Liberty COUN5006 Diagnosis Treatment Plan Exam Worksheet

Question Description

Description

This is an open-book and untimed exam. Your primary resources for this exam are the DSM-5, course notes and books, and your personal notes taken during this class. You must do your own work in completing the exam; you may NOT receive help from others. Part I of the exam requires you to complete a diagnosis list (with rationale for each diagnosis) for four Case Studies. Be sure to write the number that identifies the case study otherwise it cannot be graded. Each student will have a different combination of case studies so identifying the cases you are assigned will be very important. (4 @ 60 pts each) Each case will have at least one primary diagnosis and at least one secondary diagnosis and/or Z-code. Part II requires you to choose one of the four previous case studies and develop a full Treatment Plan. (60 pts; exam total of 300 pts.)

Case 1D

Rosa is a 35-year-old woman who has been brought to the inpatient psychiatric unit by police after being arrested for trespassing on Mr. Bennett’s property. Upon arrival, Rosa is cooperative with the staff but becomes adamant about needing to be released. She states that she was simply entering her husband’s home when she was stopped by the police. Rosa adamantly declares that Mr. Bennett is her husband. She explains to the staff how much the two of them loved each other when they got married, and how she is currently pregnant with his child. She also states that she left her previous husband so that the two could be together.

Mr. Bennett reports that he used to be Rosa’s boss, and had fired her because of her inappropriate romantic advances three years prior. He also reports that her amorous advances have continued on a fairly consistent basis since then and that her breaking into his house is the last straw so he called the police. He does intend to pursue legal proceedings on the trespassing charge. Rosa reported to the police that this was nonsense and that he has kidded like this in the past about her breaking in. Rosa goes on to explain that this time the police believed his joke that she was someone who had broken into his house and removed her from the house. Rosa explains to the staff that this scenario of her “pretending” to break into the house is a common role play that she and her “husband” engage in. Rosa shares that she was previously married to another man in Florida, with whom she denies any current relationship, stating that she escaped a loveless relationship with him and moved to California to be with her husband, Mr. Bennett.

While Rosa reports that this situation of being arrested and being brought to the inpatient unit has been frustrating she does not report any symptoms of depression or anxiety. In addition, she reports no use of alcohol or substances except to have a glass of wine once or twice a week with Mr. Bennett. A substance abuse test revealed the presence of no drugs in Rosa’s system. In addition, a physical examination confirms that Rosa is not currently pregnant. A thorough psychosocial history reveals that Rosa is currently maintaining employment in a bank and has been employed there for the past two years. It is also discovered that she is maintaining her own residence and is in contact with family members (mother, father, sister) in Florida. When the family members are questioned they reveal that they thought Rosa was in a mutual relationship with Mr. Bennett as this is what she had explained to them. Although they had never met him they were not overly concerned as they do not have the funds to visit Rosa in California and she is too busy with work to make the trip home. Due to not being able to spend time together they had no reason to doubt what Rosa was telling them about her relationship. To be specific, nothing about what she shared seemed out of the ordinary or bizarre.

Although Rosa is hesitant at first to engage in treatment at the inpatient unit she reports that she is willing to attend counseling as this may assist with relationship issues that she and Mr. Bennett have been having.

 

Case 2A

Frank is a 27 year old, unemployed single male, who was released from jail three weeks ago after being arrested for a felony assault and battery. Frank is out on bond and has court in two months for a probation violation. He was ordered by the judge to attend an assessment and any recommended therapy as a condition of his bond. He was also ordered to abstain from alcohol and submit to random drug testing. Frank’s probation officer, who made the appointment, stated that if Frank misses any appointments or violates any conditions of his bond, he will be immediately jailed.

Frank reported “I do not see what the big deal is. I got into a fight. I get into a lot of fights. This time it got a bit out of hand and I put the other guy in the hospital. It is not my fault that the jerk picked a fight with someone who was a better fighter than he was.” Frank reported he does not know the individual he assaulted, stating that he was“ just some idiot at the bar”, and does not know the status of the individual’s well-being. “I am not calling that stupid hospital and checking on that loser.” Frank has been getting into physical fights since he was 10 years old. He was in detention for over two years for various assaults and other law violations prior to 18 years old and has been in and out of jail for the past 10 years. He stated that he has spent about 4 of the last 10 years in jail “a lot less than I should. I am just that good! I can break the law, steal, fight and sell drugs and not get caught. I figure 4 years is not bad considering how much I have really done.” Frank indicated that he has been purposefully breaking the law since he was 12 years old, when he was expelled from school. He did not complete high school and has never held a job for longer than 2 months at a time, stating, “They never pay what I can make selling drugs or stolen stuff on the streets. So why bother?” Frank expressed no remorse for any of his illegal or aggressive behaviors “this is who I am. The ladies love me. The cops fear me. What more could I ask out of life.”

