Journal Entry Week 2- Patient Description

The first client was a 15-year-old African American living with both parents in the suburbs of Florida. He had two siblings, a 10-year-old brother, and a 14-year-old sister. He attended a special needs school. He presented at the clinic accompanied by both parents with a protracted history of insomnia, diagnosed six months ago. The client’s inability to sleep at night and in other instances, he had frequent awakenings with the inability to return to sleep. These symptoms severely affected the family where both the father and mother had countless sleepless nights that subsequently interfere with their livelihood and work during the day. Initially, the following drugs were prescribed; clonidine 1 mg QHS, Benadryl 50 mg PO at bedtime, Xanax 1 mg PO QHS, and Trazadone 50 mg PO at bedtime. However, after a comprehensive assessment, to improve on the quality of his sleep, the PMHNP prescribed Seroquel 25 mg PO every morning and Seroquel 100 mg PO at 1800 and immediately discontinued Trazadone and Clonidine. Journal Entry Week 2- Patient Description

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The second client was a 14-year-old referred from the ED to the outpatient clinic for a psychiatric evaluation. Her alcoholic mother abused her when she was a child, before placement for adoption. She had a history of a self-inflicted cut injury on her ankle and wrist after emotional and verbal abuse by peers in school due to her physical appearance. Based on the parent’s reports, the client suddenly became socially withdrawn as opposed to her previous outgoing, jovial, and enthusiastic nature (Krystal, Prather & Ashbrook, 2019). Besides, she had no interest in things that she was previously interested in. When reporting the incident to her parents, she received great support from her mother but her father reprimanded her citing that she had a childish behavior in issues that she had to let go. Due to a lack of guidance and support from her father, she felt disappointed and frustrated. Journal Entry Week 2- Patient Description

DSM Diagnosis

According to American Psychiatric Association (2013), insomnia is the most common sleep disorder among young adults globally characterized by interrupted, unsatisfactory, and difficulty to maintain or initiate sleep, having non-restorative or poor-quality sleep that negatively impacts daytime functioning. The criteria for diagnosing insomnia are; difficulty to initiate sleep, maintain sleep (waking frequently and difficulty returning to sleep), waking early morning with the inability to return to sleep, and sleep difficulties present for less than three months. Similarly, the 15-year-old client presented with a history of insomnia diagnosed six months ago characterized by sleeping difficulties. Besides, since the client could not verbalize his needs, there was negligence to his attention to comfort, elimination, and food. The negligence often contributed to frequent night awakenings due to hunger or wetness. Although the parents gave special attention in addressing his needs just before bedtime, the client often refused to feed or eliminate before bedtime. These symptoms met the DSM-V criteria of insomnia.

The second client, a 14-year-old was adopted. Her alcoholic mother reportedly abused her as a child. On presentation, she had a history of a self-inflicted cut injury on her ankle and wrist after emotional and verbal abuse by peers in school. Based on the parent’s reports, the client suddenly became socially withdrawn as opposed to her previous outgoing, jovial, and enthusiastic nature. Besides, she had no interest in things that she was previously interested in. These symptoms met the DSM-V criteria for PTSD whereby, to diagnose PTSD, Bisson, et al., (2015) emphasize that a patient should have a history of exposure to a stressor. Besides, the patient should have symptoms of intrusion, avoidance signs, and negative mood and cognitive changes, symptoms recurring for more than one month causing functional and social impairment not influenced by substance use, an underlying illness, or medications.

Legal and Ethical Implications

In both patient scenarios, the ethical principle of patient confidentiality and privacy was integral to providing individualized care. This is particularly important since both clients were teenagers and had specific symptoms that contributed to individual health concerns. In this state, it will be necessary to consider input from family members and friends to achieve good health outcomes. In the process, there are high chances of disclosing vital patient information, and this can violate the patient’s right to confidentiality. However, both clients must understand that the provider must share any information that possesses danger of harm to self or others with other healthcare providers.  Journal Entry Week 2- Patient Description

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Bisson, J. I., Cosgrove, S., Lewis, C., & Robert, N. P. (2015). Post-traumatic stress disorder. BMJ (Clinical research ed.)351, h6161. https://doi.org/10.1136/bmj.h6161

Krystal, A. D., Prather, A. A., & Ashbrook, L. H. (2019). The assessment and management of insomnia: an update. World psychiatry: official journal of the World Psychiatric Association (WPA)18(3), 337–352. https://doi.org/10.1002/wps.20674

Raman, S., & Roy, A. (2019). Insomnia – A general review. Drug Invention Today, 12(1), 123–126. Retrieved from

Saxe, G. N., Ellis, B. H., Fogler, J., Hansen, S., & Sorkin, B. (2017). Comprehensive Care for Traumatized Children: An open trial examines treatment using trauma systems therapy. Psychiatric Annals35(5), 443-448.

