Chapter 17 Case Study Ms. H, an attractive, petite, 42-year-old full-time housewife came to psychotherapy initially for severe bulimia, vomiting as many as 40 times each day for the

Advanced Psychiatric Mental Health Nursing Clinical Decision-Making-HFN-HY01 Robinson Remonville Week 15 Case Study (Final)

Please choose one of the case study assignments listed below.

Using APA formatting, please submit a paper with cover page, content followed by reference page. This is a SafeAssign assignment that my be your original work.

Chapter 17 Case Study

Ms. H, an attractive, petite, 42-year-old full-time housewife came to psychotherapy initially for severe bulimia, vomiting as many as 40 times each day for the past year. She had previously been diagnosed with PTSD, anorexia nervosa, DDNOS, dependent personality disorder, panic anxiety, major depressive disorder, and polysubstance dependence. In the past, Ms. H self-medicated with alcohol, Vicodin, Xanax, and OxyContin. The Vicodin and OxyContin were taken to relieve her long-standing severe back pain. She was hospitalized twice for polysubstance abuse, and medications taken after hospitalization included Paxil (60 mg each day) and Depakote (250 mg twice daily). Ms. H was physically and emotionally abused as a child by a sadistic father and a neglectful, narcissistic mother. At intake, in addition to the bulimia, she reported depressive symptoms, trouble concentrating, anxiety, and periods of depersonalization and feeling dizzy and confused. She forgot periods of time; for example, she found herself in the grocery store and could not remember how she got there. This occurred particularly when she was stressed and anxious. She denied self-harm and suicide ideation. She had been married for 22 years and reported long-standing marital difficulties.

The history of childhood trauma and her tumultuous psychiatric history indicated that a long period of stabilization most likely would be needed. The APPN explained to Ms. H about her RZ and how it would be helpful to learn some strategies so she could stay regulated and in her RZ. The APPN worked with Ms. H once a week initially and, after several months, began twice-weekly psychotherapy, which continued over the next 5 years. Within 6 months of beginning treatment, her bulimia subsided. Much of the content of beginning sessions focused on building in resources and later on the abuse she suffered from her husband, which was ongoing and included emotional, sexual, and physical abuse. Ms. H initially appeared frightened and confused, especially when asked about her feelings. The therapist supported and validated Ms. H and told her that she was being abused as she vacillated between thinking that she deserved such punishment to feeling anger at her husband. She had idealized her husband, and as she began to see him more realistically, she also began to see herself in a different light, and her self-esteem increased. She began to assert herself more, and her marital relationship further deteriorated because her abusive husband was enraged that he was losing control of her. Plans for her safety were made, and 2 years after starting therapy, she filed for divorce and moved out of their house. This represented a significant turning point because stabilization was not possible previously as long as she was not safe. Her medication was changed to 20 mg of Prozac, and she found a full-time job shortly after the divorce. Over the course of treatment, various stabilization strategies were gradually integrated, which helped to widen her RZ so she could stay regulated. These included safe/calm place, container, circle of strength, rating negative feelings, basic self-care, yoga, progressive muscle relaxation, journaling, grounding, cognitive restructuring, walking, and deep breathing, in addition to other soothing activities. All were new to Ms. H; she had never practiced any of these before therapy.

Through mindfulness, Ms. H learned to manage her dissociative symptoms, and these periods decreased dramatically as she was able to stay in the present, understand the triggers, and talk about some of her traumatic experiences. Her back pain all but disappeared as she became aware that the triggers for these episodes were linked to feelings of anger. Her identification of her feelings in the present, the ability to experience these feelings, and understanding the meaning of her symptoms were crucial to her development of affect-regulation skills. Along with the deepening of her identity apart from her husband, her sense of humor and keen intelligence emerged. Some of her early childhood trauma was processed with EMDR therapy, but much of the work in psychotherapy focused on increasing resources, psychoeducation, and support, with the therapist bearing witness to her struggle and courage. Her healing reflected the return and expansion of her full consciousness through the integration of adaptive memory networks with dissociated neural networks. This was accomplished by creating positive experiences through the therapeutic relationship, learning and practicing specific resources, and weaving a narrative that connected her old and new memory experiences into a coherent tapestry reflecting a stronger, more resilient sense of self.

