Do Kendra’s presenting problems result from patterns of interaction with others?
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Indeed, Kendra seems to be having personal problems especially when it comes to interacting with other people. It is evident from the case study that she feels quite uncomfortable mixing with peers and other acquaintances. For instance, she is often quite scared of going to bed at night. This might be as a result of intense fear that has built up with time and therefore her mind perceives people as less friendly. Besides, she appears to lack trust and confidence in people bearing in mind that her level of interaction is very low.
Additionally, Kendra also demonstrates symptoms of low self-esteem as it is evident when she admits that she is “empty” alongside being frustrated most of the time. This perceived frustration may also be a symptom of developing stress that is now culminating in depression. The fact that she feels pity may explain why Kendra does not seem to value being sociable with others.
Are there recent stressors that may account for Kendra’s symptoms? Do these symptoms warrant an adjustment disorder? If so, is this an isolated situation or part of a general pattern?
Kendra’s problems are caused by internal feelings of being abandoned. For example, she tells that her friends do not want anything to do with her. She has strong feelings that her friends ignore her yet she has done nothing to warrant this kind of behavior. However, it can be noted that there are no strong stressors, just minor ones that emanate from within. These symptoms and the stressors lead Kendra to isolate herself from the rest, which in itself is an adjustment disorder. By definition, adjustment disorders are strong reactions to a particular stressor and are quite diagnosable (Schultz & Videbeck, 2008). This is quite an isolated situation because, in essence, the factors are not contributed by any external influence. They are just some hard feelings of neglect, low self-esteem, and is empty.
Is Kendra under the influence of any substances or medical conditions that may account for her anxiety or depression?
Kendra is not under the influence of some substances and hers is just a medical condition. The fact that her condition worsens when she has sleepless nights means that the problem is quite internal and not from any triggers. She also suffers from frustrations which prompt her to do strange things like hitting the wall.
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Might Kendra have a mood disorder? Can her self mutilation behaviors be considered suicidal?
By definition, mood disorders are adjustment problems that come from stressors emanating from the inside and which at times can be triggered by factors that cannot be controlled and which are capable of altering the behavior or an individual (Ghaemi, 2007). Here then, it is easy to identify Kendra’s problem as a mood disorder. This is because her problems come only after some factors like sleepless nights and feelings of isolation. These problems make her feel frustrated and neglected and trigger her to hurt herself. These problems can lead her to commit suicide; for example, she even hurts herself by hitting the wall.
Are there any manipulative behaviors displayed by the client? If so, are they related to a desire for nurturance or personal gain?
From the case study, the problems Kendra is suffering from are not manipulated nor are they for gaining some favors. In some instances, Kendra has come to hurt herself meaning that it is impossible to manipulate oneself resulting in injuries. In the definition of manipulative behavior, Columbus (2007) notes that the latter is usually planned by an individual before acting and is usually executed for gainful purposes. This is different from Kendra’s case, where, she is genuine of her problems and cites several causes for these extreme behaviors.
How would you characterize Kendra’s sense of identity?
Kendra hates herself, and therefore, she seemed to disapprove of herself as somebody who is of worth. She has low self-esteem and does not believe that she can control the problem all by herself. This is characterized by the many time she has to visit the hospital meaning that anytime she has a little problem, she rushes to the aid of other people. Persons who have low self-esteem or lack self-worth believe that they cannot solve any problem all by themselves and when they fail to get assistance, they become aggressive towards other people (Leary & Tangney, 2005).
The Multi-Axial Diagnosis assists in describing a person by some domains that are perceived to be of high clinical importance (Woo & Keatinge, 2008). The following discussion places Kendra’s problems into this form of diagnosis and looks at the weight of each axis as per Kendra’s condition.
Kendra has an anxiety disorder which is characterized by frustrations, fear, and lack of self-confidence. Doctors can only treat her to stabilize her mind.
