Glee Essay

Topic 2. ‘There is nothing ironic about show choir! ’ – Rachel Cohen Is Rachel’s assessment of the musical performances on Glee correct? Discuss the interplay of melodrama, irony and intertextuality in Glee. Your essay should contain detailed analysis of at least two scenes from Glee’s 1st season. Your essay should also make reference to your core course readings on television and postmodernism. Due 14 September heir true voice; and this one was, to me, ultimately about the series demonstrating its own voice and its space within the world of contemporary musicals. I don’t know what exactly I expected when I heard Joss Whedon would be directing, although it did send me diving for my Buffy The Vampire Slayer sing-along DVD. What I didn’t expect was an episode that didn’t feel like Whedon at all but felt intensely like Glee, more specifically the Glee that endeared itself to me in the first half of the season.What has always appeale d to me about Glee, and apparently to Joss Whedon based on this episode and his interview on Fox’s website , was the show’s delicate balance of tongue-in-cheek bitter cynicism, which keeps Glee blessedly away from High School Musical territory, and a sometimes heartbreakingly authentic sentimentality that draws me into a deeply emotional engagement with the characters and a desire to see them triumph.As others on this blog have mentioned, the stunt shows, focusing around a musical theme or dance conceit, are fun but can bring the show away from its narrative engagement and this mix of sincerity and cynicism that musical numbers have often been harnessed in service of. â€Å"Dream On† brought back this dynamic and foregrounded it in contrast to some of the more music-themed recent episodes. Neil Patrick Harris is the king of bitter(sweet) cynicism, and his performance as Bryan Ryan maintained the comedy in what otherwise was in danger of becoming a maudlin episod e.Rachel and Artie’s storylines gave both characters an opportunity for growth. Artie’s triumphantly joyful flash mob scene (fangirl moment – thank you Glee, for a flash mob! ) in particular made his final moments of aching vulnerability that much more poignant. There has been reflection on this blog about the way that Glee sometimes uses, one might even say exploits, disabled characters for emotional endings and to humanize its more difficult characters (Sue and Rachel), and Artie’s storyline comes dangerously close to becoming part of this trend.There are certainly issues with how Artie’s storyline is presented in this episode, and I leave those issues for other commentators more knowledgeable in these areas. Problematic though this is, it is consistent with the series’ ethos from the beginning. The show has always undermined its own after-school special themes, or at least made them less saccharine, by unabashedly drawing on stereotypes a nd refusing after-school special endings: Artie cannot dance, Tina doesn’t do the â€Å"right† thing. All is not well in McKinley High.If it were, it wouldn’t be Glee. That this episode spoke most clearly with what I feel is Glee’s unique voice is made even more important through its intertextuality, which evoked a self-awareness on the part of the series about its place amongst contemporary musicals. Here again we return to Joss Whedon and Neil Patrick Harris. Both figures have had important roles in bringing contemporary uses of the musical to television and the web. They worked together on the web series Dr. Horrible’s Sing-Along Blog.Neil Patrick Harris has performed in musical episodes of How I Met Your Mother and Batman: The Brave and the Bold, and Whedon’s musical episode of Buffy often makes lists of the best musical television episodes of all time. In this same episode that the guest director and guest star positioned Glee within th e contemporary use of the musical on television, we discover that Shelby Corcoran is Rachel’s mother. Shelby is played by Idina Menzel, who originated Maureen in Rent and Elphaba in Wicked on Broadway, with Glee guest star Kristin Chenoweth.Menzel and Chenoweth further link Glee to the tradition of the contemporary musical that may be a much more appropriate reference here than for the more obvious, but deceptive, High School Musical. Contemporary musicals have become increasingly mature, cynical, parodic and subversive, trends that Glee falls squarely within. In an episode so drenched in references to the contemporary musical context, it was all the more important that Glee followed the examples of its characters in the last episode and emphasized its own unique voice.Whedon showed himself to be a true Gleek by emphasizing the voice of the show over his own. egardless of whether you are a Gleek (if you don’t know this term, read on), you may have noticed the buzz surr ounding FOX’s musical comedy, which returned Tuesday to the second-best ratings of the night after a â€Å"Gleek Week† of promotional appearances and news coverage. Created by Ian Brennan, Brad Falchuk, and Ryan Murphy, Glee focuses on a diverse group of teenagers participating in a high school show choir, treating the participants in â€Å"New Directions† with alternating doses of warmth and snark.It also is one of the first series in the last few decades to successfully incorporate musical numbers; its music has become a lucrative cross-promotional element of the Glee phenomenon. The series has garnered ardent fans, or Gleeks, around the world — evident in the many websites dedicated to it, such as Gleeks United, Glee Club Online, Forum Francais de Glee, Glee Brazil, and my favorite, What Would Emma Pillsbury Wear? , inspired by the fashions worn by the eponymous guidance counselor with a penchant for all things sterile and for sexy-librarian sweaters.J ust as notable, it appears to have been embraced as particularly American. The cast was invited by First Lady Michelle Obama to sing at the White House’s annual Easter egg roll last weekend, and they followed that up with a Glee-themed episode of The Oprah Winfrey Show (she praised them as the â€Å"hardest working cast on television†). News coverage on the return of Glee and spoilers have followed in most major news outlets—including two dueling reviews in The New York Times—and in scholarly forums (a shout out to In Media Res, which recently hosted a Glee-themed week).What is it about Glee that has inspired this phenomenon? Based on my own experience, as a Gleek and as a scholar focusing on the series in my research, I find the show’s play with diversity equally satisfying and frustrating, and always compelling (arguably, it is â€Å"post-racial† and reinforcing of traditional racial stereotypes). And it seems that for many fans, the showà ¢â‚¬â„¢s focus on underdogs overcoming challenge, sly satire, and feel-good musical numbers are clear pulls.With respect to these and other appeals, Glee is a prime illustration of what Valerie Wee has described as hyper-postmodern media culture. A mash-up of generic influences, intertextual references, music, and ideological content that is both eerily nostalgic and forward-thinking, the series can be read and enjoyed by fans in multiple and diverging ways. This week’s episode, â€Å"Hell-o,† provided a full helping of these and other pleasures.We witnessed cheerleading coach Sue Sylvester (Jane Lynch)’s return to the high school and renewed mission of obliterating the glee club and the long-awaited blossoming of two romantic relationships, Mr. Shuester and Emma and Rachel and Finn, although difficulties naturally arise for both couples. In these and other entanglements as New Directions looks toward regionals, the timing and humor are spot on, not the least of which was the limiting of the musical numbers to songs with the word â€Å"hell† in the title.The hilarious mix that ensues includes â€Å"Hello, I Love You,† â€Å"Highway to Hell,† and â€Å"Hello, Goodbye. † And the narrative may not be important as the sum of Glee’s parts; they include the hyper-postmodern mash-up described above, exciting and talented performers, upbeat music that can be enjoyed in other arenas, sweetly geeky fandom, and the overall ethos of embracing the loveable loser in all of us. Are you a Gleek, and if so, what do you think encourages its appeal? What do you make of the series as a contemporary television, music, or theatrical text?In response to this complicated series we plan to follow Glee, its paratexts, and its fandom on a weekly basis as it continues to air this season. We hope you’ll take part in the discussion Reprinted with permission from our good friends at InsideCatholic. com, the leading online journa l of Catholic faith, culture, and politics. The musical comedy-drama Glee debuted on Fox just over a year ago. The story of a high school Spanish teacher's attempts to resurrect the Lima, Ohio, high school glee club surprised critics by ending its first season ranked at 33 in the Nielsen ratings.Now in its second season, the show's ratings have only gone up, as it climbed to the #15 spot last week. On May 23, the plans for a third season of Glee were announced. While there's no reason its popularity won't continue to climb, the challenge of producing a primetime musical series to appeal to a generation not brought up on the traditional musicals like Camelot, West Side Story, and The Sound of Music is obvious: How do you combine a contemporary story and characters with music and dance in a way that does not send viewers, especially younger ones, groaning in the direction of their PS3s and iPhones?The producers of Glee found their solution in the example of Chicago, the Broadway show where the musical numbers were always performed in the context of a cabaret. The characters of Glee don't burst into song in the manner of, say, Rodgers and Hammerstein; rather, the strongly choreographed musical numbers – five to eight each episode – are usually staged as the glee club's performances or rehearsals. Thus, Glee retains enough of a realistic feel to appeal to a younger audience. The music, a combination of pop and Broadway standards newly rranged by Adam Anders, appeals to all ages and has been a phenomenal success on CD and downloads, with over $2 million in digital sales. The cast of Glee had 25 singles on the Billboard Hot 100 in 2009, more than any artist since the Beatles in 1964. Their performance of â€Å"Don't Stop Believin'† went gold last November, with over half a million dollars in sales. Perhaps the most remarkable aspect of Glee's achievement its ability to keep three generations of viewers – children, parents, and grandparent s – in front of the TV together.The choreography of Zachary Woodlee, sexy without being sleazy, evokes Broadway's Jerome Robbins rather than Bob Fosse, much less the crotch-grabbing antics of tuneless rappers. Viewers with memories of Gene Kelly and Fred Astaire, or even the June Taylor Dancers on The Jackie Gleason Show, find themselves smiling once again. The producers and cast members also maintain tasteful control over material chosen – from older classics like â€Å"Over the Rainbow,† â€Å"One Less Bell to Answer,† â€Å"Smile,† and â€Å"I Could Have Danced All Night,† with newer ones such as â€Å"Proud Mary,† â€Å"Piano Man,† â€Å"Jump,† â€Å"Bootylicious,† and Josh Groban's â€Å"You Raise Me Up. When a Rolling Stone critic snidely chides Glee's leading actor, Matthew Morrison, saying he â€Å"couldn't rap his way out of 98 ° rehearsal,† he seems oblivious to the fact that more than an occas ional nod to rap would immediately begin thinning its audience (starting with me). The choice to offset the Disney-like innocence of Will Schuester, played by Morrison, with the cynical cheerleading coach, Sue Sylvester (Jane Lynch), works perfectly. The conflict between Schuester and Sylvester becomes nothing less than the perennial clash of ars gratia artis (arts for arts sake) with the cultural philistines.The writing for Sylvester's character is so good it has spawned its own wiki thread. Take, for example, her attitude toward intimacy in marriage: â€Å"I, for one, think intimacy has no place in a marriage. Walked in on my parents once, and it was like seeing two walruses wrestling. † But beyond the Schuester and Sylvester rivalry, Glee fails to achieve the generational integration of taste in its characters and storyline that it has attained with its music and dancing. Will's wife, Terri (Jessalyn Gilsig), seems like a refugee from John Sayles' Serial Mom, where the ent irety of middle-class family life is cynically, and hilariously, parodied.The viewer is left constantly questioning how Will, whose fundamental decency and kindness are repeatedly evoked, could have married such a demented twit as Terri. Such jarring contrasts of character abound in Glee. Finn Hudson (Cory Monteith), the lead singer of the glee club and quarterback of the football team, doesn't seem to know a hot tub cannot serve as a medium for impregnating his cheerleader girlfriend, Quinn Fabray; meanwhile, his best friend, Puck Puckerman (Mark Salling), who did get Quinn pregnant, is rampaging though the neighborhood sleeping with the â€Å"cougar† mothers of his classmates.There are also politically correct touches. Kurt Hummel (Chris Kolfer), the member of the glee club who likes to dress in black lace, not only â€Å"comes out† in the course of the first season but also leads the winless football team to their first victory by teaching them all how to dance. Yet Kurt's character is not made into a complete caricature: While his achievement on the gridiron is simply silly, the scene where he admits to his blue-collar father his same-sex attraction is quite affecting – and, I might add, realistic.Not to be outdone, Rachel Berry (Lea Michele), who has the best voice in the cast, is also the most neurotic, having been raised by two homosexual fathers. Rachel eventually discovers that her birth mother is the coach of the rival glee club. Such is