Stella is in her teen years and goes to school at Greenland High School. Stella has been experiencing symptoms that can be diagnosed as depression and social anxiety disorder (SAD). Some of the emotional symptoms she is experiencing include hopelessness, restlessness, agitation, self-consciousness, and avoiding social situations; she prefers seclusion and is generally shy. Physical symptoms include sleeplessness, shortness of breath, and in some cases, hyperventilation. Cognitive symptoms include lack of concentration, forgetfulness, and being unable to start or complete tasks. Depression and anxiety are dangerous psychological disorders for teenagers. At their age, adolescents undergo many hormonal changes; hence they can be too self-critical and aware. Teenagers also might not like talking to adults about their problems, which makes it difficult to identify symptoms of depression or anxiety. Extreme cases of depression and anxiety could lead to suicidal thoughts. This is the main reason these psychological disorders should be taken seriously among teenagers.
Clinical History
Stella comes from a predominantly Latino neighborhood distinguished by cases of drugs and undocumented residents. Growing up, she has witnessed several occasions of police officers raiding homes in their neighborhood, including her own. The constant urge to live in fear and uncertainty has made her live on edge. She is always scared and agitated by the idea that she is Latino and is not sure of what might happen to her. Like most people in her neighborhood, her parents were illegal immigrants who stayed in the country for years before getting their documents. Because they were undocumented, they only got poorly paying jobs, which necessitated them to live with extended family and poor neighborhoods where they could afford bills. Stella's father occasionally repairs plumbing works t Stella’s school and doubles as the janitor. On the other hand, her mother works in a restaurant, mostly cleaning dishes and the restaurant’s restrooms.
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Teenagers are generally self-conscious and would not want to go to the same school their father works as a janitor. The fact that her parent’s wages are low and she lives in a poor neighborhood, she is hopeless about whether she will ever have a better life than what she has currently. Her household is generally composed of people working jobs with poor wages and convicts who have been prosecuted either for drug possession or undocumented. Having to live under such a scenario has limited how big she can dream, and the uncertainty of whether she will make it in life or not is taking a toll on her health. Because she comes from a low-income family and a setup where every person is mostly thinking about their problems, her family has not noticed her symptoms. Additionally, depressive and anxiety disorders are usually disregarded, especially with families that are not economically stable or those having unlearned people.
Adolescence age has recently been associated with an increase in social cases and anxiety. The kind of changes that occur during adolescence are directly associated with the need for independence and being liked by peers. Even though most teenagers get through this period with no mental illness, some are not so lucky. In Stella's case, her psychological disorders are generated from what she is experiencing at home. Family and friends have a significant role to play in the development of teenagers. Stella is self-conscious as most of her peers. Her need to be liked in school might not happen because her father is a janitor and plumber in their school. She is going through the kind of changes because of her age, and her situation at home has generated depressive and anxiety symptoms.
In adolescence, the need to be independent also makes it difficult for teenagers to open up to their parents or adults. The symptoms shown by Stella, like secluding herself, might be confused with teenagers wanting to keep to themselves. Additionally, the fact that her parents are always working and her household is full of several relatives, it isn't easy to give attention to one person's needs. The population in her house makes it difficult for anyone to notice her symptoms. Like most immigrant families and people of color in the US, parents and adults concentrate on providing financial stability to their kids to the point they forget their emotional needs. The negativity in Stella’s life might affect her studies and future if not recognized and treated early.
Diagnoses
Anxiety and depressive disorder are some of the most dangerous psychological disorders in teenagers because most adolescents are good at hiding these symptoms. These symptoms can also be missed because most teenagers like Stella might not have enough emotional and psychological support at home. With parents working more than one shift and most people of color concentrate on providing for their family’s financial needs to point the psychological needs are disregarded. In cases of extreme depression, for instance, teenagers might contemplate suicide. This is one reason why awareness needs to be enhanced on depression and anxiety in children and teenagers.
