Clinical diagnosis essay example

The Five-Axis Diagnosis

Axis I- 308. 3-Acute stress disorder
Rationale; her body was displaying stress symptoms; she trembled and felt coldness in her hands when she watched her father die.
311 Depressive disorder

Rationale: She displayed depressed mood and the therapist reports that she was depressed

309. 21 Separation anxiety disorder

Rationale: she felt depressed, lonely and hopeless because death of her father separated her from the father

Axis II-301. 0 Paranoid personality disorder
Rationale-She has had conflicts with the father over her future career and perceives the father as being rejecting and emotionally cold

She is quite unforgiving because since she crossed paths with her father, she had never forgiven him

Axis III- No medical condition
Axis-IV 310. 1 Post-traumatic stress disorder
Rationale-After the loss of her father, she felt confused and unable to cope with the loss.
Axis V: GAF 55; GARF 50; SOFAS 55
Axis I 302. 84 Sexual sadism
Rationale: The wife complains that he is bullying and disinterested in sex, yet he is only experiencing minute problems with his marriage. This means that he derives his sexual satisfaction from bullying and humiliating the wife.

Axis II 301. 50 Histrionic personality disorder

Rationale: he considers the relationship between him and the wife intimate, yet the wife is dissatisfied; he considers the wife a perfect mate
301. 81 Narcissistic personality disorder
Rationale: he is preoccupied with fantasies of unlimited success and power. He is arrogant because he describes his children as dolls

Axis III-No medical condition

Axis IV-He works many hours and makes several business trips; this has negative impact on the relationship with his family
Axis V GAF 50; GARF; 50; SOFA 50

Axis I-314. 01 Attention Deficit Hyperactive Disorder; predominantly hyperactive impulsive type
Rationale: He has persistent pattern of inattention and hyperactive impulsive behavior, which causes problems at school and other social places. He has few friends because his high energy level puts off most children. In addition, he interrupts his colleagues and does not wait for his turn
312. 81Conduct disorder; with onset in childhood
Rationale: He displays behavior of being destructive to property because he broke and entered private residence, he bounds into the house destroying objects in the house. Serious violation of laws and has been arrested by police because of breaking the law. He stays up at night and requires very little sleep. He is deceitful; steals his mother’s money but denies to have taken any money. He assaulted the police at the time of arrest and was unable to restrain himself
305. 90 Inhalant disorder

Rationale: His parents admit that they suspect that he has been smoking cigarettes, which he could experimented from glue sniffing

315. 1 Mathematics disorder

Rationale: He has IQ of 126 and performs relatively well in other subject except mathematics

Axis II-301. 7 Antisocial Personality Disorder
Rationale: He had few friends at school because most children could not put up with his conduct. He is socially isolated

He could not get along well with his fifth grade teacher.

Axis III- No medical condition
Axis IV-His parents are supportive even though he always does contrary to their expectations because he is unable to control himself and his behavior in the environment. He has always been in trouble with the law. The fact that his fifth grade teacher does not like him has reduced his academic performance.

Axis V-GAF 50; GARF 45; SOFAS 40

Axis I-307. 50Eating disorder
Rationale: She develops binge-eating behavior especially when she is depressed or distressed
291. 9 Alcohol related disorder; non specified
Rationale: She has been taking drugs occasionally; two to three times a week, but reports that it is not a habit

Axis II-301. 83 Borderline personality disorder

Rationale: She has had six relationships, which she claims were stable but they were not sustained. She displays mood instability with marked reactivity of mood changes; she experiences affect swings ranging from fantastic optimism to unbridled gloom
She displays suicidal behavior; she has been having thoughts about attempting to kill herself; signs of self-injury and self-mutilation evidence this

She has dissociative or paranoid disorder

She is impulsive; she does not reason before acting and is potentially self-damaging
301. 4 Obsessive-compulsive disorder

She is unable to maintain a job for long; she has had seven jobs in the past year.

Rationale: she is obsessed with shopping and always overspends leading her into debts
Axis III-No medical disorder
Axis IV-the habit of being a shopaholic puts her into economic problems because she has endless debts
Axis V- GAF 50; GARF: 45; SOFAS: 50

Treatment Plan Chart

Problem or Concern
Objective
Treatment
Intervention
Expected Achievement Date
Evaluation
Follow-Up
Paranoid personality disorder associated with lack of trust in people and suspicion.

Depression; displayed by frequent crying and weeping spells

Post-traumatic tress disorder; associated with anxiety symptoms following the loss of a loved one

Assist client to develop trust in harmless people and avoid being too suspicious

Assist the client to adopt higher level of coping with the situation; loss of a loved one

Develop a trusting relationship between the therapist and the client through counseling sessions
Develop professional stance
Allow the client to talk about his fears and assist with those fears
Provide clear explanation to the patient about his condition
Avoid directly challenging the paranoid ideations

Antidepressants to alleviate the symptoms of depression
Psychotherapy; allow the client to talk about her fears in life then provide reassurance

Interpersonal psychotherapy through involvement of social groups to offer social support
Cognitive and behavioral therapy; allow the patient to change her attitude and behavior towards the situation in order to effectively cope with the situation

Family and group therapy to assist in the client overcome the frightening symptoms through sharing of experiences

Give medication for the associated symptoms for example selective serotonin reuptake inhibitors to alleviate symptoms of anxiety
Allow the client to express fears (Frank & Ross, 2001)

After one year of treatment, the symptoms will have reduced and the client will have developed desired behavior.

After six months, the patent should have understood and accepted his problem

After six months will experience reduced depressive symptoms

Suspicion level has reduced

After six months, client has reduced manifestations of depressive symptom

Every two weeks; to assess the progress of the client and continue with medication as prescribed

Give appointments for counseling sessions every two weeks and assessment of progress

After every month to assess client’s progress
Monthly counseling sessions

Treatment Plan
Problem or Concern

Objective

Treatment
Intervention

Expected Achievement Date
Evaluation
Follow-up
Eating disorder

Alcohol related disorder

Borderline personality disorder
The client will stop taking alcohol

Behavioral therapy
Psychotherapy
Counseling

Psychotherapy
Help the client to develop strategy on how to stop drinking

Psychotherapy
Group therapy
Family and social support to help client in dealing with her problems

After six months

After six months

Patient able to cope with stress without taking alcohol

Patient does not have suicidal ideations anymore
Every two weeks to assess the progress of the client

Every month to assess client progress

Every six months

Reference
France, A., & Ross, R. (2001). DSM-IV-TR case studies: A clinical guide to differential
diagnosis. New York, NY: Oxford University Press.