MMbAssignment 2: LASA: Etiology and Treatment
Jessica Case: Psychological Evaluation
Confidential: For Professional Use Only
Date of Birth:
Date of Evaluation: Clinician:
Reason for Referral
Jessica E. Smith 7-18-68
S. Freud, PhD
Smith was referred for a psychological evaluation by Bart Jackson of the Division of Vocational Rehabilitation to assess her current level of cognitive, behavioral, and emotional functioning and to provide recommendations for vocational service planning.
The following background information was obtained from an interview with Smith and a review of the demographic information sheet that she completed before the evaluation.
Smith is a forty-one-year-old Caucasian female who was referred for a psychological evaluation by the Division of Vocational Rehabilitation to assist with determining eligibility and to assess whether her emotional problems are interfering with her ability to work. She initially requested assistance from the Division of Vocational Rehabilitation in October 2008 to assist her with maintaining employment. At this time, she is interested in learning new skills to enable her to find full-time work in an office setting.
Smith was born in Jersey City, New Jersey, and raised in a small nearby town, Williamsport, Pennsylvania. She is the oldest of three children born to her mother and father following an uncomplicated pregnancy and delivery. Her younger sisters relied upon her for their after-school child care once their mother returned to work when she was twelve years old. She spoke of her mother as having been physically and emotionally abusive in the past, often yelling, hitting her, and pushing her around. While her mother took her frustration out on Smith, her father would drink alcohol in excess. To cope with the difficult situation at home, she began to drink alcohol and cut herself with a straight-edged razor. Smith was active in school-related activities. She did not receive special educational services or have significant behavioral problems in school, describing the classroom as a safe place where she could be a ―kid.‖ Smith graduated from high school and began attending a business college in Allentown, Pennsylvania.
After attending classes for several months, Smith dropped out to spend more time with her friends and to begin working at various part-time jobs. She has worked as a waitress, in a grocery store, and as a babysitter. After leaving school, Smith returned home, where she began spending time with old friends who drank alcohol and used recreational drugs. By the age of eighteen, she had begun to starve herself and burn herself with a lighter. Her second to youngest sister was killed in a car wreck around this time. To assist her with coping, Smith began to drink on a regular basis and rely upon crank (crystal meth) to regulate her mood. She attempted suicide by taking someone else’s prescription medications and slitting her wrists. She was subsequently hospitalized on a psychiatric unit for one week. After discharge, Smith did not follow through with recommendations to follow up with outpatient counseling. Instead, she resumed her alcohol and drug use as a means of coping with the emptiness that she was feeling inside. As her substance use became more problematic, Smith began to participate in inpatient and outpatient substance abuse programming. She met with a counselor at the local community mental health center and was admitted to a residential rehab program. She has remained drug free since leaving the program in 2004; however, she has had difficulty in remaining sober. Smith has been arrested three times for drinking under the influence (DUI) and at times, has temporarily lost her driver’s license. In November 2005, she sought mental health services again to assist her with remaining sober and to address her underlying history of depression. She continued to attend outpatient counseling on a sporadic basis until August 2006 when she recognized that her depressed mood rendered her incapacitated. Thus, she began attending two individual psychotherapy sessions per week, biweekly psychiatric consultations, and participating in weekly home- based case management services.
Smith identifies her eight-year-old daughter and her boyfriend as her supports and sources of motivation to remain sober. She describes having had a series of physically and emotionally abusive relationships with men in the past, which have affected her mood and ability to cope with difficult situations. Smith has often become depressed and had thoughts of suicide after a relationship has ended. She acknowledges turning to alcohol or isolating herself when she feels overwhelmed. She initially moved to Jersey City two years ago to get away from the people whom she described as ―bad influences.‖ She has worked part-time at a local grocery store and participated in the vocational rehab program to assist her with returning to work. Despite their interventions, Smith has failed to maintain employment for longer than six months. She has also described herself as having difficulty maintaining friendships and trusting others. Smith currently lives in New Jersey with her daughter. She is unemployed and receives food stamps and Medicaid.
