Evaluating Mental Disorder Case Studies

¶ … Mental Illness from a Counselor's Perspective

Alcohol Dependency in Women

Symptoms of Alcohol Dependency

Alcohol dependency or alcoholism is suspected when persons appear to be preoccupied by the consumption of alcoholic beverages (Johnson, 2003). The three prototypical markers of alcohol dependency are a loss of control over the consumption of alcohol, preoccupation with alcohol consumption, and the use of alcohol despite adverse affects on the person's quality of life. For example, Elaine Gustafson was disturbed by her inability to have just a few drinks. According to her, when she went out with friends they would have two to three drinks and she would invariably consume over a dozen drinks until she was drunk.

Effects of Illness

The social consequences of alcoholism differ between men and women, with men typically incurring less condemnation (Johnson, 2003). A drunk male is generally seen as out having a good time, but a drunk female is often characterized as a bad person and sexually promiscuous. This may help explain why 75% of all sexual assaults involve alcohol. In addition, when men and women drink equivalent amounts of alcohol the outcomes differ. Women will become inebriated quicker and symptoms will persist longer. The physiological consequences of long-term exposure to alcohol differs substantially, as well, with organ damage occurring for women with just two glasses of wine per day, compared to six for men. The main organ affected is the liver, but the cardiovascular and nervous systems are also negatively affected. Other problems may manifest, including vitamin deficiencies and cancer. The risk of death is also twice as high for women compared to men. The gender difference in alcohol susceptibility is due in part to women having less water in their bodies to dilute the alcohol and producing less alcohol dehydrogenase enzyme in their stomachs to metabolize ingested alcohol. Women suffering from alcohol dependence are therefore more susceptible to negative health and behavioral outcomes when compared to men.

Alcoholic families can still be socially successful, but the negative consequences will affect all family members (Johnson, 2003). Women who become pregnant and continue to consume alcohol may give birth to children with birth defects. For example, Cathy Mitchell gave birth to five children while she continued to drink. Accordingly, one infant died shortly after a premature birth and another died of Sudden Infant Death Syndrome (SIDS) a few months after birth. Her oldest child suffers from Fetal Alcohol Syndrome (FAS), but Cathy only became aware of this fact after her child reached adulthood. Other disorders related to alcohol exposure during pregnancy include autism spectrum disorders, attention deficit hyperactivity, borderline personality, depression, mental retardation, oppositional-defiant disorder, posttraumatic stress, and receptive-expressive language disorder.

Counseling Interventions

Counseling is an important component of recovery from substance abuse, including alcohol dependence (Marsh, Dale, & Willis, 2007). The three main symptoms of alcohol dependence discussed above, loss of control, preoccupation, and denial, are all amenable to counseling interventions. Of primary importance is the ability of the therapist to quickly establish a therapeutic alliance with the client. Doing so requires the therapist to become a recovery advocate for the client. Another important role is that of educator, thereby helping patients understand alcohol dependency and how to begin and maintain recovery. The video featuring Cathy Mitchell devotes a considerable amount of time to explaining how she was never told that alcohol was more damaging than the opiate drugs she had been taking, especially to fetuses (Johnson, 2003). Although less relevant to the two women featured in the video, therapists should work to ensure that the basic needs of clients are being met, such as food, shelter, and safety, because alcoholism is not uncommon among the homeless, poverty stricken, or domestic abuse victims. When this situation arises the therapist takes on the role of social worker and helps clients find and access the social services needed to resolve these issues. Once these basic needs are met, the work of recovery from alcohol dependency will be that much easier to accomplish. The therapist may also need to evaluate the overall physical and mental health of clients and provide referrals as needed to address comorbid conditions.

Treatments and Supports

Once Elaine Gustafson accepted the possibility that her alcohol dependency was destroying her life, rather than holding it together, she began to attend alcoholic anonymous meetings (Johnson, 2003). This step helped her realize that she was not alone in her struggles with addiction or the only one living the life of an alcoholic. She also learned that stress was a trigger for alcohol consumption and began to engage in effective stress management techniques, including exercise. Elaine also learned to be comfortable spending time alone with herself and gradually became comfortable with the person she became when sober. Cathy Mitchell began her path to sobriety by moving into a residential recovery program for a year away from her family and then spent another year reengaging with her family while remaining in the residential recovery program. These approaches to recovery seemed to work well for these two women. A key element of recovery for both women was becoming educated about the negative effects of alcohol dependency, not only for themselves, but for their children and families.

