PRAC 6635 WEEK 2 Clinical Hour and Patient Logs

Sample Answer

1. Generalized Anxiety Disorder

Name: H.L
Age: 23 years

S H.L is a 23-year-old AA female on psychotherapy for GAD. She is currently on her fourth psychotherapy session. The client was referred for psychotherapy by her psychiatrist since she was not responding adequately on medications alone. She is currently on Paxil 30 mg per day. She had persistent excessive worries about her work for about eight months. The worries were accompanied by restlessness, easy fatigue, difficulties initiating and maintaining sleep, irritability, frequent headaches, and muscle tension. The worries affected her occupation functioning since she had a limited concentration capacity. She did not also give much attention to her family, which impaired her social interactions with her spouse and two children. The client reports that the excessive worries are alleviating gradually and she now sleeps better and does not always feel fatigued.

• O: The client is neat and appropriately dressed for the event and weather. She looks calm and maintains eye contact throughout the session. However, she occasionally fidgets on her chair and cracks her knuckles. Self-reported mood is ‘a bit at the edge’ and affect is euthymic. Speech is clear and thought process is coherent.
• A: The client has successfully identified and managed the factors that contribute to her anxiety symptoms. The anxiety symptoms have markedly improved with psychotherapy and she demonstrates improved coping abilities.
• P: Continue with weekly CBT sessions and taking medication.

2. Obsessive Compulsory Disorder

Name: W.F
Age: 23 years

S W.F is a 23-year-old female on psychotherapy for OCD. She was diagnosed after presenting with intrusive thoughts of being contaminated. The thoughts resulted in a compulsion of excessively washing hands and using disinfectant to reduce the distress that came from the obsession. The intrusive thoughts of getting contaminated had contributed to social impairment evidenced by avoiding touching objects in public places, avoiding interacting with people, and frequently visiting the restrooms to wash her hands. Besides, she takes a shower about three times a day since she always feels that she is sweaty and might have bad body odor. Today she reports that although she still feels anxious about being contaminated the anxiety is reducing with time. She states that she tries to abstain from washing or sanitizing her hands as much as possible to improve the OCD.

• O: Self-reported mood was anxious and affect was broad. Coherent thought process and clear speech. She expressed worries about getting contaminated since she had not washed her hands since she entered the office. Obsessions and compulsions noted. No delusions, phobias, or hallucinations.
• A: The client is gradually improving with exposure and response prevention (ERP) psychotherapy treatment. Her coping skills have improved significantly from the previous session and she also puts more effort into relieving associated anxiety.
• P: The client was instructed to continue with the ERP sessions to help eliminate the obsessions fully.

3. Post-Traumatic Stress Disorder

Name: C.H
Age: 48 years

S C.H is a 48-year-old White male on psychotherapy for PTSD. He serves in the military and came from combat four months ago. He reported experiencing flashbacks and nightmares of his experiences during combat mostly when he watched one of his colleagues get multiple shots on his chest. He states that the memories of that shooting incident flashes on his mind every now and then and often leaves him distressed. The flashbacks occurred for six weeks after combat and he was forced to seek treatment. The client reports that he avoids being reminded of the shooting incident since it fills him with fear and he becomes helpless. He also reported having sleeping difficulties due to constant nightmares. The client reported that the PTSD symptoms have significantly impaired his social interactions with colleagues, friends, and family. Besides, he gets the flashbacks mostly when he is at his work station, which has impaired his occupation since he cannot concentrate.

• O: The client is neat and appropriately dressed. He is alert and oriented to persons, place, time, and event. Self-reported mood is ‘terrified’ and affect is constricted. Coherent thought process and speech is clear. No phobias, obsessions, delusions, or hallucinations noted.
• A: Impairment in social functioning from PTSD symptoms. Hallucinatory-like flashbacks noted. No significant improvement with CBT.
• P: Incorporate trauma-focused psychotherapies, including Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT). Instruct the client to continue treatment with Paxil to adjunct psychotherapy.

