Writer’s choice

Instruction: Review the following cases and then answer the questions associated with the case. Do not re-type the cases.
Case 1: The Case of John

John called the mental health centre to ask if someone could help him. He had been having trouble sleeping for the past four weeks, and was becoming concerned about his health. Although going to bed at his regular bedtime, he would wake up at irregular intervals throughout the night with heaviness in his chest. After submitting to a comprehensive physical as well as several diagnostic tests, the family physician was unable to identify a physical explanation for his problem; he suggested that John
implement an exercise programme regime or possibly see a psychologist to help him relax.

The therapist began by asking several questions about John and his family. John was
40 years old and had been divorced from his wife, Joan for a little more than
12 months. His three children Richard (5), Donna (8) and Trudy (10) all lived with his ex-wife but he visited the children once or twice every month and took the children to spend weekends with him once a month. He reports having a good relationship with his children and that they got along well with their new stepmother. The relationship with his ex-wife is strained.

John’s early childhood had been uneventful. He had four younger siblings, and spent most of his time with them. He remembered his parents’ relationship as being good and everyone seemed to enjoy being together. John completed high school without any difficulties but did not complete his college degree as he felt that he would do better entering the working world. He has been employed as at the same company for the past twenty-years and was recently promoted to plant supervisor. He did note that with the promotion he received a salary increase as well as additional benefits. However, with the new promotion, John is expected to return to college and complete his first degree. He is expected to complete his studies within three years as a requirement of his new position.

John is experiencing significant tightness in his chest and at times feels as if he is unable to breathe or his heart raced when he thought about returning to school. He then disclosed that he had actually dropped out of university decades earlier because he felt that he could not cope with the demand of being a student; now just the thought of having to face the prospect once again made him sweat and shake. Sometimes he would be so fearful and his heart would beat so fast he thought he would have a heart attack. John recalled feeling similar sensations when he had just entered university as a young adult but the feelings went away when he dropped out. He did not have a reoccurrence until recently.

He also told the therapist that since he had a new baby on the way and worried about meeting his financial obligation to his older children as well as his current family in addition to going back to school. As time wore on, John found himself brooding more and more about the challenge of going back to school as well as the birth of his new child and so found himself having problems sleeping. He notes that he has even fallen asleep at work. This, he was afraid could escalate and compromise his work standards. To make matters worse, John has begun feeling dizzy and suffering from frequent nausea.

He wondered about how he would find the time for all these changes, and even if he could he did not think his wife realized the challenges he was facing and he did not want to cause her any distress so is seeking your assistance because he really feels as if he is going crazy.
1. What is the DSM 5 diagnosis (es).
2. Which other diagnosis could you have considered? Explain why this disorder was ruled out in favour of the one chosen.
3. Provide a detailed case formation of how this client’s disorder developed.
4. Provide a comprehensive treatment plan for this client.
Case 2: Case of Carol
Carol was 15 years old when she was attacked by a group of men on the way home from school. They took turns screaming abuse at her and then they each raped her. Finally, they tried to stab her to death and would almost certainly have succeeded had the police not arrived on the scene. For months after this horrifying event, Carol was not herself. She was unable to keep the memories of the attack out of her mind. At night she would have terrible dreams of rape, and would wake up screaming. She had difficulty walking back from school because the route took her past the site of the attack, so she would have to go the long way home. She felt as though her emotions were numbed, and as though she had no real future. At home she was anxious, tense, and easily startled. She felt “dirty” and somehow ashamed by the event, and she resolved not to tell close friends about the event, in case they too rejected her.

1. What is the DSM 5 diagnosis (es). Justify your response (s).
2. Which other diagnosis could you have considered? Explain why this disorder was ruled out in favour of the one chosen.
3. Provide a detailed case formation of how this client’s disorder developed.
4. Provide a comprehensive treatment plan for this client.

Case 3: Case of Apryl
Apryl, aged 10, was referred to the Centre by her parents. Generally, Apryl is a pleasant little girl who relates well with adults and peers alike. Apryl’s parents report that she is a healthy child with normal sleep and appetite. Her birth was unremarkable and she attained her developmental milestones within the expected range for her age. Apryl’s parents are concerned with her speech and have noted that she stutters, however she can be understood. The family is becoming very concerned about how she would cope with the move to secondary school.

During therapy Apryl described the worries that she has every day about answering the register, reading aloud and answering questions. Some of the children in her class make fun of her by imitating her stuttering, both in the classroom and on the playground. The teacher has told them off but they continue to make fun of her. Apryl shared that she has stopped putting her hand up and sometimes complains of a sore tummy or headache when she knows that she will have to speak aloud in front of the class. Apryl really wanted to be in the school play but was too frightened to volunteer.