Finding the Line between Health and Illness

The CAGE test was discussed in the video, which helped identify whether someone may be suffering from alcohol dependency (Johnson, 2003). If a person has ever felt that they should cut back on their drinking, then they have met the "C" diagnostic criteria. If they have been annoyed by anyone criticizing their drinking, this meets the "A" criteria. Feelings of guilt about drinking or needing a drink first thing in the morning would fulfill the last two criteria of the CAGE test. The more of these criteria a person answers yes to, the more likely they may be suffering from alcohol dependence. The diagnostic criteria recommended by the American Psychiatric Association (APA, 2013) are similar and alcohol use disorder is diagnosed when an individual meets only 2 of the 11 criteria within the past 12-months. The diagnostic criteria include loss of control over drinking, preoccupation with alcohol consumption, and denial of a drinking problem, in addition to alcohol consumption interfering with the ability to meet work, school, or family obligations. Cravings, tolerance, and withdrawal are also diagnostic criteria.

Teen Anxiety Disorder

Symptoms

Based on the video from Alexander Street Press (2008), teen anxiety disorder manifests when a pre-teen or teenager experiences constant fear, doubts, and insecurities to the point that it interferes with their ability to function at school or socially and may elicit other serious health problems, such as major depression. From a clinical perspective, these symptoms fit within social anxiety and general anxiety disorders. Clinically-relevant social anxiety can involve an extreme fear or anxiety about being judged negatively by others or making a social mistake that leads to embarrassment. General anxiety disorder, by comparison, consists of chronic worrying about any number of issues, such as those associated with family, health, or academic performance, or may involve a more general concern, such as the threat of terrorism. In contrast to the fears, doubts, and insecurities that accompany the lives of normal adolescents, teen anxiety disorder is not transient and requires treatment by mental health professionals.

The main symptoms that parents may notice include their child avoiding social and school activities (Alexander Street Press, 2008). If this behavior can be verified, then parents may notice that their child is gradually eliminating social activities from their life, alienating friends, and putting the burden of engaging socially on everyone else's shoulders. Another telling sign of teen anxiety disorder is that a child's hesitancy to engage in social activities is refractory to attempts to reassure the child. More generally, parents should be concerned if their child experiences changes or problems with eating, sleeping, schoolwork, general activity levels, mood, relationships, and aggressive behavior, especially if these changes appear to be more than transient.

Effects of Teen Anxiety Disorder

In the Alexander Street Press video (2008) the symptoms of Mia DeSimone were described. These symptoms included her feeling like she didn't fit in socially and these feelings worsened in larger social gatherings, leaving Mia to feel that she could never relax. As Mia approached puberty, physical symptoms began to manifest, including stomach aches, sweating, throat constriction, and ringing in the ears. Spending time at a friend's house would often result in a phone call from Mia asking to come home and when she did return appeared traumatized by the experience. When sitting in classrooms Mia would occasionally experience mental detachment (derealization) or upon waking in the morning begin crying, sweating, experiencing chest pains, shortness of breath, or stomach pains.

These symptoms naturally elicited parental concern, but lacking an understanding of the source of this anxiety, frustration would result (Alexander Street Press, 2008). Some parents will react by becoming overprotective and attempt to ensure their child never experiences anything negative. This in turn fosters the impression, in the mind of the child, that they are incapable of handling the world as it is, which in turn justifies their anxiety. Eventually, the ability of families to function in a healthy way is compromised because family members begin to behave in ways that minimize the chances that the anxious child will experience anything negative. In essence, the family begins to walk on eggshells.

Counseling Interventions

The recommended treatment approach for anxiety disorders is cognitive behavioral therapy (CBT), with adults benefitting the most from individual therapy and children benefitting from either individual or group sessions (Armstrong, 2014). However, social anxiety disorder is best treated by mental health professionals who have training in treating this disorder. When children and adolescents are the clients, involving the parents in treatment is recommended. Given that seeking and obtaining treatment is essentially a social event, anxieties surrounding the initial contact and sessions can be moderated somewhat by minimizing exposure to crowded waiting rooms or using the phone for initial counseling sessions. Clients who cannot or will not attend sessions, self-help materials are available that may provide some benefit. Clients can also be referred to a physician if they are interested in taking antidepressant medications.

