Prop 3
Posted: Mon Aug 25, 2008 1:34 am
Cognitive-Behavioral Case Formulation and Treatment Plan for "Natasha"
Name: Natasha
Identifying Information: 25 SWF, Honours Student, living in shared student accomodation.
Problem List:
1. Depressive symptoms. BDI = 22. Sadness, lack of enjoyment, feeling like a failure, self-criticism, lack of energy, suicidal thoughts but no plan or intent, difficulty making decisions, loss of interest in others, insomnia, loss of appetite. "Things are not good. Nothing much matters. Sometimes I don't care if I live or die."
2. Social phobia. Feels socially isolated. She has two women friends in her classes that she speaks to, but she is not close to either, does not initiate any activities with them. "It's hard to speak when others are watching but I need to talk".
3. General lack of social skills. Capacity to talk in multiple languages exarcebates feelings of being incapable of easy communication.
4. Relational problems. Professes great difficulty in being touched by people. Hugs engender panic attacks. Professes desire to be close to someone and be intimate with someone. Fears sex to such an extent, imagining its occurrence is enough to give her a panic attack.
5. Frequent worrying. She consistently ruminates about possibilities for failure and doubts her capacity to engage in any activity without considering the myriad of ways in which it could go wrong. She also worries about other people's enterprises, their risks, and what could happen to them.
Diagnosis:
Axis I: Major depressive disorder, panic disorder, social phobia, generalized anxiety disorder.
Axis II: Dependent personality disorder.
Axis III: None. History of gross neglect, criminality.
Axis IV: Relational problems, socially isolated.
Axis V: 50.
Working Hypothesis:
Schema:
Self: "I'm not ready for and can't handle adult responsibilities." "I can't make good choices/decisions." "I'm weak and vulnerable and need lots of nurturing, support."
Other: "People don't care about me, won't be supportive of my needs." "Everyone I care about is just going to be taken away." "Most people just want me to be normal, that's all they want from me, to forget me."
World: "It's illegal to look after people, considered morally reprehensible." "The world wants everyone to be the same person, if you're not, it'll remove you."
World/Future: "The world is always going to keep me alone."
Precipitants: Loss of foster family 10 years ago; as part of this transition, Natasha was forced to move to Moscow and told to become normal. Other precipitants include transition to university, public attention on translation of the Liltian tablets, demands that she go on the expedition.
Activating situations: Public speaking, writing letters as it reminds her of an imprisoned foster family that sends her no letters, attending class, watching others interact.
Origins: Gross neglect until the age of 5 where she wasn't taught how to eat solids, toilet, walk or interact with others. Foster family was overprotective and fearful: "The world is a bad place, it does this to all of it's children". Foster family was otherwise supportive and patient with her learning to achieve her goals. Foster family modeled close ties. Foster family was imprisoned when she was 15 due to their survivalist, anti-government activities. Haven't contacted her since she was removed to a second foster family that modeled normalcy and disciplined her by ignoring her when she behaved contrary to social norms.
Summary of the working hypothesis: Natasha's move to Moscow and her later enrollment in Moscow University has given her some direction, satisfaction, and feedback that she can make decisions and handle adult responsibilities activated her beliefs that she cannot handle adult/demanding decisions/responsibilities. In response to these beliefs and the axiety they produced when activated, she withdrew from responsibilities, including extra-curricular activities, looking for a job and engaging in social interactions, which left her isolated, resulting in a loss of potential sources of gratification, leading to her depression. Natasha's bliefs that she cannot make good choices and cannot choose people to trust, coupled with her social problems, inertia from depression, and resentment toward the world, block her from seeking meaningful contact with others. The loss of her first foster family and resulting unhappiness supported or activated Natasha's beliefs that she needs lots of support/nurturing, that the larger world is unsupportive, and that those around her are responsible for her unhappiness, contributing to her depression, inertia, and social problems.
Strengths and Assets: Stable life circumstances, mastery of multiple languages, translations of the Liltian Tablets, well-educated, bright, psychologically minded.
Treatment Plan:
Goals (measures):
1. Reduce depressive symptoms (BDI).
2. Increase comfort while talking in public (measured through patient's ratings of items on a fear hierarchy).
3. Make a friend and arrange for social encounters outside of normal university-requested activities.
4. Reduce social tension and estrangement.
Modality: Individual cognitive-behavioral therapy. Frequency: Weekly.
Interventions
1. Activity scheduling to increase sources of pleasure and mastery, alone and perhaps with friends.
2. Built a hierarchy and use gradual exposure to alleviate public speaking fears.
3. Teach anxiety-management skills, including diaphragmatic breathing.
4. Interceptive exposure.
5. Cognitive restructuring to work on fears that she cannot handle public speaking or other challenges, beliefs that her happiness depends on the world around her, fears that bad things will happen to those she gets close to, beliefs that she cannot choose and act on a social goal.
6. Schema change methods to tackle her belief that she is weak/vulnerable.
7. Assertiveness training.
Adjunct therapies: Consider antidepressant medications, group therapy.