4. Major Depressive Disorder

Name: W.A
Age: 58 years

W.A is a 58-year-old male who presented with symptoms of having a sad, empty mood nearly every day. He reported losing interest in his work and other activities that previously interested him. Besides, he reported having a reduced appetite that had contributed to a significant weight loss. He also reported having difficulties in sleeping and would get easily fatigued with low energy levels during the day. The low energy levels have affected his work since he is less productive and makes fewer sales. He reported having a diminished ability to concentrate at work and even make decisions independently, which led to a significant impairment in occupational functioning. The client admitted to drinking alcohol and stated that in the past few weeks his consumption has increased since alcohol helps to relieve stress.

• O: Patient is well-groomed and appropriately dressed. He is alert and oriented. Self-reported mood is ‘sad’ and affect is constricted. Coherent thought process. Speech is clear but tone varies throughout the interview. Long term and short term memory are intact. No delusions, hallucinations, or obsessions noted. Judgment is good and insight is present.
• A: Stress overload; Disturbed sleep pattern; Sleep deprivation; Activity intolerance.
• P: Start weekly individualized CBT sessions for 14 weeks. Monitor for suicidal/homicidal ideations in every session. Refer to a psychiatrist for pharmacotherapy.

5. Bipolar Mood Disorder

Name: D.A
Age: 42 years

D.A is a 42-year-old AA male diagnosed with Bipolar after having episodes of severely elevated mood which alternated with episodes of severely depressed mood. The episodes of elevated mood were characterized with high excitement and delusions of grandeur. Besides, the client was overactive, restless, and very talkative than usual. He presented with pressure of speech and flight of ideas. The accompanying relative reported that he would take part in excessive planning but would not finish any of the tasks. In addition, he had a reduced need for sleep and would feel rested after two hours of sleep. However, during the episodes of depressed mood, the client engages in minimal activity, loses interest in activity, and sleeps excessively. He also has an increased appetite and has low concentration levels.

• O: The client is well-groomed but inappropriately dressed for the weather. He is alert and oriented to person, place, and time. He maintains minimal contact and appears over-excited. The self-reported mood is ‘excited’ and affect is broad. Speech is fast with a high volume and tone. He has pressure of speech and flight of ideas. Delusions of grandeur noted. No hallucinations or obsessions noted. Memory is intact. He has poor judgment and no insight to his illness.
• A: The client has severe mania. The mania episodes have not improved from the previous session.
• P: Continue with weekly CBT sessions. Refer to psychiatrist to review drug therapy.

6. Schizophrenia

Name: E.J
Age: 45 years

S E.J is a 45-year-old male who presented for psychotherapy after being diagnosed with schizophrenia. He initially presented with visual hallucinations whereby he reported seeing angels which were following him. He also had delusions of grandeur and claimed that the angels were sent to him by God since he would be the next Messiah. The client’s relative reported that he would often exhibit bizarre behaviors in public and he was always unpredictable. Besides, he could not maintain social norms which affected his social interactions with others. Today, the client reports that the angels still appear but they do not visit him often. He no longer speaks of himself as the next Messiah and does not remember claiming he is a Messiah. The client is currently on oral Risperidone 4mg twice daily.

• O: The client is shabby and inappropriately dressed. He is alert; oriented to person, place, but disoriented to time. The self-reported mood is ‘angry’ and affect is constricted. Speech varies from inaudible to high volume and tone. The client demonstrates loosening of association and poverty of content and speech. He speaks very little using brief and empty phrases. Visual hallucinations present. No delusions, obsessions, or suicidal thoughts noted. Judgment and memory are grossly impaired. He lacks insight.
• A: The client’s has a significant improvement from the previous session with abated delusions and reduced visual hallucinations.
• P: Continue with weekly CBT sessions. Advise the client on medication compliance.

