The Effect of Culture and Comorbidities on Patient Care Jesse Chavarria, M.S. January 19th, 2017

The Effect of Culture and Comorbidities on Patient Care Discussant Dr. Lindsay Brauer

YM Sex: Female Age: 61 Race: Chinese (immigrated in 1973) First intake: 3/16/15 Transfer: 7/27/16 Number of sessions: 42(8) Seeking treatment for: Depression Anxiety Obsessive Compulsive Disorder

Y.M. Initial Intake Panic Disorder with Agoraphobia in partial remission Frequent panic attacks Wouldn’t leave room/house Generalized Anxiety Disorder “nervous” at all times Easily fatigued, tense, problems with concentration Major Depressive Disorder Low appetite, poor sleep, low energy, anhedonia Obsessive Compulsive Disorder Denied intrusive thoughts Compulsive checking and manipulation of locks and stove 2-3 minutes per day -Panic: first began 27 years ago after her children contracted salmonella -reappeared in 1997 after contracting hep B - occasional symptoms currently, but far less impairing -GAD: has increased and become problematic since a laparoscopic cholecystectomy -Lorazepam for anxiety (first presscribed 27 years ago) -Sertraline for OCD/Depression (100mg/ daily)

Y.M. 1st Therapist OCD MDD Showering 2-3 times per day Washing hands until red/chapped Spend whole day cleaning Refuse to handle eggs, trash, or leave home Excessive concerns about germs and contaminating others MDD Continued to endorse previously mentioned depressive symptoms. 5-weeks later OCD Therapy consisted of Exposure and response prevention. -Little gains due to a lack of commitment/buy in MDD Behavioral Activation -Some gains made

Y.M. 2nd Therapist Sessions conducted in Cantonese Focus on OCD symptoms Distracted self by watching TV Focused heavily on ERP Colon Cancer diagnosis Processed diagnosis Began to focus on Depression Sx -Pt reported that she did not enjoy the added stress of homework assignment -Distraction was causing disturbances in pt’s sleep schedule and mood.

Y.M. Current Therapist Sessions conducted in English GAD Constant fear of cancer recurrence Avoid meat, only eat vegetables Very invested in Chinese herbal remedies despite Conflict with physicians and family Concern of terrorist attack when children travelled Focused primarily on MDD Behavioral Activation (BA) Buy-in accelerated due to work done by previous therapist Sleep Hygiene very skeptical Poor insight Treatment terminated due to insurance change

Y.M. Behavioral Activation Set of techniques in which patients monitor and notice the connection between mood and daily activities (Lewinsohn, Biglan, & Zeiss, 1976) As efficacious as Cognitive Therapy during acute treatment (Jacobson et al., 1996) BA effects as enduring as CT and Anti-Depressant medications over at 2-year follow-up (Dobson et al., 2008)

The Effect of Culture and Comorbidities on Patient Care Discussant Questions

Audience Questions What effect does speaking the pt’s preferred language have on rapport? How do you navigate issues of culture with regards to untested medications? How do you deal with pseudoscience and movement (by some) towards the rejection of science (i.e., vaccine deniers)? What effect will possible changes to the ACA have on patient care? What role will we as psychologists/psychiatrists play in this? Is it our ethical responsibility to find care alternative care providers?