Case Assignment
Read the Case of Emily at the end of these instructions and complete the following:
Use critical thinking skills to understand the information in the prompt.
Assess your client using what you have learned so far in class. Write up an initial assessment of your client.
Formatting:
The entire Case Assignment should be 5-8 pages in length. Youmust use the APA format. Please see the Purdue Owl Websitefor any APA formatting questions.
Use the seven (7) headers listed below.
Use at least two professional sources
Support your thoughts with professional sources throughoutthe paper.
Use the following as headers for your paper (use bolded words only):
Introduction: Introduce what you will be writing about in your paper.
Assessment: Include the symptoms and other details from the case to come up with an evaluation and assessment of this client. Information supporting your provisional diagnoses andfinal diagnosis can come up in this section. This is where you would use information from professional sources to support your case.
Provisional Diagnoses (other possible diagnoses that the client might meet criteria for): You will prove/disprove reasons why
these diagnoses fit or does not fit Emily. Please list a minimum of two provisional diagnoses and a maximum of four provisional diagnoses. For example, you may share that Client X displays F02.81 Alzheimers Disease with behavioral disturbance. State why this disorder does/does not fit Client X.Clearly explain your reasoning.
Z codes: Look at the DSM 5-TR: Other conditions that may be a focus of clinical attention. Choose between one to five Z codes for Emily. Include the code and name. Please state why these codes are relevant to Emily. This may be a bulleted section.
Questions: What further information do you need to make a proper diagnosis/provisional diagnoses? Include questions you would ask Emily in order to diagnose her properly. This section may be written in bullet form. For example, how long has your depression persisted? or Was there any time in your life that you did not feel depressed?
Final Diagnosis: Choose only one diagnosis. Include diagnosiscode, name, specifiers, and severity. State why you chose this diagnosis for Emily. Clearly explain your reasoning. Reminder: Do not use Axis I, II, III, IV, and V to diagnose (that was the format for DSM IV-TR and is no longer necessary today).
Conclusion: Provide a summary of your assessment of Emily.
You are not discussing the treatment plan and interventions in this paper (that is for your Signature Assignment). However, you should clearly discuss symptoms and other details from the case to come up with an assessment/evaluation of this client.
Note: You will use this Case Assignment as a foundation for your Signature Assignment.
The case of Emily
Emily is a 41-year-old Caucasian female who has never been married and has no children. She is a substitute teacher for the Los Angeles school district but has been on unemployment for the past 12 months. She currently shares an apartment with a roommate in Venice. She has a B.A. in communications from the University of Michigan. Client is the oldest child and also has a younger sister, age 38. Her sister is married with 2 children. Her parents and sister still live in Michigan where she was born.
Growing up, her mother was an alcoholic and both physically (hitting, pinching, pulling hair) and verbally abusive (threatened to kill client and her sister). Her mother constantly put her down, stating that she was not good enough to do anything. Emily states that her mother attempted to kill her father when she was a child. She further states that her mother never physically hurt anyone outside of the family. Both clients uncle and grandfather (mothers side of the family) have bipolar disorder. At age 8, Emily attempted suicide by ingesting the ink in board pegs thinking it was poisonous. She currently denies any suicidal ideation. Emilys father was passive and quiet he never got involved and kept to himself.
Client was bulimic from ages 15-18 but recovered on her own. Her sister was also bulimic in high school. Client left home senior year of college and has since lived in Boston, San Francisco, and Los
Angeles. Client has been attending Alanon for the past year to deal with her mothers alcoholism as a child. She stated in session that she has learned in life to be invisible which has negatively affected her adult relationships.
Presenting Issue:
Client reports increasing depression since she has been on unemployment for the past 12 months. Since her move to the Venice area, she has difficulty getting continuous work due to low student enrollment in the LA school district. She is struggling with unemployment and not being able to pay the bills. Client has major dental work that needs to be done but has been holding this off due to lack of income. This further frustrates her.
Client currently attends DA (Debtors Anonymous), which she finds helpful. She admits that she gets bored easily and has had numerous careers over the past several years including screenwriter, documentary filmmaker, and stunt woman. Client has not been in a long-term relationship with a man in 10 years. In the past, she dated narcissistic, alcoholic men who treated her poorly. If not, I feel like I have to destroy him before he destroys me.
She has few friends (mostly acquaintances) but reports her closest friends live back home in Michigan. She also reports that she doesnt have much of a relationship with her roommate. Client feels that she is not able to move forward and tends to sabotage anything good that comes her away. She thinks this is because her mother did not allow her to feel good about herself and did everything in her power to make her life difficult.
Symptoms:
Client is very depressed and angry. She moves from topic to topic but mainly discussing her mother with much anger and resentment. She becomes tearful in session during much of the time. Client makes self- defeating remarks. A significant point the therapist has observed is that during every session, Emily picks at her fingernails consistently. As she talks about more sensitive issues, her picking becomes more aggressive.
Client/Therapist information:
Client is on time and even early for most sessions. She shows a very strong attachment towards the therapist. During one session, she was 10 minutes late and was very apologetic to the therapist for being so tardy. She gives holiday cards and small gifts to the therapist and continuously praises the therapist for helping her.
Last Completed Projects
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