A 30-year-old woman.
The fourth of 6 brothers.
Single, lives with her parents, 4 brothers, 1 nephew and the maternal grandmother.
Inactive labor.
Perceives a sense of social security.
Personal history: Since early childhood she has relationship problems with others; she only talked (with monosyllables) with people in her family environment; at school she had no relationships with peers.
He presented behaviors to avoid social relationships "when someone from outside came to my house he told me to be under bed".
He kept thinking of being bad and wishing to die.
Poor school performance.
At 8 years old, there were long rats looking at the sun "because I wanted to stay blind not to see people because they were scared".
At 11 years old thoughts of hanging out with strong desire for death
He was different from the others, and thought that he was not from this world, that he was "extrinsic".
At the age of 13 she suffered several months amenorrhea being convinced that she was pregnant because she explained to her mother the last pregnancy she explained to her that when she was pregnant she did not have her husband, and that her husband
Studies up to 2nd of UPB with poor performance.
He abandons his studies when he was 16, starting to work in an internment where he remains for a year and in which he suffers sexual abuse from the boss, a fact that he never denounced or suffered from parents.
This fact reacted to the family home for 12 days.
It was found by the police in Sevilla, appearing mu and frightened.
The true reason was not known by the police or the family.
Then he worked for another year and a half in another institution that abandoned to suggest to him those in charge that needed psychiatric care for presenting avoidance, isolation and mutism behaviors.
Family situation: Nine family members live in the household: both parents, 5 brothers, an 8-year-old nephew (with mental retardation) and the maternal grandmother.
Leader: pensioner for an occupational accident.
Drinker.
Absent and uninterested in family problems.
Mother: insulin dependent diabetic and diagnosed with T. anxious-depressive.
"Sisters, sir."
Living with parents
Disability pensioner.
Drinker.
She lives in her own home.
You don't know mental illness.
Single, a 7-year-old son.
Diagnosed mental deficit.
The child presents delayed development.
Single.
Student, 16 years old.
Conflictive, rebellious, difficulties in meeting standards, school failure with several exponents of the center.
Supervised by the Court of Minors for damage to property.
Grandmother: Have Parkinson's disease
History of the disease: The patient consulted for the first time in August 1989, at 17 years, after an overeating drug with autolytic intent.
According to the family, she has attempted suicide since she was 14 years old, which has led to frequent visits to the emergency room.
She was diagnosed with personality disorder and social phobia.
She presented avoidance and escape behaviors in social relationships, inability to look at her eyes, conviction that others laugh at her because she is "bad".
Excessive alcohol consumption, frequent self-harming and heteroaggressive behaviors, low mood, great anxiety.
Egodonic homosexuality.
Seasons of restrictive anorexia and others with bulimic episodes with self-inflicted vomiting.
Throughout the history of his disease has had 4 admissions in the Acute Unit of H. Reina Sofiía (96, 97 (2), and 99) with long hospitalization times (3-4 months).
Hospitalizations have been caused by suicide attempts through drug and alcohol intoxication, obsessive thoughts of "I am bad, I want to die" associated with self-controllable behaviors and hetero-aggressive impulse conducts with apparent urgencies.
The patient was admitted to the Acute Unit from October 99 to his transfer to the Community of «Associated desire» , and suffered from anorexia. During this period, he attempted several times to sit down intensely, restlessness.
Family approach.
Clinical Judgment: -Affective instability disorder, type Litis (F60.31).
ICD-10) -Anxious disorder (with avoidance behavior) of personality (F60.6.
ICD-10).
Therapy in the Therapeutic Community: Voluntary income in February 2000.
For the initial evaluation of the patient the following techniques are used: -In individual and family clinical interviews. -Nursing observation records. -Interview for assessment of psychoeducation.
Arkowitz, H. 1981). "Wechsler Intelligence Scale for Adults.
ASD.
1995.
Initial evaluation results:
1- Functional abilities: There are no alterations in basic cognitive functions such as attention, concentration, memory, although they are often reduced by continuous rumination.
Regarding intellectual capacity, the WAIS results are as follows: CIV: 95; CIM: 83; CIT: 87.
We discard the hypothesis of mental deficiency that has been masked during his personal history but that it has not been possible to assess until now for his continued mutism.
Regarding the skills of daily living, it presents difficulties in managing money, use of public transport and domestic skills for not having acquired them both for their psychopathology and for the family dynamics.
