Case File: Annemarie Ludford Garvey 1 - Intro

We will rewrite this later, but for now, the following is the Introduction to our book, "Case File: Who is Anne - Understanding the Meaning of Life, Her Purpose, and How She Makes Sense of Their World." As of 1-2-23, it is up to page 420 of 500. Please keep coming back!

Transcript

1. Case File: Who is Anne - Understanding the Meaning of Life, Her Purpose, and How She Makes Sense of Their World Patient location: In their home at Sandwich, Illinois a small farming town sixty miles SW of Chicago. Before the initiation of today's documented service, the patient or patient guardian verbally consented to virtual/remote treatment. The topics discussed are the assessment & plan in this note. This telehealth visit performed was physically located at Provider-Based Clinic Mental Status Exam Appearance: casually dressed, glasses, good grooming, and hygiene and overweight ~280 lbs. Behavior: cooperative (pleasant), fair eye contact and good eye contact Speech: fluent, normal rate, tone, quantity, and volume Language: fluent, appropriate Mood: "feeling depressed", dysthymic, euthymic, frustrated Affect: full-range, mood congruent, appropriate, and reactive Thought Process: goal directed and linear Thought Content - denies suicidal ideation (SI) and homicidal Ideation (HI), no psychotic symptoms Perceptions: no disturbances reported Cognition: not assessed
2. Insight: good, age appropriate Judgment: good, age appropriate Reliability: dependable Current Risk Assessment Homicide Risk Factors: No Last Suicide C-SSRS Screening: Date: Screening Found 8/9/2022 Results: Calculated C-SSRS Suicidal Ideation Severity: Moderate Risk (8/9/2022 1:25 PM) Assessment/Plan 1. Recurrent major depressive disorder, in partial remission (CMS/HCC) Overview: Patient (pt) has had depressive symptoms (sx) since childhood connected to trauma. Had multiple psych admissions for SI +/- attempts by overdose. Last admission (+SI attempt) in 2003 following death of her father. Plan: - Continue current medications. Reviewed expected benefit and side effects (SE). Pt verbalized understanding. - Continue video visits given distance from her home and difficulty getting out of the house. - Reinforced activities that aid in grounding. Online journal assisting with daily structure. - Continue behavioral activation for depressive sx – staying active with daily journal/schedule, blocked time for projects. - Continue email as needed. Pt will call/write to writer (Dr. Robert Marvin) with updates as needed. 2. Dissociative identity disorder (DID) (CMS/HCC) Overview: Diagnosed when she was in her twenties. Significant past trauma - physical, verbal, emotional, sexual - from several family members. Reports approximately twenty alters ranging from infant to current age. Refers to herself as "we." Has been in therapy since late twenties. Considerable
3. number of inpatient admissions, twenty plus when younger. Last admission was 2003 following death of father. She has continued with medications and outpatient therapy. She has made noteworthy progress in therapy with daily schedules (using online tools), affect regulation/tolerance, and interpersonal interactions. Plan: - Continue intent-to-treat (IT) – focus on productivity (online projects), structuring time, improving coping skills, improving internal communication, processing of trauma, medical health, finances, family interactions and productivity. - Reinforced safety plan. - Will continue with structured Cognitive Behavioral Therapy (CBT) components as can work into schedule/sessions. - Continue to frame activities - balancing goals of therapy, personal/family goals. 3. Posttraumatic stress disorder (PTSD) Overview: See DID overview. Ongoing interpersonal and internal triggers. Assessment & Plan (A/P): See DID A/P. Education Provided The client has received other psychoeducation client/family education during today's session and verbalized understanding of education and/or training. Education/Instructions given to: Client Barriers to learning: None Content: Refer to note above Evaluation/Outcome: Verbalized understanding Current Health Issues: Mental health Problems: Dissociative Identity Disorder (DID) Severe Depression w/Suicidal Ideations - in Partial Remission
