Solution Manual for Mental Health in Social Work: A Casebook on Diagnosis and Strengths Based Assessment, 3rd Edition
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Instructor’s Resource Manual F or Mental Health in Social Work: A Casebook on Diagnosis and Strengths - Based Assessment Third Edition Jacqueline Corcoran , University of Pennsylvania Joseph M. Walsh , Virginia Commonwealth University
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Table of Contents Instructions for Use iv Chapter 3: Autism Spectrum Disorder 1 Chapter 4: Attention Deficit Hyperactivity Disorder 10 Chapter 5: Schizophrenia 19 Chapter 6: Bipolar Disorder 29 Chapter 7: Major Depressive Disorder 35 Chapter 8: The Anxiety Disorders 42 Chapter 9: Obsessive - Compulsive Disorder 49 Chapter 10: Post - Traumatic Stress Disorder 5 3 Chapter 11: Eating Disorders: Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder 6 2 Chapter 12: Oppositional Defiant Disorder and Conduct Disorder 72 Chapter 13: Substance - Related and Addictive Disorders 81 Chapter 14: Gender Dysphoria 95 Chapter 15: Alzheimer’s Disease 102 Chapter 16: Borderline Personality Disorder 11 5
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Instructions for Use Directions Part I, Diagnosis: Given the case information, prepare the following: a diagnosis, the rationale for the diagnosis, and additional information you would like to know in order to make a more accurate diagnosis. Directions Part II, Bipsychosocial Risk and Resilience Factors Assessment: Formulate a risk and resilience assessment, both for the onset of the disorder and for the course of the disorder, including the strengths that you see for this individual. Directions Part III, Goal Setting and Treatment Planning: Given your risk and protective factors assessments of the individual, your knowledge of the disorder, and evidence - based practice guidelines, formulate goals and a possible treatment plan for this individual. Directions Part IV, Critical Perspective: Formulate a critique of the diagnosis as it relates to this case example. Questions to consider include the following: Does this diagnosis represent a valid mental disorder from the social work perspective? Is this diagnosis significantly different from other possible diagnoses? Your critique should be based on the values of the social work profession (which are incongruent in some ways with the medical model) and the validity of the specific diagnostic criteria applied to this case.
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Chapter 3 Autism Spectrum Disorder Case 1 Questions to consider when formulating a diagnosis for Emmanuel 1. What are Emmanuel’s significant symptoms with regard to a possible mental disorder? Emmanuel had a hard time separating from his parents at school and was continuously crying, trying to run away, and throwing tantrums. He had difficulty with transitions at school and did not follow directions well. He did not approach other children and did not respond to their attempts to play or talk. Emmanuel used fe w of his own words but repeated what others said. When upset, he made guttural noises or screams. He was sensitive to loud noises and reacted by covering his ears and screaming. Emmanuel had no interest in his peers. He preferred to play on his own. When Emmanuel got exited he flapped his hands, clapped his thighs and crotch, and tapped his face. He appeared to be in a world of his own. He was content with writing numbers and letters over and over, and he frequently wrote down numbers to sooth himself when upset. He showed some developmental delays in areas of self - help and adaptation. His parents report that Emmanu el acted impulsively at times. 2. For how long have Emmanuel’s problem behaviors been evident? The extent of Emmanuel’s problem behaviors and developmental difficulties were noted immediately upon his enrollment in school, when he was five years old. While the family may have minimized their prior suspicions of some of these difficulties, the formal assessment revealed that they had begun having concerns about Emmanuel’s development at 30 months of age, due to his language diffic ulties. It is possible that his problems had been emerging before then. 3. Has there been any recent stressful event occurring in Emmanuel’s life that might account for any of his symptoms? There is no evidence of any recent stressors in Emmanuel’s life, although his beginning kindergarten has placed him in a more structured environment th an he experienced before. Rather than accounting for his symptoms, however, this seems to have made them more evident. 4. To what extents do Emmanuel’s (and his parents’) cultural traditions contribute to his problem behaviors? Because of their mixed Spanish and American heritage and lifestyles, the family did not acknowledge Emmanuel’s developmental delays as evidence of any internal problem. Rather, they perceived Emmanuel’s delays as being due to his need to live bi - culturally and make a gradual transition between his two cultures. 5. Given that Emmanuel has a developmental disorder, with what other disorders of childhood and adolescence (if any) do his symptoms overlap? In addition to the autism spectrum disorders, Emmanuel’s inability to follow directions and adhere to the demands of the structured environment could be seen as symptoms of oppositional defiant disorder. His problems with attention and concentration could be seen as symptoms of attention - deficit hyperactivity disorder. His academic limitations, and slightly below - normal measured IQ, might make an observer suspect an intellectual disability. Still, Emmanuel does not meet the full criteria for any of those disorders.
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DSM Diagnosis F84.0 Autism Spectrum Disorder, without accompanying intellectual impairment, with accompanying language impairment, requiring substantial support Rationale The diagnosis of Autism Spectrum Disorder was made because Emmanuel displays significant deficits in his social interactions, such as reduced eye contact, lack of social reciprocity, and failure to develop relationships with others. His communication skills are considerably limited; he does not initiate or sustain conversations with others, and his language development has bee n delayed since he was a baby. He also uses unusual forms of language, such as echolalia. For all these reasons, he was given the additional specifier with accompanying language impairment . Moreover, Emmanuel is unable to pa rticipate in imaginative play. Additionally, he exhibits restricted interests, such as writing numbers repeatedly in an artisti c, almost calligraphic manner. Emmanuel displays repetitive motor mannerisms, including h and flapping and face tapping. Further support for this diagnosis is evident in his impulsivity and difficulty with sensory integration. Emmanuel’s developmental and psychological testing has determined the absence of Intellectual Disability. His IQ is 95. Therefore, the specifier without accompanying intellectual impairment was added. He was assessed as Level 2, requiring substantial support because of his language delays and lack of ability to interact socially. A review of Emmanuel’s medical history indicates that he is a healthy five - year old with no problematic medical condition. His mother reports that pregnancy and delivery were normal and uncomplicated. He wa s toilet trained at age three. Additional Information Required Emmanuel’s assessment was comprehensive, including input from a range of health professionals, and thus there is no other info rmation required at this time. Risk and Resilience Assessment It is more appropriate to focus on risk and protective influences for the course of the disorder because little is kn own about its origin other t han it has a biological basis. The only significant risk mechanism s are that Emmanuel is male and has limited social skills and interest in peers. Regarding protective factors he experiences significant parental involvement in his care and has an average IQ, a good support system, and health insurance. What questions could be used to assess for additional strengths in this client? 1. What types of social situations seem to bring out Emmanuel’s positive adaptive qualities? How can they be facilitated? 2. What are the features of the 1:1 interpersonal situations in which Emmanuel is effectively able to interact? What are the personality characteristics of those who “bring out the best” in his interactional qualities? 3. How can Emmanuel’s various interests be encouraged, since he can participate in activities with others so long as the activity interests him?