Smith is a Caucasian female of average build who appeared to be her stated age. She was dressed casually and her grooming and hygiene were adequate. She wore small, round-framed glasses with her short-brown hair pushed back behind her ears. She maintained good eye contact with the examiner, often pushing her glasses up on her nose or placing her hair behind her ears as she spoke of something that made her feel uncomfortable. Smith was cooperative during the evaluation, appearing motivated to answer all questions posed to her in an honest and forthright manner. She seemed alert and well rested, relating appropriately to the examiner. Smith often apologized for not knowing an answer to a test item or stated that she could not do something that she perceived as difficult.
Tests Administered · Wechsler Adult Intelligence Scale®—Third Edition (WAIS®–III) · Wide Range Achievement Test—Third Edition (WRAT-3) · Minnesota Multiphasic Personality Inventory: Second Edition (MMPI-2) · Bender Visual-Motor Gestalt Test · Clinical Interview
Mental Status Examination Results
Smith reports an extensive history of mental health treatment, having received inpatient and outpatient treatment for depression and substance abuse. She has been prescribed Prozac, Paxil, Remeron, Klonopin, Xanax, Valium, and Librium to assist with managing her depressive symptomology and difficulties with controlling her anxiety and physical withdrawal from alcohol and methadone. Smith’s attitude toward this evaluation seemed quite positive as evidenced by her interest in participating in the evaluation and self- report. She appeared to answer all questions honestly and did not appear to be irritated with the evaluation process. Her responses were spontaneous and she needed minimal redirection to respond to the questions that were asked of her. Smith was oriented to person, place, and time and denied having experienced auditory or visual hallucinations. She denied current thoughts of suicide; however, she acknowledged having attempted suicide as a teen. Smith reportedly used a razor blade to slash her arms, hit herself with a hammer in the face, took someone else’s prescription medication, and burned her arms with a lighter after fighting with her mother, breaking up with a boyfriend, feeling rejected, and losing her younger sister. She reported having had a couple of mutually fulfilling relationships in the past, although she indicated that she had difficulty getting along with people. Her remote and recent memory showed no signs of impairment; however, her ability to make realistic life decisions was marred. Medical history is significant for a back injury that occurred following a car wreck (1984) and removal of her gall bladder (1996). Since the car wreck, Smith has experienced lower back pain when lifting heavy weights or moving in an awkward fashion. Assessment Results and Interpretations
The WAIS®–III was administered to obtain an estimate of Smith’s current level of cognitive functioning. The results from this evaluation suggest that Smith is functioning within the Low Average range of cognitive functioning with no significant difference evident between her verbal and nonverbal reasoning abilities. Overall, Smith demonstrated abilities ranging from the Low Average to Average range with relative strengths in her word knowledge, categorical thinking, and ability to distinguish essential from nonessential details with a relative weakness in her abstract reasoning skills.
Smith’s WRAT-3 performance showed high school–level reading, eighth grade–level spelling, and fifth grade–level arithmetic skills. She achieved a Low Average range standard score on the reading and spelling subtests with a Borderline range standard score on the arithmetic subtest. She reported having had difficulty with arithmetic in school and often becoming too anxious to complete her assignments or finish test items. Thus, this score is likely an underestimate of her current level of functioning. Results suggest that her fundamental academic functioning is below average; however, due to the lack of discrepancy between her achievement and intelligence test scores, the presence of a learning disorder was not evidenced.
Visual Processing and Visual–Motor Integration
Smith’s ability to reproduce or copy designs was assessed on an instrument involving visual–motor integration and fine-motor coordination. She appeared to accurately see the stimulus figures and understand what she saw; however, she had difficulty translating her perceptions into coordinated motor action. She completed the Bender-Gestalt test in two minutes, forty-two seconds and incurred four errors of distortion and rotation. A short completion time such as this is often associated with impulsiveness and limited concentration.
Personality Assessment Results
The MMPI-2 was administered to assess Smith’s personal attitudes, beliefs, and experiences. Smith’s MMPI-2 profile suggests that she acknowledges that she is experiencing a number of psychological symptoms. She is likely to be experiencing a great deal of stress and seeking attention for her problems. At times, Smith comes across as a confused woman who is distractible, has memory problems, and may be exhibiting personality deterioration. Thus, she is in need of intensive outpatient therapy and psychotropic medication to continue to address her long-term personality problems. Smith might be described as an angry woman who is immature, engages in extremely pleasure-oriented behaviors, and feels alienated. She is likely to feel insecure in relationships, act impulsively, and have difficulty developing loving relationships with others. She often manipulates others (men) and may hedonistically use other people for her own satisfaction without concern for them. She has difficulty meeting and interacting with other people, is uneasy and overcontrolled in social situations, and tends to be rather introverted.
