____________________________________________________________

CLINICAL ASSESSMENT PROCESS

SUSAN: A Case Study
By
Roco Areta, Irene Bermejo, Sara Garca , Andrea Sols

_____________________________________________________

Submitted to Professor Carolina Marn

In partial fulfilment of the requirements for the subject
Assessment Applied to Clinical and Educational Contexts
May 6th, 2014

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Case Study 5: Susan

Susan is a 21-year-old woman who was referred for psychological testing by her
psychiatrist. She had several hospital admissions since she was 17. Her last hospital
admission was due to her last suicide attempt when she was 19, then was diagnosed
with both major depression and a borderline personality disorder. She was resistant to
testing and complied only because my shrink and father are making me do this.
SESSION 1: Deciding or Exploratory session
The main goal of this session was to get general information about Susans problems
and framework and establishing rapport and a trustable professional relationship with
her. We first gave Susan a form on sociodemographic data to fill before entering the
consultation. (Please, see Appendix I). The reason for the consultation is that she had
been referred by the psychiatrist and forced by her father to attend therapy after she
started to receive treatment for her drug abuse problem.
Intake Open Interview
An intake interview is the most common type of interview in clinical psychology and it
usually takes place when a client first comes to seek help from a clinician. It is a nonstructured interview which purpose often includes determining the suitability of the
therapist to offer his/her services to the patient, assessing and responding to a crisis or
an urgent situation in the persons life, familiarizing the person with the counselling
process, as well as getting a general picture of the client situation (concerns, brief
history). During the intake interview, both parties form opinions about one another; the
client begins to perceive the characteristics of the therapist and the clinical relationship
between the two starts to form here. In some cases, particular clinician may feel that he
or she lacks the expertise to best help the client. It is during the intake interview that the
clinician should refer the client to another source

(1.)

if he considers it appropriate.

Usually, a Mental Status Examination is simultaneously carried along with this intake
interview.

1.Seligman. L. (2004) Diagnosis and Treatment Planning in Counselling. Springer Science & Bussiness Media

Identifying information:
-

Good morning. I am _______, what is your name?

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How old are you?

Where do you live?

Do you live alone?

Do you suffer from any disability?

What is your occupation?

Presenting concerns
-

Tell me, what does concern you?

When did it start? What other events were occurring at that time? How often does it
occur?

What thoughts, feelings and observable behaviours are associated with it?

Where and when does it occur most? Least?

Are there any events or persons that precipitate it? Make it better? Make it worse?

How much does it interfere with your daily functioning?

What previous solutions/plans have you tried and with what result?

What made you to seek help at this time? What influenced the psychiatrist to refer
you at this time?

What are your goals?

Past psychiatric/counselling history:

-

Did you received any previous counseling and/or psychological/psychiatric

treatment?

What type of treatment? How long did it last? Where did it take place?

What was the outcome of the treatment? What was the reason of its termination?

Have you ever been hospitalized?

Have you ever been prescribed drugs for any emotional or psychological issue?

Suicidal and homicidal ideation

-

Have you ever have any suicidal thought? When did it happened?

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How many times has it happened?

Are you thinking or trying to suicide currently?

What did drive you to having it?

How intense this thoughts are?

How long did they last?

Have you ever made a suicidal plan? (here we considered the details of plan:
method, lethality, availability of method, and timeline of plan)

Have you ever threat or attempted suicide? Did any relative has?

Why did you intent to suicide?

Have you ever had any homicidal ideation?

Drug use/abuse history

-

Have you ever taken any drug? Which one/s?

Where do you usually take those?

How often do you consume them?

Do you consider that you take them sporadically or regularly?

Do you still take the same drugs that you used to?

Why do you take drugs?

How do you feel about it? Which are the advantages and disadvantages of
consuming?

What is the function they have for you?

