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Assessment and Diagnosis in Psychotherapy Essay

A 30-year-old Caucasian female S K was referred by her primary care physician to our outpatient clinic with complaints of : extreme worry, stress, difficulty to concentrate, a lot of anxiety and thoughts. She had also been unable to sleep for the past one month. These symptoms were her first and were as a result of a divorce with her husband. She had reportedly not felt as bad before. She denied panic attacks but admitted to experiencing excess worry. Assessment and Diagnosis in Psychotherapy Essay. The husband left her with three children for another woman and she was worried that her job was well paid to support her with the children. For approximately four months, she has persistently been in court about the divorce and has used a lot of finances to seek support for the children from her divorced husband. SK denied delusions, homicidal and suicidal ideation, audio and visual hallucinations. The client had been undergoing counseling for four months now but the counseling had not proven to be effective. She had also been started on Sertraline 100 mg daily and Xanax 0.25 mg before going to bed but had also not proven to be effective. Due to poor progress in treatment, she was thus referred by her primary care physician for further management.Assessment and Diagnosis in Psychotherapy Essay

Pertinent History, Medical Information, and Prescribed Medications

The client’s paternal grandfather suffered from the major depressive disorder. The paternal grandmother abused ETOH. Her senior sister had previously suffered from general anxiety disorder when she lost her job the year 2005 and was managed with Paxil. Both her parents are alive but her father has mild cognitive deficits. Her mother and other four siblings are alive and well. The client was previously diagnosed with moderate anxiety immediately she had been laid off her first job in the year 2017. She consulted a counselor who helped to relieve some of the symptoms but was not prescribed any medications and neither was she hospitalized. Despite the client denying childhood history of abuse and trauma, she reported psychological and verbal abuse and physical trauma by the husband. The client suffered from varicella at 2 years of age, frequently suffers from recurrent tonsillitis, had appendicitis in the year 1999 and underwent an appendectomy the same year. The client denied use of tobacco, ETOH, and illicit drug use. She was taking sertraline 100mg orally QD and Xanax 0.25mg orally at bedtime (Lader, 2015). Assessment and Diagnosis in Psychotherapy Essay

Justifying the Diagnosis Based on DSM-V Criteria

According to American Psychiatric Association (2013), a client is diagnosed with generalized anxiety disorder when he/she presents with complaints of excessive worry and anxiety over an event or activity that has occurred for more than 6 months, the client has found it difficult to control the worry and anxiety which may be associated with any three of the following symptoms: easy fatigue, irritability, restlessness, muscle tension, difficulty in paying attention and sleep disturbance.  Besides, a patient’s focus on anxiety should not be associated with panic attacks, social phobia, obsessive-compulsive disorder, separation anxiety disorder or post-traumatic stress disorder(Er, 2015). Assessment and Diagnosis in Psychotherapy Essay

The client’s symptoms, worry, and anxiety experienced by a client should cause significant distress that can clinically be observable. These symptoms should cause impairment to a client’s occupational, educational and social functioning (Cuijpers et al., 2014).  Lastly, the symptoms should not be as a result of the direct physiological effects of a substance, medications or an underlying medical illness and should not occur exclusively during a development, psychotic or mood disorder (Stein & Sareen, 2015).

Similarly, in the context of this client, SK presented with the complaints of extreme worry, stress, difficulty to concentrate, a lot of anxiety and thoughts for more than six months and inability to sleep for approximately one month. SK did not abuse drugs, had no chronic underlying medical illnesses and denied having panic attacks. These symptoms resulted in significant social and occupational impairment on her life to an extent that she only wanted to be alone most of the time. Besides, SK had also started performing poorly at work. These signs and symptoms meet the diagnostic criteria for General Anxiety Disorder. Assessment and Diagnosis in Psychotherapy Essay

Legal and Ethical Implications Related To Counseling This Client

One of the ethical implications in counseling this client is confidentiality. This client will greatly benefit from individual, group and family counseling. However, the information shared by the client during individual counseling ought to remain confidential during family counseling with her children. This confidentiality limit can only be violated in case the patient proves to be suicidal or self-harm. However, there is a likelihood that at some point during counseling, some confidential information about the divorce will have to be shared with the children. However, information should only be shared with the client’s consent and understanding (Sori & Hecker, 2015).Assessment and Diagnosis in Psychotherapy Essay

Another ethical implication is whether the client will be able to make well-informed decisions regarding her involvement in psychotherapy. This means that some of the decisions made by the client might be influenced by emotions and this would only contribute to failure (Sori & Hecker, 2015). However, the client ought to undergo prior counseling to be informed of the positive and negative implications of her decisions regarding treatment before being given the opportunity to make individual decisions.