Smith has a negative self-image and often engages in unproductive ruminations. She frequently reports having numerous somatic complaints when she is anxious and feels as though other people are talking about her. Under stress, her physical complaints will likely exacerbate. Her insight into her problems is limited and she often attempts to find solutions that are simple and concrete. She may prefer to be alone or with a small group due to feeling alienated from the environment. She often exhibits poor judgement, emotional liability, and impulsivity. Smith may become upset easily and overreact to situations. Her profile reflects a chronic pattern of maladjustment, which may affect her ability to solve problems and fulfill her obligations. It is likely that Smith has a history of underachievement in school and in the work force due to her inability to cope with difficult situations.
M3 Assignment 2 RA,
Jenny Smith is a 41-year-old woman living with her husband and her eight-year-old daughter in Jersey City. She is currently unemployed and survives on Medicaid and food stamp. Jenny frequently takes alcohol and isolates herself whenever things are overwhelmed with situations. The motive for her stay in Jersey was to keep off peers who she believes brings terrible influence on her life with regards to drugs and alcohol. The primary diagnosis for Smith is acute stress disorder (ASD) because she has experienced traumatic events in her past life.
Smith has been struggling with alcohol and substance abuse. She has difficulties in maintaining her job and often resorts to substance and drug abuse whenever she feels depressed Jenny has a problem staying sober even after having gone through individual psychotherapy sessions in the past. She has emotional instability, and sometimes contemplates suicide. Smith cannot cope with the challenges of life. Smith is socially withdrawn from people whenever he is sober, and whenever she is experiencing difficulties in life. She is incapable of controlling her alcohol and drug addiction. Smith has low self-esteem and has a negative self-perception. This attitude can be a significant contributing factor to the drug addiction behavior since she tries to be the happy app the time through substance and drug abuse.
Acute Stress Disorder
Acute stress disorder (ASD) or post-traumatic stress disorder (PTSD) is a metal condition signified by experiencing imaginations of adverse events that happened in the past. People with this disorder tend to avoid people, specific places, and activities that bring back negative memories of past experiences (McKinnon et al., 2016). Individuals may have difficulty sleeping, are jumpy, and are easily angered or irritated by specific actions. The required stressors for this condition include exposure to life-threatening situations, or learning that a loved one’s life was exposed, or loss of a loved one, intrusion symptoms such as unwanted negative memories, flashbacks, and emotional distress (McKinnon et al., 2016). Smith’s conditions fit these criteria since she was consistently beaten by her mother when she was young, her sister who. Jenny was close to died in an accident, and she also almost got an accident. She has even gone through negative experiences in the past relationships with men who beat her up. The traumatic memories hurt her well-being because Jenny resorts to alcohol, and avoids people. As such, what she has gone through makes it likely that she has ASD. It is the most likely disorder affecting her according to the experiences that she has had in life, thus making it the primary diagnosis.
Non Suicidal Self-Injury Disorder
Non-suicidal self-injury disorder is a mental condition signified by the tendency to intentionally inflict pain and injury to oneself without thinking about ending one’s life (Zetterqvist, 2015). The criteria for a condition to be regarded as this, there should be at least five attempts to inflict bodily injury in the past one year. The damage is related to an irresistible behavior, negative cognitive state, negative emotions, and thoughts such as depression or sadness, low self-esteem, the act lead to clinically significant injuries, and the behavior are not exhibited during periods of psychosis, or mental condition (Rudd et al., 2015). Smith’s tendency to inflict injuries on herself points to the possibility that she may have this disorder. This disorder has been considered as a secondary diagnosis because the frequency at which she injures herself within one year has not clarified. Besides, this behavior can be as a result of another mental disorder.