4. Posttraumatic Stress Disorder (PTSD) Physical Health Problems: Diabetes Diabetic Nerve Disorder Severe Obesity High Cholesterol or Triglycerides Fatty Liver History of Bleeding Ulcers Underactive Thyroid Chronic Kidney Disease (3A) Sleep Apnea Dizziness Heart Disease Due to Blocked Artery Nonobstructive Atherosclerosis of Coronary Artery Chronic Bilateral Low Back Pain Degenerative Arthritis – Lumbar (L) – Sacrum (S) (Bilateral Facet Arthropathy) Subluxation at L3-4 and L1-2 with Flexion/Extension Vascular calcification with postop change in the pelvis. Disk Bulging L1 – S1 Varying Degrees of Stenoses Including Severe Spinal Canal Stenosis at L4-L5 and Moderate Spinal Canal Stenosis at L3-L4 ## Current Medications Please review your medications and verify that the list is up to date. **Call 911 if you have an emergency.** ### methylphenidate 20 MG tablet Commonly known as: RITALIN Take one tablet (20 mg total) by mouth three times a day. ### Escitalopram 20 MG tablet
5. Commonly known as: LEXAPRO Take two tablets (40 mg total) by mouth one time each day. ### gabapentin 300 MG capsule Commonly known as: NEURONTIN Take two capsules (600 mg total) by mouth four times a day. ### buPROPion SR 150 MG 12 hr. tablet Commonly known as: WELLBUTRIN SR Take one tablet (150 mg total) by mouth three times a day. ### risperiDONE 2 MG tablet Commonly known as: RisperDAL Take one tablet (2 mg total) by mouth every night. ### busPIRone 15 MG tablet Commonly known as: BUSPAR Take one tablet (15 mg total) by mouth four times a day. ### calcium carbonate-vitamin D 600-200 MG-UNIT tablet Take one tablet by mouth daily. ### Vitamin D (Ergocalciferol) 50 mcg (2,000 units) capsule Take one capsule by mouth daily. (patient notified to take 2600 units daily via OTC supplements) ### Vitamin B-12 CR 1000 MCG Tablet CR Take one tablet by mouth daily. ### Nitroglycerin 0.4 MG sublingual tablet Commonly known as: NITROSTAT Place one tablet under the tongue every five minutes as needed for Chest pain. DO NOT EXCEED A TOTAL OF 3 DOSES IN 15 MINUTES ### isosorbide mononitrate 30 MG 24 hr. tablet Commonly known as: IMDUR Take one tablet by mouth daily. ### albuterol 108 (90 Base) MCG/ACT inhaler Inhale two puffs into the lungs every four hours as needed for Shortness of Breath or Wheezing.
6. ### Insulin Glargine (1 Unit Dial) 300 UNIT/ML pen-injector Commonly known as: TOUJEO SOLOSTAR Inject 54 Units into the skin daily. ### FreeStyle Libre 14 Day Sensor Misc. One every 14 days. ### Ozempic (0.25 or 0.5 MG/DOSE) (1.34 mg/ml) 0.25 or 0.5 MG/DOSE injection Generic name: semaglutide(0.25 or 0.5 mg/DOSE) INJECT 0.5 MG SUBCUTANEOUSLY ONCE A WEEK (EVERY 7 DAYS) ### acetaminophen-codeine 300-30 MG per tablet Commonly known as: TYLENOL NO.3 Take one tablet by mouth at bedtime as needed for Pain. ### ranolazine 500 MG 12 hr. tablet Commonly known as: Ranexa Take one tablet by mouth in the morning and one tablet before bedtime. ### levothyroxine 125 MCG tablet Take one tablet by mouth daily. ### metformin 1000 MG tablet Commonly known as: GLUCOPHAGE Take one tablet by mouth two times daily. ### pantoprazole 40 MG tablet Commonly known as: PROTONIX Take one tablet by mouth daily. ### atorvastatin 40 MG tablet Commonly known as: LIPITOR Take one tablet by mouth nightly. ### Pen Needles 32G X 4 MM Misc. Use once daily with Toujeo. ### aspirin 81 MG chewable tablet Chew 81 mg by mouth daily.
