Client Name: Emily Colas Sex: Female
Age: Adult
Medical Condition(s): _____________________________________________
Reason for Referral:
Emily Colas was brought to Psych Associates because she was completely unable to manage normal life. Her husband verified these claims; she was making life for the whole family extremely difficult.
Tests Administered/Test Scores & Interpretation/Behavioral Observations:
[There may be test results available, perhaps an intelligence test, neuropsychological battery, or MMPI (for example). These should be reported in some detail. If no tests are available, it’s common to describe the examiner’s initial observations and impressions of the client upon first contact.]
Client/Family Background:
As a teenager, Emily’s mother had a stomach illness that required surgery.
Emily’s mother manifested a sign of OCD when she continued to stroke a light switch that was apparent to Emily as already off.
Emily’s father and mother divorced.
[It may be important to know something about the client’s family. Have others had psychological disorders? If so, what kind and when? Is the family functional or dysfunctional? In what way(s)? Have there been any traumatic events in the family that may have precipitated the client’s behavior? Etc.]
Detailed Case History:
Symptom of OCD: The action of numbering spoken words pictorially as stars so they are in multiples of five.
In college, Emily suffered from a horrible drug habit, had a negative situation occur, after which she suffered with flashbacks for months, declaring that she would never take a pill again
Her first date with her future husband was normal enough; they met in a bar and went back to his house for poetry.
Emily described the repetition her dad would make in his daily eating of breakfast. This was a situational model that possibly contributes to her current behaviors.
Emily also detailed a time when she had uncontrollable thoughts about the dangerous histories of people she ran into in daily life. She thought her coffee seller was a serial killer.
Irrational thoughts in her early life of dating were revealed in her continual episodes of her boyfriend having to deal with her fears of contaminated food. The cause of this fear, as explained by Emily, was that she was at a party when someone joked that they put acid into some sugar cubes.
Her first time eating at her boyfriend’s house was punctuated by her dilemma of whether or not to eat his food. She thought that he might be trying to poison her.
Emily’s stays at summer camp were continually reported by her counselors to have been full of behavior that was excessively neat and orderly.
Emily has an intense fear of blood, bordering on Hemophobia.
Emily was worried over her past sexual history to an extreme degree because of her promiscuous previous boyfriend Randy. Even after repeated testing, she continued to get blood exams.
A concern over whether or not inappropriate thoughts made their way to her mouth was an issue of contention. She feared that she spoke nasty phrases and needed reassurance from others that she didn’t say what she thought she said.
The patient suffered an episode of anxiety over the possible growing her tongue so large that she would be unable to breath.
During college, Emily took a course in Abnormal Psychology, and, as a result, spent time volunteering at the local mental institution.
According to Emily, there was “no going back” after the point where she admits to her husband that she has a fear of food poisoning, and he agrees to taste-test her food.
Emily better explained a facet of her life than could be summarized. She said, “My husband and I moved around a lot. I have a short attention span. First we both stayed at his apartment. It was small and not “ours,” so we found a new place. We signed a one-year lease and everything was going smoothly until I decided that it was too small. We broke our lease and found a new place. We settled in, got a cat, then two, then my husband got asthma and he coughed a lot. We needed more space. We decided to buy. We had one year left in North Carolina, but we didn’t care. We broke another lease, bought a bigger place and put his study at the far end of the house. We stayed put until we moved to California. In the meantime my husband got a Ph.D., I went though a few jobs, [and] we had one kid… I hated Los Angeles, but we never changed apartments. My husband didn’t get any more advanced degrees, I didn’t get any jobs, but we did break our lease and have another kid. The next move was to Michigan. We fully intended to buy a house again, but needed time to look. We signed a six-month lease, found a place in two, broke the lease, and moved into our new house. I got antsy, made up some excuse like, “It’s too small,” and we sold the house. We rented a new place while we looked for a bigger one to buy. A few months later we separated. My husband got his own place…”(22-23). This long winded explanation better explains a major chunk of her history than a paraphrasing would. Her symptoms shine through, as does a framework of necessary historical events.
At five years old, Emily Colas used to throw up all the time. She would go into her parents’ room in the middle of the night and say she had to vomit, at which point she got attention and was helped by her parents to the bathroom. Her mother was stuck cleaning up the mess.
Directly after college, Emily worked at a substance abuse center as a counselor. This access to the medical world continued to feed her phobias of contamination.
Emily and her husband also visited a couple’s therapist at one point. This therapist blamed all problems on a past dysfunctional family. Emily and her husband thought he was not competent to help them.
Another incident of anxiety: Emily thought she had a flea living in her head.
At a dining out experience, Emily fears that the waiter will contaminate their food because he has bandages on his hand which means he had some type of cut which could leach out blood to the food he handled. Emily panics over this and makes her husband interrogate the waiter. Emily said, “I possess an endless capacity to keep a worry alive.”