Differential Primary Diagnosis
Dysthymia is a chronic condition in which the patient always feels depressed. Patients often experience some periods of ordinary life that can span into days and even weeks. The criteria for determining the presence of this disorder is sleep disturbance, e feeling of inadequacy and everything does not seem to be useful in life (Vandeleur et al., 2017). The sufferers are usually able to cope up with the demands of day-to-day life. The onset of the disorder is often in late teenage and the twenties.
Furthermore, there is a lack of interests in leisure activities or almost everything in the most time of the day, which can continue for many days. The patient also has reduced the ability to stay focused for a long time. The reason why this Smith can be suffering from neurotic depression is that she exhibits these symptoms. Smith’s health issues started during her teenage years when she dropped out of school to join alcohol and drug-addicted peers. Jenny has a feeling of guilt and worthlessness whenever in social environments and avoids people as much as possible can. Further, she feels normal on some occasions, but sometimes the depression overcomes her to the extent that she resorts to alcohol and drug abuse. This is the primary differential diagnosis since all the descriptions of the disorder fit what Smith is going through, except that in this disorder, there are no traumatic experiences to qualify thereby making it the differential primary diagnosis.
Differential Secondary Diagnosis
Severe Alcohol Use Disorder
Smith may likely be suffering from acute alcohol use disorder (SAUD). Many symptoms are associated with SAUD that indicate the presence of the disease. The DSM-5 provides 11 criteria which indicate that someone is suffering from the disorder depending on the severity. A person is said to be suffering from SAUD if he/she has at least six of the 11 symptoms provided in the MSM-5 (Connor, Haber & Hall, 2016). Smith can be suffering from this disorder because she exhibits the following symptoms that are among the 11 in the list. She has wanted to quit drinking or reduce her intake but has not been able to more than once.
Further, Smith spends a lot of her time drinking alcohol and also takes time to get over the aftermath of drinking. She sometimes ends up drinking more alcohol than she originally planned, and take more than planned time in drinking. Another DSM-5 pointer of SAUD depicted by Smith is that alcohol consumption or the sickness effects that it brings have often made her lose her work, and made her quit school. Another pointer is that Smith has given up essential activities such as visiting relatives and games for the sake of alcohol (Connor, Haber & Hall, 2016).
Another element that exhibited by Smith is that she has on some occasions got in dangerous situations after drinking alcohol, and has also increased her chances of sustaining injuries. Finally, Smith has continued to drink alcohol despite often feeling depressed and anxious as a result of alcohol abuse. Smith exhibits almost all the symptoms in the SAUD category. Smith has been having trouble controlling her alcohol addiction. Alcohol on one occasion endangered her life when she was driving under the influence and lost control of the vehicle, which made her license to be revoked. Smith has also been unable to resist the urge to drink even when acknowledges that her depression is at a high. This weakness coupled with the fact that alcohol has derailed her personal and professional growth indicates that she is suffering from SAUD. Nevertheless, Jenny also takes recreational drugs, which can have similar or worse effects, although it is not clear whether Jenny has taken recreational drugs in the past one year. Although Smith has SAUD, this disorder may have been propagated by the difficulties that she has experienced in her entire life thereby making this diagnosis to be the differential secondary diagnosis.
The possibility of Appropriateness or other diagnoses
According to the symptoms that Smith is experiencing, other diagnoses can work for her. This is because the criteria for determining the complications that she is suffering from are related. Besides, the descriptions of her experiences; the symptoms that she feels; and her lifestyle and behaviors induced by the disorder fit in a wide variety of diagnoses. As such, any determination different from the provided ones can be applied depending on the extent to which she can cooperate. However, when other diagnoses with which her disorder share similar symptoms are used, it will be recommended that they are applied in combination rather than be used singly. This is because their remedies may not be as comprehensive as the ones that will be applied for the regular diagnoses.
Why the Actual Diagnoses are a Better Fit than the Differential Diagnoses
The actual diagnoses are a better fit than the differential diagnoses because according to the symptoms of Smith’s disorders, there are elements in which her life was threatened at one time or another. From her history, she had experienced traumatic events when she was young, which have the potential to leave a trail of disturbing memories. The traumatic events are usually signified by severe depression that can significantly interfere with a person’s normal life operations. Therefore, the actual diagnoses are a better fit than the differential ones since they both involve a scenario in which the patient or their loved ones were in life-threatening conditions one time during their lifetime, and the memories persist.