After carrying out the Intake Interview, we found that Susans interpersonal
relationships with others, both family and friends, are unstable. She does not usually
trust on others because sooner or later everyone ends up leaving. Her mother
committed suicide when she was 14 and she has an ambivalent relationship with her
father. She reported having tried to commit suicide three times: four, three and two
years ago because she felt empty, was extremely angry and thought that life was
senseless. The attempts mainly consisted on wrist cutting without any severe damage
for her life. She admitted having been thinking about death nearly every day since she
was 15 years old and that the only thing she perceived to control was whether
continuing alive or not. She always obeyed her fathers rules and tried to please him by
getting high gradess at school, but this changed when her mother died. Susan reported
that she usually feels the impulse of doing things, as the drug use and sporadic sexual

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relationships that destabilize her. She started abusing drugs (Marijuana, LSD) when
she was 16 years old, although nowadays she is getting this problem treated. She has
had three hospital admissions since she was 17 because of her suicidal attempts and she
went through treatment for depression (Fluoxetine) after her first attempt. Susan admits
getting easily irritated even by minor things (noises, others behaviour). In fact, she
report to effortlessly losing her temper whenever something upsets her and engaging in
a series of choleric behaviors like throwing things and yelling. She is convinced that she
is a weird person who will never be able of knowing who she really is. She believes
insomnia to be a consequence of the rumination produced by her problems.

Brief Mental State Examination (See Appendix II)

The Mental Status Exam (MSE) is a series of questions and observations that provide a
snapshot of a client's current mental, cognitive, and behavioural condition. Its goals are
(1) to get a baseline measure of psychological functioning, (2) to get a hint of
biological, psychological and social factors that predisposed, precipitated, and
perpetuate the client's current functioning and (3) to establish a client's capacity to
function. The Mental Status Exam is done during first interviews, when there is reason
to believe a client is cognitively altered, and during a crisis or an emergency situation.
During this first session, we applied the short form of the MSE simultaneously along
with the intake interview.
Susan had a normal and groomed appearance, but his attitude was uncooperative at
the beginning since she felt forced to come for consultation by her psychiatrist and his
father. Concerning behaviour, no unusual or psychomotor changes were observed. The
speech rate, tone and volume were moderately high; she made some short pauses while
speaking. Her affect was reactive since she was a little angry because of being there.
She seemed labile but she did not cried, although she displayed both depressive affect
and mood. Susan got irritated by nearly each of the addressed issues. Her thought
processes were goal-directed and logical, but with respect to the content, she reported
past active suicidal ideation and recurrently talked about death. No delusions, phobias
nor obsessions/compulsions were detected. Concerning perception, there were no
delusions or hallucinations. Her orientation was fine with time, place and person, but
she displayed a slightly self-disturbance with respect to her identity since she reported

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an inconsistent self-view. Her memory was fine, as well as her concentration. Susans
judgment and insight were halfway between poor and fair, since she displayed some
problems when making decisions and while making a self-reflection.
Summary of the exploratory session:
During this first session, and according to the collected information both from the
Intake Interview and MSE, Susans depressive mood and insomnia episodes, among
others, make us hypothesize that she might suffer from a mood disorder. We also
handle the option of her still suffering from drug abuse (Marijuana, LSD) as she
reported its consumption since she was 16 years old. This presumable abuse along with
her impulsivity, identity disturbance, mood reactivity, fear of being abandoned and
others, make us hypothesize that she may suffer from a personality disorder, although
further verification is needed.
Thus, after having estimated the case, we think we have the necessary therapeutic skills
and that we are qualified to carrying out the assessment.
Right before Susan leaves, we ask her to think at home whether she wants us for
carrying her assessment. After all, we have started to assess Susan but she has also
started to evaluate us.

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SESSION 2: Gathering Information Sessions

The main goal of this session is to gather further information about Susans problems
and concerns, to know more about the historical background for the functional analysis.
We also asked her to sign an agreement form related to both ours and hers duties and to
the assessment process (Please, see Appendix III).
SEMI - STRUCTURED INTERVIEW WHILE APPLYING MSE LONG FORM
(See Appendix IV)
A semi structured interview has a general framework on the themes to be explored, but
the questions are open not fixed like in the case of a Structured interview.
We conducted a semi structured interview at the beginning of the second session in
order to gather more specific information about our client and to focus on her current
concerns, the ones we perceived at the first session based on observational assumptions.
Identifying Information of the patient
-

Good morning Susan, how are you feeling today?