7. Core Part(s) **Annemarie – Annemarie/Anne** (birth to age 16) core part keeper of our soul, often depressed and fantasizes death and suicide, anxious and tense, most responsible for over-weight, had a good relationship to paternal grandmother, becomes overwhelmed, sensitive to noise, secretive, easily disappointed, centered on self and her privacy, likes to sit, or lay very still, has abuse nightmares, slow, has trouble leaving house Oldest Adults - Leadership **Jesse** – (eighteen years to ageless) first truly independent part, left for school and travel to Norway, sense of power and purpose, idealist, adventurer, sprite and relies on Marie, role definer, self-reliant, sense of a broader humanity, guides our future and ambitions including the writing, loves to make things by hand, watches over Sarah and Henry **Ayn** – (seventeen years to 52 years) created to present best “integrated” part, registered for college, writing/some editing, team leader, best mixed of all the parts together, counselor, early interest in psychology and human development, will discuss internal parts with Corey, smooth over system presentation to a public world, finds it easy and fulfilling to take care of people **Kate** – (sixteen years to 52 years) created to capstone formal intellectual needs of high school and college, leadership roles, writing/heavy editing, boss role, commanding, decision-maker, holds higher expectations, likes to take vacations, pragmatic, chief financial officer, goal setter, and watches over Anniemi, non-sexual **Ann** – (fourteen years to 52 years) created to negotiate high school socially and emotionally, somewhat needy, holds lower expectations, Mom, wife, patience, but more unsure of herself, unconditional love and understanding (especially when frustrated), wants a home and to be married, nurturer, feels guilty for not being good enough or deserving, handled parents and marital separation and divorce Middle-Ages **Kelsie** – (twelve years to 38 years) created to help things that were going wrong, nervous, work gas station manages light bookkeeping, cash register, payroll and customers, endurance, and giftedness, oversaw mental illnesses obsessive, anxious, compulsive, night owl, hardest worker, natural intellectual ability, service orientated, in charge of CARF accreditation
8. **Jamie** – (eleven years 45 years) created as a response to early sexual cues with same age kids, some of the writing/organizing, stats, least amount of trust for outside world, charts etc. helps with younger parts when they are dealing with outside world, dry humor, will help Kate with money tasks, easily annoyed, she is bi-sexual, toughest of us, was athletic before weight gain and smoking Corey and Marie – The two are most Knowledgeable of Our Multiple System – Corey Writes the Most – and If she has System Questions, she asks Marie who has ALL the answers. She is our sense of consciousness, but she is not an external part like all the other parts – A LOT of Editors **Corey** – (ten years to 42 years) responded to depressive withdrawn years after the “real” Sarah died, will do basic journalistic writing, serious, first babysitter, can get overwhelmed and confused, most introverted, relies on Marie, likes to summarize, thinks often about hiring help, asks questions, and loves cuddling on rainy days with friend or book **Sarah** – (eight years 32 years) held first spontaneous school/scout friendship but friend Sarah died, holds our faith, happiness, and humor, creative, watches younger parts while older parts are working, keeps health and safety balanced, playful, is