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4. What are the circumstances in which Emmanuel is most likely to engage in his artistic pursuits, including calligraphy and listening to music? 5. What playground conditions does Emmanuel seems to enjoy the most? What are the features of those times when he is most able to attend to his puzzles? 6. What are the circumstances that seem to encourage Emmanuel’s use of humor? 7. How can Emmanuel’s visits with family members be structured to maximize his positive engagement with them? Intervention Plan In the case of autism spectrum disorder, it is necessary to develop and implement an intervention plan as soon as possible, especially in light of Emanuel’s relatively late diagnosis. Emmanuel is eligible for special education within his school district, and his parents and the special education team will meet within the next two weeks to develop an IEP (Individualized Education Program). As soon as this has been accomplished, Emmanuel will be able to join a class appropriate to his needs. The elementary school he attends offers a class for children with autism spectrum disorder, which is small in size and staffed with two special education specialists. This class focuses on the development of social skills, as well as the reduction of stereotyped behaviors. Speech therapy will also be necessary to enhance his pragmatic language skills. In addition to these services it is important to educate Emanuel’s parents about the dis order, relevant parenting practices , and resources in the community. Fortunately, the school district has a Parent Resou rce Center, which offers an array of informational material in Spanish, as well as wor kshops and classes on various disorders and their treatment. The social worker has provided the parents with some basic information and has set up a meeting for the parents with Spanish - speaking staff at the Parent Resource Center. Due to the parents’ difficulties with consistent parenting, the so cial worker has already shared information on discipline and has introduced them to a behavioral approach to reinforce desired and reduce problematic behaviors. She has also suggested strategies to decrease the extent of Emmanuel’s TV watching. The social worker will check in weekly with the family to review progress and assist when necessary. The diagnosis of autism spectrum disorder came as a shock to the family, who had viewed Emanuel’s behavior as a temporary delay in development. Therefore, they may need to go through a grieving process. They also might require support for their adjustment. A number of organizations in the area offer support groups for the Spanish - speaking population. This will give the parents the opportunity to share their feelings without having to rely on an interpreter. Additionally, disability in the Latino community is often viewed with stigma. In a support group of their peers, Emmanuel’s parents could receive advice and support from people with a similar cu ltural background to their own. A sibling support group could also be offered to Emmanuel’s brother and sister. Critical Perspective While the primary diagnosis appears to be valid, t he DSM - 5 criteria are less clear about how to determine its severity level, despite including a table for determining requiring very substantial support (level 3), requiring substantial support (level 2), and requiring support (level 1). Although the DSM provides some general guidelines on how to assess social communication and restricted repetitive behaviors along these lines, there is much subjectivity on how these ratings
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are reached. In Emmanuel’s case, his parents had just found out about the disorder and he had, up until tha t time, limited supports. It may not be fair to judge Emmanuel as “requiring very substantial support” when he ha d not yet received intervention. For that reason, he was not given that rating, although it my later be come evident that he needs it. Case 2 Questions to consider in formulating a diagnosis for Hao: 1. What are Hao’s significant symptoms with regard to a possible mental disorder? Hao is unable to relate to other children in class or follow directions, and he frequently engages in hand w ashing. He cannot follow classroom routines and only persists with activities in which he is interested. He speaks with an inappropriately loud volume in close proximity to others’ faces, and is unable to retain the teacher’s instructions about standing back and speaking more quietly. Hao looks off into space while the teacher speaks, and he does not react to comments she makes. At times he has temper tantrums at school. His mother noticed in preschool that Hao was not connecting with other children and only wanted to play alone. Hao is not developing socially. He does not follow the rules set forth by his family, and tends to ignore his parents when they try to discipline him. Hao tends to laugh inappropriately during activities at the park to a degree that his father threatens to take him home. 2. For how long have Hao’s problem behaviors been evident? Hao’s problem behaviors have only been evident for one year. They were formally identified only when he enrolled in school and demonstrated an inability to function within the structure of that institution. His parents had been concerned about his social isolation one year before, when he entered preschool, but his teachers at the time did not see Hao’s withdrawal and preference for playing alone as significant issues. 3. Have there been any recent stressful events occurring in Hao’s life that might account for any of his symptoms? The Hao family has experienced much stress at times in their lives, but there is no evidence of significant stress in the past year or so that might help to account for Hao’s symptoms. 4. To what extent do Hao’s (and his parents’) cultural traditions contribute to his problem behaviors? Interestingly, Hao’s being in America may have delayed the recognition of his developmental problems. According to his mother, in Vietnam Hao’s behavior would be considered unacceptable and outside the norm. Her own observations of the patience of American teachers led her to be less concerned about Hao’s behavior. In Vietnam children are warned against bad behavior by being threatened with physical punishment. While it is not clear what interventions Hao would have received in Viet Nam, his abnormal behavior would have been less tolerated. 5. Aside from autism spectrum disorder, what other disorders of childhood and adolescence do Hao’s symptoms possibly represent? While ASP is distinct from the disruptive behavioral disorders, there is some overlap among their symptoms. Hao might be considered for a diagnosis of oppositional defiant disorder in that he seems to ignore instructions from adult authority figures (his parents and teacher). He also could be considered for attention deficit/hyperactivity disorder in
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that he seems to have difficulty at times with his attention span, concentration ability, and activity level. Diagnosis F84.0 Autism Spectrum Disorder, without accompanying intellectual impairment, without accompanying language impairment, requiring support Allergies (which can result in eczema, by parent report) Rationale Social workers do n ot diagnose neuro - developmental disorders without contributions from a multi - disciplinary team. Ther efore, Hao should participate in a physical examination, visual and hearing examinations, and neurological exams, as well as a speech and language assessment , before the diagnosis can be confirmed. Moreover, most of the information in the above report comes from Hao’s mother’s perspective, and other perspectives should be sought, including those of Hao’s father. Extended observations of Hao, in free play sit uations and with his parents, might yield additional information. That being said, Hao appears to tentatively meet the DSM criteria for Autism Spectrum Disorder as follows: A. Hao exhibits qualitative impairments in social communication and interaction as evidenced by a failure to develop peer relationships appropriate to his developmental level (as noted in his preschool class and in his interactions with most of his cousins) and a lack of social or emotional reciprocity (as noted by his inability to relate to others at his preschool, the parochial school kindergarten, and most of his cousins, with the exception of Thanh, who will talk about subjects of interest to Hao.) B. Restricted, repetitive, and stereotyped patterns of behavior, interests, and activities, as manifested by an encompassing preoccupation with stereotyped and restricted patterns of interest that are abnormal either in intensity or focus (Hao frequently washes his hands) and an inflexible adherence to specific, nonfunctional routines or rituals (Hao displays frustration, sometimes culminating in temper tantrums, when he is not allowed to pursue what he wants to do at home and in the kindergarten setting). C. There is evidence that the relevant symptoms were present in Hao’s early development even though they were not discovered until he attended school. D. The disturbance causes clinically significant impairment in social (lack of sustained play with age mates and most family members of his age) and school functioning (Hao was expelled from the parochial school due to his behaviors). E. Criteria are not met for another specific pervasive developmental disorder or schizophrenia. Hao’s diagnosis includes the specifiers without accompanying intellectual impairment and without accompanying language impairment because he is both intelligent (by testing) and able to communicate and be social. He is also given the specifier requiring support because he functions rather well in some ways and this is the mildest functional indicator. Additional Information Required As noted earlier , it would be necessary for Hao to undergo a multi - disciplinary assessm ent to make a valid diagnosis. Additionally, other reporters, such as h is father, should be involved.
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Risk and Resilience Assessment There is no repor ted family history of ASD, although Hao’s father was 40 when Hao was conceived, which may present a risk factor, as older age of fathers has been associated with the disorder . Regarding the course of the disorder, Hao appears to possess a number of resilience influences. He has temper tantrums but he doesn’t hurt h imself or others. He is intelligent and gifted in music and computers. At the social level, Hao’s family is supportive and financially secure. He has a large extended family available , although at this point they don’t understand the nature of his disorder. In addition to the extended family, Hao is being brought up in a r eligious faith. Hao’s disorder could have been caught earlier ( he is being di agnosed at five years of age) but on the positive side he will now be receiving services thr ough the public school system. What questions could be used to assess for additional strengths in this client? 1. How can Hao’s treatment providers nurture his talents and curiosity? 2. Given that Hao is responsive to time - outs, strong verbal communication, and direct eye contact from his mother, what kind of structured program of reinforcement could be implemented for him? 3. How can sports activities be used to facilitate Hao’s learning and serve as reinforcers for adaptive behavior? 4. How can Hao’s family be encouraged to support Hao’s adaptive activity and perhaps incorporate spirituality into his activities of daily living? 5. How is it that Hao becomes focused when engaged in his artistic interests? What related skills can be put to additional productive use in his treatment? 6. How can Hao’s endearing personality qualities, noted by his teachers, be further developed toward his interpersonal skill development? 7. How can the professionals’ learning about Vietnamese culture provide a better understanding of how his behaviors are reflective of that culture? Intervention Plan Parent Interventions It is important that Hao’s parents understand that he is not purposefully acting in a willful and defiant way, but that his behaviors and style of interacting are a result of his disorder. At the same time, managing the behaviors and training the chi ld with ASD is challenging for parents, and the Chu ngs will require much support. Lang and An will be encouraged to attend a local support group for paren ts of special needs children, and an e ffo rt will be made to find a support group conducted in Vietnamese. The Chungs should receive parent training and information and training on how to promote Hao’s c ommunication and social skills. Lang should be encouraged to re turn to part - time haircutting. Further, Lang and An should inform the extended family about Hao’s disorder to ensure a more supportive network. Child Interventions Hao’s individual intervention s will include three strategies : communication and social skill training; behavioral therapy; and educational intervention.
