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Psychology & Psychiatrist Treatment Melbourne: Case Studies

Psychology & Psychiatrist Treatment Melbourne: Case Studies

This series of case studies has been published to provide patients and referrers with an insight into the assessment and treatment process for various conditions, and some general information on how our treatment team manage common presenting issues.

The case studies are fictitious and are provided as a guide for educational and information purposes only.

The case studies below are:

Case study 1 - A 62 year old business analyst referred for neuropsychological assessment following complaint of memory changes and chronic sleep disturbance.

Case study 2 - A 10 year old boy referred for neuropsychological assessment following concerns about his behaviour and learning at school, and a suggestion that he may have ADHD.

Case Study 3 – A 52-year-old man referred for a neuropsychological assessment following his complaint of poor concentration and memory, combined with a history of morbid obesity and high blood pressure

Case Study 4 - A 38-year-old woman referred for neuropsychological assessment to assist in determining her eligibility for the Disability Support Pension (DSP).

Case study 1

Rebecca was a 62 year old divorced business analyst referred for neuropsychological assessment by her GP following her complaint of memory changes. She had a history of chronic sleep disturbance. Her medications were diazepam and a fish oil supplement. Rebecca had a strong family history of early onset Alzheimer’s disease and noticed changes in her thinking for the previous 1-2 years. She was most worried about losing her place in conversation, forgetting what others have told her, and forgetting people’s names. Her work colleagues had not commented on any problems, though Rebecca relied on taking notes during conversations and meetings and sometimes avoided social situations because she felt embarrassed and frustrated by these difficulties. At home she left reminder notes for herself on the fridge to check that she had turned off the oven and put out the rubbish. Rebecca’s son Bill reported no concerns about Rebecca’s memory but had noticed that she was quicker to anger when plans were changed or in response to unexpected events.

A comprehensive assessment of Rebecca’s thinking skills and general psychological function was completed. Rebecca’s neuropsychological profile was characterised by intellectual abilities in the average range for her age, with slowed processing speed and impaired verbal memory and naming abilities. Her responses on a screening questionnaire also suggested significant anxiety. Rebecca’s pattern and level of neuropsychological function was suggestive of change from premorbid estimates and consistent with amnestic mild cognitive impairment (aMCI). There were also a number of treatable contributors whose effective management was expected to result in improved function regardless of a potential underlying neurodegenerative process. Neurological review was recommended for further investigation of potential early neurodegenerative change. Psychological management of anxiety and sleep disturbance was also recommended.

The findings of the assessment were discussed with Rebecca along with a set of strategies for supporting her memory and other thinking skills in everyday life. When Rebecca learned about the impact of anxiety, sleep disturbance and benzodiazepine use on thinking skills, she was interested in working on these issues. She discussed this with her referring GP who prepared a mental health care plan, which included psychological treatment for anxiety and sleep disturbance. Rebecca was seen over four more sessions for psychoeducation and CBT. By the end of the fourth session she felt she had improved her sleep quality and had learned the cognitive and behavioural strategies she needed to manage her anxiety independently. She had also implemented a range of practical ideas to reduce the impact of her memory difficulties. Rebecca and her referring GP were advised that 12 month neuropsychological review would assist in monitoring any further change in her memory and other thinking skills.

Case study 2

Stewart was a 10 year old boy referred for neuropsychological assessment by his GP because his parents Olivia and Craig were concerned about his behaviour and learning at school. Olivia reported that he walked and talked around the same age as his older siblings, but he was always a bit clumsy and still used training wheels on his bike. Since age 4 family members and friends had commented on his poor listening skills, ability to follow instructions, and solve problems. Olivia found his behaviour very frustrating and sometimes wondered whether he intentionally didn’t listen to annoy others. In grade 5 he was receiving extra support for maths and literacy, but continued to fall further behind his classmates. His teacher Sarah said that other children had started to tease him recently, and that he now stood with staff members at lunchtimes rather than playing with other children. She noticed that he was easily distracted and impulsive, and suggested that he may have ADHD.

Comprehensive neuropsychological assessment was conducted over four sessions. Stewart’s neuropsychological profile was characterised by intellectual abilities in the Extremely Low range for his age, indicating that he had a Moderate Intellectual Disability and that his ability to understand and reason with information was at the level expected for a 4-5 year old. His memory and attention skills were consistent with his level of intellectual ability, as were his academic skills. He was found to be at significant risk of emotional difficulties, particularly around his peer and family relationships. It was recommended that an application for funding be made by his school on the basis of Intellectual Disability, and that he and his family practice some additional ways to promote self-esteem and healthy coping.

