Fictional Case of Ms. Jean

¶ … fictional case of Ms. Jean Harlow and her need for a treatment plan. The beginning of the paper describes the case in detail of Ms. Harlow and her mental disorder. It describes the events that took place in her life that would lead her to seek the attention of a psychiatrist as well as a more in depth look in how someone with a mental disorder might behave in order to be able to observe and evaluate.

The treatment plan for her mental disorder involves antipsychotic medications as well as antidepressants. She demonstrated symptoms of Major Depressive Disorder with Mood-Incongruent Psychotic Features. This was evidenced by her hearing voices and feeling lethargy and disinterest in her daily life and social interactions.

In the later sections her reactions and responses to treatment will be discussed followed by the ways problems experienced by the patient can be solved and alleviated. The section titled: "Treatment Plan" is the short version that raps up the overall treatment phase. The latter will describe more of the process along with short- and long-term goals.

Ms. Harlow experienced a lot of mental health issues that are recurring and therefore this paper explains ways patients with recurring mental health problems can learn to better cope with their issues to effectively deal in the long run with mental stress and depression. Certain outcome measures will be assessed such as how the patient is able to function in a social setting and how she is able to deal with stress triggers to see just how far along in terms of progress she is making.

As difficult as it is to manage mental health problems, the last section will explain how difficult or easy it was to help and treat the patient. There are certain strengths and weaknesses that can hinder or progress the overall tratment of a patient. The doctor patient relationship is important and trust must be established in order to effectively help the patient get better and stay in a form functioning that isn't destructive to the patient and the world around them.

Detailed Description of Case

Ms. Jean Harlow is a scrawny, messy 59-year-old overweight woman with a slight British accent. She was being treated at a medical clinic for an upset stomach when she mentioned briefly she had been hearing voices. This immediately prompted the doctor treating her to send her for a psychiatric evaluation. During the evaluation Jean expressed through a story what exactly happened to her that would prompt her to say she heard voices.

One day she invited her friend for coffee. She and her friend, a male, shared a plutonic friendship. Nevertheless they went to her house and while Jean was taking a nap, she felt as though her friend was on top of her. She opened her eyes, saw him on top of her and ran out of her house confused and worried. When she came back shortly after he was gone, she decided to call him to find out why he was on top of her and found out he never was. He left shortly after she took a nap. Was this a hallucination, she asked herself.

She always had problems with her weight and one day she heard someone call her a fatso. She brushed it off even though it upset her a little bit. Then when she was walking to the grocery store she heard of string of taunts saying she's fat, ugly, and even insulted her clothes. She looked around and didn't recognize any evidence that these words spoken were actually coming from people's mouths. She didn't know whether they were in her head or real, though it seems they were more so in her head. All of this happen within a one month span.

She became so paranoid, she genuinely believed everyone in her neighborhood thought she was a hideous beast. Jean was so rattled by this she decided to go to her mother for some guidance. Her mother simply stated it was all in her head and to pay no mind to it. During the evaluation as Jean is explaining all of this, she is still hearing those voices taunting her.

When describing her mood and how she felt, Jean said she felt crappy and "nervous, rattled." She doesn't admit to feeling depressed though exhibits signs of depression. These signs are: lack of interest in socially interacting with friends or participating in any sort of activity. She even stated her appetite has decreased and she has lost weight. At first she was excited to see the weightloss but now she states she feels weak and tired all the time. The one thing she says has stayed the same is her sleep habits.

She mentions she only really feels guilt when the voices are taunting her. Although she has no suicidal tendencies due to her religious beliefs, she expresses how better off she would be if she somehow stopped breathing. She mentions an episode like this happened to her 10 years ago. It was not to this extent, but she did hear voices and felt lethargic.

She went through outpatient treatment for 6 months and took medication though Jean cannot recall the name of the medication she took. She continued her job as a store manager at a GAP store. Her weight during this time fluctuated and eventually she gained so much weight that she was experiencing pain in her knees when she walked.

She has been with her live in boyfriend now for 11 years and has a 9-year-old son. Jean drives him to various sports activities. She spends a lot of her time with her son or at work. Her boyfriend works as a sales representative and puts in long hours.

One thing that Jean mentions is she has not had an alcoholic beverage or a cigarrette for 35 years. When her memory was evaluated she just said she sometimes forgot her keys or would leave the door to her home unlocked. Later the psychiatrist performing the evaluation wanted to interview her boyfriend to find out more information about her.

Her boyfriend mentioned to the psychiatrist that her episode prior was similar to this one now and that she was looking anxious and nervous for the past few days. He also mentioned she was and has always been very sensitive to remarks from others.

