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Running head: GUIDED IMAGERY AND PROGRESSIVE MUSCLE RELAXATION

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Case 4 - Larry: Diagnostic Worksheet

Diagnosis: 303.90 Alcohol Use Disorder, Moderate

Justification:

A. A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period.

1. Alcohol is often taken in larger amounts or over a longer period than was intended AEB.

· Client reported that he started drinking when he was 16 years old.

· Client stated that he drinks every day; “a couple of beers” on weekdays and a six-pack on weekends.

2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use AEB.

· The client was unable to successfully complete two previous attempts at substance use treatment programs.

5. Recurrent alcohol use resulting in a failure to fulfill role obligations at work, school, or home AEB.

· The client’s work has suffered because of his inability to drive due to his suspended license.

6. Continued Alcohol use despite having persistent social or interpersonal problems caused or exacerbated by the effects of alcohol AEB.

· The client and the client’s girlfriend report not getting along and argue about his drinking. The client becomes violent with his girlfriend while drinking.

8. Recurrent alcohol use in situations in which it’s physically hazardous AEB.

· The client drove his vehicle while under the influence as evidenced by his three DUI offenses.

Specify Moderate: Presence of four to five symptoms.

· Client exhibits five symptoms of Alcohol Use Disorder

Diagnosis: 305.20 Cannabis Use Disorder, Mild

Justification:

A. A problematic pattern of cannabis use leading to clinically significant impairment as manifested by at least two of the following, occurring within a twelve- month period.

4. Craving, or a strong desire or urge to use cannabis AEB.

· Client reported that in order for him to relax, he has to use cannabis.

6. Continued Cannabis use despite having persistent social or interpersonal problems caused or exacerbated by the effects of cannabis AEB.

· The client and his girlfriend state that they argue because of his “marijuana use”.

Specify Mild: presence of two to three symptoms.

· The client exhibits two symptoms of Cannabis Use Disorder.

Diagnosis: 314.00 Attention- Deficit/Hyperactivity Disorder, Predominantly inattentive presentation, mild.

Justification:

A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning, as characterized by (1) and/or (2).

1. Inattention: Six or more of the following symptoms have persisted for at least six months that negatively impacts on social and academic/occupational activities.

B. Often has difficulty sustaining attention in tasks or play activities AEB

· Client reported that he has difficulty keeping his attention on paperwork.

C. Often does not seem to listen when spoken to directly AEB.

· Client’s girlfriend complains about his inattentiveness to her, even when she speaks to him directly.

D. Often does not follow through on instructions and fails to finish schoolwork or duties at work (Loses focus and is easily distracted) AEB

· Client has difficulty keeping his train of thought and he stated that he felt “distracted” during the assessment.

E. Often has difficulty organizing tasks and activities AEB

· Client states if he were better organized, he would probably be able to make more money at work.

F. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort

AEB

· The client reported that he avoids tasks that require mental energy from him.

I. Is often forgetful in daily activities AEB

· Client’s girlfriend complains about the client’s forgetfulness

2. Hyperactivity: Six or more of the following symptoms have persisted for at least six months and negatively impacts social, academic, and occupational activities.

A. Often fidgets with or taps hands or feet or squirms in seat AEB

· During the assessment, the client appeared to be fidgety; he was constantly wringing his hands.

C. Often runs about or climbs in situations where it is inappropriate (for adults, may be limited to feeling restless) AE

· The client reports that he feels restless in the absence of substances.

B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years.

· The client was diagnosed with Attention-Deficit/Hyperactivity Disorder in elementary school.

C. Several inattentive or hyperactive-impulse symptoms are present in two or more settings AEB.

· The client’s inattentiveness is evident in his occupational setting as evidenced by his inability to focus on his paperwork and inability to stay organized.

· The client’s inattentiveness are present in his social setting as evidenced by his girlfriend’s complaints.

· The client’s inattentiveness was present in an academic setting. The symptoms were observed in elementary school; he struggled through academic subjects.

D. There is clear evidence that the symptoms interfere with or reduce the quality of areas of functioning AEB.

· The client’s inattentive symptoms strain his relationship with his girlfriend.

· The client reported that because of his inability to organize at work, he is not able to make as much money as he could.

E. The symptoms do not occur exclusively during the course of another mental disorder and is not better explained by another mental disorder.

· The clients Attention-Deficit/Hyperactivity symptoms occur outside of his substance use disorders.

Specify Predominately inattentive presentation: If Criterion A1 (inattention) is met but A2 (hyperactivity) is not met for the past six months.

· Client meets the criteria for inattentiveness by displaying six of the inattentive symptoms. Client does not meet full criteria for hyperactivity during this assessment.

Specify Mild: Few, if any symptoms in excess of those required to make the diagnosis are present.

· Client meets minimum requirement of symptoms.

Diagnosis: Provisional General Anxiety Disorder

Justification:

A. Excessive anxiety and worry, occurring more days than not for at least six months, about a number of events and activities AEB.

· The client complained that he “feels anxious all the time and cannot remember when he has not felt that way”.

· The client claims he worries about a number of things, such as, his children, his girlfriend, his job, and his need to complete the program.

B. The individual finds it difficult to control the worry AEB

· The client self-medicates with cannabis to help him relax

C. The anxiety and worry are associated with three or more of the following six symptoms.

1. Restlessness AEB

· Client reported that he feels restless if he “does not drink or smoke marijuana”.

4. Irritability AEB

· The client has been arrested twice for family violence

5. Muscle Tension AEB

· The client stated that “feels” the anxiety in his stomach, head, and neck.

6. Sleep Disturbance AEB

· The client has sleeping problems; he wakes frequently and has trouble getting back to sleep.

D. The anxiety, worry, or physical symptoms cause significant distress in social, occupational, or other areas of functioning AEB

· The client’s anxiety about being able to complete the substance use program will affect his functioning in his social and occupational settings.

· The client’s sleep problems could be causing more impairment in his social and occupational functioning.

E. The disturbance is not attributable to the physiological effects of a substance or another medical condition.

· The substances that the client uses relieves his symptoms of anxiety.

F. The disturbance is not better explained by another mental disorder.

· The client does not meet criteria for any other mental disorder.