Based on the case study as attached.. please write a answer all these question in the essay. 2 single-spaced pages. Each case study summary and it include the following elements. • Description of the Presenting Problem (medical problem or functional problem or diagnosis etc)
• Background information (e.g., sociocultural factors, family mental health history, relationships, substance use history, early and current life stressors, goals, and coping skills)
• Relevant current and past mental health symptoms
• DSM-5 diagnosis (or diagnoses) with rationale and specifiers if appropriate (discuss which
information from the case study was used to formulate your diagnosis).
• Discussion of differential diagnoses (Was there another diagnosis that you considered? Explained why you did not assign that diagnosis).
• Recommended interventions and rationale (please include references)
Please include intext citation and end text reference. thank you
John Quinn was 31 years old, divorced, and a successful insurance salesman. He had experienced panic attacks
on several occasions during the past 10 years, but he did not seek psychological treatment until shortly after the
last incident. It happened while John and his fiancée Jacklyn were doing their Christmas shopping at a local
mall. Their first stop was a large department store, where Jacklyn hoped to find a present for her mother. John
was in a good mood when they arrived at the store. Although he was usually uneasy in large crowds of people,
he was also caught up in the holiday spirit and was looking forward to spending the bonus that he had
recently received from his company. Ten minutes after they began shopping, John suddenly felt very sick. His
hands began to tremble uncontrollably, his vision became blurred, and his body felt weak all over.He
experienced a tremendous pressure on his chest andbegan to gasp for breath, sensing that he was about to smother.
These dramatic physical symptoms were accompanied by an overwhelming sensation of apprehension. He was terrified
but did not know why. Without saying anything to Jacklyn, he ran out of the store and sought refuge in their
car, which was parked outside. Once there, he rolled down the windows to let in more air, lay down on the back
seat, and closed his eyes. He continued to feel dizzy and short of breath for about 10 minutes more.
Jacklyn did not find him for more than an hour because she had been browsing in an adjacent aisle and had
not seen him flee from the store. When she noticed that he was gone, she tried to reach him on his cell
phone but he did not answer. After awhile she realized that something was wrong and finally decided to check
the car. This was the fast panic attack that John had experienced since he and Jacklyn had begun dating
several months previously. After they returned to his apartment he explained what had happened and his
past history of attacks in somewhat greater detail; she persuaded him to seek professional help.
When John arrived at the clinic for his first appointment, he was neatly dressed in an expensive suit. He was
five minutes early, so the receptionist asked him if he would like to take a seat in the large, comfortably
furnished waiting room where several other clients were sitting. Politely indicating that he would prefer to
stand, John leaned casually against the corridor wall. Everything about his physical appearance-his posture, his
neatly trimmed hair, his friendly smile-conveyed a sense of confidence and success. Nothing betrayed the real
sense of dread he had struggled with since he had promised Jacklyn that he would consult a mental health
professional. Was he, in fact, crazy? He wanted help, but he did not want anyone to think that he was emotionally
unstable.
The first interview was not very productive. John cracked jokes with the counselor and attempted to engage in
an endless sequence of witty small talk. In response to the counselor’s persistent queries, John explained that he
had promised his fiancée that he would seek some advice about his intermittent panic attacks. Nevertheless, he
was reluctant to admit that he had any really serious problems, and he evaded many questions pertaining to
his current adjustment. John seemed intent on convincing the counselor that he did not have a serious
psychological problem. He continued to chat on a superficial level and, at one point, even began asking the
counselor whether she had adequate life insurance coverage.
In subsequent sessions, it became clear that the panic attacks, which never occurred more than two or three
times per year, were simply the most dramatic of John’s problems. He was also an extremely tense and
anxious person between attacks. He frequently experienced severe headaches that sometimes lasted for several
hours. These generally took the form of a steady diffuse pain across his forehead. John also complained that
he could not relax, noting that he suffered fromchronic muscle tension and occasional insomnia. Hisjob often
required that he work late in the evening, visiting people in their homes after dinner. When he returned to
his apartment, he was always “wound up” and on edge, unable to sleep. He had tried various distractions
and popular remedies but nothing had worked.
John was very self-conscious. Although he was an attractive man and one of the most successful salespersons
in his firm, he worried constantly about what others thought of him. This concern was obvious in his
behavior both before and after sessions at the clinic. At the end of every session, he seemed to make a point
of joking loudly so that anyone outside the counselor’s office would hear the laughter. He would then open
the door, as he continued to chuckle, and say something like, “Well, Alicia [the therapist’s first name], that
was a lot of fun. Let’s get together again soon!” as he left her office. The most peculiar incident of this sort
occurred prior to the fourth treatment session. John had avoided the clinic waiting room on past visits, but
this time it happened that he and his therapist met at a location that required them to walk through the
waiting room together to reach her office. Thinking nothing of it, the therapist set off across the room in
which several other clients were waiting, and John quickly followed. When they reached the middle of the
long room, John suddenly clasped his right arm around her shoulders, smiled, and in a voice that was slightly
too loud said, “Well, Alicia, what’s up? How can I help you today?” The therapist was taken completely by
surprise but said nothing until they reached her office. John quickly closed the door and leaned against the
wall, holding his hand over his heart as he gulped for air. He was visibly shaken. After he had caught his
breath, he apologized profusely and explained that he did not know what had come over him. He said that
he had always been afraid that the other people in the clinic, particularly the other clients, would realize that
he was a client and therefore think he was crazy. He had become extremely uncomfortable as they walked
across the waiting room and had been unable to resist the urge to divert attention from himself by seeming to
be a therapist.
