Vignette analysis - Case Study Example

Vignette analysis Vignette: A middle aged, African American couple and their three children, ages 13, 10, and 8 come to see you regarding the recent death of their 16-year-old son .The entire family was present at the time of the accident. The mother tells you “it is all my husband’s fault for letting our son drive” and that she would consider divorce if the Church allowed. The husband tells you he is afraid to go to sleep for fear that the wife will “kill me in revenge”. The other children appear distraught and withdrawn. What are your diagnostic impressions of the wife? What are your goals and treatment suggestions for both the wife and family, and why? Diagnostic impressions of the wife: The wife has suffered from a traumatic event wherein she witnessed the accident and death of her dear son. The response of the wife involves intense fear, helplessness and horror. This experience has caused significant impairment in social function and detachment, to an extent that she begins to blame her husband for the accident and considers even divorcing him, thus exhibiting derealisation and depersonalisation. She is highly irritable. The disturbance is not due to physiological effects of substance or a general medical condition. Also, the duration of symptoms is short, unlike in post-traumatic disorder where the duration of symptoms is more than one month. Hence a probable diagnosis of acute stress disorder can be made under Axis-I. The wife has distrust and suspicion attitude towards her husband without any sufficient basis. She thinks her husband has deceived her by being the cause of her sons death. She threatens to divorce him and has a revengeful attitude. She has an unforgiving nature. These symptoms can be attributed to paranoid personality (Axis II). The history is not suggestive of any medical condition that can be attributed to the symptoms of the wife (Axis III). The woman has difficult relationship with her husband (partner-relational problem- Axis IV). The wife has few symptoms which can be considered temporary and are expected reactions to stressors. The Global Assessment of Functioning (GAF) Scale code of this woman fall between 71-80. Hence, the multiaxial diagnosis can be put as follows (APA Diagnostic Classification, DSM-IV-TR): Axis I: Acute stress disorder (308.8) Axis II: Paranoid personality disorder (301.0) Axis III: NIL Axis IV: Partner relation problem (V61.1) Axis V: GAF Score: 71-80. Goals of treatment 1. Reduction of the severity of ASD or PTSD symptoms: The treatment aims to reduce the emotional distress of the patient and reduce certain symptoms that impair social functioning. The patient must be helped to manage the immediate distress of the memories of the accident and death of her beloved son. The patient should be advised that the danger is no longer present and is a past event. The treatment also aims to reducing behaviors that unduly restrict daily life, impair functioning, interfere with decision making, and contribute to engagement in high-risk behavior (Ursano, 2004). 2. Prevention or reduction of trauma-related comorbid conditions: Depression and substance abuse are common comorbid conditions. Presence of these conditions must be evaluated to fasten recover. 3. Improvement of adaptive functioning and restorement or promotion of normal developmental progression: Since acute stress disorder is associated with functional impairments in various areas of daily life, these areas must be identified and dealt with appropriately. 4. Prevention of relapse: Relapse is very common in acute stress disorder. This can be prevented by allowing the patient to participate in problem solving skills, emotional regulation and take advantage of appropriate interpersonal relationship and professional help (Ursano, 2004). Treatment Psychopharmacology Pharmacological intervention is necessary to relieve the overwhelming psychological pain or emotional distress, sleeplessness and extremes of agitation, rage and dissociation. This is the first line of management. Selective serotonin reuptake inhibitors (SSRIs) and other antidepressants like monoamine oxidase inhibitors may be useful. Benzodiazepines are useful in reducing anxiety and improving sleep. But they can not be recommended as monotherapy. SSRIs ameliorate all the 3 symptoms clusters like re-experiencing, avoidance and hyperarousal. They also treat comorbid conditions like depression, social phobia and panic attack. They reduce symptoms like suicidal ideations, impulsiveness and aggressive behaviour. They have fewer side effects. The commonly used SSRIs are fluoxetine, sertraline, and paroxetine. They can be given for a short duration for 8 to 12 weeks. The symptom reduction can be usually seen in 2 to 4 weeks (Ursano, 2004). The commonly used MAOIs are amitriptyline and imipramine. However, there are not many studies demonstrating the efficacy of these drugs in the current scenario and especially in women. Benzodiazepines are useful in relieving anxiety and sleep disorders but are not useful in relieving symptoms of stress disorder. Other drugs which may be useful are anticonvulsants like divalproex, carbamazepine, and topiramate; antipsychotics like olanzapine, quetiapine and risperidone and adrenergic inhibitors like beta blockers. Antipsychotic drugs are mainly useful in those with psychotic symptoms (Ursano, 2004). Psychotherapeutic interventions 1. Cognitive and behaviour therapies: These involve education about the symptoms of the disorder and relaxation training techniques. After the initial assessment of the patient’s ability to tolerate within-session anxiety and temporary exacerbations of symptoms, a series of sessions are placed wherein the patient is allowed to imagine and describe the traumatic event and the aftermath. The therapy also involves reassurance and relaxation exercises. Since for women, stress inoculation and prolonged exposure techniques have been proven to be useful, these can be tried for the patient. Stress inoculation training involves breathing exercises, relaxation training, thought stopping, role playing, and cognitive restructuring (Ursano, 2004). 