POST-MASTER’S TRAUMA TRAINING AND CERTIFICATION REQUIREMENTS

The APPN who wishes to attain competency treating traumatized patients should pursue additional training and ongoing supervision. Working with dissociative patients requires a high level of clinical expertise to do so successfully. The International Society for the Study of Dissociation (ISSD) offers post-master’s training in the treatment of DDs but not certification. The program consists of nine monthly or biweekly sessions of 2.5 hours, which are held in many major cities listed on the website (www.issd.org). The sessions are designed to focus on readings and clinical situations. A distance-learning module is also available, along with advanced coursework.

In addition, integrative trauma psychotherapy programs are offered in large cities in the United States. An Integrative Trauma Psychotherapy Certificate Program is offered at Fairfield University and includes Basic Training in EMDR and the Trauma Resilience Model (TRM), a somatic therapy described in Chapter 11. See fairfield.edu/resiliencetraining.

CONCLUDING COMMENTS

Stabilization and safety are always the first order of business for any psychotherapy. This ensures that the processing needed to integrate the dissociated memory networks will not destabilize the patient. Enhancing resources ensures that positive adaptive memory networks exist for the eventual linking of dysfunctional material so that integration can occur. Strategies for stabilization are basic tools that all APPNs need to know to work with patients who present for psychotherapy. These skills build on the stress management techniques that registered nurses are familiar with. This foundation is deepened by understanding how and when to tailor specific stabilization strategies. Competency in stage 1 (stabilization) reflects the beginning-level skills needed for APPN practice.

There is a wide spectrum of trauma responses, and stabilization is needed before processing trauma. The limiting diagnosis of PTSD does not capture the complexity of traumatic experiences and their sequelae. Neurophysiological research demonstrates the importance of even subtle negative life events on the developing brain when a state of helplessness occurs (see Chapter 2). The physiological changes that occur and the perpetuation of those changes over time are determined by the meaning of life events in relation to past trauma (Shapiro, 2018). The learned associated responses embedded in memory networks are modified in the safety of the therapeutic relationship. Managing arousal and altering procedural memories begin the work of healing trauma.

The patients of severe childhood trauma are chronically disenfranchised and re-create betrayal and abandonment scenarios wherever they go, especially in the psychotherapeutic relationship as early attachment schemas are reactivated. Most complex child-onset trauma requires painstaking work as resources are increased and a narrative is woven about the nuances of the meaning of the events as the trauma is processed. Individuals who are survivors of childhood abuse present treatment challenges and the complexity and severity of symptoms can seem insurmountable to even the most experienced psychotherapist. However, healing occurs in this relationship with patience, caring, and skill. Novice APPN psychotherapists who continue to train and obtain supervision to develop skill in trauma treatment will be richly rewarded in their work. The APPN’s presence bears witness with empathic resonance, creating the atmosphere needed for the most vulnerable of patients to be whole again. Those of us who work with this population marvel at the remarkable capacity for endurance, compassion, depth of character, and resilience of the human spirit. The honor of assisting in the growth of another person changes the patient and the therapist. In the healing journey with another, we heal ourselves.

DISCUSSION QUESTIONS

1.Discuss the spectrum of trauma-related diagnoses with respect to specific symptoms that overlap. Pick one trauma-related DSM diagnosis and identify what might be some, and differential diagnoses.

2.Identify goals of treatment for trauma.

3.What happens physiologically during dissociation, and what would you observe in the patient who dissociated during a session?

4.Fill out the DES, which is included in Chapter 3 on yourself and score it. Keep track with a log of all the times you notice yourself dissociating over the course of the next week.

5.How would you know whether a person was stabilized and ready to go on to processing?

6.Discuss why a person who has been traumatized as a child most likely has pervasive feelings of guilt.

7.Develop a comprehensive plan of all the potential issues and strategies that you need to teach a patient who has flashbacks.

8.Explain why mindfulness underlies all stabilization, why you should develop this skill, and how you plan to do so.

9 Practice the progressive muscle relaxation exercise and the safe/calm place exercise in Appendices 13.2 and 1.7 with a friend or family member. Ask for feedback so that you can improve.

Case Study Chapter 24

Ms. K, a 60-year-old divorced, home health aide, presented for outpatient psychotherapy a week after discharge from a 5-day inpatient stay at the local psychiatric hospital after her ex-husband moved in with another woman. Ms. K had subsequently recurrent suicidal thoughts and voluntarily admitted herself. She was started on fluoxetine 30 mg and participated in group therapy but remained depressed after discharge.

