SOCW6090 Walden University Psychopathology for Social Work Project
The sign of an effective clinician is the ability to identify the criteria that distinguish the diagnosis from any other possibility (otherwise known as a differential diagnosis). An ambiguous clinical diagnosis can lead to a faulty course of treatment and hurt the client more than it helps. In this Assignment, using the DSM-5 and all of the skills you have acquired to date, you assess an actual case client named L who is presenting certain psychosocial problems (which would be diagnosed using Z codes).This is a culmination of learning from all the weeks covered so far.To prepare: Use a differential diagnosis process and analysis of the Mental Status Exam in “The Case of L” to determine if the case meets the criteria for a clinical diagnosis.By Day 7Submit a 5- to 7 page paper in which you:Provide the full DSM-5 diagnosis. Remember, a full diagnosis should include the name of the disorder, ICD-10-CM code, specifiers, severity, and the Z codes (other conditions that may need clinical attention).Explain the full diagnosis, matching the symptoms of the case to the criteria for any diagnoses used.Identify 2–3 of the close differentials that you considered for the case and have ruled out. Concisely explain why these conditions were considered but eliminated.Identify the assessments you recommend to validate treatment. Explain the rationale behind choosing the assessment instruments to support, clarify, or track treatment progress for the diagnosis.Explain your recommendations for initial resources and treatment. Use scholarly resources to support your evidence-based treatment recommendations.Explain how you took cultural factors and diversity into account when making the assessment and recommending interventions.Identify client strengths, and explain how you would utilize strengths throughout treatment.Identify specific knowledge or skills you would need to obtain to effectively treat this client, and provide a plan on how you will do so.The Case of L
Presenting Problem
Client presented in the emergency room (ER) having been brought in the previous night
by her parents. Following an argument with her parents, L cut her right wrist. L's mother
reported that L started screaming rapidly and became physically violent toward her prior
to cutting her own wrist.
Psychological Data
L is a 17-year-old Hispanic female who resides in Pennsylvania with her mother, father,
and older sister. She is in 11th grade at the local public school.
L appeared to be of average to above-average intelligence, as she was able to respond
to numerous questions in an articulate and intelligent manner. She was well versed
about world history and current affairs. Her mother confirmed that she has done well in
school, maintaining a B+ average and participating in various school activities (e.g.,
chorus, school paper) until last year. L slowly dropped out of many activities she liked in
the past. Her mother noticed about 8 months ago that L had also begun having difficulty
doing schoolwork.
Erratic behavior arose during episodes when L also became irritable and explosive.
During these repeated episodes, she became quite defiant, cut classes, had to be
placed in school detention, and had even assaulted the principal. L has numerous
friends and believed she can relate to all types of people. She has a boyfriend who
adores her, but she said she doesn't feel the same about him. The school counselor
confirmed that L is outgoing, popular, and smart; but during these episodes she became
another person, one who is very violent and difficult.
Medical History
A physical examination by a staff doctor revealed superficial cuts on L’s left and right
wrist. The cuts appeared to be a few weeks old. There were cigarette burns on her right
wrist that looked to be approximately one week old. In questioning L about the cigarette
burns, L responded, "I just wanted to see how it felt—now I know." When questioned
about old cuts on her left wrist, she responded, "I don't want to talk about it." L weighs
103 pounds and is 5’ 6” tall. L denied any dieting or fasting, but her mother noticed over
this past year that her weight has dropped.
Substance Abuse History
L denied any drug or alcohol use. When she was questioned regarding such, her
response was "I could do drugs if I wanted to. I don't want to, because it’s dumb."
Family History
L’s mother is 42 years old and works as a secretary for a large telephone company. Her
father is 49 years old and operates a small landscaping business. Both are U.S.
citizens, with a cultural background from Guatemala of which they are proud. Both have
2
a high school education. L’s sister is considerably younger, aged 8. Their relationship is
described as unremarkable, although L’s mother noted that the younger sister stays
away when L is upset. Marital circumstances are uncertain, although the parents
admitted that they are trying to keep the family together for their children, and they are
of the Catholic faith. Treatment costs for L have been an additional difficulty for the
family, but they said they are very worried about L’s lack of self-control and discipline.
Extended family are far away and mostly still in Guatemala. L’s parents were not aware
of any other family members with psychiatric problems.
Psychiatric History
L was evaluated three times at the community hospital ER during the past 4 years.
Hospital evaluations were usually done after suicide attempts or threatening violent
behavior toward others. L thought that the clinicians trying to diagnose her only had
book skills and no people skills. She assumed that no one will ever know what is wrong
with her; she did not plan to tell them because she doesn't like them. L said she knows
she “is not crazy,” but she was convinced that the therapist thought she is crazy or a
“bad” kid. "They're just experimenting with me," L said. L indicated that she had been
prescribed medications to alter her mood, but she couldn't recall what it was, as she
stated, "I don't need those; nothing is wrong with me."
