Case Study
Patient Demographic:  Initial Intake: Age: 16 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: African American Relationship Status: Single Counseling Setting: Community Health Type of Counseling: Individual
Mental Status Exam: The client presents as a thin young woman, whose weight is appropriate for her age. Her clothing is appropriate for her age and to the situation. She identifies her mood as happy and her affect is congruent. The client shows some retardation in movement but no spasticity or physical or abnormal movements. The client appears open and honest in her responses, though responses are short. She responds to closed questions without pause but appears to struggle to answer open-ended questions as evidenced by staring and smiling without speaking or saying “I don’t know.” On examination, the client shows little insight into her mother’s concerns and uses childlike judgement when responding to hypothetical questions. The client denies suicidal or homicidal ideations or intent, delusions, or hallucinations, but does admit to playing a game with children at her maternal grandmother’s house where they attempt to see ghosts in the bathroom mirror.
Presenting Problem: You are a counselor in a community health setting which includes in-office sessions as well as home visits. Your client is a 16 year-old female who presents with a history of academic difficulties, problems following rules at home, and fighting with her sister, which recently included threatening to cut her sister with a kitchen knife. Her mother tells you that the client has always had some problems in school but they are getting worse. Her teachers say that she doesn’t pay attention and struggles with simple concepts, but is always polite and friendly to others. When asked to tell you how she thinks things are going, she answers “good” and smiles. You notice that she often smiles while her mother is talking but when her mother talks about the problems at home, the client looks away from both of you and stares out the window. The client’s mother reports that the client does not clean her room, has to be told to attend to her hygiene, and does not complete chores when they are assigned, such as cleaning out the refrigerator or vacuuming the living room. Mother reports that the client stays at home alone or with her two younger sisters when her mother or mother’s boyfriend are at work or away from home during the day.
Other Contexts: Family History:
The client is the oldest of three children born to her mother. Her siblings have different fathers and her youngest sister’s father currently lives in the home and is identified as “mom’s boyfriend” or “Robert.” Client’s mother reports no family history of mental health disorder or substance abuse. The client reports that she often spends several nights a week with her grandmother “to give Mom a break” and plays games and spends time with the neighborhood children. The client states that her grandmother “makes me sit and she reads the Bible to me” for several hours each day. She reports that she likes spending time at her grandmother’s house because she and her sister watch “scary movies” including movies about monsters, murders, and witchcraft.

Question: Given the information provided, which diagnosis is most likely to be accurate for this client?
(A): Schizoaffective Disorder
(B): Autism Spectrum Disorder
(C): Bipolar I Disorder
(D): Major Depressive Disorder

Correct Answer: Schizoaffective Disorder
Explanation: The client is diagnosed with Schizoaffective Disorder. She meets criteria for a major depressive disorder including sadness, loss of appetite, fatigue, irritability, and psychomotor retardation over the past two weeks. Concurrently, the client has been experiencing delusions and hallucinations for over one year during times when she is and is not experiencing a depressive episode. Thus, she meets the criteria for the disorder. While the client is experiencing a major depressive episode, it is within the context of and better explained by the Schizoaffective diagnosis. The client exhibits no deficits in communication that are not explained through her IQ scores and does not demonstrate restricted or repetitive patterns so she does not qualify for an Autism Spectrum disorder. The client does not show symptoms of Bipolar I disorder as she has not experienced manic episodes, including pressured speech, psychomotor agitation, racing thoughts, or high-risk activities. Therefore, the correct answer is (C)
Competency: treatment planning