INTAKE OUTLINE AND REPORT

YOUR NAME: Courtney Manarky

CLIENTS NAME: Dr. Alice Howland

CLIENTS APPROXIMATE AGE: 50

A. IDENTIFYING INFORMATION AND REFERRAL STATEMENT:

The client, Dr. Alice Howland, is a 50 year old mother of three, and professor of
linguistics at Columbia University in New York City. She currently lives with her
husband, Dr. John Howland, 52, in New York City. She has never seen a
psychologist before, though has reported recently seeing a neurologist, Dr.
Benjamin, 45. Ive been seeing a neurologist for the past few months, (Glatzer,
2014). The client appears intelligent, optimistic, and persistent.

The client was referred to the clinic through the neurologist, who suggested that
she engage in social support. During one of their early meetings, Dr. Benjamin
requested of the client, And the next time that you come and see me, can you
bring in someone that knows you well? Your husband or a close relative?
(Glatzer, 2014).

B. PRESENTING COMPLAINT:

The client is very concerned with her lack of memory. She states, I got lost
when I was running on campus a while ago. I cant remember appointments.
Words (Glatzer, 2014). She insists that these are more than memory lapses,
exclaiming, I know what Im feeling. And it feels like my brain is fucking dying.
And everything Ive worked for in my entire life is going. Its all going (Glatzer,
2014). The client wants to get some answers and closure on her lack of
memory.

C. HISTORY OF PRESENTING COMPLAINT:

The client began reporting memory loss and confusion right after her 50th
birthday, in October. She reports that during a lecture that she completely lost
her train of thought, something that was out of sorts for her, being a professor.
She casually blames her alcohol, I knew I shouldnt have had that
champagne, (Glatzer, 2014) but feels unsettled at being unable to remember
the word. Shortly thereafter, the client reports getting lost on a run in the
middle of Columbias campus, her place of work. She reports her feelings on the
forgetfulness, Ive started forgetting things. Little annoying things like words
and names. And I got lost completely lost running on campus, (Glatzer,
2014). At this time, she began to see Dr. Benjamin, 45, a neurologist.
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There was no real stressor for the clients symptoms. She reports I work a lot
but I thrive on it, (Glatzer, 2014). She is happy with her home life, her work
life, and has healthy relations with her family (See Family Constellation for
more information). The presenting complaint appears to have begun without a
direct stressor.

The client functions at a very high level. She is a professor of linguistics at

Columbia University, who frequently gives guest lectures. Despite her decline,
she continues to give lectures, and teach in the classroom. However, she has
been unable to deliver in the classroom with the same ease she once used to.
Her students reported, I had a hard time following Dr. Howlands lectures
even she seems like she gets lost in them, (Glatzer, 2014). She also begins to
forget people who she has just met. At Christmas, her son Tom, 26, introduces
the client to his current girlfriend. The client introduces herself while preparing
food, and again at the actual meal. You didnt know Toms girlfriend when she
came over at Christmas (Glatzer, 2014). The client continues to show a high
level of functioning despite her impairment. As stated by her neurologist,
Alices memory is failing but shes still incredibly resourceful, (Glatzer, 2014).

The client does not have any previous treatments regarding her current
presenting complaint.

D. MEDICAL:

The client appears to be in good physical health. She previously had three
children, and during her consultation with her neurologist, she exhibited no
physical health issues. The client currently is taking, a multivitamin, flax seed
oil, calcium, iron, and occasionally a sleeping pill when I travel, (Glatzer,
2014). She has a balanced diet, and cooks frequently. She has not experienced
any previous head injuries, and does not report excess stress or depression.
The client also reports getting a decent amount of sleep, like seven hours a
night, (Glatzer, 2014). She reports running frequently, and getting physical
activity in multiple times a week.

The client does not report any substance abuse, but notes that her father was
an alcoholic (See Family Constellation for more information).

E. PERSONAL HISTORY:

The client does not discuss much about her early life, childhood or adolescence.
However, she reports that she spent a good amount of time on the beach with
her mother and sister, Anne. Her family originated from New Hampshire, but
she moved to New York later in life. The client reports that My sister and I were
very close, actually, (Glatzer, 2014). She reports that her mother and sister
died early on in her life. My mother and sister died in a car accident when I
was eighteen, (Glatzer, 2014). She also reports that her father was not a large
part of her life. (See Family Constellation for more information).

