Case Study
Patient Demographic: Initial Intake: Age: 35 Sex: Male Gender: Male Sexuality: Gay Ethnicity: African American Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Individual
Mental Status Exam: The client presents appropriately dressed and is well-groomed. His stated mood is congruent with stated affect but you note a limited range of emotions. He appears to be cooperative and forthcoming. He endorses no use of illegal or inappropriately prescribed drugs and a 20-year history of alcohol abuse, with one driving citation at age 21. He currently drinks 3 to 4 beers per day and 16 or more on the weekend. He acknowledges using alcohol to relieve emotional discomfort and feels the need to cut down. He is able to offer insight into his thoughts and behaviors, and demonstrates appropriate memory and judgement.
Presenting Problem: You are a counselor in a private practice setting.  During the intake session, you learn that your client and his spouse have been married for 7 years and together for 10 years. He states they have 2 children and he is their primary caregiver from early afternoon until evenings; this includes transportation, preparing dinner and homework. He states his spouse and he moved their family here earlier this year to be closer to his husband’s family. He works as a high school teacher. He presents relationship issues as his main concern and rates these as “very difficult,” and has been told that he and his husband “may be heading for divorce.” He states he often feels “suspicious” because his husband has multiple friendships with other males, online and face-to-face, including old boyfriends. The client tells you he feels this is inappropriate but that his husband disagrees and will not end these friendships.  He admits being stressed, overwhelmed, sad, having little energy, and experiencing crying spells, irritability, and angry outbursts. He says he feels like a failure. He says his husband said he has not been “emotionally available” since their marriage. The client notes that during the year they married, he finished his teaching credentials, the couple adopted their first child, and he began working as a first year teacher in a high school with tenure requirements.
Other Contexts: Family History:
The client states he has three siblings. He relates he has a “pretty good” relationship to his brother, a moderate connection to his younger sister, and a tenuous connection to his older sister. He says he has cut himself off “emotionally and physically” from his own parents and his husband’s family due to “conflicts.” He describes his mother as manipulative and attributes the lack of many extended family relationships to her. He describes the relationship between his parents as conflictual but that his father “goes along with her” and has cut off relationship with the client’s older sister, his father’s twin sister and her spouse. The client says his mother has never liked the client’s spouse. He said she was not happy he married a man, but was even more upset that his husband is White. During one family visit, his mother left a derogatory email about his husband in a visible place so he would find it.

Question: Based on the information gained in the intake, what diagnoses are most appropriate to consider for this client?
(A): Schizoid personality disorder; Alcohol use disorder
(B): Alcohol use disorder; Paranoid personality disorder
(C): Alcohol use disorder; Adjustment disorder
(D): Major depressive disorder; Alcohol use disorder

Correct Answer: Major depressive disorder; Alcohol use disorder
Explanation: The client's symptoms are most closely related to a depressive disorder (MDD) including sadness, crying, lack of energy, feelings of failure. While the client may not yet have expressed all the symptoms needed for the diagnosis, MDD should be investigated along with alcohol use disorder (AUD) based on the clients' concerns about his drinking. While the client endorses suspiciousness based on his spouse's activities, these are not irrational suspicions and do not indicate paranoid personality disorder. The client expresses strained relationships with many family members and restricted range of emotional expression, but does desire close relationships, does not appear indifferent to praise or criticism, and does not endorse "almost always choosing solitary activities". The client reports moving this year, which could point to an adjustment disorder, however his spouse indicated through the client's report that the problems have been longstanding. Therefore, the correct answer is (C)
Competency: intake, assessment, and diagnosis