It presents the following disruptive behaviors: -Self and heteroaggregates - Walking fast and continuous -Tendence to isolation and get into bed in situations that increase their anxiety.
2-Self-care: Low level of self-care.
Inadequate personal hygiene (no daily clean-up, no bucco hygiene).
Difficulties in cleaning and caring for the environment (room, closet), as well as care and washing their clothes
Difficulties in chewing due to the lack of enough teeth.
Use corrective lenses for significant vision loss.
She complains of back pain due to continuous postural change in the neck, fully leaning to the chest to avoid visual contact.
3-Disease awareness: Acceptance of mental illness but little knowledge of it.
For the patient, various symptoms of her Avoidance Personality Disorder are proof of her evilness (I'm bad because I don't have friends, I can't talk to people).
It denies the possibility of improvement because the symptoms would be intrinsic characteristics of itself that cannot be modified.
He knows pharmacological treatments, although not main or secondary effects.
Non-autonomy in taking medication due to risk of overeating.
4- Social skills: The patient presents important deficits in this area.
He has total incapacity to maintain visual contact and great difficulties in basic social skills (listening, initiating conversations, etc.)
Disability is total in complex HHSS (failure, planning, problem solving, etc.).
5-Social Support: Null outside the family environment.
Family support is scarce and inadequate due to the high level of psychopathology in the family.
Very pathological family dynamics that tend to block and prevent the inadequacy and autonomy of its members.
Continuity situation, celos and manipulative behaviors of children to end the care and attention of the mother.
6-Psychopathology: The patient presents the following symptoms:
-Frequent self- and hetero-aggressive behaviors.
It beats patients and staff with their wrists, justified by sudden increases in anxiety " laugh at me inside because I'm bad".
He hits his head against the wall to punish himself for his evilness.
Several suicide attempts with death wishes (shocklessness, intake of radiocassett batteries, hanging fire to your bed).
"Very intense and variable moods triggered more by internal factors than by external events.
Chronic feelings of emptiness and loneliness.
-Structured thoughts in a dichotomic way and distorted thinking schemes (I have difficulties in social relations, so I am bad and have to punish myself and the others too).
Although these thoughts are creative, invasive and that the patient lives as he cannot control, they are not experienced as absured, so we qualify them as overvalued ideas.
The certainty of these thoughts fluctuates at different times.
He maintains that all the negative things that happen around him are his fault, which reaffirms his thinking of being bad and his need to punish himself (e.g., family alcoholism, non-aggressive transmission of guilty sister).
"He has an excessive dependence on the mother figure with a need and continuous desire for protective care, attention and affection.
Handling gestures and behaviors to attract their concerns and care
Fear of abandonment and loss of maternal care.
The family presents some schemes learned, maintained and shared by all its members according to which everything that comes from outside can be dangerous and destructive to the family unit, imposing a code of conduct abuse not even the abuse therapist apart from that family.
It is an agglutinated family with great influence and emotional repercussion among the members.
All this places the patient in a continuous struggle and ambivalence within the following poles: dependence/independence; negative family situation/dangerous external world; need to express/prohibite to do so.
The impossibility of expressing makes them communicate their feelings, desires, fears through aggressive, manipulative acts.
-Avoidance and escape from social situations.
Intolerance to be surrounded by several people
-Intense and changing interpersonal relationships from idealization to devaluation (with colleagues, staff and, of course, with the therapist), typical of their dichotomic cognitive schemes.
-Episodes of significant alcohol abuse with autolytic intent or as a facilitator of social relationships by reducing anxiety.
-Episodes of eating disorders with restricted intake and self-harmed vomiting.
"Egodonic homosexuality."
For the patient his homosexuality is another proof of his evilness.
Therapeutic interventions:
-Psychotherapy: At the beginning, the intervention focused on establishing a cooperative therapeutic relationship; this implies a way of working in which one avoids the struggle of power and the excessive control and directivity between the patient and the patient.
For this purpose, the difficulties of the patient to trust the therapist are explicitly addressed.
Strong emotional responses are addressed quickly and directly.
During the psychotherapy process, an attempt is made to maintain a balance in the sessions between a focused methodical and strategic approach and the immediate concerns of the patient; seeking under each concern, problem or concrete crisis, the underlying cognitive schemes or behavioral strategies.