She graduated from college and obtained her Doctorate in Linguistics. She is an
accomplished author, professor, and parent. Alice Howland is the Lillian Young
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Professor of Linguistics at Columbia University. She famously wrote her seminal

textbook, From Neurons to Nouns, while raising three children, (Glatzer, 2014).
This textbook is now considered, One of the cornerstones of linguistics
education all over the world, (Glatzer, 2014). The client teaches at Columbia,
but also guest lectures in many different areas of the country. She is a very
ambitious person, who is described as being, pretty relentless. You wanted
everything all at once, (Glatzer, 2014).

The client is the mother of three children, Anna, 28, Tom, 26, and Lydia, 23.
(See Family Constellation for more information). All of her children live outside
of the home, leaving the client at home with her husband, Dr. John Howland,
52.

The client is financially doing well, and lives in a house on the outskirts of New
York City.

F. FAMILY CONSTELLATION:

Growing up, the client was very close with her mother, and sister, Anne. Her
father was not very present in her life. The client reports that her mother and
sister were not in her life for very long. My mother and sister died in a car
accident when I was eighteen. My father died in 1999 of liver failure, (Glatzer,
2014). She describes her relationship with her sister before she died, my sister
and I were very close, actually, (Glatzer, 2014). The client reports having
frequent flashbacks of her sister and her mother, which increased as the
disease progressed. While the clients mother and sister were very present in
her life, her father was not. The client explains his death, and then mentions,
To tell you the truth we didnt see a lot of each other. He lived in New
Hampshire and we werent that close, (Glatzer, 2014).

The client currently lives with her husband, Dr. John Howland, 52. He is also a
professor at Columbia, who specializes in a science field. The client and her
husband have a very loving relationship. Dr. John Howland toasted his wife on
her birthday by saying, To the most beautiful and the most intelligent woman I
have known my entire life, (Glatzer, 2014). The couple has been together for 30
years, and John cannot seem to picture life without his wife. When the client
brings up seeing her neurologist, Dr. Travis Benjamin, 45, John immediately
shuts down any thought that she may be suffering from neurological damage.
He questions her feelings, stating Honey, we all have memory lapses. Thats a
sign of getting older. The other day I forgot the word glucose, (Glatzer, 2014).
John also remarks that he thinks the possibility of her suffering from
neurological damage is ridiculous. Its complete bullshit, Glatzer, 2014).

He appears to have a hard time accepting that his wife will not maintain a
normal cognitive functioning. After getting results of genetic testing, the clients
husband comes across angry and short-tempered. Where the hell is this
goddamn elevator? Here we are in a major hospital, and they only have one
elevator running, (Glatzer, 2014). He also tries to continue with his normal life,
denying his wifes situation. John wants to take a job at the Mayo Clinic in
Minnesota, which would leave his wife in a new city, or at home alone. The
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client calls him out on his feelings, You you dont want that. A year at home,
with me, watching this. You dont want it, (Glatzer, 2014). He is struggling to
deal with his feelings of grief towards his wifes failing cognitive function.

The client is also parents to three children, Anna, 28, Tom, 26, and Lydia, 23.
Anna Howland-Jones is a 28 year old lawyer and married to Charlie Howland-
Jones, 29. The two are currently trying to get pregnant, Its a very big decision.
Were excited. The place was recommended by a couple of friends whod been
trying for years and have just had their first child, (Glatzer, 2014). The two of
them do become pregnant. Anna is intelligent, and matches her mother word
for word in the game Words with Friends. They are both competitive, and
constantly trying to beat the other. Aside from wishing her mother a Merry
Christmas, the first thing Anna said to the client was, Have you seen my latest
Words with Friends? (Glatzer, 2014). Although she is competitive with her
mother, she is also extremely caring and protecting of her. When the client tells
her children about her cognitive impairment, Anna begins to cry and remarks,
Youre so young, Mom. I dont understand that, (Glatzer, 2014). Genetic
testing reveals that Anna will also undergo this same deficiency later in life.
Anna births twins, Allison and Charlie Jr., both of which are negative for the
clients cognitive deficiency.