Frank has never been in a serious relationship, even though he has three children with three different women. He has not contact with his children or their mothers. Frank reported he is the “world’s best liar” and that he has never been truthful with anyone. He gets into physical fights on a monthly basis and is often called “an impulsive hot head” by others. Frank reported no significant relationships and views others as simply pawns in “the game of getting what I want and deserve”. Frank stated he is never without a girl when he wants one, but often feels they are “more trouble than they are worth”. Frank stated that he has never planned anything and that “I live for the moment. Whatever happens at this moment is what I will deal with.” Frank reported that he was taken to a psychiatrist and counselor before he was expelled from school. He did not participate in treatment and refused to take his medications. His mother was never around and his father was in jail, so there were no adult figures to force compliance with treatment or school boundaries. Frank remembered being given some “label” about “being a really bad kid. Especially after I killed the cat at 11 years old and then broke my teacher’s nose at 12 years old” but he does not remember what he was diagnosed with at that time.

Frank indicated that the one thing about his life that does bother him is that he has been unable to secure a place to live. He is currently residing in a homeless shelter and has to be out of the shelter from 8 a.m. until 8 p.m. every day. He does not enjoy being homeless, but cannot find a place that will rent to him due to his multiple felony convictions and pending aggressive act. Because he often refuses to pay rent for the last 3-4 months he lives in a place, he has developed a reputation in the low income housing and private housing arena.

Case 3A

Ella is a 72 year old retired widowed female. Ella currently resides in an assisted living facility and has been there for three years. She was moved to the facility when her husband died and she could not care for her home or a majority of her physical needs. Ella was referred for assessment after she was discovered unresponsive in her room in the mid-afternoon. At first the staff thought she had experienced a stroke but upon closer examination it became apparent that Ella had passed out from alcohol consumption. Ella smelled of stale alcohol at the time of assessment and appeared drowsy. Ella admitted that she had consumed six beers prior to the mid-afternoon assessment.

Ella reported that she has been consuming more and more alcohol over the past three years. Prior to her husband’s death she would drink a glass of wine or beer with dinner three to four nights a week. Since moving into assisted living she has increased her drinking to the current level of 12-18 beers or two bottles of wine per day. Ella reported she is still allowed to drive, so the first activity of her day is driving to the neighborhood store to get her morning and afternoon drinks. She will then return in the late afternoon to get her evening drinks. Ella stated that she does not want the staff or other residents to know about her drinking so she spends a great deal of time hiding the containers and figuring out ways to get her drinks in without being caught. It is not against the assisted living facility rules, but she was embarrassed at how much she was drinking. Ella stated that she has tried to cut back for the past 18 months but has been unable. Each time she attempts to stop “I fail and become so angry with myself I drink more.” She has also attempted to limit the amount she drinks, planning to only have one drink with each meal. She has never been able to keep these boundaries in place due to “craving another drink”. She stated that she does not like drinking daily, but at this point she feels shaky, achy and “like I have the flu” when she does not have a drink by noon. Once she drinks the symptoms stop. She has also noticed that she can have 3-4 drinks without “getting buzzed and relaxing” which has led to the increase. “I hate living in this place and the only way I can stop myself from being so angry and sad is to drink.” Ella has been experiencing headaches and dehydration in the mornings. “The hangovers after I get drunk in the evening have been lasting longer. Sometimes they last so long I do not get out of bed until noon, then I have to get to the store quick.” Ella reported she gets noticeably intoxicated 2-3 nights per week. The rest of her drinking is described as “just trying to keep myself calm and from shaking”.

Ella reported feeling a great deal of guilt over her drinks and has been avoiding spending time with her children and friends over the past six months. She also avoids any type of social situation in the assisted living facility due to worry that the other residents will know she is drinking and will judge her. Her children and friends have been questioning her about the change in her social patterns. Her daughter specifically questioned why her once “social butterfly mother” would choose to spend every waking moment alone. Ella stated that she did believe she was “a touch depressed for six months after my husband died, but I do not feel depressed anymore.” Ella missed her children and friends and wants to have more social contact but she hates the assisted living facility, she resents having to leave her home and is angry about growing old and not being able to control her life completely. She wants to stop drinking but does not know how she will deal with her current life situation without the alcohol.

 

Case 4A

Joey is a 38 year old divorced father of two who is on disability due to a mental health condition. He decided to participate in an assessment and possible treatment after his fourth girlfriend since his divorce ended their relationship. His girlfriend told him that she was exhausted by his shifting moods and needed to find someone “more stable”. He also has been drinking more than he is comfortable with in an attempt to manage his “down moods”.