During her development, Smith had terrible childhood experiences. Her mother frequently assaulted her and did not relate with her kindly while her father was an alcoholic who never defended her. These frequent abuses by her mother may have led to the development of anxiety and depression. Furthermore, in the course of her development, one of her siblings died, which also may have contributed to her psychological and emotional issues. Smith dropped out of high school and joined peers who influenced her into drug abuse. She has attempted suicide on several occasions and has also inflicted pain to her body using objects. Her adulthood frustrations are likely caused by abusive boyfriends. Smith has been on individual psychotherapy, psychiatric consultations, and has undergone a home-based care system. The primary diagnosis for Smith is acute stress disorder (ASD) because she has had traumatic experiences on many occasions in her past life.
Connor, J. P., Haber, P. S., & Hall, W. D. (2016). Alcohol use disorders. The Lancet, 387(10022), 988-998.
McKinnon, A., Meiser‐Stedman, R., Watson, P., Dixon, C., Kassam‐Adams, N., Ehlers, A., … &Dalgleish, T. (2016). The latent structure of Acute Stress Disorder symptoms in trauma‐exposed children and adolescents. Journal of Child Psychology and Psychiatry,57(11), 1308-1316.
Vandeleur, C. L., Fassassi, S., Castelao, E., Glaus, J., Strippoli, M. P. F., Lasserre, A. M., … & Angst, J. (2017). Prevalence and correlates of DSM-5 major depressive and related disorders in the community. Psychiatry research, 250, 50-58.
Rudd, M. D., Bryan, C. J., Wertenberger, E. G., Peterson, A. L., Young-McCaughan, S., Mintz, J., … & Wilkinson, E. (2015). Brief cognitive-behavioral therapy effects on post-treatment suicide attempts in a military sample: results of a randomized clinical trial with 2-year follow-up. American Journal of Psychiatry, 172(5), 441-449.
Zetterqvist, M. (2015). The DSM-5 diagnosis of nonsuicidal self-injury disorder: a review of the empirical literature. Child and adolescent psychiatry and mental health, 9(1), 31-46.
you reviewed a case study about Jessica, made primary and secondary diagnoses, and identified differential diagnoses for each principal and secondary diagnosis. The skills you developed and the feedback you received after completing this required assignment, will significantly help you in completing the following LASA. For example, both assignments (RA and LASA), require you to complete similar tasks such as identifying the principal and secondary diagnoses, providing rationale for the diagnoses, and offering differential (alternative) diagnoses.
In this assignment, you will discuss the etiology and treatment of your principal and secondary diagnoses for the following case study using a minimum of five peer-reviewed sources on etiology and a minimum of five peer-reviewed sources on treatment. Your paper should have separate sections for the etiology of each principal and secondary diagnosis, therapeutic modalities for each principal and secondary diagnosis, justification of the selected therapeutic modalities for the disorders, application of the treatment for the disorders, and a reference page for your sources. Your citations and references should be in APA style, and your paper should be 8–10 pages in length.
read the second case study (Psychological Evaluation for Homer Brine).
Confidential: For Professional Use Only
Date of Birth:
Date of Evaluation: Clinician:
Reason for Referral
Homer Brine 1-11-65 7-30-08
A. Adler, PhD
Brine was referred by the Division of Family Services for a psychological evaluation to assess his current level of cognitive, behavioral, and emotional functioning and to provide recommendations for outpatient mental health services and family reunification.
The following background information was obtained from an interview with Brine and a review of available records.
Brine is a forty-three-year-old Caucasian male who was referred for a psychological evaluation by the Division of Family Services to assist with providing recommendations for outpatient mental health services and family reunification. He became involved with the Division of Family Services after he was arrested for sexually abusing his daughter. Brine was informed that the results of the evaluation would be utilized to develop opinions and conclusions regarding the likelihood that he would revictimize his daughter. In addition, he was told that the report or the examiner might appear at his court proceedings to give evidence regarding his past, present, or potential future mental state. Brine chose to participate in the evaluation recognizing the nature of the evaluation and its purpose.
