SCWK 2331: ABNORMAL BEHAVIOR

A mental health diagnostic report represents a complex collection of information. The clinician must use oral, written, and observational skills to critically analyze the client’s story while gathering information. Human Services student Virginia Dray, skillfully manages these complex pieces as she narrates the diagnostic picture of the fictional client, Ashley Brandt and her probable Diagnostic and Statistical Manual of Mental Disorder (DSM-5) diagnosis. She writes in a professional tone that is respectful, nonjudgmental, and objective. Her case study documents significant client comments and uses professional terminology throughout the report. Virginia’s well-written case study utilizes rich detail to structure and substantiate her client’s mental health diagnosis.

– Cynthia Trumbo

Case Study: Ashley Brandt
Name: Ashley S. Brandt
Agency # 58546
SOCIAL HISTORY
Date: 11/23/15

PRESENTING PROBLEM:

      Ashley is a 33-year-old white female. She is the divorced mother of two daughters, ages eleven and eight. She was referred to this facility by Memorial Herman Emergency Room after an intentional sedative overdose, which she admits was a suicide attempt.

Ashley says she feels hopeless and can’t sleep at night because of feelings of guilt, which causes her to be sleepy and have no energy during the day. She thinks about committing suicide often but has never attempted until now. Ashley says that she is irritable with her daughters, so much so that she avoids spending time with them by locking herself in her bedroom. Her daughters are frightened by her sudden mood swings. Ashley feels as though she has no control over her words or actions when she’s angry and is embarrassed that she can’t bring herself to apologize afterwards. She copes by cutting her legs “where no one can see.” She also breaks things and drives erratically when angry. Ashley says that she would like to “be happy and be a better mother,” as well as learning to control her anger.
Ashley is only able to keep a few friends at a time and makes new friends every few years. Although she sometimes knows that it is unrealistic, she constantly feels as though all of her friends have ill feelings toward her. She has had many intense, short-lived friendships and her few long-term, valued friendships are often discontinued over minor disputes, after which she immediately regrets her decision or holds a grudge for years. Ashley says that her friends eventually grow tired of her constant need for help. Her suicide attempt stemmed from one friend telling her, “if you want to die, you should just kill yourself.”

FAMILY OF ORIGIN:
Ashley was an only child, raised by both natural parents. She was close to her maternal grandparents before they passed away recently, but says that her paternal grandmother is cold toward her. She was also close to one cousin as a child, but they had a disagreement as teenagers and have only spoken at family functions since then.
Ashley’s father works as an insurance claim investigator and her mother is a schoolteacher. Ashley was a “spoiled” child who was doted on and “always had the best of everything.” She laments that she has not received her father’s praise or affection since childhood. Ashley’s parents divorced and later reconciled when she was in junior high school. She says this was the most traumatic event of her life, if not the defining moment, and that she spent most of her eighth grade year in the school counselor’s office.

      Ashley says that her mother is passive-aggressive she “never knows when [her] mother is angry.” Although her mother is sometimes depressed, she has little understanding of mental health issues. Ashley says that her mother is the “strongest person [she] knows.” Ashley says that her father is “full of himself,” has a “horrible temper,” and is sometimes overly critical of her mother, although he adamantly denies the possibility of having a mood disorder and feels no empathy for those who do. During a family counseling session when Ashley was fifteen, her father said, “We have a dysfunctional daughter, not a dysfunctional family.” At a later session, the therapist mused that while Ashley “identifies with her father, she sympathizes with her mother.”
As a child, Ashley was bullied because she was “shy and weird.” Her family moved frequently while she was in grade school and she says that she always felt like an outsider. Ashley had very few friends until high school when she joined the “goth crowd.” She began smoking cigarettes at age thirteen, drinking alcohol at fifteen, and became promiscuous at sixteen. Ashley had one serious boyfriend in high school. They dated for one year and planned to marry after graduation, but he abruptly left her for another girl after senior prom

MARRIAGE AND SIGNIFICANT RELATIONSHIPS:

      Ashley was married to Derek, the father of her daughters, soon after high school graduation. They had only been together for six months, but they were pressured by family members because of an unplanned pregnancy. Their marital discord began immediately, as Derek would stay out all night drinking and “hustling pool,” leaving her home alone and pregnant. She had hoped his behavior would improve when the baby arrived, but it only escalated and Derek eventually began using narcotics. Ashley reports being angry and depressed during both pregnancies. She once scratched Derek’s truck with a key while he was sleeping off a hangover and she was battling morning sickness. Ashley threatened to park her car on the railroad tracks with both children inside shortly after her second daughter was born. She says that she often resents her children for “ruining [her] life.”
While not working as a sous chef or partying with friends, Derek spent his time at home sleeping, leaving Ashley to care for their children by herself. However, he attempted to appear as an attentive father when friends or family were present. Derek had countless affairs and verbally berated her even though she was “an amazing wife.” Shortly after their first child’s birth, Derek gestured toward Ashley’s slender friend and asked, “Why can’t you look like her?” Ashley says that she blamed herself for his verbal abuse and once punished herself by cutting off her hair in clumps. After ten years of marriage and several separations, they were divorced. She still refers to him as “the love of [her] life.”
Ashley encouraged Derek to visit the children after their divorce, but he moved to another state, telling everyone who would listen that she refused to let him or his family contact the children. She displayed a recent text message from Derek where he claimed to be, “very happy with a beautiful woman.” The message continued, “You’re a joke. Nobody has one good thing to say about you. You’re a loser who everyone thinks is the most disgusting person they never want to see again. Nobody likes you at all.”

