Part I: Complete a diagnosis list (with rationale for each diagnosis) for four Case Studies. Be sure to write the number that identifies the case study. Each case will have at least one primary diagnosis and at least one secondary diagnosis and/or Z-code.
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.
Janet is a 42 year old unemployed divorced female, who came for assessment due to her recent divorce. Janet reported that she just signed the papers for her third divorce and is afraid that she will never find a husband who will “stick with me through all the difficulties of life”. She is tired of going through divorce proceedings and wants to learn how to stay married. When questioned about the current divorce, Janet stated her husband told her he was “tired of having to make every decision in his and my life” and filed for divorce after five years of marriage. Janet was married to her first husband of 10 years when she was 18 years old. They had three children who she has a “sort of good, sort of stressful” relationship with. Janet married her second husband three months after her first marriage ended. That marriage ended in divorce after 8 years. Janet married her third husband 13 months after her second marriage ended. She reported having four other boyfriends in the 13 months she was single. She met and married her third husband in under two months’ time.
Janet stated that one of the primary reasons her three adult children are angry with her right now is because she has met another man four weeks ago and has begun talking about marrying him. Janet and her third husband have been separated for six months and she has dated three men in that time. Janet reported that all her relationships, but her first marriage have ended because the men felt she was too clingy and fearful when they were not with her and she expected them to make all of the decisions for her. Janet expressed confusion over how men react to her being a “good submissive woman”.
Janet has always struggled with making decisions, which was not a problem when she was young because her father was always more than happy to make any type of choice for Janet. She stated this was a point of friction for her older and younger sisters, but she appreciated her fathers “good counsel and proving that he really cared. I have never been able to make good choices and learned early that if I have someone to check with, my life will be fine.” Janet seeks assistance in making daily choices of what to cook for dinner, the color of clothing to buy, the gas station to buy gas from, the groceries to buy, and even the grocery store to shop at. When she is not married, in a relationship, or her significant other is not available, Janet will call her adult children or her friends from church. “I have a lot of anxiety when faced with choices. I do not know what I would do if I had to choose on my own. It would be terrible!” Janet does not understand why others become so angry with her about seeking “wise counsel” in her life. She stated that she works very hard to never argue or disagree with significant others and will do anything she is asked, as long as others remain happy and in relationship with her. Janet talked about multiple times she has completed requests by her family and friends that terrified her because she wanted them to be happy with her.
Janet stated that “I simply do not like to be alone. I have been abandoned so many times and it feels like the end of the world when men leave me.” She does not understand why her children are so angry about her new fiancé. “I am so afraid when I do not have someone to help me make choices, and my kids get really angry when I call them more than twice a day for advice, so I figured getting married again is the best way to make everyone happy.” Janet reported that when alone she thinks about the devastation of being alone. “The thoughts of how terrible it is to be single are always in my mind. Even when I am married. I just need others to help me. If I were left on my own, I know I could not survive.”
Edna is a 55 year old widowed female who has come for assessment after her two adult children discovered that she was missing $300,000 from her IRA. Edna stated that her children are clearly overreacting and that she does not have any type of psychiatric problems “Never have, never will”. Edna reported that she has different views than her children do on what is entertainment, and she can use her money how she likes.
Edna stated that her husband died 10 years ago, suddenly of a massive heart attack. She spent two years mourning him and then began building a new life consisting of work, spending time with friends and family and going on biweekly trips with a local group of 50 something’s. Edna stated that the trips are to a nearby casino. She reported “I love chasing that winning high!” Edna verified that she thinks of her next trip to the casino daily and will spend a large amount of time reliving her last big win. She has used all the money her husband left her and has taken two early withdrawals out of her IRA to fund her casino weekends. “I crave the feeling of winning. Even though I have to hide it from my kids, I live for my next trip. My travel friends have been encouraging me to set limits and not spend the entire weekend in the casino, but when I lose I have to keep playing to win my money back.“ Edna reported she hates lying to her children about where her time and money are going “they have their own lives and often do not have time for me, which makes me feel so sad. The only thing that makes me feel better is winning a big wad of cash!”
Edna became excited when talking about her time spent in the casino gambling, and her affect became somewhat flat when talking about her relationship with her children. “I love my children, but being a widow with an empty nest at 55 was not what I had planned on. My youngest daughter moved out two years ago, and that is when I started taking my casino trips more often. Before then I only went every six months.” Edna stated she knows her children are very angry and have threatened to “cut me off” if she continues to loss large amounts of money at the casino. Right after talking about her children’s threats, Edna began excitedly talking about her upcoming trip to a new casino in 10 days. Edna reported that it has been taking more and more money “on the table” to keep the excitement going. She stated that in the last year she has begun taking “side trips” to the casino. She explained that when she becomes sad about her current living situation or if she fights with one of her children she will go to the casino to “spice my life up.” “The dealers are getting to know me and are very nice to me, even when I win!”
