Wk3 Discussion Diagnostic Conceptualization

Case Study: Jane

Jane is a withdrawn, 35-year-old Caucasian female from the Midwest who attended 1 year of community college while in her 20s. When asked about her religious and spiritual beliefs and practices, she says, “If there were a God, he wouldn’t have let my life turn out this way.” Jane expresses some interest in Buddhism; she would like to learn more about this religion and “develop her spirituality.”

She has lived with her mother her entire life and has struggled to maintain stable friendships. Jane’s relationships have been tumultuous and often end with people pushing her away as they increasingly perceive her as being “needy” and “depressing.” She describes a pattern of relationships that begin with an intense feeling of connection, yet end with her feeling victimized and rejected. She often lashes out in anger as these relationships begin to unravel, and she even slashed the tires of one friend after that relationship ended. She has identity struggles, and it is difficult for her to describe herself, her interests, beliefs, values, and hopes for her future. She tends to take on the interests of the people with whom she is associating with as her own. In talking with her, she is negativistic in her thinking; she often sees the world in black-and-white terms.

As a child, Jane experienced an extensive sexual abuse history by both her older brother and her father’s best friend. Jane does not believe that her mother was aware of the sexual abuse she experienced, and to this day Jane has maintained these “family secrets.” Jane was repeatedly and violently sexually abused from the age of approximately 4 to about 14, when her brother left the home. Adding to her shame and confusion is the fact that her older brother now works as a high-ranking military general and is what she calls the “family hero.” In her family, Jane received the message that women were less valued than men. She witnessed her mother being physically and emotionally abused by her father until his death when Jane was 18 years old. Jane has internalized the family belief that her brother is special, makes excuses for his abuse of her, and expresses no anger toward him. Jane indicates that she is leery of most men, and she generally only seeks relationships with women. She has never had any sexual or romantic contact with men or women, and the thought of doing so makes her feel exceptionally anxious.

Since she was about 20 years old, Jane has engaged in severe self-injury. She has had upward of 15 stitches during various incidents in which she has self-injured. She also sometimes bangs her head against the wall, and she will burn herself using bathroom cleaning chemicals. Jane self-injures about three times per week. Jane’s self-injury is typically precipitated by either conflicts with her mother or people with whom she works; feelings of loneliness and emptiness that sometimes overwhelm her, especially when she has unstructured down time; or flashbacks and intrusive memories of her past sexual abuse.

Every few months, Jane experiences what she calls “dark times” when she is overwhelmed by feelings of sadness and hopelessness, during which she spends her weekends in bed. She denies having made any suicide attempts since her teen years; however, she regularly wishes she were dead and fantasizes about suicide.

Jane also has a history of bulimia that ensued from the age of 13 until she was about 23. As her bulimia dissipated, the rate at which she self-injured increased. She refers to herself as “the original self-injurer” and takes pride in her knowledge of the topic. Jane has read a great deal about self-injury and has even shared her story with a local newspaper that published a story on the topic.

Jane also has asthma, and she is able to induce asthma attacks, which result in her making frequent trips to the emergency room at her local hospital. She has been to the emergency room at least twice a week for the past year, and she only feels “safe” and “loved” when receiving medical treatment at the hospital. Jane is especially fond of a female medical intern with whom she perceives she has made a special connection over the past few months.

Jane has spent the past 2 years in counseling. She refers to her counselor as her “surrogate mother.” Jane used the internet to find her counselor’s home address, and she used to drive by the counselor’s house when she felt agitated and needed to self-soothe. Jane also secured her counselor’s phone number and would frequently call her at home, resulting in the counselor setting firm boundaries with Jane around out-of-session contact. Jane was initially angry when her counselor set these boundaries, and she left treatment. Eventually Jane settled and returned to treatment.

Four years ago, Jane was fired from her previous job because she self-injured at work with a box cutter after an altercation with a colleague. Despite Jane’s interpersonal struggles, she has maintained employment at a factory for the past 4 years. She reports that some of her colleagues are hostile toward her and she has occasional conflicts, but for the most part her job is stable. She perceives that working in an all-male environment is adaptive for her, as she isolates herself from her colleagues and rarely has a need to interact with them.

Jane is intelligent and creative, enjoys photography and nature, and has a passion for taking wildlife photos, but recently she has not been engaged in this activity. She is also intermittently involved in a wildlife photography club in her community. She is interested in possibly returning to school to earn a graphic arts degree, but her mother has been discouraging, stating that she “does not see the point in it.” While she describes her relationship with her mother as “cold,” Jane’s mother, in some ways, serves as a source of support. Jane also has occasional contact with a friend from high school whom she admires and respects. Jane is able to seek help and support, and she is quite knowledgeable about many of the issues with which she struggles. She presently takes Paxil as prescribed by her primary care physician.

Diagnostic Conceptualization Template

COUN 6720 DIAGNOSTIC CONCEPTUALIZATION TEMPLATE Page 2 of 2

ICD-10 codes — important

The ICD-10 code is the code that helps identify a diagnosis. It is typically used for insurance reimbursement purposes. In your DSM-5, you have two sets of codes listed, ICD-9 and ICD-10. For purposes of diagnosing and our class, we will only be using ICD-10 codes. Those codes are listed in parenthesis and they typically begin with the letter F. So, for example, let’s use Disruptive Mood Dysregulation Disorder. The diagnosis would look as follows: Wk3 Discussion Diagnostic Conceptualization

F34.8 Disruptive Mood Dysregulation Disorder

(Always list the ICD-10 code followed by the title of the disorder and any relevant specifiers).

In your DSM-5, you will notice there is a section called “Use of the Manual.” In this section, you will find a subsection called “Elements of a Diagnosis” and then another subsection called “Coding and Reporting Procedures.” This last subsection, “Coding and Reporting Procedures” helps explain the role of the ICD-10 code. ICD-10 codes are simply a part of a DSM-5 diagnosis. The codes are the numerical value that corresponds with the diagnosis. You are not using them instead of the DSM-5 written diagnosis; rather, the ICD code is an element of your diagnosis. All diagnoses have two parts: the ICD-10 code and the corresponding name of the disorder (see my example above for disruptive mood dysregulation disorder). Wk3 Discussion Diagnostic Conceptualization

Your manual contains two sets of codes: ICD-9 and ICD-10 (when DSM-5 was published in 2013, the US was still using the ICD-9 coding system). In October 2015, we switched to ICD-10. So, moving forward, only use the ICD-10 coding, which will always be located in parenthesis for each of the diagnoses listed in your manual.

Again, check out the “Coding and Reporting” section of your DSM-5 for additional detail on this.

When formatting your diagnosis, it should always look like this:

ICD-10 CODE – Full Name of Diagnosis

Here is another example. Note—do not include parentheses before or after the ICD-10 code. Simply list the ICD-10 Code and then the diagnosis name:

F93.0 Separation Anxiety Disorder