Assessment and Diagnosis Identifying Information

Case Presentation Template
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Author Note
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Case Presentation Template
Part 1 – Assessment and Diagnosis Identifying Information
Identifying Data
Date of Initial Assessment: 01/01/23
PSEUDO Name: Malvin R. Hawkins
Age: 41 years
Gender: Female
Sexual Orientation: Lesbian
Race/Ethnicity: Hispanic
Marital Status: Married
Employment Status: Employed and schooling
Reason for Referral/Presenting Problem
Malvin R. Hawkins reported for the therapy since she was experiencing symptoms of distress related to her childhood trauma, difficulties in managing her anxiety and triggering instances in her work. She reported that she had recurrent memories from her childhood that she did not want. Moreover, Malvin expressed having challenges avoiding distressing nightmares and thoughts, excessive worry, restlessness, detachment feelings, and fatigue. Also, she said she experienced relationship challenges with her spouse and communication distress with her mother.
Source of Information: This assessment's information was acquired from the therapy sessions of Malvin R Hawkins.
Background, Family Information, and Relevant History
The client is a 41-year-old Hispanic woman who is a lesbian and was raised in New Jersey (NJ), and lives in California. As per her report, she has four siblings. Malvin was raised in a Christian family but reported that she did not affiliate with her family's faith. She expressed challenging transitions during her schooling years and her difficult home life. Moreover, Malvin noted that she was taken from her home at the early age of 16 due to domestic abuse and, at 17, was emancipated. She is a high school graduate who attends school while maintaining her employment.
Problem and Counseling History
Malvin expressed problematic experiences of continuous, unpleasant memories from her past. She also spoke of challenges in avoiding distressing nightmares and thoughts, excessive worries, restlessness, detachment feelings, and fatigue. From her report, Malvin had problems in the couple in her relationship and communication distress with her biological mother. However, she noted that she lacked a counseling history as she had not attended counseling sessions.
Diagnostic Impression
Principal diagnosis: F43.10 Post-Traumatic Stress Disorder (PTSD).
Diagnosis 2 or z-code: F41.1 Generalized Anxiety Disorder.
Diagnosis 3 or z-code: Z62.820 Parent-Child Relational Problem.
Differential Diagnosis: Major Distress Disorder.
Discussion of Diagnostic Impression
Malvin's diagnosis revealed that she had Post-Traumatic Stress Disorder as her principal diagnosis. The diagnosis used her symptoms of recurrent memories that she considered unwanted, distressing nightmares, thoughts, and challenges of evading negative thoughts. Moreover, the diagnosis finds support from her domestic abuse and childhood trauma experiences. Furthermore, the diagnosis showed she had Generalized Anxiety Disorder considering her symptoms of sleeping challenges, excessive worries, restlessness, and fatigue. Also, Malvin was diagnosed with Parent-Child Relational Problem because she confessed that she avoided communication with her biological mother and had too little familial interaction. This Parent-Child Relational problem significantly affects Malvin's treatment plan and thus its inclusion in her diagnostic impression. Lastly, Malvin was diagnosed with major Distress Disorder due to her continued life and communication distress.
Part 2 – Case Conceptualization: Inverted Pyramid Model (IPM)
STEP 1: IDENTIFY AND LIST CLIENT CONCERNS AND ANY OTHER PROBLEM AREAS
Childhood trauma at home.
Separation from her mother to a children's residential center.
Parents divorce
Recurrent memories from her past she considers unwanted.
Triggering work scenarios.
Detachment feelings.
Restlessness.
Difficulties of evading distressing nightmares and thoughts.
Fatigue.
Excessive worries.
Disruptive sleep pattern.
Rough transitions during schooling life.
Troubled home life.
Domestic abuse.
Emancipation at the age of 17 years.
STEP 2: ORGANIZE CONCERNS INTO LOGICAL THEMATIC GROUPINGS
Post-Traumatic Stress Disorder (PTSD)
Recurrent, unwanted memories, blaming oneself, challenges avoiding negative thoughts and nightmares, and childhood trauma.
Generalized Anxiety Disorder
Disruptive sleeping patterns, restlessness, irritability, and feeling fatigued.
Parent-Child Relational Problem
Evading communication with the biological mother, little familial interactions, and continued arguments
Relationship Difficulties with spouse
Triggered instances at work that cause arguments.
STEP 3: THEORETICAL INFERENCES:
ATTACH THEMATIC GROUPINGS TO INFERRED AREAS OF DIFFICULTY
Maladaptive or irrational thoughts
Irrational or maladaptive thoughts are common in patients suffering from Generalized Anxiety Disorders and Post-Traumatic Stress Disorders, which is a significant inference of difficulty for the client. She may express such thoughts as "I should have the ability to work things out on my own," "I blame myself for things that happened," and "I should be successful, stable, and mature," which can impact her and brings feelings of inadequacy, guilt, and shame.
Deeper difficulties
More profound difficulties may be evident, like clients believing they are a failure and feeling broken or unlovable. Such adverse self-beliefs can be due to childhood trauma and challenging experiences in previous relationships. Arguably, those mentioned above more profound difficulties need more focused and extensive exploration and attention in therapy since they potentially lead to self-sabotage, low self-esteem, and self-doubt.
STEP 4: NARROWED INFERENCES AND DEEPER DIFFICULTIES
Relationship issues, anxiety, and low self-esteem
The client seems to struggle to sustain healthy relationships, like her family members and partner. This problem may be based on a lack of assertiveness, negative self-talk, a...