PRAC 6635 WEEK 1 Clinical Hour and Patient Logs

Sample Answer

1. Separation Anxiety Disorder

Initials: D.P
Age: 6 years

S D.P is a 6-year-old boy on psychotherapy for Separation Anxiety Disorder. The mother reported that the child has an intense fear when being separated from his family. He develops anxiety when leaving home because it entails such separation and when sleeping in a different room from loved ones. The anxiety is accompanied by fear about isolation from loved ones. The child has persistent and excessive fear of being left alone at home without close family members being around. As a result, the child is often reluctant to go to school and he has in many circumstances refused to go to school until he is accompanied by his parents. The mother reported that the child often complains of having stomachaches and headaches when going to school or when he is separated from his family.

• O The boy is neat and appropriately dressed. He is alert and leans close to his mother throughout the session. He appears anxious and maintains minimal eye contact with the therapist. His self-reported mood is nervous and affect is appropriate. He speaks in low volumes and talks minimally. He demonstrates coherent thought process.
• A Physical symptoms secondary to separation anxiety. School refusal.
• P Start the child on family CBT comprising psychoeducation and exposure to anxiety producing stimuli and situations. Incorporate training of somatic management skills, such as diaphragmatic breathing and progressive muscle relaxation.

2. Post Traumatic Stress Disorder

Initials W.A
Age 15 years

S W.A is a 15-year-old AA female who presented with complaints of having intrusive thoughts about a fatal road accident she was involved in five months ago, which left her with a broken femur. She witnessed several people profusely bleeding and two died on the spot. The memories of the accident constantly recollect in her mind, which give her an intense fear and leave her helpless. She reported having a specific flashback of a man who was stabbed by a glass in his left eye and the screams he made during the accident. The client stated that hooting and loud bangs startle her since they remind her of the car accident. Besides, she avoids travelling because being in a car reminds her of the traumatic event. She often gets distressed when in a vehicle, which is accompanied by palpitations and profuse sweating. The client also reported having difficulties sleeping because she often gets nightmares about the accident. She wishes that she never has to sleep due to the constant nightmares.

• O The client is neat and appropriately dressed. She is alert and oriented to person, place, and time. Self reported mood is nervous and affect is appropriate. Coherent thought process and clear speech with normal rate and volume. No obvious obsessions, phobias, delusions, hallucinations, or homicidal/suicidal ideations.
• A Impairment in social functioning. Insomnia; Startle reactions; acute episodes of anxiety and panic.
• P Initiate exposure therapy. Teach the client stress management techniques, such as relaxation techniques and cognitive approaches, to coping with stress.
  and response prevention (ERP) sessions to alleviate obsessions.

3. Avoidant Personality Disorder

Initials S.N
Age 11 years

S S.N is a 11-year-old White accompanied by her mother with reports that she is usually unwilling to get involved with other people. The girl has been socially withdrawn because, which she attributed to having an increased sensitivity to criticism from others. Besides, she avoids social situations due to a yearning to avoid criticism and she disengages from friendships due to the fear of others’ disapproval. The client admitted to having very few friends and has difficulties making friends at school. She stated that her feelings of inadequacy have inhibited her from interpersonal relationships.

• O The client is well-groomed an appropriately dressed. She is alert and oriented to person, place, and time. She appears anxious and tensed and maintains minimal eye contact throughout the interview. The self-reported mood is nervous and affect is constricted. She speaks in low tones and a slow rate. She has a coherent thought process.
• A The client has an excessive concern about social rejection She has a withdrawal from new social situations. She has a negative self-concept.
• P Incorporate assertive training in behavior therapy to teach the client to openly express her needs and improve her self-esteem. Introduce the client to group therapy to help gain an understanding of the impact that sensitivity to rejection has on her and others.

4. Social Anxiety Disorder

Initials R.L
Age 11 years

S R.L is a 11-year-old Black client who reported having an intense fear of public situations such as speaking in class, eating in a restaurant, and speaking in public. The phobia was caused by fear that she might do or say something embarrassing while being watched. As a result, she avoids being in public or acting in a manner that will make her a center of public attention. Besides, she would experience intense nervousness while in public places which interfered with her ability to socialize with others. The client reported that she would also experience episodes of profuse sweating, palpitations, and increased urinary frequency while in a public place or when asked to speak in class. This has affected her participation in class as well as her academic performance.

• O She is alert but appears nervous. She maintains minimal eye contact and occasionally fidgets on her chair. She has a coherent thought process. Social phobia is apparent. No hallucinations, obsessions, delusions, or suicidal ideations noted. Short-term and long-term memory is intact. She has good judgment. Insight is present.
• A The client has anxiety secondary to the social phobia. Avoidance behavior has interfered with her academic and social functioning.
• P Initiate CBT to alleviate anxiety related to public places and social awkwardness.