Joey was married for ten years. He has no contact with his children or ex-wife. He reported that his ex-wife complained of the same types of difficulties with him as his girlfriends have complained about. Joey reported that his mother described him as “a brooding child” and that he remembers his first significant depression at age 18. He described 12-15 episodes of depression that lasted anywhere from 8-10 months each. During these times Joey experienced daily sadness, daily feelings of hopelessness, daily difficulty getting to sleep and staying asleep, continuous feelings of fatigue and difficulty concentrating. He has been hospitalized three times for suicidal ideations and twice for “hearing crazy voices”. Joey has no desire to do the things he enjoys, like fishing and hunting, during these times and he isolates himself from friends and family. He stated that all his significant others have complained that during his depressions he “pushes them away. I feel like I do not deserve them or to live when I am sad. I feel like a wasted piece of junk during those times.”

Joey has been in treatment for his depression many times and has taken Prozac, Zoloft and Cymbalta in the past. He reported that they never seem to help and in his late 20’s medications set off a “crazy hyper time”. He has experienced three “crazy hyper” times where he needed only 2 hours of sleep and felt great. Daily for four weeks Joey would experience racing thoughts, initiate sex multiple times per day with his significant other, be very talkative and socialized non-stop. He indicated that during his “hyper” times he would believe he was “king of the world” and that he could do anything he put his mind to. Twice, towards the end of the four weeks, he began hearing voices and was hospitalized. It was at his first “hyper” hospitalization and third episode that the psychiatrist took him off anti-depressants and tried him on several medications to “even me out”. He would take the medications for 3-6 months after each hospitalization but when he dipped into a depressed episode he would stop taking the medication. “The drugs made me feel terrible and then I would get depressed anyway… so why take the stupid things.”

Joey has been a client at the local community mental health agency. He receives case management and psychiatric services. He will comply with treatment after hospitalization but as soon as he starts in another depressed episode he will stop attending. Joey believes that the level of treatment he receives is not helpful and began drinking alcohol 5 years ago to help manage his depression. “When I feel normal I drink 2 beers a day, when I am depressed I will drink 6-8 a day. I do not like drinking so much, but when I am depressed it takes more and more beer to make me forget what a loser I am.” Joey indicated that two years ago he had a significant depressed episode and began drinking 8-10 beers per day. He has struggled since that time to cut back on his alcohol intake. He has attempted multiple times to cut back and verbally berates himself for not cutting back after the depression lifted. “I used to have a handle on my drinking but for the last 18 months I have felt a bit out of control.” Joey admitted that this past two girlfriends complained about his drinking and attributed the end of the relationships to both his depression and alcohol use. I would like to stop, but when I am not drinking all I think about is the next drink. Joey stated that he is currently in a “down time” and has not had a “hyper time” for over 18 months. He has had two distinct “down episodes” since his last “hyper episode”. Joey reported that he would like to go back to work someday but the episodes have made it impossible to hold a job for longer than two years at a time. “Being on disability makes me feel like a huge loser.”

Treatment Plan

 

Treatment Plan Assignment

At the time of intake a history reveals that Roberta is a Caucasian female, 53 years of age, and single again. She divorced her second husband about 4 years prior to intake. Throughout her life, she had been hospitalized several times (more than once for depression), and has been prescribed a number of psychotropic medications during much of her adult life: Lithium, Depakote, Tegretol, and most recently Wellbutrin. Roberta has three children, all born to her early in her adult life with a live-in lover, with whom she broke off an engagement after 13 years of a live-in relationship. She has been married twice. Her relationship with her children is fair, with the exception of her youngest daughter, age 24, who exhibits anti-social behavior.

The assessment reveals that her story is one of episodic physical abuse in her family of origin. She has, as an adult, shown erratic behavior including excessive spending and holding grandiose ideas about her self-worth and intelligence. Many years ago, she wrote Oprah that she was the “perfect case” for one of Oprah’s TV shows with “Dr. Phil.” She has tended to write high-profile celebrities and then if anyone responds (even with a very general cover letter), she tells people that she is now “working” as an assistant or agent for the person. She had also spread the story that she was working undercover with the FBI.

She smokes cigarettes and has been diagnosed with congestive heart failure. She states that she wants to die, but gives no indication of active suicidal ideation, plan, or intent. She has also had numerous doctors of varying kinds. If one MD did not suit her in some way, she would go to another. Often, her primary rationale was to find an MD that saw her as gifted intellectually. Just prior to intake, she had stopped taking her medications, and become manic and forgetful. Her work performance has been very erratic over the years. Though gifted in sales, she has struggled to maintain jobs. Her current supervisor told her that she needed to straighten herself out or he would discharge her