1The Case of L
Presenting ProblemClient presented in the emergency room (ER)having been brought in the previous night by her parents. Following an argument with her parents, Lcut her right wrist. L’s mother reportedthat Lstarted screamingrapidlyand became physically violent toward herprior to cutting her own wrist.Psychological Data L is a 17-year-oldHispanicfemale who resides in Pennsylvania with her mother, father,and older sister. She is in 11th grade at the local public school.Lappearedto be of average to above-average intelligence,as she was able to respond to numerous questions in an articulate and intelligent manner. She was well versed about world history and current affairs. Her mother confirmedthat shehasdone well in school, maintaining a B+ averageand participatingin various school activities (e.g., chorus, school paper) until last year. Lslowly dropped out of many activities she liked in the past. Her mother noticed about 8months ago that Lhad also begunhaving difficulty doing schoolwork.Erratic behavior aroseduring episodes when Lalsobecameirritable and explosive. During theserepeated episodes,she becamequite defiant, cutclasses, hadto be placed in school detention, and had even assaulted the principal. Lhas numerous friends and believed she can relate to all types ofpeople. She has a boyfriend who adores her, but she said she doesn’t feel the same about him. The school counselor confirmedthat Lis outgoing, popular,and smart;but during these episodes she became another person, one who is very violent and difficult.Medical History A physical examination by a staff doctor revealed superficial cuts on L’sleft and right wrist. The cuts appeared to be a few weeks old. There were cigarette burns on her right wristthat looked to be approximately one week old. In questioning Laboutthe cigarette burns, Lresponded, “Ijust wanted to see how it felt—now I know.”Whenquestioned about old cuts on her left wrist,she responded, “I don’t want to talk about it.”Lweighs 103pounds and is 5’ 6” tall. Ldeniedany dieting or fasting,but her mother noticed over this past year that her weight has dropped. Substance Abuse History L denied any drug or alcohol use. When she was questioned regarding such, her response was “I could do drugs if I wanted to.I don’t want to,because it’s dumb.”Family History L’s mother is 42 years old and works as a secretary for a large telephone company. Her father is 49years old and operates a small landscaping business. Both are U.S. citizens, with a cultural background from Guatemala of which they are proud. Both have
2a high school education. L’s sister is considerably younger, aged 8. Their relationship is described as unremarkable,although L’s mother notedthat the younger sister stays away when Lis upset. Marital circumstances are uncertain,although the parents admittedthat they are trying to keep the family together for their children,and they are of the Catholic faith. Treatment costs for Lhave been an additional difficultyfor the family,but they said they are very worried about L’s lack of self-control and discipline. Extended family are far awayand mostly still in Guatemala. L’s parents were not aware ofany other family members with psychiatric problems. Psychiatric HistoryLwasevaluated three times at the community hospital ER during the past 4 years. Hospital Assessments wereusually done after suicide attempts or threatening violent behavior toward others. Lthoughtthat the clinicians trying to diagnose her only hadbook skillsand no people skills. She assumedthat no one will ever know what is wrong with her; she didnot plan to tell them because she doesn’t like them. Lsaid she knows she “is not crazy,”but she was convinced that the therapist thoughtshe is crazy or a “bad”kid.”They’re just experimenting with me,”Lsaid. Lindicated that she had been prescribed medications to alter hermood,but she couldn’t recall what it was,as she stated, “I don’t need those; nothing is wrong with me.”L’s mother reported that Lwasinvolved in outpatientcounseling on at least four occasions as well as being placed ina shelter once after school truancy, running away fromhome, andthreatening to assault her. A socialworker was even sent for home visits for a 3-monthperiod. Each time,Lwould abruptlyend therapy by becoming verbally abusive or totallynoncommunicative toward the therapist and would adamantly refuse tocontinue therapy. She even admittedto shoving a desk toward atherapist and threatening her with a pencil. When questionedabout this behavior,Lresponded, “Well she told me to expressmyself and let my true feelings out, so I did.” (Lalso laughed andglanced ather motherduring this exchange.)L’s mother wasparticularly perplexed and overwhelmed by these behaviors.She statedthat her husband is completely frustrated and angry. Both admittedthat L’s behavior is part of the considerable strain on their marriage. Ldeniedbeing under any continued psychiatric care eventhough it wasrecommended numerous times.She refusedto go,stating, “The therapists are the ones who are crazy.”Lwas first seen in outpatient counseling 9 years ago after she began to have nightmares and experienced tremendous anxiety after her godmother threatened to kidnap her. Her godmother became obsessed with LwhenLwas 6 years old,first threatening to kidnap her then. Her godmother had to be institutionalized after exhibiting bizarre behavior. Recently,the godmotherstarted threateningto kidnap Lagain. Three years ago,Lwas sent for counseling after she ran away from home after getting a bad report card and also discovering that her parents were considering a divorce. Lrequested therapy,as she reported that at 8 years of age she was sexually molested by an older man inthe community (who is now deceased). She expressed having mixedemotions,because she viewed her perpetrator as her friend.By pretending that nothing
The sign of an effective clinician is the ability to identify the criteria that distinguish the diagnosis from any other possibility (otherwise known as a differential diagnosis). An ambiguous clinical diagnosis can lead to a faulty course of treatment and hurt the client more than it helps. In this Assignment, using the DSM-5 and all of the skills you have acquired to date, you assess an actual case client named L who is presenting certain psychosocial problems (which would be diagnosed using Z codes).