Tom Howland is a 26 year old ER doctor. He is not as close with his mother as
he is with his father, but Tom is very passionate about his work. After arriving
late to his mothers birthday dinner, he engages in a passionate discussion with
his father regarding the action-packed ER. The ER was like a mad house. This
one guy came in six stab wounds. I swear one missed his heart by seriously,
an inch, (Glatzer, 2014). Tom accompanies his mother places, but appears to
show more social support and is less likely to have an open conversation with
her than her other two children. He seems more concerned with the medicine
than with his mothers disorder, as one of the first things he asks her is, What
medications are you on? (Glatzer, 2014).

Lydia Howland, 23, the clients youngest daughter, did not take the traditional
college route, which is a constant source of arguments between the two. Lydia
lives in Los Angeles, aspiring to be an actor. After a visit to L.A., John asks if
the client argued with her daughter over acting, to which the client replied,
Well we spent the whole evening trying not to, (Glatzer, 2014). During her
mothers decline, Lydia moves back home to help support her family. Lydia is
not afraid to ask the difficult questions about her mothers life changes. While
the other two children are being supportive and pitying their mother, Lydia tries
to understand what she is going through. She asks, What is it like? I mean
what does it actually feel like? (Glatzer, 2014). While Lydia is the one that the
client tended to get along with least, and disprove of her life choices the most,
Lydia is the child that ended up moving back home and sacrificing her career,
showing her true caring and loyal character. This is New York. Ill audition. Do
theater. I know this is where I need to be so (Glatzer, 2014).

G. CLINICAL DESCRIPTIONS, IMPRESSIONS, AND OBSERVATIONS:

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The client did express the intention of harming or killing herself. She also had a
plan, and intentions to execute that plan. During the middle of her suicide
attempt, she kept forgetting the instructions of how to kill herself. She had to
keep replaying her instruction video, and by the time she got to pour the entire
bottle of pills in her hand, her care taker entered the house, spooking the client,
which caused her to drop all of the pills. Her instructions were to Take all pills
with water There are a lot of pills in that bottle, but you need to swallow
them all. Then go to the bed, lie down and go to sleep. And dont tell anyone
what youre doing, okay? (Glatzer, 2014). The client also reportedly asked her
doctor for rohypnol to help her sleep. The client does not want to feel like a
burden, and wants to prevent her family from having to deal with her mental
decline and memory loss.

The client suffers from excessive memory loss. She reports that I find myself
learning the art of losing myself every day. Losing my bearings, losing objects,
losing sleep, but mostly losing memories, (Glatzer, 2014). The client reports
that she gets lost easily, forgets people, things, and occasionally herself.
According to husband, Dr. John Howland 52, There are days she knows where
she is, certainly, but just as many days when she doesnt. Maybe she thinks
shes a child back in New Hampshire, or who knows where (Glatzer, 2014).
She is incapable of being alone, and completing daily activities. Recently, the
client was unable to find the bathroom in her summer home, and wet her
pants. I couldnt find the bathroom, (Glatzer, 2014). She attempts to read to
pass her time, but finds that she repeatedly gets stuck in the same place. When
reading Moby Dick, the client stated, I got tired of reading the same page over
and over again. I couldnt focus, (Glatzer, 2014). She has significant cognitive
impairment, with memory loss on the forefront of her disorder.

While she is declining rapidly, she is motivated to improve, or at least stabilize

her condition. She sets goals for herself, and tells Lydia Howland, 23, I want to
take a sabbatical year with daddy, but I dont think thats going to happen. I
want to read some classical books Ive always meant to read. And I want to see
Anna have a baby, I want to see Tom graduate and Id like to see you go to
college, (Glatzer, 2014). As well as setting goals for herself and remaining
positive about living in the moment, she also is extremely resourceful. Dr.
Travis Benjamin, 45, the clients neurologist, reports, Clearly Alices memory is
failing but shes still incredibly resourceful, (Glatzer, 2014). She puts questions
in her phone that she answers every morning, as well as quizzing herself on
random words after an allotted time period. During a speech that she gave, to
prevent herself from losing her place, she highlighted what she had already
read, allowing herself to stay focused and on track. She is trying to counteract
her impairment to the best of her ability by being creative (Glatzer, 2014).

