The task of coming to an accurate diagnosis and treatment plan for a client can be a challenge for any mental health professional. All symptoms need to be considered and criteria must be accurately met before arriving at a conclusion in order to plan for the best therapeutic interventions. The success of any medications and other therapies rely on an accurate diagnosis. A case study of Ms. A. is reviewed. Ms. A.’s symptoms, diagnosis, and possible treatment options, including medications, are discussed. All possible diagnoses are ruled out before coming to an accurate conclusion. Also discussed are ways in which possible medications affect brain chemistry, the side effects of these medications, and ways in which Ms. A. can manage these side effects.
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Arriving at a mental health diagnosis can be a challenging process for any mental health professional. Many symptoms of one mental illness can overlap those of another illness or disorder. Symptoms for any diagnosis need to be looked at very closely, to determine whether or not the client’s specifically meet the criteria. For example, a client can have symptoms that match a disorder but don’t meet criteria for the amount of time they have had those symptoms. Also, side effects of certain over the counter and/or prescription drugs can mimic symptoms of certain mental illnesses or disorders, and that needs to be considered as well. It is important for the mental health professional to rule out all possible diagnoses before coming to a conclusion.
The project will present a case study of Ms. A. that came to me. It seems to me that her life is getting out of control, because of her symptoms the past three months; and she realizes her life is not the same. The author will determine the mental health issues of Ms. A, select and explain an appropriate possible pharmacological treatment approach, describe how this treatment approach will alter brain chemistry and influence behavior, determine the anticipated side effects of this pharmacological treatment, describe how the client can manage drug side effects and comply to prescribed medication, and tell how the use of over-the-counter and illicit drugs affect the chosen pharmacological treatment.
As a psychologist working in an outpatient counseling center for Kaplan University, I needed to give a diagnosis to a client, Ms. A; and determine the type of treatment and intervention that, as a professional, I would suggest for her. Ms. A. is a 28-year-old married executive complaining of “nervousness” and difficulty sleeping. She has been taking over-the-counter medication to help her sleep. Ms. A. is in good health and is well-groomed, although she appears very fatigued. She reports that problems have developed over the past three months, following her husband’s last business trip. She reports that she has been worrying constantly that her husband will “leave her.” Ms. A.’s symptoms include: irritability, fatigue, an inner sense of restlessness, a 15-pound weight loss over the past three months, and a loss of libido and sleep disturbance (restless sleep and early-morning awakening). Ms. A. also admits to using “street drugs” in her early 20’s, but denies using any illicit drugs for the last five (5) years (Kaplan University, 2010).
The first objective would be to do a thorough assessment of Ms. S; she would be referred to her medical doctor, to rule out any medical reason for her symptoms, so that a formal conclusion would be given as a diagnosis. During the interview/assessment, I would get some background information about whether she has ever had any former depression, eating disorder, or sleep disorder; or if any of these occurred in her family as she was growing up. I would then find out if she has ever taken any other medication in the past, including over the counter medication, or natural supplements. This can help me see if there can be a genetic foundation, or if medication may be a possible reason for her new symptoms. I would determine possible diagnosis from each of the five Axes for Ms. A.
Axis I- Psychological disorders could be anxiety, generalized anxiety disorder, major depressive disorder, eating disorders, and sleep disorders.
Axis II-Personal disorders from the three clusters could be paranoid personality disorder; because she was constantly worried about her husband having an affair, or else an anxious and fearful disorder.
Axis III- Medical reasons for the disorder: Gastrointestinal, because of her weight loss.
Axis IV- A psychosocial stressor, which is from her life circumstances, would be insomnia, from worrying about her husband leaving her.
