3:1 Assignment 2: RA: Diagnostic Formulation
Review the case given below case study (Psychological Evaluation for Jessica E. Smith) for this required assignment (RA). On the basis of the information in the case study, provide a principal (primary) and a secondary diagnosis for the person using the most recent DSM codes. You will also discuss your diagnoses in narrative (paragraph) form. Then, identify and discuss at least one differential (possible alternate) diagnosis for the principal diagnosis and at least one differential (possible alternate) diagnosis for the secondary diagnosis that you gave. Lastly, discuss whether a diagnosis from other conditions that may be a focus of clinical attention is warranted.
While you are welcome to list medical conditions that might be a concern, your primary and secondary diagnoses should be psychological conditions listed in DSM-5.
Your paper should have separate sections for:
- Principal and secondary diagnoses
- The reasons for selecting the principal and secondary diagnoses
- Social and cultural factors that may influence the principal and secondary diagnoses
- Differential diagnoses, including a consideration of whether a diagnosis from other conditions are applicable
- The reasons for selecting the differential diagnoses
- Your rationale and justification for why your actual diagnoses are a better fit than your differential diagnoses
Include citations and references in APA style. Your paper should be 5–7 pages in length.
read the case study (Psychological Evaluation for Jessica E. Smith).
Confidential: For Professional Use Only
Date of Birth:
Date of Evaluation: Clinician:
Reason for Referral
Jessica E. Smith 7-18-68
S. Freud, PhD
Smith was referred for a psychological evaluation by Bart Jackson of the Division of Vocational Rehabilitation to assess her current level of cognitive, behavioral, and emotional functioning and to provide recommendations for vocational service planning.
The following background information was obtained from an interview with Smith and a review of the demographic information sheet that she completed before the evaluation.
Smith is a forty-one-year-old Caucasian female who was referred for a psychological evaluation by the Division of Vocational Rehabilitation to assist with determining eligibility and to assess whether her emotional problems are interfering with her ability to work. She initially requested assistance from the Division of Vocational Rehabilitation in October 2008 to assist her with maintaining employment. At this time, she is interested in learning new skills to enable her to find full-time work in an office setting.
Smith was born in Jersey City, New Jersey, and raised in a small nearby town, Williamsport, Pennsylvania. She is the oldest of three children born to her mother and father following an uncomplicated pregnancy and delivery. Her younger sisters relied upon her for their after-school child care once their mother returned to work when she was twelve years old. She spoke of her mother as having been physically and emotionally abusive in the past, often yelling, hitting her, and pushing her around. While her mother took her frustration out on Smith, her father would drink alcohol in excess. To cope with the difficult situation at home, she began to drink alcohol and cut herself with a straight-edged razor. Smith was active in school-related activities. She did not receive special educational services or have significant behavioral problems in school, describing the classroom as a safe place where she could be a ―kid.‖ Smith graduated from high school and began attending a business college in Allentown, Pennsylvania.
After attending classes for several months, Smith dropped out to spend more time with her friends and to begin working at various part-time jobs. She has worked as a waitress, in a grocery store, and as a babysitter. After leaving school, Smith returned home, where she began spending time with old friends who drank alcohol and used recreational drugs. By the age of eighteen, she had begun to starve herself and burn herself with a lighter. Her second to youngest sister was killed in a car wreck around this time. To assist her with coping, Smith began to drink on a regular basis and rely upon crank (crystal meth) to regulate her mood. She attempted suicide by taking someone else’s prescription medications and slitting her wrists. She was subsequently hospitalized on a psychiatric unit for one week. After discharge, Smith did not follow through with recommendations to follow up with outpatient counseling. Instead, she resumed her alcohol and drug use as a means of coping with the emptiness that she was feeling inside. As her substance use became more problematic, Smith began to participate in inpatient and outpatient substance abuse programming. She met with a counselor at the local community mental health center and was admitted to a residential rehab program. She has remained drug free since leaving the program in 2004; however, she has had difficulty in remaining sober. Smith has been arrested three times for drinking under the influence (DUI) and at times, has temporarily lost her driver’s license. In November 2005, she sought
mental health services again to assist her with remaining sober and to address her underlying history of depression. She continued to attend outpatient counseling on a sporadic basis until August 2006 when she recognized that her depressed mood rendered her incapacitated. Thus, she began attending two individual psychotherapy sessions per week, biweekly psychiatric consultations, and participating in weekly home- based case management services.
Smith identifies her eight-year-old daughter and her boyfriend as her supports and sources of motivation to remain sober. She describes having had a series of physically and emotionally abusive relationships with men in the past, which have affected her mood and ability to cope with difficult situations. Smith has often become depressed and had thoughts of suicide after a relationship has ended. She acknowledges turning to alcohol or isolating herself when she feels overwhelmed. She initially moved to Jersey City two years ago to get away from the people whom she described as ―bad influences.‖ She has worked part-time at a local grocery store and participated in the vocational rehab program to assist her with returning to work. Despite their interventions, Smith has failed to maintain employment for longer than six months. She has also described herself as having difficulty maintaining friendships and trusting others. Smith currently lives in New Jersey with her daughter. She is unemployed and receives food stamps and Medicaid.