2. Eye movement desensitization and reprocessing (EMDR): In this form of psychotherapy, exposure based therapy with multiple, brief and interrupted exposures to traumatic material are delivered along with eye movement, recall and verbalization of traumatic memories of the event. 3. Psychodynamic psychotherapy: There are 2 major approaches to this form of therapy. In one approach, the individual’s defenses and coping skills are viewed as a product of her biopsychosocial development and the approach focuses on the meaning of the trauma for the individual. The second approach focuses on the effect of traumatic experience on the individual’s prior self-object experiences. It helps the person to identify and maintain a functional sense of self in the face of trauma. Both these approaches use supportive and insight-oriented interventions based on an assessment of the individual patient’s symptoms, developmental history, personality, and available social supports (Ursano, 2004). 4. Psychological debriefing: This treatment aims at preventing the development of the negative emotional sequelae of trauma. This involves staged, semistructured interview and education of the traumatic experiences and exploration of the emotions associated with the events. 5. Psycho-education and support: Both these are useful helpful as early interventions to reduce the psychological sequelae of trauma. Education mainly focuses on the expected physiological and emotional response to traumatic events, strategies for decreasing secondary or continuous exposure to the traumatic event, stress reduction techniques and self care. Treatment of other family members The other family members also have a tendency to suffer from stress for 2 reasons: 1. The sad loss of their loved one 2. The stressful condition of the wife (mother to the children). These family members may need cognitive and behaviour therapies in the early stage itself to prevent development of acute or post-traumatic stress disorder. They may also be given benzodiazepines to relieve anxiety and sleep disorders. Cultural issues In mental illness, social factors play an important role in a persons decision to seek treatment (Goldman, 2000). People from different cultures have different mental health problems and help-seeking behaviours. Individuals with culturally diverse populations like Africo-Americans are exposed to a multiplicity of physical, social and psychological stressors. They are very unlikely to seek help for mental health problems. This is due to various factors like the cultural belief that mental health is stigmatizing, language communication problem, different cultural explanations for the problems, and an inability to find culturally competent services (Surgeon General Report, 1999). They indicate behaviors that do not meet any one diagnosis but whose severity demand therapeutic intervention (Canino, 2000). Culture influences the way the patients elaborate their symptoms and which symptoms they consider as important reporting. Asian patients are likely to express psychological distress as physical complaints (Kramer 2002). Culture also influences help seeking behaviour of the affected individual, what types of help they seek, their coping styles, the social support they get and the social stigma attached to the mental disorder. A person diagnosed with mental illness may be distanced socially (Lauber, 2004). Each culture has its own style of coping with disorders which buffers some people from developing certain disorders. Legal issues In acute traumatic stress disorder, the victim is a witness to the event of trauma. Hence, the victim has an obligation to report the crime and to cooperate with law enforcement officials. This can be difficult after experiencing the event itself, and characterizes loss of power, control, and dignity. The process of trial also can be traumatizing for the victim. Though the victim requires the support and advocacy of legal representation, the system does not provide it. Though the prosecuting attorney is actually the advocate for the victim, yet, the attorneys job of defending the interests of justice may conflict with the interests of the victim (Gore, 2006).. References APA Diagnostic Classification. DSM-IV-TR. BehaveNet® Clinical Capsule™. Retrieved on 17th December, 2007 from: http://www.behavenet.com/capsules/disorders/dsm4TRclassification.htm Canino, I. A., & Spurlock, J. (2000). Culturally Diverse Children and Adolescents: Assessment, Diagnosis, and Treatment. (2nd ed.). New York: Guilford Press. Goldman, H.H., 2000. Review of General Psychiatry. New York: McGraw-Hill Professional. Gore, A.T., 2006. Posttraumatic Stress Disorder. eMedicine from WebMD. Retrieved on 17 th December, 2007 from: http://www.emedicine.com/med/topic1900.htm Kramer, E.J., Kwong, K., Lee, E., Chung, H., 2002. Cultural factors influencing the mental health of Asian Americans. West J Med., 176(4), p.227–231. Lauber, C., Nordt, C., Falcato, L., Rossler, W., 2004. Factors Influencing Social Distance Toward People with Mental Illness. Community Mental Health Journal, 40(3), p.265-274 Surgeon General Report., 1999. Mental health: Culture, Race and Ethnicity. US Public Health Service. Ursano, R.J., 2004. Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Posttraumatic Stress Disorder. Psych.Org. Retrieved on 17th December, 2007 from: http://www.psych.org/psych_pract/treatg/pg/PTSD-PG-PartsA-B-C-New.pdf Read More