Presenting Problems
-

You told me last session that you are feeling blue and moody; have you felt the same
this week?

So are you feeling more like this or less? Do you have any further concern that you
want to talk about?

Have you noticed any new change in your mood?

Family Background (Family tree)

-

Susan have you talked with you father about our last session?

Does he know about your concerns?

How would you describe your relationship with your family?

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Health Background
-

How many hours have you been sleeping these days?

Are you feeling rested?

Have you consumed drugs lately?

Have you had any ache or soreness?

Employment Background
-

How do you feel about your past jobs? Did you like them?

Did you feel pleased with your current or past jobs?

How many jobs have you have and for how long?

Which job do you think will suit you?

Sexual History
-

You told me that you have had some couple, can you tell me how many?

For how long have you been in those relationships?

How these relationships affected you?

Were you satisfied with any of them?

Previous Medical History

-

Do you know if any of your relatives had diseases?

Did you have any disease or illness when you were younger?

You told me that when you were younger you were hospitalized, can you tell me
something more about it?

Previous Psychiatric History

-

You told me that you were diagnosed before with depression and border line
personality, how long ago was it?

Can you tell me something more about your therapy?

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How you felt about your diseases at that moment?

History of Traumas
-

Have you had any trauma in your childhood?

Do you think that maybe something happened in your life that could have caused
you a trauma?

Developmental History (Lifeline, Story)

-

Susana can you tell a little bit about your childhood? How was it?

You have told me that you had problems as a teenager, what happened?

Is there something that happened to you as a teenager that may have affected you?

After high school what did you do?

Could you resume me your life nowadays?

Semi Structured Interview Summary

Susan was a child with social troubles as she has said, she did not know how to
socialize when she was a child and still doesn't know how to do it now. Her mother was
depressive and stayed in bed most of the time, her father, on the other hand, was
authoritarian, but traveled often and was not always home, despite his absent he was
strict with Susan and always asked for more from her (school, marks, behavior) so she
felt that she was never enough.
When her mother committed suicide when she was 14, it was a trauma for her, she
began to fail most of her subjects in school and final dropped out. At 16 she started
with drug abuse and about that time she also attempted suicide. She was referred to a
psychiatrist who started dealing with her LSD and marihuana abuse, she was on
treatment for 2 years and keeps on with this treatment, She says that she has overcome
her LSD addiction and most of marihuana though she continues to consume on
weekends. Her current concerns are her mood swings which she is conscious about,
her death ideation and feelings of abandon. She also presents dysfunctional relationships
both with her couples and her father.
Life Timeline

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Family Tree

MSE Long Form (simultaneously applied along with the interview)

(See Appendix IV)
The Mental Status Examination is also part of the assessment process. It is a more
detailed structured observation list than the short MSE, and it describes the patients
state of appearance, attitude, behaviour, mood and affect, speech, thought process,
thought content, perception, cognition, insight and judgment.

