THE TOPIC is F16.14 Alcohol Use Disorder
For this Benchmark Case Presentation Paper Assignment, you will create a case presentation to review, diagnose and provide treatment recommendations for.
Step 1: Choosing the Diagnosis
At the end of Module 3: Week 3 in the Quiz: Case Presentation Topic for Instructor Approval you will submit your request for the diagnosis on which you will base your case presentation. You must receive written approval from your professor to proceed with the case presentation. You will need to provide the full name and ICD 10 code for the diagnosis you are requesting, including any specifiers. Once you receive approval, you can begin to construct your case.
Step 2: Writing the Benchmark Case Presentation Paper Assignment
For this case presentation the following sections are to be organized using Level 1 and Level 2 APA headings:
Title of Paper
Part I: Intake Information
Identifying Data (approximately 1/4 page)
This section needs to include the following information exactly as listed here:
Date of Initial Assessment: Sexual Orientation:
Pseudo Name Race & Ethnicity:
Age: Marital/Relationship Status:
Gender: Employment Status/Grade Level:
Reason for Referral/Presenting Problem (approximately ½ page)
For example, you may provide a brief description of the client’s situation, signs of the symptoms of the disorder they are experiencing, how the signs of the symptoms are affecting major areas of life (functioning in relationships, employment, school, etc.). This section should be told in third-person narrative style, including some direct quotes from the client. In this section you will connect some of the symptoms in the DSM of the disorder by presenting corresponding signs (client report) of the symptoms.
This section should be clearly worded and sound like something you would expect a client to report. It should not be a listing of symptoms from the DSM; rather, how a client would represent their experience of the symptoms.
Example of language not to include in this section:
DSM: Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful).
Example of language to include in this section:
“I feel so sad all the time. Sad, empty and I cry at the drop of a hat. I have been at lunch with two different people since this started and I started crying uncontrollably, which was pretty embarrassing. I have never cried in public like that. And it just happened! This has been going on every day for about eight weeks… but it feels like it has been going on for years and I am starting to worry I will never feel happy or hopeful again.”
Not all signs of symptoms to support the diagnosis must be in this section, but there must be a strong foundation for the diagnosis. You will provide additional information to support the diagnosis in the “Mental Health” heading under “Psychological Assessment.”
Part II: Client’s Biopsychosocialspiritual Assessment (approximately 2-3 pages)
Below are points to include in your Benchmark Case Presentation Paper Assignment. Please use Level 2 APA headings to organize this section. The required information is as follows:
Biological Assessment
In paragraph/narrative form, discuss the following:
• Client’s Demographics (age, gender, sexual orientation, ethnicity, marital status, children, etc.)
• Sleep Habits
• Diet
• Exercise
• Medical History/Medication (including reason for medication)
Psychological Assessment
In paragraph/narrative form, discuss the following:
• Client’s Mental Health History (e.g. whether the client has been to counseling in the past, any psychiatric hospitalizations, and any previous mental health diagnoses)
• Trauma History
• Substance Use History (including description of client’s alcohol/drug use, patterns of use, and last use; as well as how often client uses and how much)
• Risk Assessment (including how the client’s risk was assessed)
• Family Mental Health History
Social Assessment
In paragraph/narrative form, discuss the following:
• Cultural Factors (e.g., does the client have any factors such as acculturation, discrimination, etc. that impact the client and may be source of signs, symptoms? How would the client explain the problem from their cultural lens?)
• Family of Origin (identifying information about the client, parents, and siblings [i.e., ages, occupations, etc.]. Client’s perception of the home environment and relationships within the family. Critical family incidents may be included.)
• Romantic Partner Dynamic (include any information about the client’s current relationship that would be helpful)
• Academic History (description of pertinent information in relation to educational background including academic achievement, school instances that were significant for understanding the individual and the client’s attitude toward education. Any assessment information would be helpful.)