      Since her divorce three years ago, Ashley has had a few short relationships that have all followed a similar pattern. She says that she falls in love easily, but loses interest “as soon as they get serious.” After that, she sabotages the relationship, then she is “devastated” and harbors resentment toward the other partner. She has also had numerous one-night stands, including one with a married man.

CURRENT LIVING ARRANGEMENTS:
      Ashley and her children live with her parents in their home, located in the suburbs of north Houston. Her parents provide financially and take care of her children. She has never lived alone and doesn’t feel capable of supporting her children or running a household on her own. Ashley feels as though her family thinks she chooses to continue her behavior. She feels “useless” and “in the way” at home, as though she “doesn’t belong there.” Her mother often repeats the phrase, “If you’d just eat right and exercise, everything would be okay.” Ashley would like to return to her role as her daughters’ primary caregiver.

EMPLOYMENT AND EDUCATION HISTORY:
      Ashley works in the stockroom of a department store. She has established a pattern of working hard, then quitting a job impulsively because of her temper. She often feels undervalued at work, but acknowledges that she is overly sensitive to criticism. Her longest period of continued employment is one year.
A similar pattern has developed with Ashley’s college education, wherein she does well in her classes, then drops them before completion because she changes her major, although she is “definitely smart enough to graduate.”
Ashley took honors level courses in high school. She was a reporter for the school newspaper and aspired to be a professional journalist. She won an award for writing and started a literary magazine with friends.

MEDICAL HISTORY:

      Ashley has an insignificant medical history. She was hospitalized as an infant for pneumonia. Both of her pregnancies were normal. Ashley drinks alcohol once a week or less, and smokes cigarettes occasionally. Her weight fluctuates because she skips meals or overeats when depressed, depending on the severity. She blames her constant sense of fatigue for her caffeine addiction.

      Ashley’s mother told her that her problems began at age fifteen. She was hospitalized “far away from home” at age seventeen when her mother became “desperate” to “cure” her mood swings. She has been diagnosed with various forms of depression over the past sixteen years. Her most recent diagnosis is Bipolar Disorder II, although she denies ever having a manic episode. She has been prescribed antidepressants and mood stabilizers on several occasions, which she reported as effectively treating her symptoms, but she quit taking them each time she felt better.
LEGAL HISTORY:

Ashley completed one year of probation after she lost her temper and assaulted Derek. At one point, she almost lost her driver’s license for excessive speeding tickets. No other legal history exists.

SOCIAL AND RECREATIONAL INTERESTS:

      Ashley’s only social activity is occasional cocktails with friends. She would like to learn to play guitar or do arts and crafts projects, but she says she lacks the “motivation or energy.” In the past, she enjoyed photography, writing poetry, and attending concerts. She says she would like to do “artsy things” with her daughters, such as, “experiencing foreign foods and taking them to museums and festivals.”

IMPRESSIONS AND RECOMMENDATIONS:

      Ashley is well-mannered, intelligent, and articulate. She was dressed in a baggy t-shirt and sweat pants; her hair wasn’t brushed. During the interview, she was calm, but sad and cried throughout, especially when talking about her children. Ashley alternated between sadness and anger when she was referring to her ex-husband, Derek. She seems to have good insight into her symptoms.
Ashley’s scores on the World Health Organization Disability Assessment Schedule, Version 2.0, (WHODAS 2.0), showed “moderate difficulty” in “getting along with others” and “participation in society” with an overall “mild disability” (APA, 2013, pp. 747-748). On the Level One Cross Cutting, she tested as “severe” in the areas of depression, suicidal ideation, personality function, and substance use, and “moderate” in anger (APA, 2013, pp. 738-739). The next step is to complete the Level 2 Cross-Cutting Symptom Measures for depression and anger.
My recommendation is a psychiatric evaluation to resume her antidepressant and mood stabilizer medications, as well as individual psychotherapy sessions with a specialized clinician twice weekly, and a support group or group therapy. I also highly recommend she educate herself about her disorder and have supplied her with informational literature. Ashley is agreeable with my recommendations and appears hopeful.

Primary Diagnosis: 301.83 Borderline Personality Disorder, Secondary Diagnoses: 300.4 Persistent Depressive Disorder (Dysthymia), severe, early onset, with persistent major depressive episode, Tertiary Diagnoses: V15.42 Personal History (Past History) of Spouse or Partner Psychological Abuse, V15.59 Personal History of Self-Harm, V62.5 Conviction without Prison

Reference
American Psychiatric Association. (2013). Diagnostic and statistical manual of             mental health disorders, (5^th ed.). Arlington, VA: American Psychiatric

               Association.