Client 1

The client was a 17-year-old African American living with both parents in the suburbs of Florida. He had two siblings, a 10-year-old brother, and a 14-year-old sister. He attended a special needs school. He presented at the clinic accompanied by both parents with a protracted history of insomnia. Raman & Roy (2019) acknowledge insomnia as the most common sleep disorder among young adults globally. It further describes insomnia as having interrupted, unsatisfactory, and difficulty to maintain or initiate sleep, having non-restorative or poor-quality sleep that negatively impacts daytime functioning. The client’s inability to sleep at night severely affected the family where both the father and mother had countless sleepless nights that subsequently interfere with their livelihood and work during the day. Since the client could not verbalize his needs, there was negligence to his attention to comfort, elimination, and food. The negligence often contributed to frequent night awakenings due to hunger or wetness. Although the parents gave special attention in addressing his needs just before bedtime, the client often refused to feed or eliminate before bedtime. Journal Entry Week 2- Patient Description

Initially, the following drugs were prescribed; clonidine 1 mg QHS, Benadryl 50 mg PO at bedtime, Xanax 1 mg PO QHS, and Trazadone 50 mg PO at bedtime. However, after a comprehensive assessment during the most recent visit, to improve on the quality of his sleep, the author prescribed Seroquel 25 mg PO every morning and Seroquel 100 mg PO at 1800 and immediately discontinued Trazadone and Clonidine.  I also urged the client’s caregivers to fill forms to receive liners, diapers, and gloves for incontinence and was to follow up after four weeks. The family was also initiated into family CBT with the primary aim of improving sleep onset latency (SOL), anxiety symptoms, and sleep efficiency (SE) %.

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Client 2                                            

The client was a 14-year-old referred from the ED to the outpatient clinic for a psychiatric evaluation. She had a history of a self-inflicted cut injury on her ankle and wrist after being abused emotionally and verbally by peers in school due to her physical appearance. Based on the parent’s reports, the client suddenly became socially withdrawn as opposed to her previous outgoing, jovial, and enthusiastic nature. Besides, she had no interest in things that she previously had an interest in. When reporting the incident to her parents, she received great support from her mother but her father reprimanded her citing that she had a childish behavior in issues that she had to let go. Due to a lack of guidance and support from her father, she felt disappointed and frustrated. According to the American Psychiatric Association (2013), the best differential for this client according to the DSM V criteria was PTSD (Post-traumatic Stress Disorder). However, during the visit, both parents realized how they negatively influenced their child’s behavior and were ready to take part in counseling through family therapy.

When managing PTD patients, family therapy involves developing a conceptualization for trauma as an issue within the family setup, education, developing communication skills and a support system, and resolving any conflicts or misunderstandings that might have occurred (Saxe et al., 2017). It can also include the identification of common dyadic pattern processes in a family and developing interventions to teach about the trauma while encouraging members to offer support. In this case, the family therapy focused on the relationship that existed between family members and the client,  educating family members about PTSD, how it impacts relationships, how to manage anger, developing communication skills, self-care, building self-esteem, and developing new interaction patterns. Journal Entry Week 2- Patient Description

Journal Entry Week 3: Comprehensive Client Family Assessment

The family assessed comprised of a 15-year-old male teenager accompanied by his 35-year-old mother and 41-year-old father. The client was referred from a primary care setting for a psychiatric evaluation following parental concerns on the adolescent’s behavior change. The son had suddenly changed from being social and outgoing to being sad, withdrawn, and moody. He had even lost interest in the activities he previously found interesting. The client’s father nodded as a sign of agreement with the information that was shared by the mother. It was after realizing an overall decline in his hygiene and academic performance as a result of smoking bhang that they decided to visit a primary care provider. During the assessment, the client acknowledged being emotionally and verbally abused by peers in school but declined emotional, sexual, and physical abuse within the family setup. According to Saunders (2017), this client’s presentation and assessment met the DSM V criteria for substance use disorder.

The family enrolled for family therapy, during which it was evident that although the client was determined to change with immense support from his mother, he received very little to no support from his father. Instead, his father’s attitude discouraged him. Besides, both parents noted how their busy schedules left minimal to no time for family bonding and hence directly or indirectly contributed to their son’s change in behavior. As suggested by Gates (2016), the primary goals of counseling were to make intrapersonal, interpersonal, and environmental changes affecting their son through teamwork. Through counseling, members defined their personal goals for therapy as they worked towards improving family functioning and preventing generational substance abuse. 

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Gates, P. J., Sabioni, P., Copeland, J., Le Foll, B., & Gowing, L. (2016). Psychosocial interventions for cannabis use disorder. Cochrane Database of Systematic Reviews, (5).

Raman, S., & Roy, A. (2019). Insomnia – A general review. Drug Invention Today, 12(1), 123–126. Retrieved from

Saxe, G. N., Ellis, B. H., Fogler, J., Hansen, S., & Sorkin, B. (2017). Comprehensive Care for Traumatized Children: An open trial examines treatment using trauma systems therapy. Psychiatric Annals35(5), 443-448.

Saunders, J. B. (2017). Substance use and addictive disorders in DSM-5 and ICD 10 and the draft ICD 11. Current opinion in psychiatry30(4), 227-237. Journal Entry Week 2- Patient Description