Age: 40 DOB:
Referral source: Gender: Female
Sonia B., 40 y.o. Asian-American divorced woman
Presenting Problem:
Sonia claims that her problems are begging to interfere with her life. Being divorced for 6 months and living both her son and daughter possess huge stress of survival. Initially she presents a character regarded as professional and neat appearance to insinuate a middle-level management lady who is successful in career something that is not the cases. Sonia reports that she considers herself as a lady of high class and standards who criticizes herself especially if she fails to meet self target and expectations. Failure to achieve or attain her set objectives, Sonia feels worthless and even shame. She has been struggling with the feeling of shame and worthless due to her inability to perform for a long time both at workplace and at home (Colbert, 2004).
Sonia reports that she always experience fatigue which in return destructs her concentration both at workplace and at home. She does not give her two children the attention and concentration they deserve. She exhibits some characteristics of unfriendliness, dissatisfied and has suicidal thoughts which force her to have this desire of dying. However, she also has the feeling that her death may affect her children greatly and thus denies having suicidal thoughts.
History of the present Illness:
Sonia is reported to have come from an abusive marriage which saw divorced in the past 6 months at the age of 40 years old. Sonia is reported to have developed this unfriendly behavior which has exhibited her as irritable as well as withdrawn habit. She displays signs of a lost concentration and less attention towards her children and work. Therefore, the doctor claims that she be assessed for thyroid condition. It seems that her status began after her divorce about six months ago which led to her incompetence at place of work. Her coworkers claim that she has been an easy-going personality and very friendly. She wishes for her own death but still thinks of her children’s reaction after her death. She reported that after the divorce her life has not been the same again. There is no other historical information conveyed.
Lethality Rating/Concerns:
Sonia wishes for her early death even though she denies having suicidal thoughts. She has eventually lost her concentration for her job as well as her own children. She has a feeling of being worthless and shameful due to her incapability to perform effectively at her place of work.
Mental Health History & Previous Treatment:
Sonia has never been to a psychiatrist in the past as her problem started immediately after the divorce. However, a doctor recommended that she undergo through a thorough assessment for thyroid condition due to all the symptoms recorded.
Medical and Substance abuse History:
Sonia seems to have no history of related medical as well as substance abuse such as alcohol or drug history.
Legal history:
Sonia seems as a person who has no significant legal history. However, she was divorced in a period about 6 months ago.
Family Growth and Development
Sonia reports that she has had an abusive marriage which eventually led to a divorce. Since her condition, Sonia has shifted all attention from her two children to her sorrows as a result of professional incompetence. She seems to value her job than her two children and thus giving them less concentration than before.
Clinical Formulation:
Sonia is supposedly to be a successful a middle–level manager who works harder to make her career more effective. She has been the employment for 10 years in which she worked in the same company. Despite the fact that Sonia has worked for this company for 10 years, she has developed some fears of losing her job. This issue appears to have a negative influence on her condition. Sonia appeared to have encompassed a lifestyle aimed at achieving all her set targets and interests and thus she aims to accomplish her OCD behaviors. This simply portrays Sonia as a person with an extensive past that unveils her obsessive as well as compulsive thoughts and behaviors. This feeling has forced her to regard her job as more important than her two children. Even though Sonia is an accomplished and successful middle- level manager, her job seems to control all her symptoms that unveil her obsessive behavior. This condition has pushed her to the extent of seeking assistance from a professional who in return determines the fact that her willingness to change also distresses her. For instance, Sonia wishes to die but at the same time she shifts her attention to start minding her children reaction and life after her death.
Therefore, Sonia’s Symptoms are heavily persistent with DSM-IV TR’s OCD criteria.
DSM-IV
Axis I
300.3 Obsessive Compulsive Disorder
309. 29 R/O Adjustment Disorder with Depression
Axis II
301.4 Ruled out the possibility of a possible Obsessive Compulsive Personality Disorder Fatigued. This characterized by feeling of worthless, irritable, low concentration, self-critical, wishes for her own death.
Axis III
Possible high production of thyroid glands and hormonal conditions
Axis IV
Problem with social environment, problem related psychosocial and environmental problem.
Axis V
GAF 65
Recommendations and Referrals:
It would be essential for Sonia to start her therapy sessions in order to deal with OCD. This implies that she should be recommended to an effective physician for an appropriate evaluation which would confirm the presence of thyroid disorder which is the main cause of Sonia’s OCD as well as any available medical factor contributing to her illness. Additionally, Sonia should be referred to a psychiatrist who will be able to apply the use of psychotropic medications on her effectively. Sonia can always be encouraged and even supported to regularly attend any meeting involving persons with OCD symptoms in the society. This move would ensure that she receives various types of counseling on the current situation which would enable her related appropriately with her coworkers well as well as showing compassion and giving her two children the concentration they deserve. Moreover, the counseling sessions would enlighten her that at times a person may fail to deliver as expected but still there is always another chance to redeem herself.
Suggested Treatment Plan
Long Term Goals:
- Alleviate and ease the depressed mood and thus return to the previous or earlier appropriate functioning.
- Reduce or decrease the negative impact of the traumatic event as well as the pre-trauma level of functioning.
- Identify, recognize, accept and manage the feelings of depression.
- Eliminate and terminate all behaviors considered as destructive that promote self-denial and implement all behaviors that promote acceptance of events, responsible living and total healing (Rothfeld, & Romaine, 2003).
- Establish and develop healthy and cognitive patterns as well as beliefs concerning self and the world which lead to the alleviation of the depression symptoms.
- Eliminating all beliefs, thoughts and perception connected to the past life events and thus maximize the time free issues such as obsessions and even compulsions.
- Resolve main conflicts, emotional stress and beliefs that usually fuels the obsessive compulsive actions or behavior and compulsions of the patient.
Short Term Goals:
- Describe all the past and current experiences with the complete depression with its full impacts and attempt to resolve the problem.
- Determine all necessary measures to stop the depression or any death wishes through completing the psychological testing to analyze the depth and level of the depression.
- Stating that the patient has no longer any sign of harming herself.
Possible treatment methods:
In order for one to restore the thyroid disorder, normal blood levels of the thyroid hormones through usage of certain drugs (Friedman, & Yu, 2008). Therefore, the professional should establish effective rapport with the patient which aims towards developing a therapeutic alliance. This would provide a chance for professional to examine all possible causes which lead to obsessions and compulsions. Therefore, the expert would start administering the OCD treatment in order to determine both the illness depth and breadth.
Medication:
Usage of levothyroxine and triiodothyronine drugs will help in the treatment.
Additional Information Questions:
- Have ever experienced any other signs and symptoms apart from the ones mentioned?
- Do you have the feeling of being agitated or restless?
- Do you experience panic attacks?
- Do you experience insomnia or difficulty in sleeping even if it is for a day?
- Do you act on dangerous impulse
- Have you noticed unusual changes in your behavior?
- Do you experience new or even worse irritability?
- What are some of the activities you do when angry or irritated?
References
Colbert, D. (2004). The Bible cure for thyroid disorders: [ancient truths, natural rememdies, and the latest findings for your health today]. Lake Mary, Fla: Siloam.
Friedman, T. C., & Yu, W. (2008). The Everything Health Guide to Thyroid Disease: Professional Advice on Getting the Right Diagnosis, Managing Your Symptoms, and Feeling Great. Avon: Adams Media.
Rothfeld, G. S., & Romaine, D. S. (2003). Thyroid balance: Traditional and alternative methods for treating thyroid disorders. Avon, Mass: Adams Media Corporation.
