DIAGNOSTIC REPORT AND REVIEW
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Diagnostic Report and Review
Reilly Walsh
University of Oklahoma
Chad V. Johnson, Ph.D.
Diagnosis in Human Relations Counseling
HR-5483-992
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Identifying data – 22-year-old female, tense
Chief Complaint – “My mood swings are so severe that my relationships are falling apart, and I
feel like I’ll never be able to control them.”
Informants: The client reported preliminary information with additional information from her
sister. The parents could not be reached.
History of Present Illness: The client went in depth about her past issues with mental illness and
noted that it all seemed to culminate around age 11. As a young child, the client was quite happy
with life. The client was very outgoing and brought much positive energy to the world around
her. The client discussed how she never seemed to connect with her parents and didn’t feel like
any of her thoughts mattered. As she got older, the client became more distant and began to lash
out whenever her parents questioned her avoidance of family gatherings. As she entered her
teenage years, she became increasingly removed from her life and found little excitement in
anything. The client was introduced to alcohol at age 14 and started drinking religiously. The
client notes that this was a way to escape the world and ignore her problems, but it was never
enough. The drinking became more severe, and soon enough, the client went to school severely
hungover, resulting in her grades plummeting. The client would see the counselor every other
day to figure out the roots of her issue, but it never got anywhere. Eventually, the client was
suspended because she missed school for three days straight. The client returned to school the
following week and was assigned a counselor to check in with her throughout the day. The client
would occasionally experience a significant burst of energy and act erratically concerning her
friends and family. During these episodes, the client reported talking a mile a minute and being
unable to focus on the tasks in front of her. The drinking would subside during this period but
quickly return as the episode ceased. These spurts became increasingly common, lasting roughly
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a week each time. The week(s) following her episodes, the client would crash and struggle to get
out of bed. The client would be late for school almost daily, and the subsequent decline in grades
affected her self-esteem. The depression only worsened as the client finished the rest of high
school. The client could not develop a healthy sleep schedule and would fall asleep during
lectures. The client began eating irregularly throughout the day, with her usually sleeping
through lunch. There would be days when the client would eat at every chance she got, while
other days would see her eat almost nothing. During this time, the client got her first job, and the
stress from work would often carry over into her personal life. The client was quiet at work,
often avoiding those around her who tried to communicate with her. Those who did manage to
talk to her struggled to understand what she said, and the client would push them away out of
embarrassment. The client recently started talking to a coworker and has grown fond of him. He
has noticed her struggle to communicate and put the idea in her head of receiving professional
help. The client utilized a recent episode to get herself out of the house for counseling.
Personal and Social History: The client was born in Boise, Idaho. The client has an older sister
and parents who have since divorced. Soon after being born, her family moved to Reno, Nevada.
The client remembers most of her childhood happening here and recalls liking her neighborhood.
The client has a close relationship with her sister, which got stronger when her parents finalized
their divorce. The client spent most of her time hanging with her sister and remembers coming
home to find their parents passed out drunk often. The client’s sister always said they were tired
from work and only recently told the client the truth. The client only noticed how often it was as
she entered her teenage years.
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The client moved in with her aunt when she was 15, noting that it was the best
environment for her to handle her drinking issues. The client had to give up all her alcohol and
says this was the most challenging period of her life mentally. During this time, the client’s
mental struggles were coming into full effect, which significantly strained her relationship with
her aunt. At one point, the client was taken to a psychiatric hospital due to her self-destructive
thoughts and erratic episodes. After three weeks of treatment and counseling, the client returned
to her aunt. The client resented her family for a long time, often blaming her issues on their lack
of care. The client remained here until she was 19. The client reported moving out to live with a
close friend from high school and has been in this situation since. During this time, the client
also began receiving help for her alcohol abuse.
The client graduated high school and turned down college as she felt it would be a waste
of time. The client found a job at a factory that paid well before graduating but has since
regretted passing on college. The client has worked at this job for five years and notes that she
has thought about her future a lot over the last few months. The client reported wanting to
overhaul her life and start fresh somewhere else but needs more motivation. The client also noted
that her mood swings make it hard to get anyone on her side for encouragement. The client had
had enough of the conflict and talked it through with her sister, who recommended she get
therapeutic assistance.
