Case Study_Phil draft

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CASE STUDY PHIL 1 Case Study: Phil Phil is a 15-year-old Hispanic male who lives with his mother and three sisters. Phil is a sophomore at the local public high school. He has been struggling with feelings of sadness and angry outbursts over the last four months since his parents’ divorce and father’s recent remarriage. He has been experiencing the following: Client Concerns Symptoms Behaviors Stressors Sadness Good relationship with parents and close with all family members prior to the separation. Parents separation 2 ½ years ago, and the final divorce 1 year ago. Anger Argumentative with his mother 3-5 times week and his sisters daily. Father remarried 4 months ago Feelings of hopelessness Engaging in verbal and physical fights including friends. teachers, and principal. Hope for his family to be normal again is gone. Irritability Experiencing bouts of crying spells, and anger outburst for past 4 months Decline in behavior while at school and being reprimanded for the last 4months. Unable to sleep Phil has stopped engaging in sports. Struggling academically, Phil went from a Bs to C’s and D’s. Isolation Comparing his family to his friend’s family. Recognizing the dysfunction of his circumstances surrounding his family. Unable to concentrate Begging his father and mother to get back together Mother pushing Phil to leave the house for social reasons Argumentative Refusing to attend his father’s wedding or see him since. Feeling guilty because his mother thinks faith is the “center of life” and he is

CASE STUDY PHIL 2 “just not sure.” Loss of enjoyment in daily activities Not signed up for Drivers Education even though he was looking forward to driving. Assessment One assessment that would be helpful in Phil’s case is the Adjustment Disorder-New Module 20 (ADNM-20). The ADNM-20 is a structured clinical interview used to diagnose adjustment disorders in individuals who have experienced significant life stressors. This assessment will evaluate the client’s recent self-reported feelings and behavior and provide information about the severity and duration of his symptoms, which would be important in determining an appropriate treatment plan. The ADNM-20 provides a more comprehensive assessment of adjustment disorder than some other assessments and can help identify the specific subtype of adjustment disorder. According to a study by Lorenz et al. (2015), the ADNM-20 is also a well-validated measure, with studies showing good psychometric properties (e.g., high inter-rater reliability and validity) and sensitivity to change over time. Diagnostic Impression According to the diagnostic criteria in the DSM-5-TR, Phil is presenting symptoms of Adjustment Disorder with mixed disturbance of emotions and conduct F43.25 (American Psychiatric Association, 2022). Signs and Symptoms DSM-5-TR Diagnostic Criteria: Adjustment Disorder (AD) with mixed disturbance of emotions and conduct F43.25 Client’s Signs/Reported Symptoms :

CASE STUDY PHIL 3 Criterion A : The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s). Phil’s parents were separated 2 ½ years ago and divorced 1 year ago. His father remarried 4 months ago and that is when Phil’s angry and sad outbursts and emotional behavior began. Criterion B : These symptoms or behaviors are clinically significant, as evidenced by one or both of the following: 1. Marked distress that is out of proportion to the severity or intensity of the stressor, taking into account the external context and the cultural factors that might influence symptom severity and presentation. 2. Significant impairment in social, occupational, or other important areas of functioning. Around the time of his father’s remarriage, Phil’s mother began getting calls from Phil’s teachers and principal about his verbally aggressive behavior at school. Until this time Phil has never had any behavioral problems. Phil’s mother reports that, “his reaction just seems to be so much bigger than what his sisters’ and other kids’ reactions are.” (1) Phil has also been struggling academically. His mother reported “Phil has always been a solid B student. His grades are now a few C’s but mainly D’s.” Phil stated, “I have had a really hard time concentrating in school since the divorce.” (2) Phil and his mother agreed that his social life has been negatively affected by his change in mood. He also reports that he has stopped hanging out with friends and playing sports (2) Criterion C : The stress-related disturbance does not meet the criteria for another mental disorder and is not merely an exacerbation of a preexisting mental disorder. Phil reported that he has never been diagnosed with an illness and only takes vitamins. Criterion D : The symptoms do not represent normal bereavement. Phil’s mother reports that, “his reaction just seems to be so much bigger than what his sisters’ and other kids’ reactions are.” Criterion E : Once the stressor or its consequences have terminated, the symptoms do not persist for more than an additional 6 months. Phil’s father remarried 4 months ago, and the symptoms have continued to persist, but it is too early to determine if he meets this criteria. Phil reported “I still feel sad about my family,