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Communication and social skills training: Hao will be t aught in an explicit and rote fashion the rules of socialization and communication. He will learn how to monitor his own speech in terms of volume and rhythm, as well as how to interpret the communication of others, such as gestures, eye contact, and tone of voice. Opportunities to role - play communication and social skills will be important, as well as practice in social interaction through supervi sed and structured activities. Initially, it may be helpful for Lang to schedule play dates for Hao with other children with Asperger’s to practice developing skills. Behavior therapy: This class of techniques is targeted at curbing problem behaviors, such as obsessions (freque nt hand washing) and tantrums. These behaviors are identified and specific guidelines will be devised to deal with them. Hao’s parents and his teachers/school staff will be taught to handle the behaviors in the same way, so that clear expectations are set and consistency is maintained. Behavior therapies also focus on training a child to recognize a troublesome situation — such as a new place or an event with lots of social demands — and then select a specific learned strategy to cope with the situation. Educational interventions will make full use of Hao’s individual's interests and talents in the areas o f computers, music, and books. In school, there may be opportunities in the classroom for Hao to take on leadership in activities revolving around these interests. Teaching other students skills can help Hao’s self - esteem, as well as assist him in learning social skills, such as taking the perspective of others, following conversational and social interaction rules, and engaging in two - way exchanges. Hao may be able to participate in the mainstream classroom given his intellectual abilities, but may nee d additional help from a support person. He also may require individualized curriculum centered on his deficits. Critical Perspective A debate occurred during the school system’s Individualized Educational Plan meeting when discussing a possible diagnosis for Hao. The psychologist who had administered the IQ testing determined that Hao has Autism Spectrum Disorder since his social awkwardness was profound. However, the representative from the city school district’s gifted and talented program maintained that Hao’s symptoms were a function of his giftedness. In other words, Hao’s high IQ and intellectual interests made him unable to relate to same - age mates and caused him to be bored and under - stimulat ed by the classroom routine. These differences of opinion underscore the care with which any neuro - developmental diagnosis should be made. Despite these different perspectives , Hao was ultimately diagnosed with Autism Spectrum Disorder beca use of his social deficits, m anner of communicating, and r igid, circumscribed interests. Case 3 Questions to consider when formulating a diagnosis for DeShon: 1. What are DeShon’s symptoms with regard to a possible mental disorder? DeShon is distant from ot hers, even his family members. He is unable to relate to others in his class and does not play imaginatively. He repeats other people’s w ords when he speaks with them. He displays flat affect and fails to make eye contact. Additionally, he rocks back and forth and waves his hands in front of his face. According to his mother, DeShon also becomes frustrated when he is asked to transition to a new activity. Finally,
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he shows sensitivity to tactile experiences, particularl y with regard to food texture. 2. For how long have DeShon’s problem behaviors been evident? DeShon’s problem behaviors and developmental difficulties became evident between 18 to 24 months; at that time, his speech development slowed and his already minimal eye contact decreased further. 3. Have there been any recent stressful events occurring in DeShon’s life that might account for any of his symptoms? The family seems subject to many financial hardships, contributing to their frequent mov es and temporary homelessness. However, DeShon’s symptoms have been stable since he was 18 to 24 months old, and he is now five years old. If his problem behaviors were in reaction to a stressful live event, there would have been some shift in his symptoms over the years. Diagnosis F84.0 Autism Spectrum Disorder , with accompanying intellectual impairment, with accompanying language impairment, requiring substantial support. Rationale Criterion A: Deficits in social communication and social interaction across multiple contexts as evidenced by: 1. Deficits in social and emotional reciprocity, manifested by an inability to sustain eye contact; a failure to develop peer relationships appropriate to developmental level; impairment in the ability to initiate or sustain conversations; echolalia; and a lack of social or emotional reciprocity. 2. Deficits in nonverbal communication as noted by an inability to sustain eye contact, a misunderstanding of gestures, and poorly integrated verbal and nonverbal communication. 3. Deficits in developing and maintaining relationships as evidenced by a lack of imaginative play appropriate to his developmental level and a lack of spontaneous seeking to share enjoyment, interests, or achievements with others. Criterion B: Restricted, repetitive and stereotyped patterns of behavior including rocking and w aving his hands back and forth. Criterion C: The abnormal functioning occurred prior to age three. DeShon has a tested IQ of 60 and thus is given the specifier with accompanying intellectual impairment and also, due to his limited use of language, with accompanying language impairment . He is further specified as requiring substantial support because he functions poorly on his own unless involved in an isolated activity of particular personal interest. Additional Information Required We can assume DeShon went through the appropriate testing needed to determine his diagnosis, although not much information is provided in the case study about the results of various assessments and tests.
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Risk and Resilience Assessment Biological factors are the major contributors t o the development of autism spectrum disorder, but we know very little about how any such factors are affecting De Shon. Regarding his risk influences for the course of the disorder, he has serious problems with play deficits and stereotypical behaviors, and the family routinely experiences material hardships. On the protective side, DeShon is not aggressive, has a supportive mother and extended family structure, and is part of a school system that can offer and coordinate a range of interventions. What questions could be used to assess for additional strengths in DeShon? The assessment could focus more carefully through additional interviews with DeShon’s mother on his strengths with coping questions (It sounds like y ou’ve had a lot of challenges. How have you been able to manage with all you’ve be en through? How do you go on? What are the q ualities you draw on? What would yo ur stepmother say that you do? How about your boyfriend?) and exceptions (When doe s DeShon seem more responsive? Who is there? What are they doing and saying?). Other questions may include “What are the types of social situa tions that seem to bring out DeShon’s talents and positive adaptive qualities?” and “What positive characteristics can be channeled to enhance DeShon’s adaptation to the newly structured setting?” Intervention Plan The social worker should ensure that mother is linked with social services (e. g., Medicaid, food stamps, Temporary Aid to Needy and Dependent Families) so that DeShon’s basic health, medical, and nutritional needs can be consistently met. The state Autism Society might have further information on available family resources. DeShon’s mother’s financial situation needs to be stabilized so that DeShon can remain in the same school sy stem once he begins services. The social worker will present education about autism to DeShon’s mother and a referral to a support group for parents of children with ASD. Special education services will be provided by certified professionals at and through the school, including a pplied behavior analysis that can te ach DeShon skills and knowledge and extinguish his negative behaviors (i.e., tantrums) by consistent ignoring. DeShon’s mother and her boyfriend will be taught behavioral techniques so they can apply the same structure with him in the home. Critical Perspective It seems clear in this case, based on the thoroughness of the examination process, that DeShon has a neuro developmental disorder, and he most clearly fits the criteria for autism spectrum disorder. However, such a diagnosis implies that the client has less potential to improve with regard to social and interpersonal functioning, so it is important that the social worker continue to look for evidence of strengths when this diagnosis is made, and not assume that the client’s change capacity is modest.
