Diagnosis of Anxiety and Obsessive Compulsive Disorders Discussion

 

 

The Case of Aretha

 

Intake Date: November 21, 2020

 

 

IDENTIFYING/DEMOGRAPHIC DATA:  Aretha is a 62-year-old, single, heterosexual, African American female

 

CHIEF COMPLAINT/PRESENTING PROBLEM:  Aretha is seeking treatment for anxiety. She says she is very concerned with her anxiety that she is always playing with her hair to calm herself down.  Recently, it has become noticeable that her hair is missing on top of her head. She is taking to wearing hats and wigs which she is fine with to hide the bald spots.

 

HISTORY OF PRESENT ILLNESS:  Aretha worries about so many things, which is not new to her, and she finds that by scrubbing her home clean is her best therapy to ease her anxiety, in addition to her hair pulling. Aretha reports that germs have been a regular concern of hers since adolescence, when she learned in health classes about the risks of serious diseases including sexual transmittable disease.  Aretha presented with meticulous grooming, although the knees of her pants were noted as worn. She has arthritis in her spine and knees and uses a walker to help her manage mobility safely.  With her physical disabilities, it is challenging sometimes to scrub the house clean daily.  This worries her in case she gets a visitor and the house is not in order as she would like it.  Luckily, she is no longer working so the amount of time it takes her to scrub the house clean doesn’t delay her daily schedule as it used to.  Aretha receives Social Security income and is not employed. Although the social security is sufficient, her living expenses are always a concern to her. She lives alone in a rent-stabilized and subsidized apartment in the same building as her 72-year-old, unmarried sister.

PAST PSYCHIATRIC HISTORY:  Aretha and her sister shared an apartment for over 30 years, beginning when each of their marriages dissolved. Aretha reported that when her sister began a romantic relationship 5 years ago, Aretha began to feel very anxious. Aretha moved into an apartment down the hall in the building and began to pull the hair from her head, hiding her hair loss by wearing wigs. This behavior occurred, at different times and resulted in scabbing. Aretha said she feels better after but does not always notice how much she is pulling. Her sister learned of Aretha’s hair pulling after her wig slipped off one evening to reveal bald spots. She set up a schedule over the past few months with her sister to help stop the hair pulling.  Sometimes it works and sometimes it doesn’t.  She is worried that she will be disappointing her sister by not sticking to the schedule to reduce her hair pulling.  Her sister encouraged Aretha to seek treatment rather than “hiding her ways.” Aretha is reliant upon her sister for transportation and for a sense of social and emotional connection. Aretha worries about bothering the sister due to her transportation needs and worries if she doesn’t have her sister what would she do.  She knows she is edgy with her sister often and worries that might be from lack of good sleep.  She agreed to this session even though she is pessimistic about anything working. Diagnosis of Anxiety and Obsessive Compulsive Disorders Discussion

 

SUBSTANCE USE HISTORY:  Aretha noted that she drinks occasionally but not to excess.  Her Uncle was an alcoholic and she would never want to be like him.

 

PAST MEDICAL HISTORY: No significant medical history noted.

 

FAMILY HISTORY INCLUDING MEDICAL AND PSYCHIATRIC:  Aretha shared that when she was 2 years old her mother died from tuberculosis, and the following year her father, an army officer, died from colon cancer. After his death, Aretha lived with her paternal aunt from whom she felt no love. Her older brother and sister were placed in an orphanage, and Aretha was permitted to see them on Sundays. When it became apparent that the children were entitled to death benefits, Aretha’s aunt agreed to take custody of all three siblings. The household then consisted of Aretha’s paternal aunt, her husband (who Aretha described as an alcoholic), their three children, and Aretha and her two older siblings.

CURRENT FAMILY ISSUES AND DYNAMICS:  Aretha was briefly married in her early 20s (4 years) but was disappointed and hurt by her husband’s infidelity. She moved in with her sister at that time. Aretha reported it as an “anxious” time but denied hair pulling then. Aretha also enrolled in a cosmetology school and liked her work. She had to stop working “for health reasons” when she was 58 years old. With all this going on in her life now, Aretha feels tired a lot trying to keep up with the cleanliness of the house especially with her lack of mobility and finds herself napping often.  This then interferes with a restful sleep at night.

 

MENTAL STATUS EXAM:  Aretha in a plain non-descript manner with little makeup.  She was dressed appropriately in casual attire with some wear on her pants at the knees.  Aretha had good eye contact and was collaborative during this assessment.  The conversation flowed freely after a reluctant start.  Thought and speech patterns were clear.  Affect was appropriate.  She was oriented in three spheres.  Aretha denied feeling depressed, suicidal or homicidal.  She admitted to being sad.  She states her concentration is definitely affected by her lack of sleep.  When asked about her behaviors concerning her hair pulling, Aretha reluctantly admitted that if she cannot get to her hair she will pick at a scab or skin. Generally, she avoided social situations so that her behavior is not exposed because she worried what others would think of her.  She denied other behavioral rituals but became noticeably anxious at this question. When asked about “goals” if treatment was to be effective for her, Aretha stated that she wanted to “cope better”.