12 Nov Psychiatric Assessment and Docuemntation for Special Population
Accurate diagnostic formulation and the implementation of evidence-based interventions are essential to optimizing client outcomes. Review the case scenario presented below and respond comprehensively to all questions, incorporating appropriate scholarly references and in-text citations.
Case Scenario
Marissa, a 15-year-old high school sophomore, was referred by her school counselor due to declining grades, increasing isolation, and recent concerning messages posted on social media. Over the last three months, she has reportedly withdrawn from her friend group, stopped attending soccer practice (which she used to enjoy), and spends most of her time in her room.
Her mother reports frequent irritability, tearfulness, and an episode of self-injury two weeks ago after an argument. Marissa says she feels “overwhelmed and empty,” occasionally has trouble sleeping, and experiences periods of intense anxiety before school. She denies using substances. She states, “Sometimes I wish I didn’t have to wake up,” but does not elaborate further when asked.
No history of ASD, ADHD, or learning disabilities. No past history of psychiatric treatment. Family history is notable for a mother with an anxiety disorder and a maternal uncle with bipolar disorder. There is no known trauma history, though Marissa mentions feeling “socially excluded and left behind.”
Questions
1. What elements of the presentation require further assessment?
2. What assessment tools and techniques will you utilize to interview Marissa?
3. Provide three DSM-5-TR differential diagnoses that should be explored. Explain the reason for it
4. What immediate safety assessments are needed?
5. What documentation elements are essential?
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