Evaluacion Susan

7/24/2019 Evaluacion Susan

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CLINICAL ASSESSMENT PROCESS

SUSAN: A Case Study

By

Roco Areta, Irene Bermejo, Sara Garca , Andrea Sols

_____________________________________________________

Submitted to Professor Carolina Marn

In artia! fu!fi!ment of t"e re#uirements for t"e sub$e%t

Assessment Applied to Clinical and Educational Contexts

May &t"' ()*+


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Case Study 5: Susan

Susan is a 21-ear-old !oman !"o !as re#erred #or psc"olo$ical testin$ % "er

psc"iatrist& S"e "ad se'eral "ospital admissions since s"e !as 1(& )er last "ospital

admission !as due to "er last suicide attempt !"en s"e !as 1*, t"en !as dia$nosed

!it" %ot" major depression and a %orderline personalit disorder& S"e !as resistant to

testin$ and complied onl %ecause +m s"rin and #at"er are main$ me do t"is&

SESSION 1:.ecidin$ or Explorator session

T"e main goalof t"is session /as to -et -enera! information about Susan0s rob!ems

and frame/or1 and estab!is"in- raort and a trustab!e rofessiona! re!ations"i /it"

"er2 3e first -a4e Susan a form on so%iodemo-ra"i% data to fi!! before enterin- t"e

%onsu!tation2 5/lease, see Appendix I62 T"e reason for t"e %onsu!tation is t"at s"e "ad

been referred by t"e sy%"iatrist and for%ed by "er fat"er to attend t"eray after s"e

started to re%ei4e treatment for "er dru- abuse rob!em2

Intake Open Interview

An inta1e inter4ie/ is t"e most %ommon tye of inter4ie/ in %!ini%a! sy%"o!o-y and it

usua!!y ta1es !a%e /"en a %!ient first %omes to see1 "e! from a %!ini%ian2 It is a non7

stru%tured inter4ie/ /"i%" urose often in%!udes determinin- t"e suitabi!ity of t"e

t"eraist to offer "is8"er ser4i%es to t"e atient' assessin- and resondin- to a %risis or

an ur-ent situation in t"e erson0s !ife' fami!iari9in- t"e erson /it" t"e %ounse!!in-

ro%ess' as /e!! as -ettin- a -enera! i%ture of t"e %!ient situation 5%on%erns' brief

"istory62 urin- t"e inta1e inter4ie/' bot" arties form oinions about one anot"er; t"e

%!ient be-ins to er%ei4e t"e %"ara%teristi%s of t"e t"eraist and t"e %!ini%a! re!ations"i

bet/een t"e t/o starts to form "ere2 In some %ases' arti%u!ar %!ini%ian may fee! t"at "e

or s"e !a%1s t"e e


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7 ?o/ o!d are you>

7 3"ere do you !i4e>

7 o you !i4e a!one>

7 o you suffer from any disabi!ity>

7 3"at is your o%%uation>

!resenting concerns

7 Te!! me' /"at does %on%ern you>

7 3"en did it start> 3"at ot"er e4ents /ere o%%urrin- at t"at time> ?o/ often does it

o%%ur>

7 3"at t"ou-"ts' fee!in-s and obser4ab!e be"a4iours are asso%iated /it" it>

7 3"ere and /"en does it o%%ur most> Least>

7 Are t"ere any e4ents or ersons t"at re%iitate it> Ma1e it better> Ma1e it /orse>

7 ?o/ mu%" does it interfere /it" your dai!y fun%tionin->

7 3"at re4ious so!utions8!ans "a4e you tried and /it" /"at resu!t>

7 3"at made you to see1 "e! at t"is time> 3"at inf!uen%ed t"e sy%"iatrist to refer

you at t"is time>

7 3"at are your -oa!s>

!ast psyc"iatric#counselling "istory

7 id you re%ei4ed any re4ious %ounse!in- and8or sy%"o!o-i%a!8sy%"iatri%treatment>

7 3"at tye of treatment> ?o/ !on- did it !ast> 3"ere did it ta1e !a%e>

7 3"at /as t"e out%ome of t"e treatment> 3"at /as t"e reason of its termination>

7 ?a4e you e4er been "osita!i9ed>

7 ?a4e you e4er been res%ribed dru-s for any emotiona! or sy%"o!o-i%a! issue>

Suicidal and "omicidal ideation

7 ?a4e you e4er "a4e any sui%ida! t"ou-"t> 3"en did it "aened>


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7 ?o/ many times "as it "aened>