5. Obsessive-Compulsive Disorder

Name J.O
Age 14 years

S J.O is a 14-year-old White female with recurrent and persistent thoughts about being dirty and contracting disease-causing organisms. The obsession with thoughts and ideas that she might have contracted microbes led to marked anxiety and distress. To overcome the obsession, she is compelled to repetitively wash her hands, take a shower about three times a day, and would spend lots of time in the shower than usual. The obsessive symptoms negatively impacted her social life as she avoided public places, shaking hands, and touching surfaces in public.

• O The client is well-groomed, alert, oriented x3, and maintains eye contact. The self-reported mood is nervous, and affect is broad. The client reports that she still feels at risk of contracting infections, especially in public places. However, she is can now shake hands with people, and the urge to wash her hands has reduced to some degree.
• A The client’s anxiety symptoms have reduced to some extent. She recognizes the connection between cognition, affect, and behavior, as well as the presence of distorted automatic thoughts.
• P Continue with weekly CBT sessions, to help the client identify and challenge the cognitive distortion of OCD symptoms. Incorporate Exposure and response prevention in the CBT.

6. Anorexia Nervosa

Name A.Z
Age 15-years

S A.Z is a 15-year-old who reported being afraid of gaining weight. She was concerned that if she took lots of food, she would gain weight. The client admits to eating very small portions of food and missing some meals to avoid weight gain. She also avoids taking fluids since they enlarge her tummy. When she takes large portions of food, she always feels guilty and, in return, induces vomiting and uses OTC enemas to limit food absorption. She states that weight gain will be a personal failure and thinks that her thighs and arms are too fat and thus needs further weight loss.

• O The client is neat and appropriately dressed but emaciated. The client is alert but appears anxious and maintains minimal eye contact. The self-reported mood is nervous, and affect is broad. Speech is clear with normal rate and volume. Coherent thought process and no hallucinations, delusions, and suicidal ideations noted. Preoccupation with thoughts about weight gain and body shape. Cognition, judgment, memory, and abstract thought are grossly intact. Insight present. Weight- 98 pounds, Height-5’4, BMI-15.3.
• A Anxiety; Profound psychological disturbance about body size and weight.
• P Weekly Cognitive-behavioral and cognitive remediation therapies. Include Insight-oriented Individual therapy and Motivational enhancement therapy.

7. Major Depressive Depression

Name P.L
Age 45-years

S P.L is a 45-year-old White woman presented with a depressed mood for about six weeks, characterized by feeling sad, empty, and hopeless most of the day and nearly every day. She also reported having a decreased appetite which had caused a weight loss of about 8 pounds. A.L also stated that she had low energy levels and would feel fatigued even after sleeping for long hours. She reported having lost interest in most pleasurable activities and decreased ability to concentrate and make decisions. The symptoms had significantly impaired her occupational and social functioning. She was diagnosed with MDD and started on CBT.

• O The client is well-groomed and appropriately dressed for the weather. She is alert and maintains eye contact. The self-reported mood is happy, and affect is euthymic. Speech is clear with normal volume and rate. The thought process is coherent. No delusions, hallucinations, or suicidal/homicidal ideations were noted. The client is oriented and recent, and long-term memory is intact. PHQ-16
• A Improved mood and behavioral changes. Increased attention and concentration span. The client exhibits an increased interest in psychotherapy.
• P Continue with weekly CBT sessions. Focus CBT to Mindfulness-based cognitive therapy to prevent relapse of depressive symptoms.

8. Bipolar Disorder

Name R.S
Age 37-years

S R.S is a 37-year-old AA male with a history of prolonged and profound episodes of depression that alternated with episodes of excessively elevated mood. He had severe mania, which was marked with severely elevated mood with delusions of grandeur and excitement. The wife reported that when the client had an elevated mood, he would be very talkative than usual, overactive, and restless. He would also be engaged in excessive planning but unable to complete any tasks. The client engaged in excessive pleasurable activities that often had painful consequences. The client stated that he did not find the need to sleep and felt rested after 2-hours of sleep.

• O The patient is untidy and inappropriately dressed for the weather. He is alert and oriented but restless. The self-reported mood is excited, and the affect is expansive. He has a pressure of speech, flight of ideas and is somewhat distracted. He has delusions of grandeur. Insight is impaired and has poor judgment. The client was distracted at the beginning of therapy but became calm with time.
• A Increased manic symptoms with elevated self-worth. Reduced symptoms of the pressure of speech and flight of ideas. The client is more engaged and interested in psychotherapy compared to the previous session.
• P Weekly Interpersonal therapy. Introduce Milieu therapy to encourage the client to take personal responsibility.