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Chapter 4 Attention Deficit Hyperactivity Disorder Case 1: Questions to consider when formulating a diagnosis for Billy: 1. Has Billy suffered any recent stressors that c ould account for his symptoms? Did his symptom pattern precede or follow the stressful life events? Billy has recently disclosed sexual abuse that went on during a recent six - month period. However, to make the criteria for an adjustment disorder, the behaviors would have had to start shortly after (within three months) of the stressful life event, and, according to Mrs. Bronsky, Billy has been exhibiting the pattern of behaviors (oppositionality, poor school performance, bedwetting, and encopresis) since he was a young child. 2. Do the oppositional behaviors arise out of frustration due to inattention and hyperactivity? According to Mrs. Bronsky, the opposite is the case; she views his inattention symptoms (forgetfulness, inability to concentrate, losing things, inability to complete work) as being purposeful ly undertaken to annoy others. The teacher sees the existence of both inattentive and oppositional symptoms rather than the oppositionality stem ming from ADHD. Although Billy’s mother attributes his inattentive symptoms to oppositionality, in general school report is the more valid source of information on ADHD. In addition, Billy’s mother does note the inattentive symptoms. One must also remember that ADHD and oppositional defiant disorder often occur together. 3. Has Billy been exposed to trauma? Could his sy mptom pattern be indicative of PTSD? The presenting problem for treatment is the sexual abuse. Although Mrs. Bronksy insists that his behaviors started long before the sexual abuse, witnessing family violence can be a traumatic event for children. Billy, like most children his age, may not be able to detail his internal experience about the violence. For this reason, parents are an important source of information for PTSD symptoms in children, although they may tend to minimize symptoms. Mrs. Bronksy denied that the sexual abuse or the family violence has had an impact on her children, although she is willing to seek counseling at the recommendation of the child advocacy workers. In terms of re - experiencing , both Billy and his mother say he does not have nightmares, but it would be important to hear from him what he dreams of and if particular dreams are a ssociated with his bedwetting. She says he does not report flashbacks. In the therapist’s sessions with Billy, it will be important to see if re - experiencing of the abuse occurs throu gh drawings, stories, or play. The child’s re - experiencing the event can be facilitated through its re - enactment wi th drawings, stories, and play. The hyperarousal criterion for PTSD could be manifested by his inattention symptoms (forgetfulness, lack of concentration, inability to sit still) and his bursts of irritability and anger. His incontinence could further be construed as indicative of PTSD, and one could speculate that the sexual abuse by his cousin could have resulted from possibl e decreased arousal to threat. Avoidance symptoms could be seen in his tendency to avoid discussions about the sexual abuse, although other motivations could be re sponsible, such as
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embarrassment, threats from the abuser, a desire to please adults by not discussing negative events, and the belief that he is at fault (James, 1989). In a conversation with the therapist, Billy was positive about his father and his girlfriend and didn’ t mention the family violence. Again, this could be avoidance due to PTSD, or it could be embarrassment, pressure from the family, his wanting to preserve a good image of his father for himself and people outside the famil y, and possibly other reasons. Numbing could have been signified by Billy’s refusal to talk or respond to the therapist when she first met with him, although this could also have stemmed from his oppositionality. 4. Is Billy’s enuresis primary (there never was a period that he had a dry bed) or secondary (developed after a period of time when there was a dry bed)? From Mrs. Bronsky’s report, the enuresis is primary, which is considered to relate to either a physically and/or neurologically immature bladder and/or a deep sleeping pattern in which the child is unaware of messages to the brain that the bladder is full (Child Development Information, 2006). Note further that children with ADHD are at increased risk of bedwetting compared to children from the general population. DSM Diagnosis 314.01 Attention - Deficit/Hyperactivity Disorder, Predominantly Inattentive Type, Mild 313.81 Oppositional Defiant Disorder, Mild 307.7 Encopresis, without constipation and overflow incontinence 307.6 Enuresis, Nocturnal Only V61.21 (995.53) Sexual Abuse of Child, Confirmed (Reason for visit) Rationale Billy has been given the diagnosis of Attention Deficit Hyperactivity Disorder, P redominantly Inattentive Type. He meets the following seven symptoms of inattention for longer than six months (six are required) and for that reason he was given a “Mild” severity: 1. Does not give close attention to details or makes careless mistakes in schoolwork. 2. Has trouble keeping attention on tasks (schoolwork) . 3. Does not follow instructions and fails to finish schoolwork or chores, or duties. 4. Avoids, dislikes, or doesn’t want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework). 5. Loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools). 6. Is easily distracted (looking out the window instead of completing work) 7. Is forgetful in daily activities (forgets to bring homework home, forgets what teacher tells him) Billy meets only two of the hyperactivity symptoms (fidgeting and squirming , often gets up from seat when remaining in seat is expected ). The impairment (strained relationship with his mother, poor academic performance) is presen t in two settings as required. Billy was given the Sexual Abuse of a Child V code because his recent abuse was th e reason for treatment seeking. Oppositional Defian t Disorder was also diagnosed. His mother states that Billy’s behaviors began before the sexual abuse and as far back as she can remember. The
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diagnosis requires that symptoms st arted before the age of seven. Billy displays four of the eight criteria in section A that are required for si x months or longer, as follows: 1. Refusal to carry out rules or requests by adults (refuses to do schoolwork) 2. Blaming others (blaming another student at school for his misbehavior) 3. Arguing with adults 4. Deliberately doing things to annoy o thers (banging stick in house) Billy exhibits these behaviors both at home and at school, according to his m other. It is currently affecting his ability to function appropriately in school and is causing strained relationships in the home. Because he only has four symptoms and that is the minimal requirement, the “ mild” specifier is indicated. Another diagnosis is Encopresis without constipation and overflow. Billy passes fe ces in his pants once a month. Although we need to confirm that it meets the minimal time frame of three months, it sounds like the behavior has been ongoing for a while. He meets the age r equirement for this diagnosis. Billy also exhibits behaviors that led to the diagnosis of Enuresis, nocturnal only, because he w ets the bed almost every night. It is clinically significant because of its frequency and duration. Additional Information Required Most of the information for Billy’s diagnoses is from maternal report, supplemented by teacher report. Other questions for Billy’s mother could involve her pregnancy and delivery of Billy to assess if there were any early complications. Did she smoke during Billy’s pregnancy? Did he have exposure to lead? She also might know of any family history of ADHD (particularly abou t Billy’s biological father). An assessment of mother’s current adjustment is necessary, as maternal stress and lack of social support are associa ted with poor outcome for ODD. Her perspective on Billy’s peer relationships is also i mportant, as is the teacher’s. From the case study, it is unknown if Billy has friends and if his oppositional and inattentive symptoms have ca used children to avoid him. Once Billy has built some trust with the therapist, it would be helpful to have more direct information to rule out Post - Traumatic Stress Disorder. Several measures have been designed to assess PTSD in children (see Corcoran & Walsh, 2006), including the Children’s Impact of Traumatic Events Scale, which was specifically formulated to assess PTSD symptoms in children who have been sexually abused. A release to talk to Billy’s doctor about his enuresis and encopresis and a recommended tr eatment plan is also suggested. Additionally, results of IQ and learning tests might indicate that Billy meets other diagnoses for intellectual or learning disorders and would thus need additional resources in the school setting. Risk and Resilience Assessment The neurodevelopmental risks that may have contributed to the development of ADHD in Billy are unknown at this time, but are assumed. Billy’s gender places hi m at additional risk for ADHD. Other risk and p rotective influences may affect the persistence of ADHD over time. Risk influences involve Billy’s mother’s inconsistent and ineffective efforts to manage her child’s behavior. Fortunately, Billy’s mother does not prese nt with ADHD symptoms herself. Another p rotective influence is that Billy lives in a two - parent home, although the adjustment into a stepfamily household mig ht have been stressful for him. The fact that Billy is diagnosed with oppositional defiant disorder increases his overall risk for poorer outcome. Other strengths
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involve fa ther involvement in activities. Billy reports a positive relationship with his biological father and sees him regularly. His stepfather has stable employment, and mother is seeking mental hea lth services for her children. What questions would you ask to elicit further strengths? For Billy’s mother: 1. When are she and her husband able to follow throu gh with consequences to Billy? What do they do? How does he respond? H ow do they support each other? 2. What is different about times when Billy had a dry bed at night? 3. He is able to control hi s defecation most of the time. What is he doing to achieve this? For Billy and his teacher: When is Billy abl e to complete his assignments? What i s different about those times? What time of day is it? Who is he sitting near? What is he doing and saying to make this happen? For Billy: Externalizing techniques might be helpful for Billy; these may involve getting him to give a name to the behaviors that are getting him in trouble, then drawing it (“the volcano,” “the fooling around,” “the silly stuff,” “the fighting,” and so on), and showing how he is able to exert control o ver this “externalized entity.” Treatment The sexual abuse is the presenting problem for treatment, although other aspects of his care require an immediate approach. The sexual abuse will be addressed using a cognitive - behavioral approach that has been validated with children who have experienced PTSD, as well as other symptoms, as a result of sexual abuse (Deblinger & Heflin, 19 96). The focus with Billy will be on stress management (progressive muscle relaxation, thought stopping, positive imagery, or deep breathing) and desensitization procedures, so that he will be progressively able to talk about the traumatic event and its aftermath in a way that diminishes arousal and distress ing emotions. This intervention will include Billy’s mother since maternal support is critical to a child’ s adjustment for sexual abuse. Billy’s mother has shown her support in a number of ways (i.e., she has cooperated in the civil and criminal investigations, she has brought Billy for therapy), but there is als o some ambivalence on her part. Her remark about the children not being able to play with their cousin anymore was of concern, although she was able to respond appropriately once she was questioned. She also shows a reluctance, like many parents do, about talking with t heir children about the abuse. Intervention with mother will help her communicate more effectively with her children about the sexual abuse and handle their questions, co ncerns, and possible symptoms. Another critical aspect of the intervention involves Billy’s having an Individualized Education Plan in the school system. The social worker will find out from the State Department of Education how Mrs. Bron sky can initiate this process. Specifically, Billy will need to be tested for his IQ and any learning disabilities. It could be that many of his frustrations are due to the wor k being too difficult for him.
