aCase Study on Kathy
CASE STUDY ON KATHY
1. Demographic Information
The client, Kathy, is a 45-year-old Caucasian woman. She is divorced with two children, ages 14 and 12. She works full-time as a nurse for a nephrology practice. Kathy made an appointment for herself at the Family Counseling Center seeking therapy after an extended period of feeling depressed, despondent, and lethargic.
2. DSM-5 Diagnosis
Kathy presents with a principal diagnosis of late onset Persistent Depressive Disorder (F34.1) with melancholic features. The current severity of this diagnosis is moderate to severe.
Kathy’s symptoms are consistent with persistent depressive disorder. During the appointment, Kathy presents with a depressed mood. According to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association [APA], 2013), the depressed mood must be present on most days, for most of each day, for at least two years (p.168). Kathy states that she has felt especially despondent for at least 2 1/2 years, although she has experienced some symptoms of depression for more than ten years, and that she is usually lethargic and “blue”. The DSM-5’s criteria for persistent depressive disorder includes poor appetite (APA, 2013, p.168). Kathy explains that she doesn’t feel like eating when she feeds her children, and that she has involuntarily lost 20 pounds within the last year. The DSM-5’s criteria for persistent depressive disorder includes insomnia (APA, 2013, p.168). Kathy states that she has a difficult time falling asleep at night and wakes up very early in the morning; she is usually unable to go back to sleep. DSM-5 criteria for persistent depressive disorder includes fatigue (APA, 2013, p.168). Kathy reports that she is lacking energy on a daily basis.
CASE STUDY ON KATHY She states that she doesn’t have the energy to do everyday tasks, like going to her health club or cooking dinner for her family. DSM-5 criteria for persistent depressive disorder includes low self-esteem (APA, 2013, p.168). Kathy has expressed concern that she is not an adequate mother for her children. The DSM-5’s criteria for persistent depressive disorder includes poor concentration (APA, 2013, p. 168). Kathy states she has had difficulty concentrating when she is at work, and that she has struggles to focus on her children’s activities. DSM-5 criteria for persistent depressive disorder includes feelings of hopelessness (APA, 2013, p. 168). Kathy explains in the interview that she feels negatively about her future. The DSM-5 states that a criteria for persistent depressive disorder is a consistency of symptoms wherein a break from symptoms lasts no longer than two months (APA, 2013, p. 168). Kathy explained that she experienced a time of feeling better when she joined a health club, but that this period of time only lasted for two months.
According to the DSM-5, persistent depressive disorder is characterized as late-onset when onset is at age 21 or older (APA, 2013, p.169). Kathy’s diagnosis of persistent depressive disorder can be characterized as late onset; she states that her symptoms began at age 32, and that her childhood, adolescence, and early adulthood were happy.
Kathy presents with persistent depressive disorder with melancholic features. According to the DSM-5, a persistent depressive disorder with melancholic features diagnosis is given when an individual presents with a loss of pleasure in almost all activities, or a lack of reactivity to usually happy events (APA, 2013, p. 185). Kathy has stated that she has become increasing despondent and has lost interest in her children’s lives. Her diagnosis is characterized as having
CASE STUDY ON KATHY melancholic features because she also meets the necessary three criteria out of the six: she presents with depressed mood characterized by profound despondency, she detailed her early-morning awakening, and she has experienced significant weight loss. These are diagnostic components of persistent depressive disorder with melancholic features, according to the DSM-5 (APA, 2013, p. 185). Kathy’s persistent depressive disorder is specified as severe because she meets six of the six criterion symptoms, the intensity of her symptoms is distressing, and the symptoms are interfering with her functioning, specifically her functioning as a parent and at her job (APA, 2013, p. 188).
There are several Z Codes to consider for Kathy. The first Z Code is Z63.5, Disruption of Family by Separation or Divorce. According to the DSM-5, this category is used when an adult couple is living apart due to separation or divorce (APA, 2013, p. 716). Kathy has only been divorced for three years, after a marriage of over 20 years. Another Z code to consider is Z63.4, Uncomplicated Bereavement. According to the DSM-5, this category is used when clinical attention is directed to the reaction to the death of a loved one (APA, 2013, p. 716). Kathy’s mother died of cancer two years ago, only one year after her divorce. A few months later, her father was diagnosed with cancer, and Kathy became his caregiver. Kathy is grieving the death of her mother, the end of her marriage, and the impending death of her father at the same time. The Z Code Z60.2, Problem Related to Living Alone, can be considered as well. This category should be used when a problem related to living alone has an impact on the client’s treatment (APA, 2013, p. 724). Kathy moved into her husband’s home directly from her parents’ home at the age of 21. While she is currently living with her children, she has never lived in a home without another adult. This situation may be contributing to her feelings of loneliness and isolation. A final Z Code to consider is Z60.4, Social Exclusion or Rejection. According to the DSM-5, this category should be used when the individual experiences a recurrent social exclusion within one’s social
CASE STUDY ON KATHY environment (APA, 2013, p. 724). Following her divorce, Kathy has been feeling rejected from her group of friends, who were mostly an extension of her ex-husband’s social circle. She does not reference any other source of friend or family support in her interview.
