Anxiety and Difficulty Concentrating Treatment

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Table of Contents

Introduction
Presenting Problem
Client History
Potential Diagnosis(es) and Analysis of Symptoms
Case Formulation
Treatment Options
Conclusion
References

Introduction

The family doctor referred Eric for treatment of anxiety and further assessment. Moreover, Eric voluntarily seeks therapy to deal with stress, chronic worry, and concentration problems. Eric has been experiencing these symptoms for more than eight months at the moment of the first visit. As Eric is on medication, the referral for seeking psychological interventions can be viewed as complementary treatment and development of life skills.

Presenting Problem

Eric’s main reason for seeking treatment is anxiety and difficulty concentrating. However, he also expresses a range of other symptoms through his description of past events and his record of medical treatment. The combination of the mentioned issues has led Eric to lose his job and move in with his parents. The longevity of symptoms – more than eight months – worries Eric and leads to thoughts of personal failure and worthlessness, which further exacerbate his negative moods. He also expresses loneliness, fear of becoming a burden for his parents, and anxiety about events that may negatively affect him or his loved ones.

Client History

Family History

Eric’s family is supportive and close-knit; he has a father, a mother, an older brother, and two younger sisters. Eric’s mother has a history of being treated for anxiety, but his other siblings and father do not have any mental health history recorded. His siblings have achieved much in their careers, and the self-comparison of Eric to his older brother is a source of anxiety and depressive moods for Eric. His father and brother were at one point working for the federal police. His parents appear to acknowledge his struggles and are involved in his mental health improvement. Eric’s parents are in a somewhat tense relationship as they have differing views on control over Eric’s finances and activities. It is known that Eric’s father has tried to monitor Eric’s medication daily and tried to predict when the symptoms would worsen. He also interfered with Eric’s access to driving and money by making the car non-usable and taking away Eric’s credit card.

Childhood, School, and Social History

As a child, Eric was reserved and quiet; he struggled with some subjects due to stress, and his grades fluctuated between As and Cs. Eric feared he would not be able to go to college, comparing his school performance with that of his older brother, who had a scholarship. Nevertheless, Eric finished college with a business administration degree, but his anxiety about academic and job performance persisted, leading to problems at college.

Medical History

Eric has a long history of assessments and attempts at medical and psychotherapy. At 19 years old, Eric was hospitalized for an injury not related to suicidal attempts as he crashed his parents’ car. However, after diagnostic tests, it became apparent that Eric was not under the influence of any medication or alcohol, but his moods were persistently elevated. As a result, he was diagnosed with an emotional disorder and prescribed medications. Following the accident, Eric continued to take medications and go through assessments for psychosis and anxiety. He also got into two more car accidents which were caused by elevated moods. Finally, during one episode, he burned up his family car due to increased distractibility.

Potential Diagnosis(es) and Analysis of Symptoms

Eric’s symptoms range between prolonged depressive and manic episodes, and he does not feel any particular symptoms between these periods. At the moment of the visit, the primary symptom was anxiety – Eric worried about his career, family, other relationships, personal value, and other issues. At 19 years old, Eric had a 2-week period of elevated and agitated moods, where he engaged in reckless behavior by crashing his parents’ car. He was distractable and talkative, and his speech was described as quick and loud, which indicates euphoria and racing thoughts. One of the notable symptoms during such periods, which frequently occurred after the first episode, was that Eric heard voices and ideas about the Australian Security Intelligence Organisation, suggesting delusions and auditory hallucinations. Specifically, Eric was worried about being watched by the organization, fearing that it would act to prevent him from achieving success in life. Eric’s episodes outside of elevated moods were characterized by depressed moods, loss of pleasure and interest in activities, feelings of shame, guilt, worthlessness, suicide ideations, and attempts. At the latest visit, Eric expressed no particular symptoms of elevation or depression, stating that he felt anxious.

Some missing information may be the lack of available assessment information from previous events. While it is known that Eric was not under any influence during his first car accident, it would be helpful to see whether he went through assessments previously and how he performed in them. Moreover, explanations of the previous diagnoses or suspicions of psychosis and anxiety could demonstrate why other professionals made these particular conclusions, as they led to Eric taking medication.

The primary diagnosis for Eric is bipolar I disorder with anxious distress and mood-congruent psychotic features. The periods of elevated moods described by Eric are consistent with manic episodes as they are persistent, reoccurring, and last more than one week (American Psychiatric Association [APA], 2013). According to the APA (2013), one manic episode is enough for a person to be diagnosed with bipolar I disorder. During his first car accident, Eric expressed such key signs as talkativeness, racing thoughts, distractibility, agitation, engagement in dangerous activities, and social and job impairment (APA, 2013; Carvalho et al., 2020). As noted in his history, Eric’s first episode was confirmed as happening not under the influence of substances or alcohol and lasting for about two weeks, which is consistent with manic episode duration (APA, 2013). The following instances of manic episodes have similar traits, which leads one to conclude that one part of Eric’s psychological condition is mania.

