client map for Jay

Jay is a very successful executive in the high-powered world of corporate finance. The company's Employment Assistance Program (EAP) has referred him to you. Jay presents himself as a "no-nonsense" business professional. He is frank and honest about the events that have brought him to your office.

Jay tells you, that although he will only have one or two glasses of wine nightly with dinner, he usually finishes the whole bottle. "About five years ago I was having trouble sleeping and started taking tranquilizers (2 mg Clonazepam). I normally take one or two pills, four nights a week to help sleep through the entire night."

In the morning, he drinks at least 3 to 4 cups of coffee, even on the weekends. He noticed that his sleeping problems developed around the same time his wife died. "She was only in her early fifties and we were very close". Her death hit him hard and he says he wanted to "give in to his depression". However, he fought against it and lost himself in work.

He makes a point to work out at least three times a week in the morning before going to work. In addition to the above medication, Jay is prescribed Xanax as needed for panic attacks and diet pills (amphetamine congeners) to control his weight, a problem he has had since childhood. Over the last year, he has become more reclusive. He can barely make it to business dinners and after-work functions. Lately, he has noticed that he has been steadily increasing his use of wine.

Before, he would only have a few glasses with dinner but now, "more often than not I finish off the bottle before going to bed. I just cannot seem to stop. A lot of times I will come home and tell myself that I'll only have one glass and no more but by the time I go to bed, the bottle is empty and I'm deciding whether I should open another or not. I never used to drink to excess or take anti-anxiety medication before. Now I cannot seem to stop drinking or taking these 'downers' at social events. I cannot seem to control myself when I take them and things are happening that I am not too happy about. Of course, alcohol adds to my weight problem, which then causes me to take more of my Redux. Then I have to increase my Xanax to calm my nerves and take my Clonazepam to make sure I get a full night's sleep. It has become a very vicious circle. All this has been going on for about a year but last week I put the "cherry on the cake."

Jay tells you that last week he was to meet the firm's top client at a business luncheon. He could not get out of bed that morning. It took all his willpower to get up and get dressed. As it was, he was still 20 minutes late, "which is inexcusable." He was so nervous and sick he had to excuse himself in the middle of his presentation. In the bathroom, he took another Xanax to calm his nerves. Then at the luncheon, he could not stop himself from ordering several glasses of wine and had to be assisted to a taxi after the meeting was over.

"My client spoke to my boss and staff and then canceled his account with me. The next day I met with my boss and he recommended (ordered) I make an appointment with our EAP program or be terminated. I am scared. Work is all I have. I cannot afford to blow it. Do you mind if I smoke?"

Communicating a DSM-5-TR Diagnosis

The CLIENT MAP must contain aPrincipalDiagnosisfor the client. (Additional diagnoses may be warranted but you will be graded on the accuracy of the Principal Diagnosis). Write out the name of the disorder. Add anyspecifiers or subtypesthat fit the presentation. Additionally, document thediagnostic code number-use the ICD-10-CM code.Next, do not document the entire criteria set, only thecriteria met by the client.You will also illustrate the rationale for each criterion met (indicated by either a subjective account or observation of others) based upon the client's presentation.

Ex: Client Z meets criteria for the following DSM-5-TR diagnosis:F43.1 Posttraumatic Stress Disorder (Principal Diagnosis) Criterion E: alterations in arousal and reactivity Trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event: (two required)1.Irritable or aggressive behavior(e.g., Per client's self-report, he is irritable on most days than not)4.Exaggerated startle response(e.g., Client was easily startled during the mental health assessment and observed 'ducking' twice under the chair when the phone rang in the clinic)

(Please note the example only illustrates one criterion in the criteria set for PTSD)

TIP:The CLIENT MAP must demonstrate your knowledge on how to link assessment and diagnoses to intervention. The intervention choice must be well supported by citing the DSM5TR and text. Remember, your diagnosis guides which intervention(s) will be utilized, therefore refrain from documenting a variety of interventions unless you can clearly demonstrate the link between your chosen diagnosis and intervention.