According to DSM-5, one of the essential addition to the diagnosis of depression is the feeling of hopelessness, sadness, or feeling empty. In DSM-IV, these symptoms were mainly empty and sad. The patient feeling hopelessness increases the diagnosis of depression. In the case of Stella, she is feeling hopeless because she is in no position to make their life better, not any time soon at least. Additionally, being uncertain about her future makes her sad and hopeless. DSM-5 recognizes hopelessness as one of the clinical risk factors for suicide (Park & Kim, 2018). Depression, because it is primarily untraced or unrecognized in teenagers, could lead to negative results like suicide. Stella has not even had the opportunity to diagnose or tell her parents, who are busy meeting her financial needs.
DSM-5 also made changes to the definition of common depressive disorders by eliminating “bereavement.” An individual does not only have to undergo loss for them to be depressed. Park and Kim (2018) indicate that the new model also changed depression identifiers such as “with psychotic features,” “with anxious stress,” “with mixed features,” and “with peripartum onset (p. 3). Stella’s symptoms are associated with anxiety and from the symptoms depression and anxiety share many symptoms. Park and Kim (2018) show that DSM-5 also identifies “ bleak and pessimistic view of the future ” as an addition to hopelessness (p. 4). Park and Kim (2018) describe hopelessness as a feature that is distinct from the depressive mood. This is because the depression symptoms can exist on their own without a depressive mood.
Additionally, hopelessness is regarded as a perception rather than a state of emotion. Stella shows symptoms of hopelessness and looks is not sure about her future. She is surrounded by so much negativity and relatives whose dreams might not be as big as hers might. The pessimism around her has affected her view of the future.
Fuentes-Rodriguez et al. (2018) describe social anxiety disorder as per the latest DSM-V to be distinguished by “fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others” (p. 1). Fuentes-Rodriguez et al. (2018) illustrate that SD is one of the most common disorders among teenagers. Stella is self-conscious of what the students in her school will think of when they find out his father is a plumber and a janitor in the school. She is also scared of her future and does not want to end up like her relatives, who have taken poorly paying jobs and have been imprisoned for being undocumented or having drugs. Living in a house and neighborhood that is mainly distinguished by poor choices, she is uncertain about her future. SAD has been defined as an assortment of disorders. However, in DSM-5, the definition is differentiated according to specifiers.
Rationale
Cognitive therapy (CBT) is a psychotherapy that has become one of the best developments in treating depressive disorders and anxiety. CBT is essential because it facilitates modification of habits of mind and behavior. In 1979, Aaron Beck published a comprehensive manual for treating depression (Barlow, 2014). The research conducted by Beck and his colleagues has generated a revolution in psychotherapy. The CBT model mainly concentrates on negative thoughts. Negative thoughts generate distortion of beliefs and emotions, which consequently bring about depression and anxiety. CBT is the best model for Stella’s treatment because it combines both behavioural and cognitive methods to treat. Cognitive emphasizes the patients' thoughts and emotions, while behavioural is based on the actions and behaviours of the patient.
Beck’s model of treatment will be strengthened using the Schema Model (SM). The SM theory is based on psychoanalytical theories, especially relations between objects and attachment conjectures. SM will help in giving an image of Stella's emotional issues as supported by a characterological foundation. Since CBT is founded on recognizing and treating developing emotions and behaviors, the SM theory will be the best way to describe its significance. The theory describes how teenager’s early experiences and volatile nature might generate new needs. Stella has grown up in an area where law enforcement officers did not merely survey the area to ensure everything is okay but mainly came to arrest criminals. Growing up with this fear and other ensuing factors in her life have brought about symptoms of depression and anxiety. Lim et al. (2018) state that when children's primary needs are not met, they are highly susceptible to Early Maladaptive Schemas (EMS). This is based on the assumption that a person has regarding their relationship with others and on themselves. Because of the risks presented by EMS, a child looks for other ways of coping by adopting maladaptive and adaptive behavior. Stella does not like to socialize because it makes her anxious. The behavior she adopts to avoid feeling the anxiety is seclusion. In addition, beginning new tasks or completing the ones she has begun is difficult. This behavior makes it difficult for her to maintain her grades in school.