3. Differential Diagnoses
Major depressive disorder was considered but ruled out based on the duration of the client’s symptoms. The DSM-5 states that major depressive disorder symptoms must be limited to a two week timeframe (APA, 2013, p.160), and Kathy’s symptoms have been present for over two years. Schizoaffective disorder was considered due to Kathy’s depressed mood but was omitted because Kathy did not experience delusions or hallucinations (APA, 2013, p. 105). Bipolar disorder was considered but ruled out. The DSM-5 states that major depressive episodes must be preceded by or followed by manic episodes (APA, 2013, p.123). Kathy has not experienced manic episodes. A substance/medication-induced depressive disorder was considered but eliminated. Kathy stated that she was evaluated by a medical doctor six months ago, and was cleared of any medical concerns. There is no mention of medications being taken, and no indication of a substance use issue. The focus of clinical attention will be a reduction of Kathy’s symptoms as they relate to persistent depressive disorder.
4. Strengths and Challenges
Kathy has many strengths which supports a good prognosis. She has sought treatment for herself of her own volition, which speaks to her motivation to get better. She makes another appointment for herself before leaving, and expresses pride in taking steps toward getting well. Kathy is communicative in her interview, and willing to discuss personal details that are
CASE STUDY ON KATHY potentially shameful and/or uncomfortable to speak about. Kathy is intelligent and has a steady, highly-regarded career as a nurse in a successful medical practice. She is in good health, as proven by her recent medical exam. She presents as well-groomed, which speaks to her current ability to manage her self-care at home. Kathy is a mother, and is highly concerned about the welfare of her children which may serve as motivation to sustain treatment.
Kathy’s biggest challenge is social isolation. She does not mention the support of any friends; instead she discusses having lost her circle of friends because of her divorce. She is currently not in a romantic relationship with a partner. One parent has passed away and another is very ill. She mentions having a sister but does not name her as a source of support. She does not mention what kind of assistance she is getting from her ex-husband.
5. Cultural Implications
Kathy is a white, employed, highly-educated, mid- to upper-middle class woman, and is therefore a person with privilege. However, being a middle-aged, divorced woman can be looked upon with scorn within the white culture. In her middle forties, Kathy is already seen as “past her prime” within her culture; this is compounded by her being a divorcee. Kathy may face social challenges because of this status if she attempts friendships and relationships within her own culture.
6. Conceptualization of the Client
Conceptualization of the client will be done within the context of the Bio-Psycho-Social-Spiritual Model. This approach considers the holistic view of the client; it will examine Kathy as a whole person, with considerations given to environment, experiences, and outside influences.
Biologically, Kathy has been found to be physically healthy by her doctor. She is not
CASE STUDY ON KATHY under the influences of substances or medications, and she does not reference this as an issue for herself or any of her family members. However, Kathy stated in the interview session that her mother suffered from depression; the National Institute of Mental Health considers a family history of depression to be a risk factor for developing depression (National Institute of Mental Health, 2018). Also, she is in her mid-forties and is most likely experiences some symptoms of perimenopause, which can include sleep issues, fatigue, and mood swings.
Psychologically, Kathy is currently facing some profound difficulties. She is grieving the recent death of her mother. She is anticipating the death of her father as he battles a life-threatening illness. She is also mourning the end of her marriage. Grieving these three things concurrently is incredibly difficult, as all the situations have might have some degree of differing emotional responses. Kathy is also living on her own for the first time in her adult life, as she moved directly into her husband’s home from her parents’ home at the age of 21. The full weight of adult responsibility for herself and for her children is on her shoulders. Furthermore, her children are at an age when they are beginning to become more independent; they are starting to separate from her emotionally as they enter their teenage years. This shift in a mother’s life can be confusing and painful.