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Another important component to the intervention will be Mr. and Mrs. Bronsky’s participation in parent training to manage Billy’s ADHD and ODD symptoms. Further, Mr. and Mrs. Bronsky (as well as Billy’s father) needs to be pro vided information about ADHD. Treatment for bedwetting in children includes behavioral conditioning devices (pad/buzzer) and/or medications (anti - diuretic hormone nasal spray and the anti - depressant medication imipramine). Eventually the child becomes conditioned to wake up and to go to the bathroom once he or she ex periences the urge to urinate. Although these conditioning devices may take months to work, they have high success rates long - term. The American Academy of Family Physicians (2003) recommends that the treatment of encopresis should entail management of any oppositional behaviors. For both the enuresis and the encopresis, Mrs. Bronsky should be encouraged to follow her physician’s recommenda tions as to treatment approach. As part of a behavioral reinforcement system that Mrs. Bronsky will learn to implement through parent training, she can set up positive reinforcement for Billy having “dry nights,” as well as appropriate use of th e toilet for bowel movements. Critical Perspective Billy has already experienced many stressful life events, including domestic violen ce, divorce, and sexual abuse. Some of these events, particularly the domestic violence, might have o ccurred from a very young age. Therefore, this is a case that shows the possible impact of a dysfunctional environment on a person’s functioning. Although there are biological aspects to ADHD and enuresis, an argument could be made that some of his central diagnoses (sexual abuse of a child, oppositional defiant disorder) are a reaction to a stressful environment, which includes family violence, divorce, mother’s re - marriage, and sexual abuse. The diagnosis of PTSD was considered for Billy. However, some of the difficulties with diagnosing PTSD in children became apparent, although DSM 5 has taken some pains to create criteria that is ap plicable to children under six. First, there is a great deal of symptom overlap between ADHD and PTSD (Perrin, 2000). At the time of the assessment, Billy was not able to convey information about his internal experience. Parental report may be biased, and Billy’s mother may b e minimizing his PTSD symptoms. Case 2: Questions to consider in formulating a diagnosis for Wayne 1. Has Wayne suffered any recent stressors that could account for his symptoms? If so, did his symptom pattern precede or follow the stressful life events? Wayne came to the agency because of a specific stressor – the break - up with his girlfriend, an event for which he accepts blame. While some his symptoms have certainly been exacerbated by that event (especially his low mood and the constant calling of his girlfriend), it appears that all of them have been present for many years, and some for perhaps his entire life. Wayne’s difficulties controlling his temper and his absent - mindedness appear to be long - standing aspects of his personality. 2. Do Wayne’s angry outbursts arise out of frustration due to inattention and hyperactivity? Wayne’s outbursts are due at times to his symptoms of inattention and hyperactivity, but those symptoms do not fully account for that behavior. The angry outbursts also seem to arise from his feelings of insecurity and fears of rejection. In fact, Wayne describes many
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of his episodes of forgetfulness rather calmly; as if this is a characteristic to which he has become accustomed. It appears that when his inattention and hyperactivity cause problems in his primary relationships (with women), they are more likely to result in angry outbursts. 3. Has Wayne been exposed to trauma in his past? Could his symptom pattern be indicative of PTSD? Wayne has experienced trauma in the past, although the nature and extent of that trauma needs to be more fully evaluated. Wayne experienced physical abuse by his father, as well as witnessing the abuse of his mother. These experiences may have provoked fear, helplessness, or horror in Wayne. Further, Wayne and Wendy both describe a variety of situations where Wayne becomes intensely angry at normal life occurrences. His outbursts of anger could represent physiological reactivity but whether it is in reaction to cues o f trauma is questionable. Wayne spoke primarily of the breakup and only briefly and vaguely of his past experiences with his father. This could represent his efforts to avoid thoughts, feelings, or conversati ons associated with the trauma. Wayne did not appe ar to exhibit signs of numbing. Therefore, without additional information, the social worker would be unable to consider further a diagnosis of PTSD. 4. Was a learning disorder behind Wayne’s frustration and inability to complete schoolwork? It is possible that Wayne has a learning disorder, but without the corroboration of school records or new testing this will be difficult to determine. Clearly, some symptoms of ADHD and its outcomes are similar to those involving learning disabilities. DSM Diagnosis 309.28 Adjustment Disorder with Mixed Anxiety and Depressed Mood. 314.01 Attention - Deficit/Hyperactiv ity Disorder, Predominantly Inattentive Type, Mild 995.81 Spouse or Partner Violence, Physical, Confirmed Rationale An adjustment disorder provides a least restrictive diagnosis that accommodates the fact that Wayne’s responses could be considered “normal” for someone going through a breakup with a significant other (a week prior). Wayne’s anxiety manifests through constantly recurring thoughts about Wendy, and his depression can be indicated by insomnia and an irritable mood. Wayne copes with the breakup by staying as busy as possible. The V code Spouse or Partner Violence, Physical, was added because of Wayne admitting to being physically violent with his previous girlfriend. Also of concern was his violence to his ex - girlfriend’s child. When the social worker inquired about this, Wayne was vague, but sounded regretful about hitting the child. The social worker notes that this will be something to explore in further sessions, as it relates to the experience of Wayne’s own physical abuse and watching the physical abuse of his mother by his father. Wayne was also diagnosed with Attention - Deficit/Hyperactivity Disorder, Predominantly Inattentive Type. Wayne meets six of the symptoms of inattention: 1. Often has difficulty sustaining attention in tasks or play: Wayne admitted to having a hard time concentrating on anything other than watching television.
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2. Difficulty organizing tasks and activities: Wayne said he became easily frustrated if he had to deal with too many things at once, such as a lot of work orders. 3. Avoids, dislikes, reluctant to engage in tasks that require sustained mental effort: The client typically avoids activities that require him to do a lot of thinking, and typically spends his time watching television. Wayne chose his current occupation because he is able to move around a lo t, through the apartment units. 4. Loses things: Wayne leaves his tools in different apartment units and wastes time at work searching for them. 5. Easily distracted: If Wayne is cleaning the kitchen, he will sometimes leave the tap water running as his attention becom es diverted on something else. 6. Forgetful: Wayne will forget instructions that have been given to him at work. Wayne does not seem to meet enough criteria to meet the hyperactivity - impulsivity subtype. He does leave situations in which remaining seated is expected. For instance, during the counseling session, Wayne jumped out of his seat to go to the water fountain wi thout announcing his departure. He is also restless and impatient when faced w ith traffic. Wendy states his mother found him to be an “exhausting” child. He ran around constantly, was easily distracted, and acted on every whim he had. Although he did not receive a diagnosis as a child, we can assume that he met crite ria for ADHD before age twelve. Wayne’s symptoms cause both social (relationship problems) and occupational impairment (he is unable to hold jobs for long periods of time). Additional Information Required The social worker would like to explore Wayne’s background and current symptoms in more detail to rule out several other possible diagnoses. Specifically, she would like to inquire further about possible PTSD symptoms, including re - experiencing, avoidance, and numbi ng of general responsiveness. Risk and Resilience Assessment Onset Many of Wayne’s risks for ADHD are unknown as they are theorized to invol ve neuropsychological factors. Very little is also known about his biological father and his history of mental illness, although he was said to have an alcohol proble m and was physically abusive. On the protective side, Wayne’s mother did not smoke or us e substances during pregnancy. Course From the information provided, it does not appear that Wayne developed ODD or CD in his youth, which bodes well for the course of ADHD. However, the past physical abuse of his ex - girlfri end and her child is troubling. With the help of his girlfriend, Wayne has some insight into his behaviors and seems determined to get be tter, if only to get her back. Wayne suffers financially, which puts him at risk; he is in debt, earns little, and does not rece ive health insurance benefits. This means that treatment might be difficul t to pay for. What techniques could be used to elicit additional strengths? Wayne has many strengths. It is known, for example, that he is well liked by his co - workers, does well on the job, and has an attractive personality to some women. Further, he always feels
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remorse for his angry outbursts. His strengths could be further assessed by asking Wayne to recount the various successes he has experienced throughout his life, asking him to make a list of his personal qualities, asking how he learned to be such a good repairman, and how he has been able to implement the organizational task s suggested by his girlfriend. Other techniques could include: 1. Exception - finding Attention: When are you able to focus your attention on what you need to get done, even f or a little while? W hat are you doing differently? Wh o is there? What is going on? Frustration and anger: When was a time you started to feel mad but was able to stop yourself from letting i t take over? What did you do? 2. Future without the problem: When you are able to control your anger and focus yourself, what will you be doing differently? How wil l you be responding to others? What wi ll they be saying towards you? Talk about times this happens now. When you have the kind of relationship you want towards your girl friend, how will you be acting? How will she be responding to you? What will you be doing together? Treatment Medical Goal: To receive a comprehensive assessment for ADHD and appropriate biological interventions for that disorder. Plan: Wayne will receive a medical exam to determine if there is a physical basis to his irritability and angry outbursts. He will also complete a series of rating scales for further assessment of his ADHD. He will be referred for a psychiatric evaluation to d etermine a need for medication. Psychological Goal: To become educated about ADHD and its management. Plan: Wayne will attend a psychoeducational group on ADHD at agency. Goal: To increase quality of social and occupational functioning. Plan: Wayne will receive cognitive - behavioral interventions concentrating on anger management, frustration tolerance, time management, problem - solving skills, and communication skills. The social worker will continue to support and guide Wayne’s efforts to increase structure in life, including budget schedules, increased usage of dry erase board and memos, and files for important documents. Goal: To resolve the nature of romantic current relationship. Plan: Wayne and Wendy will attend couples counseling and problem - solve about the nature of their relationship. Social Goal: To resolve financial concerns. Plan: The social worker will refer Wayne to a legal aid agency to determine whether he has a basis for not being liable for the student loans. He will also be helped to inquire about health insurance options through his current place of employment, and possible to inquire about other places of employment that provide such benefits.