The client also attempts to stay productive. She wants to continue teaching and
working, but her supervisor does not allow this, as her students are struggling
to learn. Its still in the early stages. I mean obviously it will limit my abilities
as time goes on but for now I feel perfectly capable, (Glatzer, 2014). She also
reports that she would like to remain in the department for as long as we all
think its possible, (Glatzer, 2014) which shows not only her passion for the
job, but her willingness to continue to live a normal life.
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While working is considered a pleasurable activity for the client, she is losing
the capability to participate in work. She does, however continue to try and
cook and run. When she was baking at Christmas time, she cannot remember
the bread pudding recipe, one she has made many times before. How many
goddamn eggs? (Glatzer, 2014). She also loses her way running across her
campus, which limits her ability to be alone and engage in pleasurable
activities. She is unable to complete tasks without struggle, which limits her
abilities.

The client also tries to maintain relationships with her family members.
However, once again her cognitive functioning gets in the way. She expresses
her thoughts, For who can take us seriously when we are so far from who we
once were? Our strange behavior and fumbled sentences change others
perception of us and our perception of ourselves. We become ridiculous,
incapable, comic, (Glatzer, 2014). Her family members begin to realize the
burden she is becoming on their family, and sometimes talk about her as if she
is not there. Guys, this is difficult for all of us. But what we have to remember
is who Alice was. She would not want to be a burden, (Glatzer, 2014). The
client is trying to maintain her relationships with her family members, but just
cannot quite hold on. Anna questions that her mother even knows who Lydia is
at her play. Mom! Mom, this is Lydia. Your daughter, (Glatzer, 2014).

Overall, the client just tried her hardest to maintain the lifestyle that she is
accustomed to living. Her cognitive decline is greatly impacting her life, and she
is unable to be resourceful enough to prevent further decline. The decline will
continue, and she will be even more unable to live independently, and complete
basic daily tasks.

H. TENTATIVE DIAGNOSIS:

The client exhibits signs and symptoms for a Major Neurocognitive Disease,
specifically, Familial Early Onset Alzheimers Disease. According to the DSM-5,
Alzheimers is described as, a major (or mild) neurocognitive disorder
(Butcher, 491). Symptoms of Alzheimers are a characteristic dementia
syndrome that had an imperceptible onset and a usually slow but progressively
deteriorating course, terminating in delirium and death, (Butcher, 491).

The symptoms of Dementia, according to the DSM-5 are as follows:

Substantial cognitive decline compared to a previous level of functioning,
in one or more of the following areas, complex attention, executive
function, learning and memory, language, perceptual-motor, or social
cognition, (Butcher, 490). These are evident through:
o Self-assessment, or assessment through an educated informant or
doctor that substantial decline is present.
o Significant impairment in cognitive performance, preferably
documented by standardized neuropsychological testing or, in its
absence, another quantified clinical assessment, (Butcher, 490).
Mental decline interferes with daily independent activities.
Mental decline does not only occur as a result of delirium.
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Mental decline is not better described by another mental disorder

(Butcher, 490).

Those who suffer from Early Onset Alzheimers Disease experience symptoms
earlier in life. The disease begins much earlier and affects people in their 40s
or 50s. In such cases, cognitive decline is often rapid, (Butcher, 494). Early
Onset Alzheimers Disease also, appear to be caused by genetic mutations,
(Butcher, 494).

The client exhibits signs and symptoms of dementia. Completing her doctorate
in linguistics, and teaching at Columbia University puts her at a very high
cognitive level, especially in terms of language. Aside from teaching, writing
textbooks, and giving talks, one way that she expressed her knowledge of
language is through the game, Words with Friends. Before her decline, the
client was known for playing high scoring, less common words, such as
HADJ, (Glatzer, 2014). Later on, her ability to recall less common words
deteriorates, and she plays simpler words, such as TONE, (Glatzer, 2014). She
is unable to recall words that she has known, and can feel that ability slipping
away from her. She also describes this feeling, Ive always been so defined by
my intellect, my language, my articulation, and now sometimes I can see the
words hanging in front of me and I cant reach them and I dont know who I am
and I dont know what Im going to lose next, (Glatzer, 2014). Her memory is
failing, and her ability to recall her language, her forte, is dissipating as well.