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CASE STUDY PHIL 4 Specify whether: 309.4 (F43.25) With mixed disturbance of emotions and conduct: Both emotional symptoms (e.g., depression, anxiety) and a disturbance of conduct are predominant. and some nights I cry, and some days I get angry, and every night I have a hard time getting to sleep. Phil has been argumentative with his mother 3- 5 times per week, daily with his sisters, and has refused to speak to his father. Other DSM-5-TR Conditions Considered Other diagnoses considered in this case were Disruptive Mood Dysregulation Disorder (DMDD) and Major Depressive Disorder (MDD). DMDD is characterized by severe and recurrent temper outbursts that are out of proportion to the situation and inconsistent with developmental level. While Phil met some of the requirements for this diagnosis, his outbursts and argumentative behavior were not grossly out of proportion in intensity or duration to the situation or provocation or persisting for at least 12 months. If Phil’s symptoms continue to persist for 12 months and increase in intensity, he may meet the criteria for DMDD. Secondly, according to the DSM-5-TR diagnostic criteria, Adjustment Disorder (AD) is a more appropriate diagnosis for Phil's case than Major Depressive Disorder (MDD) for a couple of reasons. In Phil's case, his parent’s divorce and father’s recent remarriage appears to be the primary stressor that triggered his symptoms, which is consistent with the criteria for AD. In contrast, MDD does not require a specific stressor as a trigger. Phil's symptoms also do not meet the severity criteria for MDD, which requires a minimum of 5 symptoms, including significant weight loss, excessive guilt, or recurrent thoughts of death for at least two weeks which Phil reported none of, leaving his symptoms more consistent with the criteria for AD. Developmental Theories and/or Systemic Factors As a 15-year-old teenager, Phil is in Erikson's stage of identity vs. role confusion. During this stage, adolescents must establish a sense of identity while grappling with social roles and

CASE STUDY PHIL 5 expectations (Wong, et. al., 2021). Phil's difficulties with his family and his declining academic and social functioning suggest that he is struggling to find a sense of identity and purpose. He is experiencing conflicting emotions and is having trouble expressing his feelings and coping with his stressors. Phil's family system has undergone significant changes over the past few years, which have likely contributed to his current difficulties. The divorce of his parents and his father's remarriage have disrupted the family's stability and caused Phil significant distress. Phil's mother is also struggling to manage his behavior and has had to find new consequences for his behavior, which may be contributing to his anger and frustration. Phil's mother and sisters may also be experiencing their own difficulties related to the divorce and its aftermath, which could be contributing to the family's overall stress level. Multicultural and/or Social Justice Considerations Phil is a 15-year-old Hispanic male, which suggests that his cultural identity may impact his experience. Hispanic culture is often characterized by strong family values and a focus on interdependence, where the family unit is highly valued and central to daily life (Almeida, et. al., 2019). Phil's reactions to his parents' separation and his father's remarriage may be influenced by his cultural background, as he may be struggling with feelings of loss and disconnection from his family unit. Phil's experiences may also be shaped by issues related to discrimination, marginalization, and oppression. As a Hispanic male, Phil may face prejudice and discrimination based on his ethnicity, which could impact his self-esteem and contribute to his feelings of anger and sadness. Additionally, the intersection of his identity as a young male in a society that often

CASE STUDY PHIL 6 values emotional suppression in men may contribute to his difficulty expressing his emotions and seeking help. Lastly, another key factor influencing Phil's experiences may also be his socioeconomic status. As a member of a family that has recently undergone a divorce, he may be facing financial hardship, which can lead to increased stress and anxiety. Treatment Recommendations Key Issues for Treatment  Helping Phil manage his current emotional state ( specifically addressing his emotional response to his parents' separation and divorce ).  Work on relationship dynamics with family.  Address social isolation and relationships with friends/sports.  Academic performance and concentration issues. Recommendations for Individual Counseling According to a study by Young et al. (2016), two highly effective treatments for adjustment disorder in adolescents include problem-solving therapy and interpersonal psychotherapy. Problem-solving therapy is a brief, structured therapy that focuses on teaching individuals how to identify and solve problems in their lives. In Phil's case, this type of therapy could help him identify and address the stressors related to his parents' divorce, such as his anger and sadness, as well as his behavioral problems at school. This type of therapy could prove particularly useful for Phil By helping him develop coping strategies and problem-solving skills to navigate his current challenges more effectively. The study also found that problem-solving therapy was effective in reducing symptoms of adjustment disorder, particularly for adolescents with academic problems (Young et al., 2016).

