1. Case SummaryProvide a brief summary of      what you have learned about the individual reviewed in the case. Include information about the individual      in terms of demographics and gen

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1. Case Summary

  • Provide a brief summary of      what you have learned about the individual reviewed in the case. Include information about the individual      in terms of demographics and general history, and the sources of that      information, and the reason that the individual was referred, and by whom.
  • Summarize any information      you may have about evaluations that have been conducted, including the      results.


2. Clinical Impression (Diagnosis)

Write the clinical impression in the DSM-5 format:

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XXX.xx (Yyy.yy) Primary Diagnoses (list in order of salience).

(DSM-5 Code is first, as in XXX.xx, and ICD-10 codes next, in parentheses.)

OTHER FACTORS:

Use the V and Z codes, or simply appropriate descriptors to psychosocial and contextual factors of importance to the diagnostic case. These replace the DSM-IV-TR Axis IV & V used to address these concerns.


3. Recommendations

Explain any recommendations for interventions, treatment, and/or disposition.


4. Questions

Address the specific questions that were asked in the instructions for this assignment.

Here is a sample assignment question and an appropriate brief response:


Question: Describe what further information you would need to accurately diagnose this case.

1. Case SummaryProvide a brief summary of      what you have learned about the individual reviewed in the case. Include information about the individual      in terms of demographics and gen
Case Study of Kimberly (Part One) Case Study of Kimberly, Part One Kimberly is a 17-year-old female brought in for an evaluation by her mother, Diana. Even before you meet them, you hear the commotion in the waiting room, which concludes with Kimberly calling Diana a “stupid fucking bitch” and kicking a chair across the room. Once in your office, the contrast between them is striking. The family lives in one of the pricier suburbs, and Diana works as an advertising executive. She is successful and well regarded, as is her husband, Kimberly’s father, who works in international banking. Diana says that he regrets not being present, but there was a sudden meeting in Barcelona that required his attention. Diana is well-dressed, poised, and soft-spoken. Kimberly, on the other hand, is quite gaunt, surly, noticeably unwashed, and dressed in full anarchist punk regalia. You count 11 piercings, some quite large, involving her tongue, lower lip, both nostrils, one eyebrow, and both ears; there may be more hidden by her dramatically dyed and styled hair. Diana gives the following account as Kimberly shreds a Styrofoam cup, dropping the small pieces on the carpet, sighing loudly, scowling, and mumbling, “Bullshit.” Diana notes that she and her husband have “bent over backwards” to accept Kimberly’s “lifestyle choices” and her friends. Kimberly has not been appreciative, but they understand that adolescence is a difficult time. In the past few months, however, Kimberly has lost 25 pounds and has become verbally abusive. She also displays dramatic mood swings and is physically violent, and she is completely disengaged from school, family, and her old friends. She has also taken to hoarding strange objects, and Diana has noticed strange burns on Kimberly’s arms. Diana has concluded that Kimberly has developed an eating disorder and is perhaps engaging in self-mutilation. Diana fears for Kimberly’s health and for the loss of educational opportunity that will occur if Kimberly continues nonparticipation in the expensive private school she attends. When you ask Kimberly her view on her mother’s concerns, she says, “Whatever.” You take some initial background information. Kimberly has one sister, four years older, who attends an Ivy League school on the East coast. Her sister had “eating disorder issues” in her freshman year in college, but worked through them in therapy and is now doing well. Diana reports that Kimberly was without problems until last year, when she began hanging around “a rougher element.” Kimberly and her friends often spent weekends in a cabin in an isolated rural area, and Diana initially discounted the dangers of these rougher companions, thinking, “How bad can they be if they are into nature?” When questioned, Diana says that Kimberly has been hoarding all sorts of odd flasks and containers, “just junk,” but Diana has not otherwise examined them because