Case Study
Patient Demographic:  Initial Intake: Age: 37 Gender: Female Sexual Orientation: Heterosexual Race/Ethnicity: Caucasian/non-Hispanic Relationship Status: Married Counseling Setting: Mental health counseling agency Type of Counseling: Individual telemedicine
Mental Status Exam: Leah is casually dressed, presenting with anxious mood and affect. Speech is of fast rate but with normal tone. Breathing is shallow from speaking fast, you note she stops to take deep breaths before continuing. Leah denies SI/HI, reports many protective factors, and admits that nothing in her life is “really that wrong.” Leah demonstrates good insight and judgment into the nature of her concerns.
Presenting Problem: Diagnosis: Generalized Anxiety Disorder (F41.1), Adjustment disorder with mixed anxiety and depressed mood (F43.23)
 

Leah is referred to your counseling agency by the U.S. Department of Veterans Affairs (VA) mental health program due to their inability to accommodate her because of their high caseloads. Leah is a 37-year-old married woman with a 2-year-old child and is a disabled combat veteran who served 8 years in active-duty Air Force service. Both you and Leah work full-time as mental health counseling interns in your respective practices. Leah struggles to manage her own anxiety which causes both interpersonal and professional problems for her. Leah reports experiencing trauma related to deployments, past divorce, death of a pet and birth trauma with her daughter. Leah tells you she needs someone to process everything with regularly as she does not want to exhaust members of her family with her stress. Leah’s biggest problem, she shares, is that she knows how to resolve her negative thoughts that lead her to act impulsively but cannot apply her skills when she feels overwhelmed.
Other Contexts:  
Education and Work History:
Prior to military life Leah worked several different jobs since the age of 13. Leah joined the Air Force at age 21, worked overseas as well as in the states, and had several deployments including one year in Kabul, Afghanistan as a Staff Sergeant during her fifth year of service. Leah obtained her bachelor’s degree right after separation, and then returned to Afghanistan as a contractor. Following this experience, she completed her master’s degree in counseling. She admits she is “skeptical” working with someone who has the same amount of experience as herself.
 
Family History:
Leah grew up with two younger siblings, and her parents divorced when she was 11. Due to joint custody, her and her siblings moved back and forth weekly every Friday until she originally left home for college at 18. Both of Leah’s parents remarried; her father having three more children with her stepmother, and Leah inheriting a stepsister when her mother married her stepfather. Leah was also previously married to an Army Sergeant while active duty, but her husband had an affair and left her prior to her military separation.

Question: What tool can help you learn more about Leah's reported "impulsivity"?
(A): Adult Needs and Strengths Assessment (ANSA)
(B): CBT thought record
(C): Young Schema Questionnaire (YSQ)
(D): Adult ADHD Self-Report Scale

Correct Answer: CBT thought record
Explanation: A Cognitive Behavioral Therapy thought record can help both you and Leah understand how a triggering event makes her feel, followed by what automatic thoughts Leah has in the moment and how she responds to situations with her behaviors. The record further helps Leah develop insight into her underlying distorted core beliefs and challenges her to develop healthier thought processes while also reducing her maladaptive reactions to stressful stimuli. This can help inform the diagnostic process during intake as well as be applied later in counseling. The ANSA is a comprehensive tool used for clients and treatment teams to score progress and goals and helps determine appropriate level of care and quality improvement; it is primarily only used as insurance requirements dictate and can be useful in the intake process but will not provide any details regarding Leah's behaviors as it is there for you to mark down your perspectives of her functioning based on information you already have. The YSQ is related to long-term personality deficits and is conducted when applying schema therapy interventions; this can be useful as a treatment intervention but will not target a better understanding of how Leah behaves impulsively and her reasons. There is no evidence to suggest Leah struggles with ADHD, as impulsivity can be present in adults without ADHD. Therefore, the correct answer is (D)
Competency: intake, assessment, and diagnosis