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Case Study

 

CASE STUDY

Jennifer Neher

4/18/2011

Client Case Study

Questions to consider when formulating a diagnosis for Kendra

1.Do Kendra’s presenting problems result from patterns of interaction with others?

Kendra’s presenting problems are a result of patterns of interactions with others. She feels lonely when she is alone, but does not get too close to anyone including boyfriends that try to get close to her and she pushes them away.

2.Are there recent stressors that may account for Kendra’s symptoms? Do these symptoms warrant an adjustment disorder? If so, is this an isolated situation or part of a general pattern?

Kendra moved in with 3 coworkers and she does not trust them. She has a stressful job as an EMT. Kendra has been hospitalized 10 times in the past year when being alone triggers her anxiety.

3.Is Kendra under the influence of any substances or medical conditions that may account for her anxiety or depression?

Kendra has recently been hospitalized and was given scripts for antidepressants that she is not taking. She has no known substance abuse issues.

4.Might Kendra have a mood disorder? Can her self-mutilation behaviors be considered suicidal in nature?

Kendra may have a mood disorder, but Borderlines have swift changes in moods that are reflective of Bipolar disorder. This should be monitored, but could be a result of the personality disorder. Also, attachment disorder with anxiety and depressed mood can present as a mood disorder as well. Kendra’s self-mutilation behaviors can certainly be considered suicidal in nature due to the feeling it gives her to feel in control and takes the pain away. Suicide can do the same thing, and she has threatened suicide in the past.

5.Are there any manipulative behaviors displayed by the client? If so, are they related to a desire for nurturance or personal gain?

There are many instances that Kendra exhibits manipulative behaviors. Threatening to commit suicide if left alone, is one instance where she just doesn’t want to be abandoned. Nurturance is what she is longing for. She wants to trust the therapist with information about the incest, but she is testing her to see if she is trustworthy, this is also for nurturance that she did not receive when she was younger.

6.How would you characterize Kendra’s sense of identity?

Kendra’s sense of identity is unstable at best. She gets her sense of self from the acceptance of others and her sense of identity is based on which person she is with. She wants attention from other whether it is starting fights with others or driving fast in her car at night. During different visits to her therapist, Kendra exhibits an unstable sense of identity.

Multi-Axial Diagnosis

Axis I: 309.28 Adjustment Disorder with mixed anxiety and depressed mood

Axis II:301.83 Borderline Personality Disorder

Axis III:None known

Axis IV:Lack of Support System, Stressful Occupation

Axis V: GAF score: 50

Rationale and Differential Diagnosis

Kendra has attachment disorder that can be resulting from her sexual abuse and failing to attach to her mother. Borderline personality Disorder is displayed by Kendra in suicidal tendencies, unstable relationships, impulsivity, and self-mutilation. Kendra’s symptoms are worsened because she lacks a support system and is involved in a stressful job. Kendra’s GAF score is 50 due to Kendra’s suicidal ideation and serious impairment in social settings including the lack of support system.

Additional Information Needed

Additional information on Kendra’s recent past medical history when admitted to the hospital in the past year. Medications and treatments that did and did not work so that new treatment can begin. Kendra’s incest should be explored along with her relationship with her mother and attachment disorder. PTSD should be ruled out.

TABLE 1 Biopsychosocial Risk and Resilience Assessment for the Onset of the Disorder

RISK INFLUENCES PROTECTIVE INFLUENCES

Biological

• Locus Coeruleus Dysfunction

• Female

• Hispanic

• No dysfunction

• Male

• Non-Hispanic

Psychological

• Lack of Intervention

• Poor Insight into Disorder

• Feelings of Abandonment

• Early Intervention

• Understanding of Disorder

• Internalized sense of being cared for

Social

• Lack of Support System

• Negative Life Events

• Sensitivity of Neg Emotions

• Presence of Support System

• Lack of Negative Life Events

• Lack of Sensitivity to intense experiences

TABLE 2 Biopsychosocial Risk and Resilience Assessment for the Course of the Disorder

RISK INFLUENCES PROTECTIVE INFLUENCES

Biological

• none • none

Psychological

• Substance Use

• Attachment Deficits

• Co-Morbid Disorder •Lack of substance abuse

• Resolution of attachment issues

• Lack of co-morbid disorders

Social

• Social Maladjustment

• Poor Academic Achievement

• Poor Work Performance

• Absence of Enduring Relationships

• Living in Poverty•

• Social Adjustment before symptoms

• Proactive such as tutors

• Symptoms decrease with age

• Some stable relationships

What techniques would you use to elicit additional strengths in this client?