Kendra has an anxious personality disorder which is characterized by feelings of inadequacy. She has a negative evaluation of herself which makes her avoid social interaction with others. This is a long-term problem hence the diagnosis should also be long-term.
The problems exhibited by Kendra are physical or medical problems. For example, sleepless nights and high frustrations lead her to harm herself by hitting walls and other objects. These are impacted by her present condition and these can be treated as short-term measures.
There are no environmental factors that are prompting Kendra to behave the way she does. However, some psychosocial factors are influencing her behavior. For example, the feeling of being neglected by her peers worsens the situation. Doctors can concentrate on alleviating her feelings to alleviate her from these deep hurting feelings.
Kendra’s mental stability can be put at only 30 on a scale of 1-100. 30 as her grade is prompted by the analysis that she recognizes herself and can describe her problems. The remaining 70 percent is because she is unable to control herself and some of her behaviors are extreme to an extent of hurting her.
Rationale and differential diagnosis
Doctors should first start by alleviating her physical problems. For example, they should start by treating wounds that are inflicted by mental instability. The second step should be giving her confidence or trying to improve her worth (Stout & Randy, 2005)… The third step is confining her to high attention units where her conditions would be monitored diagnosed by qualified medical personnel.
Since her condition emanates from feeling a lack of self-worth and neglect by her peers, it would be necessary if she is confined for some time in a place that she can interact well. Mental homes cannot solve this problem since she is not suffering from mental instability. She should be placed in a community that would encourage lots of interaction without having a feeling that she is suffering from mental problems.
Techniques and Support to be given
The client needs adequate socialization and encouragement from doctors. The doctors are the only friends that she runs to whenever she has problems, and therefore, socialization should start with the doctors.
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Columbus, A. (2007). Advance in psychology research: Volume 38. New York: Nova Science Publishers.
Ghaemi, S. N. (2007). Mood disorders: A practical guide. Philadelphia: Lippincott Williams & Wilkins publishers.
Leary, M. R., & June, P. T. (2005). Handbook of self and identity. New York: Guildford Press.
Schultz, J. M., & Sheila, L. V. (2008). Lippincott’s manual of psychiatric nursing care plans. Philadelphia: Lippincott Williams & Wilkins Publishers.
Stout, C. E., & Randy A. H. (2005). Evidence-based practice: Methods, models, and tools for mental health professionals. New Jersey: John Wiley & Sons, Inc.
Woo, S. M., & Carolyn, K. (2008). Diagnosis and treatment of mental disorders across the lifespan. New Jersey: John Wiley & Sons, Inc.
Table 1: Biopsychosocial Risk and Resilience Assessment for the Onset of the Disorder.
|RISK INFLUENCES||PROTECTIVE INFLUENCES|
|Biological || |
|Psychological || |
|Social || |
Table 2: Biopsychosocial Risk and Resilience Assessment for the Course of the Disorder.
|RISK INFLUENCES||PROTECTIVE INFLUENCES|
|Biological || |
|Psychological || |
|Social || |
Table 3: Suicide Risk Assessment.
|SUICIDE RISK INDICATORS|
|1. PRESENTING PROBLEM OR REQUEST FOR ASSISTANCE: |
– Anxiety adjustment disorder and avoidant personality disorder
|2. TRIAGE: |
|Note: If the person answers “Yes” to 2d above and the level of risk is determined to be severe at this point, and a mobile crisis response team has been dispatched to continue the assessment, it is unnecessary to complete the remainder of this form.|
|3. IDEATIONS: (Describe any thoughts of dying or killing oneself in detail, using the person’s own words. Include circumstances that trigger suicidal thoughts.) |
Ideation is: Periodic
|Middle- it starts with a feeling to hurt me against a hard surface such as a wall |
It occurs only when there is a strong feeling of neglect and self-worth
|4. PLAN: (How would the person carry out ideations? Use details, a person’s own words.)||By use of cognitive skills and especially engaging the brain of the client|
|5. MEANS: (Instruments/methods to be used; access to instruments. Use details, person’s own words.)||Low: This method would not require any physical instrument but just engaging the brain of the individual|
|6. LETHALITY: (Dangerousness of the plan. Use details, person’s own words.)||Low: This method is not dangerous since it does not involve putting an individual under intensive care|
|7. INTENT: (Reports desire and intent to act on suicidal thoughts. Use details, person’s own words.)||Low: there are no thoughts of suicidal actions|
|8. HISTORY: (Suicide and self-harming behaviors, self and family; Attempts: number, when, method, lethality, rescues, etc. Begin with past three months.) |
What has prevented a person from acting on suicidal thoughts in the past?