Her sensitivity was noted when observing the way she looked for approval as she was being evaluated. She wanted to know if she was a good listener. She also wanted to let it be known she is good at following directions and wanted very much to be liked.

Treatment Plan

The first step in creating a treatment plan is determining the appropriate diagnosis. The first diagnostic question to consider is whether or not the voices Jean hears are hallucinations or obsessions. The fact she described the "voices" as repetitive, and stereotypical suggests that they are most likely obsessions. The problem with this is that she perceives it as coming from other people, eventually everyone she interacts with or sees therefore pointing to the "voices" as being true hallucinations that are delusionally elaborated.

Could a Mood Disorder be at the root of the delusions and hallucinations? Her behavior points to that being the case. She said she experienced a decrease in mood and desire. Even her recurrent thoughts of death contribute to this being a Mood Disorder although she ruled out suicide. There are enough symptoms to classify this as a Major Depressive Disorder (DSM-IV-TR, p.376) Also what can be added is that it is recurrent since she experienced a similar episode 10 years ago.

Another facet of the diagnosis to acknowledge is her lack of guilt when experiencing the hallucinations and delusions. So in addition to the diagnosis would be with Mood-Incongruent Psychotic Features (DSM-IV-TR, p. 413) The preferred treatment would be for a prescription of antipsychotic medication on an inpatient unit. Thereshould be no antidepressent medication used until the voices disappear and the depressive symptoms worsen.

As the patient was treated with the above mentioned plan for four weeks, she was allowed to be treated on an outpatient basis. Although the patient was much improved she demonstrated Obsessive-Compulsive Disorder evidenced by the recurring requests for ressurance that she is not gaining weight and is not ruining her diet. New antidepressents were then applied that specifically helped with Obsessive-Compulsive Disorder. A year went by and Ms. Jean Harlow was free of her symptoms and was able to return to a baseline form of functioning.

Relevant Information

Major Depressive Disorder is a disorder that often is identified by a low mood associated generally with low self-esteem. This is followed by a loss of interest in normally enjoyed activities such as social gatherings and hobbies. This disorder affects a patient's work, family, and/or school life. Not only are the social areas of a person's life diminished in quality and connection but also there is an effect also in a patient's eating and sleeping habits.

A diagnosis of Major Depressive Disorder is usually determined through the observation and evaluation of the person's own self-reported experiences. No form of testing, including laboratory tests can determine if a person has this kind of disorder. It is only through analysis of the person's behavior and communication can a psychiatrist identify the disorder.

Major Depressive Disorder tends to exhist in people who have had depression for quite some time or have had recurring depression. Although it is difficult to identify it can be determined and identified. Treatment usually involves cognitive-behavioral therapy.

Mood- Incongruent psychotic features is a term used to describe the characteristics of psychosis. The psychosis usually consists of delusions and hallucinations. They tend to be consistent with an elevated mood such as experienced in Bi-Polar disorder or in depression such as Major Depressive Disorder.

Something such as Schizophrenia is a Mood-Incongruent Disorder. Mood- Incongruent psychotic features tend to be established in people with depression if the hallucination does not involve themes of personal inadequacies, death, or deserved punishment. When it comes to manic disorders the hallucinations would not consist of themes of inflated worth or a special relationship to a deity.

An example of Mood- Incongruent psychotic features would include self-derogatory or grandiose hallucinations. This would include thought insertion and broadcasting along with delusions of being controlled. People with Mood- Incongruent psychotic features tend to feel as though they are being judged in some way.

DSM-IV-TR Multiaxial Diagnosis

Axis I is used for disorders such as Major Depressive Disorder. Axis II in the DSM system is used for personality disorders such as Obsessive-Compulsive Personality Disorder. The patient Ms. Harlow demonstrated characteristics that would fall in this Axis. Although she was not suffering from catatonia, she did display some of the symptoms. "Catatonia is a syndrome of motor dysregulation characterized by mutism, immobility, negativism, posturing, staring, rigidity, stereotypy, mannerisms, echophenomena, perseveration, and automatic obedience, among others." (Fink & Taylor 2003)

Axis IV deals with environmental issues such as social issues and financial difficulties that might add to a person's existing mental issues. Studies have also linked age to display signs of difficulty in creating effective treatment for mental disorders. "Intolerance to antidepressant medications and the presence of medical conditions are known to be age related." (Fink et al., 1996) Ms. Harlow is at that age where an intolerance to medication can be an issue.

