Posted: March 6th, 2014

PSYCHOLOGICAL EVALUATION of Jessica Smith.

 

 

Provide a multiaxial diagnosis for the case study.

 

Identify and discuss at least two differential diagnoses for each of the Axis I and Axis II disorders that you gave.

 

Please read below and follow closely.  It seems like a lot but it is actually pretty simple.  Do not hesitate to contact me for questions.

 

Please read the below PSYCHOLOGICAL EVALUATION and see the GRADING RUBIC below it.  The professor will use the grading rubic to grade the assignment.  Basically, figure out what disorders the patient has, i.e.,

 

• Bipolar Disorder
• Adjustment Disorder
• Major Depressive Disorder
• Eating Disorder
• Acute Stess Disorder
• Borderline Personality Disorder

 

BELOW are the DSM AXIS I, II, III,  IV, V.  Using the grading rubic below discuss the rationale why each disorder applies to the patient and each AXIS that goes with each disorder.

 

PLEASE let me know if you have any questions…..

 

I need citations and references in APA format.  Thank you.

 

Psychological Evaluation

Confidential: For Professional Use Only

Name:                                  Jessica E. Smith

Date of Birth:                     7-18-68

Date of Evaluation:          4-12-09

Clinician:                              S. Freud, PhD

 

 

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Reason for Referral

 

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.

 

Background History

 

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 deliver.  Her younger sisters relied upon her for their after-school child care once their mother returned to work and 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.

 

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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 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 her 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 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 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.

 

Behavioral Observations

 

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.

 

Tests Administered

 

• Wechsler Adult Intelligence Scale (WAIS-III)
• Wide Range Achievement Test (WRAT-3)
• Minnesota Multiphasic Personality Inventory (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.  She 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.

 

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Assessment Results and Interpretations

 

Intellectual Functioning

 

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 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 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 becomes 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 judgment, 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.

 

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PLEASE READ AND FOLLOW THE GRADING RUBIC BELOW:

GRADING RUBIC:

Assignment Component	Proficient	Max Points
Provide a multiaxial diagnosis for the case study by addressing each of the five axes. Â	Students addressed each of the five diagnostic axes.	/40pts
Discuss the rationale for EACHdiagnoses.	Students discussed clear reasons for their diagnoses based on the DSM criteria.	/32 pts
Identify a minimum of two differential diagnoses for each Axis I and Axis II disorder.	Two plausible differential diagnoses were provided for each Axis I and Axis II disorder.	/40 pts
Discuss the reasons for their differential diagnoses.	Students discussed clear reasons for their differential diagnoses based on the DSM criteria.	/32 pts
Justify why their initial diagnoses are a better fit than the differential diagnoses.	Students clarified why their actual diagnoses are better suited for the person in the vignette than any of the differential diagnoses.	/40 pts
Write in a clear, concise, and organized manner; demonstrates ethical scholarship in accurate representation and attribution of sources (i.e., APA); and displays accurate spelling, grammar, and punctuation.	Wrote in a clear, concise, and organized manner; demonstrated ethical scholarship in accurate representation and attribution of sources; and displayed accurate spelling, grammar, and punctuation.	/16 pts
Total	Â	/200 pts

 

BELOW IS FOR INFORMATION PURPOSE (AXIS I – IV)

Multiaxial Assessment

With the intent of capturing a good deal of the complexity of psychological problems, the DSM focuses simultaneously on several dimensions. This effort is referred to as multiaxial assessment. Simply stated, an axis is a dimension to be considered in assessment. Recent versions of the Diagnostic and Statistical Manual of Mental Disorders developed by the American Psychiatric Association (see DSM-IV, 1994) include a focus on five dimensions — thus the term multiaxial. The five are:

For the four axes (I-IV) that focus on specific areas, the DSM-IV classification scheme provides a range of possible categories and delineates relevant criteria. The categories are:

Axis I

-Disorders usually first diagnosed in infancy, childhood, or adolescence (excluding Mental Retardation, which is diagnosed on Axis II)

-Delirium, dementia, and amnestic and other cognitive disorders

-Mental disorders due to a general medical condition

-Substance-related disorders Schizophrenia and other psychotic disorders

-Mood disorders

-Anxiety disorders

-Somatoform disorders

-Factitious disorders

-Dissociative disorders

-Sexual and gender identity disorders

-Eating disorders

-Sleep disorders

-Impulse-control disorders not elsewhere classified

-Adjustment disorders

-Other condtions that may be a focus of clinical attention

 

Axis II

– Paranoid personality disorders

-Schizoid personality disorders

-Schizotypal personality disorders

-Antisocial personality disorders

-Borderline personality disorders

-Histrionic personality disorders

-Narcissistic personality disorders

-Avoidant personality disorders

-Dependent personality disorders

-Obsessive-compulsive personality disorders

-Personality disorder not otherwise specified

-Mental retardation

 

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Axis III

 

-Infectious and parasitic diseases

-Neoplasms

-Endocrine, nutritional, and metabolic diseases and immunity disorders

-Diseases of the blood and blood-forming organs

-Diseases of the nervous system and sense organs

-Diseases of the circulatory system

-Diseases of the respiratory system

-Diseases of the digestive system

-Diseases of the genitourinary system

-Complications of pregnancy, childbirth, and the puerperium

-Diseases of the skin and subcutaneous tissue

-Diseases of the musculoskeletal system and connective tissue

-Congenital anomalies

-Certain conditions originating in the perinatal period

-Symptoms, signs, and ill-defined conditions

-Injury and poisoning

 

Axis IV

 

-Problems with primary support group

-Problems related to the social environment

-Educational problems

-Occupational problems

-Housing problems

-Economic problems

-Problems with access to health care services

-Problems related to interaction with the legal system/crime

-Other psychosocial and environmental problems

 

With respect to Axis V (Global Assessment of Functioning), the point is to clarify the level of coping ability/adaptive functioning. The assessor rates the individual on a scale of 1 to 100.

 

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91-100 = superior functioning, no symptoms

81-90 = good functioning, minimal symptoms

71-80 = a few transient and commonplace symptoms

61-70 = mild symptoms but functioning pretty well

51-60 = moderate symptoms and functional problems

41-50 = serious symptoms and impairment in functioning

31-40 = some impairment in reality testing or major impairment in several functional areas

21-30 = delusions or hallucinations or serious impairment in judgment or inability to function

11-20 = some danger of hurting self or others or occasional failure to maintain hygiene

1-10 = persistent danger of severely hurting self or others or inability to maintain hygiene

 

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