It is a case of psychosomatic pain disorder in which a twenty seven year old lady named Nasrin is suffering from lower abdomen pain. Recently she had hysterectomy due to heavy periods and regular severe uterine pain. But after six months of her surgery she still feeling pain in her lower abdomen and she have no improvement in pain after six months of her surgery. Her gynecologist confident her that everything was normal but she was not satisfied with this statement. She visits many specialists but found no relief. She felt sharp pain everyday from few minutes to hours. In recent times she felt chest pain and thought she is having heart attack. But after her checkup in emergency the physician recommended that it might be anxiety. She felt insulted . Her GP influenced her to go to psychologist. GP clarified her that at times even emotions causes difficulties in medical problems
Client’s problems and Diagnosis:
Nasrin went to consultant and told her problems. She explained that she has severe low backache and her pain is presently radiating both legs. Pain is very sharp and brought herself to tears. Pain occurs every day at different time intervals. She has lack of motivation and interest. She didn’t sleep properly in night. She felt insulted when GP told her that these are only the signs of anxiety and tell her to see a psychologist. She avoids to meet anyone and seen herself failure and weak. By studying the whole case the case is diagnosed with the help of DSM IV checklist and it is diagnosed as a case of pain disorder associated with psychological factors. The client has following features: Her main problem was significant pain from long time. There are many psychological factors which play main role in the beginning, severity, exacerbation or preservation of pain. As pain felt everyday at different times and intervals. Pain is very sharp that brings Nasrin to tears. The symptoms are not purposely produced by the patient.
Background:
Patient Nasrin is the youngest one in her family. Since puberty she has not good health. She was having severe recurrent headaches but those headaches were not diagnosed as the attacks of migraine. When she was twelve years old her grandmother died. She was suffered with the symptoms of after stroke for four years before her death. After the death of her grandmother her mom showed sympathy towards her and whenever she felt those headaches she told her lie down. Her mother gave cold compression to her head. Mostly she felt chest pain during the stress period of exams. She got married at the age of twenty one and she left her study because of her severe headaches. She always tried to become an ideal companion. Her husband Alfred was also caring but due to her continuous appointments with doctors and their expenses he started criticizing her. Her husband left her after two years of her marriage. She was heartbroken at that time then she started work for supporting herself but soon she lost her job due to her health problems. Because of her continuous visits to doctors she was absent from work many times and this was the reason for her job lost. After that she joined her parents and moved to their house.
Case formulation:
For formulating the case, first of all the consultant assesses and socializes into cognitive therapy. CBT is the therapy of choice in various mental health problems. CBT promote patient to talk about himself in a way that how the patient think about himself, the surrounding world and the other persons surrounding him. What are the things affects patient’s thoughts and feelings. By knowing all these things CBT helps in patient’s thinking (Cognitive) and what he do (behaviour) and this can help patient to feel better regarding his life. After that assessed the detailed description of the problem of client and in this case it is recurrent lower abdominal pain. Assess the predisposing factors and in Nasrin case these are recurrent headache and chest pain during stress like in exams etc. The precipitating factors were her grandmother’s death and separation from her husband soon after her marriage and the maintaining factor is long term complaint of lower abdomen pain. Then ABC analysis of problem was done by the consultant. Diagnose historical context of the problem, its assumptions and core beliefs. After that constructed a treatment and management plan . Afterwards socializing the client towards the self task.
When client came to consultant initially in first session he/she should tell the client about the confidentially of their conversation for gaining faith of client, tells the cognitive therapy and regarding the estimated time of the therapy. CBT sessions are depends upon the patient’s problems and objectives. Generally with CBT results are better realized when sessions are between 6-20 and varies from 40 minutes to one hour each session. Every session is generally has a gap of one week or fifteen days. CBT cannot remove the patient’s problems but it can help to handle them in an optimistic way. Therapist helps patient to find ways by changing your thoughts and behaviour so that the patient cope with the problems in better way. (Sheldon, 2011). Consultant assesses the details of the problem as in this case Nasrin has a problem of severe lower abdomen pain. She suffers from this pain from a long time. She has heavy menstrual bleeding and severe lower abdominal pain. Her gynecologist was not agreeing to do surgery for this pain but Nasrin’s frequent visits and continuous pain problem agreed her to do surgery. Because of this continuous and sharp pain she influenced her surgeon and had hysterectomy in her young age. After six months of her surgery she felt no improvement in her pain. She visited to many specialists for finding the cause of her pain problem. But nothing was found by any specialist. Recently she felt chest pain and thought that she was having heart attack. But physician told her she is normal and this all was because of anxiety. She felt insulted with this comment. At last her GP influenced her to consult a clinical psychologist and clarify her that at times emotions made worse to medical problems. GP explained her that psychological assessments will better treat her condition.
ABC analysis of Nasrin case: In this case A- activating events are the hysterectomy of client which was done at young age. Nasrin is separated from her husband and stay with her parents. B-Her rational thoughts and beliefs are that she is having severe pain in her lower abdomen. She also felt chest pain. She thoughts that she is pathetic for being like this . C- Consequences regarding the emotions she is nervous, irritated, shame and hurt also. In her behaviour she is always sad, there were crying episodes as sometimes the pain bring her to tears and she feels isolated also.
