Isabella, a 29-Year-Old Woman, Presents to HerEssay

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Isabella, a 29-year-old woman, presents to her GP with a primary complaint of difficulties in sleeping. She also is concerned about her work-related stress and general well-being. She is diagnosed by her GP with insomnia. However, there are other considerations, such as features of her anxiety and limitations of the metrics used to evaluate her, that suggest additional diagnoses may be warranted. Because of the importance of an accurate diagnosis in determining treatment, Isabella should be evaluated further for the possible diagnoses of generalized anxiety disorder and major depressive disorder.

This answer to question 1 will discuss Isabella's complaints and test results as well as suggest additional diagnoses.

Isabella is a 29-year-old woman who sought help from her general practitioner for difficulty in sleeping and for concerns about her work performance and general well-being, perhaps secondary to sleep difficulties. She gave a verbal report to her GP and also completed the Depression Anxiety Stress Scales questionnaire (Lovibond, 1995).

According to Isabella's verbal reports, she has difficulty falling asleep and has found it difficult to relax and finds herself worried about work problems in her non-working hours. Her insomnia and other problems have led her to complain about decreased work performance, and therefore she is seeking help.

In addition to her insomnia, Isabella reports that most of the time she is tired and irritable. She has difficulty concentrating and making decisions. Not only does Isabella think that her work performance is decreased due to her problems, but she also reports that her well-being is suffering.

Isabella's general practitioner diagnosed her with primary insomnia associated with work stress. The main reason for this diagnosis, as opposed to an anxiety disorder or depression diagnosis, was Isabella's result on the Depression Anxiety Stress Scales questionnaire (DASS) (Lovibond, 1995). Isabella's scores on the Depression and Anxiety scales were in the normal range, whereas her score on the Stress scale was in the severe range.

There are several alternate diagnoses that Isabella's GP may have made, other than primary insomnia associated with work stress. One alternate diagnosis is Generalized Anxiety Disorder (GAD). This seems to have been ruled out due to Isabella's score on the Anxiety scale of the DASS, but several other considerations suggest that GAD should not be ruled out in Isabella's case. First, she has reported that she has always worried a lot about her school and work performance, and about her family and minor things. These worries have persisted throughout and beyond childhood, and her insomnia is only a recent phenomenon. It is possible that the insomnia is secondary to a GAD that manifested more fully when Isabella received her promotion.

A second reason that GAD or another disorder should not be ruled out in Isabella's case is that it is possible that the DASS is not a completely accurate evaluation scale for depression, anxiety, and stress disorders. The GP did not use additional self-reporting metrics for evaluating Isabella's case, and it is possible that different tests would have yielded different results. For example, one study found that only medium-sized correlations exist between results of different tests for depression, anxiety, and post-traumatic stress disorder (Einsle, 2010, p. 584). An additional potential problem with self-report tests is lack of accurate reporting by patients due to perceived stigma. One method to gain better insight into patients' conditions is to use multiple screening tests, as has been reported (Janeway, 2009, p. 36). In Isabella's case only one self-report screening test was used, which may have led to inaccurate conclusions.

A third reason that GAD or MDD/dysthymia should not be ruled out is that Isabella reports difficulty in concentrating and making decisions. These are features of MDD/dysthymia (Diagnostic and Statistical Manual for Mental Disorders IV, 2000) and are not assessed by the DASS (Lovibond, 1995). Difficulty in concentrating is also a feature of GAD (Diagnostic and Statistical Manual for Mental Disorders IV, 2000). These symptoms may be secondary to insomnia, but they may also be due to an underlying depression or GAD.

Several considerations make GAD a more likely alternate diagnosis than MDD/dysthymia. Isabella complains of all six of the diagnostic symptoms of GAD, whereas she lacks some important symptoms of MDD/dysthymia, such as persistently low mood and lack of pleasure in previously enjoyable activities (Diagnostic and Statistical Manual for Mental Disorders IV, 2000). Moreover, Isabella clearly exhibits excessive worry and anxiety, likely not due to an underlying mood disorder, an essential feature of GAD (Diagnostic and Statistical Manual for Mental Disorders IV, 2000).

