Comprehensive Case Study

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Lincoln Land Community College *

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552

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Psychology

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Dec 6, 2023

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Comprehensive Case Study Identifying Information The client Ms. A is a 33-year-old single, straight, biracial (African American and Caucasian), unemployed woman, who is the mother of two children, Helen, age 4, and Arthur, age 18 months. It was reported that the client currently does not have any paramours and lives alone. Presenting Concern The client comes to therapy seeking treatment regarding symptoms of Sources of Information The sources of information utilized include client interviews, medical record reviews, DCFS records, and interviews with Dr. J, who the client was seeing for outpatient medication management and psychotherapy. History of Present Illness/Symptoms The client reported that her psychiatric illness began at age 18, when she had a “nervous breakdown.” She began to hear voices, although she doesn’t recall what the voices said. The client believed people were following her. She recalls hitting her mother as well. She stopped eating, speaking, and moving. The day after these symptoms began, her aunt took her to a local hospital where she was admitted. In the hospital, the client began banging her head against the wall. She was diagnosed with schizophrenia and was treated with an antipsychotic medication and an antidepressant medication. Several months after hospital discharge, the client discontinued her medications. She reported that for the next nine years, she heard voices intermittently, without recurrence of other symptoms. At age 27, 10 months after having her first child, she experienced what she termed as

postpartum depression. She recalls experiencing a depressed mood, significant crying, and difficulty sleeping. She reports paying diminished attention to her grooming: she bathed, but didn’t buy clothing, and didn’t get her hair done. She also recalls that she didn’t always read and respond to her daughter’s cues accurately. She sought hospitalization to a local hospital again, because she was sad and tearful. She was admitted to the local hospital again and diagnosed with bipolar mood disorder and treated with the same medications utilized during her first hospitalization. Around a year ago the client began outpatient medication management and psychotherapy with Dr. J. She was prescribed an antidepressant but no antipsychotic. The client reported that she sometimes has racing thoughts and has talked rapidly. She says she has sometimes spent a lot of money, and that she used to “go off” on people, by which she meant she would get into verbal altercations easily. The client reported that she occasionally drinks alcohol, but reports no use of other recreational drugs. The client is currently taking an antidepressant and is seeing Dr. J once a week. She takes her psychotropic medication regularly and takes an extra pill if the day is stressful, and she attends psychotherapy sessions regularly. Records document the client’s psychiatric care was initiated by DCFS after she lost care of her son. When first presented for treatment, the client had a depressed mood, irritability, sadness, decreased concentration, anhedonia, decreased sleep and appetite, increased energy and activity level, and spending sprees. On mental status examination, she was tangential, circumstantial, avoidant, and had a flight of ideas. Records indicate that she didn’t believe she had a mental illness and refused medications. She agreed to individual psychotherapy and showed some improvement. A mental status exam revealed that the client understood the purpose of the interview and was willing to proceed. She was well groomed. She made very little direct

eye contact. Her speech was of normal rate and volume. Her motor activity was of normal rate with no abnormal movements and her affect was blunted, but capable of full range. She displayed little to no emotion other than mild irritation. Her thought processes were coherent, with no loose associations, current hallucinations, current delusions, suicidal or homicidal ideations. A review of records revealed that the client was first noted to have symptoms of mental illness 12 years ago. She had come to her aunt’s home with a split lip and a gash on her forehead, saying her mother had beaten her. She was mute at times and was easily startled. She said things like “Do you hear her? She’s trying to get in!” when no one else heard anything. She also said “She’s going to kill me and the whole family.” She reported seeing people that others didn’t see and seeing blood. She locked herself in her bedroom, ate very little, and woke frequently during the night. She said bizarre things such as she was getting married on Sunday and that her classmates were beating her. Relatives noted that she became quiet and distant, and moody for several weeks prior to these symptoms. She was brought to the hospital; she was noted to be intermittently nonverbal and unmoving. When she spoke, it was in barely audible, rapid bursts. She showed thought disorder and intense anger. After discharge, she continued outpatient treatment for 6 months, but stopped treatment because she felt she no longer needed it. For several years, she traveled using marijuana, cocaine and alcohol. She was readmitted to the psychiatric unit of the hospital when people at church observed her clutching her baby so tightly that the baby was crying. She feared someone was going to take her baby. She reported feeling like she was suffocating. She was found to be having auditory and visual hallucinations, paranoid delusions, inappropriate affect, tearfulness, suicidal thoughts, disrupted sleep,

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hopelessness, and slowed speech. She was diagnosed with schizophrenia. She then had additional admissions shortly after, for similar symptoms. Past Client Psychiatric History and Treatment History Family Psychiatric History The client reported that there is no known family history of psychiatric disorders among biological relatives, except for one relative of her biological father who may be addicted to alcohol. Psychosocial History The client is a 30-year-old single, straight, biracial (African American and Caucasian), unemployed woman, who is the mother of two children, Helen, age 4, and Arthur, age 18 months. The client was raised by her mother and stepfather, along with three younger siblings who are the biological children of her mother and stepfather. She has had little contact with her biological father, whom she regards as a stranger. The client completed high school with A’s and B’s. She worked for a year, then enrolled in a community college. She didn’t complete college at the time, but has since re-enrolled in school. The client has had several relationships with paramours, two of which were abusive. She left each abusive relationship and returned to live with relatives. She doesn’t have a current paramour and lives alone. The client has lost custody of her daughter, due to her refusal to cooperate with taking her medication and attending a parenting class. As a result, her mother gained custody. She raised her son for a year because DCFS didn’t know she had another child. He was removed from her custody when his father turned her in. She doesn’t visit her daughter often due to her poor relationship with her mother. She sees her son more often but has missed recent visits due to studying for exams.

Strengths and Support System The client reported that she currently doesn’t have a support system. DSM Diagnosis and Rationale The diagnosis that I would give this client would be Schizoaffective Disorder, Bipolar Type, F25.0. Differential Diagnoses A possible differential diagnosis for this client would be Clinical Formulation

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