|High: she tends to harm herself and in the past 3 months she reported on 6 occasions involving harming herself. However, her past does not have such kind of cases, and this only means that the problems do not have high ties with the past|
|9. SUBSTANCE ABUSE/USE: (History of use/abuse, access to substances, including family member substance abuse) |
Is the person currently using? If so, list substance(s), amount, and when taken.
|Note: The client does not have any history of using drugs. However, her father has had a history of using some inferior substances|
|10. ACUTE LIFE STRESSORS: (Situation/recent changes with family, relationship, job, school, health, divorce, marriage, grief, losses, financial, residential instability, bullying, etc.)||She lives alone, no family member is close to her residence, is jobless, single, and out of school. Her financial status is worse.|
|11. DEPRESSION/AGITATION: (Affect, anxiety, restlessness, symptoms of depression)||High: The client suffers from restlessness, some signs of depression, and high anxiety.|
|12. HOPELESSNESS: (Future orientation)||High|
|13. PSYCHOTIC PROCESSES: (History/symptoms of psychosis, delusions, and auditory/visual hallucinations. Include dates, diagnoses, meds.)||High – 12th, 15th, 21stand 27th|
|14. MEDICAL FACTORS: (History/current medical conditions including chronic and severe pain, terminal illness, etc.)||High: Mental instability and physical harm|
|15. BEHAVIORAL CUES: (Isolation, impulsivity, hostility, rage, etc.)||High|
|16. COPING SKILLS: (Helplessness, the negation of self and others)||High|
|17. SUPPORT SYSTEM: (Family, friends, co-workers, roommates, spiritual affiliation, civic, school, etc. Define relationship(s) and details using a person’s own words.)||Low: she seems to be alone in her world|
|18. OTHER FACTORS: (OPTIONAL.If previously mentioned, describe any recent lifestyle changes, sexual identity/orientation issues, involvement with w/justice system, communication skills)||She is single, low communication skills, and low involvement in justice matters|
|19. CULTURAL CONSIDERATIONS: (OPTIONAL.If mentioned, describe a person’s attitude towards suicide—acceptance, ambivalence, rejection, etc; cultural views on death and suicide; specific concerns) |
– She has an attitude towards harming herself, does not seem to have any strong following of her culture, and accepts herself as a failure and hopeless.
|20. OVERALL RISK LEVEL(based on clinical judgment): Middle|
|21. REASONING: (Identify risk factors and factors offsetting/mitigating identified risks) |
– Low self-worth, lack of socialization, lack of maternal care, and joblessness
|22. ACTION TAKEN: |
Yes: Client signed crisis plan- the client agreed to be placed under mental care with other individuals
Yes: Interim Service Plan Completed- confining her to intensive care to alleviate some of the identifiable mental problems
Medical Report 1: Goal Setting and Treatment Planning
- Treat any symptoms emanating from biological problems
- Diagnose problems that are connected to the psychology of the client
- Devise measures to alleviate Kendra from socialization problems
- Devise treatment measures of curing medical problems emanating from biological factors, low socialization, and psychological problems.
Medical Report 2: Evidence-Based Practices
- Adopt a group therapy method whereby the client would be placed among others suffering from the same condition.
- Prescribe anti-anxiety medications and anti-depressants especially for Axis I diagnosis
- Put the client in self-help groups and communities that are experts in handling such kind of cases.