The findings of the assessment were discussed with Stewart’s parents Olivia and Craig. They were surprised that Stewart had an Intellectual Disability and were interested to hear that his learning and behaviour were more like a 4-5 year old than a 10 year old because that was the level at which his brain development allowed him to process information. They were initially worried that this would mean people would ‘give up’ on Stewart and were relieved to hear that even though his disability would be a permanent one, there were lots of steps that could be taken to maximise his development. Over the next few weeks Stewart’s parents began to understand his behaviour differently and introduced a range of ideas at home for supporting Stewart’s thinking skills. Stewart and Olivia also attended a session together to learn some ideas that Stewart could practice with support at home and school. At the beginning of the new school term the neuropsychologist was attended a planning meeting for Stewart at his school, where his classroom teacher, the student support coordinator and the neuropsychologist shared information and developed a plan to address some key learning goals for Stewart using the resources available within the school.

Case Study 3

David is a 52-year-old man, who was referred for a neuropsychological assessment by his GP following his complaint of poor concentration and memory. David had a history of morbid obesity and high blood pressure. He and his wife also reported a long history of heavy snoring and gasping for breath during sleep. They were most worried about excessive daytime sleepiness, and David’s tendency to fall asleep in many situations. David had recently fallen asleep while stopped at a red light, and was concerned about his risk of drowsy driving. Furthermore, David was employed in a factory and was required to operate heavy machinery. He reported that unless he was managing many machines at once, he had a high tendency to feel drowsy, and was concerned about his risk of accidental injury. This was resulting in significant anxiety for David which was affecting his performance at work and his overall quality of life.

Following his complaint of excessive daytime sleepiness, David underwent a sleep study and was found to experience moderate to severe obstructive sleep apnoea. It was recommended that he commence treatment with a Continuous Positive Airway Pressure (CPAP) mask every night, and that he also consider weight loss. David was concerned about the intrusiveness of the mask and felt that it would be difficult for him to adhere to the treatment.

David completed a neuropsychological assessment to explore his cognitive functioning and to determine the effects of sleep apnoea on his thinking skills. The assessment was also necessary to rule out any other underlying cause of his cognitive complaints, especially given his vascular risk factors. The assessment showed that overall David’s intellectual abilities were at the level expected. He did demonstrate slowed information processing, and reduced higher-level attentional skills. These difficulties negatively impacted on his memory, making it difficult for David to efficiently retrieve information.

David was seen over ten more sessions to address the following: 1. education about the effects of sleep apnoea on his cognition and the importance of effective treatment to improve this, 2. Acceptance and Commitment Therapy (ACT) to explore his values in relation to his compliance with treatment and improving his quality of life. 3. Behavioural modification (through ACT) to aid his weight loss goals, and 4. Strategies to manage his anxiety. By the end of the sessions, David felt more motivated to address his weight loss and had begun a diet and exercise regime. He had also agreed to trial the CPAP treatment to learn of the improvement this could make to his daytime sleepiness, cognition and overall quality of life.

Case Study 4

Amanda is a 38-year-old woman who was referred for a neuropsychological assessment by her employment consultant to assist in determining her eligibility for the Disability Support Pension (DSP). Amanda was a mother of seven children and, since leaving school after Year 9, had never been employed due to her full-time commitments as a mother. She was now required to look for work since she was no longer eligible for parenting payments from Centrelink. Amanda had a supportive partner who was in receipt of the disability support pension.

Amanda had a long history of learning difficulties, including poor literacy and numeracy. However, she had never received any formal assessment of her intellectual functioning. Amanda also experienced long-standing anxiety and depression that she attributed to a complex history of trauma and abuse. Amanda reported that she had never received psychological support in relation to these traumatic events and continued to experience flashbacks and intrusive thoughts. She also described significant depression and panic attacks which she had attempted to minimise with the use of alcohol. Amanda described that she had recently endured a period of very heavy drinking. She had since been prescribed anti-depressants (Pristia) which she reported had improved her mood slightly and reduced her alcohol intake.

Amanda’s employment consultant was concerned about Amanda’s ability to obtain and maintain meaningful employment given her history of learning difficulty and her current mood disturbance. Amanda had recently attempted a literacy and numeracy course, but was unable to cope in the classroom setting and had significant difficulty learning the necessary material. It was felt that the investigation of a possible underlying intellectual disability was warranted, together with recommendations for management of Amanda’s anxiety and depression.

A comprehensive neuropsychological assessment was completed and it was determined that Amanda’s overall level of intellectual functioning fell within the Extremely Low range, and her performance was consistent with a Mild Intellectual Disability. These findings were discussed with Amanda and her employment consultant and it was recommended that she be eligible to receive the disability support pension. Amanda was seen over four more sessions for psychoeducation and strategies that she could use to manage her anxiety independently. She was also assisted to implement a range of cognitive strategies to manage her cognitive difficulties. Amanda’s assessment and diagnosis also assisted her to access disability services and support packages that could be useful in assisting her community integration and engagement in meaningful activities.