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A Well Documented Case Study Subject Has A Diagnosis Of Alcohol Abuse, Cannabis Abuse, Schizophrenia, Paranoid Type, Schizotypal Personality Disorder, Borderline Personality Disorder

1377 words - 6 pages

Subject Name: Doe, JaneJane Doe is a stated twenty two year old female. She has a history of reoccurring problems on the work site and at home. Most recently, Jane experienced a "psychotic" episode at work and was hospitalized for two weeks during which time she received treatment geared at stabilization of the acute episode. Little is known about Jane?s family history and she has had no prior hospitalizations. Information available comes from her current therapist, hospital reports, and coworkers. Jane also has presented some information though the credibility of her reports is questionable.Physical PresentationThe client I am presented with is a woman who looks obviously much younger than her stated age. She is estimated as being within the above average range of intelligence. Her attire was extremely provocative and she was heavily made-up. She was demonstrating childlike mannerisms and speech. Ms. Doe carried only a large backpack that she described as her "safe". She reports carrying all her important papers and items with her at all times "in case someone needs to know something about me". Her speech was extremely rapid and slightly pressured. She constantly fidgeted in the chair, dominating the conversation with drawn out explanations of her own history, behaviors, and problems.Cognitive PresentationThought processes were organized and non-delusional with some bizarre paranoid and compulsive features. She did not appear to be experiencing the effects of any substances at the time of this interview. Ms. Doe admitted to frequent use of alcohol and marijuana, which she uses to make herself "feel better, and forget about things" but denies dependency to either substance.Emotional PresentationClient?s mood at the time of this observation was somewhat elevated and anxious. She admitted to a history of attempted suicides and violent episodes but denied current suicidal ideation.Client Assessment of the ProblemShe states that her current problem is understanding what happened when she "cracked up", "getting the shrinks off her back", and "putting some money back in her pocket." She sees herself, as someone who is different from all the other people, smarter than most people, a loner, and that she is at her best when everyone leaves her alone. She admits to needing other people to help her get her needs met, but finds that she can get what she wants most often by giving people what they want and then "dumping them". She explains that she knows more about herself than anyone.Childhood Experiences (by client report):Ms. D. is the youngest of three children. She reports that her family was "the personification of dysfunctional" and that she was rarely ever a happy kid. She attended school beginning in kindergarten. Once in Junior high school she had started skipping classes and was building a high record of absenteeism. She remembers being taught by a neighbor to read when she was four years old and spent a great deal of time by herself reading books...

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