the search for postmodern innocence in Glee – there is too much water under the cultural bridge to directly revive the musical idiom and heritage of the 1940s and 1950s that became second nature to so many baby-boomers.Before Glee, of course, there was Stephen Sondheim, who throughout his career as a composer and lyricist struggled with the same question of how to extend the musical to an audience that no longer believed in the univocal meaning of â€Å"I love you. † We can be grate ful to the creators of Glee for making an effort to bring us a popular entertainment with such a high level of singing and dancing. The temptation will be to lose sight of the initial choices that have led to its success and, particularly, the generational breadth of its audience.Just as American Idol has found out the hard way from its plunging ratings, once you start trying to please only the teenagers, the whole enterprise will quickly collapse Mid-April, with its tax deadline, is a time that many people dread; this year, however, millions looked forward to it with great eagerness, because April 13th brought the first episode of â€Å"Glee† after a four-month hiatus. The Fox show, set in the fictional William McKinley High School, inLima, Ohio, is part satirical comedy, part musical, and—since its setting is high school—a bit of a drama. It’s not exactly a high-school musical, and it’s not exactly â€Å"High School Musical,† the Disney so ng-and-dance franchise, although, like that TV movie and its brand extensions, it has a long tail of tie-in merchandise and live performances. It also has over-the-moon fans—â€Å"gleeks,† they happily call themselves—which is a notable thing for a mainstream, non-niche network show that began only last fall.The first post-hiatus episode had more than thirteen million viewers; the second, which featured the songs of Madonna, was close behind. Of course, it doesn’t hurt that the show follows â€Å"American Idol† on Tuesday nights—though the pairing did pain many people a couple of weeks ago, when a live edition of â€Å"Idol† ran long, causing DVRs across the land to cut off the last minutes of â€Å"Glee. † And â€Å"Glee,† although a work of fiction, is â€Å"Idol† ’s spawn, part of the current craze for watching star-making (and dream-crushing) machinery at work. Glee† was created and is written by Ryan Murphy, Brad Falchuk, and Ian Brennan. Of the three, Murphy is the best known, having created the just ended FX psychomelodrama â€Å"Nip/Tuck† (for which Falchuk was a writer and a producer) and the 1999 WB comedy â€Å"Popular,† which was also a sendup of teen-age archetypes—as in â€Å"Glee,† there was a star football player who was torn between sports and the stage—but involved much more extracurricular activity among parents and families.Except for the teachers and the administrators at McKinley High, few adults appear in â€Å"Glee,† which gives the series a cartoonish feel that’s reinforced by the fact that the grownups we do see, well meaning though they may be, are as cluelessly wrapped up in themselves as the young people are. (Oddly, or not, of the group of about ten students we hang out with two have lost a parent.It seems like a lot. ) The success of â€Å"Glee† depends on the energy and the obvious talent of its young (but way beyond high-school age) performers, and on Jane Lynch, who plays Sue Sylvester, the acid-tongued, sneaky, and completely loony cheerleading coach, whose every line of dialogue is quotable (and is duly quoted, minutes after being delivered, on Facebook pages and in Twitter feeds).Sue’s counterbalance, and nemesis, is Will Schuester (Matthew Morrison, who has a solid Broadway background and Leyendecker good looks, including thick, wavy hair that Sue mocks, in elegant variations, pretty much every time she sees Will), a youngish Spanish teacher and a graduate of McKinley High in the days when it had a top-notch show choir. Will makes it his project to bring back that glory, and he starts by tricking the captain of the football team (Cory Monteith), whom he hears singing in the shower after practice one day, into joining his ragtag crew.If Will gets funding for his group, the economy being tough—Sue’s cheerleading crew will lose theirs. Will also wants some of Sue’s girls—the Cheerios—for his group. She tells him that he doesn’t get it—that he can’t blur the lines in the rigid caste system that is high school: â€Å"Your jocks and your popular kids—up in the penthouse. Your invisibles and the kids playing live-action druids and trolls out in the forest—bottom floor. † What about the Glee kids? Will asks. What category are they in? â€Å"Sub-basement,† she says. from the issue * cartoon bank * e-mail this The real engine of the show isn’t the machinations of its characters or its unfolding plot but its basic structure. Because â€Å"Glee† is actually about a group of singers, it doesn’t seem artificial when the cast breaks into song; the music fits into the proceedings organically. The songs—which Murphy chooses—range from oldies to newies, so that there is, theoretically, something for everybody, from â€Å"Sing Sing Sin g† and â€Å"Sweet Caroline† to â€Å"Gives You Hell† and â€Å"Single Ladies. Still, it must be said, even people who love these songs may find something to hate in the style of singing sometimes showcased in â€Å"Glee†Ã¢â‚¬â€the earsplitting, maniacally melismatic car-alarm whine that Whitney Houston popularized—but, thankfully, there are quiet ballads to balance things out. Rachel, one of the choir members, has a bit of that pleading quality in her voice, but it suits her desperate ambition. She’s played by Lea Michele, who, at twenty-three, is a fifteen-year Broadway veteran.Yet her large talent doesn’t extend to the non-singing parts of her performance. I give it up for her gifts, but I don’t feel soul there. Rachel takes herself very seriously, and things very literally; one of the other kids, Artie (Kevin McHale), is wheelchair-bound, and Rachel complains to Will that Artie shouldn’t be singing â€Å"Sit Down Y ou’re Rockin’ the Boat† because he’s already sitting down. Artie’s take is that Will’s choice was meant to be ironic, and Rachel responds, â€Å"There’s nothing ironic about show choir! Of course there is, but there’s more, too—there’s also real glee, when things come together and when the characters get as much fleshing out as the stereotyping and the time constraints allow. With several production numbers per episode, almost all of which have remarkably weak choreography and poorly synched lip-synching, the writers haven’t been able to go very deep into anyone’s lif Read more http://www. newyorker. com/arts/critics/television/2010/05/10/100510crte_television_franklin#ixzz25UpjRdrc And then there’s Glee.Because there are no original songs, they’ve got to reference other works multiple times in every episode. When the show is at its best it takes cultural referents such as the video for Beyonce’s â€Å"Single Ladies (Put a Ring on It)† and turns it into something else by putting it in the context of trying to win a football game. It’s an utterly ridiculous and goofy scene that belies the reality of the way football works, but it’s also enormously satisfying and pretty funny to boot.The show’s musical numbers are to me more successful when they transport their sources to locales away from the stage or the classroom. And even when a musical number starts within the walls of William McKinley High School, if there are sequences that take us to other places and/or elsewhere in time, such as when Kurt recently sang â€Å"I Want to Hold Your Hand† for his classmates, that can also work incredibly well.But when their numbers are stagebound things often become stagnant, sucking the life out of the song and leaving a strong distaste in the mouths of many viewers, or at least those who know the original. Kurt poses for photos when he ’s not transporting us through time via the power of song. The apotheoses of these occurrences take place in the episode titled â€Å"The Substitute,† which features renditions of classic numbers from Singin’ in the Rain (Donen/Kelly 1952), which were themselves new takes on old songs.I’m not saying some texts are untouchable, but if you’re going to cover something so culturally iconic, you might want to do something totally new with it. So Gus Van Sant’s shot for shot remake of Psycho (1998)? Probably not a good idea. Conversely, Martin Scorsese’s reimagining of Ford’s The Searchers (1956) as an urban western in Taxi Driver (1976)? That works. If you don’t approach homage in this way it becomes nothing more than imitation, which might be the highest form of flattery but doesn’t make for good TV or cinema.So Glee’s rendition of Singin’ in the Rain’s title song incorporates a mash-up with Rihan na’s â€Å"Umbrella† and takes place on a stage full of water featuring the cast re-enacting moves from Gene Kelly’s classic sequence while also incorporating new moves into their set-piece number. There’s revision, and there’s imitation, and then there’s shitting on sanctity. I’m no purist and I’m not saying they shouldn’t have done it, but I would argue that despite the attempt at innovation, it doesn’t go far enough in its departure from either original.And the one thing that it’s missing that makes the movie’s original so great is passion you can feel. Kelly’s rendition takes place within the context of his falling in love with Kathy (Debbie Reynolds) and it results in Dionysian abandon, bringing to Technicolor life the giddy exhilaration that comes with new love, whereas Glee’s version is akin to watching craftsmen make shoes: there’s artistry in their production and the fin ished product is expertly made, but it lacks the soul that still makes Kelly’s sequence so resonant.Worse still is their take on â€Å"Make ‘Em Laugh,† which features Will Schuester (Matthew Morrison) and Mike Chang (Harry Shum, Jr. ) in a duet that is at times a near step for step imitation of Donald O’Connor’s version. Again, failing to revise the setting and context in an interesting way leaves their rendition flat. It lacks the visceral joy of O’Connor’s sequence, the best part of which is that it makes the audience do what the title suggests, which is laugh.Will and Chang are great dancers, but as there’s no real reason for the scene other than to show that they can do a rote imitation of the steps, their version is totally devoid of life and spontaneity, making it seem as though it’s performed by technically proficient but non-sentient automatons. There’s no reason you can’t do a scene that’s al most identical to the original, so long as you update it in such a way so as to give the audience a new way to interpret it. Take Spike Lee’s incorporation of the Love/Hate tattoo sequence from Night of the Hunter (Laughton 1955) into Do the Right Thing (1989).Robert Mitchum’s iconic scene is as seemingly inviolable as anything from Singin’ in the Rain, but by transposing it from a depression era white psychopathic murdering preacher in the deep south to Radio Raheem (Bill Nunn), a socially aware young African-American male living in what was at the time contemporary Bedford-Stuyvesant, Lee both pays homage and avoids pastiche, creating something new in the process, a model of artistic quotation that I’m afraid might be falling out of favor in our current media landscape, as evidenced on Glee and elsewhere * Why a blog and not a website? TUESDAY, 30 AUGUST 2011 Project: Art History. † Evolution of musical film genre†. â€Å"Williams and Hall both have argued that culture is not so much a set of things (television shows or paintings, for example) as a set of processes or practices through which individuals and groups come to make sense of things, including their own identities within and even against or outside the group† Stunken ; Cartwright (2009) The intention of the essay is to link evolution in cinema genres with the changes in the structure of popular culture.The quotation expresses the approach to culture as a process in which individuals interact, and this is the way the essay would like culture to be seen. Cinema is the perfect method to analyse popular culture from this point of view. Since its invention, it has given human beings a new and different opportunity of enjoying simulated worlds. Musical genre is particularly interesting because it has been present since the beginnings of cinema as one of the main Hollywood genres, and it has needed to introduce new strategies to survive. There are periods whe n it nearly disappeared before coming back in a new form (Hayward 2000).This essay is structured in such a way that it describes the periods of the genre and how its codes and conventions have been applied in each, and then analyses the main ideas from a social and theoretical point of view. But first, it may prove useful to discuss genre theory. Genre can be considered a strategy created by the cinema industry to identify a category of film. But it also can be described as a cognitive mechanism to help the viewer and filmmaker to know the expectations and hypothesis of the viewers when sitting in front of a screen to watch a film.Any genre is formed by a set of codes and conventions that the spectator has learned and can decode automatically and unconsciously. He or she feels pleasure in identification. This last point of view agrees with the one of the essay, as its aim is to connect the research on genre with what spectators experience when watching a film (Nelmes 2007) (Hayward 2000). It is also interesting to analyse what makes the spectator enjoy watching a film. Hayward (2000) identifies three stages in spectatorship theory. The first stage in the 70's treats the spectator as a passive subject.It is inspired on Freud's idea of the Oedipal complex and on Lacan's idea of the â€Å"mirror stage† that says that our identity is not coming from within, but from the way we see ourselves for the first time