Diagnostic Conceptualization Template

Case Conceptualization ( Note: Include specific information about client symptoms and presenting concerns

Jane is a 35-year-old Caucasian female who self-referred for treatment. Jane reports experiencing feelings of withdrawal, sadness, and hopelessness. She stated that she has struggled to maintain relationships and has lived with her mother her entire life. Jane’s relationships are often volatile and characterized by others viewing her as “needy”, “dramatic”, “emotional” and “crazy. ” Jane declines any current religious involvement but noted some interest in exploring Buddhism and spirituality.

Jane has a history significant for sexual abuse by her older brother and her brother’s best friend. Jane reported that the abuse took place from the ages of 4 to 14 and stopped only when her brother left home. Jane reported that she has never disclosed the abuse to her mother. Jane has experienced instability in relationships with friends, and reported no support system beyond her mother. Jane struggles with individuation and often internalizes the interests of her others.

Jane tends to think very concretely and she struggles with a general negative outlook. She has a past history significant for severe self-injury (i.e., self-cutting). She’s also had periods of suicidal thoughts but she reports no current suicidal ideation at the time of session. Jane also has a history of disordered eating but she reports that she has not engaged in any binge/purge behavior for approximately the past several years.

Jane’s medical history includes previous diagnoses of Major Depressive Disorder and Posttraumatic Stress Disorder. She has been diagnosed with asthma. Jane reports that she has the ability to induce an asthma attack and she admitted to doing so at least twice weekly over the course of the past year in an effort to seek medical care. Jane reported that she enjoyed the attention associated with medical care.

Jane has a history of inappropriate boundaries with her previous counselor and she acknowledged going to great lengths to obtain her previous counselor’s home address so that she could drive by her house.

Jane has previously attended college but is not currently enrolled. She was the first individual in her family to attend college and she reports that her mother was not supportive of her education. Jane reported that she would like to eventually return to school but she fears that she will be able to complete her studies until her medical care is addressed.

Diagnostic Impressions (Note: Be sure to use the ICD-10 code, name of the disorder, and all of the specifiers)
F60.3 Borderline Personality Disorder (Reason for Visit)

F33.1 Major Depressive Disorder, Recurrent, Moderate, Provisional

F43.1 Posttraumatic Stress Disorder, Provisional

 

Rationale for Diagnostic Impressions (Note: Use the DSM-5 to explain how the client’s symptoms are reflected in the diagnostic criteria for each diagnosis that you render. If you do not render a diagnosis, you still must use the DSM-5 to explain why you chose not to render a diagnosis.)
Jane’s medical history includes past diagnoses of F33.1 Major Depressive Disorder, Recurrent, Moderate and F43.1 Posttraumatic Stress Disorder, Provisional. Based on her current presentation, it appears that reason visit is related to symptoms of F60.3 Borderline Personality Disorder.

Consistent with the symptoms of Borderline Personality Disorder, Jane demonstrates a pervasive pattern of instability in multiple facets of her life that appears to have begun in late adolescence. Jane reports that those with whom she has had relationships have called her “needy” and she indicated that her relationships tend to vacillate between ideation and devaluation (Criterion 2). Jane reported that she doesn’t feel connected to a particular identity and she often takes on the identity of those in her life (Criterion 3). Jane has recurrent suicidal thoughts and self-injurious behavior (Criterion 5). She also experiences affective instability and her mood appears reactive to those around her (Criterion 6). Jane reports feeling empty and she often struggles to find meaning in her life (Criterion 7). Jane is prone to bouts of anger, especially in response to situations in which she feels out of control – for example, slashing a friend’s tires after a fight (Criterion 8).

In order to qualify for a diagnosis of a personality disorder, an individual first must meet the General Criteria for a Personality Disorder. Jane’s symptoms have been evident since at least age 20, which suggests that her symptoms represent an enduring pattern of behavior that have impacted her thoughts (“If there were a God, he wouldn’t have let my life turn out this way”; Criterion A1), her affect (characterized by overwhelming feelings of sadness and hopelessness; Criterion A2), her interpersonal functioning (volatile relationships with friends; Criterion A3), her impulse control (a history of self-injury and bulimia; Criterion A4). Jane’s symptoms have been evidenced in numerous situations (e.g., work, school, home; Criteria B) and the symptoms cause clinically significant distress across numerous areas of her life (e.g., home, relationships, work, school; Criteria C). Jane’s symptoms appear to have begun in late adolescence (Criteria D). Although the client has asthma, there are no other medical conditions that are responsible for her current symptoms (Criteria E). The client is prescribed Paxil but there is no evidence of substance use and thus, no evidence that substance are causing her symptoms (Criteria F).

The client reports that she has previously been diagnosed with F33.1 Major Depressive Disorder, Recurrent, Moderate and F43.1 Posttraumatic Stress Disorder. The client’s current presentation does not provide enough evidence to support rendering either diagnosis at this time. However, based on the client’s past trauma history and her self-reported “dark times”, both disorders warrant further exploration.

 

Cultural and Ethical Considerations (Note: Include information that may be pertinent to the diagnosis).
The client does not have any current religious involvement but she reported some interest in pursuing Buddhism. The client is a first generation college student and she reports limited support for pursuing her education from her friends and family. The client has a limited social support system and spends the majority of her time with her mother.

Jane is not currently sexually active and she reports discomfort with the idea of intimacy. She appears to feel more comfortable with females; however, she is not currently in a relationship and does not appear to be actively seeking out romantic partners.

The client has a history of inappropriate boundaries in relationships. The client previously engaged in stalking-type behavior toward her previous therapist. Thus, it is important that boundaries are enforced for the duration of the counseling relationships.

 

Student Name and credentials (e.g., Frida Kahlo, B.A.)

Victoria Woodhull, B.A.

*Note: Case Available in Chapter 9 of Kress, V.E., & Paylo, M.J. (2018). Treating those with mental disorders: A comprehensive approach to case conceptualization and treatment (2nd ed.) New York, NY: Pearson

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