1. What is the DSM 5 diagnosis (es)? Justify your response (s).
2. Which other diagnosis could you have considered? Explain why this disorder was ruled out in favour of the one chosen.

Case 4: The Case of Joseph
Joseph is a nineteen year old youngster who came to see the company psychologist because of problems with his social skills and this is a source of concern for him. Currently Joseph is employed in a large family owned business, fitting components into radios. He is considered to be a reliable and careful worker but his employers feel unable to give him any more responsibility because he is unable to master social skills required for dealing with colleagues and costumers. He has some awareness of these problems and talks about how difficult he finds understanding people to be, “I never know what to do next” he says. Although he has mastered simple social pleasantries, he still finds social gatherings very difficult, and always ends up on the periphery of any group. He has not established any close friendships, despite his desire to do so; sadly this troubles him. Recently he asked his parents how he could make friends and they find this hard to explain as to them it just comes naturally. Despite this he has expectations of the future, in that he wants to marry and have a family, but seems to have no firm grasp of what this might entail.

Reports from Joseph’s mother revealed that as an only child, James was born after a normal pregnancy and delivery. As an infant, he was easy to breast-feed, the transition to solid foods posed no difficulties, and he also slept well. At first, his mother and father were delighted at how easy he was: he seemed happy and content to lie in his crib for hours. He sat unsupported at six months and soon after he crawled energetically. His parents considered him to be independent and a little willful. However, his grandmother was puzzled by his independence. To her mind, he showed an undue preference for his own company: it was as if he lacked interest in people. Joseph walked on his first birthday, yet during his second year he did not progress as well as expected. Although he made sounds, he did not use words; indeed his ability to communicate was so limited that even when he was three years old his mother still found herself trying to guess what he wanted. Often she tried giving him a drink or some food in the hope that she had guessed his needs correctly. Occasionally he would grab hold of her wrist and drag her to the sink, yet he never said anything like drink, or he would just point to the faucet.
This was obviously a source of concern in itself, but at about this time his parents noted that even if he fell down, he would not come to them to show them he had hurt himself. At times they even felt he was uninterested in them, because he never became upset when his mother had to go out and leave him with a friend or relative. In fact, he seemed to be more interested in playing with his bricks than spending time with people. He made long straight lines of bricks over and over again. He spent an extraordinary number of hours lining them up in exactly the same way and in precisely the same sequence of colours. From time to time, his parents also worried about his hearing and wondered if he were deaf, particularly as he often showed no response when they called his name. At other times, however, his hearing seemed to be very acute, he would turn his head to the slightest sound of a plane or a fire engine in the distance. In the weeks following his birthday they became increasingly concerned, despite reassurances from health professionals. He was not using any words to express himself, and he showed no interest in playing with other children. His mother agonized about her relationship with Joseph, because he always wriggled away from her cuddles, and only seemed to like rough and tumble play with his father. She worried that she had done something wrong as a mother, and felt depressed, rejected and guilty.
In his fourth year, Joseph suddenly began to speak in complete sentences. His parents were greatly relieved; however, his speech was quite unusual. For example, he often repeated word for word whatever his parents said, so if they asked him ‘ do you want a drink?’ he would say ‘ you want a drink’ in reply. The years from four to six were very difficult for the family. Despite speech therapy and special help at school, James only made slow progress. He developed a fascination with vacuum cleaners and lampposts and started to draw them over and over again. He became exceptionally excited whenever his mother took the vacuum out, jumping up and down and vigorously waving his arms and flicking his fingers near to his eyes (this is also known as flapping). He also became preoccupied by lights, rushing around the house switching them off and on. Even family outings became an ordeal; Joseph threw wild tantrums unless the family took exactly the same route and let him count the lampposts. He never seemed to tire of doing the same thing over and over again.

Joseph’ behaviour was also unusual in other ways in that he never really seemed to look at any one directly. Rather, he would look at them only fleetingly or not at all. Despite this Joseph seemed to notice everything in minute detail. He could ride his bike along the most crowed pavements without knocking anyone over, and he spotted car number plates with a figure four in them long before anyone else had noticed. He would also do things that his parents would find embarrassing, like grabbing and eating sandwiches from strangers’ plates in restaurants.