I would use strength based techniques that will empower Kendra to build self-esteem, focus on aspects of her life/job that she performs well. In order for this to happen, Kendra will have to seek treatment to have her meds reevaluated.

The diagnosis of attachment disorder with anxiety and depressed mood relates to this case because of Kendra’s fear of abandonment and being alone. This goes back to when she was an infant and did not get her needs met from her mother. Borderline personality disorder is co-morbid due to the trauma experienced as a child. It is a different diagnosis from PTSD which could be considered as well as a depressive or anxiety disorder. Kendra’s impulsiveness could be considered as possible as adult ADD. I believe this is a significantly different diagnosis because it includes the attachment symptoms, the anxiety, the depression, and suicidal tendencies.

Suicide Risk Assessment

Using the information provided in the case study, conduct a Suicide Risk Assessment of Kendra. If the case study does not provide sufficient information for this purpose, use the space provided to identify what questions you would ask Kendra in order to be able to complete the assessment. Type narrative answers directly into the spaces provided. Use your cursor to highlight (select) the shaded area of the appropriate box, then highlight the box with red (instead of placing an X). Example: 0

Name: Kendra Starnes ID#:90-34762 DOB: 6/17/1991

Address: 404 Lincoln Blvd, Biloxi, MS 39501

Date: 4/18/2011

Phone: (555) 769-3218

Contact Type: Telephone 0 Walk-in 0

Time: 1:15pm

Location of Person (if other than above):

Gender: M0 F0 Primary/Preferred Language: English Crisis Plan? N 0 Y 0

Date: 4.18.2011

SUICIDE RISK INDICATORS

1.PRESENTING PROBLEM OR REQUEST FOR ASSISTANCE: Suicidal tendencies, depression, not taking medications, self-mutilation, intense anxiety when left alone, fear of abandonment, insomnia.

2.TRIAGE:

a.Are you able to keep yourself safe until this assessment is completed? 0 Yes 0 No

b.Are you in possession of a gun or weapon or do you have easy access to a gun or weapon? 0 Yes 0 No

c.Have you felt like hurting yourself? 0 Yes 0 No

or anyone else? 0 Yes – Refer to Core Risk

Assessment for Harm to Others 0 No

d.Have you already hurt yourself or anyone else? 0 Yes 0 No

Note: If person answers “Yes” to 2d above and the level of risk is determined to be severe at this point, and a mobile crisis response team has been dispatched to continue the assessment, it is unnecessary to complete the remainder of this form.

3. IDEATIONS: (Describe any thoughts of dying or killing oneself in detail, using person’s own words. Include circumstances that trigger suicidal thoughts.)

When you feel depressed, what causes you to feel that way? What circumstances make you feel that way?

Ideation is: Fleeting 0 Periodic 0 Constant 0

Increasing in: Severity 0 Urgency 0 Frequency 0

Kendra has threatened to kill herself to her housemates. Not taking her antidepressants and being alone triggers thoughts of severe depression and thoughts of suicide.

0 0 0 0 0

None Low Med High Severe

(No thoughtsObsessive thoughts)

4.PLAN: (How would person carry out ideations? Use details, person’s own words.)

Have you ever thought about hurting yourself? Have you thought about how you would do it?

While Kendra threatens to kill herself, she has not devised a plan.

0 0 0 0 0

None Low Med High Severe

(Unclear  Detailed & specific)

5.MEANS: (Instruments/methods to be used; access to instruments. Use details, person’s own words.) Do you have access to a weapon, drugs, etc?

Kendra does not have any access to weapons in her home or work. 0 0 0 0 0

None Low Med High Severe

(No access  Continuous access)

6.LETHALITY: (Dangerousness of plan. Use details, person’s own words.)

As above states, Kendra has only expressed the desire to kill herself, she has not devised a plan or means to do so. 0 0 0 0 0

None Low Med High Severe

(Minimal riskCertainty of death)

7.INTENT: (Reports desire and intent to act on suicidal thoughts. Use details, person’s own words.) What do you do when you feel this way?

Kendra threatens others to that she wants to kill herself, especially when left alone. While the intent may be for company, the threat is still there and should not be ignored.

0 0 0 0 0

None Low Med High Severe

(No desire/denialDesire to complete plan)

8.HISTORY: (Suicide and self-harming behaviors, self and family; Attempts: number, when, method, lethality, rescues, etc. Begin with past three months.)

Kendra has been hospitalized 10 times in the past year. She has been rescued by house mates and sent to the hospital. She has not devised a plan, means, etc.

