Psychiatric Nursing Depression Case Conceptualization
Mrs. Williams is a 56-year-old woman who was referred by the social worker at the senior citizen community center for possible depression. In the past, Mrs. Williams had been very sociable and extroverted, but she is now withdrawn and quiet. On questioning, Mrs. Williams states that she is tired of the people at the community center and prefers to stay in bed. She has difficulty sleeping at night (“tosses and turns”), but when she finally does fall asleep, she wakes up very early in the morning. She feels as if she doesn’t have the energy to do things anymore. She has a decrease in appetite but is unsure if she has lost any weight. She does not feel like cooking or eating. She has difficulty concentrating and has stopped reading the newspaper and watching television. She often feels sad, hopeless, and worthless. Her social history is significant for her husband of 25 years leaving her for another woman and filing for divorce. Mrs. Williams blames herself for the divorce and feels she should have been a better wife. She has no children; a 3-yearold son died by drowning 20 years ago. Mrs. Williams recalls a hospitalization at that time for psychiatric reasons and for taking pills but feels it was not a suicide attempt. She is evasive when questioned about present thoughts of suicide but states she has a bottle of pills at home. She has little hope for the future. The patient is cooperative but is often irritable and indifferent when responding to questions. She is tearful with paucity of speech. If patient is talking about sensitive issues, she does not have good eye contact and her voice is low. Overall, her affect is blunted, and her movements are slow. She does not abuse alcohol. She denies suicidal thoughts.
Mrs. MacDonald had a previous psychiatric hospital admission following a suicide attempt and depression after the drowning death of her infant son over 30 years ago. Now the patient is expressing feelings of sadness, worthlessness, and hopelessness since her husband of 35 years left her for another woman and filed for divorce. She exhibits psychomotor retardation and has a blunt affect.
Primary Diagnosis: Depression
Secondary Diagnosis: Dysthymic disorder
Sequence of Case Conceptualization
Introduction of Self and Patient
Ask pt. the reason for the visit and also if their clinician provided a referral to a Therapist)
Explain Tenets for Case Conceptualization to Patient:
- Serve as a foundation on which to build our counseling
- Is a map for understanding why things are happening and how we help people get better while taking in to consideration cultural aspect
- Helps us to understand client worldview.
- Work collaboratively with the clients
- Allow us to have more empathy and understanding of our client.
- Helps to on formulate on diagnosis and treatment plan
- Serve for us to look at through the lens of multiple theories and further expand our abilities to see the big picture and to make even more connection and association.
Description of the current problem (including background information)
Example Generalized Anxiety
REASONS FOR VISIT ( Anxiety, or panic attack)
P-Provoking factors ( precipitating factors/ what cause it/ ) Crowded places, super market, driving on the freeway.
Q-Quality (Describe characteristic/ how much of it is there, how does it feel/look) Chest pain, S.O.B, Palpitation, fear of dying, sense of choking, sweating, sudden overwhelming fear.
R-Religion/radiation( where is it, does it spread) is it localized (chest pain. Radiate down your arms or abdomen.
S-SEVERITY ( Does it interfere with activities) Job, sleep pattern.
T-TIME (Time of onset/how often it occurs/ is it sudden or gradual/How long has this been going on and does anything makes it worse or better.
Explore if there is any history of substance misuse
Any medical conditions
Past experience and response to treatments
Explain use of over the counter medication and potential drug interractions
Symptoms
- Restlessness
- Muscle Tension
- Sleep disturbance
- Autonomic hyperactivity/vigilance
- Decrease concentrations
- Irritability
- Fatique
Account of why and how these problems occurred or developed
- What are some of the triggers( things that make the problem more likely to occur. for example having an argument with a partner because it will make you and worsen your anxiety).
- What are some modifiers (some thing that make a problem better or worse. Physical modifieres like getting more sleep, medication).
What are some Precipitants? These are things that happened just before the event, which a causal pathways For example the losing your home, ending of a significant relationship, getting a letter of impending layoff from work that could a trigger.