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CASE STUDY PHIL 7 Secondly, interpersonal psychotherapy for adolescents (IPT-A), is another short-term, structured form of therapy that focuses on improving an individual's interpersonal relationships and communication skills (Young et al., 2016). This type of therapy could be helpful for Phil because he has been struggling with relationships with family members and friends since his parents' divorce. IPT-A could help him to express his feelings and communicate more effectively with his family members, which may lead to improved relationships and reduced conflict. Additionally, this type of therapy could help Phil identify and address any interpersonal issues that may be contributing to his current difficulties, such as difficulty expressing emotions or feelings of isolation. According to a recent review article by Bet et al. (2021), antidepressant medication can be used as an adjunct treatment in adjustment disorder with depressive symptoms. The article also suggests that if medication is used, it should be closely monitored for side effects and efficacy. The choice of medication and dosing should also be individualized to the patient's needs and symptom presentation. It is important to remember medication should not be used as a standalone treatment for adjustment disorder and should only be used in conjunction with psychotherapy. Specific Considerations Phil's age is a crucial factor in diagnosis and treatment recommendations. As a teenager, Phil is going through a period of significant developmental changes, including hormonal and neurological changes. These changes may influence his emotional and cognitive functioning, making him more susceptible to developing Adjustment Disorder. Additionally, Phil's teenage years are characterized by a growing need for independence and autonomy, which may further contribute to his difficulty in adjusting to the changes in his family structure.

CASE STUDY PHIL 8 In terms of making consideration for the family system, a combination of individual and family therapy may be appropriate for Phil. Family therapy can involve all family members, including Phil's parents and siblings, and can address family dynamics, communication patterns, and conflicts related to the divorce and remarriage. Phil may feel isolated and misunderstood, and involving his family in therapy can help them understand his perspective and provide support. Family therapy can also provide a supportive environment for Phil to process his emotions related to the divorce and develop healthy coping strategies. One study by Kim et al. (2015), highly supports the importance of family therapy in the treatment of adjustment disorder. The study found that family therapy was effective in reducing symptoms of adjustment disorder in adolescents, and that involving the family in treatment improved overall family functioning. References

CASE STUDY PHIL 9 Almeida, R., Molina, K. M., Kawachi, I., & Subramanian, S. V. (2019). Ethnicity and nativity status as determinants of perceived social support: Testing the concept of familism. Social Science & Medicine, 224 , 20-28. American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed. Text Revision). Washington, D.C.: American Psychiatric Publishing. Bet, P. M., Hugtenburg, J. G., Penninx, B. W., & Hoogendijk, W. J. (2021). Pharmacotherapy for adjustment disorder: A systematic review. Journal of Affective Disorders, 282 , 1046- 1057. Kim, J. M., Park, S. Y., Kim, S. W., Shin, I. S., & Yoon, J. S. (2015). Family Therapy for Adolescents with Adjustment Disorder: A Randomized Controlled Trial. Journal of the American Academy of Child & Adolescent Psychiatry, 54 (9), S305. doi: 10.1016/j.jaac.2015.06.012 Lorenz, L., Bachem, R., & Maercker, A. (2015). The Adjustment Disorder – New Module 20 as a Screening Instrument: Cluster Analysis and Cut-Off Values. International Journal of Occupational and Environmental Medicine, 6 (4), 249-259. Wong, D.W., Hall, K. R., Hernandez L. (2021). Counseling individuals through the lifespan, 2nd ed Sage Publications, Inc. Young, J. F., Benas, J. S., Schueler, C. M., Gallop, R., Gillham, J. E., & Mufson, L. (2016). Effect of Problem Area on Outcomes Among Adolescents Receiving Interpersonal Psychotherapy-A. Journal of Consulting and Clinical Psychology, 84 (3), 251-262.

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