7. Anorexia Nervosa

Name: G.G
Age: 16 years

S G.G is a 16-year-old female on psychotherapy for anorexia nervosa. She was referred for psychotherapy by her PCP due to her overwhelming concern about her body size, weight, and shape. The client was emaciated but still perceived herself to be fat. She was terrified of gaining weight and was preoccupied with plans to lose more weight. The PCP identified the client’s refusal to maintain a minimally normal body weight. Although she realized that she had become underweight she was afraid of consuming adequate food portions out of a concern that she will gain weight and it might get out of control. The client admitted to having a marked dietary restraint, using laxatives, inducing vomiting after eating, and taking appetite suppressants when she is on total fasting.

• O: Weight- 86 pounds, Height-5’2 ft BMI-15.7.
  The client is neat but is emaciated. She is alert and oriented. She appears anxious and maintains minimal eye contact. Speech is clear with normal volume and rate. She has a coherent thought process. She is obsessed with her body shape and thoughts of losing more weight. No delusions, hallucinations, and suicidal ideas noted. She demonstrates good judgment and memory is intact.
• A: The client has gained 3 pounds from the previous session but is severely underweight. She appears less socially withdrawn compared to previous sessions.
• P: Continue with nutritional counseling. Continue with weekly individual CBT and remediation therapy sessions. Integrate Motivational enhancement therapy to help the client become motivated to change her dietary habits.

8. Conduct Disorder

Name: D.N
Ag: 9 years

S D.N is a 9-year-old male referred for psychotherapy by his psychiatrist with a diagnosis of conduct disorder. The child had a history of showing cruelty and disrespect of others’ rights. The disrespectful behavior began at around 7 years and had evolved over time. The boy’s mother reported that there were numerous complaints from school of the boy bullying his classmates, threatening, and intimidating them. Besides, he would steal his classmates’ lunch and often picked fights with them. The mother had been given several warning and the boy was in the verge of being expelled. In addition, she reported that the boy was aggressive to people and animals at home and has severally destroyed peoples’ belongings. The behavior has interfered with the child’ school performance and interaction with his peers.

• O: The boy is neat and appropriately dressed. He is alert and oriented to person, place, and time. He appears anxious and maintains minimal eye contact. Self-reported mood is ‘angry’ and affect is constricted. Speech is clear with normal rate and volume. Coherent thought process.
• A: The child demonstrates ineffective coping behavior and self-esteem disturbance. He has a risk of violence. The child has impaired social interaction
• P: Begin family therapy and incorporate parenting skills in psychotherapy. Encourage parents to put the child in a less stimulating environment. Encourage parents to educate the child on unacceptable behaviors and their consequences. Teach the child appropriate social skills. Introduce play therapy for the child to learn social and basic skills and express his feelings.

9. Attention Deficit Hyperactive Disorder

Name: F.L
Age: 6-years

S F.L is a 6-year-old male accompanied by his mother for psychotherapy. The mother states that the boy is hyperactive and easily distracted and he cannot even complete a simple task due to a short attention span. Besides, the boy is impulsive and does things without thinking of the consequences. His low attention span has led to significant problems at school and home. The child’s class teacher reports that he experiences difficulties at school and lags behind in his class. The teacher attributes the academic difficulties to deficits in memory and thinking. In addition, the mother states that the boy is uncontrollable at home due to his impulsive behaviors. He must be supervised by an adult at all times to avoid causing problems. He is currently on Methylphenidate 18 mg once a day.

• O: The boy is well-groomed, neat, and alert. He maintains minimal eye contact, but repeatedly moves from his seat and roams around the office. He frequently interrupts the therapist and with unnecessary talks. His Speech is loud but has a coherent thought process. The self-reported mood is “bored,” and the affect is constricted. He has a limited attention span with easy distraction and recent memory is impaired but long-term is intact. Deficits noted in calculation concentration. Judgment and abstract thought are intact.
• A: Attention deficit and easy distractibility. Hyperactivity and Impulsivity. Thinking and memory deficits.
• P: Continue with Behavioral psychotherapy in school. Continue treatment with Methylphenidate. Continue with weekly parent training and social skills training.