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Critical Perspective Wayne’s case highlights some of the problems in applying the ADHD DSM diagnostic criteria for adults, although improvem ents have been made in DSM - 5. Wayne suffers from such symptoms as overreacting to frustration, poor motivation, and difficulty with time management, although these are not listed in the DSM. As it is, he only met criteria for the “Predominantly Inattentive Type” of ADHD, but many of his symptoms involve impulsivity, and these are not captured in the diagnosis.
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Chapter 5 Schizophrenia Case 1 Questions to consider in formulating a diagnosis for Anna: 1. What symptoms of problematic thinking, feeling, and behavior does Anna present? Anna displays a variety of thoughts, feelings, and b ehaviors that are detrimental to her social functioning. She exhibits poor self - care, is withdrawn from almost all interpersonal interaction, displays little emotion, ma intains a blank affect , does not communicate coherently, talks to herself, seems preoccupied, and uses poor judgment by agreeing to live with a relative stranger. S he has nightmares and evidently no motivation to make any changes in her life. 2. Are any of the above symptoms clearly psychotic? Many of Anna’s symptoms appear to represent psychotic ideation, including her level of withdr awal, talking to herself, absence of affect, and preoccupation with internal stimuli. Because she does not communicate well verbally, however, it is difficult to understand the extent of her psychotic ideation. 3. Is it possible that Anna has, or has had, a mood or schizoaffective disorder? Anna’s presentation is striking in that she does not exhibit any affective range. There are no symptoms of depression or elation. S chizoaffective disorder can be ruled out because of this absence of a strong and variable mood component to her psychotic symptoms. 4. How does Anna’s poor communication complicate the process of her assessment and diagnosis? Anna is somewhat puzzling diagnostically because she is not verbally engaged with her service providers, and as such is not a valid self - informant. Without the benefit of the recent tes ting, physical exams, reports from her recent hospitaliz ation, and input from her father, it would be difficult to confident ly reach a conclusion about her diagnosis. Still, medical conditions have been ruled out as contributing to her bizarre behavior, and it is known that she does not use any substances that might be mind - altering. 5. Is there evidence of a premorbid personality disorder in this client? A diagnosis of s chizoid personality disorder could be made as a premorbid condition. This is based on her father’s history of Anna’s being a quiet, withdrawn girl who always did what was expected of her, but without evident enthusiasm or conviction, and then withdrawing to her room. Since her adolescent years she has rarely lef t the confines of her home, has taken no social initiatives, and seems most comfortable w hen alone. Her premorbid behavior was not bizarre enough to warrant a consideration of schizotypal personality disorder. 6. How would you characterize Anna’s childhood and adolescent functioning, given the information presented? Anna’s childhood and adolescent functioning appears to have been characterized by a dutiful fulfillment of some family and school responsibilities but also social withdrawal, affective fla tness, a lack of desire for social contact, and a lack of interest in many conventional daily living activities. She does not appear to have ever been distressed about her lifestyle.
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DSM Diagnosis F20.9 Schizophrenia, Continuous F60.1 Schizoid Personality Disorder (Premorbid) Rationale Regarding the diagnosis of schizophrenia, Anna exhibits abnormal patterns of thought and behavior that have persisted for well more than six months. It is not clear whether she is having delusions or hallucinations right now, because she is not sharing much of her thinking. However, it appears that she is distracted by, and preoccupied with, thoughts unrelated to here - and - now circumstances, so we may assume the presence of auditory hallucinations or delusions. Further, her behavior is clearly disorganized, as she is unable to care for herself. She does not bathe or wash her clothes and has no evident sense of the effects these actions have on others (such as the secretaries who objected to her behavior). Therefore, she meets the criteria for two of the active symptoms of schizophrenia. What is equally striking about the client is her affective impairment, or her negative symptoms. Her affect is continuously flat; she is socially isolated, non - communicative, and passive in her orientation to those around her. She rarely asserts what she wants or how she is feeling. Finally, An na’s social functioning is poor, and seems to have declined from the higher level of her early college years. Her functioning is currently so marginal that it does not appear that she could carry out any of those activities. The spe cifier “continuous” was added, as it appears from the history that Anna’s active psycho tic symptoms are always present and have been for more than six months. A diagnosis of schizoid personality disorder can be made as a premorbid condition based on the symptoms summarized in the first section. At present the client does not experience medical problems. The client’s gross lack of personal hygiene does place her at risk for a variety of physical illnesses, for which the social worker should stay alert through observation and referrals for physical examinations. Risk and Resilience Assessment Onset Anna appears to have a genetic loading for schizophrenia, since her mother also has a psychotic disorder. The specific biological factors are not known, and cannot be directly investigated, but they may involve a disorder in her limbic system, enlargement of certain brain ventricles, and abnormal levels of certain neurotransmitter s . There is no evidence of early trauma, but it is possible that Anna’s risk could have been complicated by birth complications or prenatal viral exposure. Regarding psychological factors, it is possible that the household in which Anna grew up was not a nurturing one, given the reports of erratic and unpredictable behavior of her mother. This may have activated Anna’s biological sensitivity to the disorder . There are a variety of traumatic events along the lines of parental neglect and family tension that could have been present in her household. Finally, Ann’s poor level of social skills indicates that she would have difficulty making trans itions into adulthood . Regarding protective factors, Anna’s environment was materially comfortable and there is no eviden ce that she experienced physical trauma that may have contributed to constitutional weakness. Regarding the course of her disorder, Anna faces certain risk influences . She experienced a gradual onset of schizophrenia, demonstrated marginal premorbid social functioning, does not experience her psychotic symptoms as strange, and shows prominent negative symptoms. She
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lives in a large urban area and continues to experience high levels of family tension with her father’s disapproval and her stepmother’s lack of support. She has poor social skills and has experienced deterioration in her intellectual capacity. Regard ing protective factors, Anna is part of a family system that could potentially become more supportive. Further, she has some independent living skills, to the extent that she has been living in a condominium with her sist er. What questions can help to assess for further strengths in Anna: 1. Despite An na’s limitations, does she demonstrate any personal qualities that are functional or adaptive? Where, when, and with whom does she demonstrate these qualities? 2. Does Anna express any personal goals that might be used to motivate her for change? 3. What talents did Anna demonstrate in her childhood and adolescence? Does she ever utilize these talents now, or indicate a desire to do so? 4. In what kind of environments (both housing and social) does Anna seem to best manage her activities of daily living? What characteristics of those settings seem to be appealing to her? 5. When does Anna seem most comfortable with other persons? In what situations is she most verbal? Is Anna capable of developing relationships in which she seems trusting? Intervention Plan There are many services from which Anna might benefit with regard to the remission of both the positive and negative symptoms of schizophrenia, and her acquisition of social and vocational skills. Still, the social worker needs to be cautious in developing an initial treatment plan. Like many persons with schizophrenia, Anna is reluctant to participate in an extensive intervention process at the outset because she seems to be easily overwhelmed. She may also be reluctant to trust others because she is not comfortable in relationships. It will initially be important to engage Anna in a relationship of trust, and then later she may take the initiative to participate in other interventions. What follows here is a summary of interventions that could be utilized now and others that might eventually be used with the client. Anna may well benefit from taking antipsychotic medications, given the severity of her symptoms. The social worker can schedule Anna to meet with the physician in the coming week so that he may at least talk with her about the possible benefits of medication. Family edu cation and support will be important if the client’s father (and perhaps step - mother) would be obliging. M r. Yannucci appears to have little awareness of schizophrenia and its treatment. He has suffered greatly as he has tried to help his daughter, but he does not know how to do so, given her condition. This service may be provided individually or in a group setting. Anna’s parents could learn about her disorder, avai lable interventions, and behavior management strategies; and find support for the burden that they experience. The remaining goals could be provided by a case manager or though an assertive community treatment team. Clubhouse involvement would be a helpful way for the client to add structure to her life, improve her activities of daily living skills (budgeting, laundry, home care) and improve her social skills . Anna might learn to cook and engage in modest work activities. Vocational assessment and rehabilitation could assess Anna’s skills and potential for work, and place her in programs where her skills could be d eveloped. Through referrals for recreational activities the client might be able to expand her range of daily activities. For example, since she enjoys walking, she might be helped to get a membership at a health club. Linkages with entitlement
