Case Study
Identifying Information: AA is a 32-year-old African American heterosexual Christian male residing in the Bronx, New York. AA reported graduating from New York University with a Bachelor’s degree in finances and indicated that he currently works at a large company as a financial analyst. Although AA has reported a successful career, he has been struggling with feeling restless and tired over the last 7 months. AA has been attending counseling for the past few months.
Reason for Referral and Presenting Problem: AA was referred to the Bronx Counseling Center by a psychiatrist. The client had several panic attacks, including pounding heart, trembling, chest pain, fear of dying, and nausea, for which he was hospitalized 3 months ago. He reported struggling to comply with his medications, which has warranted re-hospitalization. He has disclosed abusing marijuana for the last year, smoking 2-3 joints a day, every day. He reports often feeling depressed and overwhelmed by his numerous tasks as a financial analyst, indicating low energy, lack of appetite, lack of pleasure in daily activities, insomnia and psychomotor agitation for the past 2-3 months.
He reports feeling nervous and irritable when he has a major project to complete, although discloses that the sense of tension is present nearly all of the time. He often reports taking work home, but is still overwhelmed and experiences muscle tension. He indicated difficulty sleeping and when he eventually does get to sleep, he wakes up in the middle of the night and is unable to fall back to sleep. Within the past two months his interest has declined significantly and he does not find pleasure in activities he used to. He was an avid runner and practiced yoga, but has since stopped engaging in either. He feels like his job is a major source of stress, has little energy, often complains of headaches, and isolates himself from his friends and colleagues.
Family History: AA grew up in Bronx, NY and recently moved to Brooklyn, NY in his own apartment. He reports his father is deceased and reports one younger sibling with whom he has a strained relationship. AA indicates that he has never been married, although reports a few long-term relationships with women. The client reported that his father died from a car accident 2 years ago, but denies any psychiatric history within his family. Client reported he was sexually abused at the age of 11 by his uncle.
Education/Employment History: AA acquired a college degree from NYU and reported having an extensive history of working in nonprofit companies in finance. He presently works for a large company in Manhattan. He has been in his current position for the last three years and was promoted to Executive Manager 10 months ago, and his work demands increased dramatically.
Social History: He reported a current relationship of one year with his girlfriend, indicating that he attempts to make quality time for them, when possible. AA reported enjoying sporting events and listening to live music.
Psychiatric/Medical History: AA has reported several panic attacks at work, each lasting several minutes and a history of hospitalization for panic, beginning 3 months ago. He denies any current allergies. AA’s medications include Xanax once a day. He reports using marijuana daily for the last year, although discloses smoking marijuana recreationally since high school. AA denies the use of any other prescribed or recreational drug or substance.
Mental Status/Behavioral Observation: AA appears oriented to person, place, and time. He presents as aware, attentive, and makes fair eye contact. Client appears irritable, as indicated by remarks of a sarcastic nature, abrupt responses and psychomotor agitation. He is dressed appropriately for the season and location. He presented as reserved but engaged in the dialogue, and was eager to self-disclose about his experience and use of marijuana. He appears able to advocate for himself, as indicated by detail in self-report, strong command of language and expressive language. He reports unpredictable sleep patterns and discloses fleeting thoughts, difficulty “slowing down,” after the workday and restlessness at night. AA demonstrates the ability to remain on-topic, his thoughts are linear and follow a logical pattern, although occasionally extends into tangential topics and is easily re-directed. At session, he presents as friendly and collaborative, often apologizing for moments of irritability, smiling when appropriate and building rapport easily.
Questions for Consideration:
1. Given the client’s self-report and data provided, what are your diagnostic impressions (from the DSM 5). List all diagnostic impressions first (there should be several) and include what symptoms, markers, or cues are you utilizing to generate your impressions.
Once all listed, consider symptomology, duration, frequency and intensity to help you narrow down your impressions (this is a differential diagnosis process).
Share your rationale for rule outs and give your final diagnostic conclusion. Remember, there may be more than one possible diagnosis- just make sure you build the case for any diagnosis you settle on.
2. How do you conceptualize this client’s presenting problems? Be sure to look for theory-specific language.
3. If this were one of your clients, what issues would you address first and why? List one goal and two interventions.
4. What factors do you consider would impact this client’s prognosis?
5. Write up a brief summary of the client’s case, which could be included in a report. Below is a template that you can utilize for your summary and which will also help prepare you for the final project.
