Treatment plan for Ms. Jean Harlow's major depressive disorder

¶ … 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.

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.

Objectives (describes what will be accomplished in order to meet longer term goals)

Behavioral-cognitive therapy to establish more awareness and better understanding.

Increased exposure to perceived stressors and situations that cause anxiety to lessen its effect.

Relaxing techniques to keep the patient level-headed when faced with anxiety and struggle.

Group therapy to express and communicate stress and anxiety.

Methods or Interventions

Interventions are needed if patient is not responding well to treatment. Signs of not responding to treatment involve: regression to old habits, disturbances in sleep or eating habits, and increased hallucinations and delusions. One such intervention could be done with the psychatrist followed by a re-evaluation of medications to see which ones are not working and which ones are. This would be followed up by blood tests to observe any changes in patient's body. Lastly close monitoring a few days after the intervention to see if any progress is made.

Group therapy can be an effective method because it lets the client know he/she is not alone. It's helpful to know there is a person having the same exact problems as you. It also teaches patients about what not to do when faced with dilemmas and improves their overall communication and ability to convey thoughts and emotions.

Estimated Length of Treatment

It takes a long time to effectively treat patients with recurring mental health problems. In patient treatment where the patient is in a psychatric facility lasts anywhere between 4-6 weeks Out patient treatment follows for 6-12 months with monitoring of the medication dosages and gradual lessening of visits and medications.

Patient needs to be taught effective coping strategies and self-esteem buidling. Behavioral therapy also takes time as exposure to stressors is done slowly and gradually. Things of this nature can take more than a year. There needs to be monitoring and evaluations made periodically to check for progress.

Outcome Measures (what measures you will use to assess client progress/outcome)

If patient has decreased or no hallucinations and delusions. This would be an excellent sign that progress is made. Through therapy if the patient seems more upbeat and interested, this is also a sign she is getting better. It is important to note that patients who show signs of increased social interaction and less isolation point to signs of progress.

Another outcome measure would be the increased ability to comminicate and convey emotions and thoughts. Usually people who are depressed exhibit no signs of communication and if they attempt to are met with confusion. They do not understand or are aware of what is presently there. They instead are focused on the cycles and patterns that took over their life. Increased awareness is an excellent marker for improvement.

Self-Critique

The strengths one possesses in regards to treating the client was the ability to effectively communicate and convey a sense of trust. If the client feels as though they will not be judge and can indeed trust the doctor treating him/her, success proves to be easier and faster. The weakness is the overall limitations of diagnosis. One cannot see and understand exactly what the client is feeling because one cannot be in their shoes. Having good interpersonal skills is a must in creating a bond with the client therefore getting more from the client in order to diagnose and treat. Lack of diagnostic tools to help identify disroders constantly presents a challenge. Any ethical issues faced by building a doctor-patient relationship is always on the horizon because of the chance a patient or doctor might become too close and cross personal boundaries.

It is difficult to improve the quality of life for a patient. This is especially true for patients of increased age and recurring mental health problems. It is possible to alleviate the struggle these people face by providing a structure and set long-term goals patients can follow. Communication is key in order to improve anything. Without effective communication, the doctor nor the patient will be able to solve any problem.