PSYC 645 Developmental Psychology

Example Case Presentation: Mr. D.

Your Name

Department of Psychology, Liberty University

EXAMPLE CASE PRESENTATION

1

I. Key Clinical Issues

A. Client Demographics

Mr. D. is a 28-year-old, male who currently is employed as a Wall Street Investment advisor. Mr. D. reports that he had a wealthy upbringing in a small, northeastern, suburban town. Mr. D. is an only child of two intelligent, educated, professional and successful parents; and he is newly married to an intelligent, educated, professional and successful woman. Mr. D. reports that he recently was promoted to group manager at his work.

B. Presenting Problem

The client comes in presenting with stomach problems that have caused him: 1) to be absent from work and 2) to not finish assigned work on time. The stomach problems started about 2 months ago—about 1 month after his promotion to group manager at work. The stomach problems have been medically evaluated, and no physical cause was found. Because of his absences and incomplete work, he is in danger of losing his job. The client also reports anxiety-producing thoughts about his own feelings of competence and about his credibility with his bosses. His wife “pushed him into counseling.” He says that he does not have a problem, and is only in counseling to “make his wife happy.”

II. Diagnosis

A. Diagnostic Impressions

1. Social Anxiety Disorder, Performance Only: Client has marked anxiety about giving presentations to his bosses at work, in part because he is worried about what they think of him. He endures these presentations with anxiety, and his anxiety is causing significant occupational impairment.

2. Somatic Symptom Disorder: Client is experiencing somatic symptoms (i.e., stomach problems) that are disrupting his functioning at work.

3. Adjustment Disorder: Client is experiencing an emotional response to an identifiable stressor (i.e., being promoted at work and having to give presentations). His symptoms are clinically significant in that they are impairing his functioning at work.

B. Differential Diagnosis

1. Client most likely is not experiencing Social Anxiety Disorder because his symptoms have not been present for at least 6 months (Criterion F), and because his anxiety is not out-of-proportion to the threat (Criterion E; DSM-5, 2013). It is likely that most new, young executives on Wall Street would be similarly anxious presenting in front of their bosses.

2. Client most likely is not experiencing Somatic Symptom Disorder because he does not have excessive concern about his somatic symptoms (e.g., he is only in treatment at his wife’s prompting, Criterion B), and the stomach problems have only been present for about two months (Criterion C; DSM-5, 2013).

C. Full DSM Diagnosis

1. The most likely diagnosis for Mr. D is Adjustment Disorder, with Anxiety ( DSM-5, 2013).

(A) Client has developed anxiety-related and somatic symptoms (i.e., stomach problems) in response to a promotion at work and new responsibility of giving presentations. Symptoms began within 1 month of his promotion.

(B) Client is experiencing significant impairment in occupational functioning as evidenced by absences from work, unfinished work, and the resultant possibility of losing his job.

(C) Client does not meet the criteria for any other mental disorder, and he reports no history of a preexisting mental disorder.

(D) The symptoms are not a result of normal bereavement as the client reports no recent loss.

(E) Because the stressor is ongoing, this final criterion currently does not apply to the current case.

2. The specifier “with Anxiety” was chosen because, although Mr. D. does not explicitly report anxiety, he appears to be experiencing some consequences that indicate the presence of anxiety (e.g., somatic symptoms, worry about his competence and about what his bosses think of him).

3. A provisional diagnosis is necessary as Mr. D. meets all of the necessary criteria for a full diagnosis. After an adjustment period to his new responsibilities at work, re- assessment of Mr. D’s symptoms is recommended to see if they would abate once he has gotten used to his new role and tasks as group manager.

III. Etiology of the Problem/Disorder

A. Biological Theory: As a stressor-related disorder, Adjustment Disorder requires exposure to a stressful event for diagnosis (e.g., Mr. D.’s promotion at work and a stressful new responsibility). In the normal physiological response to stress, the HPA- Axis is activated (Parritz & Troy, 2018). In the case of chronic stress, sustained hyperactivity of the HPA-Axis has the potential to cause physical consequences (e.g., Mr.

D.’s stomach problems; Chang et al., 2009). This chronic stress response is the most likely cause of the client’s problems that should be treated first in order to reduce his acute feelings of distress.

B. Cognitive-Behavioral Theory: Because of Mr. D.’s’s family history, he has developed some distorted and illogical beliefs about success and failure. These distorted cognitions likely are creating and maintaining an anxiety response that is producing physical symptoms (i.e., stomach problems) and behavioral consequences (i.e., missing work, not finishing work) for Mr. D. (Parritz & Troy, 2018). From a very young age, Mr. D.’s parents have instilled in him the idea that failure is not an option. Mr. D. reports that whenever he was not performing up to his parents’ expectations, they would intercede to ensure his success. Also from a very young age, he worked hard so that he would be successful at whatever he did (e.g., high grades, soccer “star”). Because of his parents’ tremendous professional success, Mr. D. likely feels that he must be as successful on the job as they are. Although he has not said so explicitly, the thought of failure likely is intolerable to Mr. D. because of the importance that his parents have placed on the appearance of success.

IV. Treatment Receommendations

A. Biological Intervention: Because Mr. D.’s anxiety appears to be very narrowly circumscribed to the stress of having to give presentations to his bosses at work, it is recommended that Mr. D. gets evaluated by his primary care physician or a psychiatrist so that he could receive pharmacological treatment for his symptoms. Specifically, it is suggested that Mr. D. would benefit from taking a beta-blocker medication only on days

when he is required to give presentations to his bosses in order to reduce his sympathetic nervous system response to that stressor (Bailly, 1996).

B. Cognitive-Behavioral Interventions: In order to help Mr. D. learn to cope with the chronic stress that comes with being a Wall Street investment advisor, the use of somatic management techniques (e.g., progressive muscle relaxation, diaphragmatic breathing) is recommended to help ameliorate the effects of chronic stress on Mr. D.’s physical and emotional functioning (Parritz & Troy, 2018). Utilization of some cognitive restructuring exercises is also recommended to help Mr. D. learn a more realist and adaptive understanding of failure (i.e., failure tolerance; Parritz & Troy, 2018).

References

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). American Psychiatric Publishing.

Bailly, D. (1996). The role of β-adrenoceptor blockers in the treatment of psychiatric disorders.

CNS Drugs, 5(2), 115-136. https://doi.org/10.2165/00023210-199605020-00004

Chang, L., Sundaresh, S., Elliott, J., Anton, P. A., Baldi, P., Licudine, A., Mayer, M., Vuong, T., Hirano, M., Naliboff, B. D., Ameen, V. Z., & Mayer, E. A. (2009). Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis in irritable bowel syndrome.

Neurogastroenterology & Motility, 21, 149-159. https://doi.org/10.1111/j.1365- 2982.2008.01171.x

Parritz, R.A. & Troy, M.F. (2018). Disorders of Childhood: Development and Psychopathology

(3rd ed.). Wadsworth.