DSM 5 Case Conceptualization

Description

The assignment deals with a hypothetical that requires knowledge of the DSM-5 diagnoses along with possible incosistencies and supporting reasoning.

Case of Adam Archer (AA)
History
AA was born at 37 weeks gestation after a pregnancy marked by high blood
pressure and rupture of membranes during an amniocentesis at 16 weeks
followed by bed rest. Early motor milestones were normal. He began to use
single words at 12 months, but between 16 and 22 months showed a gradual
regression in communication and social skills. Eye contact decreased, play skills
and imitation declined, and he lost the use of many of his words. Testing at 24
months showed cognitive skills at the 10-month level and language skills at the 7month level. He showed a lack of interest in interactive play, hand flapping and
other repetitive behaviors, staring off into space, and he was described as
remote from familiar people. He would occasionally poke himself in the eye, bite
his hands, or carry around an object in each hand. He received the diagnosis of
PDD-NOS from a pediatric neurologist and a child psychologist, both of whom
specialized in autistic disorders. From the age of 2–7 through 5 years, AA was
involved in an intensive Applied Behavior Analysis (ABA) program with additional
occupational and speech/language therapy. By age 3, he was able to follow
some two-step directions. By 3–5, he was using 2-word phrases and by 4 years he
was speaking in full sentences and asking ‘wh’ questions. He began to initiate
play with another child at 4 years and pretend play emerged at 5 years. AA
attended an ABA-based integrated preschool for 2 years and was included in a
typical kindergarten for the following 2 years, from age 5–8 through age 7–6; he
then transitioned to a regular first grade.
Medical History
AA’s history was significant only for recurrent ear infections. From age 3–6 to 5,
he was on a gluten and casein-free diet, which parents felt was associated with
an increased rate of language development and firmer stools. One dose of
secretin had no effect on his behavior. Sleep, appetite, vision, and hearing were
normal. Mother reported that fevers were associated with fewer atypical
behaviors and better conversational ability.
Current Presentation
An evaluation at age 6–8 that included cognitive testing showed nonverbal
ability in the borderline range and verbal skills in the average range with his
lowest ability in the area of Arithmetic. Vineland Communication was average
but Daily Living and Socialization were low for his age. He showed age
appropriate toy play, greeting, sustained eye contact with the examiner, and
separation from mother. He was consistently interactive but his high activity level
and impulsivity interfered with his social exchanges.
He engaged in some limit testing (flopping to the floor, attempting to leave), but
he responded well to limit setting, rules, and a reinforcement schedule. He was
motivated by social praise and showed pride in success, but gave up easily
when tasks became difficult. He needed ongoing prompts to stay on task and
was highly distractible by external stimuli. Hand flapping and pacing were seen
when he became agitated. Mother described immature relationships with
peers; although he engaged in reciprocal pretend play with peers, his
impulsivity and difficulty with perspective taking interfered with sustained play.
His fantasy play was often creative and novel, but tended to focus on
aggressive themes, sometimes in a perseverative manner. When very excited,
he would sometimes still jump and flap his hands. Joint attention was good, and
he was attuned to others’ emotions, although his responses were on some
occasions prosocial and on others immature and ‘silly’. On interview, his mother
stated that AA failed to give close attention to details, had difficulty sustaining
attention, sometimes did not listening when spoken to, had trouble following
through on or organizing tasks, frequently lost things such as gloves and hats at
school, and was easily distracted and forgetful. AA’s classroom teacher, Mrs.
Cash, indicated that he was often fidgeting, leaving his seat, and had difficulty
playing quietly; she reported that AA also talked excessively, had difficulty
waiting his turn in the playground, and interrupted his classmates daily. The
school counselor also reported that AA had poor peer relationships
characterized by immaturity and impulsivity rather than aloofness or ‘onesidedness,’ as well as occasional perseverative play (but marked by impulsivity
and aggression) and rare motor stereotypies (jumping and flapping) when
excited.
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DSM 5 Case Conceptualization
1) Please provide one or more DSM 5 diagnoses for this case using the categorical
system. Please include the specific name(s) and/or subtype.
DSM 5 – V Code
Diagnostic Category
2) Please describe the observations that support each diagnosis in #1. Be sure to
cite evidence from several of these sources: (a) the clinical file (case history), (b)
you online research/DSM, (c) your class notes, and (d) your Kring Abnormal
Psychology textbook.
3) Please describe any clinical evidence that seems to be inconsistent with your
Axis I or II diagnoses – i.e., symptoms that might suggest a different DSM
diagnosis other than the one(s) you listed above.
DSM 5 Case Conceptualization
Carla describes this treatment in detail in the following VIDEO.
http://faculty.fortlewis.edu/burke_b/Abnormal/Abnormal%20Cases/ABNORM
AL%20PSYCHOLOGY%20Cases%202013-Carla.pdf
1) Please provide one or more DSM 5 diagnoses for this case using the categorical
system. Please include the specific name(s) and/or subtype.
DSM 5 – V Code
Diagnostic Category
2) Please describe the observations that support each diagnosis in #1. Be sure to
cite evidence from several of these sources: (a) the clinical file (case history), (b)
you online research/DSM, (c) your class notes, and (d) your Kring Abnormal
Psychology textbook.
3) Please describe any clinical evidence that seems to be inconsistent with your
Axis I or II diagnoses – i.e., symptoms that might suggest a different DSM
diagnosis other than the one(s) you listed above.

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