Case I – Read the following case narrative and then fill out the sections below. When you have completed the assignment, submit it as a word document or PDF in Blackboard.
Byron is a 25 year old single male who works as a server at a restaurant. He had been a solid B student in school, had a network of several close friends and generally got along well with his parents and younger twin sisters age 7.
Although he had no previous psychiatric history, Byron also was diagnosed with juvenile diabetes since age 3 for which he was prescribed insulin but it made him feel vulnerable to have to have self-administered insulin injections twice a day.
One day on the way home from the restaurant where he worked he was hit by a drunk driver and suffered several broken bones, internal injuries and had to be in the hospital for 6 weeks. Upon release from the hospital, on the way home in the family car, he began to experience extreme hyperarousal, fear and a sense of helplessness and horror, he had a flashback reliving the earlier accident and this was overwhelming to him. Once home he began to have regular nightmares of his accident and woke up in a panic so he was afraid to go back to sleep. After 4 weeks more of continued anxiety, arousal, hypervigilance and periods of feeling numb or angry, he agreed to seek counseling. He was also avoidant of riding in cars and tried to avoid any reminders of the accident.
Presenting Problem: (include demographic information, description of the problem in the client’s own words)
Trauma history: (explain)
Medical history:
Psychological assessment: (what assessments would be helpful)
Diagnosis: For DSM IV – If no diagnosis then put No Diagnosis on Axis I or No Diagnosis on Axis II. Also show how the diagnosis would look in DSM 5, 2013 format (see below)
DSM IV – Diagnosis
Axis I –(list primary diagnosis first)
Axis II –(Intellectual Disability (formerly called Mental retardation) and or *Personality disorder only)
Axis III-(Medical diagnosis/conditions)
Axis IV-(Psychosocial and environmental problems – *see below, describe and rate 0 – none to 9 – catastrophic
Axis V- (GAF)-Global assessment of functioning (0-100) in increments of 10 – 0-10 is lowest level of functioning)
DSM 5, 2013 diagnosis – List all diagnoses in one sentence starting with primary diagnosis. Add Note: Psychosocial and Environmental Stressors. Add Note: Global Assessment of Functioning.
Justification of diagnosis – List the symptoms that support the diagnosis/diagnoses
Case formulation – Explain how the disorder developed using one or more of the models of psychopathology (cognitive, behavioral, psychodynamic, biological, etc.). Include two recent references from peer reviewed journals supporting your explanation.
Treatment Suggestion: Include a supporting cited journal source for an evidence-based treatment.
For Axis II -If you think there is a personality disorder (or enduring/stable traits present since early childhood reflecting maladaptive, inflexible patterns of behavior) choose from- disorders below or list as traits if not enough information for a disorder
• Otherwise put no diagnosis Axis II on Axis II.
• Antisocial Personality Disorder
• Schizoid Personality Disorder
• Borderline Personality Disorder
• Paranoid Personality Disorder
• Schizotypal Personality Disorder
• Histrionic Personality Disorder
• Narcisisstic Personality Disorder
• Obsessive-compulsive Personality Disorder
• Passive-aggressive Personality Disorder
• Avoidant Personality Disorder
For Axis IV: Psychosocial and Environmental Problems
(From DSM-IV-TR, pp.31-32)
• Problems with primary support group – e.g., death of family member; health problems in family; disruption of family by separation, divorce, or estrangement; removal from the home; remarriage of parent; sexual or physical abuse; parental overprotection; neglect of child; inadequate discipline; discord with siblings; birth of a sibling.
• Problems related to the social environment – e.g., death or loss of a friend; inadequate social support; living alone; difficulty with acculturation; discrimination; adjustment to life-cycle transition (such as retirement).
• Educational problems – e.g., illiteracy; academic problems; discord with teachers or classmates; inadequate school environment.
• Occupational problems – e.g., unemployment; threat of job loss; stressful work schedule; difficult work conditions; job dissatisfaction; job change; discord with boss or co-workers.
• Housing problems – e.g., homelessness; inadequate housing; unsafe neighborhood; discord with neighbors or landlord.
• Economic problems – e.g., extreme poverty; inadequate finances; insufficient welfare support.
• Problems with access to health care – e.g., inadequate health care services; transportation to health care facilities unavailable; inadequate health insurance.
• Problems related to interaction with the legal system/crime – e.g., arrest; incarceration; litigation; victim of crime.
• Other psychosocial and environmental problems – e.g., exposure to disasters; war; other hostilities; discord with non-family caregivers such as counselor, social worker, or physician; unavailability of social service agencies.