This preoccupation with social evaluation was also evident in John’s work. He became extremely tense whenever he
was about to call on a prospective client. Between the point at which an appointment was arranged and his
arrival at the person’s home, John worried constantly. Would he or she like him? Could he make the sale?
His anxiety became most exaggerated as he drove his car to the person’s home. In an effort to cope with this
anxiety, John had constructed a 45-minute audio recording that he played for himself in the car. The
recording contained a long pep talk, in his own voice, in which he continually reassured and encouraged
himself: “Go out there and charm ’em, John. You’re the best damn salesman this company’s ever had! They’re
gonna be putty in your hands. Flash that smile, and they’ll love you!” and on and on. Unfortunately, the net
effect of the recording was probably an increase to his tension. Despite this anxiety, he managed to perform
effectively in the selling role, just as he was able to project an air of confidence in the clinic. But, on the
inside, he was miserable. Every 2 or 3 months, he would become convinced that he could no longer stand the
tension and decide to quit his job. Then he would make a big sale or receive a bonus for exceeding his quota
for that period and change his mind.
Social History
John was an only child. His father was an accountant, and his mother was an elementary school teacher. No
one else in his family had been treated for psychologicalproblems. John and his mother got along well, but
his relationship with his father had always been difficult. His father was a demanding perfectionist who
held very high, probably unrealistic, expectations for John. When John was in elementary school, his father
always wanted him to be the best athlete and the best student in his class. Although John was adequate in
both of these areas, he did not excel in either. His father frequently expressed the hope that John would
become an aeronautical engineer when he grew up. Now that John was working as an insurance salesman,
hisfather nevermissed an opportunity to express his disapproval and disappointment. He was also unhappy
about John’s previous divorce. When his parents came to visit, John and his father usually ended up in an
argument.
John remembered being shy as a child. Nevertheless, he enjoyed the company of other children and always
had a number of friends. When he reached adolescence, he was particularly timid around girls. In an effort to
overcome his shyness, he joined .the high school drama club and played bit parts in several of its productions.
This experience provided an easy avenue for meeting other students with whom he became friends. He also
learned that he could speak in front of a group of people without making a fool of himself, but he continued
to feel uncomfortable in public speaking and social situations.
After graduating from high school, John attended a state university for two years. Although he had been a
reasonably good student in high school, he began to experience academic problems in college: He attributed
his sporadicperformance to test anxiety. In his own words, he “choked” on examinations. Shortly after he entered
the classroom, the palms of his hands would begin to perspire profusely. Then his breathing would become
more rapid and shallow, and his mouth would become very dry. On the worst occasions his mind would
go blank.
Some of his instructors were sympathetic to the problem and allowed him to take extra time to finish
examinations; others permitted him to complete the exam in a different room away from other students.
Nevertheless, hisgrades began to suffer and by the end of his first year, he was placed on academic probation.
During his second year in college, John began to experience gastrointestinal problems. He had always
seemed to have a sensitive stomach and avoided rich or fried foods that often led to excessive flatulence or
nausea. Now the symptoms were getting worse. He suffered intermittently from constipation, cramping, and
diarrhea. He would frequently go for 3 or 4 days without having a bowel movement. During these periods, he
experienced considerable discomfort and occasional severe cramps in his lower abdominal tract. These
problems persisted for several months until, at the urging of his roommate, John finally made an appointment
for a complete gastrointestinal examination at the local hospital. The physicians were unable to find any evidence
of structural pathology and diagnosed John’s ‘s problems as irritable bowel syndrome. They prescribed some
medication, but John continued to suffer from intermittent bowel problems.
John had several girlfriends and dated regularly throughout high school and college. During his sophomore
year in college, he developed a serious relationship with Maria, who was a freshman at the same school.
She and John shared some interests and enjoyed each other’s company, so they spent a great deal of time
together. At the end of the academic year, John decided that he had had enough of college. He was bored
with his classes and tired of the continual pressure from his parents to get better grades. An older friend of
his had recently landed a well-paying job with an insurance firm, so John decided that he would complete
applications with a number of companies. He was offered a position i n sales with a company in a nearby
state. Maria decided that she would also .drop out of school. She and John began living together, and they
were married 2 years later.