they smell bad. “They must be filthy; I wonder if she got them out of a dumpster.” She also reports that Kimberly has broken furniture, driven one of the family sports cars through the rose garden in a rage, and very recently physically threatened the housekeeper when she attempted to clean Kimberly’s room, to the extent that the housekeeper quit. Diana has spoken to her other daughter’s therapist, who suggested that as the eating disorder worsens, Kimberly’s self-esteem is plummeting, and as a result she associates more with “degrading people and objects.” The therapist speculated that Kimberly might be giving herself cigarette burns. Diana also notes that Kimberly has taken up cigarette smoking in this period, and “smokes like a chimney.” Use this outline to structure your case assignments. Case Summary Provide a brief summary of what you have learned about the individual reviewed in the case. Include information about the individual in terms of demographics and general history, and the sources of that information, and the reason that the individual was referred, and by whom. Summarize any information you may have about evaluations that have been conducted, including the results. Clinical Impression (Diagnosis) Write the clinical impression in the DSM-5 format: XXX.xx (Yyy.yy) Primary Diagnoses (list in order of salience). (DSM-5 Code is first, as in XXX.xx, and ICD-10 codes next, in parentheses.) OTHER FACTORS: Use the V and Z codes, or simply appropriate descriptors to psychosocial and contextual factors of importance to the diagnostic case. These replace the DSM-IV-TR Axis IV & V used to address these concerns. Recommendations Explain any recommendations for interventions, treatment, and/or disposition. Questions Address the specific questions that were asked in the instructions for this assignment. Here is a sample assignment question and an appropriate brief response: Question: Describe what further information you would need to accurately diagnose this case. Response: To diagnose this case accurately, I would also need to review any pertinent medical records. I would want to interview this client’s mother, with whom he lives, to corroborate the clinical interview data supplied by the client, and to learn more about his developmental history. I would also want to… Mental Status Evaluation (MSE) Checklist Appearance Physical Appearance. Client appears stated age, appears older, or appears younger, hairstyle, fingernails, and so on. Dress. Appropriate, clean, pressed, wrinkled, disheveled, and so on. Hygiene. Clean, well groomed, presence of body odor, and so on. Behavior and Mannerisms Gait limping, slow, hurried, and so on. Posture. Slumped or rigid. Eye Contact. Mannerisms. Foot tapping, eye blinking, hand rolling, head nodding, and so on. Attitude Toward Interviewer. Toward Treatment. Toward Others. Mood and Affect Mood. Sad, elated, happy, bored, and so on. Affect. Outward expression of mood such as smiling, frowning, crying, or laughing. Appropriateness. Does the affect match the mood and the situation? Speech Quantity. Talkative, poverty of speech, and so on. Quality. Circumlocution, monotonous, loquacious, loud, and so on. Rate of Production. Mumbles, slow production, pressured speech, and so on. Perceptual Disturbances Hallucinations. False perceptions. Illusions. Misperceptions of reality. Thought Thought Content. Delusions, obsessions, phobias, suicidal ideation, homicidal ideation, and so on. Thought Processes. Flight of ideas, poverty of thought, relevancy, and so on. Sensorium and Cognition Alertness. Awareness of surroundings, goal-directed thinking, responding to the environment, and so on. Orientation. Person, place, time, and situation. Memory and Concentration. Remote, recent past, recent, and immediate recall. Abstract Thinking. Conceptual thinking, ability to understand abstract ideas, ability to use inductive and deductive reasoning. Intellect and Fund of Knowledge basic knowledge and intelligence. Impulse Control Sexual. Ability or lack of ability to control sexual impulses. Physical. Ability or lack of ability to control physical impulses such as hitting, biting, or yelling. Social. Ability or lack of ability to control social impulses. Judgment and Insight Social Judgment. Awareness of others, empathy, social decision making, and so on. Insight. Awareness and understanding of one’s mental illness, insight into cause, effect, and course of illness. Reliability. Is the client a good source of information, is he or she honest, aware, and able to report to the therapist his or her daily happenings? 4

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