Question 2:

This answer to question 2 will discuss and evaluate several major theories as they relate to Isabella's case.

Two potentially competing theories involve the etiology of the development of her symptoms. According to one theory, Isabella's insomnia and stress are due to an organic/endogenous disorder, whereas according to another theory, her insomnia is due to a reactive disorder. In the second case, the insomnia and stress would likely be caused by work problems due to her recent promotion.

Of course, these two theories are not mutually exclusive. It is possible that an underlying organic change underlies a reactive insomnia. For example, it has been found that in comparing two neurological diseases, rheumatoid arthritis and multiple sclerosis, disease type independently predicts whether depression will manifest (Holden, 2011, p. 1). Direct neurological manifestations of the disease, which would be classified as organic/endogenous, partly cause the depression associated with the disease. An organic/endogenous etiology may also underlie Isabella's insomnia and stress problems, even if they are partly due to an increased work load.

An additional theory regarding Isabella's insomnia, alluded to above, is that it is caused by another primary disorder, such as major depression, dysthymia, or an anxiety disorder. It is clear that the DASS does not evaluate some key components of major depressive disorder (MDD), as described by DSM IV (Diagnostic and Statistical Manual IV). For example, the DASS questionnaire does not directly address loss/slowing down of motor function, as does the DSM IV questionnaire for major depression. Also, the DASS does not ask the patient about loss of/low energy or loss of/low concentration, as does the DSM IV questionnaire. Finally, the DASS questionnaire does not address social support networks, which are important in assessing the possibility of MDD. From these observations it may be concluded that MDD or dysthymia should not be ruled out in Isabella's case.

A key reason that these concerns about the underlying disorder in Isabella's case is important is that the diagnosis is important for determining her treatment(s). While a diagnosis of insomnia due to work stress might warrant treatment with a medication to aid sleep, such as zolpidem (Ambien) or a benzodiazepine, these medications may not be ideal if MDD or an anxiety disorder underlies or is comorbid with her insomnia. If there is an anxiety disorder underlying or comorbid with Isabella's insomnia, then benzodiazepine treatment may be ideal. However, if MDD or dysthymia underlies or is comorbid with her insomnia, then an antidepressant medication, such as a selective serotonin reuptake-inhibitor (SSRI) may be the best treatment. Regardless, it must be noted that there is evidence that early, mild presentations that may be sub-clinical according to DSM IV have a strong potential to become severe disorders, and it may be cost-effective to treat these milder presentations aggressively (Kessler, 2003, p. 1117).

In summary of the first part of the theoretic appraisal of Isabella's case, it is clear that more than one assessment questionnaire should be used to determine her diagnosis. There are clear limitations of the DASS questionnaire in that they do not evaluate some key components of depression, such ability to concentrate and energy level. Moreover, even if Isabella's case is a mild case of MDD or GAD, it is possible that the case may worsen in the future (Kessler, 2003, p. 1117). Therefore, any treatment should be aimed to prevent exacerbation of her condition.

An additional consideration to be taken into account is that Isabella's insomnia may be cormorbid with another condition, a condition possibly undetected by her verbal reports and the DASS questionnaire results. The two most likely possibilities are MDD/dysthymia and GAD. An important distinction is whether a potential cormorbid condition is MDD/dysthymia or GAD. This is because treatment options differ depending on the diagnosis. If a comorbid condition is MDD/dysthymia, then treatment involves antidepressant medication and/or cognitive-behavioral therapy. On the other hand, if a comorbid condition is GAD, treatment likely involves benzodiazepines and/or cognitive/behavioral therapy. As argued in the answer to question 1, GAD is a more likely diagnosis than MDD/dysthymia, but more evaluation (through DSM questionnaires, other anxiety / depression questionnaires, verbal report) is required to determine which, or both, of these conditions are involved in Isabella's case.

Given the information provided, it seems that cognitive-behavioral therapy (CBT) is recommended in this case. This would not only provide therapy for Isabella, but also help determine what type, if any, pharmacological interventions should be made. It would also make Isabella's diagnosis more clear. One general theory is that CBT may… [END OF PREVIEW]

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