from the outside. In our adulthood we are in a constant state of desire that cannot be fulfilled because our unconscious mind cannot be influenced by the world around us. Freud's ideas associate the mirror stage with the relationship between the child and his mother. The male character sees his mother as an object and identifies with the father to try to meet the child's feeling of â€Å"castration† of not having access to the mother (Ward 2003).The spectator identifies the cinema screen with this â€Å"mirror†. The second stage, from the middle of the 70’s, is influenced by Laura Mulvey. She introduces the idea of sexual difference in identification with personalities and criticises the masculine point of view in cinema narrative that fetishizes women. The option for the female spectator is to identify with the passive female or with a masculine third character. In the third stage, from the 80's, we find investigations derived from the debate started by Mulvey. Some ideas talk about the bisexual position of the female child after her mirror stage.She first has the mother as her object of desire and then she has to change to the father as her object of desire. And the male spectator can also position himself bisexually, when identifying with the active and passive modes of the male character. The spectator is treated as an active subject, he or she does not occupy just one position in relation to the characters. Dyer considers that there are three periods in a genre: primitive, mature and decadent (Hayward 20 00). On the experimental primitive period, before the 30's, musical is generated as a hybrid from European operetta and American vaudeville and music hall (Hayward 2000).On the mature period, from the 30's to the 60's, first we find a director such as Busby Berkeley. His films do not pay attention to the plot, but rather, are vehicles for song and dance that are introduced in an artificial way. It is pure spectacle and sensuality. Sex is offered through the gaze (Hayward 2000). Later, songs and dances move with the narrative and are introduced on a more natural way. Fred Astaire develops an elegant, stylised style and Gene Kelly develops a more energetic one. The music was often composed by talented authors brought from Broadway.In the 50's, it is the first time the studio system pay special attention to the youth audience, linked to the rise in the music record industry. Singers as Elvis Presley and Cliff Richard became actors (Hayward 2000). For Altman musicals of the mature perio d are an â€Å"ode to marriage†. The narrative is based on the principle of pairing and mirroring. Male and female are paired, maturity is paired to immaturity. The main characters are mirrored in other couples; settings are mirrored in other settings (Hayward 2000). This conclusion was made following a synchronic analysis, i. . , just focusing in a moment in the film, specifically in the final scene. Recently, this same author has reflected about that approach and has analysed musical films diachronically. He proposes two hypotheses. Following the first one, in musicals main characters are first paired with a â€Å"wrong† partner to be finally paired to the â€Å"right† one. Films such as â€Å"An American in Paris† (Minnelli, 1951) follow this structure. The second hypothesis is more speculative. It is based in the idea that the relationships of the characters turn from homosocial to heterosexual.This structure is found in many films, from â€Å"An Ame rican in Paris† (Minnelli, 1951), to â€Å"Grease† (Kleiser, 1978). In â€Å"Grease†, the main actress and actor belong to a group where all members are women or all men, respectively, and eventually left these groups to become a couple. This can be seen as an evolution from childhood to adulthood. The author also speculates on whether this structure tries to avoid the character moving from a homosocial relationship to a homosexual relationship (Altman 2010). Cohan (2010) considers that the dual register between narrative and performance is one of the distinctive conventions of the genre.It breaks the dominant codes of realism in cinema, whose aim is to guide the audience through the story, so the codes and conventions become â€Å"transparent† to avoid distracting them (Nelmes 2007). The concept of diegesis refers to the fictional world described inside the story. In musicals, filmmakers can add extra-diegetic shots that have no logical reason for being t here. And they can add a diegetic to call public attention to the star, to show that they are amazed when they see and hear the main characters dancing or singing, and to create the illusion that the real non-diegetic audience is part of that public (Hayward 2000).Dyer (2002) distinguishes three tendencies of musicals: one that keeps narrative and number separate, another that identifies narrative with problems and numbers with scape, but trying to integrate the number through signals, and a last one that dissolves this distinction between narrative and number, which makes this narrative also utopian. Richard Dyer writes that the strategy of the genre is to â€Å"provide the spectator with an utopia through the form of entertainment†.Any film reflects these categories: abundance, energy, intensity, transparency and community in opposition to the real society, where we can find: scarcity, exhaustion, dreariness, manipulation and fragmentation. Abundance is shown through the lu xurious costumes and huge settings. Energy is shown through the dance and also the camera work. Intensity refers to experiencing emotions directly. Transparency refers to spontaneity. Community refers to the sense of belonging. This utopia is associated with the specific mainstream ideology of this period: capitalism, economic and social stability (Hayward 2000), (Stacey 1994).Of the decadent period, from the 60's, codes and conventions are questioned. Musicals are more realistic; subjects such as racism and delinquency are treated. Examples are â€Å"West Side Story† (Wise, 1961), â€Å"Saturday Night Fever† (Badham, 1977) and â€Å"Grease† (Kleiser, 1978). We also find Julie Andrew's films such as â€Å"The Sound of Music† (Wise, 1965). This is identified as a family film that follows traditional conventions. But its structure differs from the classical one. There is no more a duality, instead, there is a female main character and the male character has a secondary role.She represents liberated femininity. In Barbra Streisand's films – â€Å"The Way We Were† (Pollack, 1973) – the girl needs a partner but does not always achieve it. When she fails to do it, the film shows her drive for freedom and female independence (Farmer 2010), (Robertsib Wojcik 2010). This reflects how conventions in cinema have changed with changes in society; in the 70's women rebelled against the traditional patriarchal society. It has been almost 50 years since the period of decline of the musical genre begun. It looked as if it was going to disappear. But lately, we are seeing a revival of the genre.Sometimes it is successful, such as â€Å"Moulin Rouge! † (Luhrman, 2001), â€Å"Chicago† (Marshall, 2002) and â€Å"Mamma Mia† (Lloyd, 2008), sometimes it is not, such as â€Å"Nine† (Marshall, 2009). At this point, we can ask ourselves about the reasons for bringing back musicals. Cohan (2010) mentions David R ooney and Jonathan Bing describing them. They mention how development of new technology can help with the task of shooting and editing, and reducing costs. Also, the after-market of the fans of musical can be economically attractive, as they are repeating viewers, so DVDs and soundtracks would sell well – as well as merchandising would do.Another interesting fact is that the youth audience has grown up watching music videos and Disney's animated films. Finally, another reason can be that the golden period of musicals happened during the 30's Big Depression. Maybe it is not a coincidence that in the actual moment of economic recession, the public is going back to watch films that supply escapism (Burgess-Alllen 2010). Feuer (2010) argues that in the decline period, there are reconstructive musicals and deconstructive musicals. Reconstructive musicals can be â€Å"Moulin Rouge† (Luhrman, 2001), â€Å"Chicago† (Marshall, 2002), â€Å"Nine† (Marshall, 2009). Cabaret† (Fosse) in 1972 already has influences of art cinema (Hayward 2000). They are targeted at art-house audiences, while keep the classical conventions, and show an interest in aesthetic and nostalgia for the past. Following the these, â€Å"Moulin Rouge† (Luhrman, 2001) mixes cinematic references, historical intertexts and cultural allusions, this makes it difficult to define which genre it belongs to as it can be considered a musical, a melodrama, and author film, or even a music video (Nelmes 2007).Deconstructive Musicals are oriented towards the teenage public and create new conventions, they do not represent lead performers but amateurs that love singing and dancing, they â€Å"take up the position of spectators of Old Hollywood musicals in a world where it is no longer possible to be Fred Astaire† (Daldry, 2000). Following these, there are productions for TV, such as â€Å"High School Musical† (Ortega, 2006) and, more recently, â€Å"Glee† (Murphy, 2009). Conventions in â€Å"High School Musical† (Ortega, 2006) follow the traditional ones. It follows the principle of duality with two main characters.What it adds new to the genre is a contrast between authenticity, represented by the main couple, and manipulated artistry, represented by another couple. It also adds a reflection of a rigidly hierarchical world, where the characters move between conformism and rebellion. The characters are stereotypes: jocks, cheerleaders, and brainiacs. â€Å"Glee† (Murphy, 2009) takes the idea of â€Å"High School Musical† and exaggerates it. We again find the same stereotypes but they are taken to the extreme of satire. All the characters know that to be someone at the school they have to belong to a group: cheerleaders, football team†¦Wearing a distinctive uniform is important for them. â€Å"Glee† also adds being playful with reality. It highlights being a simulation of reality and reminds us often about it, advising us not to take it too seriously. The narrative is an utopia in the same way as the performances. And this utopia again follows a specific ideology. Subjects that affect teenagers are treated: pregnancy, alcohol, sexuality, family relationships, †¦ (Cohan 2010), (Payne 2010). Another thing these films have changed from classic films is that musical soundtracks are not created specifically for the film, now it appropriates pop music or music from other films.The concept of film genre is directly related to the concept of intertextuality. The film is always going to be framed by the genre as each film belonging to it uses conventions previously used by other members of it (Nelmes 2007). But this can be a contradiction, because intertextuality is also associated with taking the text beyond the boundaries of the genre. This semiotic term was first used by Julia Kristeva, who understands that the text connects in two ways, first the author to the reader and then t he text to other texts (Chandler 2009). The growing preponderance of visuals in ads has enhanced the ambiguity of meaning embedded in message structures. Earlier advertising usually states its message quite explicitly through the medium of written text†¦ , but starting in the mid-1920s visual representation became more common, and the relationship between text and visual image became complementary – that is, the text explained the visual. In the post-war period, and especially since the early 1960s, the function of text moved away from explaining the visual and towards a more cryptic form, in which text appeared as a kind of ‘key' to the visual.In all, the effect was to make the commercial message more ambiguous; a ‘reading' of it depended on relating elements in the ad's internal structure to each other, as well as drawing in references from the external world. † Leiss (1997) This paragraph talks specifically about the use of intertextuality in adverti sing, which is not the subject of the essay, but it is included here because it expresses that the way creatives communicate messages has evolved from being explicit to being ambiguous. Leiss talks about how the â€Å"receiver's brain is an indispensable component of the total communication system†.Explaining it clearly, the spectator is no longer considered stupid. Viewers have a wider visual knowledge that make them able to understand messages transmitted on ambiguous ways. We have grown with the rapid association of images in film, TV, and advertisement (Kolker 2002). The visual knowledge of the spectator has helped to make it more sophisticated. The basis of the plot remains simple but the filmmaker can and must introduce mechanisms to appeal a target audience that has become highly media literate.As a result of the the research can be taken the most interesting ideas about the way contemporaneous filmmakers apply the codes and conventions of the genre. They follow some o f the conventions of films from the classical era: keeping a simple plot, selling an ideology. And they add to the genre: using soundtracks from pop music or other films instead of creating it specifically for the film, the creation of fictional worlds that make reference to another fictional world, playing with reality and stereotypes, playing with the dual register between narrative and performance.It can be found in several essays and articles that talk about contemporaneous musical films being postmodern, as the following one written by Edwards (Cohan 2010): â€Å"The charm and artistic merit of the original High School Musical movie lies in its ability to consider a sophisticated theatrical and musical heritage and consequently revise it for a modern audience †¦ it simultaneously conforms to genre