The Case of Mr. Z: Diagnosis of Comorbid Disorders

Complete the writing assignment for the questions below based on the attached case history. Number each question and adhere to the minimum page length specified for each question. Please include a title page (name and date) and a reference page and double-spaced throughout. Please follow APA style and include at least twelve (12) references from the references attached. Please use reference from, Hays (2016) and the ADRESSING model, in considering diversity issues in question Number 6; and Armeresha & Venkatasubramanion (2012) in answering a question on expressed emotion in question #4; and Vaillant (1992) in answering defense issues in question Number 2 and the DSM 5 (2013) in question Number 1. Other relevant reference (such as First (2014), Frese (1993), Hanson & Gottesman (2012), McWilliams (2011), and others) also may be cited if appropriate.

Please answer the following questions for the attached case report of Mr. Z, which follows based on the course readings noted above. To stay organized, please number each section of your paper according to the questions below and follow the minimum length requested.
1. What DSM 5 diagnoses would you assign for Mr. Z? Are there any specifiers that you would use for the diagnosis? Consider comorbid disorders. Is there a personality disorder? Justify your response. (Cite the DSM-5). (at least one-half page in length)
2. What are the specific symptoms (e.g., positive, negative, and/or mood symptoms) behaviors to consider for Mr. Z. How serious do you consider the suicide attempts? In addition, what defenses does Mr. Z employ? What defense do you consider most important for treatment considerations? Why? (cite Vaillant) (at least one-half page in length)
3. What are the substance abuse issues for Mr. Z? What are some options in treating substance abuse for Mr. Z? Explain. Cite the articles by Sellman (2009) and Sterling et al., (2011). (at least one page in length)
4. What role does expressed emotion play in treatment for Mr. Z? What recommendations would you make regarding expressed emotion and treatment for Mr. Z? (Cite Armeresha & Venkatasubramanion (2012). (at least one-half page in length)
5. What type(s) of treatment would you recommend for Mr. Z such as family, individual (cognitive/behavioral, psychodynamic etc.), the recovery model (Anthony (1993), hospitalization, medications, group, or assertive community treatment? Why would you make these recommendations? (Cite Kreyenbuhl et al., (2009). Monroe-DeVita et al. (2012) and possibly other readings such as (Anthony (1993), Angell (2011) and Oldham et al. (2011)). (at least one and one-half pages in length)
6. What stigma issues may be relevant for Mr. Z (Corrigan et al. (2014). In addition, if Mr. Z were of a different race, gender, or other characteristics, what additional information would you like to collect or consider for diagnosis or treatment? Why? Please cite P. Hays (2016) ADDRESSING model in your response (or possibly Combs (2018)). (at least one page in length)
7. Evidence based on best practice treatments are advocated by professional organizations (such as the American Psychological Association) yet Angel (2011 and Shedler (2015) express reservations about standard treatments widely espoused by others. Briefly critique (positive and negative aspects) arguments made by Angel and Shedler about standard or best practices of treatment (medications, CBT). (at least one page in length)
8. What strengths or resources does Mr. Z possess that a therapist mat consider? (at least one-half page in length)
9. Bellack (2006) contrasts two models of recovery in schizophrenia (i.e. the “scientific” model and the “consumer” model or Anthony’s recovery model). Based on the literature cited in the article for these models, what do you think the prognosis is for Mr. Z? Also, according to Bellack, can the “scientific” model and the “consumer” model be reconciled in understanding (e.g., etiology, prognosis) and treating persons with severe mental illnesses such as schizophrenia? If so, why so? If not, why not? (at least one page in length)

(THE CASE OF Mr. Z)