Co-rumination is also significant for Stella’s anxiety disorder. Like depression, anxiety is also treated along with schema patterns. The behavior and thoughts of Stella generate patterns that provide clinicians with context to what she is suffering from and how to use CBT to treat it. Stella’s conduct and thoughts can be used as a way of predicting her experiences and her future thoughts (Carlucci et al., 2018). Co-rumination is essential in determining the internalization of thoughts and conduct for teenagers like Stella. According to Beck’s framework, one of the causes of anxiety is the change in perception schema. Change in patients’ patterns can generate anxiety. Stella could have grown in an average household and neighborhood like most children. Still, the typical situation was changed by the frequent presence of police officers, living with extended family, and parents who are not aware of her emotions changed the schema. These changes have led to anxiety disorder.
The treatment will utilize 10 therapy sessions because of the severity of Stella’s depression and anxiety. According to DSM-5, there are many levels of anxiety and depression, but Stella’s symptoms do not indicate the most severe cases. The patient can be described as being in the “first-level” of both psychological disorders because they have not manifested suicidal thoughts or attempts. Therefore, the patient is likely to show improvements after 10 therapy sessions because of the type and severity of her psychological disorders. The number of therapy sessions is also likely to increase response to treatment while reducing depressive and anxiety-related thoughts. Ten sessions are around the maximum number of counseling that can be done; therefore, this figure will ensure all the symptoms are dealt with and determine if more sessions are required.
CBT will provide Stella with an opportunity of identifying the current problems generating her depressive and anxiety disorder symptoms. Distortion of our emotions and beliefs generates negative thoughts. CBT, therefore, works in the opposite direction to many psychoanalysis treatments. The source of depression and anxiety in Stella will be determined before treatment can begin. The therapists and the patient will work on the identified symptoms to be replaced with positive ones. CBT is significant for Stella’s case because it works by determining the source of the problem before treating it.
Treatment Protocol
CBT is mainly used to treat depression and anxiety because of evidence-based research to support the model. In sessions 1and 2, the therapist will work on determining Stella’s symptoms and their source. The best way to keep track of the symptoms is to keep a journal where she will write her symptoms and source. In session 3 and 4, the therapist will use identified symptoms in session 1 and work backward by determining the patient's background, family, and living situation before indulging in the symptoms. In the 5 and 6 session, the therapist will work on breaking down the patient’s schema and categorizing it to help in the treatment. Stella is presenting symptoms of a bleak future. Her perception of the world can be described as “black and white.” Stella is of the idea that she will either succeed or end up like her family. There is no in between in her thoughts; this perception of life leaves her with thoughts of either having it all or nothing.
CBT is crucial for Stella because her thoughts are primarily negative. In this case, there is no instance of positivity, for instance, appreciating that her parents are doing everything they can to improve her life. Stella does not dwell on the little positive in her life; instead, her thoughts are of the poor neighborhood, her living situation, and the fact that she cannot look up to her relatives. She has concluded that she will end up like them because the thought of succeeding and living a better life seems far-fetched to her. Lim et al. (2018) state that the family and personal history of the patients are significant in the treatment of depression and anxiety.
After recognizing the negative thoughts of the patient, the therapist in sessions 7 and 8 will help Stella overcome them. Getting over anxiety and depression will necessitate Stella to learn to control her twisted thoughts and notions. This can be done by analyzing the ideas that generate anxiety and depression. Helping Stella see that her thoughts are just part of distorted beliefs and notions, which can be controlled. After identification, in session 9 and 10 the therapist will help Stella replace realistic thoughts with negative feelings. Worrying alone cannot prevent certain things from happening. In Stella’s case, her anxiety and depression will affect her schoolwork leading to poor grades. One way Stella can avoid living in the same neighborhood, and the same situation in the future is by working hard in her studies. However, showing her how her distorted emotions and conduct have affected that alternative will help her get a new perspective. Replacing negative thoughts with realistic thoughts will help Stella enjoy her current life and work hard towards improving her future.