expectations and pays homage to its textual influences while taking a postmodern delight in exposing its own limitations and playing with some gentle pastiche of literary and ci nematic predecessors†.Flanagan (2002) wrote about the features of a film that can be identified as postmodern. The first ones are playfulness and self reference. It reminds us that it is a construction, that is not real, and that we must not take it seriously. The musical film's creators play with the way they integrate the performances in the narrative, with the stereotypes. It follows the tendency of dissolving the distinction between narrative and number, meaning that this narrative is also utopian. The second ones are generic blurring and intertextuality.The use of references to other texts is very usual in musicals. The third ones are popular and commercial media mixed with high culture. Current musical films do not have a soundtrack created for them, but they appropriate music. The fourth ones are fragmentation and death of representation. This refers to the way audience make sense of things through representations of reality instead of doing it through the reality itsel f. And finally uncertainty and the loss of context as consequence of the previous ones. According to this, films such as â€Å"Glee† (Murphy, 2009) can be considered postmodern.But probably to label a film as postmodern is not going to influence the audience as to whether to be interested on it or not, what probably can be considered more important is the â€Å"sophisticated hyperconsciousness† in contemporaneous popular entertainment, i. e. , the high degree of media literacy in the audience that allows playing with the conventions (Collins 1993), (Nelmes 2007). Why is Glee Postmodern In this blog and our discussion of postmodern television, the TV showGlee  has come up as an example.. One of the theories we’ve learned about postmodernism is that it rejects the idea of metanarratives (stories about stories).In postmodernism there is not black and white, good vs. evil, etc. In the show  Glee  there is the character Puck, a football player who seems to be y our typical tough-guy bully. However, even though Puck is a bully and even shoves around some of the other characters that we like, we still do not dislike him. We don’t see him as the villain even though typically the jock/bully is seen as the â€Å"bad guy. † Plurality is another term we learned regarding postmodernism, and this is when there are multiple stories and multiple identities.This show has so many characters, each with their own personal story and all of their stories get told in one way or another. Within Season 2 episode 8 the character ‘David’ is focused on and he is being questioned about whether he is gay or not. The glee club is a dance singing club but within this is another story. This gives the program room to expand and here for example the program deals with modern day issues that are publicised in the media. Grand narratives are clearly contradicted in this episode as homosexuality is put in the limelight and is praised.One of the male characters shows very feminine attributes and in their rehearsal wears a top which says â€Å"Likes Boys. † This is done to try to numb the shock of homosexuals coming out and normalise it so that the program can move forward. There are different races, different personalities, different handicaps; different cliques, all represented in this show and all of their stories are being told. Nostalgia is another postmodern term represented in  Glee. Many of the songs performed on this show are songs from the past for example Les Miserables – Kareoke and Born this Way.The teacher in charge of Glee Club, Mr. Schuester, loves doing songs from when he was younger and this really brings nostalgia to the show. Convergence, the flow of media content across a range of different platforms is also part of this show. You can download the songs performed on the show, many viewers discuss the show online, and many people attempt to win parts on the show by creating videos of thems elves singing and performing and posting them online. There are many forms of media involved with this show other than simply watching the show.Not to mention the fact that you can also watch the show online, just one more form of media regarding this show Glee draws people in by creating stereotypical situations and characters, each with their own flaws that the audience can easily identify with. This identification process allows viewers to become more intimate with the show, especially when the actors begin to sing songs that modern viewers already know and love. Fox originally took a chance on the new musical project, but hedged their bets with innovative marketing strategies and with a huge lead in audience from American Idol.The use of cultural classics and songs that recently premiered on the top 40, drew in the American Idol audience members specifically, and music lovers generally. This target audience was strong in the 18-49 demographic, and particularly strong with women. The strength in these demographics enabled Glee to become the 3rd most expensive show to buy advertisements on. This advertising revenue is supplemented with a steady stream of money made from selling singles on ITunes. This model has been so successful that Glee has now become a tent-pole of its own and anchors the entire comedy lineup on Tuesdays. contrast, in recent years American television has brought us Scrubs, Ugly Betty and now Glee, shows that combine boldly imaginative approaches to narrative with a humour and humanity that is often exhilarating to behold. While we seem to be mired in an endless debate about platforms, content, news values and the multimedia revolution, the Americans have managed to retain an enthusiasm for the dramatic possibilities of television. And what's clear is that those possibilities are founded upon an enduring belief in sharp, savvy writing and deeply committed performances.At first sight, Glee (C4) follows a stupefyingly familiar path. It's se t in a midwest high school, amid the over-fictionalised world of geeks and jocks. And in a nod to the High School Musical fad, it focuses on a glee club, or singing society. However, Glee takes these tropes and cliches and stretches them in surprising directions to create a whole new form, as different to its original source as a butterfly is to a caterpillar. Last week, teen pregnancy, the difficulty of coming out in high school, and sexual attraction between teacher and pupil were plot themes but, unlike many American shows, not moral â€Å"issues†.Glee is possessed of a liberal heart but its balls, as well as some of its most memorable lines, belong to the politically incorrect coach, Sue Sylvester (played by Jane Lynch). Like two opposing grammarians, kitsch sentiment and killer sarcasm wrestle over every line. Yet, at the point where conventional drama plunges into pathos, Glee slips into song. At one moment the school quarterback was singing â€Å"I'll Stand by Youâ₠¬  to the ultrasound of his unwanted child (which isn't his), the next his friends were rallying round in a stirring rendition of â€Å"Lean on Me†.A lot of the humour stems from snappy social observation, but the show also boasts the kind of verbal extravagance that, in the wrong hands, can sound written rather than said. Typical was the scene in which a former schoolgirl stalker, who once responded to rejection by eating a lethally hot pepper, advised her equally deluded successor: â€Å"Let me tell you a few things I learned from two years of intense psychotherapy and an oesophagus transplant. The reason that line worked is the same reason the songs and outrageous storylines work: because the characters are immersed in their own reality. They never act as if they've said something funny. There's no pause for laughter, no nods or winks, as Glee shows the same faith in its audience as it does in its characterisations. Laughter isn't forced, so isn't false. In common with U gly Betty and Scrubs, there is plenty of cultural commentary and knowing asides but failure to spot the reference doesn't undermine the scene. The action just moves swiftly on.If Glee is postmodern, it doesn't bother knocking twice. The show has attracted a lot of plaudits, particularly in America, so it's probably soon due for a backlash. This might be an opportune moment, then, to say that the hype is deserved. It's a rare and heartening pleasure to watch so much energy and emotion expended in the unfashionable cause of family entertainment. Some of its fans might say Doctor Who performs a similar feat, though really the nearest British television comes, or attempts to come, to Glee is in shows like Strictly Come Dancing.Where US networks can be persuaded to invest in good writing and acting, our TV executives prefer to back the all-dancing duo of celebrity and reality. Only in an atmosphere in which originality is viewed as marginal or suspect could a series like Life of Riley (B BC1) be produced. It may seem unfair to pick out this harmless sitcom as an illustration of the failings of British comedy drama, but perhaps not quite as unfair as the decision to recommission another series. Why is Glee Postmodern?Glee is an American musical-comedy drama series. It started in 2009 and is produced by Ryan Murphy, Brad Falchuk and Ian Brennan, who originally wanted Glee to be a film, but decided to make it more interesting as a series. The episode I have chosen to focus on is the ‘Britney/Brittany’ episode, which pays tribute to Britney Spears when a member of the club Brittany Pierce experiences an anesthesia-induced hallucination in which she recreates iconic Spears moments, and comes to self-realization.I believe that this episode shows examples of being postmodern, as for a start the songs are in the past, and therefore have been created from an idea that’s already happened, Postmodernism postulates that many, if not all, apparent realities a re only social constructs and are therefore subject to change so Glee supports this view, it highlights that it is taking the original idea (song) that we all know from Britney Spears, and constructing it into their own, like the ‘Toxic’ version they performed on stage, straight away it’s obvious that this episode is showing pastiche, as the hole episode is making tributes to classic pop culture, and it gives us as audience ( or those who are old enough) a nostalgic feeling. One of the theories learned about postmodernism is that it rejects the idea of metanarratives (stories about stories). In postmodernism there is not black and white, good vs. evil, etc. There is the character Puck, a football player who seems to be your typical tough-guy bully.However, even though Puck is a bully and even shoves around some of the other characters that we like, we still do not dislike him. We don’t see him as the villain even though typically the jock/bully is seen as the â€Å"bad guy,† and in this episode, he shows examples of this by fitting in with the rest of the club and wanting to perform the Britney songs, when typically you’d expect the ‘jock’ to go against this idea as it wasn’t ‘cool enough’.Plurality is another term regarding postmodernism, and this is when there are multiple stories and multiple identities, and this is shown in this particular episode when although the focus is on Britney, there are several storylines going ahead with each individual character like with Will coming to terms that the girl he loves if with someone else, and then the high school problems the glee club members are all facing.The characters are also known for having multiple identities, this episode especially shows the members like Brittany and Rachel dressed up mimicking Britney Spears, and Santana also comes across as being tough, but in this episode she performs with Brittany in ‘Me Against the Musi c’ and we find out she is also in love with Brittany. Many of the songs performed on this show are songs from the past. The teacher in charge of Glee Club, Mr.Schuster, loves doing songs from when he was younger and this really brings nostalgia to the show, but in this episode he rejects the idea of doing Britney week, as he believes she gives out the wrong messages, but eventually he comes around and performs with them, which causes outrage to the school, which is also very postmodern, although Glee is a fun, light-hearted comedy series, it can also have many adult references in, especially in this episode, which I believe to be very postmodern as it ignores the typical conventions of a ‘high school drama’ and actually takes the stereotypes to an extreme but twists them.Glee has also been quoted to be described as hyper-postmodern media culture. A mash-up of generic influences, intertextual references, music, and ideological content that is both eerily nostalgic and forward-thinking, and this episode is a prime example showing all these things, the fact that the students go to the dentist to get their teeth fixed which is an ‘underlying’ important message, influencing the audience to take care of their selves, its then twisted when they get put under an anesthesia, and hallucinate Britney Spears fantasies, Glee is known for taking simple, conventional ideas and turning them to almost inappropriate. Like two opposing grammarians, kitsch sentiment and killer sarcasm wrestle over every line. Yet, at the point where conventional drama plunges into pathos, Glee slips into song† was quoted by a news article, showing how Glee takes a completely different take on high school drama. Convergence, the flow of media content across a range of different platforms is also part of this show.You can download the songs performed on the show, many viewers discuss the show online, and many people attempt to win parts on the show by creating videos of themselves singing and performing and posting them online. There are many forms of media involved with this show other than simply watching the show. Not to mention the fact that you can also watch the show online, just one more form of media regarding this show. In conclusion, I believe that Glee is postmodern because it uses examples of hyperreality, pastiche, intertextuality and is not your ordinary high school drama.