Identifying Characteristics: Mr. Z is a 39 year old, cisgender, married, white man with two sons, ages 11 and 17. He has worked as a clerk for the past 6 months after 18 months of virtual unemployment. Mr. Z completed one year of college but has had nine jobs over the past 7 years. He and his wife struggle to support the family, in part because of his episodic and marginal employment. He receives disability compensation from the VA in addition to his salary.
Presenting Problem: Mr. Z is seeking outpatient treatment at this time because he is quite upset about the supervisors on his job who he says “are out to get me.” He believes one man in particular is trying to “break” him. Mr. Z wrote down a heated conversation he had with this supervisor and distributed it to other employees. He is afraid of losing his job because of this. He also fears that his supervisor is part of a militia group who is following him around and may cause him harm.
Background: Mr. Z reports being socially awkward and withdrawn as a child and adolescent. He describes himself as a loner and he has always lacked close friends. He reports that he felt most comfortable as an adolescent in solitary activities.
Mr. Z joined the army at age 18. He was first hospitalized at age 19 while in the service following an encounter with a prostitute. Afterwards he received a medical discharge from the army. For the next 7 years there were no apparent difficulties. Then at age 25 he started hearing voices after seeing an old girlfriend. Mr. Z has had a total of seven psychiatric hospitalizations. He has not been hospitalized for the past year but maintains a tenuous adaptation experiencing ideas of reference, auditory and visual hallucinations, paranoid delusions and thought disorder which periodically disrupt work and relationships. Although he does not experience mood episodes, Mr. Z also suffers from anxiety and depression. Symptoms periodically intensify and he gets in difficulties with supervisors and loses jobs. However, he perseveres in finding new jobs after losing jobs and despite extended periods of unemployment.
Mr. Z has a long history of alcohol abuse. He has a cycle of severe abuse followed by periods (sometimes six months) in which he does not drink at all. He has had two DUIs within the past two years, and his wife and other family members have complained about his drinking. His drinking precipitates arguments with his wife although he has not abused either his wife or children when he drinks. Incidents of heavy drinking have been followed by intense guilt and anxiety in which Mr. Z attempts to remain sober.
Mr. Z is impotent with his wife and fantasizes about relationships with other women. In addition, he has approached a woman supervisor at work for a date. He experienced great guilt over this action as well as continuing guilt for having arranged an abortion for his wife 18 years ago. However, Mr. Z knows he will never leave his wife and eventually confesses all of his fantasies and actions to her because of overwhelming guilt.
Mr. Z’s wife is quite critical of Mr. Z’s actions as well as his work difficulties. His wife often berates him for a variety of problems, including his work habits and drinking habits. They often argue which intensifies various symptoms for Mr. Z., and has precipitated hospitalizations in the past. Also, one son is in therapy due to depression and social isolation, and this son is having difficulty in school.
Mr. Z’s depression and alcohol abuse has increased in recent months. Mr. Z sees himself aging in a meaningless job. Although he reports a few casual friends, he rarely meets them and he is quite inactive socially and otherwise. Mr. Z and his wife rarely go out socially. His primary spare time activity is isolating himself in his room where he smokes, drinks and listens to music.
In addition, Mr. Z has made several suicide gestures, usually by cutting himself. He is preoccupied with thoughts of self-mutilation as a way of absolving himself of guilt. He has attempted suicide 4 times in the past two years, and he reports attempting suicide when he is extremely upset. In the most recent attempt, Mr. Z overdosed on medications saying: “I did it just to show people I am hurting, it was nothing serious.”
Mental Status: Mr. Z is of average height and weight and looks his stated age of 39 years. He was very articulate, cooperative and anxious to tell his life story. Mr. Z appeared disheveled and smoked throughout the interview. His answers are rambling, and digress into irrelevant areas before finally reaching a goal. Mr. Z often intermingles bizarre, idiosyncratic material into his speech. For example, he included inappropriate details in discussing his sexual fantasies and behaviors. Although Mr. Z appears agitated, he maintained good eye contact, and his physical movements and rate of speech are within normal limits. He is in good physical health and reports no medical problems.
There is no evidence of manic symptoms now or in the past. Psychotic symptoms include a variety of delusions and hallucinations which have been present daily in varying forms for years. He believes supervisors (and others) comprise a militia group out to get him. He reports hearing 3 male voices commenting on his actions and telling him what to do. Mr. Z believes electricity controls his thoughts and actions in some ways. He also believes television occasionally refers to him directly, and he suspects that he has impregnated “Rachel” (of Friends). Although he does not experience a full mood episode, depressive symptoms have increased over the past month and include depressed mood, severe guilt and thoughts of suicide experienced concurrently with psychotic symptoms. As job problems have increased so has his alcohol use and Mr. Z currently has about 5 or 6 drinks alone in his room about 5 times per week. He occasionally drinks in the morning and has had periods of memory loss for recent events. He denies using other substances. Mr. Z reports no sleep or eating problems.
Mr. Z has been in individual therapy episodically through the VA for many years. He has taken the anti-psychotic medication Thorazine within the last year but he has not been compliant because of the side effects, which he dislikes and maintains “slows” him down.