PRESENTING ISSUE A 31-year-old white female presents in the office in an anxious state. Her physician referred her for a mental health evaluation as he didn't know how to help her. At work, she was accused of having head lice and since then she believe she has head lice. She states, "I've always been a neat and orderly person. I feel like I have no control over anything."
NOTES
The physician who sent this patient is a good referral source, we've referred to each other and shared several patients. He sent preliminary information saying that her laboratory results were normal and that he knows of no previous psychiatric history for the patient. He has checked all physical systems and knows of no physical reason for her symptoms. He notes that an EKG is normal except for a consistently elevated heart rate. He confirms that she does not have lice but the patient doesn't believe him. Her belief causes him to believe she is possibly psychotic because of her "delusion of having head lice.". He wants to place her on anti-anxiety medication and/or anti-psychotic medication but is reluctant; hence, he wants to gain another perspective on the patient. However, he did recently prescribe Lexapro for the patient and she is compliant with same. Patient moved to the Midwest from California at age 12 when her father retired from the military. She has a high school diploma and wants to become a nurse. She recently found out that she was due to be laid off from her position at the factory where she works as the factory is downsizing. She has been married for four years, this is her second marriage. Her husband has a "good job." Her first marriage was for five years but they were together a total of nine years and they have a ten-year-old son together. The patient has a 2-year-old daughter from the second marriage. She limits her social life to her two children and her current husband.
HEALTH HISTORY
The patient is worried about her health. She has been feeling "exhausted all the time, even after a good's night sleep. Usually, though, I get up several times a night to go to the bathroom or wake up easily by sounds." She has lost about 15 pounds over the last month and hasn't been eating well. She has been having diarrhea over the last two weeks as "food seems to go right through me." She smokes 1 pack of cigarettes daily and denies the use of alcohol and other drugs. She states, "at times, it feels like my heart is beating out of my chest and I'm afraid I'm dying."
PREVIOUS COUNSELING HISTORY
The patient received domestic violence counseling approximately five years ago when living at a shelter for those who have experienced domestic violence. She believes her father was an alcoholic and he died one year ago from liver failure. She acknowledges no other personal or family history of psychiatric and addictions issues.
MENTAL STATUS EXAMINATION Affect: Anxious
Appearance: slightly disheveled
Mood: Nervous Moderate psychomotor agitation present No apparent psychotic phenomena outside of belief she has lice No noticeable body odor Denies suicidal/homicidal ideation and intent Appears to be of above average intelligence Judgement and insight appears to be poor Speech: Rapid, no idiosyncratic features noted Sleep: Awakens easily, sleep is not restorative
INITIAL DIAGNOSES 309.24 Adjustment Disorder with anxiety
780.52 Other Specified Insomnia disorder, brief insomnia disorder
297.1 Delusional Disorder, somatic type R/O: 300.01 Panic Disorder
R/O: 300.02 Generalized Anxiety Disorder
R/O: 309.81 Post-traumatic Stress Disorder
SURPRISE
In the first session, about 10 minutes before the session ended, I was thinking about her elevated heart rate. I had just had my first consultation a week earlier with a cardiologist for a heart beat issue and one of his recommendations was to avoid all caffeine. My countertransference (remember, in Adlerian theory countertransference is simply increased sociability) prompted a question of asking her about her sugar and caffeine intake as both elevate a heart rate. To my surprise, she was drinking approximately five (5) two-liter bottles of Mountain Dew daily. Mountain Dew is full of sugar and loaded with caffeine. As she is interested in nursing, I told her of my recent visit to a cardiologist (appropriate self-disclosure) and wondered if she wanted to follow the advice he gave me and run an experiment. She agreed to experiment with her caffeine intake and to cut back to three (3) two-liters a day. I told her that I had "caffeine headaches" when I stopped caffeine but my heart beat wasn't as troublesome. She said she had been getting headaches as well as that was when she would drink more Mountain Dew.
Revised INITIAL DIAGNOSES 305.90 Caffeine Intoxication (the only time I've used this diagnosis)
309.24 Adjustment Disorder with anxiety (remember, she is getting laid off from her work)
292.85 Substance Induced Sleep Disorder, caffeine (the only time I've used this diagnosis)
297.1 Delusional Disorder, somatic type (believes she has head lice) R/O: 300.01 Panic Disorder (probably from caffeine)
R/O: 300.02 Generalized Anxiety Disorder (probably from caffeine)
R/O: 309.81 Post-traumatic Stress Disorder (history of domestic violence)
TREATMENT PLAN
Run experiment of drinking less caffeine
Monitor sleep hygiene
Referral to Bureau of Vocational Rehabilitation for nursing career
Coordinate treatment with physician
Explore ACOA (adult child of alcoholic) issues
Explore past experience with domestic violence (first marriage)
Increase social circle (remember she limits her social life to her children and husband)
Firm up diagnoses
COURSE OF TREATMENT Second session (two weeks later):
The patient had such good results with reducing her caffeine to three (3) two-liters that she reduced to one (1) two-liter of Mountain Dew daily on her own.
Her restless sleep and nocturnal urination decreased significantly.
She contacted BVR on her own and started the paperwork to use their assistance in finding a nursing program
Physician responded, "I hadn't thought of her caffeine intake! Keep me posted!!"
Patient didn't want to discuss
Patient didn't want to discuss
Patient joined several nursing groups online
Patient no longer believed she had head lice.
Third session (two weeks later, client left early, just wanted to report on her progress):
The patient eliminated all caffeine on her own. She also stopped smoking because "nicotine raises your heart rate."
She was sleeping through the night rarely arising or waking up during the night
Accepted into a nursing program
The patient was advised to follow-up with her physician.
Reported to physician that patient seemed greatly improved and no longer desired counseling nor Lexapro.
DISCHARGE DIAGNOSES Z03.89 No Diagnosis POSTSCRIPT
Imagine the unnecessary anxiety and continued delusions that this patient would have experienced had she had a counselor and a physician who didn't work together. She could have been placed on anti-psychotic and/or anti-anxiety medication. And in the case of the anti-anxiety medication, an iatrogenic addiction could have ensued. This case study shows the importance of collaboration with other professionals.
I suspect that the patient will need mental health treatment in the future as I don't think all of her issues were caused by caffeine. I believe her caffeine intake exacerbated unresolved issues that she has experienced by her childhood and her first marriage. However, if you notice, the client said in the initial session, "I feel like I have no control over anything!" Therefore, it is not my responsibility to control her but have her increase her own sense of control. Further, I needed to making counseling a positive experience for her so that if those issues which she didn't want to discuss (and any other issues) came up, she would seek me or another counselor out to gain assistance. Always leave the door open for patients. Further, note the Adlerian concepts of - holism (checking into her diet, encouraging her desired career path)
- using countertransference and self-disclosure of same to benefit the client's progress
- running experiments to gain cooperation and self-control
- disconfirmatory hypothesis testing (looking for evidence that does not confirm my or other
professionals' hypotheses)
- differential diagnosis - why one diagnosis and not another
- increased sociability (Gemeinschaftsgefühl: Community Feeling/Social Feeling/Social Interest)
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