Case Analysis of Mdd, Gad, and Substance Use

Case Analysis of Comorbid Major Depressive Disorder, Generalized Anxiety Disorder, and Substance Abuse Nicole Gapp University of Minnesota School of Nursing Case Analysis of Comorbid Major Depressive Disorder, Generalized Anxiety Disorder, and Substance Abuse Major Depressive Disorder (MDD) is a mood disorder with symptoms that greatly affect the life of the individual. MDD could in fact be called a public health crisis, as it is projected that it will soon overtake heart diseases as the major worldwide health concern (Boyd, 2008).Diagnostic criteria for MDD are depressed mood or loss of interest or pleasure in nearly all activities, present for at least 2 weeks. Findings and behaviors associated with MDD are disruption of sleep, suicidal ideation, feelings of worthlessness and hopelessness, and fatigue and loss of energy. MDD is also associated with a high impairment in occupational, social, and physical functioning, causing as much disability and distress as chronic medical disorde rs (United States Department of Health and Human Services, 1999).MDD has been shown to be associated with increased medical illnesses. MDD can make everyday living a challenge, as research shows that depressive symptoms are associated with impaired everyday problem-solving ability directly and indirectly mediated through learning and memory, and reasoning (Yen, Rebok, Gallo, Jones, & Tennstedt, 2011). It is important for MDD to be identified and treated early on, as MDD that is not treated appropriately results in recurrent depressive episodes, with each successive episode increasing in severity.As MDD is highly associated with suicidal ideation and suicide, it is imperative that MDD be treated to ensure patient safety. Risk factors for MDD are a prior episode of depression, lack of social support, lack of coping abilities, medical comorbidity, substance use, and presence of life and environmental stressors. In addition, major depression may follow adverse or traumatic life events, especially those that involve the loss of an important human relationship or role in life. Social isolation, deprivation, and financial deprivation are also risk factors (APA, 2002).Genetics play a role in the development of MDD, and deficiency or dysregulation of neurotransmitters are also thought to play a part in its etiology. Psychological theories of MDD hypothesize that an early lack of love and warmth may be involved with the development of depressive symptoms, while developmental and family theorists have proposed that parental loss, emotionally inadequate parenting styles, or maladaptive patterns in family interaction may contribute to the etiology of MDD.Women are twice as likely as men to be diagnosed with MDD, though it is believed that the incidence in men is under-diagnosed. Prevalence rates are unrelated to race (Boyd, 2008). Nursing responses to MDD should involve interventions to treat symptoms within the biologic domain, such as changes in appetite, weight, sleep, or energy, as well as symptoms within the psychological domain, such as changes in mood and affect, thought content, suicidal behavior, and cognition and memory. Many types of interventions are used to treat the varied effects and symptoms of MDD.Pharmacologic interventions, such as selective serotonin reuptake inhibitors, tricylic antidepressants, monoamine oxidase inhibitors, and other classes of antidepressants may be used to decrease or manage depressive symptoms. Medication should be continued for at least six months to a year after complete remission of depressive symptoms. Lifestyle patterns, such as good sleep hygiene, activity and exercise, and adequate intake of well-balanced meals should also be encouraged, as these patterns help the client move toward a healthy daily routine that supports remission or recovery.Psychotherapy, such as cognitive therapy, behavior therapy, and interpersonal therapy, has been shown to be effective in individuals with MDD, and a combination of psychotherapy and pharmacotherapy is recommended for patients with severe or recurrent MDD as a strategy to prevent relapse (Boyd, 2008). In addition, electroconvulsive therapy has been shown to be an effective treatment for MDD, especially severe MDD that has not responded to medications. Major depression frequently occurs in conjunction with ther psychiatric disorders, such as anxiety or substance use disorders, which can also affect antidepressant responsiveness. In such cases, the co-occurring mental health problem should be treated in addition to major depression (President and Fellows of Harvard College, 2011). The patient described in this case analysis has comorbid diagnoses of generalized anxiety disorder and substance abuse. Generalized Anxiety Disorder is a psychiatric disorder characterized by excessive worry and anxiety with an insidious onset.The anxiety of GAD persists for at least six months, with excessive anxiety and worry occurring for more days than not, and for some individuals, persisting daily. Risk factors for GAD are thought to be unresolved conflicts, cognitive misinterpretations, and multiple stressful life events (Boyd, 2008)). Few studies have examined the genetic basis of GAD, but it is thought to be moderately heritable. In clinical settings, the incidence of GAD is equally distributed in women and men. However, in wider studies GAD is twice as common in women.In no studies has the prevalence of GAD been related to race (Boyd, 2008). Patients with GAD often have associated depressive symptoms, and MDD is a common comorbid disorder. For this reason, there has been debate surrounding whether GAD is a separate disorder than MDD, or if GAD symptoms are part of the course of MDD. However, research shows that many patients with GAD do not present with a distinct MDD symptom profile. This does not support the hypothesis that co-morbidity between MDD and GAD is artificially inflated because of the similar symptom criteria required by th e current diagnostic system.Instead, MDE and GAD may be thought of as two distinct diagnostic entities that frequently co-occur because of a shared underlying trait (Sunderland, Mewton, Slade & Baillie, 2010). Current diagnostic criteria state that GAD exists when the excessive worry does not occur exclusively during a mood disorder, psychotic disorder, or pervasive developmental disorder. For example, a patient who experiences persistent excessive anxiety but has minimal or no depressive symptoms would be diagnosed with GAD (Boyd, 2008). However, research has shown that the presence of a comorbid anxiety disorder may make MDD harder to resolve or manage.One particular study comparing individuals with MDD and individuals with MDD and a comorbid anxiety disorder showed that after adjusting for the severity of depression, those in the anxious depression group had significantly younger onset age, had been suffering from depression for a longer period, were more likely to experience a r ecurrence, and obtained lower scores on a scale assessing quality of life. The anxious depression group was also characterized by a significantly higher proportion of individuals reporting significant suicidal ideation and previous suicide attempts (Seo, Jung, Kim, T. , Kim, J. Lee, Kim, J. & Jun, 2011). Patients with GAD are often highly somatic, with many complaints of physical symptoms. One study concluded that painful physical symptoms in patients with GAD are twice as prevalent as in the control group, which consisted of individuals with neither GAD nor MDD. The presence of comorbid MDD was associated with a significantly higher prevalence of painful physical symptoms. Painful physical symptoms were significantly associated with functioning and health status impairment both in GAD alone and in GAD and comorbid MDD compared with controls (Romera, Fernandez, Perez, Montejo, Caballero, F. Caballero, L. , Arbesu & Gilaberte, 2010). In addition, those with GAD also often experience poor sleep habits, irritability, and poor concentration. Patients with GAD often feel frustrated, demoralized, and hopeless. They often feel restless and on edge and experience clinically significant distress or impairment of functioning resulting from anxiety, worry, or physical symptoms. GAD has a significant negative impact on work functioning, although smaller than the effect of MDD (Plaisier, Beekman, de Graaf, Smit, van Dyck & Penninx, 2010).Interventions addressing symptoms of the biologic domain include eliminating caffeine, diet pills, amphetamines, ginseng, and ma huang, which have all been shown to be anxiety-producing substances (Boyd, 2008). In addition, good sleep hygiene should be promoted, as a common symptom of GAD is sleep disturbances. The nurse should teach the patient breathing control and progressive muscle relaxation as calming techniques, help the patient identify other positive coping strategies, and educate the patient on time management.Pharmacological int erventions, such as the use of benzodiazepines, certain antidepressants, and other non-benzodiazepine anxiolytics may be effective in reducing anxiety. Roughly 75% of those with GAD have at least one additional current or lifetime psychiatric diagnosis, with MDD being one of the more common comorbidities. Alcoholism is also a significant problem associated with GAD. Patients may use alcohol, anxiolytics or barbiturates to relieve anxiety, and this may lead to abuse and dependency. Such is the case of the patient described in the case analysis, who also has a substance-related disorder.The DSM-IV-TR defines substance abuse as a maladaptive pattern of substance use leading to clinically significant impairment or distress. This impairment may be manifested by recurrent use, resulting in failure to fulfill major role obligations at work or home, recurrent use in situations that are physically hazardous, recurrent substance related legal problems, or continued use despite feeling persist ent or recurrent effects of the substance. To constitute substance abuse, three or more of these manifestations must be present within a 12-month period.In general, men consume more alcohol and abuse drugs more than women, though women are more likely to abuse prescription medication. Substance abuse and dependency are not correlated so much with gender as with an early age of initiation of substance use (Boyd, 2008). Comorbid mental disorders occur often with substance dependence and abuse. For some, comorbid mental disorders are byproducts of long-term substance abuse. Other people have mental conditions that predispose them to substance abuse, with substance abuse becoming a comorbid problem as they use drugs and/or alcohol to self-medicate existing mental illnesses.There is a well-documented association between depression and alcohol abuse and dependence which cannot be explained solely by the random overlapping of these two conditions. A systematic review of 35 studies estimate d the prevalence of current alcohol problems in depressed patients to be 16%, as compared to 7% in the general population. The three most commonly described causal hypotheses for this comorbidity are as follows: 1) an independent depressive episode (e. g. he self-medication theory), 2) alcohol induced depressive symptoms and 3) the existence of shared biological and environmental factors that predispose persons to both (Cohn, Epstein, McCrady, Jensen, HunterReel, Green & Drapkin, 2011). In addition, men with at least four heavy drinking occasions were found to be 2. 