The agreement of marriage of Emily and her husband took place in a general conversation where Emily wanted to get married, but her husband wanted to wait. She pesters, he relents, and they get married.
Another eccentricity involves Emily biting her lip to get to sleep.
On a seeming whim, Emily has the desire to become a mother, so she petitioned her husband, and they agreed to aim for parenthood.
Growing up, Emily was raised in part by a German nanny. This woman kept Emily on a strict schedule, reinforcing repetitive patterns in Emily’s neural networks.
Emily also developed a fixation of protecting her baby, going so far as to call a deodorant company to make sure the chemicals would not harm her child. After not getting a satisfactory response from the helpline, Emily decided to stop using deodorant. Emily grew to have a fear that maybe the baby she took home from the hospital was not her child. A possibly traumatic event for Emily occurred throughout her childhood when her dad would have her go around kissing frogs to make them turn into princes. One can see a later connection to a fear of germs.
[Here you provide whatever relevant information you have available as to how this disorder has unfolded and evolved. You may need to begin with events in the person’s childhood. Consider that you’re somewhat of a detective seeking and reporting clues regarding what illness this person has and why. A chronological order usually works best here, but you need to use your own judgment.]
Diagnosis (attach report sheet summarizing Axes):
Reason for Diagnosis:
[In this section you should summarize the key symptoms the client has exhibited and exhibits and explain why/how they have led you to make the diagnosis or diagnoses you make.]
Treatment Plan:
[In this section you should outline the kind of treatment you think the client should receive. You’re in much the same position as a teacher who has to lay out a lesson plan before teaching a class in school. What objectives do you want to reach? In what order do you want to reach them? What sub-goals may be involved? Most importantly, how are you going to achieve the objectives? If you recommend a psychotherapy, explain the kind and your reasons for preferring it over other alternatives. Explain how the therapy should be implemented. If you recommend medication, explain what and why.]
Prognosis:
[In view of the nature of the illness and the treatment plan you have offered, what kind of improvements do you think this client can achieve in the future, and why?]
Multiaxial Evaluation Report Form
Name Emily Colas Date____________
AXIS I: Clinical Disorders (use DSM numbers and names)
OCD
AXIS II: Personality Disorders (use DSM numbers and names)
Dependent Personality Disorder
AXIS III: Relevant General Medical Conditions
Rotoscoliosis, but possibly just bad posture.
AXIS IV: Psychosocial/Environmental Problems
Cutting
Trichotillomania Impulse Control Disorder other axis?
AXIS V: Global Assistant of Functioning Score: 30
Age: Adult
Medical Condition(s): _____________________________________________
Reason for Referral:
Emily Colas was brought to Psych Associates because she was completely unable to manage normal life. Her husband verified these claims; she was making life for the whole family extremely difficult.
Tests Administered/Test Scores & Interpretation/Behavioral Observations:
[There may be test results available, perhaps an intelligence test, neuropsychological battery, or MMPI (for example). These should be reported in some detail. If no tests are available, it’s common to describe the examiner’s initial observations and impressions of the client upon first contact.]
Client/Family Background:
As a teenager, Emily’s mother had a stomach illness that required surgery.
Emily’s mother manifested a sign of OCD when she continued to stroke a light switch that was apparent to Emily as already off.
Emily’s father and mother divorced.
[It may be important to know something about the client’s family. Have others had psychological disorders? If so, what kind and when? Is the family functional or dysfunctional? In what way(s)? Have there been any traumatic events in the family that may have precipitated the client’s behavior? Etc.]
Detailed Case History:
Symptom of OCD: The action of numbering spoken words pictorially as stars so they are in multiples of five.
In college, Emily suffered from a horrible drug habit, had a negative situation occur, after which she suffered with flashbacks for months, declaring that she would never take a pill again
Her first date with her future husband was normal enough; they met in a bar and went back to his house for poetry.
Emily described the repetition her dad would make in his daily eating of breakfast. This was a situational model that possibly contributes to her current behaviors.
Emily also detailed a time when she had uncontrollable thoughts about the dangerous histories of people she ran into in daily life. She thought her coffee seller was a serial killer.
Irrational thoughts in her early life of dating were revealed in her continual episodes of her boyfriend having to deal with her fears of contaminated food. The cause of this fear, as explained by Emily, was that she was at a party when someone joked that they put acid into some sugar cubes.
Her first time eating at her boyfriend’s house was punctuated by her dilemma of whether or not to eat his food. She thought that he might be trying to poison her.
Emily’s stays at summer camp were continually reported by her counselors to have been full of behavior that was excessively neat and orderly.
Emily has an intense fear of blood, bordering on Hemophobia.
Emily was worried over her past sexual history to an extreme degree because of her promiscuous previous boyfriend Randy. Even after repeated testing, she continued to get blood exams.
A concern over whether or not inappropriate thoughts made their way to her mouth was an issue of contention. She feared that she spoke nasty phrases and needed reassurance from others that she didn’t say what she thought she said.
