Clients do not enter treatment due to the symptoms of a personality disorder—since the symptoms are ego syntonic. That is, the symptoms are comfortable to them, and thus they are often not able to identify that those symptoms are creating difficulties.
Clients with personality disorders enter treatment for many other reasons, such as depression, substance use, work demands, or family demands. When diagnosing personality disorders, it is important to always list the diagnosis that brought the client in first, followed by the personality disorder, then Z codes.
Keep these important characteristics in mind as you continue your practice this week. To Prepare
· Review the case study for this week. ATTACHED BELOW.
· Start by familiarizing yourself with the disorders from the DSM-5-TR found in the Learning Resources this Week.
· Look within the noted sections for symptoms, behaviors, or other features the client presents within the case study.
· If some of the symptoms in the case study cause you to suspect an additional disorder, then research any of the previous disorders covered so far in the course.
· This mirrors real social work practice where you follow the symptoms.
· Review the correct format for how to write the diagnosis noted below. Be sure to use this format.
· Remember: When using Z codes, stay focused on the psychosocial and environmental impact on the client within the last 12 months.
Assignment
Submit your diagnosis for the client in the case. Follow the guidelines below.
· The diagnosis should appear on one line in the following order. Note: Do not include the plus sign in your diagnosis. Instead, write the indicated items next to each other.
Code + Name + Specifier (appears on its own first line) Z code (appears on its own line next with its name written next to the code)
Then, in 1–2 pages, respond to the following:
· Explain how you support the diagnosis by specifically identifying the criteria from the case study.
· Describe in detail how the client’s symptoms match up with the specific diagnostic criteria for the disorder (or all the disorders) that you finally selected for the client. You do not need to repeat the diagnostic code in the explanation.
· Identify the differential diagnosis you considered.
· Explain why you excluded this diagnosis/diagnoses.
· Explain the specific factors of culture that are or may be relevant to the case and the diagnosis, which may include the cultural concepts of distress.
· Explain why you chose the Z codes you have for this client.
· Remember: When using Z codes, stay focused on the psychosocial and environmental impact on the client within the last 12 months.
Week #10: case study
CASE of AYANNA
Intake Date: August xxx
IDENTIFYING/DEMOGRAPHIC DATA: Ayanna is a 29-year-old, African American female who lives with her partner Cassandra in a townhouse in San Francisco. They have been together for 6 years but have known each other since junior high school. Ayanna’s extended family lives in Oakland, California. Ayanna has a very close relationship with her mother and older sister.
CHIEF COMPLAINT/PRESENTING PROBLEM: Cassandra initiated Ayanna coming to her first intake session due to Ayanna feeling sad, down, and having trouble sleeping. Sometimes she has periods of thinking she is dying when she experiences heart palpitations. She gets overwhelmed and starts sweating and feels nauseous. This has brought her to the hospital on two occasions.
HISTORY OF PRESENT ILLNESS: Ayanna reports she has trouble sleeping at night thinking she is losing control of things in her life. She falls asleep then awakens and has trouble going back to sleep. Although this has been ongoing for about a year, now she thinks she is losing control of her life. She has recently gained weight since her life is less active because she does not want to go out. Ayanna finds herself sitting around often daydreaming and not focused on anything, with no concentration. Cassandra gets upset that they seem to have been hibernating much more than they need to since Ayanna fears losing control when they do go out.
PAST PSYCHIATRIC HISTORY: Ayanna reports she was in therapy for a year with another therapist but was unsure how to do therapy. The therapist rarely asks her anything. Sometimes the therapist would sit back and read a magazine, and Ayanna believed she was a bad patient. When Cassandra saw that was not helping, Cassandra found a different therapist for her.
SUBSTANCE USE HISTORY: Ayanna denies drug or alcohol use.
PAST MEDICAL HISTORY: Ayanna reports feeling ill often. It is disappointing to her that her illnesses (colds, flus, sometimes pain in her joints) come on so suddenly it stops her from activity that she was planning on and looking forward to. She visits her doctor, which she has been with for 25 years, and he gives her medicine to try and help her with illnesses.
FAMILY HISTORY INCLUDING MEDICAL AND PSYCHIATRIC: Ayanna is the youngest of three children (one brother and one sister), both of whom are married and live in the same community. Ayanna believes she is close to both her siblings and very close to her mother. Ayanna works in a library and was recently promoted to supervisor although there are no other employees in her area. In a collateral consultation with her mother, mom reports that Ayanna has always been different and has isolated a lot. During summer vacations at the lake Ayanna would prefer hanging around mom or playing by herself rather than joining the other kids. Ayanna believed the kids were not interested in her since her likes were different than theirs. Ayanna reports never feeling as important as her siblings and believes they look at her differently.
CURRENT FAMILY ISSUES AND DYNAMICS: Ayanna really enjoys her job but is always worried that she will be fired. She concerns herself with thinking she is just not doing enough, even though she recently became an employee of the month. She has known Cassandra since junior high school. Finally, about 6 years ago Cassandra expressed her feelings for Ayanna, and they immediately started dating. This comforted Ayanna because she has never been to social activities like bars and clubs to meet people. Cassandra encouraged Ayanna to get into therapy so they can expand their social circle. Cassandra wants to become involved in the rock and gem club, but Ayanna refuses. Ayanna’s hesitation is that she does not know a lot about gemstones, and the others will recognize that. Ayanna reports shopping has been a great relief from the time she was working full-time but ends up with a lot of returns since she just does not know how to pick out the correct items.
MENTAL STATUS EXAM:
Ayanna presented as casually groomed and appeared at her stated age. She was coherent and goal directed. Ayanna denies suicidal or homicidal ideation. She was dysphoric. Posture was tense. Facial expressions are appropriate to thought content. Motor activity is appropriate. Speech is clear and there is no speech impediments noted. Thoughts are logical and organized. There is no evidence of delusions or hallucinations. Ayanna was found to be oriented to three spheres. Fund of knowledge is appropriate to educational level. Recent and remote memory appear intact. The intake itself was challenging, and the information seemed to be coerced from Ayanna and not easily presented.