6 times as likely to be classified as being depressed as men who drank heavily less than four times in the previous 28  days (Levola, Holopainen & Aalto, 2011). Specific substances that have been abused by the patient who is the subject of this analysis are alcohol, cocaine, heroin, and the prescription drugs oxycodone and Valium.At the time of admission, the patient was no longer regularly using drugs or alcohol, but his history of substance abuse, including overdose, is extensive. Thus, although the patient is already withdrawn from drugs and alcohol, his long-term substance use has significant physical and mental consequences. The depression of the central nervous system by alcohol causes relaxed inhibitions, heightened emotions, mood swings, and cognitive impairments such as reduced concentration and attention, and impaired judgment and memory. In particular, this patient engages in periodic binge drinking, drinking up to 15 drinks in one evening.This alcohol use would result in several days of intoxication, which were interspersed with periods of sobriety. The amount of alcohol consumed in an episode of binge drinking can cause severely impaired motor function and coordination difficulties, emotional lability, stupor, disorientation, and in extreme cases, even coma, respiratory failure, or death. Long-term abuse of alcohol can adversely affect all body systems, and research has shown a conne ction between alcohol dependence and increased risk for diabetes mellitus, gastrointestinal problems, hypertension, liver disease, and stroke (Smith & Book, 2010).Cocaine users typically report that cocaine enhances their feelings of well-being and reduces their anxiety. However, long-term cocaine use leads to increased anxiety. Severe anxiety, restlessness, and agitation are all symptoms or cocaine withdrawal. Withdrawal causes intense depression, craving, and drug seeking behavior that may last for weeks (Boyd, 2008). Valium, a benzodiazepine, is a prescription drug that this patient abused. Patients who abuse benzodiazepines often feel hyperactive or anxious after using them.Often, patients who abuse these drugs combine them with alcohol, putting the patient at risk of coma or death. Symptoms during benzodiazepine withdrawal include anxiety rebound, such as tension, agitation, tremulousness and insomnia, as well as symptoms of autonomic rebound, sensory excitement, motor excitati on, and cognitive excitation, such as nightmares and hallucinations (Boyd, 2008). Opiates are powerful drugs that can quickly trigger addiction when used improperly. Heroin is an opiate that was abused by this patient.Heroin is the most abused and most rapidly acting of all opiates. It can be injected intravenously, and such was the method of delivery for this patient. Heroin produces profound degrees of tolerance and physical dependence. Withdrawal from opiates should be tapered, and if abruptly withdrawn from someone dependent on them, severe physical symptoms may occur, along with nervousness, restlessness and irritability (Boyd, 2008). In addition to heroin use, the patient attempted to commit suicide by overdosing on oxycodone, a prescription opiate.Overcoming substance abuse and preventing relapse can be especially difficult as denial is common in substance abusing patients. Denial is defined as the patient’s inability to accept his loss of control over substance use, o r to accept the consequences associated with the substance use (Boyd, 2008). Because many patients find it difficult or impossible to believe they have a serious problem with drugs and alcohol, many do not seek treatment, or stop treatment prematurely. Motivation is a key predictor of whether individuals will change their substance abuse behavior.Several effective modalities are used effectively to treat addiction, such as 12-step programs, social skills groups, psychoeducational groups, group therapy, and individual and family therapies. Depending on the individual, different treatment techniques will be more or less helpful. History of Present Illness The patient is a 58-year-old Caucasian male who was participating in a partial hospitalization program (PHP) at Hennepin County Medical Center (HCMC) for the treatment of severe major depressive disorder. He has been involved in PHP since his last discharge from the HCMC psychiatric inpatient unit in early March.The patient was coope rative with treatment and medication compliant. He was put on a 72-hour hold after becoming angry and hostile during the PHP group and threatening to hang himself that evening when he got home from PHP. He eventually committed himself voluntarily to the HCMC psychiatric inpatient unit. Upon introduction, the patient appears to be clean, casually dressed, and of normal weight. He is alert and oriented. His attention, cognition, and abstract reasoning are intact, and his thought content is appropriate and organized.In conversation, he is pleasant and cooperative, exhibiting a stable mood and a slightly blunted affect. The patient will talk to staff members but interacts minimally with peers and does not attend groups unless encouraged by staff. The patient has a normal gait but moves quite slowly. In addition it appears that his thought processes are slowed, as he is slow to respond during conversation and seems to have difficulty finding the words to express what he wants to say. The patient appears to have intact recall, short-term, and long-term memory.He appears to be an adequate historian though he exhibits poor judgment due to his depressive and anxious symptoms, as evidenced by his extensive history of drug and alcohol abuse and dependency. The patient has psychiatric diagnoses of severe and recurrent major depressive disorder, generalized anxiety disorder, and polysubstance abuse. The patient has been suffering from MDD with chronic suicidal ideation since age 15. His first suicide attempt was at age 15, and he began abusing drugs and alcohol at approximately the same time.His extensive history of substance abuse includes use of alcohol, cocaine, and IV heroin. His alcohol abuse as a teenager led to a DWI charge. He has participated in mental health outpatient treatment and has undergone chemical dependency treatment numerous times. He completed high school without apparent difficulty. The patient seems to be of average intelligence, though his IQ is not listed in the record. He does not have a history of violent or sexual crime. He has a history of five suicide attempts. He began smoking as a teenager and currently smokes one pack of cigarettes per day.In 1983, the patient married and remained so until his wife died 25 years later, in 2008. He had no children. According to the patient, he was happily married, and he called his relationship with his wife â€Å"the best thing that has ever and will ever happen to me. † While he was married, he got completely clean from drugs and alcohol, remaining drug free and sober for 12 years. Though he struggled with episodes of depression and suicidal ideation, he was able to manage his symptoms with medication and mental health outpatient treatment. Most of my problems faded into the background,† said the patient. During this time, he and his wife bought a condo, and the patient was employed as a janitor and handyman, working at the Minneapolis-Saint Paul airport. He remained at this job for over a decade and was promoted to the position of supervisor. He had, as he said â€Å"everything I ever wanted. † In 2007, his wife became very ill and eventually died in 2008 after complications from a surgery intended to prolong her life. The patient reports that as his wife got sicker, he became increasingly depressed.Unlike in the previous 12 years, medication and outpatient treatment did not seem to manage his symptoms. In addition, he started experiencing extreme and persistent anxiety, feeling â€Å"like I was always one second away from a panic attack. † He was diagnosed with generalized anxiety disorder and was prescribed benzodiazepines to manage this condition. As his wife got sicker, he slowly began to self medicate with alcohol and admitted to â€Å"popping an extra pill† occasionally to decrease his anxiety.When his wife died, the patient became so depressed and anxious that he was unable to concentrate at work. He had to give up his job as a supervisor, and said, â€Å"I couldn’t even manage myself, how was I supposed to handle anyone else. † As his depression and anxiety got worse, he turned increasingly to alcohol and drugs. He reported binge drinking, consuming up to 20 drinks in one evening. He would remain intoxicated for several days, and would switch to using drugs as the alcohol cleared his system. He reported being either drunk, high, or both almost every day.Although he used cocaine and heroine, which were the drugs he used as a teenager, he also became dependent on prescription benzodiazepines to manage his increasingly severe anxiety. The increase in anxiety may be explained by his cocaine use, which, though it reduces anxiety while high, causes increased anxiety with long term use. Additionally, though proper use of benzodiazepines decreases anxiety, benzodiazepine abuse or dependency results in increased anxiety levels. When his request for more prescription benzodiazepines was denie d due to drug seeking behavior, he gained possession of Valium illegally and continued abusing them.He was arrested for illegal Valium possession in 2009, and received two DWIs between 2008 and 2011. His medical record notes that he has a history of antisocial behavior, though it does not expand on this statement beyond the mention of his previous arrests. With no income coming in and increasing amounts of money used to fuel his drug and alcohol addiction, he lost his condo and all of his savings and was living at the Salvation Army homeless shelter by June 2008. His depression grew in severity as the major life losses piled up and his substance dependency problem worsened.In 2008, he lost consciousness due to heroin intoxication. In August of that year, the patient overdosed on oxycodone, intending to kill himself. He was brought to HCMC, and for the past several years has experienced being in and out of the psychiatric inpatient. In 2010, he moved from the homeless shelter to Alte rnative Homes in Minneapolis. Following his latest psychiatric hospitalization in March, he began the partial hospitalization program at HCMC. Upon discharge from the current hospitalization, he will be returning o Alternative Homes and participating again in the PHP program. A common finding associated with a diagnosis of either MDD, GAD, or substance abuse is the presence of sleep disturbances. Such is the case with the patient described. These sleep disturbances may present themselves as difficulty falling asleep, trouble maintaining sleep, or waking up too early (National Insititute of Health, 2005). This patient currently experiences insomnia, getting only 3-4 hours of sleep per night. Reportedly, this insomnia has been a chronic issue.The insomnia the patient experience sets him up for a negative cycle. Because of his depression and anxiety, it is difficult for the patient to sleep. This lack of sleep, in turn, exacerbates his anxiety and depressive symptoms. As his symptoms p rogress in severity, he turns to substances to self medicate. The use of substances results in a worsening of his insomnia. Thus, finding a way for the patient to get adequate sleep is important. He has tried a variety of medications to promote sleep, but none have been effective.He can no longer be prescribed many of the medications for insomnia because of his history of abuse and overdose using prescription drugs. Thus, the options available to him for sleep promotion lie in the realm of sleep hygiene promotion. The patient might also consider participating in a sleep study, as this may reveal additional factors that prevent him from getting the sleep he needs. In addition to his mental illnesses, the patient also has significant medical problems. He has been diagnosed with hypertension, hepatitis C, diabetes mellitus, osteoarthritis of the left shoulder, and acid reflux.Research shows that diabetes mellitus, gastrointestinal problems, hypertension, liver disease are correlated wi th substance abuse (Moffitt, Caspi, Harrington, Milne, Melchior, Goldberg & Poulton, 2010). Indeed, the patient’s hepatitis C is a direct consequence from his use of street drugs. Interestingly, multiple studies have revealed that not only are depressive symptoms a risk factor for the development of type 2 diabetes, but they have also been shown to contribute to hyperglycemia, diabetic complications, functional disability and mortality among diabetic patients (Moffitt et al. 2010). Also, as previously discussed, patients with GAD and MDD report more painful physical symptoms than the general population, and the patient’s osteoarthritis pain could well be exacerbated by the presence of these psychiatric conditions. Thus, it is possible that with improved management of his psychiatric conditions, his medical problems may improve as well. Family and Social History The patient’s social and family history is somewhat lacking. The patient was adopted at a young age.He has three non-biological brothers and he reports that he is estranged from all of them, and is not willing to contact them until he has â€Å"my life back together. † In addition, both of his adoptive parents are dead. The patient was not keen on discussing his adoptive family or his childhood and adolescence, but stated that this adoptive family â€Å"were good people, and tried hard to give me everything I needed. † He denies any history of physical, emotional, or sexual abuse. According to the social history, there is no history of mental illness in his adoptive family.This does not mean that environmental or social factors play no role in the etiology of his mental illness, but that these factors may be less obvious. Information on the patient’s biological mother and family history is unavailable. The patient was given up for adoption at birth, and remained a ward of the state, living in various foster homes, until he was adopted at age 3. As the patient wa s given up for adoption and adopted at such a young age, he has he has no recollection of his biological family or his time in the foster care system.Any instances of abuse, neglect, or trauma in his early years are thus unknown. Because there is no available family history, it is impossible to know if any of the patient’s first-degree relatives suffered from mental illnesses, or if the biological mother used drugs or alcohol during her pregnancy. This lack of information is unfortunate, as it is impossible to conjecture whether, or to what degree, the patient’s mental disorders have a basis in genetics or in disturbed fetal development.Because MDD, GAD, and substance abuse have all been shown to have a moderate to high degree, of heritability, it is very plausible that mood, anxiety, or substance related disorders were present in his biological family. The patient seems to have very limited social support, as he is estranged from his adoptive siblings and has no commu nication with his biological family. The patient also has a history of limited social interactions and close friendships. He reports that he has felt disconnected from others for as long as he remembers, and that he had few close friendships throughout his childhood, adolescence, and adulthood.In addition, the patient reports that most of the relationships that he would call the closest have been with people who have substance abuse problems, as he spent â€Å"years and years running with the wrong crowd. † The basis of most of these relationships was a shared interest in drug and alcohol use, and he does not think that these friends would be of any support to him in pursuing and maintaining recovery. During the time that he was sober, he states that his wife was â€Å"the