PRAC 6635 WEEK 3 Clinical Hour and Patient Logs

Sample Answer

Social Phobia

S K.D is a 7-year-old White female on psychotherapy due to social phobia. She reported having an intense fear of public situations such as speaking in class, eating in a restaurant, and speaking in public. The phobia was due to 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.

• O: On exam, she is alert but appears nervous. She maintains minimal eye contact and occasionally fidgets on her chair. The speech is clear with normal rate and volume. Exhibits a coherent thought process.
• A: Social phobia is apparent.
• P: Cognitive behavioral therapy.

Generalized Anxiety Disorder

Ss T.D is a 38-year-old female diagnosed with GAD after presenting with symptoms of excessive worry about her job. She got a job promotion and had a lot of pressure to perform and meet the management’s expectations. She was unable to control the excessive worries for the past eight months. This resulted in being constantly restless, having muscle tension, and difficulties in concentration. Besides, she reported that she was having difficulties falling asleep, which led to constant fatigue during the day and headache.

• O: She was alert and oriented to person, place, and time. She maintained eye contact throughout the session.
• A: D-7 score-15.
• P: Continue with weekly CBT sessions. Incorporate sleep hygiene training to alleviate insomnia.

Panic Disorder

S G.F is a 17-year-old female with complaints of having panic attacks. She reported that she experienced acute attacks of worry, which were 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.

• O: She was alert but seemed anxious and maintained minimal eye contact. Her self-reported mood was anxious and affect was appropriate.
• A: Panic attacks.
• P: Initiate cognitive behavioral therapy and integrate Panic-Focused Psychodynamic Therapy.

Separation Anxiety Disorder

S D.Z is a 10-year-old male whose mother reported that he 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. When sleeping away from his family, the child develops nightmares. The boy 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 boy often complains of having stomachaches and headaches when going to school or when he is separated from his family.

• O: The boy has anxiety is accompanied by fear about isolation from loved ones.
• A: Separation anxiety; School refusal.
• P: Family CBT comprising psychoeducation and exposure to anxiety producing stimuli and situations. Training of somatic management skills.

Adjustment disorder with anxiety

S P.K is a 34-year-old female with marked distress after losing her job. She reported having a hard time adjusting to life after job loss and considers the loss a major failure in her life. She reported that in the past four months she has been having excessive worry, anxiety, sleeping difficulties, and is constantly angry. She mentioned that although she got a new job two months later, she feels trapped and isolated and does not like the job. As a result, she has poor concentration levels and has not been performing compared to her previous job.

• O: The self-reported mood was anxious and affect appropriate. She demonstrates a coherent thought process. She has a good judgment and abstract reasoning.
• A: Problems with adjustment.
• P: Initiate cognitive-behavioral therapy and incorporate supportive psychotherapy.

Post traumatic stress disorder

S B.B is a 20-year-old female who presented with complaints of having intrusive thoughts about a fatal road accident she was involved in seven 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 flashbacks about the accident. Consequently, she avoids travelling because being in a car reminds her of the traumatic event. She stated that 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.

• O: Anxious and fidgets a lot. Coherent speech and thought process.
• A: Startled reaction and avoidance.
• Plan: Exposure therapy and teach the client stress management techniques.

Obsessive Compulsive Disorder

S P.H is a 38-year-old female with an obsession of doubt characterized by constantly checking doors and locks in her house and shop. She reported having an abnormal concern about having forgotten to lock the door upon leaving the house and her shop. The doubt causes marked psychological distress, which compels her to frequently check the locks. She reports that she has in many occasions left her house at night to go check if she locked her shop. Besides, she frequently wakes up at night with doubts of having failed to lock the door. The obsession of doubt has contributed to poor concentration levels while at work since she is always concerned that she did not lock the house door.

• O: Anxious and fidgets a lot. Coherent speech and thought process.
• A: The obsessions and compulsions are time-consuming and interfere extensively with her normal routine, occupational functioning, and normal social activities.
• P: Exposure and response prevention sessions. Incorporate thought-stopping and aversive conditioning.

Postpartum Depression

S P.L is a 19-year-old female referred by her PCP for psychotherapy due to postpartum depression. She presented with uncontrollable worries about her 10-week-old child’s health and well-being. She reported having a feeling of intense sadness and despair four weeks after delivery. She was tearful most of the day with an inability to experience the pleasure of activities she enjoyed before delivery. Besides, she had sleeping difficulties and was always fatigued during the day. She mentions that the sleep disturbances are caused by the baby crying often and having to wake up frequently to breastfeed him. The symptoms had interfered with her ability to function and the PCP was concerned that they would cause risk of harm to the mother and infant.

• O: Depressed mood; Broad affect; No suicidal ideations.
• P: Individual psychotherapy with cognitive-behavioral and interpersonal therapy.

Major Depression

S W.E is a 17-year-old female who 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 12q pounds. 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.

• O: The self-reported mood is sad, and affect is broad. Her speech is clear with normal volume and rate. The thought process is coherent. No delusions, hallucinations, or suicidal/homicidal ideations were noted.
• A: PHQ-16. Impaired school and social functioning.
• P: Weekly CBT sessions in addition to medication therapy.

Obsessive-Compulsive Disorder

S U.H is a 14-year-old 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 was 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 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.
• A: Impaired social functioning.
• Plan: 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.

Attention Deficit Hyperactive Disorder

S J.K is a 6-year-old boy who presented with hyperactive, impulsive behavior, and inattention. The child’s mother reported that the behavior started when he was about 4 years. He had temper tantrums and still has problems with anger management. The mother mentioned that the behavior has interfered with his school life since he cannot remain still in class. The teacher reported that it was difficult to contain the child in class since he would move when a class was in session and talk excessively. He was also easily distracted and made impulsive decisions.

• O: He is unable to maintain one sitting position throughout the interview and wanders around in the office. The self-reported mood is happy, and the affect is elevated. His speech is clear but loud, and his thought process is coherent.
• A: Deficits in attention.
• Plan: Behavioral psychotherapy and Behavioral parent training.

Avoidant Personality Disorder

S S.D is an 11-year-old female whose mother reported 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: 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.
• A: Social avoidance.
• 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.