10. Generalized Anxiety Disorder

Name: K.G
Age: 15-years

S K.G is a 15-year-old teen on psychotherapy due to excessive anxiety. The client presented excessive anxiety and worries about her studies. She was ever-concerned about meeting her parents’ expectations. She reported that the excessive anxiety was difficult to control even when resting which caused difficulties in initiating and maintaining sleep. The anxiety symptoms begun about seven months ago. She also mentioned that she felt keyed up and had her mind would often go blank. She easily got fatigued and had become easily irritable at school and home. Today, the client reports some improvement in her anxiety symptoms with improved sleep.

• 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 was ‘anxious’ and affect was congruent. Speech was clear with normal rate and volume. Coherent, linear, and goal-directed thought process. Client expressed worries about her studies. No Delusions, hallucinations, or suicidal/homicidal ideations were noted. Memory, abstract thought, judgment, and insight were grossly intact.
• A: Significant improvement in anxiety symptoms, from a GAD-7 score of 15 to10. Client was more engaged in the psychotherapy session.
• P: Continue with weekly psychotherapy sessions alongside drug therapy.
  Focus more on CBT to enable the client change distorted thoughts contributing to the anxiety symptoms. Integrate CBT to help the client gain perspective on her stressors, create and maintain relationships, and manage her stressors.

11. Binge Eating

Name: S.L
Age: 16 years

S S.L is a 16-year-old teen on psychotherapy for Binge Eating Disorder. She had binge eating episodes that presented with a sense of lack of control over eating in the past three months. She reported feeling that she cannot stop eating and has no control over the amount she can eat. The client often experiences psychological distress due to the binge-eating episodes. She had the binge episodes 1-2 times a week in the past three months. However, she denied engaging in inappropriate compensatory behavior such as vomiting or using laxatives. The client admitted eating much more rapidly than usual until she felt uncomfortably full.

• O: The client is neat and well-groomed. She is alert, somewhat nervous, and fidgets throughout the session. The Self-reported mood is anxious and affect is expansive. Her speech is clear with normal rate and volume. Coherent and goal-directed thought process. Oriented to person, place, and time. Insight is limited. Wt-158 lbs. Ht- 5’1 BMI- 29.9
• A: The client has an improved mood compared to previous sessions. Feelings of guilt present. Overweight.
• P: Continue with weekly CBT sessions and evaluate client’s perception on body shape and weight. Incorporate Behavioral weight loss focusing on self-monitoring strategies for weight loss.

12. Autism Spectrum Disorder

Name: A.M
Age: 5-years

S A.M is a 5-year-old boy referred for psychotherapy by a pediatrician for Autism Spectrum Disorder. The boy’s mother mentioned that his social interactions were inappropriate for his age. He experienced difficulties in developing peer relationships appropriate for his developmental level. He also had a marked impairment in expressing various non-verbal behaviors such as facial expression, body postures, and gestures in regulating social interaction. In addition, the boy had delays in the development of spoken language with stereotyped and repetitive use of language. The mother stated that he did not participate in make-believe and social imitative plays appropriate for his developmental level.

• O: The boy is neat and well-groomed. He lacks a social smile when greeted. The child was bit uncooperative during the psychotherapy session. He repeatedly flapped his fingers during the session. Language delays were noted. He exhibited impairment in the use of eye-to-eye gaze, facial expressions, body posture, and gestures. He lacked social and emotional reciprocity. Exhibits impairment in the ability to sustain a conversation.
• A: Impairment in social interactions. Impairments in communication and language
• P: Begin weekly therapies in centering on Auditory and sensory integration training and Exercise, and Physical therapy. Incorporate assisted communication to the weekly therapy using letter and word boards, and keyboards to assist the child in communication.