7 Are you t"in1in- or tryin- to sui%ide %urrent!y>

7 3"at did dri4e you to "a4in- it>

7 ?o/ intense t"is t"ou-"ts are>

7 ?o/ !on- did t"ey !ast>

7 ?a4e you e4er made a sui%ida! !an> 5"ere /e %onsidered t"e detai!s of !an:

met"od' !et"a!ity' a4ai!abi!ity of met"od' and time!ine of !an6

7 ?a4e you e4er t"reat or attemted sui%ide> id any re!ati4e "as>

7 3"y did you intent to sui%ide>

7 ?a4e you e4er "ad any "omi%ida! ideation>

$rug use#a%use "istory

7 ?a4e you e4er ta1en any dru-> 3"i%" one8s>

7 3"ere do you usua!!y ta1e t"ose>

7 ?o/ often do you %onsume t"em>

7 o you %onsider t"at you ta1e t"em soradi%a!!y or re-u!ar!y>

7 o you sti!! ta1e t"e same dru-s t"at you used to>

7 3"y do you ta1e dru-s>

7 ?o/ do you fee! about it> 3"i%" are t"e ad4anta-es and disad4anta-es of

%onsumin->

7 3"at is t"e fun%tion t"ey "a4e for you>

After %arryin- out t"e Intake Interview' /e found t"at Susan0s interersona!

re!ations"is /it" ot"ers' bot" fami!y and friends' are unsta%le2 S"e does not usua!!y

trust on ot"ers be%ause @sooner or later e'erone ends up lea'in$2 ?er mot"er

%ommitted sui%ide /"en s"e /as *+ and s"e "as an ambi4a!ent re!ations"i /it" "er

fat"er2 S"e reorted "a4in- tried to %ommit sui&ide t"ree times: four' t"ree and t/o

years a-o be%ause s"e fe!t empty' /as e


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re!ations"is t"at destabi!i9e "er2 S"e started a%using drugs5Mari$uana' LS6 /"en

s"e /as *& years o!d' a!t"ou-" no/adays s"e is -ettin- t"is rob!em treated2 S"e "as

"ad t"ree "osita! admissions sin%e s"e /as * be%ause of "er sui%ida! attemts and s"e

/ent t"rou-" treatment for deression 50luoxetine6 after "er first attemt2 Susan admits

-ettin- easi!y irritatede4en by minor t"in-s 5noises' ot"er0s be"a4iourD62 In fa%t' s"e

reort to effort!ess!y !osin- "er temper/"ene4er somet"in- usets "er and en-a-in- in

a series of %"o!eri% be"a4iors !i1e t"ro/in- t"in-s and ye!!in-2 S"e is %on4in%ed t"at s"e

is a !eirderson /"o /i!! ne4er be ab!e of knowingw'os"e reall is2 S"e be!ie4es

insomniato be a %onse#uen%e of t"e rumination rodu%ed by "er rob!ems2

(rie) *ental State E+amination 5See Appendix II

T"e Menta! Status E


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an in%onsistent se!f74ie/2 ?er memory/as fine' as /e!! as "er %on%entration2 Susan0s

-udgmentand insig't/ere "a!f/ay bet/een oor and fair' sin%e s"e dis!ayed some

rob!ems /"en ma1in- de%isions and /"i!e ma1in- a se!f7ref!e%tion2

Summar o# t"e explorator session

urin- t"is first session' and a%%ordin- to t"e %o!!e%ted information bot" from t"e

Intake Interview and *SE' Susan0s deressi4e mood and insomnia eisodes' amon-

ot"ers' ma1e us "yot"esi9e t"at s"e mi-"t suffer from a mood disorder2 3e a!so

"and!e t"e otion of "er sti!! sufferin- from drug a%use 5Mari$uana' LS6 as s"e

reorted its %onsumtion sin%e s"e /as *& years o!d2 T"is resumab!e abuse a!on- /it"