9. Panic Disorder

Initials S.C
Age 23 years

S S.C is a 23-year-old female client with a history of panic attacks. She experiences acute panic attacks, which are not specific to any stimuli. The attacks occurred rapidly and peaked in intensity within 20-30 seconds and were always unpredictable. She reported that the panic attacks were accompanied by a sensation of breathlessness, profuse sweating, chest discomfort, palpitations, and a feeling of dying. The attacks occurred mostly in public places, which made her to avoid public places. She reported that she felt anxious when in public places because she feared that she would get a panic attack which would leave her helpless and in an embarrassing situation. She stated that alcohol calms her nerve and she has increasingly been taken it every day since it reduces the anxiety.

• O The client was alert but seemed anxious and maintained minimal eye contact. Her self-reported mood was anxious and affect was appropriate. The speech was clear but the rate varied from normal to fast. Coherent thought process. No apparent obsessions, hallucinations, delusions, or suicidal/homicidal ideations. Clear judgment and abstract thought. Insight is present.
• A The client has anticipatory anxiety as evidenced by fear that panic, with helplessness and humiliation, will occur. The panic attacks have resulted in a maladaptive behavioral change to avoid future attacks.
• P The client was initiated on CBT to help control anxiety and the panic attacks. Integrate Panic-Focused Psychodynamic Therapy to help eliminate panic symptoms and associated maladaptive behaviors.

10. Alcohol Use Disorder

Initials K.K Age 45-years
Sex Male Race White

S K.K is a 45-year-old White male on psychotherapy for AUD. He was brought to the clinic six weeks ago by his brother with reports of alcoholism. The client has been taking alcohol since he was 18 years. In the past year he has been taking 5-7 glasses of whiskey per day and states that he could not stay without it. The excessive drinking has contributed to social and interpersonal problems. His alcohol consumption has led to an inability to fulfill major role obligations at work and home. He states that he attended Alcoholics Anonymous severally, but he keeps on relapsing. He also smokes tobacco 1PPD but states that tobacco is not a problem like alcohol. He has no history of psychiatric admission or medical condition attributed to Alcohol use.

• O He is alert, maintains eye contact, relaxed, and cooperative throughout the session. Speech is clear with normal rate and volume and an appropriate length of answers. Coherent and goal-directed thought process. No delusions, hallucinations, or suicidal/homicidal ideations were noted. The short-and long-term memory is intact. Attention and concentration levels are somewhat affected.
• A Improved mood, behavior, and cooperation. He demonstrates more interest in the psychotherapy session. Exhibits determination in fighting off the alcohol craving. Increased attention and concentration levels compared to the previous session.
• P Group therapy to help him learn social skills and coping mechanisms to avoid relapse.

11. Generalized Anxiety Disorder

Initials N.P Age 42-years
Sex Female

S N.P is a 42year-old White female on psychotherapy for anxiety disorder. The client has excessive anxiety and worries about her job. She was promoted to a managerial position and seven months ago and is ever-concerned about meeting the expectations. The excessive anxiety is difficult to control and has caused difficulties in initiating and maintaining sleep. She reports feeling keyed up and her mind often going blank. She easily gets fatigued and easily irritable.

• O The client is well-groomed and appropriately dressed for the weather. She is alert but maintained minimal eye contact and was a bit uneasy during the interview. Her self-reported mood is nervous,’ and her affect was congruent. The speech was clear with normal rate and volume. Coherent, linear, and goal-directed thought process. The client expressed worries about her job and was preoccupied with thoughts about the job. No Delusions, hallucinations, or suicidal/homicidal ideations were noted. Memory, abstract thought, judgment, and insight were grossly intact.
• A Anxiety related to job concerns; Insomnia.
• P Initiate CBT. Train the client on coping mechanisms

12. Post-Traumatic Stress Disorder

Name P.F
Age 38-years
Sex Male

S P.F is a 38-year-old Asian male on psychotherapy for PTSD. He is a military officer and reported re-experiencing traumatic events that occurred when he was in combat. He stated that he experienced a persistent high level of anxiety when he re-experienced the combat events. The client also reported experiencing intrusive recollections and nightmares of his worst experience in the combat when he witnessed his colleague being shot by terrorists. The intrusive memories often resulted in intense psychological distress and the client reported that he avoided thoughts and feelings associated with the shooting of his colleague. In addition, he reported having an increased arousal which was not present before the combat event such as difficulty initiating and maintaining asleep, outbursts of anger, and difficulty concentrating. The symptoms had lasted for 8 weeks and had caused significant impairment in social and occupational functioning.

• O The client appears anxious. The self-reported mood is ‘Anxious,’ and affect is congruent. Speech is clear, but rate and volume escalates when the client talks about the combat event. He also becomes agitated and develops tremors when discussing the shooting event. Thought-process is coherent and goal-directed. No delusions, hallucinations, or suicidal ideations were noted.
• A Vigilance and startle response. Emotional distress when reminded of the combat events. Improved range of positive emotions.
• P Weekly sessions of Trauma-Focused CBT.