Axis V- GAF scores 55
Ms. A’s medical doctor said she was in good health; therefore, he would rule out any medical reasons for her symptoms. After carefully looking through the diagnosis, as her psychologist, I came to the conclusion that she is suffering from a major depressive disorder, because it fits the DSM-IV-TR (2002): symptoms have to last for at least two weeks, and meet one of the following criteria: they do not meet a mixed episode criteria; do not cause distress in social, work, or other important functioning; is not caused from any alcohol or substance abuse, medical condition or thoughts of death; and is not from the death of significant others ( Kelsey, Newpost, & Nemeroff (2006). It meets five of the nine symptoms. The five that it fulfills are: diminished interest in pleasurable things (she has lost interest in sex), significant weight loss (15 pounds seem significant to me or she would not have brought it up), insomnia, agitation (which can be interrupted as her agitation that she complains of), and fatigue (Kelsey, Newpost, & Nemeroff, 2006). Some of these symptoms would fit GAD, but in order to have GAD the symptoms need to be for six months; which it could become if she does not get help now.
I would need to rule out that her symptoms are caused by side effects of over the counter sleeping aid. Antihistamine is the main ingredient in over the counter (OTC) sleeping pills. This ingredient is normally used fro allergies, hay fever, and cold symptoms. One OTC sleeping aid is disphenhydranume. Some of the side effects of this are loss of appetite, muscle weakness, and nervousness (Robinson, Kemp, & Barston (2010). These are some of the same symptoms that Ms. A is experiencing; therefore, I would want to rule out that these side effects are causing her problems.
After carefully ruling out all the possible diagnoses, being her psychologist, I have successfully come to the conclusion that Ms. A is suffering from Major Depressive Disorder (MDD). Major depressive disorder can develop days or even weeks after a stressful event (husband going on a business trip). They then begin to lose interest in things that they once had an interest in; they feel depressed and fatigued; plus have insomnia, loss of appetite, loss of interest in sex, muscle tension, and poor concentration.
Pharmacological treatment
Selective Serotonin Reuptake Inhibitors (SSRIs) have been proven to treat major depression. Some of them work better than others. Each person is different, and they will need to work with their doctor to determine which medication in this class would work best for them. Prozac, Luvox, Zoloft, Paxil, Celexa, and Lexapro are all generic forms of SSRI medications (Kelsey, Newport, & Nemeroff, 2006).
Prozac is sometimes the first medication that is tried. In a study at New York State Psychiatric Institute in New York City, and the Research Program of Massachusetts General Hospital in Boston McGrath et al., (2000), they concluded that Prozac was more effective than a placebo; but it has been inconsistent in long-term recovery. It has been shown to show improvement in twelve weeks, but has a high rate of relapse during maintained and continuation care treatment. It can cause insomnia and anorexia (McGrath et al., 2000). Since Ms. A already has insomnia and weight loss, I would not use Prozac as the first line of treatment. According to Waugh & Goa (2003), Lexapro has been shown to have a fast onset of antidepressant action. It is cost effective and can come in extended release (ER). It has been shown to prevent relapse in major depression during maintenance therapy. Since over the counter sleeping pills are not helping, a sedative-hypnotic medication could be helpful. If Ms. A will be taking Lexapro, insomnia is a side effect; therefore, taking a prescribed medication would be helpful (Kelsey, Newport, & Nemeroff, 2006).
Therapy Treatment
Some form of therapy should be used in addition to medication therapy. Cognitive Behavior Therapy (CBT) is one kind of therapy that emphasizes how a person thinks feels and acts (NACBT, 2007). There are several other therapies that are included in CBT, such as: cognitive therapy, rational behavior therapy, and dialectic behavior therapy. CBT’s fundamental principles are that a person’s thoughts drive their feelings and behaviors. If a person changes their thoughts, they will feel and act better. CBT is not just “talk therapy;” it helps people understand why they are doing things and how to change them (NACBT, 2007). For Ms. A, I think CBT would help her, along with taking some form of medication. CBT can help her see that her thoughts of her husband leaving her are not reality. Helping her see and change her deep thoughts of that fear can change her consistent worry; which is possibly causing her agitation, irritability, fatigue, an inner sense of restlessness, and insomnia. I would have her talk to her husband, to determine if her fears are rational. I would assume that her husband has been worried about her lack of wanting to have sex, her not sleeping, and her being irritable. By checking it out and discussing her concerns with her husband, she can realize that her thoughts may have driven her behaviors.