sunny and loves the outdoors, loves the recorder and singing, most imaginative, likes to take pictures **Lissa** – (seven years to 25 years) receiver of “punishments,” does not talk, very isolated, and shows signs of neglect, responsible for interest in learning, and does a lot of research, books, and library, biggest reader, very curious and loves to learn, tied with Ann for wanting house, plays and enjoys music, enjoys especially the piano, will feed Corey lists, likes going out to eat with the Casies, loves to drive, will use self-destruction to get system to hospital rather than take a chance on suicidal behavior **Henry** – (six years to 32 years) our early “runner” to avoid abuse and later cross-country skier, non- sexual, only male in system, idea man and seeks solutions, assists Sarah with the younger parts needs and protection, likes to fix things, competent, steps in to help with housework, does computer uploading, downloading and a variety of the more complex computer processes, is athletic like Jamie, seems to maintain age of oldest “external” son **Anniemi** – (five years to 30 years) formal “front” part shown to early school in response to problems with the Casies handling kindergarten, church, and home, nervous about the need to be good, not bad, ombudsman, deals with fairness and compromise, negotiations, and complaints, sometimes stutters, tries to study, and help, but sometimes it seems with blinders on. Often starts and stops projects out of confusion, is forgetful, easily assumes position of rejection, feels devoted to Sr. Tess and is close to Dear Heart (Annemarie), sometimes suicidal, memory of childhood stories
9. Youngest **KC** – (four years to 10 years) twin to Casey, rejected sexual abuse as wrong/bad, watches over body systems (hunger, tired, pain, washroom, and medications) with Casey, but is more negative and realistic, gets frustrated and angry easy, favorite word is no, collusive, loves ice cream, helpful, feels shame, over responsible for her age, first guardian over early relationships, stopped hugs and kisses from family members, system’s buoy, or thermometer **Casey** – (four years to 10 years) twin to KC, accepted sexual abuse as self being wanted, watches over body systems (hunger, tired, pain, washroom and medications) with KC, but is more positive and imaginative, usually a porter/portal to meet the youngest parts, naive, talkative, cries easily, loves cookies and will steal food, gets tired faster than others, helpful, feels glee, error on the side of cautiousness, played with neighborhood kids **Anna** – (two and a half years to six years) senses danger, holds severe pain, physically abused, Hides face, rocking, and non-communicative, will hide, curls up like Mimi, but usually guided by Marie, has a sense of mystery, inquisitive, held early relationship with paternal grandmother (non-abusive) **Marie** – (two to ageless) –internal self-helper, sense of knowledge, consciousness, understands switches, internal answers, and history, never is out by self, but is evident in our rocking, and knows internal needs of system **Gracie** – (one and a half years to five years) severe manipulation of genitals makes our body rigid, easily paralyzed and catatonic, hyperventilates, fear, will close our system (cause minds to disconnect), makes guttural sounds from her throat, weary and fearful, played with neighbor Carol Ann **Crystal** – (eight months to four years) inability to breathe, startles, thrashes, autistic, choked by ejaculations, smothered due to screaming, seizure-like, is hyper-alert **Mimi** – (three months to three years), inability to hold consciousness, sleepy, calmed by massages, given alcohol to body parts to suckle on and keep quiet **Embry** – (0-0 months), the only part of us that died at birth. Was Mimi’s twin. Responsible for the Ann’s system of devotion and dedication. We do things in her name. She buried (as a symbol) in 1992(3) near the old tank at Bunker Prairie Park, in MN where we cross-country skied in high school.