Kathy is a mother and caretaker to her children, but she also identifies as a caretaker in her career as nurse. Her role at both her house and her job is to care for others. She makes no reference to any type of self-care, and would most likely (at this point) be uncomfortable with the idea of taking self-care measures. The patients that she cares for at the nephrology practice are also extremely ill, as many are undergoing kidney dialysis. She is a single mother of two children, grieving the death of her mother, coping with a recent divorce, caring for her ill father,
CASE STUDY ON KATHY while working in a medical clinic filled with people who are sick and perhaps dying. Her feelings of being “burned out” are inevitable and valid.
Socially, Kathy is increasingly isolated. She makes no reference to current friendships, and discusses being abandoned by her former friend group. She does not mention a current romantic relationship and it is implied that she is not involved in one. She does not address any emotional connection to outside family members, and it is unclear what role her ex-husband plays in her life or the life of her children. Her support system seems to be almost nonexistent at this point in her life.
Kathy’s spiritual beliefs were not discussed in the initial counseling session; it is not known what role, if any, religion plays in her life. Consequently, it is not known whether Kathy’s divorce would be met with disapproval by her religion, if she does practice a religion. Kathy’s political beliefs were not discussed; however, she could be feeling internal shame regarding the breakup of her marriage if she typically identifies with conservative beliefs.
Kathy presents as a polite, well-groomed, intelligent woman who has begun to recognize the depth of her depressive symptoms. She reports feeling hopeless, fatigued, and apathetic, and worries about the effect this is having on her children. She makes infrequent eye contact and fidgets during the interview. She is most likely uncomfortable with positioning herself as a person who needs help, considering her role inside and outside the home as caretaker. She has experienced symptoms of depression, in varying degrees, for about ten years. She is grieving the loss of her mother, the impending death of her father, and the end of her marriage. Kathy initiated her treatment, and truly wants to get better.
CASE STUDY ON KATHY
7. Treatment Care Plan
Crisis Needs
The immediate crisis need for Kathy is to administer a suicide assessment. Kathy did not mention death or report any previous suicide attempts or suicidal thoughts, but her depressive symptoms necessitate the assessment.
Case Management and Referral Needs
It does not appear that Kathy has any pressing case management needs at the time of initial counseling session. She has a home and solid employment, and most likely receives health care benefits. She has been recently evaluated by a physician and was considered to be healthy. A referral to a psychiatrist might be necessary at some point if medication for symptoms is deemed necessary.
Therapy/Treatment Recommendations
CASE STUDY ON KATHY
CASE STUDY ON KATHY
Prognosis
The prognosis for Kathy is good. Kathy has shown initiative for treatment and motivation to get better. She has stated that asking for help was especially difficult, and that she was happy she made the decision to try counseling. Her career in nursing has provided her with an appreciation for the benefit of treatment. She is determined to get better for her children and for herself.
CASE STUDY ON KATHY8. Self-Reflection
Kathy and I are the same age, race, and cultural background. This may increase Kathy’s initial level of trust as she’s beginning her course of counseling with me. I have lost a parent and can therefore empathize with the grief she’s experiencing. However, Kathy may view me as more of a peer than her counselor. Kathy may question how I can relate to her challenges considering I have never been divorced.
I would definitely have some concerns about working with Kathy that I would need to consider before agreeing to be her counselor. A great deal of Kathy’s treatment could focus on her grief over losing her mother. As someone who has recently lost a parent, trying to remain neutral and professional during these discussions could prove difficult; I might need more time and reflection before I can professionally treat others dealing with similar grief. In addition, my own mother was a single mother who suffered from severe depression. It is possible that I could unintentionally project some of my own feelings into Kathy’s situation, considering that it is similar to that of my mother’s. If I did treat Kathy, I would need to consistently assess that I was remaining impartial and objective.
CASE STUDY ON KATHY
9. Medications
Kathy might be prescribed anti-depressant medication for her persistent depressive disorder diagnosis. SSRI’s, the most commonly prescribed class of anti-depressants, can counter symptoms of depression by increasing serotonin in the brain, they are most helpful when used by individuals with severe depression, such as Kathy. However, if Kathy were to take an SSRI medication, she must be warned that side effects such as nausea, sleep issues, nervousness, tremors, and sexual problems are common, but generally improve over time (Cherney, 2017). The counselor must inform Kathy that anti-depressant medications can take 4 to 6 weeks to take effect, and that a significant rebound effect can occur if the medications are stopped abruptly. Suicidal thoughts, especially in the first few weeks, can also develop; Kathy should be given a suicide assessment in her initial treatments to address this increased risk. Finally, for best results, Kathy should remain in therapy in tandem with her anti-depressant medication.
CASE STUDY ON KATHY