Case Study
Patient Demographic:  Initial Intake: Age: 20 Gender: Male Sexual Orientation: Homosexual Race/Ethnicity: African American Relationship Status: Single Counseling Setting: University counseling center Type of Counseling: Individual
Mental Status Exam: Jonathan presents as anxious with congruent affect, evidenced by client self-report and therapist observations of fidgeting, inability to sit still, tearfulness and shallow breathing with rapid paced speech. Jonathan occasionally closes his eyes and takes deep breaths when he begins to cry in attempt to slow himself down and prevent what he calls “another emotional breakdown.” He has prior inpatient treatment history of a one-week episode where he was involuntarily committed at 17 for making comments about planning to kill himself in response to his stress over finishing high school. He admits to passive suicidal ideations in the past few weeks while studying for exams but does not report considering a method or plan. He reports that he has been losing sleep because of long study hours and feeling too keyed up to calm down. You assess him as having distress primarily associated with anxiety, which at times of abundant stress turns to episodes of depression and hopelessness.
Presenting Problem: Diagnosis: Anxiety disorder, unspecified (F41.9), Major depressive disorder, single episode, unspecified (F32.9)
 

You are a brand-new counseling intern in the counseling resource center of a local university. Jonathan is a junior in college and comes to speak with you, as you are his newly assigned college university counselor. Jonathan is concerned about finals that he feels unprepared for, stating he is “overwhelmed” and “under too much pressure” from his family to “allow himself” to fail. He is making disparaging, negative remarks about himself and his abilities, often repeating himself and talking in circles using emotional reasoning. He asks you for help in getting his teachers to modify his deadlines so that he can have enough time to accomplish all his assignments, mentioning that his last counselor did that and called it “playing the mental health card”. There are no previous records on file for this student, but when you ask him who he met with he just changes the subject and continues to express his worry that he will “never amount to anything or graduate” if he fails these exams.
Other Contexts: Education and Work History:
Jonathan has a high academic performance history, despite short periods of time where he experiences heightened stress. Jonathan has never gotten in trouble in school or had any infractions at part-time jobs later as a teenager. He has worked after-school jobs at the grocery store, bowling alley, and local town library. Jonathan had only one work-related incident where he broke down emotionally when feeling overwhelmed and left work in the middle of his shift, but his supervisor was supportive and helped him.
 
Current Living Situation:
Jonathan lives in the college dormitory with a peer and is supported by his mother. His mother is a single mom who works full-time in Jonathan’s hometown, which is almost a full day’s worth of driving from where Jonathan goes to college. Jonathan mentions that his friends call him “Jonny.” He adds that the food available to him is not very healthy and he has poor eating habits due to prioritizing studying and his involvement in extra-curricular activities.

Question: What are you assessing when you are evaluating Jonny's current presentation and ability to cope?
(A): hallucinations or delusions
(B): adult skills of daily living
(C): depression history
(D): here and now functioning

Correct Answer: here and now functioning
Explanation: Evaluating Jonny's here and now functioning is part of a mental status exam and addresses how Jonny is coping and surviving his current situation. Jonny reported not eating well, and being too stressed to sleep, which now seems to be manifesting in overwhelming emotions and the development of cognitive distortions. Conducting measurement examinations or interviewing as well as reviewing any previous charts or notes available concerning Jonny's depression diagnosis would be what you are looking for in terms of learning about his depression history. Regardless of depression history, here and now functioning can be evaluated on its own. Jonny may not be doing a great job of self-care but living alone is a good sign that he has mastered enough ADL's to be living alone at college. Hallucinations and delusions may be present during an assessment, which would change the details of the here and now functioning results. Therefore, the correct answer is (A)
Competency: intake, assessment, and diagnosis