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services could help Anna insure that she was receiving benefits such as social security disability money and health insurance. Her father has been providing her with such assistance, but he might like to assume less responsibility for this aspect of his care, if possible. Critical Perspective The DSM’s reliance on behavior observation in making diagnoses presents a problem with Anna’s presentation. She is withdrawn, passive, and marginally communicative, which makes it difficult to assess with certainty if she is experiencing the active symptoms of schizophrenia (hallucinations and delusions). Her presentation also demonstrates the necessity of relying on historical data (from her father and the referring hospital) in diagnosis. If the social worker was limited to the client’s current presentation, many other diagnoses (including cognitive, medical, and substance abuse) would need to be considered more seriously. Case 2 Questions to consider in making a diagnosis: 1. What symptoms of psychosis does Donald display and for how long have they been evident? Donald experiences delusions. He believes that people are ridiculing him and reading his mind, tha t the day treatment program is evil, that fathers are perverted, that he is possessed by the devil and that by not eating he could starve people away. The client al so experiences hallucinations. He feels a presence touching him and hears voices. Additionally, he shows disorganized behavior , sitting outside in cold weather with light clothing and sleeping in the back yard. Moreover, he displays disorganized speech as evidenced by frequent derailment. Finally, negative symptoms, namely affective flattening, are evident. Donald has experienced these sym ptoms for three years, well past the six months minimum required for the diagnosis of schizophrenia. 2. The diagnosis of schizophrenia also requires functional impairmen t. Is impairment evident in this case? Donald was unable to co ntinue with college or work, and was not able to socialize with others. 3. Are psychotic or mood disorders present among relatives? There is a family history of mental and mood disorders. Donald’s mother is taking anti - depressants and her brother has bipolar disorder with psychosis during his manic episodes and a substance use disorder. There is also history in Donald’s mother’s family of attempted suicides and a paternal great uncle having “a breakdown.” 4. Does Donald have a history of depression or mood swings that might indicate a schizoaffective, major depressive, or bipolar disorder? Donald has a long history of depression (since age 13). At the age of 20, he star ted to have psychotic symptoms. During periods of psychosis, he continues to have periods of depression, which pers ist for several weeks at time. At these t imes, he exhibits a depressed mood as indicated by his parents’ and helpers’ reports ; a decrease in appetite; hypers omnia; a loss of energy as noted by his parents’ and he lpers’ reports; and more withdrawal and isolation som etimes than others, which suggests even less intere st or pleasure i n activities most of the time. Donald has two - week periods or longer in which
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he continues to display psychotic symptoms but does not have the depres sive episodes. He does not demonstrate hypomanic or manic episodes. 5. Are there any medical conditions that may be contributing to Donald’s symptom development? Although there is no specific infor mation in the case about a medical evaluation, the psychiatrist is said to be coordinating Donald’s case with his primary care physician, so we can assume that medical causes have been ruled out. 6. Is the client’s use of substances or medications causing symptoms? Donald has no history of alcohol or drug use. 7. Are there psychosocial stressors that might be contributing to Donald’s symptom development? Donald has not experienced any recent stressors that m ight account for his symptoms. The social worker might want to inquire about any stressors that were present at the time of his first psychotic symptoms. 8. What was Donald’s premorbid functioning like? Donald was described as a shy child who started to become depressed at age 13. Little is known about Donald’s relationships before the onset of his psychotic symptoms, for example, whether he desire d or enjoy ed close relationships, had interests and activiti es that he enjoyed, was indifferent to the opini ons others had of him, or exhibited emotional coldness, detachment, or flattened affectivity even then. The se symptoms, if confirmed, might be indicative of a premorbid s chizoid personality disorder. DSM Diagnosis F25.1 Schizoaffective disorder, depressive type, multiple episodes, currently in acute episode Rationale The diagnosis of schizoaffective disorder, depressed type was made because Donald’s illness meets the criteria for schizophrenia and major depressive episodes. He shows the characteristic symptoms of schizophrenia in that he experiences the follow ing during a one - month period: Delusions (people are ridiculing him and reading his mind, the day treatment program is “evil,” fathers are “perverted, he is possessed by the devil and by not eating, he could starve them away) , h allucinations (a presence is touching him, voices) , d isorganized speech (frequent derailment) , d isorganized behavior (sitting outside in cold weather with light clothing, sleeping in the back yard) , and n egative symptoms (namely affective flattening). Donald’s social and occupational functioning is disturbed in that he is currently unable to work, continue his co llege education, or socialize. He has been experiencin g symptoms for three years. He experiences delusions and hallucinations for periods of at least two weeks in the absence of mood symptoms, but he also has prolonged depressive episodes during the majority of his illness. Donald has a hi story of depression going back to age 13. Episodes lasting several weeks have continued since he experienced his first bout of psychosis at age 20. During these periods he will sleep at least 12 to 14 hours and has difficulty waking. He eats less, is more withdrawn and isolative, and is less active than at other times. The specifier “multiple episodes, currently in acute episode” was selected to reflect the fact that Donald has fluctuating symptoms of his disorder over time, but at the present time his psychotic symptoms are prominent.
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Additional Information Needed The pattern of Donald’s illness seems to fit schizoaffective disorder without question. However, it would be helpful to know the true pattern of his psy chotic and depressive symptoms. It was not clear how long the depressive episodes last, or how long the psychotic symptoms had been present when he had his first depressi ve episode after the psychosis. It is not certain, however, that this information would change the diagnosis. It would certainly create a clearer picture of the pattern that is typical for Donald’s illness. If the depressive episodes decrease over time, whether in number or in length of the episode, the diagnosis would have to be reevaluated to determine if a diagnosis of schizophrenia would be more appropriate. Risk and Resilience Assessment Donald’s risk for the onset of the schizoaffective disorder may include the biological vulnerability present in his family. Although there is no clear familial history of schizophrenia , there seems to be a history of mental il lness. Donald’s age (early 20’s) and gender also present risk. In addition, he was born in February, whi ch puts one at a higher risk for the disorder. Protective mechanisms for the onset of Donald’s illness include the fact that he suffered no major traumatic event or brain injury and that he has a relatively high socioeconomic status and a stable, functional family. His mother also had a normal pregnancy and delivery. The main risk influence for the course of the disorder includes repeated relapses, with some resid ual symptoms between episodes. Protective mechanisms include Donald’s ability to maintain some insight. Therefore, the social worker, doctor, and his family members can talk with Donald about treatment opti ons when he is most receptive. Other protective influences involve the fact that he received the early interventions of medication and day treatment. He is currently compliant with his medication and if that continues, it will be another protective factor for the c ourse of his illness. O ne of the most critical protective factors in this case is Donald’s family’s supportiveness and their invol vement in his care . Fin ally, he has access to quality treatment in the community where he lives and his family ha s the means to pay for it. What questions can help to assess for additional strengths in Donald 1. What behaviors does Donald currently demonstrate that are functional or adaptive? Where, when, and with whom does he demonstrate these qualities? 2. Donald has attempted to live on his own on several occasions. While he was not successful in this regard, what positive survival skills account for his persistence at these times? 3. Does Donald express any realistic personal goals that might be used to motivate him for goal setting? 4. Donald demonstrated some vocational capacities in his adolescence. How might these be tapped as a means of developing vocational goals? 5. There are times when Donald’s behavior seems more socially appropriate than others, and when his symptoms are less evident. In what situations do these behaviors appear to be most prominent? 6. What personal aspirations or desires for social interaction account for Donald’s several attempts to “succeed” at the day treatment program? 7. Donald cares deeply about children. Even though the behaviors related to his caring have been inappropriate, is there a way to tap into his empathy toward a constructive end?
