CASE PRESENTATION ASSESSMENT & DIAGNOSIS
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Claire Standish Case Presentation: Assessment & Diagnosis
Allison V. Hobaugh
Department of Counselor Education & Family Studies, Liberty University
Claire Standish Case Presentation: Assessment & Diagnosis
Identifying Data
Date of Initial Assessment: October 30th Age: 17 years old
CASE PRESENTATION ASSESSMENT & DIAGNOSIS 2
Client Name: Claire Standish Gender: Female
Race: Caucasian Marital Status: Single
Sexual Orientation: Heterosexual Employment Status: High School Student
Reason for Referral/Presenting Problem
Claire was referred to the Great Lakes Clinical Associates office by her school counselor
after multiple behavioral concerns occurred. She was initially disciplined for skipping school
with Saturday detention. Claire was observed after the detention smoking marijuana by the
school janitor. She has also been observed pulling her hair out and vomiting after meals. She has
stated that “It doesn’t really matter because my teachers always give me a break” when asked
about her missing school assignments. These issues led to her counselor and her father seeking
counseling for her.
Confidentiality
Claire was informed that although her sessions will be confidential between her and the
counselor, the exception to this is if there is anything that is disclosed that means she could
harm herself or others. She was reluctant to talk in the beginning because she did not want her
father to know what was discussed behind closed doors. After the session, the counselor, Claire,
and her father came up with a plan that her father would only hear about any truancy.
Source of Information
The information for this case was gathered using the referral notes of the school
counselor, the reports from the father, and the sessions to date with Claire (three sessions).
Semistructured interview questions along with informal observations during sessions helped to
form this assessment. In practice several tests can be used to collect data. Cross-Cutting
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Symptom Measures and Eating Disorder Examination-Questionnaire (EDE-Q) are good tests to
collect data for Claire’s sessions.
Assessment
Family and Home Background/Religious Background
Claire lives in an upper-class neighborhood in the suburbs of Chicago. She lives with her
father, who is a physician and her mother who keeps the household. Her mother has a history of
alcohol and prescription drug abuse. The family is socially well known in the upper class.
Despite a strong outward appearance, the family experiences weak marital communication and
disconnect with the children. Claire has an older brother who lives out of the house on his own.
There is no report of religious affiliation.
Educational History
Claire reports having good grades and being popular with others at school. She has
served on student council president and as honor council representative. She is also a prom
queen candidate. Her school discipline record had no entries until March of this year, when she
skipped class. Recent marijuana use has resulted in missing assignments and declining grades.
Mental Health
Claire admits to regular use of marijuana, vomiting after meals, and pulling her hair,
eyelashes, and eyebrows. She has a preoccupation with her body image/ She states “When I
look good in my clothes and am extra thin, I feel hotter than any of my friends” Her symptoms
are in line with a substance use disorder, bulimia nervosa, and trichotillomania. No formal
testing has been performed at this time, but it is recommended.
Mental Status Exam (MSE)
Claire’s appearance is neat, clean and fashionable. She is of an appropriate weight for
her age and height. She does have noticeable hair loss in her eyelashes, eyebrows, and on her
CASE PRESENTATION ASSESSMENT & DIAGNOSIS 4
arms. Her mood and affect were irritable and resistant. Toward the end of the session, she
became a bit more cooperative. Her speech was clear, age-appropriate, and occasionally
defensive. Claire was fully oriented to place and time. Her thoughts were logical and clear. There
was no current suicidal ideation; admits to association with risky peers.
Risk Assessment
Suicidal and homicidal ideation were denied by Claire. Her disordered eating
(binge/purge) behaviors and drug use put Claire at moderate risk of harm. Because of the family
history of substance abuse, her vulnerability is increased for addiction.
Client’s Physical/Medical Health
There are no major illnesses reported. There are some concerns with nutritional deficits
and imbalance of electrolytes from her purging behaviors and some dermatological signs of the
hair pulling.
Occupational History
Claire is not employed in the traditional sense. Her job is a student. She excels
academically but is at risk for suspension due to her recent behaviors.
Sexual Adjustment
Claire admits to flirting with men to obtain the marijuana. This indicates risk-taking
behaviors as well as poor boundaries and a susceptibility to exploitation as a result.
Substance Use History
Claire states that she has been using marijuana several times a week since March. She
participates in this activity with her peers. She denies alcohol use, however due to her mother’s
drinking, her exposure is high.
CASE PRESENTATION ASSESSMENT & DIAGNOSIS 5
Spiritual Assessment
There is no evidence of personal or family spiritual support systems. No evidence of
faith-based coping skills.
Cultural Factors
Peer emphasis on appearance and being popular may contribute to maladaptive
behaviors. Her family’s upper-class status reinforces the need for perfection and external
validation.
Barriers to Treatment/Success
Client resistance to counseling and minimizing her own symptoms. An over reliance on
external validation from peers and parents and the lack of parental insight and understanding
(father states “it’s just what girls do”) referring to vomiting all pose barriers.
Diagnostic Impressions
DSM-5 Diagnosis
F50.2 Bulimia Nervosa, Purging Type (primary)
Secondary Diagnoses
F63.3 Trichotillomania (Hair-Pulling Disorder)
F12.10 Cannabis Use Disorder, Mild
Z-codes
Z62.820 Parent-child relational problem, Parent-biological child
Z62.898 Child affected by parental relationship distress
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Differential Diagnosis
F32.0 Major Depressive Disorder, single episode, mild. This diagnosis is not fully
supported by the criteria in the DSM-5 because she denies having a persistent low mood.
F41.1 Generalized Anxiety Disorder. Although Claire had worry, stress, and anxiety
present, the duration of these symptoms was unclear.
F45.22 Body Dysmorphic Disorder. She presents with some of the symptoms but the
symptoms are better explained by bulimia nervosa.
Diagnosis Rationale
Claire has admitted to recurrent episodes of vomiting after meals and using laxatives
that occur at least once weekly. She feels like her worth is related to how people view her, her
body image and appearance. Claire reports the compulsive hair pulling is to relieve her stress
causing noticeable hair loss. Claire also admits to the use of marijuana on multiple occasions
throughout the week, leading to poor academic performance and risky behavior patterns.
CASE PRESENTATION ASSESSMENT & DIAGNOSIS 7
References
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders
(5th ed., text rev.: DSM-5TR). American Psychiatric Publishing
Sperry, L., & Sperry, J. (2022). Case conceptualization: Mastering this competency with ease
And confidence (2nd ed.). Routledge.
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