happen (like lose her job or family).
Her colleagues have noticed that she is often short-tempered and reserved, which is quite dissimilar from her normally cheerful and friendly character. She has called in sick on numerous times, which is absolutely unlike her. Those days she stays in home ruminating about the present problems, viewing TV or sleeping. This behavior has occurred four times in a month.
In her home, Barbara’s spouse has observed changes as well. She’s presented little interest in sex, had diminished interest in almost all activities with him and the kids, had drop twenty pounds in three months and had difficulty in sleeping (3-4 hours’ sleep per night and does not feel rested upon waking).
Her sleeplessness has been keeping him awake, as she tosses and turns for a couple of hours or two after they go to bed. He’s heard her having recurrent crying phone conversations with her closest friend, which have him worried. When he attempted to talk to her to open up about what’s disturbing her, she pushes him away with an immediate “the whole thing is fine”.
The relationship with her parents and sisters also has been impaired because she lacks of motivation to visit them or talk to them frequently as she used to do. Even though she hasn’t ever deliberated or think about suicide because of her faith and Catholic religion, Barbara has found herself increasingly unsatisfied with her life. Ms. Torres gets frustrated because she knows she has all the reasons to be happy, but yet can’t enjoy all her success.
The client expressed to be overwhelmed and with much stress for not knowing what is happening to her; also reported performed excessive rumination about the problems that this symptoms has caused in her job and family.
According to Nolen, Wisco, and Lyubomirsky (2008), rumination is the method of thinking constantly about one’s emotional state and difficulties. Studies has shown that rumination have an exclusive association to depression symptoms and its negative cognitive features.
Ms. Torres was asked how intense where her symptoms in a scale of 1 to 10, where 1 means low intensity and 10 means high intensity, and she described that her symptoms were positioned between 6 and 7. In the same manner, she was asked how that symptoms’ intensity impaired her daily life activities, and she reported that the symptoms impair her daily functioning between a 7 or 8, stating that she couldn’t performed any activity as she used to.
Ms. Torres was asked if she experienced these symptoms in the past and she stated that she experienced two of the present symptoms (lack of energy and decreased weight) in her adolescence when she broke up with her first boyfriend at the age of seventeen. The symptoms last three weeks.
Mental Health Status
The client arrived to the Pan-American Mental Health Center in a clean state, properly dressed, and seemed according to her chronological age. Her physical appearance seems to be thin or underweight. Ms. Torres was attentive and well oriented on the three spheres (time, place, and person). Ms. Torres maintained eye contact, her voice tone was normal and her body movements and general attitude were according to what she expressed. The client expressed to be overwhelmed and with much stress for not knowing what was happening to her.
She voluntarily provided information about herself, the present problem and symptomatology, medical, psychiatric and family history, among others. Throughout the interview the client understood everything that was explained, proved to be rational and seemed to have good understanding of her psychological difficulties.
Developmental History
Ms. Torres stated that her childhood was remarkable. She grew up in a small town in Michigan with her parents and two older sisters. Her father was a manager in a retail store for 45 years and her mother was a Tennis trainer in a school for 25 years, and both were very caring and attentive with the kids. The parents have 55 years of matrimony.
The family relationship was described as positive and the client explained that throughout her life she has a very good relationship and communication with both sisters and both parents. She considered her family very close and united; they spend almost every Christmas together. She and her sisters were raised in the Catholic religion, and stated that ever since have a very strong faith.
In her childhood, Barbara enjoyed participate in all kind of sports, but mostly she excelled in Tennis. In school, Barbara developed very good relationship with peers, always had excellent grades, and the teachers described her as an outstanding student and an innate leader. In her adolescence and adulthood she reported that she never used drugs or has any problem with the law. She also stated that there was no substance abuse history in her family.
Medical and Psychiatric History
Ms. Torres reported that she’s never been diagnosed of any medical or mental disorder. Since she was young, her parents took the children regularly to visit the primary doctor. One of her sisters was diagnosed with asthma. A well-known family history of medical illnesses including diabetes, hypertension, strokes, multiple sclerosis, and hypothyroidism was refused.
