Psychosocial Case Study Examples

Psychosocial History
The client, Bridget, who is a 17-year-old college freshman, was sent from the University Counseling Service. The referral stated that she was very sensitive to emotional triggers and her stimulation has a slow return to normal. She started cutting herself in high school after breaking up with a boyfriend. She has started drinking in order to deal with her anxiety as well. However, her mother was a heroine addict. She was sexually abused as a child and CPS took her away from her mother at age 7. After that, she had been in foster home for 2 years, before she was adopted at age 9. Her adopted mother died of cancer when she was 15-year-old. Then her Dad sent him to Boarding School in Carmel, CA. However, she has been deceitful and dishonest by lying constantly and deceiving others for money or other favors. Also, she stated

that she has been had feelings of jealousy for male typical example, and he has wanted to be treated as a man since last month ago.
Presenting Problem
The client, Bridget, has been very sensitive to emotional precipitate and her aroused has a slow return to normal.
Case Conceptualization
The client, Bridget, is 17-year-old who was sexually abused as a child and her mother was a heroin addict and she has a history of cutting herself, drinking and manipulating others for money or favors.

Her attitude toward people who were manipulated by her as a “Chumps” is very notable. She stated that they deserve to be her victim because they are stupid. Although she feels that way about these people, she has an extreme reaction by crying for a week for an incident in her dorm for another student. However, she just wants to talk about herself and her own pain and not even talking about anything else and has become very self-observed in the last session while she was 20 minutes late. On the other hand, She had a fight with her roommate in which the Campus Police got involved, because her roommate borrowed a scarf that she got from her mother. Also, she doesn’t know who she is and she feels that several different people are in her body. She believes that cutting, which makes her to calm down, is better than drinking because it doesn’t affect her grade, while she thinks she has ADHD and asks for medication such as

Adderall.
The defense mechanisms that she uses are acting out, projection and dissociation. She uses acting out by cutting herself in order to reduce her anxiety level and her emotion. Also, she uses projection to avoid her own undesired thoughts and feelings. She tries to throw her feelings and thoughts to the therapist by accusing the therapist for not caring about her and just caring about the money. The last defense mechanism that she uses is dissociation in which she thinks she has “several different people all rolled up in one body”. Because of her sexual abused history, she uses dissociation in order to cut herself off the moment and real life. She mentions about her jealousy toward male gender which can cause by her defense mechanism and her sexually abused memory.
Deferential Diagnosis DSM V
1. F60.3 [301.83] Borderline Personality Disorder
She has most of the BPD symptoms such as her perpetual crisis of mood and behavior from being so emotional to being cold hearted to others, having insecure self-image by mentioning about her desire to be treated as a man, rapid mood, which lead to anger toward her therapist that is inappropriate and uncontrolled. Considering her strong rejection to the therapist while she was in the therapist’s favorite’s coffee shop tomorrow morning is another symptom of this disorder.
2. Substance Use Disorder
She mentions about how drinking could help her to overcome her anxiety. She even asks for the medication such as Adderall, which is stimulated medication for ADHD. Her rapid mood changes could be cause by substance use.
DSM V Diagnosis
F60.3 [301.83] Borderline Personality Disorder
I diagnosed her with Borderline Personality Disorder in which she fits on most of the symptom in this criterion. Her constant mood and behavior crisis, having insecure self-image by attaching herself strongly to others, and then rejecting them the same way, while trying to avoid abandonment are all symptoms of BPD.