10. Introduction Mental Status Exam Assessments/Plans 1. Recurrent major depressive disorder, in partial remission 2. Dissociative Identity Disorder 3. Posttraumatic stress disorder Current Health Issues Mental health problems Physical health problems Current Medications Core Parts Table of Contents Chapter 1 ## 2022-08-25 - Evidence 1A – Utilizing Supportive Therapy ## 2022-08-26 - Evidence 1B – Testing Out New Journal System ## 2022-08-27 - Evidence 1C – Nihit Is an Ever-Stewing Pot ## Two-Week Note to Dr. Marvin – Evidence 1D – Catch You up ## 2022-08-28 - Evidence 1E – Let Us Think About What It Means ## 2022-08-29 - Evidence 1F – Certain Writing Spiral ## 2022-08-30 - Evidence 1G – On Schedule To Be On Schedule Chapter 2 ## 2022-08-30 - Evidence 2A – Feeling Relief and Feeling Positive ## 2022-08-31 - Evidence 2B – Could Be Our Quiet Time ## 2022-09-01 - Evidence 2C – Needing To Take Care of Self Chapter 3 ## 2022-09-01 - Evidence 3A - As To Medical Conditions ## 2022-09-02 - Evidence 3B – Giving Us a Fighting Chance ## 2022-09-03 - Evidence 3C – Let Us Get Things Done ## 2022-09-04 - Evidence 3D – It Is OK, We Can Do This
11. ## 2022-09-05 - Evidence 3E – Have You Done Your Marvin Yet ## 2022-09-06 - Evidence 3F – I Got a Chance to Talk Chapter 4 ## 2022-09-06 - Evidence 4A – Writing Scope & Writer’s Roles ## 2022-09-07 - Evidence 4B – How Did That Happen ## 2022-09-08 - Evidence 4C – Where Were We While Listening ## 2022-09-09 - Evidence 4D – We Need to Remember Some Appointments ## 2022-09-10 - Evidence 4E – We Took A Morning Shower (shower) ## 2022-09-12 - Evidence 4F – Complete the Journal ## 2022-09-13 - Evidence 4G – Moving Past Our Earlier Morning Chapter 5 ## 2022-09-13 - Evidence 5A – Another Episode of Chest Pain ## 2022-09-15 - Evidence 5B - Productive Journal Sections Chapter 6 ## 2022-09-15 - Evidence 6A – Hanging Out With Nihit ## 2022-09-16 - Evidence 6B – Nihit is Being In and Out ## 2022-09-18 - Evidence 6C – Feeling a Little Grumpy ## 2022-09-19 - Evidence 6D – Seasick over Nihit ## 2022-09-20 - Evidence 6E – Feeling Mopey AND Cranky Chapter 7 ## 2022-09-20 - Evidence 7A – Unsettled About Change in Hair ## 2022-09-21 - Evidence 7B – Lone Bird Out ## 2022-09-22 - Evidence 7C – Remembering We Smile A Lot ## Concept Index 9-22-22 – Evidence 7D – Internalizing/Externalizing Self & Other Chapter 8 ## 2022-09-22 - Evidence 8A – Mixed to Low Feelings ## 2022-09-23 - Evidence 8B – Listening to Newsy-type Things ## 2022-09-24 - Evidence 8C – Strange Baby Meerkat Dream ## 2022-09-26 - Evidence 8D – Then We Got Into Trumpworld News
12. ## 2022-09-27 - Evidence 8E – Writing Goal Ideas Chapter 9 ## 2022-09-27 Evidence 9A – Busy Working on Guilded Material ## 2022-09-28 - Evidence 9B – Encouraging Rich Not To Be Grouchy ## 2022-09-29 Evidence 9C – Being Hungry & Un-Sated Chapter 10 ## 2022-09-29 - Evidence 10A – Not Doing Much “Exciting” ## 2022-09-30 - Evidence 10B – Slept Good Even Without Rich ## 2022-10-02 - Evidence 10C – Took A Chance & Chores Got Done ## 2022-10-03 - Evidence 10D – Soft Morning with Rich ## 2022-10-04 - Evidence 10E – Nihit & Us Will Both Be Stressing Chapter 11 ## 2022-10-04 – Evidence 