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In a study at the University of Washington Psychology Department, Dimidjian et al., (2006) used Behavior Therapy (BT), which is a part of CBT, when they discussed the relationship between activity and mood; by looking at the behaviors of avoidance, withdrawal, decreased life routines, and distressing thoughts. They helped change things, by scheduling the participants’ activities to reach their goals; by addressing their behaviors, such as increasing avoidance behavior. The author’s conclusions were that behavior therapy did better than medication alone, and did better than other therapies (Dimidjian et al., 2006).
In a study at Harvard Medical School, Jacobs, Pace-Schott, Stickgold, & OTTO (2004) said that Cognitive Behavioral Therapy (CBT) would be the most effective treatment for insomnia; by changing the thoughts that clients have right before they go to bed. CBT has produced the greatest change in sleeping patterns, and has seen the largest number of participants became normal sleepers after treatment. It was also concluded that CBT without pharmacotherapy had the greatest benefit; therefore, it should be the first line of treatment for insomnia, before giving medication. I would treat Ms. A with Cognitive Behavior Therapy plus medication (suggested by her doctor) for her major depressive disorder. I would hope she would not take any more over the counter sleeping aids to assist in her sleeping, so I could see if therapy would help first. If not, than she should go to her doctor.
How therapeutic treats affects brain chemistry and influence behavior
Antidepressants help depression by correcting chemical imbalances, through inhibiting the reuptake of neurotransmitters (Kelsey, Newport, & Nemeroff, 2006). The neurotransmitters that affect depression are serotonin, dopamine, & norepinephrine. By giving a person with any form of depression mild, moderate, or major doses, the antidepressant goes to work by slowing or removing certain chemicals (neurotransmitters) from the brain. Neurotransmitters are needed for normal brain function, and are involved in the control of mood plus other responses and functions. Antidepressants help by making serotonin, dopamine, and norepinephrine more available to the brain. By restoring the brain’s chemical balance, antidepressants help relieve the symptoms of depression. Specifically, antidepressants drugs help reduce the extreme sadness, hopelessness, and lack of interest in life that are typical in people with depression (Markou, 2010).
Taking medication can alter brain chemistry, by getting the needed neurotransmitters to become balanced. I believe, in Ms. A.’s circumstances, that medication and therapy will benefit her most. Medication will help relax her, so that her thinking will be better while doing cognitive behaviors. It will help change her thinking and modify her behaviors. If therapy was not included, there is more of a chance that the disorder will return once the medication is stopped; but if cognitive behavior therapy was in place to change her thinking and behavior, there is more chance of long term success, even after medication is terminated. If illicit drugs are taken, it will alter and affect how neurotransmitters do the work they are meant to do. It can: block neurotransmitters from releasing, force them to release too fast or too slow, prevent them from being reabsorbed by keeping them in the synapse, inhibit enzymes (medication) to be synthesized and metabolized, interfere with how neurotransmitters are stored, and may leak out before normal time. Most importantly, it can cause interaction with medication that is prescribed my a doctor (Darryl, Cohen, 2007).
Side effects of pharmacological treatment
Lexapro is well tolerable for most people. The most common side effects of Lexapro are nausea, insomnia, sexual dysfunction, fatigue, drowsiness, and decreased libido (Gainock, 2010; Kelsey, Newport, & Nemeroff, 2006). There are potential drug interactions with Lexapro. A person taking Lexpro should not also take any MAOI (nardil, phenlzene, Parnate), antipsychotics (pimozide), celexa, OTC pain relievers (advil, ibuprofen, aleve), blood thinners, or Diuretics (Lexapro, 2010). A person needs to call their doctor if any changes or severe side effects occur; such as odd behaviors, suicide thoughts, aggression, or extreme hyperness (Lexapro, 2010) .
Some sedative-hypnotic sleeping pills can cause severe allergic reactions. Signs of a reaction that should cause concern would be swelling in the face, hallucinations, and memory loss. Sleeping pills have been known to cause sleep walking, eating in their sleep, and even driving in their sleep; and they don’t remember it ((Robinson, Kemp, & Barston, 2010).
Side effects maintenance
Medication has multiple effects. One of them is the therapeutic effect it was meant to have and the other is the effect of the medication that is was not meant to have; which would be considered side effects (Kelsey, Newport, & Nemeroff, 2006). It would be important that when Ms. A.’s doctor prescribes her Lexapro that I am aware of the side effects, to help her manage them, so that she will be compliant to the medication regiment.