only friend I really needed† and as a result, he did not form many close friendships with his peers.He states that he currently has no supportive relationships. Furthermore, he has little desire to f orm such relationships. Application of Developmental Theories Viewing the patient and his family and social history through the lens of attachment theory provides a possible framework for viewing the patient’s development of mental illnesses. Attachment theory, a biologically based framework first proposed by John Bowlby in the mid 1950s, is the theoretical approach used to describe the importance of stable and secure relationships of all infants, especially those in foster care (Bruskas, 2010).This theoretical approach reasons that infants and children have a need to belong and to experience secure relationships with a small number of consistent â€Å"preferred† primary caregivers in order to successfully develop into normal healthy adults who can actively and emotionally participate in social life (Boyd, 2008). In particular, a child should receive the continuous care of this single most important attachment figure for approximately the first two years of life.If the attachment figure is broken or disrupted during the critical two year period the child will suffer irreversible long-term consequences of this deprivation, which might include delinquency, reduced intelligence, increased aggression, depression, and affectionless psychopathy–an inabilityto show affection or concern for others. Research, such as the Adverse Childhood Experiences Study, correlates untreated childhood adversity with an increased risk toward poor developmental health and other major diseases seen later in life such as cardiac disease, depression, and even premature death (Felitti & Anda, 2010).Studies reveal that infants in foster care are among the most vulnerable because of their complex and immense brain development, and the importance of attaining developmental milestones. The onset of brain development begins soon after conception and will continue to mature well into adulthood, but the most abundant and dramatic time of growth is during the first few years of life, specifically within the first three years. The primary and most important developmental milestone for any infant is to establish a relationship, especially one with a primary caregiver.This period presents sensitive â€Å"windows of opportunity† for the development of particular parts of brain structure and circuitry influenced and dependent on social experiences for optimal brain development (Bruskas, 2010). The majority of children entering foster care are infants, and the impact of not addressing mental health needs of preverbal children can have deleterious effects (National Research Council Committee on Integrating the Science of Early Childhood Development, 2000).Although an infant may not be able to articulate losses because of their preverbal age, they nonetheless experience grief and loss, and for many, these experiences will be forever embedded in their memory (Felitti & Anda, 2010). Moreover, the consequences of unresolved losses have a much more devastati ng affect in infancy than adulthood because of the potentially permanent psychological impact on the developing brain of an infant or child (Bruskas, 2010).Infants and children in foster care who are not afforded supportive primary caregivers to help them develop an internal ability to regulate their own will continue to use whatever coping methods they can. Under stress-provoking adversities such as abuse, neglect, and relationship disruptions, children’s coping strategies to manage such circumstances may present as hostility, frustration, and anxiety with underlying feelings of fear, abandonment, and powerlessness (Bruskas, 2010).The relationships infants and children develop while in foster care are crucial; relationships characterized by trust and commitment help an infant or child become more resilient toward the challenges and obstacles that all humans face in life; conversely, a lack of such relationships in life can result in long-term dysfunction socially and physica lly. Attachments and â€Å"templates† of the world are significantly developed by the time a child reaches a year old (Bruskas, 2010).Efforts to address behavioral problems later in life may prove to be more difficult and costly as brain structure becomes permanent and behavior becomes more difficult to change. Due to the patient’s experience of foster care as an infant and toddler, it is likely that he was unable to form a secure attachment with a primary caregiver. Although this disruption in attachment is not the sole contributor to his problems with depression, anxiety, and substance abuse, it is very possible that the chaotic structure of his early years play a large role in the development of these conditions.Applying the concepts of Erikson’s model of psychosocial development allow for a greater understanding of the patient’s current state. Because of the disruption of relationships early in life, the patient may not ever have resolved the developm ental conflict of basic trust vs. mistrust, which is often resolved in infancy. This may be one reason behind his feeling of disconnectedness from others. According to Erikson, this inability to resolve this developmental conflict results in a decreased sense of drive and hope. It is also likely that the patient was able to resolve the developmental conflict of autonomy vs. hame and doubt, which is often resolved in toddlerhood (Boyd, 2008). This may explain the patient’s reliance on his wife as the sole supportive relationship in his life, as well as his fast descent into previous behaviors after his wife’s death. As the patient was never able to develop a sense of autonomy, it seems that he became extremely emotionally dependent on his wife. Because of this relationship, he was able to progress at his job and maintain his recovery. However, with the death of his wife, he was brought back to the conflict of autonomy vs. shame and doubt.Really, it was through the prese nce of his wife that he was able to take initiative, be industrious, and have an intimate relationship, all of which are successful outcomes of developmental conflicts. The marriage provided him with hope, purpose, a sense of devotion and fidelity, as well as affiliation and love. In short, it seems that his wife was his mental and emotional anchor. The recurrence of symptoms of his mental disorders after the loss of the anchor of his life threw him back into the early developmental conflicts that he was unable to resolve due to his unstable childhood.According to Erikson, in order for the patient to move forward from his regressed state he must tackle and resolve the conflicts of trust vs. mistrust, autonomy vs. shame and doubt, initiative vs. guilt, industry vs. inferiority, identity vs. role diffusion, and intimacy vs. , isolation to reach the adulthood stage of generativity vs. stagnation. Ultimately, with the resolution of all these conflict, the patient will reach a mature sta te in which he is able to attain ego integrity instead of falling into despair. Patient Prognosis and Treatment RecommendationsIt is important to remember that the patient was seeking help and trying to recover prior to his most recent hospitalization. He was enrolled in and regularly attending the partial hospitalization program. In addition, he was no longer abusing drugs or alcohol. PHP staff report that he had been medication compliant, cooperative, and was motivated to change. The patient’s recent hospitalization was precipitated by a change in drug dose and type. He reported that it was only after the medication change that the suicidal ideation intensified.Thus, an important goal for this patient is to find the drug types and dosages that will successfully manage his depression and anxiety. However, because the patient has such an extensive history of addiction, primary care providers are hesitant to prescribe large dosages of often highly addictive medications. This h esitation is especially understandable given the patients past abuse of prescription drugs, including an overdose with the intent to commit suicide. However, the types and dosages of the drugs he is currently receiving are not enough to manage his symptoms.The severity of the patient’s depression and anxiety necessitates the use of powerful antidepressants and anxiolytics, but his past substance abuse and dependency make the prescription of these drugs a last resort. Appropriate pharmacotherapy is also complicated by the fact that this patient has tried various classes and types of drugs to manage his symptoms, but no drug therapy has been effective enough to prevent the periodic recurrences of major episodes of depression and anxiety.To manage his depression, the patient has tried typical and atypical antipsychotics, anticonvulsants, tricyclic antidepressants, monoamine oxidase inhibitors, and selective serotonin reuptake inhibitors, as well as other classes of antidepressan ts, such as Serotonin Norepinephrine Reuptake inhibitors, Norepinephrine Dopamine Reuptake Inhibitors, Alpha-2 Antagonists, and Serotonin-2 Antagonist/Reuptake Inhibitors. Although the apparent failure of all these drugs to manage his depression might cause one to suspect that he is exhibiting purely drug seeking behaviors, the depressive symptoms he xperiences impair and affect him so severely that a denial of the reality of these symptoms would be unsafe and unethical. Electroconvulsive therapy has been recommended to treat his depression, but the patient has refused to undergo this treatment modality. The patient’s anxiety is more easily managed than his depression, and benzodiazepines have proven effective. However, his past abuse of benzodiazepines make his primary care providers reluctant to give them to him, and they have prescribed non-benzodiazepines, such as Buspar and Zolpidem, instead.Unfortunately, these medications have not been effective in controlling the pati ent’s anxiety. As a result, the patient has been asking repeatedly for benzodiazepines, while promising that he will use them responsibly. Ultimately, for the patient to achieve effective maintenance of his comorbid mental disorders, he must be able to take medications as prescribed. Due to his history of substance abuse and his still unstable depression and anxiety, it is unlikely that the patient will be able to take his medications as prescribed.It is recommended that a staff member have control of his drugs while he is attending the PHP, and that once discharged, a home health nurse be sent to administer his medication. This would reduce the potential for abuse. In addition, the use of coping mechanisms besides substance abuse may help the patient adhere to the prescribed drug regimen, as well as decrease his depression and anxiety. Coping skills the patient has identified as helpful are watching television and spending some quiet time alone.However, interaction with othe rs should also be encouraged, as too much time spent alone will only reinforce depressive symptoms of isolation. An increase in the quantity and quality of sleep will also aid the patient in his recovery, as sleep deprivation is positively correlated with depressive symptoms and anxiety levels. The patient’s prognosis is one of cautious hopefulness. Though the patient has experienced severe recurrences of MDD, GAD, and substance abuse in recent years, the patient had maintained a long period of sobriety prior to this, during which he was happy, productive, and high functioning.The patient’s ability to achieve remission from his mental illnesses during his marriage to his wife shows that investing in a supportive relationship is an important and powerful coping skill for this patient. Thus, if the patient is able to form and maintain new supportive relationships, his chance of recovery will improve substantially. It is also important to remember that he was doing very w ell until his wife died. According to the Holmes and Rahe Index, the death of a spouse is the number one most stressful event that occurs in the life of an individual (Perry & Potter, 2009).It is not an exaggeration to say that with his wife’s death, life as he knew it ended. Many people experience periods of long and severe depression following the death of a loved one. For this patient, his descent into depression, combined with the resurgence of his anxiety sent his life into a complete tailspin. Under the severe stress of not only his wife’s death but also his inability to keep working, he returned to his former coping mechanisms of drug and alcohol abuse.These habits detracted him from working through the grief of his wife’s death, and furthermore caused him to lose his house and his savings, thus increasing his depression and anxiety, thus perpetuating the substance abuse. Now that the patient has withdrawn from drugs and alcohol and is in a safe environme nt, he can continue his grief work. As a result, his depression may begin to subside, and he may be able to get closer to his previous level of functioning. DSM-IV-TR Axis I: Major Depressive Disorder, Generalized Anxiety Disorder, Polysubstance Abuse Axis II: Cluster B traitsAxis III: Hypertension, Hepatitis C, Diabetes Mellitus, Type 2, Osteoarthritis of the left shoulder, Acid Reflux, Bilateral hearing loss Axis IV: Chronic mental illnesses, chronic medical conditions, death of spouse, family estrangement, lack of social support, unemployment, financial insecurity, acute hospitalization, Axis V: 35 (current), 75 (potential) Patient Goals: †¢ I want to find medications that will help my depression and anxiety †¢ I want to keep from abusing my medications †¢ I want my grief over my wife’s death to get better †¢ I want to take one day at a time †¢ I want to feel less alone †¢ I want to get better sleepNursing Goal: Patient will be safe during