In her initial session with the therapist, Ms. K scored 40 on the Beck Depression Inventory (BDI), indicating severe depression and described sadness, loss of interest in pleasurable activities, guilt, loss of energy, tearfulness, hopelessness, fatigue, loss of appetite, middle of the night insomnia, a 10-pound weight loss, and concentration problems over the past month. The patient’s identified complaint at the time of intake was, “I am helpless, hopeless and will never have a good life.” She denied memory problems, substance abuse, delusions, or present suicidal ideation. Her depression, lack of social supports, hopelessness, and no spouse were risk factors for suicide. However, she did not have an organized plan to hurt herself and her voluntary hospitalization for previous suicidal ideation as well as current denial of suicidal thoughts indicated that the risk for self-harm was present but not high. The APPN knew that risk might increase as she began to feel better and that Ms. K should continue to be closely monitored. There was no history of mania, hypomania, or illicit drug use. Two prior episodes of depression were reported. The first episode was 10 years previously when she suffered an automobile accident that fractured her left arm and lacerated her face after she was thrown face first through the passenger side of a non-safety-plate windshield. She was diagnosed with major depressive disorder after this event and treated with fluoxetine for a year. Eight years after this accident, she was diagnosed with breast cancer and underwent a mastectomy followed by a course of chemotherapy and radiation. She was treated at that time with CBT for 16 sessions and venlafaxine for 2 years with a partial response.

Ms. K had a history of early traumatic relationships. She reported that her early childhood was marked by emotional and physical abuse from her rageful, alcoholic father and emotional neglect by her mother. Although she had amnesia for much of her childhood, one of her few early memories was of her father demeaning her and calling her “stupid” when she made a mistake. Her mother too was berated by her father and Ms. K felt her mother was afraid to intercede on her daughter’s behalf. Her father insisted that she adhere to a strict regimen throughout her childhood; when she did not comply, he was angry and punishing. For example, she recalled that when she was learning to tie her shoes around the age of 4, her father slapped her across the face each time she did not correctly remember the proper sequence of steps to accomplish this task. She was expected to take care of her two younger sisters at an early age and was not allowed to play with other children. At the age of 10, her parents divorced, leaving her with her depressed, emotionally unavailable mother and her two sisters. Her mother remarried a year later and her stepfather frequently beat her while her mother did nothing about it. The continuing emotional and physical abuse interfered with her ability in school. She finally left home at age 17 and lived at a convent where she took classes to become a home health aide. At age 20, she met her ex-husband whom she married several months later.

She reported that her marriage of 30 years was not happy and that she was physically and emotionally abused by her husband, who was an alcoholic with frequent angry outbursts. On several occasions, he had punched and slapped her. Her husband had divorced her 10 years previously, leaving her without alimony or financial security. In fact, he financially exploited her by coming to her for money whenever he ran out. She had no children and expressed great regret at never being able to conceive but believed that she did not deserve children anyway. Her parents were both deceased at the time of intake and her relationship with her two sisters was distant and passive. Ms. K had been able to work full-time as a home health aide until her recent hospitalization and lived alone. She stated that she was hardworking and conscientious and liked helping others. Her work was a significant area of gratification for her.

Ms. K had recently had a physical exam at her nurse practitioner’s office with complete blood count (CBC) with differential and chemistry profile all within normal limits. After a comprehensive psychiatric assessment and history, a diagnosis of major depressive disorder, recurrent, severe without psychotic features was made. In addition, her chronic dysphoria and poor self-esteem warranted an additional diagnosis of persistent depressive disorder (dysthymia). Medical diagnoses included obesity, type 2 diabetes, and hypertension. Medications included IC lisinopril–HCTZ 10/12.5, Toprol XL 100 mg, and Actoplus Met 15/500 mg. A Global Assessment of Functioning (GAF) score was 45/60 at intake. A treatment plan was developed using the practice treatment guidelines from the American Psychiatric Association (2010).

Practice guidelines suggest that frequent monitoring to assess suicidality and response to psychopharmacology is important in the acute phase of treatment. CBT and IPT are identified as the psychotherapeutic approaches that have the best documented efficacy. In addition, the guidelines state that if CBT was used before with some success yet did not result in longer-term change, a combination of psychodynamic and CBT approaches should be utilized. Ms. K’s stated goal for therapy was firs