Obstacles:
1. Natasha's view that others are responsible for her happiness may make it difficult for her to work aggressively in treatment to overcome her problems.
Name: Natasha
Identifying Information: 25 SWF, Honours Student, living in shared student accomodation.
Problem List:
1. Depressive symptoms. BDI = 22. Sadness, lack of enjoyment, feeling like a failure, self-criticism, lack of energy, suicidal thoughts but no plan or intent, difficulty making decisions, loss of interest in others, insomnia, loss of appetite. "Things are not good. Nothing much matters. Sometimes I don't care if I live or die."
2. Social phobia. Feels socially isolated. She has two women friends in her classes that she speaks to, but she is not close to either, does not initiate any activities with them. "It's hard to speak when others are watching but I need to talk".
3. General lack of social skills. Capacity to talk in multiple languages exarcebates feelings of being incapable of easy communication.
4. Relational problems. Professes great difficulty in being touched by people. Hugs engender panic attacks. Professes desire to be close to someone and be intimate with someone. Fears sex to such an extent, imagining its occurrence is enough to give her a panic attack.
5. Frequent worrying. She consistently ruminates about possibilities for failure and doubts her capacity to engage in any activity without considering the myriad of ways in which it could go wrong. She also worries about other people's enterprises, their risks, and what could happen to them.
Diagnosis:
Axis I: Major depressive disorder, panic disorder, social phobia, generalized anxiety disorder.
Axis II: Dependent personality disorder.
Axis III: None. History of gross neglect, criminality.
Axis IV: Relational problems, socially isolated.
Axis V: 50.
Working Hypothesis:
Schema:
Self: "I'm not ready for and can't handle adult responsibilities." "I can't make good choices/decisions." "I'm weak and vulnerable and need lots of nurturing, support."
Other: "People don't care about me, won't be supportive of my needs." "Everyone I care about is just going to be taken away." "Most people just want me to be normal, that's all they want from me, to forget me."
World: "It's illegal to look after people, considered morally reprehensible." "The world wants everyone to be the same person, if you're not, it'll remove you."
World/Future: "The world is always going to keep me alone."
Precipitants: Loss of foster family 10 years ago; as part of this transition, Natasha was forced to move to Moscow and told to become normal. Other precipitants include transition to university, public attention on translation of the Liltian tablets, demands that she go on the expedition.
Activating situations: Public speaking, writing letters as it reminds her of an imprisoned foster family that sends her no letters, attending class, watching others interact.
Origins: Gross neglect until the age of 5 where she wasn't taught how to eat solids, toilet, walk or interact with others. Foster family was overprotective and fearful: "The world is a bad place, it does this to all of it's children". Foster family was otherwise supportive and patient with her learning to achieve her goals. Foster family modeled close ties. Foster family was imprisoned when she was 15 due to their survivalist, anti-government activities. Haven't contacted her since she was removed to a second foster family that modeled normalcy and disciplined her by ignoring her when she behaved contrary to social norms.
Summary of the working hypothesis: Natasha's move to Moscow and her later enrollment in Moscow University has given her some direction, satisfaction, and feedback that she can make decisions and handle adult responsibilities activated her beliefs that she cannot handle adult/demanding decisions/responsibilities. In response to these beliefs and the axiety they produced when activated, she withdrew from responsibilities, including extra-curricular activities, looking for a job and engaging in social interactions, which left her isolated, resulting in a loss of potential sources of gratification, leading to her depression. Natasha's bliefs that she cannot make good choices and cannot choose people to trust, coupled with her social problems, inertia from depression, and resentment toward the world, block her from seeking meaningful contact with others. The loss of her first foster family and resulting unhappiness supported or activated Natasha's beliefs that she needs lots of support/nurturing, that the larger world is unsupportive, and that those around her are responsible for her unhappiness, contributing to her depression, inertia, and social problems.
Strengths and Assets: Stable life circumstances, mastery of multiple languages, translations of the Liltian Tablets, well-educated, bright, psychologically minded.
Treatment Plan:
Goals (measures):
1. Reduce depressive symptoms (BDI).
2. Increase comfort while talking in public (measured through patient's ratings of items on a fear hierarchy).
3. Make a friend and arrange for social encounters outside of normal university-requested activities.
4. Reduce social tension and estrangement.
Modality: Individual cognitive-behavioral therapy. Frequency: Weekly.
Interventions
1. Activity scheduling to increase sources of pleasure and mastery, alone and perhaps with friends.
2. Built a hierarchy and use gradual exposure to alleviate public speaking fears.
3. Teach anxiety-management skills, including diaphragmatic breathing.
4. Interceptive exposure.
5. Cognitive restructuring to work on fears that she cannot handle public speaking or other challenges, beliefs that her happiness depends on the world around her, fears that bad things will happen to those she gets close to, beliefs that she cannot choose and act on a social goal.
6. Schema change methods to tackle her belief that she is weak/vulnerable.
7. Assertiveness training.
Adjunct therapies: Consider antidepressant medications, group therapy.
Obstacles:
1. Natasha's view that others are responsible for her happiness may make it difficult for her to work aggressively in treatment to overcome her problems.