What has prevented person from acting on suicidal thoughts in the past?

Co-workers/friends have prevented thoughts and action by admitting her to the hospital. 0 0 0 0 0

None Low Med High Severe

(No historyMultiple life threatening acts or severe attempts)

9.SUBSTANCE ABUSE/USE: (History of use/abuse, access to substances, including family member substance abuse) How many times a week do you drink?

Kendra does not have any history of substance abuse. She does not take her antidepressants as prescribed.

Is person currently using? If so, list substance(s), amount, and when taken.

Kendra does not take any known meds or substances at this time. 0 0 0 0 0

None Low Med High Severe

(NoneHeavy use/dependence)

10.ACUTE LIFE STRESSORS: (Situation/recent changes with family, relationship, job, school, health, divorce, marriage, grief, losses, financial, residential instability, bullying, etc.) Family discord, stressful job, 10 hospitalizations in a year, fear of abandonment/being left alone.

0 0 0 0 0

None Low Med High Severe

(Few stressorsMany stressors)

11.DEPRESSION/AGITATION: (Affect, anxiety, restlessness, symptoms of depression) Kendra reports that she feels tired and lonely all the time, feeling frustrated all the time and that she has poor sleeping habits.

0 0 0 0 0

None Low Med High Severe

(Normal affectSevere depression)

12.HOPELESSNESS: (Future orientation)

Negative self-image, Kendra reports that she is a nobody that does not have any skills and is really not good at anything. 0 0 0 0 0

None Low Med High Severe

(Can see futureUnable to see)

13.PSYCHOTIC PROCESSES: (History/symptoms of psychosis, delusions, auditory/visual hallucinations. Include dates, diagnoses, meds.)

Kendra has no known psychotic processes. 0 0 0 0 0

None Low Med High Severe

(No historySevere delusions)

14.MEDICAL FACTORS: (History/current medical conditions including chronic and severe pain, terminal illness, etc.)

Kendra does not have any known medical factors 0 0 0 0 0

None Low Med High Severe

(No historyMultiple symptoms)

15.BEHAVIORAL CUES: (Isolation, impulsivity, hostility, rage, etc.)

Kendra does not trust others, she starts fights with others for sport, she has reckless driving experiences that are supposed to scare her passengers, and other reckless behaviors. She also self-mutilates by punching concrete walls with her bare fist and breaking her hand. 0 0 0 0 0

None Low Med High Severe

(Minimal  Extreme)

16.COPING SKILLS: (Helplessness, negation of self and others)

Kendra displays herself as a victim that is doesn’t have any skills so that she can rely on the comfort of others instead of within.

0 0 0 0 0

None Low Med High Severe

(Good coping skillsPoor coping)

17. SUPPORT SYSTEM: (Family, friends, co-workers, roommates, spiritual affiliation, civic, school, etc. Define relationship(s) and details using person’s own words.)

Who do you talk about problems with? Who could take you to a doctor’s appointment?

Kendra has little contact with her family and superficial relationships with her housemates. 0 0 0 0 0

None Low Med High Severe

(Supportive contactsNo support)

18. OTHER FACTORS: (OPTIONAL. If previously mentioned, describe any recent lifestyle changes, sexual identity/orientation issues, involvement w/justice system, communication skills, other diagnoses.)

0 0 0 0 0

None Low Med High Severe

(Small significanceSevere impact)

19.CULTURAL CONSIDERATIONS: (OPTIONAL. If mentioned, describe person’s attitude towards suicide—acceptance, ambivalence, rejection, etc; cultural views on death and suicide; specific concerns)

Parents are Catholic,see Kendra as the blacksheep of the family, tells Kendra she is worthless and are low-income.

20. OVERALL RISK LEVEL (based on clinical judgment): Low 0 Med 0 High 0

21.REASONING: (Identify risk factors and factors offsetting/mitigating identified risks)

RISKS:

Hospitalized 10 times in past year, self-mutilating, lack of support system OFFSETS:

22.ACTION TAKEN: (Client signed Crisis Plan? Y 0 N 0 Interim Service Plan Completed? Y 0 N 0 Include details of appointments/referrals made)

Referral sent to psychiatrist, appointment made for 4.23.2011 @ 9:00am.

Assessor:

Jennifer Neher Jennifer Neher 4/18/2011

Mental Status Exam

Using the Mental Status Exam format below, complete a Mental Status Exam on Kendra.

If the case study does not provide sufficient information, add clinical information as needed so that you can complete the exam and incorporate a summary of your findings in Kendra’s Intake Report.