These declines were first noticed by the client, which led her to go see a
neurologist. Upon beginning to see Dr. Travis Benjamin, 45, the client reports,
Ive started forgetting things. Little annoying things like words and names. And
I got lost completely lost running on campus, (Glatzer, 2014). Her daughter,
Lydia, 23, also reports noticing some of her decline. I had noticed one or two
things. You didnt know Toms girlfriend when she came over at Christmas
(Glatzer, 2014).

The client also took some neurological test, which support her decline.
According to Dr. Benjamin, What worries me are the memory tests that I sent
you for. You have sporadic memory impairment totally out of proportion to your
age and there is evidence of decline in your level of mental function, (Glatzer,
2014).

The client also exhibits rapid decline in her disorder. She is unable to complete
certain independent tasks, and one example of this is when she was unable to
use the bathroom in her summer home on the beach. Before going on a run
with her husband, the client reports, Yes we are, I just have to go pee. Ill be
right back, (Glatzer, 2014). She stumbles around the house, looking behind
every door that she could find, bedrooms, closets, and the pantry. Eventually,
she was unable to find the bathroom, and wets her pants. She embarrassingly
tells her husband, I couldnt find the bathroom I dont know where I am,
(Glatzer, 2014). She also reports getting lost on runs that she goes on
frequently. Upon getting lost, and returning over two hours late, her husband
remarked, Well I hope it was worth it because you completely blew our dinner
plans, (Glatzer, 2014). She is unable to remember simple tasks, and needs
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support to continue for daily functioning. Based on her high level of

intelligence, she is able to slow the disease, but not prevent the decay.
According to Dr. Benjamin, people who have a higher level of education, it can
go faster. Often theyve managed to sustain their mental processes by
innovative means that delays diagnosis, (Glatzer, 2014). This is consistent with
the clients progression.

Between her birthday in October, and Christmas, the client exhibits a

significant decline. The client introduces herself to her son Toms, 26, girlfriend
multiple times over Christmas dinner, and she is unable to remember a recipe
that she has prepared a number of times.

The client begins exhibiting symptoms just after she turned fifty, which is
consistent with Familial Early Onset Alzheimers Disease. She also underwent
genetic testing. When the client was asked about her parents, she reports that
her father was, Incoherent. Incontinent, towards the end of his life, however
she wasnt close enough with him to notice any changes (Glatzer, 2014). The
client also reported that he had cirrhosis of the liver, which led to her disregard
of his communication and memory (Glatzer, 2014).

I. INITIAL TREATMENT RECOMMENDATIONS:

There is no cure for Early Onset Alzheimers Disease. The goal for current
treatments, and the treatment recommended for the client and her family
members is to diminish agitation and aggression in patients and reduce
distress in caregivers as much as possible, (Butcher, 497). Medication may
help alleviate the symptoms, but will not slow the progression of the disease.
Current experiments done with medication have shown that, although
antipsychotic medications may alleviate some symptoms to a very modest
degree, there is no good evidence that they are better than placebo when it
comes to patients overall daily functioning and cognition, (Butcher, 497).

The client is recommended to be placed in a treatment facility, where she will be

able to have caregiver access at all hours of the day and night. The clients
family members will be assigned to family and support therapy, where they as a
group and as individuals, will be able to talk about what they are going
through, and how they are effected by the clients mental decline.

J. INITIAL PROGNOSIS:

The prognosis is not good. Alzheimers disease will result in death. The clients
family should undergo genetic testing, and continue to screen themselves to
detect the disease early. Ensuring comfort for the client and her family is most
important during the end stages of her disease.

K. REFERENCES:

Butcher, J. N., Hooley, J. M., & Mineka, S. (2014). Abnormal Psychology (16th
ed., pp. 490-497). Boston: Pearson Education, Inc.
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Glatzer, R., & Westmoreland, W. (Director). (2014). Still Alice [Motion picture].