After assessing Nasrin problem consultant gave her a questionnaire to do at her home . It is a questionnaire based on Hamilton anxiety rating scale (HAM-A). The main reason for giving this questionnaire to know the severity of symptoms of anxiety in patient. This scale contains 14 items and each of these items distinct by a number of symptoms. This scale calculates both psychic and somatic anxiety. Each item is scaled on 0-4 in which 0 means not present and 4 means severe. Total score range is 0-56 and if a person scores less than 17 it shows less severity and 18-24 means mild to moderate severity & 25-30 means moderate to severe symptoms of anxiety ( Guy, 1976, Hamilton, 1959). In her next visit Nasrin has to bring that filled questionnaire and consultant assessed those answers.
In the next session consultant go through that filled questionnaire and identifies and clarified Nasrin problems by DSM IV checklist. The DSM (Diagnostic and Statistical Manual of Mental Disorders) is the usual classification regarding mental disorders and is used by mental health professionals in America. This has five axis in which Axis I covers clinical disorders, Axis II includes personality disorders and mental retardation. Axis III includes general medical conditions, Axis IV psychosocial and environmental conditions and Axis IV global assessment of functioning scale (American psychiatric association, 2000). Consultant assesses and found that she has a problem of pain disorder associated with psychological factors. Consultant took a detailed historical background in this visit. When consultant asked Nasrin about her background she told him that she was the youngest in her brother sisters. She has poor health since teenage. She has recurrent headaches from puberty but those headaches were not fit into migraine attacks and her grandmother died when she was 12 and her mother shows sympathy towards her after her grandmother’s death. She has chest pain during stress. She was married when she was only 21 years old and left her university study because of her severe headache problem. Her husband left her after two years of her marriage. The reason for her separation was the high expenses due to frequent visits to doctors for her complaint of lower abdomen pain. After her separation she started work as personal assistant for supporting her. She lost her job soon because of continuous absent from her job due to her health problems. After that she shifted to her parents place and stay with them. Consultant listen all the background and gave Nasrin a homework task to maintain a daily pain dairy. In which she has to write at what time she has the pain as the pain starts in morning, afternoon or evening. Where is the pain in the scale of 0-10, in which 0 means no pain, 5 means moderate pain and 10 means worst possible pain. She has to write in dairy that what she was doing when the pain started. Did she take any medicine and what was the dose of that medicine? What were the other treatments she used? After one hour what the pain rate was in the rating scale like is it relived or gone worse. What are the other problems she faces? She has to maintain this daily pain dairy (AGS Foundation for Health in Aging, 2006) for one week till her next visit and bring it with her in her next visit.
In her next visit the consultant gone through her daily pain dairy and identify her problem. Consultant done a counseling session about her hobbies and her likes and dislikes with her and in that conversation she told that she was previously used to write a personal dairy daily. But due to her health problems she didn’t do this now. By knowing this entire, consultant asked her that why not she again start writing a book on her life and choose this as a smart goal for her. But she said that she is not able to do all this because of her health problems then consultant told her to just give this a try. In smart goal it is specific for Nasrin to write a book on her life story. This is measureable as the book will have 150 pages and her progress would be measured monthly. It will be an attainable goal as if she complete twelve and half pages in a month then she would have 150 pages by the deadline. This smart goal is realistic also as at times it will be difficult for Nasrin to get her thoughts on paper, so she give herself enough time to complete her book. For time she has to finish this book in twelve months that means twelve and half pages in a month and150 pages in a year. So consultant advised her to work on this smart goal and she agreed on that.
Generating Solution:
For Nasrin consultant planned cognitive behaviour therapy for 6-12 weeks in which she has to continue her pharmacotherapy that means she has to continue her drugs prescribed by physician. She is advised for relaxation therapy and supportive psychotherapy for her anxiety problem. For relaxation therapy she has to do some relaxation techniques which helps in reducing tension of muscles and improving patients in general feeling of wellness and minimizes anxiety. Deep relaxation for 20-30 minutes reduces general anxiety, reduces the incidence and harshness of panic attacks. These techniques also good for sleeplessness and fatigue. It also increases self confidence and reduces the symptom of self blame (Bourne, 1995). In supportive psychotherapy, patient has to be supported for coping with stressors by many actions like carefully paying attention and cheering expressions regarding thoughts and feelings. Supporting the patient to understand the situation and its alternatives and trying to give a hope to patient (Douglas, 2008). She has advised for some physiotherapy to support and tone up her lower abdominal muscles and keeps her body fit.
Consultant advised Nasrin some preferred solutions for her problem. She has advised to do early morning yoga for half an hour. Then after her breakfast she is advised to visit local library for reading books on biographies. And coming back to home relax for some time and do some household works and after lunch go out for shopping and start socialising with friends and neighbours. In the evening watch tele with her parents. After dinner chat for some time with parents. Before going to bed while listening music try to write her biography. She has to follow the same till her next visit.
After all these visits Nasrin is quiet satisfied and relaxed. Her episodes of pain are reducing day by day.