Similarly, Eric’s depressive moods, which often followed periods of elevation, conform to the description of major depressive episodes. Eric showed diminished interest in hobbies and tasks, as he stated that even pleasurable activities did not bring any satisfaction, which is a significant symptom of depression. Furthermore, he expressed feelings of worthlessness, guilt, delusional thoughts of failure, indecisiveness, and suicidal ideations (Carvalho et al., 2020; McIntyre & Calabrese, 2019; Baldessarini et al., 2020; Miller & Black, 2020). Eric attempted suicide four times, one in high school and three in the last three years. While it is unclear during which episodes Eric showed suicidal ideation, this symptom is consistent with bipolar I disorder. As the APA (2013) finds, the rate of suicide among people with bipolar disorder is “15 times that of the general population” (p. 131). The strong consistency of symptoms and cycling between periods of depressive and elevated moods supports the primary diagnosis of bipolar I disorder. Additional features include increased anxiety and psychotic features such as auditory hallucinations.

The comorbid diagnosis is a generalized anxiety disorder, and Eric’s current symptoms suggest high anxiety at the present moment. The history of symptoms indicates persistent distress starting in high school and continuing during and after college. The persistence of stress and excessive worrying for more than eight months suggests the comorbid nature of this disorder rather than it being a part of bipolar I disorder (APA, 2013; McIntyre et al., 2020). Nevertheless, anxiety appears during Eric’s manic and depressive episodes, taking on different forms – delusions in manic periods and excessive worrying about personal failures during depressive ones.

The first differential diagnosis is bipolar II disorder, characterized by hypomanic and depressive episodes. In contrast to bipolar I, where manic episodes are interspersed with depressive ones, bipolar II is defined by hypomania. It is periods of elevated moods, engagement in risky behaviors, self-harm, quick communication, and hyperactivity (APA, 2013; McIntyre et al., 2020). However, hypomania is not linked to delusions and hallucinations, which are present in Eric’s symptom history (APA, 2013; Perrotta, 2019). Thus, this diagnosis does not fit Eric’s symptom analysis.

The second potential differential diagnosis is borderline personality disorder (BPD), characterized by extreme emotions and their changes, impulsive behavior, stress, and paranoia (Saccaro et al., 2021). Eric’s symptoms of self-harm, stress, paranoid thoughts, and impulsivity are consistent with BPD (Sanches, 2019). However, his presentation of interchanging periods of consistent mood patterns – two weeks of elevated moods and several weeks of depressed moods – is not present in BPD, which is defined by rapid changes (APA, 2013). Moreover, elevated moods are a strong sign of bipolar disorder while being a point of exclusion for BPD (Saccaro et al., 2021). Therefore, this differential diagnosis does not apply to the present case.

Case Formulation

Eric’s biological predisposing factor may be the history of his mother’s anxiety. His reserved personality and family position as the middle child and the youngest of two brothers is a predisposing social factors. It is a perpetuating aspect as Eric compares his achievements with his brother’s. The recent triggers include losing a job and moving in with his parents. The behavior of Eric’s father is a source of stress, as he monitors his son’s behavior, making Eric feel incompetent. However, Eric’s family bond appears to be strong, and he has a close friend, John, who is aware of Eric’s mental health struggles and is supportive.

Aetiological factors	Biopsychological factors
Aetiological factors	Biological	Psychological	Social
Predisposing	Mother’s anxiety
Precipitating		Job loss	Quiet personality
Perpetuating		Comparison to the older brother, anxiety	Father’s behavior
Protective		Personal desire to attend therapy	Strong family connections, friendships

Treatment Options

The first treatment option for Eric is cognitive behavioral therapy (CBT), and the second recommended approach is mindfulness-based cognitive therapy (MBCT). CBT is supported by Level I evidence, while mindfulness has Level II evidence (Australian Psychological Society, 2018). CBT has been found effective in treating bipolar disorder and lowering the rate of relapse (Miklowitz et al., 2021; Özdel et al., 2021). CBT is characterized by its proactive approach to negative thinking (Miklowitz et al., 2021; Özdel et al., 2021). When attending one-on-one or group CBT sessions, a person learns to recognize thinking and behavior patterns and alter them to avoid dangerous and depressive thoughts or analyze elevated moods (Miklowitz et al., 2021). Moreover, the individual learns problem-solving and communication skills to manage moods and deal with difficult situations. For example, CBT can be used to prevent manic episodes from occurring or treat the symptoms during an ongoing period (Özdel et al., 2021). Similarly, the person may use learned skills to prevent and treat depressive episodes.