This is a culmination of learning from all the weeks covered so far.
To prepare: Use a differential diagnosis process and analysis of the Mental Status Exam in “The Case of L” to determine if the case meets the criteria for a clinical diagnosis.
Submit a 6 page paper in which you:
- Provide the full DSM-5 diagnosis. Remember, a full diagnosis should include the name of the disorder, ICD-10-CM code, specifiers, severity, and the Z codes (other conditions that may need clinical attention).
- Explain the full diagnosis, matching the symptoms of the case to the criteria for any diagnoses used.
- Identify 2–3 of the close differentials that you considered for the case and have ruled out. Concisely explain why these conditions were considered but eliminated.
- Identify the assessments you recommend to validate treatment. Explain the rationale behind choosing the assessment instruments to support, clarify, or track treatment progress for the diagnosis.
- Explain your recommendations for initial resources and treatment. Use scholarly resources to support your evidence-based treatment recommendations.
- Explain how you took cultural factors and diversity into account when making the assessment and recommending interventions.
- Identify client strengths, and explain how you would utilize strengths throughout treatment.
- Identify specific knowledge or skills you would need to obtain to effectively treat this client, and provide a plan on how you will do so.
APA format
Morrison, J. (2014). Diagnosis made easier (2nd ed.). New York, NY: Guilford Press.
Chapter 15, “Diagnosing Substance Misuse and Other Addictions” (pp. 238–250)
American Psychiatric Association. (2013q). Substance related and addictive disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.9780890425596.dsm16
Note: You will access this e-book from the Walden Library databases.
Gowin, J. L., Sloan, M. E., Stangl, B. L., Vatsalya, V., & Ramchandani, V. A. (2017). Vulnerability for alcohol use disorder and rate of alcohol consumption. American Journal of Psychiatry, 174(11), 1094–1101. doi:10.1176/appi.ajp.2017.16101180
Note: You will access this article from the Walden Library databases.
Reus, V. I., Fochtmann, L. J., Bukstein, O., Eyler, A. E., Hilty, D. M., Horvitz-Lennon, M., … Hong, S.-H. (2018). The American Psychiatric Association practice guideline for the pharmacological treatment of patients with alcohol use disorder. American Journal of Psychiatry, 175(1), 86–90. doi:10.1176/appi.ajp.2017.1750101
Note: You will access this article from the Walden Library databases.
Stock, A.-K. (2017). Barking up the wrong tree: Why and how we may need to revise alcohol addiction therapy. Frontiers in Psychology, 8, 1–6. doi:10.3389/fpsyg.2017.00884
Note: You will access this article from the Walden Library databases.
Best, D., Beckwith, M., Haslam, C., Haslam, S. A., Jetten, J., Mawson, E., & Lubman, D. I. (2016). Overcoming alcohol and other drug addiction as a process of social identity transition: The social identity model of recovery (SIMOR). Addiction Research and Theory, 24(2), 111–123. doi:10.3109/16066359.2015.1075980
Hagman, B. T. (2017). Development and psychometric analysis of the Brief DSM-5 Alcohol Use Disorder Diagnostic Assessment: Towards effective diagnosis in college students. Psychology of Addictive Behaviors, 31(7), 797–806. doi:10.1037/adb0000320
Helm, P. (2016). Addictions as emotional illness: The testimonies of anonymous recovery groups. Alcoholism Treatment Quarterly, 34(1), 79–91. doi:10.1080/07347324.2016.1114314
Petrakis, I. L. (2017) The importance of identifying characteristics underlying the vulnerability to develop alcohol use disorder. American Journal of Psychiatry, 174(11), 1034–1035. doi:10.1176/appi.ajp.2017.17080915
Hom, M. A., Lim, I. C., Stanley, I. H., Chiurliza, B., Podlogar, M. C., Michaels, M. S., … Joiner, T. E., Jr. (2016). Insomnia brings soldiers into mental health treatment, predicts treatment engagement, and outperforms other suicide-related symptoms as a predictor of major depressive episodes. Journal of Psychiatric Research, 79, 108–115. doi:10.1016/j.jpsychires.2016.05.008
