Case History of Irritable Bowel Syndrome Treated with Medication and CBT

DISCLAIMER: Real case histories differ from this psychoeducational case narrative. The client in this case history is unknown. Readers are advised to avoid internet publications and web searches and see a mental health professional for proper diagnosis and treatment.

Case History: Irritable Bowel Syndrome Treated with Medication and CBT

Demographic Data:

Name: Mr. Singh (Pseudo name); Age: 30 years.

Gender: Male; Occupation: Working professional.

Educational Background: Graduate.

Mental Status Examination (MSE):

• Appearance: Mr. Singh appears neatly dressed and groomed.
• Behavior: He exhibits signs of discomfort and restlessness during the session.
• Speech: His speech is coherent and relevant.
• Mood: Mr. Singh appears anxious and exhibits signs of distress.
• Affect: He displays a constricted affect with occasional moments of sadness.
• Thought Process: His thought process is logical and organized.
• Thought Content: He expresses feelings of guilt, shame, and fear associated with the past abuse.
• Perceptions: There is no evidence of hallucinations or delusions.
• Cognition: His attention, concentration, and memory appear intact.
• Insight or judgement: Mr. Singh acknowledges the impact of his childhood trauma on his current symptoms and is seeking help.

Childhood History:

Mr. Singh's cousin's sister, a high school student, had sexually abused him during his sixth grade. Presently, he assumes that childhood abuse has had a significant impact on his mental health and contributed to the development of his current symptoms.

Adult History:

A little bit of difficulty adjusting to friends at college and then at work. He developed nausea, recurrent stomachaches, and diarrhea over time, which led to the diagnosis of irritable bowel syndrome (IBS).

Social History:

His mind and bodily conditions, which were brought on by neglect and sexual abuse as a youngster, have harmed his interactions with other people. As per his talk with a clinician, he told the therapist that he has been experiencing irritability and unusually high anxiety in the presence of other people or social situations, consequently forcing him to avoid social situations. His childhood sexual abuse trauma has strained his relationships with almost everyone around him as he struggles with trust and intimacy.

Diagnosis

• His bodily symptoms and past medical history (an upset stomach since early adulthood) met the criteria for the diagnosis of irritable bowel syndrome (IBS).
• IBS is characterized by "frequent stomach aches and unhealthy gastrointestinal habits, like diarrhea, irregular bowel function, or both. The onset of IBS symptoms is linked with stressful circumstances, which also include an unforgettable memory of childhood sexual abuse trauma. Another factor influencing the client's IBS symptoms and emotional suffering is the "psychological impact of sexual abuse," which can lead to the comorbidity of other mental health issues such as avoidant personality disorder, melancholy, PTSD, specific phobias, and social anxiety.

Treatment / Intervention

• A mix of medicine and cognitive behavioral therapy (CBT) makes up Mr. Singh's treatment plan.
• To manage his physical symptoms, antispasmodics, fiber supplements, and low-dose antidepressants were prescribed by his psychiatrist in accordance with his condition and allergy to some other medications.
• CBT targeted his thoughts, emotions, and behaviors related to his past trauma and current symptoms to address the psychological impact of the abuse.
• The objective of this case was to enhance his coping skills, decrease his anxiety, and improve his overall health.