The client noted a crush she had on a friend but recognized that her mental health was
making it difficult to delve into it further. The client discussed having a family one day and
believes she could be a good parent. The client did bring forth some concern regarding her
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parent's method of raising her, noting that she didn’t want to end up like them. When asked what
she feared the most, she stated it was a fear of failing those she cared about.
The client discussed her ways of reducing anxiety, including reading and walking. Aside
from this, the client noted having difficulty getting motivated and would usually get most of her
energy from her manic episodes. The client expressed interest in volunteering and thought
therapy could be the middle ground she needs to explore further. The client noted being open to
starting a new medication but clarified that she wanted a better explanation of her illness before
committing to it.
Past Medical History: The client reported a concussion at age seven after falling off a swing set.
While this had no lasting effects on her health, the client was out of school for a few weeks. As
mentioned, the client received psychiatric help and counseling at age 15. The client was in the
hospital for around a month and noted a significant change in her self-esteem. The client was
prescribed Zoloft for her anxiety and depression but quickly lost interest as her parent's marriage
became more strained. The client later attended AA meetings for her alcohol abuse and received
individual counseling on days without meetings. The client reported that today was the first time
she had seen a counselor since her alcohol treatment. The client has never attempted suicide but
noted a history of self-destructive thoughts and behavior.
Family History: The client stated that her relationship with her mother had been strained for a
long time, and she had not spoken to her dad in years. Recently, the client noticed some signs of
healing but is still reluctant to forgive her mother and refuses to contact her father. Her mother
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has shown signs of severe anxiety and struggled with alcohol abuse throughout the client’s
adolescence. The client only remembers her sister receiving any form of counseling. Her mother
was adamant that her issues weren’t a big deal, and her father was notoriously against therapy,
often criticizing her older sister for receiving it. The client reported feeling guilty for pushing her
family away but knows it wasn’t her fault.
Mental Status Exam: The client appeared clean and organized for the session. The client’s eyes
looked tired, but she was alert and responsive. Her tone was sometimes reserved, and she noted
nervousness about the new environment. The client spoke comfortably about her struggles and
seemed to acclimate quickly. Her leg would tap occasionally, but it was never a distraction.
When asked about her mood swings, the client reported that she was usually quiet but would get
triggered by random things and start acting out. The client mentioned that she was used to feeling
down and would get anxious when people would talk about her. Her manic episodes were few
and far between but wore her out significantly. The client recalled putting a sock in her mouth as
a kid so she wouldn’t lose her breath from speaking so much. The client was eager to mention
that her last manic episode was a few days prior, so she was more comfortable attending today,
knowing she was too worn to have one start again. The client also discussed having an extra
pillow to hug at night for comfort and that she felt more grounded as a result. Otherwise, she
would be restless and struggle to fall/stay asleep. She elaborated further, stating that having
someone there was comforting if she didn’t have to talk to them. The client noted that her
anxiety was relatively high before today’s meeting, but talking about her family helped get her
mind off it.
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FORMULATION
Summary: The 22-year-old client reported sadness surrounding her mood swings, dramatically
impacting her ability to form and maintain meaningful relationships. The client’s past struggle
with motivation and alcohol has played a significant role in her development as an individual.
The client has a strong relationship with her sister, but all other family connections are severely
strained. The client has a job but longs for something more and hopes to gain more insight into
healthy living by attending therapy.
Differential:
296.42 (F31.12) Bipolar I Disorder, Moderate Manic Episode. The client shows significant mood
swings and erratic behavior that are not severe enough for hospitalization but substantial
sufficient to impede daily life.
305.00 (F10.10) Alcohol Use Disorder, in full remission. The client has a history of alcohol
abuse, which is not a current issue. Past influences still affect the client, so the risk remains a
concern.
296.32 (F33.1) Major Depressive Disorder, Moderate. The client experiences severe lows
regularly and often feels little motivation to do anything outside work. Depending on the
severity, eating and sleeping habits can be significantly altered but never life-threatening.
300.02 (F41.1) Generalized Anxiety Disorder. The client experiences anxiety regularly that
interferes with her ability to address things adequately.