Treatment recommendations for children and young people also include psychoeducation, exposure therapy, and social skills training and rehearsal (NICE, 2013, p. 30). Parents of these children and adolescents should be offered psychoeducation and skills training opportunities, to help them teach their child coping and social skills, in addition to exposing the child to anxiety-triggering situations safely.

Treatment Approach Chosen by Mia

When Mia decided to try therapy, she did it without medications (Alexander Street Press, 2008). The course of therapy was 12 weeks, with 14 sessions, of which two included the parents. The first half of treatment focused on teaching and building the skills needed to manage anxiety, including relaxation exercises. Mia's mother learned to detach from Mias's anxiety and simply ask if it would be okay to talk about whatever was upsetting her later, thereby giving Mia the space needed to manager her anxiety on her own. Another important component of the treatment Mia received was exposure therapy. The example given in the video was making a phone call to confront her fear that nobody would answer. Mia would make the call in one room and the person on the other end would let it ring. This approach was used to reduce how much anxiety Mia would feel when confronted with anxiety-producing situations. The treatment was successful, because Mia obtained a part-time job working in a supermarket where she is required to interact with the public. From Mia's perspective, getting the job was "… one of the best things that ever happened to me" (Alexander Street Press, 2008, 00:10:50).

Clinical Social Anxiety

As discussed in the video, social anxieties, doubts, and fears are very common among adolescents (Alexander Street Press, 2008). Therefore, it is important to know when these experiences cross the line and become a threat to the health and well-being of teenagers and those who care for them. Based on the diagnostic criteria for social anxiety disorder (APA, 2013, p. 202), fear of social situations become clinically-relevant when the magnitude of fear or anxiety felt exceeds the actual threat of judgment, ridicule, or embarrassment from peers or others. If the fears, anxiety, and social avoidance behaviors persist for six months, this is also clinically relevant, but an intervention by a mental health professional should occur when these symptoms begin to interfere with the adolescent's ability to navigate life as a student, friend, and family member.

Depression

Symptoms

Based on Linda's experiences, depression created a world that had lost its color and the things that had always been interesting to her no longer were (Linda -- Interview 32). Linda had lost interest in spending time with friends, working, or pursuing an education. At best, she was only interested in sleeping and seclusion, while the thought of dying was the only solution she could think of at the time. She also experienced irritability, negative affect, fatigue, and hypersomnolence. She began to hate herself, her life, and was frustrated with not knowing why she felt this way. This frustration, in turn, fueled a growing hatred toward herself and her life.

A diagnosis of major depression depends on the onset of a depressed mood and/or a loss of interest or pleasure (APA, 2013, p. 160). Both were evident in Linda's depression (Linda -- Interview 32). Other symptoms include irritability, tearfulness, weight loss or gain (> 5%), increased or decreased appetite, insomnia or hypersomnia, loss of concentration, fatigue, feelings of worthlessness, excessive or inappropriate guilt, indecisiveness, and preoccupation with death and suicide (APA, 2013, p. 160). Others may notice psychomotor agitation or retardation.

Effects of Depression

The triggering event for Linda may have been her move to attend university at the age of 18 (Linda -- Interview 32). She remembered that her life began to go downhill, causing her to withdraw from social activities and confine herself to bed. With hindsight, Linda attributed the onset of her depression to the loss of a family support network when she went away to college. Some support for her theory is provided by the persistent feelings of isolation and drifting through life, despite taking an antidepressant medication prescribed by her doctor. Linda's quality of life continued to decline and eventually reached a point where she called her mother to request help with a move back to her home city. After the return home, Linda's depression began to respond to treatment favorably.

One of the unfortunate effects of major depression for Linda was job loss (Linda -- Interview 32). One employer implied that Linda was being lazy and that she was looking for excuses to stay home. The frustration over her employer's attitude and Linda's inability to shrug off her depressed mood and profound fatigue left Linda feeling more isolated and estranged from the world. However, based on Linda's telling of her experiences with depression, her family and friends came to her aide and provided her the support she needed. Linda's social circle may have therefore grown stronger as a result of her struggle with mental illness.

