Utilize the 7 Steps for Psychiatric Diagnosis

• Collecting Data
• Identifying Psychopathology
• Evaluating the reliability of data
• Determine the overall distinctive feature
• Arrive at a diagnosis
• Checking diagnostic criteria
• Resolving diagnostic uncertainty

Treatment Plan

-Type of Treatment

-The amount of Treatment

-The focus of the specific problem

-The Goals (Objectives) of Treatment

-Timing of Therapies

• Prognosis
• Ethical Issues
• Cultural Awareness

THE CASE SCENARIO

Name: Xavier

Age: 42

Sex Assigned at Birth: Male

Gender and Sexual Orientation: Male, Heterosexual

Ethnicity: White

Marital Status: Married

Modality: Individual Therapy

Location of Therapy : Agency General Information

Family/Extended Family: The client's mother has a history of mood issues, and his maternal grandfather was diagnosed with Schizophrenia. The client describes his father as "barely there" since he would withdraw when the client's mother would display intense emotions. The client describes his home life as chaotic due to his mother's mood swings. It was even worse when his maternal grandparents would visit due to the unstable nature of the mother's relationship with her own father. The client had no interaction with his father's family. The client describes his siblings as "easily cowed" by his mother.

Personal/Social Relationships: The client's recent behavior has severely strained his marital relationship, and his wife states that she is uncertain of the future of their marriage in light of his recent infidelity. His wife describes the issues she has been noticing about her husband, saying, "His friends don't know what to make of his behavior. One week he might be shy and withdrawn. The next, he won't stop talking. And I've seen him flirt and hit on any woman who will listen to him."

Mental Status Examination: The client is a 42-year-old Caucasian male who arrives at the session groomed and dressed casually. His hygiene appears adequate but slightly disheveled. He portrays a slight beard, and his hair appears adequately groomed. His wife notes that his motivation to keep up his appearance has slipped in the last few days, going from dressing impeccably to having difficulty maintaining his hygiene. The client is cooperative during the session. He shows inconsistent eye contact with pressured speech. His mood appears sad and withdrawn, and his affect seems to be easily altered. His impulse and judgment are poor. He has never attempted suicide, but he does have suicidal thoughts. Although his symptoms have been severe enough to seriously affect his functioning and warrant hospitalization, he has never been admitted.

First session You are a mental health therapist in an agency where a 42-year-old male presents for weekly therapy. He is accompanied by his wife, who is concerned about her husband's recent behavioral shift. His wife reports that he has previously been attentive towards her and their teenage children; however, she says he seems to have become "all wound up" two weeks ago. His wife's sister also saw him at a hotel with another woman. His wife is furious and unsure what this means for their marriage. The client fidgets in his chair, looking down at the floor as he speaks. It is clear that he is deeply uncomfortable discussing his recent behavior with his wife. "I don't know what's wrong with me," he says plaintively. "One minute I'm fine, and the next, I'm doing something completely out of character." His wife watches him and becomes angry a little more with each word her husband utters. "I've been having these...episodes," the client continues haltingly. "Where I just can't control myself. Even though I love my wife dearly, I flirt with other women." The client also spent a week's pay on golf equipment despite having never golfed before. "I make all the money in this family, and I should be able to spend some of it on myself. Especially now that the cat's out of the bag, she'll probably leave me anyway."