Case Study
WK 6 Assignment – Individual Case Study
Prompt:
For this Diagnostic Case Conceptualization assignment, you will review and choose ONE of the case vignettes below and write-up the correct diagnosis [Remember, like with previous Diagnostic Case Conceptualization assignments, the correct diagnoses will be found within the Schizophrenia Spectrum and other Psychotic Disorders section of DSM-5]. These case studies are to help you prepare as a future clinician. Remember, that as graduate students and future clinicians, it is imperative that you are well versed in evidenced-based treatments and ways of understanding how to work within a diverse world.
To assist you in this process, just as it is important to understand evidenced-based treatments for specific diagnoses/symptoms, it is also essential that you learn how to find them and stay relevant with the research as treatments and conceptualizations change and advance. It will be important to integrate at least three relevant articles into answering the below questions. Remember to apply APA writing rules with correct formatting (e.g., title page, headings, subheadings, spacing, indentations, etc.), correct citations, and references (with reference page) to give credit and reference to the source of the claims/points you will make. Your paper should be 3 – 5 pages in length; you must be both succint and thorough.
Your Tasks:
In order to provide the most comprehensive diagnosis that accounts for the clients symptom presentation, this assignment will require you to:
Read the Case Study Vignette carefully, organizing the symptoms and other relevant factors.
Review and apply your material, along with outside resources from your own research, for this week to complete this assignment.
Identify and correctly code the most comprehensive diagnosis that accounts for the unique client presentation.
Succinctly and completely justify the diagnosis by linking symptoms with the specific diagnostic criteria they satisfy.
Provide two diagnoses you considered but ruled out. Remember to be very succinct on this section. Only identify the main symptom(s)/criterion that helped you rule out these diagnoses
After you have formally coded the diagnosis and thoroughly justified that diagnosis, you all will now:
Create a formal treatment plan with at least 1 long-term goal and 3 short-term goals (Remember, goals need to be SMART: Smart, Measurable, Attainable, Realistic, and Timely). Remember, with the formal treatment plan to be succinct
fter writing the formal treatment plan, explain the rationale for the evidenced-based treatments and interventions that can alleviate the symptom severity and or treat the client. Make sure that you support your claims with evidence
Discuss this diagnosis and treatment approach from a biopsychosocial model, which will require you to:
Describe the role biology plays with individuals who meet full criteria for your assigned diagnosis. Things to consider include, physical influences/symptoms, medication considerations examining their role and side effects, etc.
Discuss the emotional and mental impact on the individual assigned the diagnosis
What are the social impacts of the assigned diagnosis?
Along with the social impacts, consider the unique cultural impacts of this diagnosis within particular groups (e.g., Hispanic).
Case Study Vignettes (Choose only ONE to satisfy the requirements for this assignment)
Case Study 1 – Jonathan
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Jonathan is a 24-year-old US Army veteran who attends community college. He presented at the emergency room (ER) with his girlfriend and sister. Upon evaluation, the LCSW noted that he is tall, slim, and well-groomed with glasses. He speaks softly, with an increased latency of speech. His affect is blunted except when he becomes anxious while discussing his symptoms. Jonathan stated that he came to the ER at his sisters request. He has had a migraine for the past several days, which feels like sharp, shooting sensations in various bilateral locations in his head. He also describes a ringing sensation along the midline of his brain that seems to worsen when he thinks about his vices. For the last 2 months hes been experiencing hallucinations of a spiritual nature.
Jonathan identified his vices as being alcohol, cigarettes, disrespecting my parents, girls. He denied guilt, anxiety, or preoccupation about any of his military duties during his tour in Iraq, but he had joined an evangelical church 4 months earlier in the context of being riddled with guilt about all the things Ive done. Three months earlier, he began hearing voices trying to make me feel guilty most days. The last auditory hallucination was two days ago. During the last few months, he began noticing that strangers are commenting on his past sins.
Jonathan believes that his migraines and guilt might be due to alcohol withdrawal. He had been drinking three or four cans of beer most days of the week for several years until he quit 4 months earlier after joining the church. He still drank a beer or two every other week but felt guilty afterward. He denied any alcohol withdrawal symptoms such as tremors and sweats. He smoked cannabis up to twice monthly for years but quit completely when he joined the church. He denied using other illicit drugs except for one uneventful use of cocaine 3 years earlier. He sleeps well except on occasional nights when he could only sleep a few hours because he had to finish an academic assignment. Jonathan denied depressive, manic, or psychotic symptoms and violent ideation. He denied post-traumatic stress disorder symptoms. Regarding stressors, he felt overwhelmed by his current responsibilities, which includes attending school and almost every day church activities. He was a straight A student at the start of the school year but he is now receiving Bs and Cs.
In separate interviews, Jonathans sister and girlfriend both stated that Jonathon had been increasingly isolating himself and quiet. Previously, he used to be fun and outgoing. He also had never been especially religious. His sister believes that the church he has become involved with is brain washing him. His girlfriend however said that when she attended a church service with Jonathon, some of the congregation members told her they have occasionally talked to new members who felt guilt over their prior behaviors, but no one who had ever hallucinated before. They expressed that they were all worried about him.
Case Study 2 – Hector
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Hector is a 19-year-old Hispanic male who was brought to the emergency room by the campus police of the university he was suspended from a few months prior. The campus police were called by a professor who reported, Hector walked into his class shouting, I am the Joker and I am looking for Batman. When Hector refused to leave the classroom the campus police were called.
Although Hector was academically successful in high school, his behavior had become increasingly odd during the past year. He quit seeing his friend and spent most of his time lying in bed staring at the ceiling. He lived with several family members but rarely spoke to any of them. He was suspended from college as a result of nonattendance. His brother has seen him mumbling quietly to himself several time and note that he has also stood on the roof of this house waving his arms as if he were conducting a symphony. He denied any intention of jumping from the roof or thoughts of self-harm, but claimed he felt liberated and in tune with the music when he was on the roof. While his parents encouraged him to see someone at the Universitys student health office, Hector avoided doing so. There is no history of prior hospitalization.
During the last several months, Hector had become increasingly preoccupied with a female friend, Janet, who lived down the street. While he insisted to his family that they were engaged, Janet told Hectors bother that they had hardly ever spoken and certainly were not dating. Hectors brother also reported that he had written many letters to Janet but never mailed them; instead they accumulated on his desk. His family has never known Hector to use illicit substances or alcohol and his toxicology scree is negative. When asked about drug use, Hector appeared angry and did not answer.
Upon evaluation, the LCSW notes Hector is well-groomed young man who is generally uncooperative. He appeared constricted, guarded, inattentive, and preoccupied. He became enraged when the staff in the ER brought him some dinner. He loudly insisted that all of the hospitals food was poisoned and that he would only drink certain kinds of bottled water. He was noted to have paranoid, grandiose, and romantic delusions. He appeared to be internally preoccupied, although he denied hallucinations. Hector reported feeling bad but denied depression and had no disturbance in his sleep or appetite. He was oriented and spoke articulately but refused formal cognitive testing. His insight and judgment were deemed to be poor.
Hectors grandmother died in a state psychiatric hospital, where she lived for 15 years. Her diagnosis was unknown. Hectors mother was reportedly crazy. She had abandoned the family when he was young and his father and paternal grandmother raised him. Hector agreed to sign himself into the psychiatric unit, stating, I dont mind staying here, Anne will probably be here, so I can spend my time with her.
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