Before looking for psychological services, Ms. Torres visited her primary doctor one month ago to see if everything was good with her health. Her doctor sends her to take several routine physical exams and tests (complete blood count, chest x ray, urinalysis, cancer screening test, mammogram, pap smear, pregnancy test, sexually transmitted diseases, stress test, among others) to discard any health conditions or concerns that could be producing her symptoms. The test showed that Barbara’s health was in good condition. Her doctor advised to use vitamins supplements to prevent malnutrition and referred her to visit the psychologist for possible symptoms of depression.
She was asked if a member of her family was diagnose with depression and she stated that her mother-side of the family has history with this disorder. Her mother, grandmother and aunt where diagnose with major depression. When she was an adolescent her mother received psychotherapy with a psychologist for five years, but never used psychotropic medication. In the paternal side of the family there were no history of mental and psychiatric disorders.
She denied the use of medication with the exception of birth control pills taken at the age of nineteen until she was twenty five years old. Barbara denied any psychiatric hospitalizations, past or present ideation, plan, or intent for suicide or homicide. She also denied any hallucinations or delusions. This is the first time seeking treatment from a psychologist, but she described participated in pastoral counseling.
DSM 5 Diagnosis
- 296.22 / 296.23 Major Depressive Disorder, Single Episode, Moderate- Severe with Anxious Distress
Depression is a medical illness or mood situation in which people face depressed feelings and have a decrease of interest or pleasure in everyday activities that usually enjoy (American Psychiatric Association, 2013).
According to Nunstead, Skarsater, and Kylen (2012), in modern society there is an increasingly serious problem of major depression in all social groups. They emphasize about the importance of individual’s capacity and how the individual’s own comprehension of the disorder and symptomatology help them to manage and cope with factors associated with the disorder.
The criteria for Major Depressive Disorder designated by the Diagnostic and Statistical Manual of Mental Disorders, (5th ed., DSM-V; American Psychiatric Association, 2013), described the main indications of Major Depression as the manifestation of a minimum five of the following symptoms: depressed feelings or mood, decrease of interest or pleasure in everyday activities, decrease or gain of weight or appetite, sleep disturbance, psychomotor agitation, decrease of energy, feelings of worthlessness, lack of concentration and recurrent thoughts of suicide or death.
Diagnosis Impression
At the present time, Ms. Torres meets criteria for the DSM 5 diagnosis of Major Depressive Disorder, Single Episode, Moderate-Severe with Anxious Distress due to the presence of the following symptoms: daily depressed moods, decrease of interest or pleasure in everyday activities, difficulty in sleeping, feelings of worthlessness, decreased of energy, weight loss and lack of concentration for the last three months.
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Ms. Torres rejected experienced in the past of similar psychiatric symptoms, making this episode a single one. The level of impairment Barbara is experiencing in her occupational, social, and other important areas is moderate to severe. There is confirmation of anxious distress by symptoms of excessive distress, worry or tension, incapable to rest as a consequence of anxiety, lack of concentration because of concern, anxiety that something terrible might occur and feelings that she will miss control.
Differential Diagnosis
Ms. Torres’s complaints do not include symptoms of persistent elevated mood, increases in goal-directed behavior, or symptoms in criteria B, lasting one week (Bipolar I – Manic Disorder) or four days (Bipolar II – Hypomanic Disorder). Consequently, any diagnosis related with either one of the above-mentioned episodes was immediately excluded.
Mood Disorder Due to another Medical Condition was ruled out, because there was no family history of medical conditions like diabetes, hypertension, strokes, multiple sclerosis, hypothyroidism and all the medical exams performed recently by her primary doctor showed no recent acquire condition.
Substance/Medication-Induced Depressive or Bipolar Disorder was disqualified since there was a negative history of substance and medication use at time of onset of symptoms.
The client reported absence of impulsivity in her family, her childhood and adolescence, and the symptoms of lack of concentration started three months ago, as a result, Attention-Deficit Hyperactivity disorder was ruled out.
Because the onset of symptoms was approximately three months ago and there was no psychosocial stressor that precipitated the symptomatology, Persistent Depressive Disorder (Dysthymia) and Adjustment Disorder with Depressed Mood were ruled out.
Sadness excluded because Ms. Torres meets the criteria of severity (five or additional symptoms), duration (for the most part the day, nearly every day for a minimum of two weeks), and clinically noteworthy impairment in functioning, needed to be diagnose as a client with Major Depressive Disorder (American Psychiatric Association, 2013).