Counseling Intervention

Linda's interview reveals counseling had a positive effect on her struggle to overcome major depression, along with antidepressant medications (Linda -- Interview 32). One of the more effective roles a counselor can assume when treating patients, based on Linda's experiences, is that of teacher. Until Linda sought counseling she had a very rudimentary and misleading understanding of depression, but with the help of the information she was given, Linda began to grasp, at least partially, what was happening to her. Although Linda was not explicit about the benefits of counseling during the interview, its effects can be intuited from her words. For example, recovery for Linda depended on the realization that depression was an illness that can affect a number of people, sometimes for no discernable reason. Recovery therefore depended on releasing the guilt she had been feeling about being depressed, a feeling based on the assumption that she should be able to control the disease. In addition, it helped Linda to realize that she is not alone and that many others have struggled with depression and recovered. Clearly, counselors have a role in helping clients come to the same conclusions.

Treatment Options

The treatments mentioned by Linda were antidepressant medications and counseling, which were apparently effective (Linda -- Interview 32). The first antidepressant Linda tried produced debilitating side effects, but the second was well-tolerated and effective. The benefits of counseling were not discussed in detail, as mentioned above, but Linda's words clearly revealed that counseling was an important component of her overall treatment plan. Any patient presenting in a primary care physician's (PCPs) office with symptoms consistent with a major depressive episode would therefore benefit from referrals to a psychiatrist for a pharmacological assessment and treatment, along with a referral for counseling. If access to psychiatric services is a significant barrier for the client, the PCP could prescribe the antidepressant and refer the patient to a counseling service. Aside from the care provided by mental health professionals, Linda's recovery has benefited greatly by the support she has received from family and friends.

Clinical Depression

Based on Linda's interview (Linda -- Interview 32), she met at least six of the required five diagnostic criteria for major depressive disorder (APA, 2013, p. 160). This included a depressed mood most of the time, lost of interest in previously pleasurable activities, hypersomnia, fatigue, feelings of worthlessness, and recurrent suicidal ideation. Linda did not mention a struggle combating a substance abuse problem or suffering from a major medical condition that could have caused these symptoms, which is consistent with a primary diagnosis of major depressive disorder. In addition, there was no indication that Linda was suffering from psychosis or bipolar disorder, which would tend to support this diagnosis. If, however, her depressed mood lasted longer than 2 years, which seems likely given the information provided in the interview, it would meet the diagnostic criteria of persistent depressive disorder (dysthymia) (APA, 2013, p. 168). Major depression also tends to be comorbid with other mental health disorders, including substance abuse, panic disorders, obsessive-compulsive disorder, eating disorders, and borderline personality disorder. Linda's doctor and counselor have probably been watchful for signs that she may be suffering from another mental disorder. By the end of the interview it becomes clear that Linda is again working full-time, has a boyfriend, and seems to be reengaged in most aspects of her life. This seems to suggest that she no longer meets the criteria for a major depressive episode and is therefore in remission.

Schizophrenia

Symptoms

Peter's symptoms include paranoia, which consists of beliefs that he is being followed and persecuted (Living with schizophrenia, 2014). Peter has also believed that the mafia was out to get him, his phone was bugged, and his TV and radio were broadcasting messages for him alone. His hallucinations include visual, e.g., flashes of light, and auditory. The auditory hallucinations consisted of voices so insidious that he could not tell the difference between his own thoughts, his own voice, and the voices inside his head. According to Dr. Campbell, schizophrenics hear voices inside, rather than outside (2:20) and see things no one else can see; therefore, the mind creates a false image of the external world. People suffering from schizophrenia will experience difficulty focusing their thoughts, remembering what is happening, planning, and dealing with complexity, such that an orderly life will allow individuals suffering from schizophrenia to manage their lives successfully. The onset of psychosis is typically preceded by a prodromal phase, which is recognizable when a person finds it increasingly difficult to relate to family, co-workers, and their environment. This results in a gradual withdrawal from social activities. By comparison, the first psychotic episode typically involves a period of auditory hallucinations, along with paranoia, including the belief that others are intent on harming them.