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CASE PRESENTATION
How does a case presentation
looks like?
Does it need to be one-on-one interaction?
PURPOSECase Presentation is the process of communicating the result of the assessment done by the clinician.
Through this case presentation, client will be screened if there are evidences of underlying physical, mental and psychological dysfunction of the client to provide bases for a full clinical diagnosis and possible therapeutic interventions that will be discussed and formulated
OBJECTIVESObjectives of case presentation are: Discuss a brief information about the client;
Discuss the reason for admission, medical and
developmental history and psychological
assessment of the client
Elaborate the diagnosis of the client using the
DSM V and;
Discuss the possible therapeutic treatment and
approaches for and on the client
Who are involved in the case presentation?PSYCHOLOGIST
PSYCHIATRIST
PSYCHIATRIC NURSE
Psychometrician
Social Worker
Client/ immediate family
Medical Doctor
Identifying InformationName :Nickname : Age/Sex/ : 24/MBirth Date : Feb. 5, 1988Birth Place: Davao CityBirth Status: Middle Child Civil Status: Single/UnemployedAddress : Date of admission:
FAMILY COMPOSITIONNAME RELATION AGE STATUS/
OCCUPATIONWHEREABOUTS
Father 59/M Married /businessman (Pomelo and banana plantation)
Mother 50/F Married /businesswoman (Pomelo and banana plantation)
Brother 26/M Single/ currently reviewing for step 2 Medical Board Exam
Client 24/M Single/Unemployed
Sister 22/F Single/ Medical Student 1st yearDMSF
History of Present Illness
Presents how the client get into his current situation. It asks when did it started? How did it started? What are the cause?
PSYCHOSOCIAL HISTORY
Presenting ProblemAs perceived by the Significant Others
How the family members see his situation?The loved one’s point of view
Presenting ProblemAs perceived by the Significant Others
After discharge, the client went back into smoking and using drugs. He manifested hostility, aggression, verbal abusiveness, insomnia, hallucinations, and elevated mood eventually until behavior became unmanageable. Besides, he attempted to overdose himself with clonazepam after the prescription was left by his father under his responsibility. Family then decided to readmit the client for re-evaluation and further treatment.
As perceived by the Client
How the client sees his situation?
The client’s point of view
FAMILY HISTORY
Roles playedLife styleDisciplinary practicesChallenges experienced
Like other families, they also experienced troubles, challenges, and turmoil:
FAMILY DESCRIPTIONFATHERMOTHER SIBLINGS
DEVELOPMENTAL HISTORY
Attachment Initiative, Freedom, and ResponsibilitySelf-ControlParental DisciplineCoping SkillsSelf-Worth/TrustPEER RELATIONSAMBITIONS, GOALS, AND WORKAcademic/School HistorySEXUALAND MARITAL HISTORY
Client encountered major problems in his life:
Family Medical HistoryFather: (+) Diabetes Mellitus
(+) Hypertension (+) Cancer
Mother: (+) Diabetes Mellitus (+) Hypertension (+) Asthma
MEDICAL HISTORYPRENATALBIRTHINFANCY AND CHILDHOOD
Mental Status Exam (Sept. 12, 2012)A. GENERAL APPEARANCE
Pt. came wearing dark blue shirt, black shorts, a pair of slippers, fairly groomed and with haggard looking face
B. GENERAL MOBILITYPosture and Gait was normal, with distant facial
expression.
C. BEHAVIORHad good eye to eye contact upon interview and was
listeningattentively with the questions.
D. DOCTOR-PATIENT INTERACTIONHe was cooperative all throughout the interview
and with a warm qualityof responses.
E. STREAM OF TALKAJ was spontaneous and able to give relevant
responses to the questions althoughwith flight of ideas at times. Accessibility was
good.
F. EMOTIONAL STATE AND REACTIONWith euthymic mood, appropriate affect,
depersonalization and homicidal werenot apparent although suicidal potential was present (with
history of OD prior to admission).
G. THOUGHT CONTENTHallucination were not apparent upon interview but
according to father patientwas yelling all to himself alone (1 day prior to admission).
Delusions, ideas ofreference, De’javu and jaimais vu were not apparent but
client was pre-occupiedabout overdosing 30 tablets of Clonazepam prior to
admission.
E. NEUROVEGETATIVE DYSFUNCTIONReported to have a good sleep (9pm-8am), appetite
decreased, weight decreased.
G. GENERAL SENSORIUM AND INTELLECTUAL STATUSAJ was oriented to time, place, person, and situation.
Immediate memory wasimpaired while recent and remote memory were intact and
calculation ability wasfair. General information, abstract thinking ability, and
judgment and reasoning,and insight was unimpaired.
F. SUMMARY OF MSEWith disturbances in Presentation, general behavior,
emotional state andreaction, thought content and neurovegetative dysfunction.
G. DIAGNOSTIC CRITERIAFunctional, Psychotic
of
AJ
PSYCHOLOGICAL TEST EVALUATION
Purpose for Evaluation:To determine the intellectual capacity,
personality dynamics and psychological adjustment of the Subject as part of a comprehensive case study and clinical diagnosis.
Psychological Tests Administered:
Raven’s Standard Progressive Matrices Projective Drawings: Draw-a-Person (DAP)
and House-Tree Person (HTP) SACHS Sentence Completion Test Minnesota Multiphasic Personality Inventory -2
(MMPI-2)Millon™ Clinical Multiaxial Inventory-III (MCMI-III)
DATE ADMINISTERED:July 26-31, 2012; September 19, 2012
Test Results and Interpretation:
Raven’s Standard Progressive Matrices:
Percentile Score: 10 INTERPRETATION:BELOW AVERAGE
A. Intellectual Functioning
BELOW AVERAGE
B. Personality Functioning
1. Projective Drawings:
•Draw-a-person and house-tree-person test on the overall communicate an apparent weak personality functioning and adjustment as the Subject is burdened with anxiety and tensions that often leads to depression. Depressed as he is, he can be passive, regressed, quiet, and may exhibits unwillingness to deal with his current situation with tendency to shut down the world…He is preoccupied with future concerns making him feel more anxious.