Brine was born in York County, Pennsylvania, in a rural farming community near the Maryland state line. He was the older of two children raised in a ―traditional Christian home.‖ When Brine was a young boy, his family moved to Wheeling, West Virginia, due to his father’s employment with a mining company. Brine’s mother was a ―stay-at-home mom‖ who was actively involved in her sons’ school-related activities. Brine described his parents as hardworking people who always supported him. He reported that he had begun having school learning problems in middle school related to comprehending and retaining learned materials. Brine described himself as a ―quiet‖ child who ―always had difficulty in school.‖ He described being involved with special educational services throughout his secondary education (middle school and high school). He received small group instruction and individualized assistance with learning arithmetic skills, developing memory skills, and improving his comprehension. Brine was an impulsive, distractible, and active boy who had difficulty completing school assignments and interacting with peers in the classroom. He obtained part-time employment after school and during summer vacations and worked for the Natural Services Department cleaning campgrounds. Although Brine enjoyed working for the Natural Services Department, he was unable to obtain full-time employment after his high school graduation due to his learning problems.
Brine continued to live with his parents after he graduated from high school, moving back to York County, Pennsylvania, with his family after his father lost his job (was laid off). He reported having felt awkward in social situations throughout his teenage years, choosing not to date due to a fear of being rejected by his female peers. Brine’s difficulty with social skills not only affected his interactions with others but also interfered with his ability to communicate with his coworkers and supervisors in a work-related environment. He has had difficulty maintaining employment as evidenced by his history of losing jobs due to poor attendance and insubordination. After many failed vocational pursuits, Brine and his family began working
with the Office of Vocational Rehabilitation (OVR) to assist him with job training and social skills development. He described having participated along with several work crews doing janitorial work at local schools, office buildings, and small businesses. Brine stated that he enjoyed working independently due to the difficulties he faced in relating to his coworkers. He often needed assistance with handling interpersonal conflicts and managing his anger (negative mood).
While at OVR, Brine met his wife, Kelda Brine, after an introduction by mutual friends. Their relationship progressed rapidly and within months, they began living together. Brine described his wife as a ―mentally retarded‖ and ―slow‖ woman who ―needs a lot of guidance.‖ She reportedly has difficulty with decision making and lacks appropriate parenting skills. Brine and his wife argue frequently due to her irresponsibility and irritable mood. They have a history of verbal and physical aggression toward one another, which has included pushing, saying hurtful things, and threatening to kill each other. Brine acknowledged having made statements that he did not mean and feeling remorseful after their arguments. Brine acknowledged that he was unable to set appropriate boundaries or create a structured environment at home. Although his parents often attempted to help him with establishing limits in his home, his wife would refuse. Brine’s mother and wife have a strained relationship due to their inability to communicate and their differences in parenting styles. Consequently, his wife has refused to accept help from her in-laws due to the fear that they ―would take her daughter away.‖ After the Division of Family Services became involved with his family, his wife’s biggest fear came true—their daughter was removed from the home and placed with his parents.
Brine stated that he was incarcerated because he sexually molested his kid—he was in the closet naked with her. He described having had a pornographic magazine that he showed to his daughter and reportedly touched her inappropriately. Brine stated that he did ―not remember‖ touching his daughter at that time; however, he admitted to having his daughter touch him in his private area in the past. He spoke of their sexual relationship beginning when his daughter was seven years old. Brine had told his daughter ―not to talk about it‖ to anyone. He reported that his wife had walked in on them two years ago, saw what was happening, and didn’t say anything. He stated that his wife probably did not understand what was happening or did not want to know about it. Brine described the abuse as including both contact and noncontact acts. The sexual abuse involved multiple incidents over time as the activity progressed from less invasive to more invasive (began with exposure and fondling and had moved to digital and oral penetration). Although Brine denied having engaged in sexual intercourse with his daughter, he stated that she ―would be able to describe what it is‖ due to having walked into their (her parents’) bedroom without their knowledge.
Brine and his wife have been referred counseling for marital therapy and assistance with parenting. He described having difficulty setting limits for his daughter and struggling with decision making. He reported that his daughter ―is in charge at home,‖ often ignoring her parents when she is told that she cannot do something. He has disciplined his daughter by taking something away from her, making her sit in
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