There are a few thing I can suggest to Ms. A, to handle her side effects. When she just begins to have side effects, I need to remind her to be patient; that when just starting to take medication, it can cause nausea and some of the other side effects which will go away in a few days. Therefore, they are only short lived (Kelsey, Newport, & Nemeroff, 2006). Sleepiness and fatigue can be handled by taking the medication before bed, instead of in the morning. But if she already takes it at night and still has these side effects, then she should try splitting the doses, by taking half in the morning and the other half at night (Kelsey, Newport, & Nemeroff, 2006). There are some medications that handle side effects. Benadryl is one that is used often to counteract allergic reaction to a medication. (Kelsey, Newport, & Nemeroff, 2006)
Ms. A already had decreased libido before she took the medication, which is important to know; so that we know if the medication caused it, or if it was from the major depression that would need to be addressed with treatment (Kelsey, Newport, & Nemeroff, 2006) If she had decreased libido or other sexual dysfunctions since taking the medication, then I would suggest her taking a medication holiday. This is where she skips the medication when she plans to have sex; or she takes the medication in the morning, so that the side effects can wear off by night time. Changing to another medication can be the last resort, if the side effects that a person is having are too much to bear (Kelsey, Newport, & Nemeroff, 2006).
How over the counter medication effects therapeutic treatments
Sleeping pills can cause side effect such as drowsiness, confusion, and forgetfulness
(Robinson) Ms. A already is tired from lack of sleep. Having her feel drowsy would possibly cause an opposite effect, which I would be working on, to help her change her life. OTC pills can cause a tolerance, so the person will start taking more. This can cause problems, since Ms. A used drugs in the past; it could cause the need to cure her problem with not sleeping, and she could relapse with her drug addiction. It can also cause dependence on sleeping pills. With Ms ‘s. previous addiction problems, it could be dangerous and fall into an addiction of sleeping pills. Possible withdraw symptoms can occur if a person stops quickly, such as shakes or sweating. Drug interactions can be a possible problem. There are two types of over the counter sleeping pills. Diphenhydranines (Nytol, Sominex, Sleepinal, Compoz) are antihistamines. They work by blocking the action of histamine, a substance in the body that causes allergic symptoms. The second type is a doxylamine, (Unisom and Nyquil) which works by blocking the action of histamine. The problem is that some of these interact with Laxapro, such as Advil PM, which has doxylamine in it (Doxylamine, 2010). If a person stops taking the OTC sleeping pill, it could cause the insomnia worse than it was before (rebound insomnia). Taking sleeping pills only masks the real reasons for not sleeping (Robinson, Kemp, & Boiston, 2010). This affects treatment. The client may think the side effect of sleepiness or agitation is from the Lexapro and not the sleeping pill; so they may stop taking the medication that is being used to treat the major depressive disorder. With Ms. A., it seems her reason for not sleeping was due to major depressive disorder and not vice versa. I would need to get to the bottom of the reason for MDD, and eventually to the point she would not need to take something to aid her to sleep.
In conclusion, it is important that when a client comes in with problems that interfere with there life, that a professional carefully rules out other possible reasons they have those problems, before a true diagnosis is given. They should be referred to a medical doctor to rule out any medical reasons for the disorder. After the client has been seen by a doctor, given an assessment by the psychologist, and a diagnosis is determined, they can be referred for a medication evaluation to see if medication would be needed to help the client start on the path of recovery. It has been concluded that therapy along with medication is the best treatment in helping someone put their life back together. Neurotransmitters in the brain are affected when taking medication, which alters behaviors by increasing or decreasing certain neurotransmitters. Over the counter medication can positively or negatively affect the treatment. Therefore, it is important that the psychologist warns the client of the possible side effects of medication they are taking, and helps them resolve those issues. The client also needs to be warned of how over the counter medications can possibly cause problems when taken with certain prescribed medication, and how they need to tell their doctor of any medication they are taking; even non prescribed ones. Once all this is in place, therapy can begin; and with hard work, the client can change what they are struggling with, and have a successful life.
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