• Occupational History (description of the client’s vocational history. Emphasis should be placed on current occupational functioning, history of work problems and reason for change. Quality of work and satisfaction and interests.)
Spiritual Assessment
In paragraph/narrative form, discuss the following:
• Spiritual/Religious History (any religious identity/affiliation/practice present?)
• Present Spiritual/Religious Beliefs (Does client believe in God? Attend church? What role does religious affiliation play in the client’s life? Are spiritual resources or issues important to client? How does client describe God? What is the state of the client’s spiritual awareness?)
• Integration Assessment (whether the client would like their spiritual beliefs to be incorporated into the counseling process? In what specific ways would the client like their beliefs incorporated (prayer, Scripture, spiritual discussion, etc.?)
Part III: Mental Status Exam (approximately 1 page)
This section should be a very brief overview of initial observations, perceptions, and impressions of the case presentation. Very briefly remark on anything that would support the diagnosis you are presenting (for depression you might comment on sadness, flat affect, or tearfulness…).
The following are required to be in the mental status exam:
o Presenting Appearance
o Basic Grooming and Hygiene
o Interpersonal Characteristics and Approach to Evaluation
o Speech
o Eye Contact
o Expressive Language
o Receptive Language
o Orientation
o Alertness
o Coherence
o Concentration/ Attention
o Thought Processes
o Hallucinations and Delusions
o Judgement/ Insight
o Intellectual Ability
o Mood
o Affect
o Suicidal and Homicidal Ideation
o Risk of Violence
A supplemental resource is provided with a list with more detail about the terms you must use. You can add from this list if appropriate.
Part IV: Answer Key (1/2 to 1 page)
As part of this Benchmark Case Presentation Paper Assignment, you will provide an answer key, to confirm that you have intentionally provided adequate information to support your diagnosis. Information under “Client’s Reported Symptoms” must be found earlier in the narrative of the paper. This Answer Key will include the chart indicating your client meets all the criteria for the chosen DSM-5-TR disorder. Be sure to include the full name and ICD 10 code for the diagnosis.
DSM-5 Diagnostic Criteria: disorder name and code number
Client’s Reported Symptoms:
Criterion A:
Criterion B:
Criterion C:
Criterion D:
Criterion E:
Criterion F:
Part V: Treatment Considerations (approximately 1 page)
Two Counseling Approaches: Choose what you think is the most important issue to address in the case and provide two counseling approaches. You will need two peer-reviewed journal articles that are not more than 10 years old to support your recommendations and the rationale for why each treatment approach was chosen for this client/symptom. Please make sure you provide recommendations that are counseling focused, e.g., what would you as a counselor do with this client in your office? Any case management (medication evaluation, etc.) can be noted but does not suffice as the treatment recommendation.
Medication Considerations: Discuss whether you would refer the client for a medication evaluation and discuss why or why not. If you would refer, provide a brief discussion of the research regarding the use of medication for this diagnosis. If not, provide the research that shows there is limited effectiveness for medication for the diagnosis. For example: which symptoms would be the most likely to benefit from the use of medication? What broad classification of medications might be prescribed (e.g., anti-anxiety, anti-psychotic, mood stabilizers, etc.)? Be sure to provide at least one scholarly reference to support your discussion.
Spiritual Integration Considerations: Based on the client’s spiritual/religious identity, in two to three sentences, discuss whether you would include any spiritual integration with this client. If so, how might you incorporate spiritual integration? If not, provide the rationale for why integration would not be used.
The Treatment Recommendations will be the final section of the Benchmark Case Presentation Paper Assignment.
This Benchmark Case Presentation Paper Assignment should be 7-10 pages long, excluding the title page and reference page. Use current APA format. No abstract is required.
This Benchmark Case Presentation Paper Assignment requires a minimum of 4 resources (the DSM-5-TR included as one of the four) from peer-reviewed journals that are less than 10 years old. You may use textbooks, but they will not count towards the required resources. You may not use web site or other non-professional literature.