• issue towards father: assertive, unexpressive…need to be understood by his father;
• vivid childhood memory: bond with his father… could fly a plane with his father as the pilot
• perception towards self: has the ability to understand other people; yet easily gets overwhelmed when odds are against him, and feels hatred about it…greatest weakness: compulsiveness
• sees importance in happiness…always wanted to be ‘normal’; could be perfectly happy if family would be together; desire for success;
2. SACHS Sentence Completion Test: Free associations on the SSCT suggest-
3. Minnesota Multiphasic Personality Inventory-2:
Profile Validity Scales
Measures of Inconsistent Responding Scales
Raw Score
T-Score Profile Validity
Variable Response Inconsistency (VRIN) 9 65
Valid; however characterized
by some inconsistent responding
True Response Inconsistency (TRIN) 10 57T Valid
3. Minnesota Multiphasic Personality Inventory-2:
Measures of Infrequent Responding Scales
Infrequency (F) 15 82 May be Invalid
Infrequency-Psychopathology (Fp) 2 56 Likely Valid
4. Millon Clinical Multiaxial Clinical Inventory- III (MCMI-III) 1st Administration
CORRECTIONS SCALES
RAW SCORE
BASE RATE SCORE INTERPRETATION
Validity Index
Scale V (Invalidity) 0 - ValidScale W (Inconsistency)
6 - Valid
Modifying Indices
X Disclosure 172 97 ValidY Desirability 5 25 Valid Z Debasement 18 73 Valid
FACET SCORES FOR HIGHEST PERSONALITY SCALES BR 65 OR HIGHER
• Highest Personality Scale BR 65 or higher: Scale 3 Dependent
Scale 3 Dependent Raw Score
BR Score
Interpretation
3.1 Inept Self-Image 8 100 High
3.2 Interpersonally Submissive 5 84 High
3.3 Immature Representations 6 100 High
SCALE 3 Dependent
3.1. Inept Self-Image: Views self as weak, fragile and inadequate. Exhibits lack of self-confidence by belittling own attitudes and competencies and hence is not capable of doing things on his own.
3.2 Interpersonally Submissive: Needs excessive advice and reassurance. Subordinates himself to a stronger, nurturing figure, without whom he may feel anxiously alone and helpless. Is compliant, conciliatory, and placating, afraid of being left to care for himself.
3.3 Immature Representations: Has internalized representations that are composed infantile impressions of others, unsophisticated ideas, incomplete recollections, rudimentary drives, childlike impulses, and minimal competencies to manage and resolve stressors.
MCMI-III 2nd Administration
September 19, 2012
5. Millon Clinical Multiaxial Clinical Inventory- III (MCMI-III) 1st Administration
CORRECTIONS SCALES
RAW SCORE
BR SCORE INTERPRETATION
Validity Index Scale V (Invalidity) 0 - ValidScale W (Inconsistency)
4 - Valid
Modifying Indices
X Disclosure 150 85 ValidY Desirability 2 10Z Debasement 19 75
DIAGNOSTIC IMPRESSION
Significant family problems and other feelings of dissatisfaction with close relationships are evident. There are also substance abuse problems on top of Subject’s intense emotional distress characterized by depression, anxiety and other schizoid trends accompanied by bizarre sensory experiences and suicidal ideation which are incapacitating and quite alarming, more so, as this is greatly affecting Subject’s intellectual functioning as gleaned from a BA score on Raven’s SPM.
DIAGNOSTIC IMPRESSIONAXIS I Polysubstance Dependence (304.80)
Provisional Diagnosis: Borderline Personality Disorder (301.83)
AXIS III
Psoriasis Scalp, Post inflammatory hypopigmentation upper extremity,Bronchial Asthma,Elevated Liver Enzyme and Blood Glucose level.
AXIS IV
Inappropriate disciplineAcademic problems and frustrations
AXIS V65 experience some difficulty in social, occupational, or school functioning, but generally functioning pretty well, has some meaningful interpersonal relationships.
AXIS I304.80 Polysubstance Dependence
This diagnosis is reserved for behavior during the same 12-month period in which the person was repeatedly using at least three groups of substances (not including caffeine and nicotine), but no single substance predominated. Further, during this period, the Dependence criteria were met for substances as a group but not for any specific substance. For example, a diagnosis of Polysubstance Dependence would apply to an individual who, during the same 12-month period, missed. work because of his heavy use of alcohol, continued to use cocaine despite experiencing severe depressions after nights of heavy consumption, and was repeatedly unable to stay within his self-imposed limits regarding his use of codeine. -PRESENT
AXIS IIDiagnostic criteria for 301.83 Borderline Personality DisorderA pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:(1) frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion S.- PRESENT(2) a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation(3) identity disturbance: markedly and persistently unstable se lf-image or sense of self
TREATMENT PLANNING
Detoxification -done(date)First week: Complete the psychological tests - done (date)Family System Therapy
Once a month (Two session with Mother and then father)
CBT-REBT session Twice a month
TREATMENT PLANNING
Attend the sessions of the addiction program for 6 monthsShall adhere to the 12 stepsOutpatient program after 6monthsAttend to NA/AA Meetings every friday