- Offer a lot of socialization to the patient so that she can feel like part of the larger community and remove her from extreme thinking.
- Employ cognitive therapy, social skills training, and exposure treatments
Medical Report 3: Critical Perspective
- Is it always that people who exhibit extreme social behavior suffer from an anxiety disorder?
- Is it always that biological factors contribute to low self-worth, and would the diagnosis always be imposing maternal care?
- With a rating of 30 on a scale of 1-100, does that equate to mental instability, and does it warrant confining a client to group therapy?
- Since some people have extreme personality and adjustment disorders, is it always that doctors would give the absolute solution?
- Could Kendra be suffering more than her feeling of low self-worth and a strong feeling of neglect from her peers?
- Is it possible that the prescription provided that goes with avoidant personality disorder would aggravate the problem more than it is already?
Medical Report 4: Mental Status Exam
- Clients interaction – good with the physicians but very low with other individuals
- Motor activity – agitated and restless
- Mood- anxious, helpless, and depressed
- Affect – appropriate to thought content
- Self-concept- low self-esteem
- Speech- normally responsive and spontaneous
- Thought process- circumstantial and loose associations
- Thought content – hypochondriacal depressive
- Intellectual functions
- Sensorium- person
- Memory- recall is immediate
- Intellectual capacity- abstraction and comprehension
- Estimated intelligence- below average
- Judgment and impulse control- poor
- Insight- poor
Medical Report 5: Report of Intake Interview
Interviewer: John Richard
Date of Interview: 12/10/11
A female, 5.2”, fairly dressed, and blonde
Kendra is suffering from intense helplessness and fair mental instability. She has reported some physical problems such as hurting herself by hitting the walls of her rooms.
Mental Status Exam Summary
Suffering from intense low self-worth and depression
Other Current Problems and Difficulties
Physical problems such as injuries in her forehead and right arm, low socialization levels, and hopelessness
Present Life Situation
Living alone and seems to have little family ties.
No close family. Her father three years ago whiles her mother left her and her whereabouts unknown.
The problem started early in the year and was said to start when her peers started to neglect her. This was then aggravated by her intense thinking of her situation.
Medical and Treatment History
For the last 3 months, she has been treated for physical injuries and an unstable mind.
Substance Use History
She does not have a history of substance use
Case Conceptualization, Including Strengths and Areas of Difficulty
The problem has complexities especially bearing in mind that her problems emanate from various factors such as family, socialization, gender, marital status, and joblessness.
Despite the many contributing factors, the client seems to respond to the initial diagnosis giving hope that the problems would be cured.
Treatment Plan Goals
- Plan on training the client on exercises which are naturally anxiety reliever and stress busters.
- Planning on a Bio-feedback program that measures some physiological functions such as heart rate, muscle tension, and breathing.
- Using relaxation therapy by training the client how to maintain composure
- Hypnosis therapy by helping the client faces her fears in new established ways.
Medical Report 6: Relevant Evidence-Based Practices
Psychosocial outpatient treatments – these are mostly for the adults’ psychotherapy, however, they can also be applied in light cases (Stout & Randy, 2005). Since the severity of Kendra’s problem is not high, it is possible to use this method on her.
Family-based therapy- a family is recognized as an integral player in any form of treatment. Family-based therapies have shown general effectiveness in several cases. Kendra does not have a family of her own or close relatives who can take care of her. However, it is possible to create an artificial family for her by assigning any concerned person to take care of her.
Community-based therapy- everyone delights being in a community. This community has friends who offer moral support to any person who may be in some problems. For Kendra’s case, confining her to a partially mental home may work to alleviate her psychological problems.
School focused interventions – Kendra is already out of the school age bracket, however, it does not mean that she cannot go back to her studies. Once she improves her condition by use of other integrated medications. School-based therapy has proved perfect for children and young adults suffering from psycho problems. It therefore can be effective if it could be applied to Kendra. However, this can only be when all medication plans have been applied.