Case Study: Jenny Doe's Generalized Anxiety and Depression (COUN 698)

This case study focuses on Jenny Doe, a patient grappling with generalized anxiety disorder and major depressive disorder. The study delves into Jenny's background, including her challenging childhood experiences and the loss of her father. It details her diagnosis, problem list, and a comprehensive case conceptualization summary statement that considers biological, psychological, and social factors. The theoretical orientation emphasizes Cognitive Behavioral Therapy (CBT) and Mindfulness-based Cognitive Therapy (MBCT) as primary treatment approaches, supported by evidence-based interventions. Ethical issues like consent and confidentiality are discussed, along with multicultural factors. The assessment section highlights the use of tools like the Hamilton Depression Rating Scale and Patient Health Questionnaire. The case study also addresses referral and access considerations, particularly the need for support and education. Finally, it provides a prognosis that emphasizes the importance of continuous assessment and intervention to prevent potential worsening of Jenny's condition and to improve her mental well-being. References are also provided at the end of the case study.

Running head: CASE STUDY
CASE STUDY
Name of the student:
Name of the university:
Author note:

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Client background information: Jenny Doe who is experiencing overwhelming amount of
worry constantly. Always fearing the worst and something to will happen. Her mother was
not constant presence in the home and often left the Jenny and her younger brother alone in
the home. Jenny’s father worked as a truck driver and often times would have jobs that
required days on the road. The financial responsibilities were maintained for the household
but there were many nights Jenny was left in charge of caring for her younger brother.
Jenny’s parents divorced when Jenny was 14 years old and her father took over custody of
her and her younger brother. Jenny’s father was very loving, caring and nurturing. He was the
children’s primary caregiver. Jenny’s father passed away when Jenny was 16 years old as a
result of an automobile accident while driving his truck on a job assignment.
Diagnosis-
300.02 (F41.1): Generalized Anxiety Disorder
296.21 (F32.0) Major Depressive Disorder, mild, single episode
A. Problem List:
1. Frustration with anxiety, and constant worry
2. Depression
Case Conceptualization Summary Statement
When practicing a Case Conceptualization Summary Statement, it is important for the
health care professional to present the health conditions which are related to the findings
attained by the health care professional. It is also necessary to focus on the physical, mental,
social and biological aspect of the patient who has been suffering (Berman, 2018). Case
Conceptualization Summary Statement is basically a representation of the patient,
susceptibility, habit to propagate and long term deposition, which guides the health care

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professionals and others to better understand the condition and factors which are associated
with the case.
After assessing the case study of Jenny, it was found that she has been witnessing
symptoms of major depression disorder and anxiety and was always worried about something
bad is going to happen. Prior to the session, the condition of Jenny was assessed, and it was
found that her family condition and lifestyle was the major reason behind her condition. as
she was left alone back homme with her younger bother with all the responsibilities to take
care of him, generated the fear and worry about getting harmed or as if something wrong is
going to happen to them. At the age of 14, Jenny witnessed her parents’ divorce and she
along with her younger brother started living with her father. After few time, her father died
in a road accident. She never got full support and company of her parents as when she was
young her mother and father used to go out for work and after the divorce she was only left
with her father and younger brother but she then lost her father also. The condition of losing
the loved one’s and the life she has been leading dragged her to her present health condition.
Theoretical Orientation and Research/Evidence-based treatment
After going through the condition of Jenny, it was assessed that it will be beneficial to
perform Cognitive Behavioral Therapy for depression. It will help her in getting involved
with others and restore her condition of anxiety and depression as the therapy involves
counselling along with group involvements (Power et al., 2017). As jenny has been along in
her life and did not have much social involvement, it will be effective to make her interact
and observe the other individuals (Zettle & Hayes, 2015). The Cognitive Behavioral Therapy
for depression will help the health care professionals to provide a composed and consisted
manner of treating and counseling Jenny for her sever health condition. It will help Jenny to
develop her behavioral condition, her depression state and anxiety by talk therapy and
interaction as well as group conversations (Trauer et al., 2015).

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Apart from the Cognitive Behavioral Therapy for depression, the use of Mindfulness-
based cognitive therapy (MBCT) can be also helpful in order to help jenny overcome her
negative thoughts and anxiety. The Mindfulness-based cognitive therapy (MBCT) uses
meditation in order to retain the condition of peace and pleasant thought and avoids the
negative thought and depressive conations in life (Alsubaie et al., 2017).
The condition she has been witnessing are:
Major Depression Disorder: in order to overcome from the condition, it will be
necessary to provide her with interactive sessions and creative activities involving other
individuals. This will help her overcome her depression and will become socialise.
Evidence based intervention: it will require to provide her with creative sessions
such as music therapy and art therapy which will keep her engage and also will make her
calm and relaxed and will avoid the encounter of negative thoughts (Schmaal et al., 2016).
Generalized Anxiety Disorder: in the condition of anxiety, it will be necessary
understand better the reason behind her anxiety and accordingly provide interactive sessions
to overcome the issue.
Evidence based intervention: it will be necessary to develop a therapeutic
relationship based on love, care and trust with the professional which will develop a zone of
comfort for her and the interaction with her (Lader, 2015).
Ethical Issues
The major ethical issues that will be faced are consent and confidentiality of the
patient. As she is not at the age group where she can take her own decisions, her mother
needs to be involve and a consent from her will be required to provide her with all the therapy
and counselling sessions. The next issue is confidentially and information safety, it would be

