Case Study
Patient Demographic: Initial Intake: Age: 35 Gender: Male Sexual Orientation: Heterosexual Ethnicity: African American Relationship Status: Divorced Counseling Setting: Community Mental Health Center Type of Counseling: Individual
Mental Status Exam: Davone presents as well-groomed, of fair hygiene and motor movements are within normal limits. Davone makes decent eye contact throughout session. Speech tone and rate are normal. Thought process unremarkable. Denies SI/HI. Davone becomes tearful when he recalls past family information, sharing that his father was never around for him for the same reasons he is not around for his family. Davone frequently refers to his racial background and where he grew up, becomes angry as evidenced by tense expression, furrowed brow, and clenched fists, and then self-soothes without prompting by taking a deep breath and moving forward in conversation. When asked, Davone tells you he learned those skills in past anger management classes he was mandated to take years ago.
Presenting Problem: Diagnosis: Adjustment disorder with mixed disturbance of emotions and conduct (F43.25) Provisional, Problems related to other legal circumstances (Z65.3)
 

Davone is referred to you by his probation officer after being mandated by the court to undergo weekly emotional and behavioral health counseling sessions for a minimum of 9 months or until his next court hearing is scheduled, whichever is sooner. Davone’s Medicaid insurance cover his sessions. The probation officer tells you Davone is undergoing sentencing for violating his probation and restraining orders put in place by his ex-wife, which render him unable to set foot on their property or visit with his children (twin boys, age 9, and girl, age 4). In the initial assessment, Davone shares that he has had run-ins with the criminal justice system for most of his life “just like his father” and that he fears a lifetime of being in prison and not being able to be there to watch his kids grow up. Davone tells you he will do anything to get out of his situation and return to having a life where he can continue going to work and providing for his children.
Other Contexts: Legal and Work History:
You learn from Davone’s referral paperwork that Davone’s legal record extends back to age 9 when he was first beginning to show signs of conduct at school. Davone was often sent to the “recovery room” in elementary school for aggressive outbursts and defiance towards teachers. He has a record with the Juvenile Justice System for breaking rules and truancy in middle and high school. After age 18, he was arrested several times for misdemeanors of vandalism, shoplifting and reckless driving. He then married and became employed full-time by age 25, where he did not get into trouble with the law again until age 31 when he got fired for stealing from his company. This caused marital discord and led to Davone’s divorce two years ago. Davone has had a continued string of misbehavior, arrests, and short-term jail stays ever since. Davone adds that his ex-wife accused him of consistently endangering her and the kids without caring, which is why she got the restraining order. He disagrees with her, saying “I would never harm my kids.”

Question: After the second session, you now feel better equipped with information to reliably diagnose Davone with a Borderline or Antisocial Personality Disorder. All of the following factors would contribute to this decision, except?
(A): Davone's persistent, inflexible pattern of maladaptive perceptions and interpretations
(B): Davone's pervasive inability to change his behavior without insight
(C): Davone's apparent fear of abandonment and extreme emotional mood swings
(D): Davone's report of trying harder to do better with increased self-esteem

Correct Answer: Davone's report of trying harder to do better with increased self-esteem
Explanation: Davone has clearly presented with a persistent, inflexible pattern of maladaptive perceptions and interpretations, a pervasive inability to change his behavior without insight, fear of abandonment and extreme emotional mood swings. He also demonstrates lack of remorse for his wrongful actions, abnormalities in his decision-making processes with criminal behavior and has an unclear or shifting self-image. These expressions can point towards further assessing for Borderline or Antisocial Personality Disorder. Davone expressing an increase in self-esteem or recent behavior changes that he has been making to improve upon himself are not factors in the determination of this diagnosis. Therefore, the correct answer is (D)
Competency: intake, assessment, and diagnosis