hos pital stay. Interventions: †¢ Assess for suicidal ideation every shift. †¢ Perform rounds every 15 minutes to ensure patient safety. †¢ Ensure that the patient has no access to potentially harmful objects and/or substances. †¢ Observe, record, and report any changes in mood or behavior that may signify increasing suicide risk and document results of regular surveillance checks. Nursing Goal: Patient will seek help in dealing with grief-associated problems. Interventions: †¢ Develop a trusting relationship with the client by using empathetic therapeutic communication (Eakes, Burke & Hainsworth, 1998). Educate the client that grief resolution is not a sequential process and that the positive outcome of grief resolution is the integration of the deceased into the ongoing life of the griever (Matthews & Marwit, 2004). †¢ Identify available community resources, including grief counselors and community or Web-based bereavement groups. †¢ Focus on enhanci ng coping skills to alleviate life problems and distressing symptoms such as anxiety and depression. Nursing Goal: Patient will practice social and communication skills needed to interact with others. Interventions: †¢ Discuss causes of perceived or actual isolation. Assess the patient’s ability and/or inability to meet physical, psychosocial, spiritual, and financial needs and how unmet needs further challenge the ability to be socially integrated. †¢ Use active listening skills to establish trust one on one and then gradually introduce the patient to others. †¢ Provide positive reinforcement when the patient seeks out others. †¢ Encourage the client to be involved in meaningful social relationships and support personal attributes (Gulick, 2001). Nursing Goal: Patient will use effective coping strategies instead of abusing drugs and alcohol.Interventions: †¢ Assist the client to set realistic goals and identify personal skills and knowledge. †¢ Use verbal and nonverbal therapeutic communication approaches including empathy, active listening, and confrontation to encourage the client to express emotions such as sadness, guilt, and anger, verbalize fears and concerns, and set goals. †¢ Offer instruction regarding alternative coping strategies (Christie & Moore, 2005). †¢ Encourage use of spiritual resources as desired. Nursing Goal: Patient will identify actions that can be taken to improve quality of sleep.Interventions: †¢ Obtain a sleep-wake history, including history of sleep problems, changes in sleep with present illness, and use of medications and stimulants. †¢ Encourage the patient to develop a bedtime ritual that includes quiet activities such as reading, television, or crafts. †¢ Encourage the patient to use soothing music to facilitate sleep (Lai & Good, 2005). †¢ Teach the patient sleep hygiene guidelines for improving sleep habits (ie. go to bed only when sleepy, avoid afternoon an d evening naps, use the bed only for sleeping, get up at the same time every morning). Use relaxation techniques to decrease anxiety before going to sleep. †¢ Refer to a sleep center if interventions are ineffective. Analysis of Interaction Before interacting with the patient, I read the patient’s medical record and notes. I paid particular attention to ways the patient said he learned best, which for my patient was one on one conversation. Prior to approaching the client, I asked myself if I had any beliefs, biases, or limitations that would affect my interaction with the patient or prevent the formation of a therapeutic relationship.In order to set the tone of a professional therapeutic relationship, I introduced myself to the client, saying that I was a student nurse and shaking his hand. I made some small talk with him about such topics as sports and the patient’s hobbies in order to show interest in the patient and develop rapport. During this conversation, t he patient grew more visibly at ease. His face became less taut, his answers became longer and less forced, and he moved from an erect posture so a somewhat more relaxed position in his chair. The patient spoke slowly and eemed to have difficult finding the words he wanted to use. Such a speech pattern is characteristic of depression, one of the patient’s psychiatric diagnoses. This first conversation was punctuated with the start of morning group. After morning group, I gave the patient some space, as I did not want him to feel overwhelmed or threatened by my questions. About a half hour later, I asked the patient if we could continue the conversation we were having that morning, and he agreed without hesitation. In this second interaction, I began with a few open-ended questions about how group had been.I then started asking the patient some more questions about his readmission into the hospital and precipitating events. I asked open-ended question, and often responded to h is answers by asking further open-ended questions. For example, after asking the patient if he was having suicidal thoughts, he responded that he did not want to hurt himself right now. I replied with the open-ended question, â€Å"So are you feeling safe? † using reflection to redirect the idea back to the patient and allow him to explore whether or not he felt safe.I focused on actively listening to the patient, following the patient’s lead and sometimes asking clarifying questions. Because of the patient’s slower rate of response, I employed the use of silence to allow him to gather his thoughts and proceed at his own pace. As the patient told me more about recent events in his life, including the death of his wife, the loss of his job and his descent into substance abuse, he began to look away more and more. This decrease in eye contact might be the result of the patient feeling ashamed, embarrassed, or guilty about his feelings and behaviors.In order to mai ntain connection with the patient and assure him of my nonjudgmental view of his situation, I used empathy and restatement, saying, â€Å"It sounds as though you have had a very difficult past couple of years. † Upon saying this, the patient looked up, maintained eye contact, and agreed. He then began to expand on his current feeling of hopelessness, saying, â€Å"I wonder if life is worth living, and sometimes I just want to go to sleep and not wake up. † As he explored and expanded on his feelings I alternated between using silence and validating what he said.The silence allowed him to express intense feelings without interruption, while statements of restatement and interpretation, such as â€Å" It sounds like you have been feeling pretty hopeless,† demonstrated empathy and a nonjudgmental attitude toward what the client was feeling. At one point, the patient put his head in his hands, saying â€Å"I had so much going for me, and after my wife died, everyth ing went to pot. † I felt that in this moment, what the client needed was neither a cheery reassurance that things would get better, nor dispensation of advice, but rather a person to understand and acknowledge his current misery.I replied that sometimes life gets you down, and sometimes when it rains it pours, and it’s ok to be sad about that. The patient seemed appreciative of the acknowledgment of his pain and the justification of his sadness. I sat silently with him for 2-3 minutes, as I felt it was important for him to feel, sit with, and process these emotions for a short period of time. During these periods of silence, I continued to lean forward slightly, as I had done throughout the interaction, to show that I was still interested and engaged despite the lack of verbalization.Because I had acknowledged the patient’s hardships and thereby connected with him, I felt that I was in a good position to explore with him goals he had for the future, and ideas th at could help him reach these goals. I made sure to approach this topic not by giving advice or suggestions, but by asking him open-ended questions about what things made him feel less sad or anxious and what things he wanted to work on during his stay. These open ended questions elicited the response of his goals for the future, and his verbalization that he needed to find better coping mechanisms, because his old ones didn’t seem to work.He also stated that he knew he needed to â€Å"continue grieving my wife, because the drugs and alcohol kept me from doing that. † I thought that this realization of substance abuse as inhibitory to his grief process was very insightful, and told him so. He made a small smiling expression and responded that he wanted to â€Å"get back on the straight and narrow† and take his medications â€Å"the way I’m supposed to—no more, no less. † The patient’s elucidation of his goals and his insight into help ful and hindering coping devices was a very positive outcome of this therapeutic conversation.The patient seemed less burdened after the opportunity to talk about his recent losses in life, and more hopeful after verbalizing his goals and ways to meet them. References Ackley, B. J. & Ladwig, G. B. (2008). Nursing Diagnosis Handbook (7th ed. ). St. Louis, Missouri: MOSBY Elsevier. American Psychological Association. (2002). Boyd, M. A. (2008). Psychiatric nursing: contemporary practice (4th ed. ). New York: Lippincott Williams & Wilkins. Bruskas, D. (2010). Developmental health of infants and children subsequent to foster care.Journal of Child and Adolescent Psychiatric Nursing, 23(4), 231-241. doi:http://dx. doi. org/10. 1111/j. 1744-6171. 2010. 00249. x Christie, W. & Moore, C. (2005). The impact of humor on patients with cancer. Clinical Journal of Oncology Nursing, 9(2), 211-218. Cohn, A. M. , Epstein, E. E. , McCrady, B. S. , Jensen, N. , HunterReel, D. , Green, K. E. , & Drapki n, M. L. (2011). Pretreatment clinical and risk correlates of substance use disorder patients with primary depression. Journal of Studies on Alcohol and Drugs, 72(1), 151-157. Eakes, G. G. , Burke, M. L. & Hainsworth, M. A. 1998). Middle-range theory of chronic sorrow. Image Journal Nursing Scholar, 30, 179. Felitti, V. J. & Anda, R. F. (2010). The Relationship of Adverse Childhood Experiences to Adult Medical Disease, Psychiatric Disorders, and Sexual Behavior: Implications for Healthcare. Cambridge University Press. Gulick, E. (2001). Emotional distress and activities of daily living functioning in persons with multiple sclerosis. Nursing Resolutions, 50(3), 147-154. Lai, H. L. & Good, M. (2005). Music improves sleep quality in older adults. Journal of Advanced Nursing, 49(3), 234-244.Lawrence, A. E. , Liverant, G. I. , Rosellini, A. J. , & Brown, T. A. (2009). Generalized anxiety disorder within the course of major depressive disorder: Examining the utility of theDSM-IV hierarchy rule. Depression and Anxiety, 26(10), 909-916. Levola, J. , Holopainen, A. , & Aalto, M. (2011). Depression and heavy drinking occasions: A cross-sectional general population study. Addictive Behaviors, 36(4), 375-380. doi:http://dx. doi. org/10. 1016/j. addbeh. 2010. 12. 015 Matthews, L. & Marwit, S. (2004). Complicated grief and the trend toward cognitive-behavioral therapy.Death Studies, 28, 849-863. Moffitt, T. E. , Caspi, A. , Harrington, H. , Milne, B. , Melchior, M. , Goldberg, D. , & Poulton, R. (2010). Generalized anxiety disorder and depression: Childhood risk factors in a birth cohort followed to age 32 years. Diagnostic issues in depression and generalized anxiety disorder: Refining the research agenda for DSM-V (pp. 217-239). Washington, DC, US: American Psychiatric Association; US. National Institute of Health. (2005). National Research Council Committee on Integrating the Science of Early Childhood Development. (2000). Perry, A. G. , Potter, P.A. (2009). Fundamentals of Nursing (7th ed. ). St. Louis, Missouri: MOSBY Elsevier. Plaisier, I. , Beekman, A. T. F. , de Graaf, R. , Smit, J. H. , van Dyck, R. , & Penninx, B. W. J. H. (2010). Work functioning in persons with depressive and anxiety disorders: The role of specific psychopathological characteristics. Journal of Affective Disorders, 125(1-3), 198-206. doi:http://dx. doi. org/10. 1016/j. jad. 2010. 01. 072 President and Fellows of Harvard College. (2011). Harvard Mental Health Letter. Harvard Health Publications. Retrieved from http://www. health. harvard. du Romera, I. , FernandezPerez, S. , Montejo, A. L. , Caballero, F. , Caballero, L. , Arbesu, J. A. , . . . Gilaberte, I. (2010). Generalized anxiety disorder, with or without co-morbid major depressive disorder, in primary care: Prevalence of painful somatic symptoms, functioning and health status. Journal of Affective Disorders, 127(1-3), 160-168. doi:http://dx. doi. org/10. 1016/j. jad. 2010. 05. 009 Seo, H. , Jung, Y. , Kim, T. , Kim, J. , Lee, M. , Kim, J. , . . . Jun, T. (2011). Distinctive clinical characteristics and suicidal tendencies of patients with anxious depression.Journal of Nervous and Mental Disease, 199(1), 42-48. doi:http://dx. doi. org/10. 1097/NMD. 0b013e3182043b60 Smith, J. P. , & Book, S. W. (2010). Comorbidity of generalized anxiety disorder and alcohol use disorders among individuals seeking outpatient substance abuse treatment. Addictive Behaviors, 35(1), 42-45. doi:http://dx. doi. org/10. 1016/j. addbeh. 2009. 07. 002 Sunderland, M. , Mewton, L. , Slade, T. , & Baillie, A. J. (2010). Investigating differential symptom profiles in major depressive episode with and without generalized anxiety disorder: True co-morbidity or symptom similarity?Psychological Medicine: A Journal of Research in Psychiatry and the Allied Sciences, 40(7), 1113-1123. doi:http://dx. doi. org/10. 1017/S0033291709991590 United States Department of Health and Human Services. (1999). Yen, Y. , Rebok, G. W. , Gallo, J. J. , Jones, R. N. , & Tennstedt, S. L. (2011). Depressive symptoms impair everyday problem-solving ability through cognitive abilities in late life. The American Journal of Geriatric Psychiatry, 19(2), 142-150. doi:http://dx. doi. org/10. 1097/JGP. 0b013e3181e89894 Case