MBCT is another approach to help individuals with bipolar disorder manage their moods. MBCT prevents relapses by adding mindfulness exercises to cognitive therapy (Lovas & Schuman-Olivier, 2018). Cognitive activities are similar in their strategy to CBT as they focus on skill acquisition for recognizing negative thinking patterns (Lovas & Schuman-Olivier, 2018). The mindfulness component involves medication and self-reflection, where the individual observes personal experiences and works to change their relationships to particular thoughts and emotions (Chu et al., 2018). In this case, self-acceptance, admission of negative patterns, and self-awareness are prioritized. Through reflection and meditation, the individual learns to regulate moods, manage stress, and gain more knowledge about his current state of mind.

Conclusion

In conclusion, both treatment approaches are covered in the literature in detail, but additional research into specific comorbidities such as anxiety and psychotic features can enhance the therapies’ success. For instance, Samamé (2021) suggests that individuals with comorbid bipolar and anxiety disorders would benefit from specific CBT techniques to address both conditions at the same time. Still, there exists a lack of research regarding such combinations. In the reviewed case, Eric has clear symptoms of both anxiety and bipolar disorders. Therefore, complex psychological treatments that acknowledge and deal with both conditions could be advantageous for helping him prevent future episodes and reduce his stress between them.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Author.

Australian Psychological Society. (2018). Evidence-based psychological interventions in the treatment of mental disorders: A review of the literature (4^th ed.). Author.

Baldessarini, R. J., Vázquez, G. H., & Tondo, L. (2020). Bipolar depression: A major unsolved challenge. International Journal of Bipolar Disorders, 8(1), 1-13.

Carvalho, A. F., Firth, J., & Vieta, E. (2020). Bipolar disorder. New England Journal of Medicine, 383(1), 58-66.

Chu, C. S., Stubbs, B., Chen, T. Y., Tang, C. H., Li, D. J., Yang, W. C., Wu, C-K., Carvalho, A., Vieta, E., Miklowitz, D., Tseng, P-T., & Lin, P. Y. (2018). The effectiveness of adjunct mindfulness-based intervention in treatment of bipolar disorder: A systematic review and meta-analysis. Journal of Affective Disorders, 225, 234-245.

Lovas, D. A., & Schuman-Olivier, Z. (2018). Mindfulness-based cognitive therapy for bipolar disorder: A systematic review. Journal of Affective Disorders, 240, 247-261.

McIntyre, R. S., & Calabrese, J. R. (2019). Bipolar depression: The clinical characteristics and unmet needs of a complex disorder. Current Medical Research and Opinion, 35(11), 1993-2005.

McIntyre, R. S., Berk, M., Brietzke, E., Goldstein, B. I., López-Jaramillo, C., Kessing, L. V., Malhi, G., Vieta, E., Vinberg, M., Young, A., & Mansur, R. B. (2020). Bipolar disorders. The Lancet, 396(10265), 1841-1856.

Miklowitz, D. J., Efthimiou, O., Furukawa, T. A., Scott, J., McLaren, R., Geddes, J. R., & Cipriani, A. (2021). Adjunctive psychotherapy for bipolar disorder: A systematic review and component network meta-analysis. JAMA Psychiatry, 78(2), 141-150.

Miller, J. N., & Black, D. W. (2020). Bipolar disorder and suicide: a review. Current psychiatry reports, 22(2), 1-10.

Özdel, K., Ayşegül, K. A. R. T., & Türkçapar, M. H. (2021). Cognitive behavioral therapy in treatment of bipolar disorder. Archives of Neuropsychiatry, 58(Suppl 1), S66-S76.

Perrotta, G. (2019). Bipolar disorder: definition, differential diagnosis, clinical contexts and therapeutic approaches. J Neuroscience and Neurological Surgery, 5(1), 1-6.

Saccaro, L. F., Schilliger, Z., Dayer, A., Perroud, N., & Piguet, C. (2021). Inflammation, anxiety, and stress in bipolar disorder and borderline personality disorder: A narrative review. Neuroscience & Biobehavioral Reviews, 127, 184-192.

Samamé, C. (2021). The rise and fall of cognitive-behavioral approaches to the treatment of bipolar disorder: A critical overview from a quaternary prevention perspective. Bipolar Disord, 23(8), 751-753.

Sanches, M. (2019). The limits between bipolar disorder and borderline personality disorder: A review of the evidence. Diseases, 7(3), 49.

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