Etiology
During the interview, Ms. Torres reported a maternal family history of major depression (mother, grandmother and aunt) and explained that her mother received psychotherapy for five years, but never used psychotropic medication. There were no history of mental and psychiatric disorders in the paternal side of the family.
Several family studies have discovered that the genetic relatives of clients with mood conditions are more likely to acquire mood disorders than are individuals in the general population.
In the present, doctors and scientist still don’t know what are the exactly causes of depression. Roetker et al. (2013) indicated that the etiology of depression is complicated and heterogeneous although many factors (biological, genetic, psychological, and environmental factors, among others) can contribute to the arrival of depressive symptoms.
According to Tamatam, Khanum, & Bawa (2012) genetic factors have been connected in the etiology of depression and numerous investigations and studies have determined that fluctuations in protein structure are associate with a predisposition to specific conditions.
In the other hand, many other studies had found no correlation between genetic factors and depressive symptoms, and concluded that the environment and social factors were more predictive of depressive symptoms (Roetker et al., 2013).
Monroe, Slavich, and Gotlib (2014) indicated that three of the most dependably informed and influential predictors of depression are a current major life experience, a family history for depression, and an individual history of previous depressive occurrences. In the case of Ms. Torres, the combination of daily activity stressors and family history of depression may possibly triggered the outcome of an episode of major depression.
Treatment Recommendations
Psychotherapy and medication is the treatment of choice for mood disorders. Based on a study performed by Casacalenda, Perry, and Looper (2002) the best treatment for depression is the combination of antidepressant medication and psychotherapy (principally cognitive behavior therapy and interpersonal therapy).
Ms. Torres will be referred to a psychiatrist to start the pharmacological intervention and treat symptoms of low mood and insomnia, among other symptoms. Medication will help in the stabilization of the chemicals in the brain to the right levels, relieving the depressive symptoms.
Along the interview, the client expressed to be constantly overwhelmed, preoccupied and anxious; likewise she reported perform excessive rumination about the problems and having feelings of worthlessness and guilt.
Cognitive-Behavioral Therapy will help Ms. Torres to people change negative thinking and behavior patterns. Also, will help the client to comprehend the issues that may be behind her thoughts and feelings, be aware of depressive symptoms and how to identify things or events that could make the depression worse.
In combination with Cognitive-Behavioral Therapy, the implementation of Interpersonal Therapy will allow the client to improve social adjustment and return to her social, occupational and family activities.
Treatments of medication and psychotherapy, will help Ms. Torres to cope with social circumstances and other factors that may trigger further episodes of depression (Casacalenda, Perry, and Looper, 2002).
References
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Casacalenda, N., Perry, C. J., & Looper, K. (2002). Remission in Major Depressive Disorder: A Comparison of Pharmacotherapy, Psychotherapy, and Control Conditions. Am J Psychiatry, 159, 1354-1360. doi:10.1176/appi.ajp.159.8.1354
Monroe, S. M., Slavich, G. M., & Gotlib, I. H. (2014). Life Stress and Family History for Depression: The Moderating Role ofPast Depressive Episodes. Journal of Psychiatric Research,49,90-95.
Nolen, S., Wisco, B. E., & Lyubomirsky, S. (2008). Rethinking Rumination. Perspectives on Psychological Science, 3(5), 400-424.
Nunstead, H., K.,Skarsater,. & Kylen, S. (2012). Experiences of Major Depression: Individuals Perspectives on the Ability to Understand and Handle the Illness. Issues in Mental Health Nursing, 33(5), 272-279. doi: 10.3109/01612840.2011.653038
Roetker, N. S., Page, D., Yonker, J. A., Chang, V., Roan, C. L., Herd, P., & … Atwood, C. S. (2013). Assessment of Genetic and Nongenetic Interactions for the Prediction of Depressive Symptomatology: An Analysis of the Wisconsin Longitudinal Study using Machine Learning Algorithms. American Journal of Public Health, 103(1), 136-144. doi: 10.2105/AJPH.2012.301141
Tamatam, A., Khanum, F., & Bawa, A. (2012). Genetic biomarkers of depression.Indian Journal of Human Genetics,18(1), 20-33. doi:10.4103/0971-6866.96639
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