What about Vulnerability factors? Genetic, and childhood events.
What about your Core Beliefs? These are thoughts and assumptions we hold about ourselves, others, and the world around us Contributes to thought feelings and behavior.
For example, Am unlovable, am not good enough, there is something wrong with me, I’m an outsider.
Have client list their core beliefs
To challenge such core belief
Ask the Pt, what experiences or empirical data to depicts this belief is completely true?
Analysis of processes that maintain the problem
Maintenance process is what keep the problem going.
For instance when one is anxious or has generalized anxiety, the person turn avoid social events, Isolate self as such we do not get a ton of positive experiences and we never get new data to challenge the idea of being anxious .
Social isolation is an avoidance and the staying at home become the maintenance factor for our anxiety.
Common Maintenance process
- Safety behaviors and Avoidance
- Reduction activity
- Catastrophic misinterpretations ( one may have tightness in the chest and may interpete that my body is in danger, having myocardial infarction and I am going to die).
- Performance anxiety ( One is going to give a public speech, experience sweating in the palms, fear of making mistake or a fool of selves. When you accomplish
- Perfectionism( tries to do so much and never get things on time)
Short term rewards ( Some one is drinking or smoking cigarette to attain short term reward, which is detrimental to health, you have to replace such negative behavior with something positive.
Differential Diagnosis
Panic Disorder
Anxiety
Social Anxiey
Diagnosis
Generalized Anxiety
Theoretical Approach ( CBT Behavioral Experiment)
INTERVENTIONS
Behavior activation by going out of the house to obtain new data to challenge those core ¸ beliefs one may perceive or infer
CBT Behavioral experiment
Ask pt. to describe self when they are anxious?
Is there anything you do to control such behavior?
Do you maintain eye contact with people?
Do you sweat when it occur?
Are you shaking during the process?
What about your appearance, are you
What do you think will happen when you stop doing those things to control your anxiety?
What do you think will have if you maintain eye contact and stop grabbing an object for instance
Assist pt’s control of life situations
Review past effective coping mechanism
Educate pt. on diagnosis of GAD
Explore Personal values
Assist pt .with accepting situations over which they have no control over
Teach relaxation techniques
Refer to support
Psychoeducation groups
Shor term Treatment is Benzo
Long Term treatment is SSRI
Case Formation Rubrics
Patient Case Study/history 5%
Assessment 5%
Treatments
Initial phase (4 Points)
Middle phase (4 points)
Termination phase (3 Points)
Complications/conclusion ( 2 point)
Please follow APA guidelines ( 2 Points)
Safe Assign should be less than 25%, a high Safe Assign, and plagiarism will result in a reduction in points and possibly have an ” F” on your paper.
CASE CONCEPULIZATION # 1 and 2
Please write a case conceptualization on any of your chosen pt. at the clinic.
- Description of problem provides sophisticated depiction of all Pt’s views; word choice conveys empathy with each perspective; descriptions clearly contribute to coherent conceptualization. Please provide detailed yet succinct intro that identifies client, age, ethnicity, occupation, grade, etc. Descriptions clearly set context for understanding problem ( 5 points)
- Identifying the client’s vulnerabilities by considering why the client more likely to
experience this problem(s) than another person (2 Points)
- Identifying the client’s triggers by considering the stimulus or source of the presenting
problem(s) 2 points
- What is the pt. Core Beliefs ( 5 points)
- What are the most central thoughts, feelings, memories, sensations, and situations that the client is avoiding or fused with? (2 points)
- Differential Diagnosis ( 2 points)
- Diagnosis( Please elaborate) 5 Points
- Exploring coping strategies by considering the ways in which the client deals with the
effects of the presenting problem(s) 2 points
- Finally, describe a comprehensive treatment plan which considers the particular processes, interventions, and measures you might want to use with this particular client ( 1 Points)
Please follow APA guidelines (2)
Safe Assign should be less than 25%, a high Safe Assign, and plagiarism will result in a reduction in points and possibly have an ” F”