Edna stated that she has no medical problems and has never been in any type of mental health treatment. She does not drink alcohol or use any illegal or legal drugs. She reported that she is often sad about her living situation and the fact that all her children have left home, but she has never experienced any depressive symptoms outside of sadness and occasional difficulty sleeping. She reported no excessive anxiety, anger or manic type symptoms. She was able to recall several times in the past two years when she became irritable when a casino trip was canceled and struggled with being happy until the next trip occurred. Edna has never exhibited any signs of a thought disorder or loss of touch with reality.
When not talking about her current situation with her children and the use of IRA money, Edna talked of living alone and how much she disliked the situation. She stated several times that she is lonely most evenings when she returns home from work and hates non-casino weekends due to worrying about being alone. She does have a few friends outside of her travel group, but they have families that they are engaged with a majority of the time. She sees her children 1-2 times per month. Edna reported that she believed getting older would be fun, that the kids would leave home and she and her husband would be able to do all the things they dreamed of doing. With his death and her children’s absence, Edna is not enjoying her aging years and is not looking forward to retirement. “Sometimes all the social life I have is at work, and when I cannot work I do not know what I will do with all my time. And the one thing I really love, my kids are trying to take away.” Edna openly discussed her difficulty transitioning from being a mother with children in the home to “having a terribly empty nest”. She also spoke often about disliking living alone, even though she did not see an alternative. Edna reported that she is willing to work on her loneliness in her living situation and possibly look at how her gambling is affecting her relationships.
Lisa was referred to an outpatient counseling office by her mother and father due to “having issues with panic”. Lisa is a 15 year-old female in the 10th grade at J.J. Hill High School where she takes 8 classes per day, 4 of which are advanced or AP level. She reports no children or spouse but does have “boyfriend”. She currently has no part-time job due to having “no time” but reports wanting a part-time job so she can have extra spending money. Lisa has an eight year history of being involved with softball. She plays for the school team and with a travel team during the fall season. Lisa’s parents have always been supportive of this activity and according to Lisa are at times more interested in her remaining a softball player than the client. Lisa’s mother is reported to be unstructured and undisciplined while her father is intensely authoritative, attempting to control all of the client’s life choices. Throughout the current school year, Lisa played approximately 10% of the time and sees her involvement as a “waste of time”. Lisa’s mother attempted to explain that Lisa felt this way due to be tired and overwhelmed at school and father said, “Well, you need to suck it up.”
Lisa described her life as “overwhelming” and “not having enough time”. She reported that at least 1 time per week she has a “racing heart”, feelings of dizziness, feelings of a “lump” in her throat, intense chest pain, and feels out of control. She reported that the symptoms “last for about 2 minutes, but they feel like they are going on for hours.” She described these symptoms as occurring “together in one big attack”. Lisa reported an increasing intense worry that these symptoms will reappear throughout the day, that the “attacks” are not predictable and there do not seem to be any specific triggers. She reported that she is not afraid to leave the house or being in large crowds where she might not be able to escape. She reported that she is afraid she will keep having attacks around her friends and they will get tired of seeing her “freak out”. She stated that right now her friends and boyfriend are supportive and verbally express worry about her. Lisa had a sports physical three months ago and no health concerns were noted. She is not currently taking any medication and has no history of any medical problems. Lisa reported no medical history in her family.
Lisa’s parents divorced when she was 11 after 20 years of marriage. Lisa reported her father was physically, verbally, and emotionally abusive towards her mother for as long as she could remember. She stated “My parents hate each other”. She agreed that she had witnessed “a lot” of turmoil between her parents and “it is best they are not together”. Lisa’s parents attempt to co-parent her, but this dynamic often places the client in the middle of conflicts between mother and father that have nothing to do with the client. When talking about this dynamic, Lisa became tearful, crying, rocking back and forth in chair, and then stated, “I just can’t take it anymore.” Client reported that 4 weeks ago, she watched her father beat her dog with a newspaper and how disturbed she felt by the incident. Lisa’s mother communicated to her father how upset Lisa felt and this triggered an intense argument between Lisa’s parents. Since the argument, Lisa reported that she has feels sad “all of the time, all day every day”, and has the reoccurring thought, “What would it be like if I weren’t here?” She reported feeling intensely guilty because her parents cannot get along and it is her fault. Lisa stated not go to sleep until 2 AM every night for the past four weeks. After falling asleep, the client wakes up 3-5 times but is able to go back to sleep. Lisa reported feeling tired every day and having increasing difficulty getting out of bed in the mornings. She denies using any substances. She also denied having any past or current suicide plans or intents, though the thoughts of wondering what it would be life if she were not “here” are “there all of the time”. Lisa stated that at this point she does not see how anything will get better in her life.
Lisa admits, “I know I need help. I hate feeling sad all the time and the attacks are embarrassing. I just don’t know how to make things better. I just wish my problems would go away.” Client was somewhat reluctant but willing to examine her current choices of activities and explore areas of change.