Referral

ECT or Electroconvulsive therapy seems to be a treatment that has had high success rates in treating most forms of depression. "Regarding subtypes of depression, ECT appears to be effective in treating both melancholic and severe nonmelancholic depression as well as bipolar and unipolar major depression. In addition it may be particularly effective in treating psychotic major depression. (Husain et al.) Ms. Harlow experienced bouts of depression before. A round of ECT might be beneficial to her.

There are some forms of delusional depressives that do not respond well to ECT. "The dichotomy lost its clinical significance after the introduction of ECT, as both groups were equally responsive. However, accumulating evidence indicates that unipolar delusional depressives are significantly less responsive to tricyclic anti-depressant therapy than non-delusional depressives. " (Kantor & Glassman, 1977) Some people who supposedly suffer from TRD or therapy-resistant depression are actually suffering from some other unrecognized illness. "Patients with what's called "therapy-resistant" depression (TRD) -- with subtherapeutic response to medications and psychotherapy -- are often actually suffering from unrecognized, inadequately treated psychotic depression."(Kellner, Fink, Knapp) Some studies have been done recognizing the high success rate of ECT as a means of therapy. "Among patients who completed the full ECT course (at least 12 sessions), remission rates were 96% for psychotic depression and 83% for nonpsychotic depression. The overall remission rate was 87%. " (Kellner, Fink, Knapp) " ECT was shown to be superior after a full course. The funnel plot showed the absence of publication bias. There was no exaggeration of effect size in the lower quality trials. No evidence was found for a superior speed of action of ECT or for a difference in efficacy between sine wave and brief pulse stimulation." (Kho et al. 2003)

Further studies analyzed delusional depression and ECT efficacy. "The treatment responses of 597 patients with delusional depression from 17 studies were compared. Patients were treated with either tricyclic antidepressants (TCAs), antipsychotics (APs), the combination of TCA/AP, or electroconvulsive therapy (ECT). The overall responses were 34% in the group treated with TCA, 51% in the AP group, 77% in the TCA/AP group, and 82% in the ECT group." (Kroessler 1985) Ms. Harlow was diagnosed with depression along with experienced delusions and hallucinations. ECT might help patients like Ms. Harlow in preventing recurrence.

Studies help to determine not only the efficacy of treatments, but also the quantitative data needed to generate a long-term solution. "The study group consisted of 125 women and 62 men, 180 (96%) of whom were Caucasian. The mean age of the subjects was 62 years (SD=18). The median length of the episode of depression before ECT was 25 weeks (range=2 -- 416 weeks), and the median number of medication trials was four (range=0 -- 30). Psychotic features were present during the index episode of depression in 53 patients (28%). Despite receiving a comparable number of medication trials before ECT, patients with psychotic depression were significantly less likely than those with nonpsychotic depression to have received at least one adequate pharmacotherapy trial (rated 3 or higher) (table 1). (Mulsant et al. 1997) ECT appears to be a means of effective treatment for different types of depression. It also appears to treat elderly patients who might be intolerant to medications.

Presenting Problems

Axis I: Primary presenting problem (such as major depressive disorder or bipolar disorder). Patient Jean Harlow demonstrated signs of disinterest in social activities as well as daily activities such as work, hobbies, etc. These problems were then followed by signs of dissatisfaction.

Obessive-Compulsive Disorder was also noted in the patient displayed by wanting constant reassurance and having cyclical, negative thoughts. Patient demonstrated desire to end life even if it was not through self means, but rather by chance. Overall Jean's behavior and daily routine presented signs of depression.

Hallucinations and delusions made up some of Jean's problems. She stated they were recurring and noted that it affected her as they worsened. All or most of the hallucinations and delusions were negative and judmental towards her. They all felt very real for her and increased her depressive state.

Goals (long-term)

The long-term goals or Ms. Harlow is to establish coping mechanisms that positively deal with sudden stressors in life and improving her overall self-image. Self-esteem seems to be crucial in developing a better reaction to stress and social interactons. Medications can be used for management of the hallucinations and delusions as well as anti-depressants to stimulate more daily activity and promote less anxiety. This in turn will provide a better outlook on the situation.

Overall Ms. Harlow should be able to deal with any mental distress seeing as her depression is recurring and could happen again during a tragedy or health scare. Poor self-image stemming from her past and her obsession with her appearance must be dealt with in order to create a positive mindset for her. A better understanding and awareness is crucial for the patient to readily identify any problems should they arise.

Reality is a difficult thing to face. A lifetime goal for Ms. Harlow is to better deal with life as a whole and to better know herself. Increased awareness, increased acceptance of who she is and what has happened will lead to a better overal outlook. This will then lessen depressive incidents.