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Best Diagnosis:
296.42 (F31.12) Bipolar I Disorder, Moderate Manic Episodes
Contributing Factors:
The client has a history of alcohol abuse, but nothing in recent years has pointed to it being a
significant issue. The client’s mood swings significantly impact her well-being, and depression
seems to fall as a byproduct. Without mood swings and manic episodes, Major Depressive
Disorder would fit the symptoms more fluidly.
Further Information Needed:
Lack of input from the parents greatly limited the perception of the issue. More information
would be needed to fully grasp the history of mental illness in the family tree. The client presents
clear signs of illness, but a deeper dive into her family’s past could provide some closure.
Treatment Plan:
Begin regular therapy sessions once a week to address symptoms and develop new habits.
Refer the client to a psychiatrist for further medication discussion.
Look into group therapy if individual therapy does not fulfill all the client's needs.
Prognosis:
Regular therapy will build a routine for the client to effectively treat her illness and open the door
for deeper insight into her past. Medication will help regulate irregular brain activity and
improve the client’s stability to work through her symptoms. Group therapy could provide an
alternate perspective from those who struggle with similar issues and allow the client to form
relationships in a controlled environment.
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Roadmap for Diagnostics
Level I. Gather a complete database:
Information was limited due to the lack of parent involvement, but medical and personal history
proved invaluable in guiding the process. The client was open and honest when discussing their
history and their feelings.
Level II. Identify syndromes:
Notable syndromes found throughout the diagnostic process were depression, anxiety and
alcoholism, and mood swings.
Level III. Construct a differential diagnosis:
After reviewing the client’s symptoms, the following diagnoses were proposed:
296.42 (F31.12) Bipolar I Disorder, Moderate Manic Episode
305.00 (F10.10) Alcohol Use Disorder, in full remission
296.32 (F33.1) Major Depressive Disorder, Moderate
300.02 (F41.1) Generalized Anxiety Disorder
Level IV. Using a decision tree:
After thorough analysis, a Bipolar Diagnosis had the most foundation concerning the symptoms
present.
Level V. Identify other diagnoses that might be comorbid with your principal diagnosis:
Major Depressive Disorder does seem plausible regarding various symptoms, including Low
Self-Esteem, little joy in doing things, etc. Generalized Anxiety Disorder would also be
comorbid due to the following symptoms: Anxiety, trouble sleeping, difficulty concentrating, and
avoiding social situations.
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Level VI. Write a formulation as a check on your evaluation:
After thoroughly analyzing the client’s symptoms, history, feelings, and mental state, I am
confident in a proper diagnosis of Bipolar I Disorder with Moderate Manic Episodes due to the
client’s behavior and subsequent struggles brought on by that behavior. Further therapeutic
endeavors will allow for the review of symptoms and necessary updates to client care.
Critical Reflection of Strengths and Limitations
When working through a diagnosis with a client, it is vital to ask the right questions at the
right time. An hour seems like sufficient time to gather necessary information from a client until
it is happening. I found that getting the client comfortable resulted in deeper conversations,
which took up considerable time. I understand the importance of getting the correct information
to begin the recovery process, but I also know how crucial it is for the client to feel heard. I can
empathize very well, which helps the conversation(s) feel more natural. However, this comes at a
cost, as some people want a punching bag, not a boomerang. Being able to adapt to either
situation quickly will benefit the outcome significantly.
Working around a client’s mental and emotional state can prove challenging, but it is all
grounded in something purposeful. Some issues overlap, and it is essential to break them down
to their roots to resolve them appropriately. Acknowledging the reality of a problem while
hearing their perception makes it easier to follow the thought process and build a plan. Therapy
is an invaluable tool that we can use to shape others’ thoughts and behaviors in a positive light.
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Taking on so much pain isn't easy, but it creates room for change and growth. Giving up a part of
ourselves can go a long way for someone else. We could all gain from reaching out to those in
need and knowing how to make a difference. Everyone experiences highs and lows, but they
don’t have to do it alone.
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Sources
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Arlington, VA: American Psychiatric Publishing.
Morrison, J. (2014). Diagnosis made easier: Principles and techniques for mental health
clinicians (2nd ed.). New York: Guilford Press.