MENTAL STATUS EXAM

While prompts are provided below, you should be sure to describe your observations and impressions of the person for each question below. You may find it helpful to review the Key Mental Status Exam Phrases from the Module 3 readings.

If the case study does not provide answers to all of these questions, add information that you might have been able to gather, had you been Kendra’s initial interviewer. Highlight the new information that you add (beyond the information provided in the case study) in yellow.

1.Describe the person’s interaction with you and others in attendance; include general observations about the person’s appearance, behavior, and social interaction:

During Kendra’s first session, she dressed casually and age appropriately, she seemed uncomfortable and suspicious. She rarely made eye contact during the session. After the second and third session, she became more talkative, but still refrained from detailed information.

2.Motor Activity (e.g., orderly, calm, agitated, restless, hypoactive, and what kinds of activity the person exhibits, such as tics, mannerisms, tremors, convulsions, ataxia, or akathisia):

Kendra seemed agitated to speak about the reason she was in therapy. She clasped her hands tightly when talking about her family, but seemed to talk with her hands excitedly when talking about driving her car fast to scare others, and when she started fights with others for no apparent reason.

3. Mood (Sustained emotional state, e.g., relaxed, happy, anxious, angry, depressed, hopeless, hopeful, apathetic, euphoric, euthymic, elated, irritable, fearful, silly):

Kendra seemed anxious, dysthymic, suspicious and pessimistic.

4.Affect (Outward expression of person’s current feeling state, e.g., broad range, appropriate to thought content, inappropriate to thought content, labile, flat, blunted):

Kendra’s affect was grim and labile depending on what the topic of discussion was.

5.Self-concept (e.g., self-assured, realistic, low self-esteem, inflated self-esteem):

Kendra has a very low sense of self when she is alone, but she has an inflated self-esteem when in a group and able to show-off by her actions of reckless behavior.

6.Speech (e.g., mute, talkative, articulate, normally responsive, rapid, slow, slurred, stuttering, loud, whispered, mumbled, spontaneous, stilted, aphasic, repetitive):

Kendra presents with a talkative, rapid responsive, but at times she mumbled her responses when it was something she did not want to talk about.

7.Thought Process (e.g., logical, relevant, coherent, goal directed, illogical, incoherent, circumstantial, rambling, pressured, flight of ideas, loose associations, tangential, grossly disorganized, blocking, neologisms, clanging, confused, perplexed, confabulating): Kendra was suspicious of the counselor and Kendra’s thought process was circumstantial, illusional and grossly unorganized.

8. Thought Content (e.g., optimistic, grandiose, delusions, preoccupations, hallucinations, ideas of references, obsessions/compulsions, phobias, poverty of content, suicidal or homicidal ideation, prejudices/biases, hypochondriacal, depressive):

Kendra has a phobia about being left alone. She becomes very anxious, has feelings of loss of self-control and depression. Suicidal ideations occur especially when she has not gotten any sleep. She feels she must strike a brickwall with her fist to gain the control back.

9. Intellectual Functions:

a. Sensorium (e.g., orientation – person, place, time, situation):

While Kendra has normal orientation of the present, she is confused as to why her housemates want her to get counseling and why it is any of their business anyway.

b. Memory (e.g., recent, remote, retention and recall (3 object memory, recall: immediate / 5 minutes; digit span memory):

Kendra’s recall/memory is defective in remote. She seems to confabulate when recalling past events that are hurtful.

c.Intellectual Capacity (e.g., general information (current events, geographical facts, current/past presidents), calculations (serial 3’s or 7’s), abstraction and comprehension (comparison and differences, proverb interpretations):

Kendra can provide general information regarding her job as an EMT, she can tell what happened last night on her calls. She can compare what is “good” and “bad” behavior.

d.Estimated Intelligence (e.g., below average, average, above average, unable to determine):

Kendra received top grades in school. She is at least average in intelligence.

10.Judgment and Impulse Control (e.g., good, partial, limited, poor, none)

When Kendra has not had much sleep and is left alone, her judgment and impulse control is limited. She also makes poor decisions and risks when she is within a group of people for attention.

11.Insight (e.g., good, fair, poor, none): Kendra’s insight is mostly in denial. She does not know how her behavior affects others. She does not know the importance of following doctor’s orders and taking the prescribed medications.

Intake Report

Report of Intake Interview

Client: Kendra Interviewer: Jennifer Neher

Birthdate: 6/17/1991 Date of Interview: 4/18/2011

Identifying Information

Kendra is a nineteen year old female. A high school graduate, Kendra excelled in school athletics. She is currently an EMT that lives with three other EMT’s who are supportive of her getting help, but Kendra does not trust them. Kendra has limited contact with family since moving out last year.

