STEP 1: Review the Case Report
Psychological Case Study
Gender: Female Education: Highschool Graduate
Ms. Smith is a 32-year-old biracial, female, who has completed high school and is currently employed as a waitress. Ms. Smith was taken to the hospital on
3/18/2019 by local police, who found her screaming, pacing, and weeping inconsolably outside of a local apartment building on 5th Street. Apartment
residents called police to the scene, concerned by the disturbance Ms. Smith was creating.
Captain Logan, with Fire and Rescue, arrived second on the scene and treated Ms. Smith for multiple cuts on her arms. Exhausted by apparent despair, Ms.
Smith conveyed she moved to town one month earlier from Memphis, TN, looking for a new start. She met her boyfriend, Frank, six days after starting her
new job, and they have gone out six times. According to Ms. Smith, “Frank is my destiny, he has to love me as much as I love him!” Officers at the scene learn
that Frank, hours earlier, told Ms. Smith he never wanted to see her again and that Ms. Smith has a restraining order against her in San Diego, CA.
Ms. Smith has been referred to Dr. Liam for psychological evaluation due to immediate concerns for risk of self-harm.
Currently, Ms. Smith, reports that her head sometimes feels numb and that her thoughts are confused. She is experiencing incredibly strong feelings of fear,
seeing herself as being abandoned and alone in a strange new town. She self identifies as a passionate woman capable of foolish things that she is
sometimes sorry for, to include unprotected sex with multiple partners before meeting Frank.
When interviewed by police the day Ms. Smith was escorted from his apartment complex, Frank reported that Ms. Smith’s behaviors toward him rapidly
became impulsive and demanding after their first date. At first Ms. Smith was charming and thoughtful. She would surprise him with small, simple gifts (e.g.,
movie tickets). She then started to send affectionate text messages every half hour. The nature of the text messages quickly shifted from casual and flirty to
strong expressions of passion and love sent every 10 minutes. When Frank did not respond to these messages, in frequency or kind, Ms. Smith would
suddenly ignore him or lash out.
When asked about this behavior, Ms. Smith reported she regretted her negative actions towards Frank immediately after she did them, experiencing regret or
panic after lashing out. Having been in many relationships before, that according to her, ‘did not work out,’ Ms. Smith could not stand the idea of Frank, her
perfect love, seeing her as unkind.
Now that Frank has broken up with Ms. Smith, she feels empty, powerless, and worthless. She attributes this sorrow as the reasons behind her sudden mood
swings. Her thoughts and emotions stray between extreme agitation and a compulsion to act out to apathy and a desire to withdraw.
Ms. Smith’s mother, Helen Taylor, and father, Jake Smith, were both heroin addicts. Her mother claims she did not use drugs while pregnant with Ms. Smith,
attributing the life-style change to having completed rehabilitation two months prior to becoming pregnant. During the pregnancy, Ms. Taylor did not seek
prenatal care due to a fear of doctors and a lack of financial security. At delivery, Ms. Smith reports she thinks she was a normal, healthy infant.
Ms. Smith reports that her mother, Ms. Taylor, was not interested in being a mother and abandoned her to the care of Mr. Smith when she was 8-months old,
upon his release from jail, following incarceration for stealing a wedding band to wed Ms. Taylor.
Growing up, Ms. Smith had two older half-brothers, and one younger half-sister. Her mother had multiple relationships prior to meeting Mr. Smith and is the
mother of Ms. Smith’s brothers. Ms. Smith’s half-sister is the child of her father and stepmother. Ms. Smith lived with her father and stepmother until she was
18 years-of-age. The years between 2 and 8 she describes as the most influential. She struggled with confusion as to why her mother did not want her and
why her stepmother ignored her. She also suffered malnutrition due to lacking food in the home.
Between the ages of 7 and 17, Ms. Smith continued to lack food and emotional security. She also withdrew into bouts of self-loathing and wishing for a
permanent out for her mental, emotional, and physical suffering. Her father’s moods were unpredictable, and her stepmother hit her frequently. Ms. Smith
reports that no longer what she did (skipped school, brought home straight A’s), her stepmother expressed upset towards her. Owning one pair of jeans, four
shirts and one pair of shoes by the time she turned 18, Ms. Smith was sensitive to the judgement of others. In middle school and high school, she was overly
self-focused and overreacted if she sensed a hint of judgement or rejection from others. This reactance often led to sudden moments of violence (fights,
throwing objects, verbal assaults) against those Ms. Smith felt wronged by. During this period, Ms. Smith also took up the use of alcohol to counter regrets
for her negativity towards others, and the wallowing emotional pit of nothingness she sometimes found herself in.
Ms. Smith did disclose a family history of mental health challenges and anger management issues, though most she attributes to illegal substance use
difficulties. Ms. Smith says she has worked with multiple therapists over the years but has not had luck finding one who understands her enough to bring
about change. Reportedly, Ms. Smith was not athletic as a child or teen, but was good at art, music, and writing. She participated in band until her stepmother
made it impossible for her to make it to band practice on time, making her miss the morning school bus.
STEP 2: Draft a Case Conceptualization
Apply cumulative knowledge from this course and others (i.e., abnormal psychology) to diagnosis Ms. Smith, support your diagnosis with evidence from the
case and recommend further assessment and treatment options. Your paper should consist of the following sections:
Part I: Reason for Referral
What was the reason for the referral?
What sources of data do you have and need?
Part II: Background Summary
Family/Social, (supports) Include ethnic/racial/cultural
Part III: Assessment Data
1. In addition to a good diagnostic interview, what assessment tools would you recommend using to aid in giving an accurate diagnosis and developing a
Part IV: Tentative Diagnosis
Select a diagnosis using the DSM-5
Defend which diagnosis/diagnoses are possible using specific examples from the case.
Part V: Treatment Recommendations
Consider which treatment would be the ethical choice (community, group, referral to a forensic psychologist, psychiatrist, physician or for a neuropsychology
Provide one or two Evidence Based Treatment recommendation for the diagnosis given. Be sure to cite the source that helped you to determine the best
Evidence Based Treatment for this diagnosis.
Part VI: Considerations
Clearly present your analysis of developmental, sociocultural, and ethical considerations that contribute to the diagnosis and treatment recommendations
Part VII: Conclusion
Conclude with a summary of your findings.
Part VIII: References
Your paper should be 6-8 pages in length. Use APA style headings and subheadings, double-spacing, an appropriate serif or sans serif font (e.g., Times
Roman12-point; Arial 11-point; Calibri 11-point), one-inch margins (left, right, top, and bottom), page numbering, and logical flow from topic to topic. Write
with clarity, paying attention to spelling, grammar, and syntax.
While a typical Case Conceptualization would not contain a reference section, you will include one here to demonstrate good practice in correctly attributing
and citing the ideas of others. Please also include in-text citations as appropriate.
Consult the UMGC Citing and Writing Guide, for proper form of APA Style in-text citations and references.
Please reference the rubric accompanying this assignment for scoring details.