"er imu!si4ity' identity disturban%e' mood rea%ti4ity' fear of bein- abandoned and

ot"ers' ma1e us "yot"esi9e t"at s"e may suffer from a personality disorder.a!t"ou-"

furt"er 4erifi%ation is needed2

T"us' after "a4in- estimated t"e %ase' /e t"in1 /e "a4e t"e ne%essary t"eraeuti% s1i!!s

and t"at /e are #ua!ified to %arryin- out t"e assessment2

Ri-"t before Susan !ea4es' /e as1 "er to t"in1 at "ome /"et"er s"e /ants us for

%arryin- "er assessment2 After a!!' /e "a4e started to assess Susan but s"e "as a!so

started to e4a!uate us2


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SESSION 2: Gat"erin$ In#ormation Sessions

T"e main -oa! of t"is session is to -at"er furt"er information about Susan0s rob!ems

and %on%erns' to 1no/ more about t"e "istori%a! ba%1-round for t"e fun%tiona! ana!ysis2

3e a!so as1ed "er to si-n an agreement )ormre!ated to bot" ours and "ers duties and to

t"e assessment ro%ess 5/lease, see Appendix III62

SE*I 0 SCED INE3IE4 4I6E 7!!68IN9 *SE 6ON9 O*

5See Appendix I3

A semi stru%tured inter4ie/ "as a -enera! frame/or1 on t"e t"emes to be e

!resenting !ro%lems

7 Hou to!d me !ast session t"at you are fee!in- b!ue and moody; "a4e you fe!t t"e same

t"is /ee1>

7 So are you fee!in- more !i1e t"is or !ess> o you "a4e any furt"er %on%ern t"at you

/ant to ta!1 about>

7 ?a4e you noti%ed any ne/ %"an-e in your mood>

amily (a&kground ;amily tree

7 ?o/ /ou!d you des%ribe your re!ations"i /it" your fami!y>


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ealt' (a&kground

0 ?o/ many "ours "a4e you been s!eein- t"ese days>

0 Are you fee!in- rested>

0 ?a4e you %onsumed dru-s !ate!y>

0 ?a4e you "ad any a%"e or soreness>

'mployment Bacground

?o/ do you fee! about your ast $obs> id you !i1e t"em>

id you fee! !eased /it" your %urrent or ast $obs>

?o/ many $obs "a4e you "a4e and for "o/ !on->

3"i%" $ob do you t"in1 /i!! suit you>

Se+ual istory

7 Hou to!d me t"at you "a4e "ad some %ou!e' %an you te!! me "o/ many>

7 or "o/ !on- "a4e you been in t"ose re!ations"is>

7 ?o/ t"ese re!ations"is affe%ted you>

7 3ere you satisfied /it" any of t"em>

!revious *edi&al istory

7 o you 1no/ if any of your re!ati4es "ad diseases>

7 id you "a4e any disease or i!!ness /"en you /ere youn-er>

7 Hou to!d me t"at /"en you /ere youn-er you /ere "osita!i9ed' %an you te!! me

somet"in- more about it>

!revious !sy&'iatri& istory

0 Hou to!d me t"at you /ere dia-nosed before /it" deression and border !ine

ersona!ity' "o/ !on- a-o /as it>

0 Can you te!! me somet"in- more about your t"eray>


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amily ree

*SE B 6ong orm ;simultaneously applied along wit' t'e interview

9"ou$"t ds#unction ScalesSusan reorts fee!in- use!ess at times' s"e is !i1e!y

to be un"ay /it" "erse!f and rone to rumination2

Be"a'ioral ds#unction Scales Susan reorts a si-nifi%ant "istory of antiso%ia!

be"a4ior2 S"e is !i1e!y to "a4e been in4o!4ed /it" t"e %rimina! $usti%e system' to fai!s to

%onform to so%ieta! norms and e


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7+is #: None

7+is $:Mot"er0s sui%ide' oor bonds /it" fami!y and friends' %onf!i%tua! re!ations"is'

$ob dissatisfa%tion2

7+is 5: EEA=: )2

Case ormulation 5)aness Model


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NCION76 7N768SIS: One E+ample


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SESSION $:0unctional )pot"esis Generation

After doin- t"e dia-nosis and Case ormu!ation' t"e fun%tiona! "yot"esis must be

defined before de4e!oin- and inter4ention !an2

By tea%"in- Susan tools )or emotional &ontrol0 I3 and by /or1in- /it" "er to

resolve emotional issues su%" as -rie4in- "er mot"er0s deat" or dea!in- /it"

"er fear of abandonment /e /i!! e


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Evaluacion Susan