Smith is a Caucasian female of average build who appeared to be her stated age. She was dressed casually and her grooming and hygiene were adequate. She wore small, round-framed glasses with her short-brown hair pushed back behind her ears. She maintained good eye contact with the examiner, often pushing her glasses up on her nose or placing her hair behind her ears as she spoke of something that made her feel uncomfortable. Smith was cooperative during the evaluation, appearing motivated to answer all questions posed to her in an honest and forthright manner. She seemed alert and well rested, relating appropriately to the examiner. Smith often apologized for not knowing an answer to a test item or stated that she could not do something that she perceived as difficult.
- Wechsler Adult Intelligence Scale®—Third Edition (WAIS®–III)
- Wide Range Achievement Test—Third Edition (WRAT-3)
- Minnesota Multiphasic Personality Inventory: Second Edition (MMPI-2)
- Bender Visual-Motor Gestalt Test
- Clinical Interview
Mental Status Examination Results
Smith reports an extensive history of mental health treatment, having received inpatient and outpatient treatment for depression and substance abuse. She has been prescribed Prozac, Paxil, Remeron, Klonopin, Xanax, Valium, and Librium to assist with managing her depressive symptomology and difficulties with controlling her anxiety and physical withdrawal from alcohol and methadone. Smith’s attitude toward this evaluation seemed quite positive as evidenced by her interest in participating in the evaluation and self- report. She appeared to answer all questions honestly and did not appear to be irritated with the evaluation process. Her responses were spontaneous and she needed minimal redirection to respond to the questions that were asked of her. Smith was oriented to person, place, and time and denied having experienced auditory or visual hallucinations. She denied current thoughts of suicide; however, she acknowledged having attempted suicide as a teen. Smith reportedly used a razor blade to slash her arms, hit herself with a hammer in the face, took someone else’s prescription medication, and burned her arms with a lighter after fighting with her mother, breaking up with a boyfriend, feeling rejected, and losing her younger sister. She reported having had a couple of mutually fulfilling relationships in the past, although she indicated that she had difficulty getting along with people. Her remote and recent memory showed no signs of impairment; however, her ability to make realistic life decisions was marred. Medical history is significant for a back injury that occurred following a car wreck (1984) and removal of her gall bladder (1996). Since the car wreck, Smith has experienced lower back pain when lifting heavy weights or moving in an awkward fashion. Assessment Results and Interpretations
The WAIS®–III was administered to obtain an estimate of Smith’s current level of cognitive functioning. The results from this evaluation suggest that Smith is functioning within the Low Average range of cognitive functioning with no significant difference evident between her verbal and nonverbal reasoning abilities. Overall, Smith demonstrated abilities ranging from the Low Average to Average range with relative strengths in her word knowledge, categorical thinking, and ability to distinguish essential from nonessential details with a relative weakness in her abstract reasoning skills.
Smith’s WRAT-3 performance showed high school–level reading, eighth grade–level spelling, and fifth grade–level arithmetic skills. She achieved a Low Average range standard score on the reading and spelling subtests with a Borderline range standard score on the arithmetic subtest. She reported having had difficulty with arithmetic in school and often becoming too anxious to complete her assignments or finish test items. Thus, this score is likely an underestimate of her current level of functioning. Results suggest that her fundamental academic functioning is below average; however, due to the lack of discrepancy between her achievement and intelligence test scores, the presence of a learning disorder was not evidenced.
Visual Processing and Visual–Motor Integration
Smith’s ability to reproduce or copy designs was assessed on an instrument involving visual–motor integration and fine-motor coordination. She appeared to accurately see the stimulus figures and understand what she saw; however, she had difficulty translating her perceptions into coordinated motor action. She completed the Bender-Gestalt test in two minutes, forty-two seconds and incurred four errors of distortion and rotation. A short completion time such as this is often associated with impulsiveness and limited concentration.
Personality Assessment Results
The MMPI-2 was administered to assess Smith’s personal attitudes, beliefs, and experiences. Smith’s MMPI-2 profile suggests that she acknowledges that she is experiencing a number of psychological symptoms. She is likely to be experiencing a great deal of stress and seeking attention for her problems. At times, Smith comes across as a confused woman who is distractible, has memory problems, and may be exhibiting personality deterioration. Thus, she is in need of intensive outpatient therapy and psychotropic medication to continue to address her long-term personality problems. Smith might be described as an angry woman who is immature, engages in extremely pleasure-oriented behaviors, and feels alienated. She is likely to feel insecure in relationships, act impulsively, and have difficulty developing loving relationships with others. She often manipulates others (men) and may hedonistically use other people for her own satisfaction without concern for them. She has difficulty meeting and interacting with other people, is uneasy and overcontrolled in social situations, and tends to be rather introverted.
Smith has a negative self-image and often engages in unproductive ruminations. She frequently reports having numerous somatic complaints when she is anxious and feels as though other people are talking about her. Under stress, her physical complaints will likely exacerbate. Her insight into her problems is limited and she often attempts to find solutions that are simple and concrete. She may prefer to be alone or with a small group due to feeling alienated from the environment. She often exhibits poor judgement, emotional liability, and impulsivity. Smith may become upset easily and overreact to situations. Her profile reflects a chronic pattern of maladjustment, which may affect her ability to solve problems and fulfill her obligations. It is likely that Smith has a history of underachievement in school and in the work force due to her inability to cope with difficult situations.