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alnonnu
Henry is a 19-year-old college sophomore referred to the student…
Henry is a 19-year-old college sophomore referred to the student health center by a teaching assistant after noticing his odd behavior and preoccupation with bizarrely threatening drawings in his lab notebook. He appeared suspicious of the reason for the referral but agreed to the psychiatric consultation. He believed that his classmates were undermining his abilities, and also alleged in the prophetic power of coins where he could predict the future by flipping a coin and that his thoughts could influence the future. He acknowledged feeling depressed and anxious at times, but these feelings did not improve when he was around other people. Upon Henry’s consent, his mother was called for collateral information, and she reported that he had been quiet, shy, and reserved since childhood. She further acknowledged that Henry never had close friends, had denied wanting to have friends, and had never dated. He was teased by other kids and would come home upset. His mother also mentioned that ghosts, telepathy, and witchcraft had fascinated him since junior high school, and he thought he could change the outcome of events by thinking about them. On examination, he was alert and wary, and his Mini-Mental State Examination (MMSE) score was 30 out of 30.
Based on the information gathered from the referral, and the consultation, it is possible to make two diagnoses a) schizotypal personality disorder and b) paranoid personality disorder. Schizotypal personality disorder is characterized by significant social anxiety, odd behavior and thoughts, and eccentric beliefs. In Henry’s case, the social anxiety can be related to him never having close friends, denied wanting to have friends, and never going on a date. His odd behavior of being fascinated by ghosts, telepathy, and witchcraft since junior high school, and his eccentric beliefs that he could change the outcome of events by thinking about them, are alarming. These behaviors, thoughts, and beliefs indicate that Henry may be suffering from schizotypal personality disorder.
Paranoid personality disorder is characterized by excessive distrust and suspiciousness, which often leads to misinterpretation of situations, and mistrust of others. Henry reported that he had been suspicious of some of his classmates, believing they were undermining his abilities. He also said that he had seen two students “flip a coin” over whether he was gay or straight, and that coins could often predict the future. These behaviors, and beliefs indicate that Henry may be suffering from paranoid personality disorder.
Instrument selection for Henry should be based on his bio-psycho-social-spiritual assessment results. Appropriate instruments include the Minnesota Multiphasic Personality Inventory (MMPI-2-RF), the Beck Anxiety Inventory, the Beck Depression Inventory, the Hamilton Anxiety Rating Scale, the Hamilton Depression Rating Scale, and the Structured Clinical Interview for DSM-5 (SCID-5). These instruments can help assess Henry’s physical, psychological, and social functioning, as well as his spiritual wellbeing.
Henry is believed to be suffering from both schizotypal personality disorder and paranoid personality disorder. When selecting an assessment instrument for a client, it is important to consider the cultural, and social factors related to the assessment and evaluation of individuals, groups, and specific populations. This is especially important when assessing individuals from diverse backgrounds. Henry is an African American male, so it is important to select an instrument that does not contain any cultural or racial bias. The MMPI-2-RF, for example, includes items that are specific to African Americans, which can help to ensure the accuracy of the results. It is also important to consider Henry’s developmental stage. Since he is 19 years old, he is likely to be more aware of, and able to understand the questions on the instruments than a younger individual. By considering the culture, and social factors related to the assessment, as well as the developmental stage of the client, it is possible to obtain more accurate results from the assessment instrument.
Henry had transferred to this out-of-town university after an initial year at his local community college. The transfer was his parents’ idea, he said, and was part of their agenda to get him to be like everyone else and go to parties and hang out with girls. He said all such behavior was a waste of time. Although they had tried to push him into moving into the dorms, he had refused, and instead lived by himself in an off-campus apartment. With Henry’s permission, his mother was called for collateral information. She said Henry had been quiet, shy, and reserved since childhood. He had never had close friends, had never dated, and had denied wanting to have friends. He acknowledged feeling depressed and anxious at times, but these feelings did not improve when he was around other people. He was teased by other kids and would come home upset. His mother cried while explaining that she always felt bad for him because he never really -fit in,? and that she and her husband had tried to coach him for years without success. She wondered how a person could function without any social life. She added that ghosts, telepathy, and witchcraft had fascinated Henry since junior high school. He had long thought that he could change the outcome of events like earthquakes and hurricanes by thinking about them. He had consistently denied substance abuse, and two drug screens had been negative in the prior 2 years. She mentioned that her grandfather had died in an -insane asylum? many years before Henry was born, but she did not know his diagnosis. On examination, Henry was tall, thin, and dressed in jeans and a T-shirt. He was alert and wary and, although nonspontaneous, he answered questions directly. He denied feeling depressed or confused. Henry denied having any suicidal thoughts, plans, or attempts. He denied having any auditory or visual hallucinations, panic attacks, obsessions, compulsions, or phobias. His intellectual skills seemed above average, and his Mini-Mental State Examination score was 30 out of 30.
1) Case Conceptualization/Formulation (5 P’s):
(Why is the client having this problem right now?)
Define the Problem:
Predisposing Factors: (e.g. family history of bipolar diagnosis)
Precipitating Factors: (e.g. parents recently divorced)
Perpetuating/Risk Factors: (e.g. client is being bullied continuously is a perpetuating factor to the presenting issues because the bullying is exacerbating their anxiety)
Protective Factors: (e.g. good support system)
2) List of Presenting Problems
How does the client define the problem? If applicable, how do others close to client define the problem? (e.g. anxiety/stress, isolating at home)
1. i.e. mother reports client has poor self esteem as evidenced by…
2. i.e. significant other reports substance abuse as evidenced by…
3. i.e. client reports he is bullied at school
3) Presenting Problem List, Prioritized (#1 is what issue needs the most immediate attention; do this collaboratively with client/caregiver)
1. (e.g. cutting, anxiety attacks)
2. (e.g. socially isolated, no friends)
4) Client presentation during session
(i.e. client presented as uncomfortable during intake session as evidenced by minimal eye contact, guarded affect, and restlessness (i.e. fidgeting). Thus, I will focus on rapport building and helping client feel comfortable. For children, ask parents what helps them feel calm)
Medications (if applicable)
Is client on any medication? Will it interfere with their ability to participate in session with you? (i.e. common issue in IOP settings, inpatient settings)
If so, could it be impacting their functioning? (e.g. client complains of severe irritability due to taking stimulant medication; you encourage client/parent to inform physician but also get consent to call physician and consult) Diagnostic impressions and
DSM 5 assessment measures
From a ____________________theoretical approach, and based on the above diagnostic impressions and case conceptualization, I will execute the following best practice interventions with client to address the identified presenting issues. I will research literature and consult with colleagues regarding any areas in question to ensure best practice and optimal outcomes.
Interventions used/to be used
Problem: (e.g. anxiety and being bullied)
Individual Intervention: (e.g. best practice CBT interventions to treat anxiety symptoms, process feelings related to being bullied, reframe any irrational beliefs connected to bullying, etc.)
System Intervention: (e.g. collaborate with teacher to consider moving client to another class away from identified bully to stabilize situation)
“To do” List: Issues and Questions needing further exploration
1. What questions do you have about the client/case?
2. Any questions regarding treatment?
3. Any to do list items? (e.g. counselor will call teachers to gather more info about client, call mother to gather more info about upbringing, family life at home, etc., call psychiatrist to coordinate care)