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kept in mind that her health care details and information are nit disclosed or shared to other
apart from the professionals involved in the treatment process of her.
Multi-cultural Factors
Jenny has never been socialized as she was kept alone at her home with her younger
brother. The health conditions she has been witnessing is due to the family condition and the
life she has been living since she was a child. the issues she has been facing was due to the
fear and worry about something negative is going to occur. Thus, in order to help her and
provide better health outcome, I will require to focus on her fear and worry which will
positively restore her condition of depression and anxiety and will provide her with a health
life.
Assessment
In order to assess the further condition of Jenny, Hamilton Depression Rating Scale
(HAM-D), Patient Health Questionnaire (PHQ-9) and The Children's Depression Inventory
(CDI) will be used (Moriarty et al., 2015). These assessment tools will be used to calculate
and evaluate the condition of depression and anxiety in Jenny and also to understand the
appropriate range to treatment needs to be delivered and the recovery. The assessment tools
will be used after every step of therapy and counselling to assess the outcomes. The data from
the tools will be recorder and after the evaluation it will provide the appropriate result and
outcome of the sessions provided to Jenny (Stumper et al., 2019).
Referral/Access
In conditions where jenny is not taking her medication on appropriate dosage and
time and also not cooperating with the therapy session, referrals and access to other
professionals and stakeholder will be necessary. As Jenny is at an age group where one does
not possess enough knowledge and idea about the medications and therapies, it will be

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necessary to attain her with a professional to educate her related to the provided medications.
She has been all alone and depressed and was also worried, thus, she become a bit
conservative and feared interacting to others which was also a barrier in her therapy sessions.
It will be beneficial if a nurse with a better communication skill can be accounted to her, who
can build a relationship of understanding and comfort with her, so that she feels comfortable
and safe and opt for her therapy sessions (Kaiser et al., 2015). A regular visit of her younger
brother may be also effective as he was the only person to be with him and she was close to.
Prognosis
The assessment of jenny provides an idea by which it can be stated that the diagnosis
of jenny focuses on the use of cognitive behavioural therapy and interventions that has been
planned according to her health condition. in order to get effective results, it will be necessary
to continuously and on routine base evaluate and operate her level of motivation and therapy.
depression has the capability to destroy the mind off jenny which will ultimately be reflected
in the life condition of her. The condition might lead her towards other severe health issues
and may gain suicidal tendencies if not treated on appropriate time and manner. Thus, it
makes it important to provide Jenny with short and long term treatment and assessment to
monitor her development and recovery state.

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Reference:
Alsubaie, M., Abbott, R., Dunn, B., Dickens, C., Keil, T. F., Henley, W., & Kuyken, W.
(2017). Mechanisms of action in mindfulness-based cognitive therapy (MBCT) and
mindfulness-based stress reduction (MBSR) in people with physical and/or
psychological conditions: a systematic review. Clinical Psychology Review, 55, 74-
91.
Berman, P. S. (2018). Case conceptualization and treatment planning: Integrating theory
with clinical practice. Sage publications.
Kaiser, R. H., Andrews-Hanna, J. R., Wager, T. D., & Pizzagalli, D. A. (2015). Large-scale
network dysfunction in major depressive disorder: a meta-analysis of resting-state
functional connectivity. JAMA psychiatry, 72(6), 603-611.
Lader, M. (2015). Generalized anxiety disorder. Encyclopedia of psychopharmacology, 699-
702.
Moriarty, A. S., Gilbody, S., McMillan, D., & Manea, L. (2015). Screening and case finding
for major depressive disorder using the Patient Health Questionnaire (PHQ-9): a
meta-analysis. General hospital psychiatry, 37(6), 567-576.
Power, R. A., Tansey, K. E., Buttenschøn, H. N., Cohen-Woods, S., Bigdeli, T., Hall, L.
S., ... & Teumer, A. (2017). Genome-wide association for major depression through
age at onset stratification: major depressive disorder working group of the psychiatric
genomics consortium. Biological psychiatry, 81(4), 325-335.
Schmaal, L., Veltman, D. J., van Erp, T. G., Sämann, P. G., Frodl, T., Jahanshad, N., ... &
Vernooij, M. W. (2016). Subcortical brain alterations in major depressive disorder:

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findings from the ENIGMA Major Depressive Disorder working group. Molecular
psychiatry, 21(6), 806.
Stumper, A., Olino, T. M., Abramson, L. Y., & Alloy, L. B. (2019). A Factor Analysis and
Test of Longitudinal Measurement Invariance of the Children’s Depression Inventory
(CDI) Across Adolescence. Journal of Psychopathology and Behavioral Assessment,
1-7.
Trauer, J. M., Qian, M. Y., Doyle, J. S., Rajaratnam, S. M., & Cunnington, D. (2015).
Cognitive behavioral therapy for chronic insomnia: a systematic review and meta-
analysis. Annals of internal medicine, 163(3), 191-204.
Zettle, R. D., & Hayes, S. C. (2015). Rule-governed behavior: A potential theoretical
framework for cognitive-behavioral therapy. In The Act in Context (pp. 33-63).
Routledge.