- Key Issues
- Roberta is a white/Caucasian female who is a 53 year old mother. She has three kids. She divorced her second husband about 4 years ago. Her relationship with her children is fair. She has just stopped taking her medications because she reports that she is experiencing mania as well as forgetfulness. During the opening assessment, Roberta stated that she has been hospitalized several times for depression. Roberta also reported that she has experienced physical abuse when talking about her family history. She is showing patterns of faulty relationships with different partners as referenced by the numerous relationships that she has been engaged in. She goes to doctor after doctor due to some not finding her gifted with intellect. If she does not agree with them, she moves on the next one to find one who does.
Roberta has displayed erratic behavior such as too much spending, grandiose ideas that pertain to her self-worth as well as her intellect. Roberta reports that she has connections with high profile celebrities. She has told people that she is an assistant for the celebrity that she “works” for. For her physical aspect, Roberta appears to not be in good health due to the fact that she is smoking cigarettes and having been diagnosed with congestive heart failure. She has stated that she wants to die but does not have any ideation or plan.
Based upon what Roberta has reported to this counselor, this counselor feels that Roberta’s physical health as a top priority since she has been diagnosed with congestive heart failure. This counselor feels that it would be best if Roberta made an appointment with her PCP so that any somatic symptoms could be ruled out as well as any other medical issues that may be contributing to her mental health.
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After Roberta has been seen by her PCP to rule any medical issues for her behavior, this counselor would like to focus on Roberta’s erratic behavior she is displaying due to Roberta’s functioning being affected. Roberta’s boss told her that if she does not get herself under control she may not have a job anymore. She struggles with keeping jobs. This counselor feels that after addressing all the key issues listed above, Roberta may benefit from counseling such as psychotherapy.
- Diagnostic Impressions
- Roberta appears to be exhibiting signs of the following disorders based on her own report: narcissistic personality disorder and possible bipolar disorder with psychotic features. According to the DSM-5 someone has to meet the following to be diagnosed with a personality disorder: pervasive pattern of grandiosity in fantasy or in behavior, need for admiration, having a lack of empathy that begins in early adulthood which will present in a variety of areas (APA, 2013.)
- A person has to show 5 or more of the following:
- Grandiose sense of self-importance. Example would be that person exaggerates their achievements or expects to be recognized as a superior without actually obtaining the achievements.
- Preoccupied with fantasies of unlimited success or power, brilliance, beauty, or ideal love.
- Believes that he/she is “special” or unique or will only associate with people of higher-status than a normal individual. These can be people such as celebrities. Thinks that the only people who can understand her/him are those who are the ones that are “important”.
- Requires excessive admiration. Example: wants people to ooh and awe over you.
- Sense of entitlement or automatic compliance with his/her expectations such as having unreasonable expectations or wanting or needing especially favorable treatment. As well as expecting others to automatically comply with his/her expectations.
- Interpersonally manipulative such as takes advantage of people to get what he/she wants.
- Lack of empathy; not willing to identify with the feelings of others as well as not recognizing other people’s feelings or needs.
- Is jealous of others or thinks that others are jealous of them.
- Displays egotistical, conceited behaviors or even attitudes (APA, 2013.)
- It appears that Roberta is exhibiting symptoms that are related to grandiosity because she thinks she is “special”, has a sense of entitlement with others in her relationship with them including her medical doctor as well as exaggerating her accomplishments to others.
- For the second possible diagnosis, Roberta appears to be exhibiting signs of bipolar disorder with mixed features. According to the DSM-5, this disorder can be diagnosed when criteria is met for a manic and a major depressive episode (APA, 2013.) If the person is experiencing an impairment that is causing them problems functioning in a daily routine, this could require that person to be hospitalized, or if the person is exhibiting any psychotic features may have to be hospitalized also.
- Symptoms are not related to a substance use.
- Not a medical condition.
- Any other somatic issues.
- Roberta appears to be struggling with functional impairment.
- Boughts of mania.
- Treatment Recommendations
- This counselor feels that Roberta would benefit from psychotherapy after distinguishing the correct diagnosis. This can help Roberta learn to relate better with others so that her relationship with others can be more enjoyable and rewarding.
- Psychotherapy can help Roberta understand the causes of her emotions, the distrust of others as well as despising herself.
- Discuss options of psychotherapy or pharmacotherapy with Roberta and made a shared decision.
- If Roberta is interested in medication for symptoms of depression, anxiety, or other issues that she may feel she needs medicine for, refer her out.
- Roberta may need to complete other assessments which could help find out any other areas of other key points.
- This counselor feels that based on this assessment, Roberta being off her medication which could be contributing to her symptoms, this counselor is reluctant to diagnosis her at this time.
- Roberta is in need of seeing her PCP so that medical issues can be rules out as well as being stabilized to receive the care that she needs.
- Case conceptualization: Use of cognitive behavior therapy.
- Monitor Roberta to keep eye on treatment and make adjustments as needed. Educate Roberta to help her learn different relaxation techniques.
- If Roberta is someone who is religious and wants to participate in religious activities, offer a time of prayer, journaling, mediating, or being in nature.
- Understand the impact of Roberta issues that she has with her self-esteem.
- Increase Roberta ability to regulate her feelings.
- Recognize and accept her actual competence as well as her own potential. This will help her be able to accept criticism from others as well as her own failures.
- Gain an acceptance of what she is actually capable of.
- Therapy can be short term to help her when she is having a stressful time or crisis or can be ongoing therapies to her achieve her own goals as well as maintain those goals.
- American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). Arlington, VA: American Psychiatric Association Publishing. ISBN: 9780890425558.