L's mother reported that L was involved in outpatient counseling on at least four
occasions as well as being placed in a shelter once after school truancy, running away
from home, and threatening to assault her. A social worker was even sent for home
visits for a 3-month period. Each time, L would abruptly end therapy by becoming
verbally abusive or totally noncommunicative toward the therapist and would adamantly
refuse to continue therapy. She even admitted to shoving a desk toward a therapist and
threatening her with a pencil. When questioned about this behavior, L responded, "Well
she told me to express myself and let my true feelings out, so I did." (L also laughed and
glanced at her mother during this exchange.) L’s mother was particularly perplexed and
overwhelmed by these behaviors. She stated that her husband is completely frustrated
and angry. Both admitted that L’s behavior is part of the considerable strain on their
marriage.
L denied being under any continued psychiatric care even though it was recommended
numerous times. She refused to go, stating, "The therapists are the ones who are
crazy." L was first seen in outpatient counseling 9 years ago after she began to have
nightmares and experienced tremendous anxiety after her godmother threatened to
kidnap her. Her godmother became obsessed with L when L was 6 years old, first
threatening to kidnap her then. Her godmother had to be institutionalized after exhibiting
bizarre behavior. Recently, the godmother started threatening to kidnap L again.
Three years ago, L was sent for counseling after she ran away from home after getting
a bad report card and also discovering that her parents were considering a divorce. L
requested therapy, as she reported that at 8 years of age she was sexually molested by
an older man in the community (who is now deceased). She expressed having mixed
emotions, because she viewed her perpetrator as her friend. By pretending that nothing
3
happened, she could think of him as a nice old man, and she didn't have to deal with the
thought of something this bad happening to her. L’s mother reported that she herself
was raped at 8 years old and that L had knowledge of this. Two years ago, L and the
entire family again became involved in outpatient counseling after L's godmother
accused L's mother of child abuse. L's mother thought this was largely done out of spite.
An investigation by Child Protective Services revealed no abuse.
Mental Status (1 day after she had been evaluated at the ER)
L presented casually, disheveled, in shorts and a tee shirt, and with minimal makeup. L
admitted to being in a nasty mood. There was little eye contact, and conversation was
difficult. Thought and speech patterns were clear. Affect was flat. She was oriented to
time, place, and person. L denied feeling depressed. When questioned about her
suicide attempt the previous day, she suddenly became quiet and teary eyed. She
lowered her head and responded, "You don’t understand, he made me do it. I don't
want to hurt myself." L denied even remembering cutting her wrist, saying, "He must
have done it or made me do it.”
L was questioned about the person she was talking about. She related that there has
been a male presence in her life since she was 6 years old and that he makes her do
things that she doesn't want to do or things she can't even remember. This presence
showed up after the funeral of her best friend, Michael. L said he communicates with
her through her mind. She seemed distressed when speaking about him. Her mother
appeared distressed and fearful as well. L’s mother confirmed that L had trouble
sleeping and concentrating at school after the funeral. She did not want to attend Girl
Scouts anymore, because the uniform had gotten tight and the male presence was
laughing at her. L’s mother remembered how scared she had become on a few
occasions when L attempted to run out into traffic. Every time L’s mother yelled at L for
doing that, L stated that the male presence explained that this was how she could join
her friend Michael. L’s mother took L to a therapist. When L entered the third grade, L’s
mother took her out of therapy.
L reported that during her awake hours she can't see this presence, but she can sense
him. She said she does see him in her dreams, and his appearances in them have
intensified within the past year. In her dreams, he torments children, and he controls
people through a haunted mirror and a magic book. He reads and controls thoughts. L
described him this way: “He looks in his 40s, but is really ageless. Always dressed in
dark colors, but I can’t tell the exact colors he wears. I know his eyes are powerful, but I
never really look at his eyes.”
L was asked why she never shared this information before. She stated, "Because I
would be put in the hospital and medicated—and I told you, I'm not crazy. I know you
don't understand, but I am him and he is me, and he eventually wants to totally control
me." She admitted to acting out impulsively at times, such as throwing things for no
reason. L reported that the presence was in the room during this interview. When
questioned about why he doesn't influence her now or make her do something, she
replied, "He's too smart, he wouldn't do that." L also mentioned that during the past
4
couple of months another male presence has been with her. This new presence seems
to be controlled by and intimidated by the primary presence. The two males
communicate with one another about how to hurt the children in her dreams.
L ended the session by saying, "I know this sounds weird, but this is what is happening
to me. If you tell any other therapist, I'll deny it, because I don't want to be put away."