Initial interventions focus on concrete behavioral objectives, working with self- and hetero-aggressive behaviors and intense emotional responses, seeking the patient to recognize them in content and verbal expressions.
In this sense, it is also essential to work on fear of change and self-perpetuation behaviors.
In order to provide control over emotions, it was essential to reduce dichotomic thinking.
The impulse control was worked exploring the motivations, thoughts and feelings, and seeking favorable behavior alternatives.
Working with cognitive techniques facilitates the development of a clearer identity, helping them to detect their characteristics and positive achievements and helping them to realistically assess their own actions.
Individual psychotherapy was carried out in 45-minute sessions with a frequency of 3 or 4 per week, depending on the moment.
-Group psychotherapy: Due to the patient's difficulties in establishing, maintaining and even tolerating minimal social relationships, the patient was included in group activities in a patulatine way and always leaving the same degree of participation in the patient's decision.
In individual sessions, group activities were analyzed and agreed with the patient, working with the thoughts and emotions they aroused.
Once their inclusion in the activity was agreed, each avoidance or escape was analyzed and modified the cognitive aspects needed to go with greater awareness, involvement and participation in the groups.
It began to be included in group activities such as classroom games, press reading group; paulatinately (three months later) it was incorporated into the following therapeutic groups: Psychoeducation, teaching and learning.
Finally, it was incorporated into group activities outside the Unit (cultural outflows, attendance to a sport, senderism.) one year after admission.
-Family Psychotherapy: The following aspects were worked with the family:
- the process of family psychoeducation about the patient's illness, thoughts, feelings and behaviors, so that the family could understand these aspects of the patient.
Evaluation and modification of family interaction guidelines.
-Evaluation and modification of negative cognitive schemes shared by the family.
-Provide a greater degree of patient autonomy with respect to his family.
Family sessions began one month after admission.
They were performed weekly with a duration of 60 minutes during the first four months.
Then, fortnightly sessions were held for two months and finally monthly sessions for six months.
Although all family members were invited, the parents always attended and some brother did so in a non-stable way.
Environmental treatment: working with patients in the Teraptics Community allows us to use therapy through the "medium" as another therapeutic strategy.
In this sense, CT provides three important aspects due to the characteristics of this patient:
"Provide an organized environment with a high external control power.
This gives you security from which you can work.
In this sense, the coherence and co-exion of the therapeutic team is of paramount importance.
-Provide opportunities for social interactions with high frequency and variability.
This allows obtaining a large amount of material that can be used in individual and group therapy.
-Provide continuous social learning opportunities.
-Pharmacotherapy: At admission, treatment with Olanzapine and Loracepam was started at high doses, in addition to Valproate.
Clomipramine and Trazodone were then combined and olanzapine was suspected due toprophamazine.
Insomnia was controlled with Flunitrazepam.
Loracepam was later modified by a long-acting Benzodiazepine (Cloracepate).
Ultimately, this entity has been introduced into the Tomato treatment with positive impulse control results.
Establishment plan:
- persistence of an important improvement in those behaviors that were considered more risky or disruptive and in which initial interventions were focused as objectives.
There was a progressive decrease in self- and hetero-aggressive behaviors, from a total of 19 in March 00 (15 mild and 4 severe or life-threatening) to 1 mild in February 01.
Rapid ambulation by the unit progressively decreases in frequency and duration until it completely disappears.
It also decreases the tendency to isolate itself in its bedroom, spending most of the day in the common lounge.
-There is greater tolerance to social relationships, becoming actively involved in group activities both therapeutic and leisure and virtually disappearing avoidance and escape behaviors.
-As a result of continuous coping with social situations, it dislikes the fear of them and at the same time increases their capacities and desires for verbal communication with people around them (influences on acting-out).
It expresses both his family and therapeutic groups, the sexual abuse suffered at work and his homosexuality.
-A greater emotional stability with decreased emotional behaviours and extreme emotions, also a product of a change in dichotomic thinking.
-There is a progressive decrease in dependence with the family, going from almost daily visits of parents caused by manipulative behaviors of the patient to get it, to tolerate seeing the family every 15 days (co).
Permission is also marked by greater familiar awareness of the patient and his problems, providing all this awareness of the patient and behavior in the most appropriate and useful.
-The patient has more information about her disease and those aspects that can be modified and how; this increases her motivation to control alcohol consumption and problematic eating behaviors.
Finally, there is an important adaptation and normalization of self-care habits and care for their environment.