Presenting Problem

Kendra is being hospitalized ten different times in the past year. She has trouble sleeping because of anxiety and depression that is started by being left alone. She hits her fist into a concrete wall to make the anxiety, depression, and feeling of losing control go away.

Mental Status Exam Summary

Kendra shows signs of apprehension and suspicion when talking to the counselor. She presented signs of anxiety and depression through her affect, mood, self-concept, and thought process. Estimated intelligence seems to be average. Sensorium and Intellectual Capacity seem normal, but memory/recall had some confabulation issues. Kendra struggles with insight into her problems and how to treat the situation.

Other Current Problems and Difficulties

Kendra has missed several days of work and her home life is affected by her disorder. Kendra has problems with sleep, and this affects her ability to keep control of her situation. She self-mutilates by punching concrete walls and threatens suicide when left alone.

Present Life Situation

Presently, Kendra lives with three of her coworkers. She works as an EMT. She has been in and out of the hospital ten times in the past year. She has refused to take medications that were prescribed to her during these hospitalizations.

Family

Kendra has a strained relationship with her family. She described to the counselor that the parents were “cold” and that she did not want to be in the session if the social worker talked to her parents. After speaking to the parents, the social worker confirmed that there were problems. The mother was distant and said she believed children should learn at an early age to take care of themselves. Kendra later reported to the counselor that she had been a victim of incest by her father from age 5-12 years of age.

Developmental History

Kendra did well in school, and excelled in sports. She did not have any developmental, medical problems or mental illnesses prior to moving out of her parent’s home. No known problems during her mother’s pregnancy or delivery.

Medical and Treatment History

Kendra has been hospitalized ten times in the past year for mental health reasons. She has broken bones in her hands due to punching concrete walls. She was given antidepressants when hospitalized but did not continue treatment once home.

Substance Use History

None known

Case Conceptualization, Including Strengths and Areas of Difficulty

Kendra’s strengths include that she is an intelligent, capable of performing a stressful career, and has the desire to become a nurse. She has difficulty understanding her disorder, how to handle her past, and how to move forward. Kendra fails to understand the importance of taking her medication. Kendra struggles most from not having an adequate support system.

Diagnostic Impression

Due to the fact that Kendra experiences extreme anxiety, insomnia and depression when left alone, and the relationship with her mother, she shows signs of attachment disorder with mixed anxiety and depressed mood. Her self-mutilating behavior can be seen as suicidal tendencies and she has threatened suicide when she is going to be left alone. Kendra’s fears of abandonment, emptiness, self-condemnation, and self destructiveness suggest Borderline Personality Disorder. The stressful job of an EMT and the lack of a support system adds to the stress that influences Kendra’s symptoms. Kendra scored a GAF score of 50 due to her serious symptoms of suicidal ideations, no support system, no friends, and multiple hospitalizations.

Axis I: 309.28 Adjustment Disorder with mixed anxiety and depressed mood-chronic

Axis II:301.83 Borderline Personality Disorder

Axis III:None known-confirmed by the physician’s chart

Axis IV:Lack of Support System, Stressful Occupation

Axis V: GAF score: 50

Treatment Goals:

1. Coordinate with psychiatrist to regulate medication

2. Kendra will take medications as prescribed

3. Kendra will develop a support system

4. Kendra will keep her visits with her therapist twice a week.

Relevant Evidence-Based Practices

Based on your assessment of Kendra’s problems, needs, and diagnosis, identify relevant two or more evidence-based practices (EBPs) that you could incorporate into your counseling strategy and treatment plan for Kendra. Identify the source from which you obtained your EBP information.

•Wraparound Program/Seligman Establish and develop collaborative therapeutic alliances, possibly developing a support system

•Individual Psychology/Seligman Encourage life skills such as taking medication, developing a support system, and keeping appointments.

References

Corcoran, J., & Walsh, J. (2009). Mental health in social work. Boston: Pearson Education.

Seligman, L. (2004). Diagnosis and treatment planning in counseling (3rd Ed.). New York: Springer.

Woody, S.R., Detweiler-Bedell, J., Teachman, B.A., & O’Hearn, T (2003). Treatment planning in psychotherapy. New York: Guilford Press.

Zuckerman, E. (2010). Clinician’s thesaurus: The guide to conducting interviews and writing psychological reports (7th Ed.). New York: The Guilford Press.

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