The patient suffered an episode of anxiety over the possible growing her tongue so large that she would be unable to breath.
During college, Emily took a course in Abnormal Psychology, and, as a result, spent time volunteering at the local mental institution.
According to Emily, there was “no going back” after the point where she admits to her husband that she has a fear of food poisoning, and he agrees to taste-test her food.
Emily better explained a facet of her life than could be summarized. She said, “My husband and I moved around a lot. I have a short attention span. First we both stayed at his apartment. It was small and not “ours,” so we found a new place. We signed a one-year lease and everything was going smoothly until I decided that it was too small. We broke our lease and found a new place. We settled in, got a cat, then two, then my husband got asthma and he coughed a lot. We needed more space. We decided to buy. We had one year left in North Carolina, but we didn’t care. We broke another lease, bought a bigger place and put his study at the far end of the house. We stayed put until we moved to California. In the meantime my husband got a Ph.D., I went though a few jobs, [and] we had one kid… I hated Los Angeles, but we never changed apartments. My husband didn’t get any more advanced degrees, I didn’t get any jobs, but we did break our lease and have another kid. The next move was to Michigan. We fully intended to buy a house again, but needed time to look. We signed a six-month lease, found a place in two, broke the lease, and moved into our new house. I got antsy, made up some excuse like, “It’s too small,” and we sold the house. We rented a new place while we looked for a bigger one to buy. A few months later we separated. My husband got his own place…”(22-23). This long winded explanation better explains a major chunk of her history than a paraphrasing would. Her symptoms shine through, as does a framework of necessary historical events.
At five years old, Emily Colas used to throw up all the time. She would go into her parents’ room in the middle of the night and say she had to vomit, at which point she got attention and was helped by her parents to the bathroom. Her mother was stuck cleaning up the mess.
Directly after college, Emily worked at a substance abuse center as a counselor. This access to the medical world continued to feed her phobias of contamination.
Emily and her husband also visited a couple’s therapist at one point. This therapist blamed all problems on a past dysfunctional family. Emily and her husband thought he was not competent to help them.
Another incident of anxiety: Emily thought she had a flea living in her head.
At a dining out experience, Emily fears that the waiter will contaminate their food because he has bandages on his hand which means he had some type of cut which could leach out blood to the food he handled. Emily panics over this and makes her husband interrogate the waiter. Emily said, “I possess an endless capacity to keep a worry alive.”
The agreement of marriage of Emily and her husband took place in a general conversation where Emily wanted to get married, but her husband wanted to wait. She pesters, he relents, and they get married.
Another eccentricity involves Emily biting her lip to get to sleep.
On a seeming whim, Emily has the desire to become a mother, so she petitioned her husband, and they agreed to aim for parenthood.
Growing up, Emily was raised in part by a German nanny. This woman kept Emily on a strict schedule, reinforcing repetitive patterns in Emily’s neural networks.
Emily also developed a fixation of protecting her baby, going so far as to call a deodorant company to make sure the chemicals would not harm her child. After not getting a satisfactory response from the helpline, Emily decided to stop using deodorant. Emily grew to have a fear that maybe the baby she took home from the hospital was not her child. A possibly traumatic event for Emily occurred throughout her childhood when her dad would have her go around kissing frogs to make them turn into princes. One can see a later connection to a fear of germs.
[Here you provide whatever relevant information you have available as to how this disorder has unfolded and evolved. You may need to begin with events in the person’s childhood. Consider that you’re somewhat of a detective seeking and reporting clues regarding what illness this person has and why. A chronological order usually works best here, but you need to use your own judgment.]
Diagnosis (attach report sheet summarizing Axes):
Reason for Diagnosis:
[In this section you should summarize the key symptoms the client has exhibited and exhibits and explain why/how they have led you to make the diagnosis or diagnoses you make.]
Treatment Plan:
[In this section you should outline the kind of treatment you think the client should receive. You’re in much the same position as a teacher who has to lay out a lesson plan before teaching a class in school. What objectives do you want to reach? In what order do you want to reach them? What sub-goals may be involved? Most importantly, how are you going to achieve the objectives? If you recommend a psychotherapy, explain the kind and your reasons for preferring it over other alternatives. Explain how the therapy should be implemented. If you recommend medication, explain what and why.]
Prognosis:
[In view of the nature of the illness and the treatment plan you have offered, what kind of improvements do you think this client can achieve in the future, and why?]
Multiaxial Evaluation Report Form
Name Emily Colas Date____________
AXIS I: Clinical Disorders (use DSM numbers and names)
OCD
AXIS II: Personality Disorders (use DSM numbers and names)
Dependent Personality Disorder
AXIS III: Relevant General Medical Conditions
Rotoscoliosis, but possibly just bad posture.
AXIS IV: Psychosocial/Environmental Problems
Cutting
Trichotillomania Impulse Control Disorder other axis?
AXIS V: Global Assistant of Functioning Score: 30
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