Provide Diagnostic Impressions Based Coun 5006 Ca
Case Study Instructions
The Case Study assignment is designed to help you make application of course content to a counseling situation. You are to read the following case study, identify key issues, provide diagnostic impressions based upon the DSM-5, list broad treatment recommendations, and develop a full treatment plan. See the Case Study Template for the format and further details. Sections I.–III. should be 3–4 pages. Section IV. includes the treatment plan.
Case Study
Reason for Referral: Anna is a 34-year-old Caucasian female who is married with two children.She is self-referred for counseling due to her primary complaints of low mood and energy, difficulty getting out of bed for work and other daily activities, trouble concentrating at work, and excessive guilt.She stated she “just can’t get out of bed and get necessary things done…I’m afraid I’m going to get fired and that my husband, Frank, will leave me.”Anna has become concerned about her recent increase in consumption of wine in the evenings after work and on the weekend.
Current Situation and Functioning: Anna stated that she wakes around 5:30 a.m. most mornings, but struggles to get out of bed to help prepare her children for school and herself for work.She stated she feels like she is “moving in slow motion with 20-lb weights on each arm and leg.”The client described her mood as “depressed” and that in the past two months there has been little fluctuation in mood to normal range.When alone, Anna reports having crying spells 2-3 times per week that seem to go on for 30 minutes or more.She stated that she is still able to get the necessary activities and tasks of life completed, but feels exhausted much of the time.When asked about her work as an accountant, she reported being concerned about declining performance, although no colleagues or clients have complained or raised concerns.In recent weeks, she has increasing felt guilty and worthless due to her decline.Anna stated that she is typically optimistic, energetic, and upbeat, readily engaging in leisure and recreational activities with her family and friends—she misses this and is concerned she may not get it back. When asked about her presenting concern of increased consumption of wine, Anna reported being a social drinker with no previous problems who might have a glass of wine with meals or friends a couple of times a week.Lately, though, she will have 2-4 glasses of wine several evenings a week and one night on the weekends.The client believes she has kept this increase hidden from her husband and friends, but Frank has mentioned a couple of times in the past week or so that he is concerned about her and is glad she decided to come for counseling.
History of Present Concern(s): Anna reported that life had gone pretty well for her until recently.When asked if she had ever experienced any of the presenting concerns before in her life at any time, she stated she had not.The client reported that her “mood had always been normal, stable, and generally pretty good” and that her use of alcohol had never been more than her typical amount described above.Given the recent changes, Anna could only surmise that the unusually heavy load during tax season a few months ago may have affected her more than she realized.
Personal and Family Psychiatric Treatment:The client reported that she has never sought out or needed counseling or psychiatric treatment before.Anna stated that her parents were “pretty rigid and stoic” but did not believe they ever struggled with mood, anxiety, or other mental disorders.She did report that her maternal grandfather was a recovered alcoholic and her paternal grandmother struggled with depression.However, she was not aware that either of them ever sought or received treatment.
Relevant Medical History:Anna reported being in good health most of her life, with no known illnesses or chronic conditions.She did have her second of two children through cesarean section, but with no complications.She report no other hospitalizations.Because of Anna’s low energy and other changes, her primary care physician tested for hypothyroidism 3 weeks ago but results were normal.
Developmental History:According to Anna, her mother’s pregnancy with her was uneventful and that she met normal developmental milestones well with no delays or deficits.Instead, she described herself as a bright and energetic child who made friends easily, with several childhood friends still being described as close and supportive.
Family and Social History:Anna is the oldest of three children born to her biological parents.Her younger brother and sister were two and four years younger.The client stated she was “the little mother” but did not consider that to be excessive or dysfunctional, just the result of being a caring older sister.She reports have close relationships with her parents and siblings, that she was loved and knew it, but did not consider her parents to be warm and affectionate outwardly.Anna had one boyfriend in high school prior to dating her current husband, Frank.They have been together for 18 years, married for the past 13 years.She was 21 years old at the time of their marriage and states that although they’ve had typical ups and downs, their relationship is close and supportive.
Behavioral Observations and Mental Status Assessment: At the time of the interview, Anna had a fair complexion and was of slight build. She presented herself in a cooperative, friendly manner during the interview, was appropriately dressed for the season, and answered questions in a direct fashion. Her eye contact was appropriate. There was some evidence of psychomotor retardation as she moved lethargically during the interview. No other unusual physical characteristics or speech patterns were noted. No evidence of current drug or alcohol intoxication was observed.During the interview, Anna appeared alert and oriented x 4. While not formally assessed, she appears to have average to above average intelligence as evidenced by her vocabulary and reported GPA in college. There was no difficulty with questions assessing her recent or remote memory, although she complained of reduced concentration in recent weeks. Anna displayed a logical, sequential, coherent flow of thought. No tangential thinking, flight of ideas, or looseness of associations were noted.Thought content appeared to be within normal limits. No evidence of hallucinations, delusions, paranoid ideation, or ruminations was apparent. No compulsions or obsessions were reported.During the interview, Anna displayed mildly constricted affect and described her mood as depressed. While eye contact was appropriate, she seldom smiled even when describing an amusing incident. Her voice tone had monotone qualities and she often sighed during the interview. No history of manic-like symptoms was reported.Anna displayed adequate impulse control and judgment. These interview qualities are consistent with her history.
Substance Use Assessment:Anna reported her first use of alcohol was at age 14 when her parents allowed her small amounts of wine with special meals.Once of legal age, she would have a glass or two of wine with meals and at social events and that this pattern of usage has been stable until the past 6 weeks or so.She denied any other substance use.As described earlier, her recent use of wine has increased to 2-4 glasses of wine 3-4 times during the week and one evening on the weekends.Anna stated that she is not aware of any other family members with difficulties related to alcohol or other drug use, other that her maternal grandfather who was a recovered alcoholic since before she was born.
Risk Assessment:Anna low mood, recently increased use of alcohol, recent decline in performance, and recent work-related stress could be considered as risk factors for harm.Her protective factors include being characteristically resilient to stress, having an active and fulfilling religious life, and being a devoted wife, mother, and business partner.Although she has had fleeting thoughts of “not wanting to wake up” in the past month, Anna denies any active suicidal ideation, plan, or intent.She is considered to be at low risk of harm to herself.
Case Study Assignment is due by Sunday to SafeAssign and LiveText at 11:59 p.m. (ET) of Module/Week 7.