John and Maria were reasonably happy for the first 3 years. He was successful at hisjob, and she eventually
became a licensed realtor. As they were both promoted by their respective firms, they found themselves spending
more and more time working and less and less time with each other. Their interests also began to diverge.
When Maria had some time off or an evening free, she liked to go out to restaurants and parties. John liked to stay
home and watch television.
John’s first real panic attack occurred when he was 24 years old. He and Maria were at a dinner theater with
three other couples, including Maria’s boss and his wife. The evening had been planned for several weeks,
despite John’s repeated objections. He was self-conscious about eating in public and did not care for Maria’s
colleagues; he had finally agreed to accompany her because it seemed that it would be important for her
advancement in the firm. He was also looking forward to seeing the play, which would be performed after the
meal was served. As the meal progressed, John began to feel increasingly uncomfortable. He was particularly
concerned that he might experience one of his gastrointestinal attacks during dinner and be forced to spend the
rest of the evening in the men’s restroom. He did not want to have to explain the problem to all of Maria’s
colleagues. In an attempt to prevent such an attack, he had taken antispasmodic medication for his stomach
and was eating sparingly. Just as everyone else had finished eating dessert, John began to experience a choking
sensation in his throat and chest. He could not get his breath, and it seemed certain to him that he was going to
faint on the spot. Unable to speak or move, he remained frozen in his seat in utter terror. The others quickly
realized that something was wrong, and assuming that he had choked on some food, Maria began to pound on his
back between the shoulder blades. There was now a sharp pain in his chest, and he began to experience heart
palpitations. John was finally able to wheeze that he thought he was having a heart attack. Two of the other men
helped him up, and a waiter directed them to a lounge in the building where he was able to lie down. In less
than 30 minutes, all of the symptoms had passed. John and Maria excused themselves from the others and drove
home.
John was frightened by this experience, but he did not seek medical advice. He was convinced that he was in
good physical condition and attributed the attack to something he had eaten or perhaps to an interaction
between the food and medication. He did, however, become even more reluctant to go to restaurants with Maria
and her friends. Interestingly, he continued to eat business lunches with his own colleagues without apparent
discomfort.
The second panic attack occurred about 6 months later, while John was driving alone in rush-hour traffic. The
symptoms were essentially the same: the sudden sensation of smothering, accompanied by an inexplicable,
intense fear. Fortunately, John was in the right lane of traffic when the sensation began. He was able to pull
his car off the road and lie on the seat until the experience was over.
By this point, John was convinced that he needed medical help. He made an appointment with a specialist in
internal medicine who gave him a complete physical examination. There was no evidence of cardiovascular or
gastrointestinal pathology. The physician told John that the problem seemed to be with his nerves and gave him a
prescription for alprazolam (Xanax), a high-potency benzodiazepine often used in treating anxiety disorders and
insomnia. John took 2 milligrams of Xanax three times per day for 4months. It did help himrelax and, in
combination with hisothermedication,seemed to improve his gastrointestinal distress. However, he did not like the
side effects (such as drowsiness and lightheadedness) orthe feeling of being dependent on medication to control his
anxiety. He saw the latter as a sign of weakness and eventually discontinued taking the Xanax (decreasinghis
dailydosagegradually, asrecommended byhisphysician).
Maria asked John for a divorce 3 years after they were married (2 years after his first panic attack). Itcame as no
surprise to John; their relationship had deteriorated considerably. He had become even more reluctant to go out with
herin the evening and on weekends, insisting that heneeded to stay home and rest his nerves. He was very
apprehensive in crowded public places and also careful about where and when he drove his car. He tried to avoid
rush-hour traffic.When he did drive in heavy traffic, he alwaysstayed in the right lane, even if it was much slower,so
that he could pull off the road if he had an attack. Long bridges made him extremely uncomfortable because they
did not afford an opportunity to pull over; he dreaded the possibility of being trapped on abridge during one of his
“spells.”
These fears did not prevent him from doing his work. He continued to force himself to meet new people, and he
drove long distances every day. The most drastic impact was on his social life. These increased restrictions led
to greater tension between John and Maria. They had both become more and more irritable and seldom enjoyed
being with each other. When she decided that she could no longer stand to live with him, he agreed to the divorce.
After Maria left, John moved to an apartment in which he was still living when he entered treatment 5 years
later. His chronic anxiety, occasional panic attacks, headaches, and gastrointestinal problems persisted relatively
unchanged, although they varied in severity. He had a number of friends and managed to see them fairly
frequently. He did, however, avoid situations that involved large crowds. He would not, for example, accompany
his friends to a professional football game, but he did like to play golf, where he could be out in the fresh air with
very few people and a lot of open space around him. He met Jacklyn 4 years after the divorce. Shewasslightly
olderthan he and much less active socially than Maria had been. They enjoyed spending quiet evenings watching
television and occasionally got together with one or two other couples to play cards. Although they planned toget
married, neitherJohn norJacklyn wanted torush into anything.
