3 page Counseling Case Study

Client Concerns

Assessment

Diagnostic Impression

Signs and Symptoms

Other DSM-5-TR Conditions Considered

Developmental Theories and/or Systemic Factors

Multicultural Competencies and Considerations

Treatment Recommendations

Key Issues for Treatment

· One

· Two

Recommendations for Counseling

Specific Considerations

References

Sam reported that about two years ago, she had a “high” episode. She didn't think much of it as it started suddenly and ended almost as suddenly. She reported that during that episode, she only needed to sleep for about five hours at night and felt pretty good. She was able to get lots of housework done, completed all her schoolwork, started writing a novel and screenplay, and had time to socialize. She reported these 10 days were one of the best times of her life and then it suddenly ended. About four weeks after this “high” period, Sam began feeling depressed. She reported that this episode lasted about four months, and she experienced feelings of sadness, a lack of enjoyment in any of her normal activities, fatigue that led to her sleeping 10 hours per day and still feeling lethargic, having no appetite, and difficulty concentrating. These symptoms occurred daily for the entire four months and seemed to slowly fade. Six months after these symptoms ended, Sam noticed she had started to feel the same overwhelming sadness again. She reported the sadness lasted for about two weeks, and then the other symptoms began. She stated this time, she also struggled with feeling worthless and had a few weeks where she thought she might be better off dead. “I didn't make any plans to hurt or kill myself, but for those few weeks, I thought a lot about what it would be like to just go to sleep and never wake up.” This episode lasted for 3 months, and she stated, “And then I started feeling like myself again.”

Sam reported she felt normal for about two months, and then she had what she described as “a manic episode.” The episode lasted 12 days and ended with Sam's roommate taking her to the emergency room due to Sam hallucinating. Sam stated that during the 12 days, she slept 1 to 2 hours per night, had lots of energy, and started writing her novel and screenplay again, which had been abandoned after the last “high” episode. She reported that she got so focused on writing her novel that she would spend 10 hours a day attempting to complete the novel so she could move to the screenplay. “I really thought I was going to write the world's greatest book and then turn it into the world's greatest movie. I saw myself as the most significant author to have ever lived during those 12 days.” Sam stated that her roommate reported that during those 12 days, she was impossible to live with, talking nonstop about what a phenomenal author she was and how she would not forget her roommate when she was famous. Sam's roommate took her to the emergency room on the 12th day when Sam began to hear voices telling her that she was a terrible writer, which resulted in her becoming hysterical and crying uncontrollably. Sam was not admitted to the hospital at that time due to being much calmer when she arrived at the ER and not expressing any type of active hallucinations or suicidal ideations. Sam reported, “Those voices were crazy! I was pretty sure it was because I hadn't slept in almost two weeks, and after my roommate did some research, she agreed. When I was at the ER, the doctor gave me some pills to help me calm down if I got really anxious again. I took those pills for about a week, got some sleep, and the episode stopped.” Sam was not able to recall what medication she was given. Sam was also scheduled for an appointment with a psychiatrist to follow up on the episode. Sam did not attend the scheduled appointment.

Sam reported she believed everything had gone back to normal for about two months and then she began to feel the sadness kick in again. She reported a mild feeling of sadness for about 30 days, and then the additional symptoms began to appear. Sam reported that for the last four months, she has felt sad daily, has little to no pleasure in her daily activities, sleeps 12-13 hours a day, is fatigued daily, has no appetite, feels worthless, and struggles with concentration. “About one month ago, I started feeling really hopeless and began thinking that all my friends and family would be better off if I were dead. Four days ago, I began thinking about making a plan. I haven't set a date, and I have not decided on what I would do… yet.” Sam reported that she researched the most pain-free methods of suicide and “right now they all sound really horrible… so I spend the days wishing I were dead. I told my roommate this, and she insisted that I come in for an evaluation. She explained how terrible it would be for her if she came home and I was in the apartment dead. Her crying at the thought of finding me dead convinced me to come see you.” Sam reported that she has no plan to kill herself right now, but she just does not see how she can continue like this long term.