Discussion
Stella is a teenager undergoing family-related problems and uncertainties that have generated anxiety and depressive disorder symptoms. She has grown in a neighborhood where most of the people are considered criminals by the American government. Her ideas of a successful life have been limited to what she sees within her household and the neighborhood. Because of her background, Stella has become hopeless of ever having a bright future. Socialization makes her anxious hence;, she has resorted to seclusion and being alone. The fact that Stella is hopeless according to DSM-5 is an indication of depression. She also sees her future as bleak and pessimistic. Stella is uncertain whether she will be successful and get out of her current situation or end up with a low-wage job. These symptoms are an indication of depression.
Apart from depression, she is showing symptoms of anxiety. Stella is terrified and worried about her future. She has mainly based her life on the negative factors surrounding her, making it difficult for her to find optimistic factors. Her inner restlessness is because of not being sure if the police will knock on her door, which of her family members will be getting arrested. Having relatives who are either illegal immigrants or some who want a shortcut to success by selling drugs is all she bases her life on. Her family members cannot act as role models because they are either criminals, convicts, or working in low-wage employment sectors. It has become ingrained in her mind that her life will either turn out good or end up like her relatives.
Anxiety and depression are mainly described by distortion of thoughts and beliefs. Stella’s life is founded on negative thoughts; her perception of life has it all or nothing. From the DSM-5 diagnoses of depression and anxiety disorder, there are overlapping symptoms of the disorders. For instance, the main difference between depression and anxiety is Fuentes-Rodriguez et al. (2018) describes social anxiety disorder as per the latest DSM-V to be distinguished by “fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others” (p. 1). On the other hand, depression is the feeling of hopelessness, sadness, or feeling empty. However, the symptoms of both disorders may be different in different people.
Depression is mainly diagnosed when the patient is experiencing feelings of hopelessness, worthlessness, and sadness. However, depressed individuals might also experience irritability, restlessness, insomnia, and difficulty concentrating. Stella is experiencing these symptoms because of her anxiety. Lack of self-esteem and, in extreme cases, suicidal thoughts are all symptoms that someone with depression and anxiety can experience. General body fatigue, loss of weight, and irritability are symptoms that can overlap in the two disorders. Stella's symptoms can therefore be misdiagnosed for either of the two disorders. Misdiagnosis is dangerous because, as stated, extreme cases of both disorders can lead to suicidal thoughts. The best way to avoid misdiagnosis is listing all the physical, cognitive, and emotional symptoms of the disorders and using the DSM-V to categorize the symptoms. Stella’s depressive and anxiety disorders can be treated by adopting the CBT treatment because it handles all the different schemas of her symptoms.
References
Barlow, D. H. (2014). Clinical Handbook of Psychological Disorders A step-by-step Treatment Manual. Journal of Cognitive Psychotherapy , 17 (1), 97.
Carlucci, L., D’Ambrosio, I., Innamorati, M., Saggino, A., & Balsamo, M. (2018). Co-rumination, anxiety, and maladaptive cognitive schemas: when friendship can hurt. Psychology research and behavior management , 11 , 133.
Fuentes-Rodriguez, G., Garcia-Lopez, L. J., & Garcia-Trujillo, V. (2018). Exploring the role of the DSM-5 performance-only specifier in adolescents with social anxiety disorder. Psychiatry research , 270 , 1033-1038.
Lim, C. R., Barlas, J., & Ho, R. C. M. (2018). The effects of temperament on depression according to the schema model: a scoping review. International journal of environmental research and public health , 15 (6), 1231.
Park, S. C., & Kim, Y. K. (2018). Depression in DSM-5: Changes, controversies, and future directions. In Understanding depression (pp. 3-14). Springer, Singapore.