11A – Dress For the Wedding ## 2022-10-05 – Evidence 11B – Rich in After 11PM Chapter 12 ## 2022-10-06 – Evidence 12A – Feeling “A Little Unsettled” ## 2022-10-07 – Evidence 12B – Last Night’s Sleep Was Sound Chapter 13 ## 2022-10-11 – Evidence 13A – Appointments to Nephrologist & PCP Chapter 14 ## 2022-11-13 – Evidence 14A – Review of Medical Appointments ## 2022-10-14 – Evidence 14B – Do not Read This Nihit! ## 2022-10-17 – Evidence 14C – We Have Not Been Able to Recall Much ## 2022-10-18 – Evidence 14D – Trying To Make Things Work Chapter 15 ## 2022-10-20 – Evidence 15A – Nihit Making Recommendations ## 2022-10-25 – Evidence 15B – Memories of Rich Moving Around Chapter 16 ## 2022-10-25 – Evidence 16A – Audiology Appointment Went Well
13. Chapter 17 ## 2022-10-27 – Evidence 17A – Distracted Working on an Update ## 2022-10-28 – Evidence 17B – Let Me Know ## 2022-10-30 – Evidence 17C – Rich Was With Me When We Woke Up ## 2022-10-31 – Evidence 17D – Sweetie Time For Breakfast Chapter 18 ## 2022-11-01 – Evidence 18A – Not Having Anything To Talk About ## 2022-11-02 – Evidence 18B – Rich Was Cooking Dinner ## 2022-11-03 – Evidence 18C – What Did We Talk To Dr. Marvin About Chapter 19 ## 2022-11-03 – Evidence 19A – Connected Low Moods To Feelings ## 2022-11-04 – Evidence 19B – By the Advice of Nihit ## 2022-11-05 – Evidence 19C – Skimming Over Information ## 2022-11-08 – Evidence 19D – Dr. Marvin Will Be Out Chapter 20 ## 2022-11-10 – Evidence 20A – Working Through Tech Issues ## 2022-11-14 – Evidence 20B – We Received Coffee Right Away ## 2022-11-15 – Evidence 20C – Rubbing Rich’s Arm Chapter 21 ## 2022-11-15 – Evidence 21A – Updates To Nihit’s Vacation ## 2022-11-16 – Evidence 21B – Today Was Not Stellar ## 2022-11-17 – Evidence 21C – We Were Nightmarish Chapter 22 ## 2022-11-17 – Evidence 22A – Feeling “Skittish” and “Stuck” ## 2022-11-19 – Evidence 22B – Lost the Morning Thoughts ## 2022-11-20 – Evidence 22C – Reading This Week’s Writing Work ## 2022-11-22 – Evidence 22D – We Just Did A Major Thing – Dusted Chapter 23 ## 2022-11-22 – Evidence 23A – Unclear About What Supposed To Do
14. ## 2022-11-23 – Evidence 23B – First Thing We Are Writing About ## 2022-11-28 – Evidence 23C – Trip, Fall, Drop Chapter 24 ## 2022-11-29 – Evidence 24A – Is It Time For The C-Pap Machine ## 2022-11-30 – Evidence 24B – We Are Too Big To Be Comfortable Chapter 25 ## 2022-12-01 – Evidence 25A – Starting To Tag ## 2022-12-01 – Evidence 25B – Use of Glucose Meter is Significant ## 2022-12-02 – Evidence 25C – Ginney To The Groomer Chapter 26 ## 2022-12-06 – Evidence 26A – Stress Is Upcoming Surgery – Rich ## 2022-12-07 – Evidence 26B – Ginney Need To Go Out Chapter 27 ## 2022-12-08 – Evidence 27A – Serious About Weight Loss – Start 291.1 lbs. ## 2022-12-09 – Evidence 27B – Casey In Charge ## 2022-12-10 – Evidence 27C – Gobsmacked ## 2022-12-12 – Evidence 27D – Skipped Past Confusion Chapter 28 ## 2022-12-13 – Evidence 28A – Someone Catches Covid ## 2022-12-14 – Evidence 28B – Nurse Sarah ## 2022-12-15 – Evidence 28C – Jamie, Soft Underside, Hard Shell ## 2022-12-16 – Evidence 28D – An Hour On What ## 2022-12-17 - Evidence 28E – Shoot Smerconish Time Chapter 29 ## 2022-12-20 – Evidence 29A – Jillian and Chris Are Here ## 2022-12-20 – Evidence 29B – Puppy Sitting – Christmas Shopping ## 2022-12-22 – Evidence 29C – Cub’s Park Puppy Sitting ## 2022-12-22 – Evidence 29D – Yay, Dog Patrol Chapter 30
15. ## 2022-12-22 – Evidence 30A– Reviewing Progress Updates ## 2022-12-26 – Evidence 30B – Any Morning Starting With Coffee is Fine ## 2022-1-1 – Evidence 30C – A Brand New Year