Estrogen Replacement Medication

Psychology homework help: Ms. A, a moderately obese 32-year-old white woman, initially presented to our office in January 1997 for a refill of her estrogen replacement medication, which she had been taking since her hysterectomy for endometriosis after the birth of her fourth child in 1995. She complained of increasing problems with depressed mood, for which she had been treated by her previous physician with fluoxetine, 20 mg/day, for the past year. Although her current level of depressive symptomatology fell short of major depression, a careful history uncovered multiple past episodes that met those criteria. Ms. A related feeling “depressed and moody” since her teenage years. Paroxetine and other antidepressants administered for previous depressive exacerbations usually caused increased lethargy and little improvement in mood.

While fluoxetine initially helped decrease her tearfulness and increase her energy and goal-directed behavior, the improvement had lasted only a few weeks. Her mood aberrations were not related merely to estrogen replacement or adherence problems. Ms. A denied current use of alcohol or illicit drugs and smoked cigarettes about 1 pack per day for 20 years. She also drank 1 or 2 servings of caffeinated beverages per day. A physical examination and routine laboratory work were unrevealing. Her TSH level was normal. She was advised to exercise, reduce her fast-food intake, consider psychotherapy, and increase her fluoxetine dose to 40 mg/day.

When seen next, Ms. A complained of continued hypersomnia and daytime lethargy, increased appetite, frequent crying, headaches, and memory problems. Increasing her fluoxetine dose from 20 mg to 40 mg seemed to help for a while, but then gradually stopped working—the same pattern of response noted on initiation of fluoxetine treatment. We asked her to describe the timing and quality of her initial improvement on the increased dose. After only 2 to 3 days on 40 mg of fluoxetine, she went from lying in bed much of the day to playing kickball in the backyard with her children. Her hypersomnia reversed abruptly to her needing only 3 to 4 hours of sleep per night. Ms. A described feelings of elation and of having her mind filled with ideas and activities, racing from one thought to another.

She became markedly more talkative and social. Those around her noticed her behavior as distinctly different than usual. This sudden and dramatic response lasted about 1 week, ended suddenly, and was followed by a steady decline in energy and motivation over the next several weeks. When asked if these episodes had ever occurred in the past, Ms. A described experiencing similar brief periods of expanded mood that occurred every 2 to 3 weeks, typically lasting from 2 to 3 days, but occasionally as long as 5 days. She recognized these periods as being time limited and would try to make the best of them by shopping and doing housework, often late into the night.

Analyze the case in an 8-page (minimum) paper. You do not need a cover page or references, and strict adherence to APA style is not necessary. You can also use first person language as needed. Your paper should have sections that address the following topics (minimum 1 double-spaced page per section):

Relevant symptoms: What psychological, emotional, social, or biological/physiological symptoms do you find while reading the case? In this section, don’t just list symptoms; you need to cluster symptoms according to DSM-5 disorder criteria (think criterion A for various disorders). Also make sure to be specific; for example, “anxiety” and “feeling anxious” are not symptoms, but feeling on edge, worrying, shaking, etc. might be. Finally, discuss any relevant cultural considerations/issues that could be impacting the case.

Substance/medical etiology: Discuss any relevant substances, medications, or medical conditions that could explain the symptoms from the previous section. If possible, rule out any substance/medication-related or medical diagnoses and clearly explain why you would rule them out. If these diagnoses cannot be ruled out, justify why this is the case.

Stressors/Clinical History: Identify any potential stressors that occurred in relation to symptomology; if there are any, do they explain the symptoms and why/why not? Discuss the timeline of symptoms to the extent possible, including when the symptoms began, how long they last, and the frequency at which they come and go. Note that timelines may vary for different sets of symptoms. If there are gaps in the clinical history, note them as well.
Diagnostic impression: Offer a DSM-5 diagnosis (you can offer more than 1), including DSM-5 code numbers, relevant subtypes and/or specifiers. Also include the ICD code numbers and the impact of utilizing the DSM version compared to the ICD version on billing and epidemiological disease monitoring. Clearly justify your diagnoses by linking the symptoms to the DSM-5 criteria and to the clinical history. Make sure to address clinically significant distress and/or functional impairment caused by symptoms for each diagnosis offered.

Rule Outs and Differential Diagnosis: What are potential competing mental health diagnoses for this client that you can definitely rule out based on what you observed? What are potential mental health diagnoses for this client that you cannot yet rule out, but would need to rule out if you continued working with this client? Make sure to justify both in the context of the symptoms you listed and what remains missing from the clinical picture.

Case conceptualization: How is it that this person came to have these particular problems? What prevention efforts might have mitigated these problems? Where are these problems stemming from (e.g., intrapsychic issues, early relationships, learned behaviors, faulty cognitions)? What are this person’s strengths? You are encouraged to utilize counseling theory to inform this section.

Treatment recommendations: What type of intervention/treatment would you implement with the client? What crisis intervention models might be helpful and when? If you were working with this client, what would be your treatment goals be? Which counseling theories would you draw upon to help this client? Why? Would the person benefit from psychotropic medications? Why or why not? What ethical and legal considerations specific to clinical mental health counseling might be at play here?

Personal reactions: What are your personal reactions to this case? What was it like for you to try to diagnose this case? What was easy for you and what was more of a struggle with this case study? Moving forward, what can you do to get stronger with diagnosis?

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