Sam is finishing her second year of a three-year master’s in social work program. She attends a local university and is scheduled to start her internship next semester. Sam stated that she's pretty sure she won't be able to start her internship as she has not been attending class and has turned in very few assignments over the past semester. She stated that her grades from the semester before were not great and she was placed on academic probation. She anticipates being removed from the program at the end of this semester. Sam became tearful when she talked about not continuing the program. She stated one of her goals was to help people and social work seemed like a good fit for her. Sam reported that she has many friends in the social work program, including her roommate. Her friends have been talking to her about her mood swings and how they seem to be affecting her school performance. Sam stated that she believes she would be removed from the program if she approached any of the faculty and told them about her difficulties. “I've had several faculty members address me one-on-one and try to get me to tell them what's is going on. How I have such a high undergraduate GPA and how, at times, I seem to be such a good student. I've just never felt safe to confide in them because mentally ill people can't be social workers.” Sam reported she completed a bachelor’s in social work with a 3.9 GPA. She has always enjoyed school until the last 18 months. Sam has no history of being interested in English or being an author.

Sam took a year between her bachelor’s and master’s to get practical experience working with people. She worked as a case manager at a local mental health clinic. Her clients were individuals with intellectual disabilities, and she enjoyed her work. She continued to work part-time at the clinic as an assistant case manager while she attended school full-time. She received good evaluations until this last depressive episode. “I was able to fake my way through the first two episodes, but this last one has been much worse, and I have not been able to hide my sadness.”

Sam reported that she is the oldest of three children. She has one brother and one sister. She stated that her parents divorced when she was 14 years old and have managed to have an amicable relationship with one another. Sam stated that her mother remarried six years ago, and she has a close relationship with her mother and stepfather. Sam's father remarried seven years ago, and she has a “decent” relationship with this side of her family. Sam did call her mom two days ago and tell her about the difficulties she is having. She stated she hasn't been fully honest with anyone in her family about how she's doing because she didn't want to worry them. When she went to the hospital for the manic episode, she did notify both of her parents but told them she was having sleep issues that led to the hallucinations. Sam has not lived with either of her parents since she was 23 years old. They live in a neighboring state, and she visits them on school breaks and for a week during the summer. Sam calls her mother and sister at least one time per week and talks to her father and brother at least once per month. Sam reported that her mother struggled long-term with depression. “Both of my parents would tell you that my mom's depression was a primary reason for their divorce. My stepfather seems more tolerant of her ongoing sadness, but my father could not manage her moods. My father used to say all the time that he did not marry a woman who was depressed and could not picture spending his life with someone who was so sad all the time.” Sam stated that her sister also has some struggles with depression. Sam doesn't think that her sister's depression is paired with the manic episodes, but she appears to be mildly depressed most of the time. Neither Sam's mother nor sister take medication to address their depression.

Sam stated that she has several close friends and many “acquaintances.” She reported that her roommate is her closest friend and she has two other female friends who she can be open and honest with. Sam reported that her depressive episodes have started to have a strain on her friendships. Her friends have started commenting that she seems down all the time and has isolated herself from the primary friend group. “My roommate was so upset with me when she found out I was thinking about killing myself that she threatened to move out of our apartment. That really scared me. That and seeing her cry. Her friendship is so important to me, and I don't want this depression to ruin it.” As Sam talked about how the depression was affecting her relationships in a negative way, she became tearful. Sam reported that she is not in a romantic relationship at this time. She has dated off and on throughout her teen years. Her one serious romantic relationship started a year before she graduated from college and ended a year into her master’s program. She has dated other men off and on since her relationship ended. She reported she would like to get married and have children but is not interested in “settling down” until she's in her 30s. “My parents got married when they were way too young. And I don't want to make the same mistakes they did.”

Sam reported that she has no history of any medical problems and has never been on medication. She reported that she drinks alcohol on a regular basis. She will have two to three alcoholic beverages a week, primarily on weekends. Sam reported that drinking is something she considers to be a social activity, so when she is not socializing due to depression, she will not drink. She stated that she and her roommate have had the same half-empty bottle of wine in their apartment for over six months. Sam has never taken any kind of illegal drugs or prescription medication that was not prescribed for her. Sam reported that she grew up Catholic and attended mass every week until she started graduate school. She stated that even though she doesn't attend mass anymore, her faith in God is very important to her, and she would like to integrate it into the therapy process.

Page 2 of 4