The paper should follow this structure:
1. Provide one or more primary diagnoses for this case. Include both the name and the DSM code for your diagnosis(es). Be conservative in the number of diagnoses that you give. Report what you believe to be primary diagnoses.
2. Describe the observations or evidence that support each diagnosis. Be sure to cite evidence from (a) the case presentation (b) your own online research, and (c) your textbooks.
3. Describe any clinical evidence that seems to be inconsistent with your diagnosis. Cite what diagnoses you would want to rule out. That is to say, what diagnoses do you think might apply but that you are not sure about given the data that you have available to you? Again, be conservative and cite what you believe is primary. Use the DSM label and code. Provide a rationale for your rule outs.
4. Cite any general medical conditions that you believe might be affecting this client, if any.
5. Cite any psychosocial and environmental factors that you believe might be affecting this client, if any.
6. Give your best estimate of the Global Assessment of Functioning Score (GAF Score) for this person and your rationale for this. .
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THE OUTLINE SAMPLE TEACHER WANTS PAPER TO COVER AND SHOULD BE BROKEN DOWN LIKE THIS
1. Cover Page
2. Abstract Page
3. Main Body of the Paper
1. Brief Introduction/overview to the paper
2. DSM Five Axis diagnosis presentation/summary
i. Axis I: Diagnostic Code and name; rule outs, if any
ii. Axis II: Diagnostic Code and name, if applicable; rule outs, if any
iii. Axis III: Medical conditions present, if any
iv. Axis IV: Psychosocial & environmental factors present, if any
v. Axis V: Global Assessment of Functioning (GAF Score)
3. Discussion of evidence that supports the diagnosis
4. Discussion of the rationale for deferring and/or ruling out certain diagnoses
5. Summary/Conclusion
6. References Page
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CASE STUDY GIVEN BY TEACHER TO WRITE PAPER ABOUT
PSYC: Psychopathology Case Study
A primary care physician has requested a consultation on Mary White, a 35 year old divorced woman who came to him for severe migraines. He was perplexed because he had treated her with every medication recommended for migraines with no lasting effect. Some of the medications seemed to work for a week or two and Mary would call the office raving about the relief. She also always asked about the side effects. Then, after about 3 weeks she was back in the office each time complaining that the headaches were worse than ever.
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The physician also reported that Mary has been treated for numerous other problems and has been hospitalized quite a few times. She has reported bouts of dizziness, double vision, weakness in her knees, extreme fatigue and frequently complains of nausea. No diagnosis was found to explain her symptoms and all tests were negative. On one of her recent visits to the clinic she vomited violently in the patient bathroom and could not stop until medication was administered. Later the clinic staff found a bottle of Ipecac in the bathroom trash and thought maybe she had taken it. Despite her physical difficulties Mary’s affect is always cheerful and oddly unconcerned. She apologizes repeatedly for being too much trouble, but doesn’t seem to mind the fuss that is made over her.
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Mary arrived early for her appointment with the psychologist. She filled out the intake forms, including a medical history. Almost everything was checked on the form. She reported a history of respiratory, cardiac, bone, muscle and metabolic problems. Her list of hospitalizations had to be continued on the back of the form. There were 20 hospitalizations in the last 5 years alone for unexplained bleeding, severe infections of the bladder, eye, leg, and respiratory system. She has had skin grafts for unexplained burns, some of which had to be done repeatedly. Included in the list was three exploratory surgeries.
Mary also signed a release of information for past medical records. She commented that she didn’t know why she was seeing psychologist, but would do anything if it would help her doctor stop her terrible headaches. Mary reported that she was basically happy person if not for her medical problems. When asked about her many hospitalizations, she appeared unconcerned that so much had been done to her. The psychologist thought it peculiar that Mary reported her long history of medical treatment as if she were enjoying herself.
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As part of the evaluation, Mary was given some psychological testing. There was some indication that she might be suffering from conversion disorder. At the same time, tests did not indicate any depression or psychosis. There were elevations indicating a possible personality disorder. A follow up appointment was scheduled for the next week. The psychologist indicated that he would do his best to help Mary and her doctor. He asked Mary to keep a record of when the headaches occurred and her activities and feelings prior to onset of headaches. Before Mary could come to the next appointment, the psychologist got word that Mary was in the hospital. Since he had privileges at the same hospital, he decided to visit Mary. When he got there, he found her groggy, and covered in cuts and bruises. She told him she got dizzy and fell down the stairs at home. She was barely able to make the 911 call.
Mary’s old medical records arrived shortly after the psychologist’s visit to the hospital. There were many volumes in which were recorded a myriad of medical episodes. Illnesses would suddenly appear and disappear. Sometimes symptoms would remit for a while only to recur with a vengeance. It was notable that Mary often did follow the advice of the treatment provider, such as when she had severe edema in her legs, but did not prop them up as instructed. Mary was also erratically compliant with medications. However, she never missed a doctor’s appointment.
One volume, the oldest, came from the town in which Mary had previously lived. The provider in that clinic wrote that she suspected that Mary might be harming herself. The last time Mary was hospitalized in that town, video cameras in the emergency room caught her injecting something into her IV tube. Subsequently she began to vomit violently. When she was confronted, Mary denied any such thing and became angry at being accused. She got much better shortly thereafter and left the hospital. Three weeks later, she moved to her current address.
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