When Joseph started preparatory school, he found it difficult to learn to read and write, although in other areas of work he was very quick, for example, he was very good with his number work, and took great delight in learning multiplication tables. He was also still quick at jigsaws, and could mange even difficult puzzles with ease. At six years old he did a 200-piece jigsaw on his own, and a100- piece one upside-down! Socially however he was unable to make any friends whatsoever. He would attempt to join a game that he liked, but his approaches were so odd that other children tended to ignore him. Most of the time, Joseph was to be found on his own, busying himself with one of his special interests, more absorbed in counting lampposts than playing with the other children.

At about age seven, Joseph’s parents also noticed he seemed more interested in their company. He would show his mother that he hurt himself when he fell down, and he even seemed to derive some comfort and pleasure from cuddles. Also he began to wait for his father to come home from work, and even started to look out for him. However his parents were never quite sure whether Joseph truly enjoyed seeing his father return from work, or whether he was simply waiting to see if his father came home at exactly seven o’clock.

When Joseph completed preparatory school, he was transferred to a private high school and progressed adequately in the academic areas. He no longer simply repeated things that he had been told, but was able to make appropriate responses and hold a simple conversation. He was able to read simple books, although he had difficulty grasping the story line, and had little interest in speaking or reading. Instead he preferred to pursue his interest, at the time, in collecting bottle tops and listing to music. He watched programmes on pop music, and seemed to derive enormous pleasure from writing out or reciting a list of all the current hit records and their order in the charts. He had learnt this entire list by heart, and could tell you what the top twenty records where on any particular date. After graduating from high school a year ago Joseph was employed in the family business.
1. What is the DSM 5 diagnosis (es)? Justify your response (s).
2. What treatment options would you consider for this client?

Case 5: The Case of David
David is a 35 year old veteran of the Jamaica Defense Force. He came to see you a counseling psychologist because of a long standing problem he was having.

In the session he said “I never thought I’d be one of those guys with a drug problem. I used to be really fit, used to be at the top of my game at work. Then I got injured in a training accident – stuffed up my back jumping out of a chopper – and all the crap hit me at once. The army was good at first. They got me the best treatment, a couple of operations and loads of physiotherapy. But it gradually dawned on me that I wasn’t ever going to be fit enough to go back to my unit or to deploy. I got more and more down. Being a soldier was the only thing I knew how to do – if I couldn’t do that, what use was I?

Eventually I was medically discharged and it spiraled downhill from there. I didn’t have a job, didn’t have anything to do with my time except sit around the house watching DVDs and feeling useless, so the marijuana and the alcohol helped, it seems bearable then. It got to a point where all I could think about was drugs – getting the cash together to get the drugs. This has been happening on a daily basis for the past six months. You know – when I was a young man I’d smoked the odd joint with mates, but when I joined up, the job provided the entire buzz I needed. Don’t get me wrong, I still loved a drink! But the weed and the bottle never got the better of me then. After I got discharged I really hammered the weed and the alcohol, got stuck on pills too – Xanax and Oxycontin. I got them from my doctor the first time to help me deal with my stress and back pain. Pretty soon I was shopping doctors to get more of the pills, and I even bought them off the net without a script.

The more time and energy I put into getting off my face, the more things fell out of my life. I used to run about 3 miles a day, but pretty soon I couldn’t climb three flights of stairs without coughing excessively. I started to stack on the weight. I was unsociable, angry – a right bastard. And it was costing a fortune. I had an investment property when I left the army and that went, pretty much up in smoke as they say. My partner kicked me out of the house earlier this year and I don’t blame her. My kids keep asking why we split, but I reckon they’re better off without me.

In the end, the wakeup call was almost losing access to my kids. I’d missed too many access visits and my ex had had enough. Luckily, she had been getting some help for herself and the kids already, and knew where I could go to get sorted out. I called the centre, with my ex there to make sure I didn’t cancel at the last minute. So here I am. This is first time I have actually opened up about everything that has happened in the last few years. I’d never really put everything together, but I hope you will help me work to get back on track. I guess I was living in a bit of a fog. It was really hard to think about all that has happened. I know it’s going to be hard getting back to being my old self without thinking about using anything. But I have to do it. I do not want to lose my children and I want my partner back. In fact I would like to marry her. Who knows, I might even be working again. Counsellor I really hope you can help. I have no other option.”

1. What is the DSM 5 diagnosis (es). Justify your response (s).
2. Which other diagnosis could you have considered? Explain why this disorder was ruled out in favour of the one chosen.
3. Provide a detailed case formation of how this client’s disorder developed.
4. Provide a comprehensive treatment plan for this client.

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