Wasson_B_AnnaCaseStudy

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CASE STUDY: JANE 1 Case Study Assignment: Jane Brittany N. Wasson School of Behavioral Sciences, Liberty University Author Note Brittany N. Wasson I have no known conflict of interest to disclose. Correspondence concerning this article should be addressed to Brittany N. Wasson Email: bnwasson@liberty.edu

Case Study: Anna 2 Case Study: Jane Client Concerns Symptoms Behaviors Stressors Worrying Excessively Irritable and angry when confronted about her worrying. Kids not keeping in touch. Strain in relationships. Fatigue Trouble sleeping, restlessness Taking care of ill mother. Sadness Frequent crying Retirement. Loss of husband. Anxiousness Change in attitude. Nervousness. Body tension Taking care of ill mother, she is worried she will end up in a nursing home. Key Issues The client is unfortunately experiencing many difficulties, resulting in several key issues. The issues Anna is facing are biological, psychological, social, and spiritual, which is resulting in stress in all aspects of her life. Biological The client states that she experiences restlessness and is unable to sleep well. This is causing constant fatigue and tiredness. Psychological The client and her family have expressed that she worries excessively and has constant fear that something will happen to her immediate family members. She also is sad for most of her day, resulting in frequent crying. Anxiousness is also another issue Anna faces, which has resulted in a change in attitude noticed by her family members and is creating body tension. Social

Case Study: Anna 3 The client has mentioned that she lives alone with her elderly mother which she spends most of her time caring for. She has some family close, while others who are not have distanced themselves even further due to the client’s attitude and demeanor being too much for them. The client has lost most of her social network due to retirement, she has stated she enjoyed having coworkers and often thinks of them and misses their company. Her husband was also a large part of her social life, and they would enjoy many things together, since his passing she stopped doing the activities they loved to do together. Recently she has picked up drinking wine again but has trouble controlling her intake. Spiritual The client practices Hinduism and values her culture. She has expressed that she would be interested in integrating her religion into counseling. Assessment The client has expressed many difficulties in her life which have resulted in symptoms similar to an anxiety disorder and possible depression due to some of the hard times she has faced. I would like to be open and honest with the client so we can build that trust between one and another, which will allow me to help her better understand her diagnosis. Due to the multiple symptoms, she has, I would not fully rely on an anxiety assessment but rather something broader to help treat any other underlying symptoms. As a counselor, I would use the DASS (Depression Anxiety Stress Scales). The DASS is a questionnaire-based assessment that measures three areas of negative emotional states, depression, anxiety and tension/stress (Lee et al. 2019). This will allow me, as the counselor, the target all areas of difficulty for the client and will provide her with the most accurate diagnosis. With this, we can than focus on a treatment

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Case Study: Anna 4 plan that will help with her primary diagnosis symptoms and then work towards treating any underlying symptoms. Diagnostic Impression The client’s symptoms are consistent with Generalized Anxiety Disorder (GAD) (F41.1). Signs and Symptoms DSM-5-TR Diagnostic Criteria: Generalized Anxiety Disorder F41.1 Client’s Signs/Reported Symptoms: Criterion A: Excessive worry, anxiety occurring more days than not for at least 6 months, about a number of events or activities. The client worries about family every day and is worried to the point she is continuously trying to keep in contact. Client has been dealing with being high strung and worried majority of the day for over 18 months Criterion B: The individual finds it difficult to control the worry. The client tries to tell herself to stop worrying but it never works. She is unable to stop them from popping into her head. Criterion C: The anxiety and worry are associated with three (or more) of the following six symptoms: 1. Restlessness 2. Easily Fatigued 3. Difficulty concentrating or mind going blank. 4. Irritability. 5. Muscle tension. 6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep) The client has reported being restless recently and also feelings of fatigue due to struggling to sleep in the last 12 months. The client has admitted to feeling irritable towards others and those around her have also reported these feelings. Criterion D: The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The client has stated that she has had trouble sleeping, body fatigue and tension, and overall sadness. This has impaired her social circle and relationship with family.

Case Study: Anna 5 Criterion E: The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism). The client was recently prescribed Paxil to help with her anxiety and has stated she consumes alcohol more often than she would like. Criterion F: The disturbance is not better explained by another mental disorder The client has no diagnosis of mental disorders prior to this session. Other DSM-5-TR Conditions Considered Due to symptoms of sadness, irritability, lack of energy and little no social life, Persistent Depressive Disorder (F34.1) was also considered. The client did not report feeling depressed or being in a depressed mood but due to her loss and other social losses and retirement, she has had three of the six symptoms present. The disorder was ruled out due to not meeting the full criteria. Developmental Theories and/or Systematic Factors The client is in Erikson’s eighth and final stage of development, Ego Integrity vs. Despair. During this time in a person’s life, a lot of contemplation and reflection on life happens and whether our lives were productive and fulfilled (Orenstein et al. 2021). Due to the strain that the clients’ psychological difficulties have put on her family and friends, the loss of her husband, and retirement, she may be feeling a sense of despair. Systemic factors also have a role in her behavior due to the loss of many of her relationships and her family and social system becoming distant. Multicultural and/or Social Justice Considerations The client has stated that her cultural background is important to her but has also had a lot of influence on how she lives her life, which has put a lot of pressure and stress on her

Case Study: Anna 6 and her way of living. Due to Asian traditions, her mother has been kept from going into a nursing home, leaving the client with full care of her elderly mother. These cultural influences have been taken into consideration. Treatment Recommendations Key Issues for Treatment  Worrying Excessively  Anxiousness  Sadness  Fatigue/Trouble Sleeping Recommendations for Individual Counseling The client would do best, based on her symptoms, partaking in cognitive behavioral therapy (CBT). CBT is known to be one of the best treatments for the symptoms the client is facing and possible diagnosis of GAD. There are many different therapy techniques that have shown to reduce or diminish GAD symptoms (Newman et al. 2020). Specific Considerations In this client’s case, she has expressed that she would like to incorporate Hinduism into her counseling, which can be crucial to her healing journey. Her Asian culture is also very important to her and should be focused on when developing any treatment plan in order for a successful client/counselor relationship and success in her healing. It would be helpful to understand her cultures counseling techniques for similar symptoms and the practices they use that could be incorporated into her treatment plan. There could be some difficulties with her how her culture views taking care of elders and the time and energy she puts towards her mother’s

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Case Study: Anna 7 care, while neglecting her own care. It could become difficult to get her to focus a little more on care for herself, while also taking care of others around her. Any personal values or opinions I have, I would avoid voicing them and keep a neutral mindset for best interest of the client. Whatever treatment plan is best for the client, I will uphold my professional ethics for client success and a healthy client/counselor relationship. References Lee, J., Lee, E. H., & Moon, S. H. (2019). Systematic review of the measurement properties of the Depression Anxiety Stress Scales-21 by applying updated COSMIN methodology. Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation , 28 (9), 2325–2339. https://doi.org/10.1007/s11136- 019-02177-x Newman, M.G., Zainal, N.H. and Hoyer, J. (2020). Cognitive-Behavioral Therapy (CBT) for Generalized Anxiety Disorder (GAD). In Generalized Anxiety Disorder and Worrying (eds A.L. Gerlach and A.T. Gloster). https://doi.org/10.1002/9781119189909.ch10 Orenstein GA, Lewis L. Eriksons Stages of Psychosocial Development. [Updated 2021 Nov 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK556096/

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