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Intervention Plan Since Donald is opposed to a hospital setting for a revamping of his medications, oth er options need to be explored. One option is that at his day treatment program, a doctor can observe his behaviors daily, monitor his medications, and gradually adjust them as needed. Another option in the community is a 16 - bed short - term residential facility in which clients are c losely monitored and receive transportation to appointments, referrals to necessary agencies, meals, recreational groups, individual therapy, group therapy, and medication management. The facility has a psychiatrist and a n urse practitioner. These professionals can help the client through a medication transition in a gradual manner . As part of Donald’s intervention, his parents could attend a family psychoeducational group that can provide them with support from others, education about schizoaffective disorder, treatment strategies, ways to manage their son’s behavior, and coping skills for themselves. Participation in such a group may help Donald avoid relapse and also help them gain needed support and knowledge about living with a son with the disorder. Critical Perspective Schizoaffective disorder is a psychotic disorder although it has some similarities to bipolar disorder with psychotic features, which is a mood disorder. It appears in this case the diagnosis could be accurately made due to the clarity of symptoms, but social workers must always take care to differentiate between the two disorders, because their treatments are quite different. Case 3 Questions to consider in making a diagnosis: 1. What symptoms of psychosis does Emma display? Emma experiences delusions. She believes she still owns a house, her son is an imposter, she was shot at work, and she has no siblings. The client also experiences hallucinations. She has been observed responding to internal stimuli in the hospital setting, and she reported that she hears the doctor’s voice telling her she has been released from the hospital. Emma appears to have experienced these psychotic symptoms for the past 14 years. She may have experienced residual periods as well , although this is not clear from the case study. Finally, Emma displays flat affect and avolition (e.g., she would sit in front of the television with no volume on and was unable to care for herself), which are negative symptoms of schizophrenia. 2. The diagnosis of schizophr enia also requires impairment. Is impairment evident in this case? Emma h as been unable to hold a job or live independently, and she is estranged from her son who is “wo rn out from dealing with her.” 3. Are there any medical conditions that may be contributing to Emma’s symptom development? There is no information in the case presentation about a medical evaluation, so this should be completed to rule out the possible influence of any medical conditions. 4. Is the client’s use of substances or medications causing symptoms? Emma has no current use or history of alcohol or drugs. She takes medication for hypertension, but this is monitored in the hospital setting and there is no reason to believe this medication results in her symptoms.
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5. Are there psychosocial stressors that might be contributing to Emma’s symptom development? The divorce in her 40s might have precipitated the psychotic symptoms, but they only worsened over time rather than di ssipating. She has now had symptoms of schizophreni a for 14 years . 6. Are psychotic or mood disorders present among relatives? According to Emma’s son, there is no family history of psychotic disorders. 7. Does Emma have a history of depression or mood swings that might indicate a schizoaffective, major depressive, or bipolar disorder? There is no evidence that Emma has suffered from depressive, manic, or hypomanic episodes. 8. What was Emma’s premorbid functioning like (to determine the presence of a possible s chizotypal , schizoid, or paranoid personality disorder)? Little is known about Emma’s personality before the onset of her current symptoms. More information needs to be gathered in order to decide if she had a personality disorder t hat preceded the schizophrenia. However, Emma seemed fairly well - functioning from the information we do have, in that sh e was married, employed, and raised a son. DSM Diagnosis F20.9 Schizophrenia, Continuous Hypertension, Essential Rationale Emma meets the first of the basic criteria for the diagnosis of Schizophrenia, in that she experiences at least two psychotic symptoms that persist for more than a month. Emma has auditory hallucinations, although it’s not clear if this symptom is present for a significant portion of a month. Emma also has bizarre delusions . Emma also has the negative symptoms of flat affect and lack of vo lition. Emma’s symptoms emerged many years ago and she has be en unable to work or take care of herself due to the illness. Schizophrenia further requires coding of course of illnes s after one year. Emma ’s disorder is specified as “continuous” as there has been no remission of “A” symptoms. It is not possible to determine for certain if Emma’s behaviors are due solely to schizophrenia or if another disorder with some relationship to her behavior is present. The fact that she did not develop clear symptoms of a psychotic disorder until midlife is unusua l. Risk and Resilience Assessment Emma’s onset of schizophrenia was unusually late in life. According to her son, there is no fa mily history of schizophrenia. There was no information provided on Emma’s prenatal development, or her delivery, so the extent to which any complications might have played into the development of Emma’s illness is unknown. It is also unknown how well Emma’s son knows her history, but he claimed that there were no trau matic events in her childhood. There were reports of Emma being “whipped,” but whether this was outside the boundaries of what a child in her historical and cultural background e xperienced is not established. A traumatic event during adulthood, the end of her marriage, seemed to have acted as a tri gger for the disorder. Emma comes from a low socioeconomic backg round, which also confers risk for the disorder.
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In assessing risk and resilience for the course of the illness, on the positive side, Emma had a relatively late age of onset an d a good premorbid adjustment. From what we know, she was married and raised a son who went on to go to college. She had an identifiable precipitating event for the disorder rather than a gradual onset, which bodes well for her adjustment. She also has an unfor tunate number of risk influences that include poor insight about the disorder, living in a large urban area, delayed treatment, repeated relapses, a history of non - compliance with medication, and the absence of a support system. Her son was involved with her care for a time, but he became “worn out,” and she doesn’t seem to have other suppo rtive people available to her. On a more formal level, Emma receives support from the mental health facility i n which she is housed. H er medication compliance is assured, although even so she continues to experience both positive (delusions and hallucinations) and negative (flat affect, lack of volition) symptoms. She receives daily supervision in living tasks, her hou sing is provided, and s he also receives psychological interventions. Additional information needed Because it is unusual for schizophrenia to develop in one’s 50s, Emma’s professionals should be alert to any additional medi cal and psychosocial information that becomes available to make sure that she has been diagnosed accurately. It does not appear that any such information is available at present. Ways to assess for additional strengths in Emma 1. Emma is said to be generally pleasant when interacting with others. How could her pleasant nature be built upon to further develop interpersonal skills? 2. Emma did not develop the symptoms of schizophrenia until relatively late in life. What social and vocational skills did she develop prior to the onset of her illness that might still be available to her? 3. Emma has generally been non - compliant with medications, but now she takes them because the nurses give them to her. Are there times when she has been willing to use medications? Why was she more willing at those times? 4. Are there times when Emma has been aware of her need for medical treatment? Are there types of medical treatment with which she seems relatively comfortable? 5. What hobbies or interests does Emma have that can be encouraged as part of her rehabilitation? 6. Emma seems to enjoy certain aspects of her hospital program (going on outings, attending groups). What is about these structured activities that she enjoys? How might these elements be transferred to other areas of her life? Intervention Plan A major goal for Emma is stabilization of her symptoms, which will hopefully be achieved by finding an effective antipsychotic medi cation at an appropriate dose. Nursing staff and the d octor on her team will monitor her symptoms and the effect of the medication. Another goal is for Emma to participate in psychoso cial interventions, which will include education about her mental and physical illnesses. At this time, Emma does not believe she has either a ment al illness or hypertension. Greater awareness and management of her symptoms will
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