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The purpose of the test is to gather a description of the patients mental state, the one
that we can observe, while combining it with an interview. At this case a Semi
structured interview.
Susan had a normal appearance and behavior, nevertheless her speech was slow with
both tone and volume slightly high and taciturn speaking specially when talking about
her past. She had a defensive and hostile attitude towards us at the beginning of the
session like the first one. Her mood was tense the major part of the session and
occasionally depressive when talking about her feelings of emptiness. When being tense
she would show an irritable mood towards us. Susan had an appropriate behavior and
affective expression towards the examiners.
Her perception was normal as far as it concerns with hallucinations and agnosia, but
she did show depersonalization a detachment from herself which Susana is conscious
about. Concerning her Thought content she reported a trend of thought on death
ideation but she had no phobias or delusions. About her Thought form she had a
concrete thinking with no disturbance of speech or aphasic disturbances. Susan reports a
history of suicidal ideation and she may attempt to do it again given her ideation history
and impulsiveness. Concerning her Sensorium & cognition she had a normal
orientation, memory, concentration and intelligence, though she seems to have a
problem with her consciousness given her somnolent state which seems plausible since
she having a lack of sleep. As reported on the last session she had a mild poor judgment
and insight towards decision making and self reflection. No reliability faking was
reported.
It is worth to mention that we observed a discrepancy between some aspects on
Susans MSE between the first session and the second one; especially concerning the
speech. During the first session, her speech rate and volume were both moderately high,
whereas during the second one there were slow (although both tone and volume
remained high). One tentative explanation for such difference could be related with
Susans consumption of drugs. Thus a possible hypothesis would be that she might
have taken some drugs prior to the first session (she seemed agitated) and another
hypothesis would be just the opposite: that she may took them prior to the second
session, which supposedly would have alleviated the starving for drugs and calmed
her, leading to a slow speech rate and volume.

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Although Susan is supposed to have gone through drug treatment, we suspect of her
consuming drugs again thus a possible relapse might have happened. In addition, we
consider appropriate to contact the medical center where she is being treated to get
more information about her treatment.
SCL 90 (Symptom checklist)
The Symptom Checklist is a self-report checklist which evaluates psychological
problems and symptoms of psychopathology. Its dimensions are; somatic, obsessive
compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety,
paranoid ideation, psychoticism. Then we have the three global indices of distress which
are Global severity index, positive symptom distress index and Positive symptom total.
After the interview we introduced the SCL to the patient who agreed to do it. This
checklist gives us more information about Susanas problems and helps us clarify what
she is going through.

SO

OBS

INT

DEP

ANS

HOS

FOB

PR

PSI

GSI

PST

PSDI

M
20

21

35

65

35

80

10

25

75

60

65

The results of the test showed that Susan has a rather depressive mood which includes
a high score on feeling blue/lonely, hopelessness about the future and feeling
worthless, we already have evidence on her depressive symptoms as well as a past
diagnosed major depression. Susan reports a high feeling of restlessness; she has high
scores on sleep that is restless or disturbed this result is explained by her lack of sleep.
Nevertheless she doesnt report feeling that everything is an effort and feeling low in
energy, which are important characteristics of Depression disorder.
Furthermore she didnt have a high score on trouble concentrating but she did have
difficulties on making decision. We have to be aware about her currently death
thinking, she has suicidal though and still thinks about death daily, this can be seen on
the question thoughts of death or dying on which she had a high score.

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These scores on the depress items are related with her global 65 score on Depression
which is second highest and yet below the 75 percentile which indicates the significance
of a possible concern.
She also seems to have a choleric mood and reactions, scoring high on having urges
to break or smash things and also shouting and throwing things, this could be related
with her drug abuse as well as her past diagnosed Border line personality. This scores
are part from the Hostility part of the test which score is 80 being the highest one.
Assessment of Suicide Risk (See Appendix V)
Given Susans history of suicidal ideation and suicidal attempts, together with her
thoughts about death, we decided to evaluate the risk of suicide before continuing any
further with our evaluation.
Becks Suicide Intentionality Scale evaluates the characteristics and severity of a
previous suicide attempt and identifies the risk for a new attempt.
Susan obtained a score of 9. The mean score for those people who committed a suicide
attempt in the period of one year was 15,5, and the mean for those people who didnt
commit a new attempt was 12,4.
With this information and that obtained during the Standard Clinical Interview we
conclude that there is no risk at the moment for a new suicide attempt.
Assessment of Drug Abuse (See Appendix VI)
Susan is being treated for her drug abuse problem. However, we consider necessary to
evaluate the present state of her drug abuse problem.
The Drug Abuse Screening Test (DAST) was used. Susan obtained a score of 11, just
below the cut off score for a substance abuse problem (12). Even though Susans score
is considered high and at risk for suffering a substance abuse disorder, given our
observations and information obtained during the first sessions, we have decided not to
interfere with the treatment she is currently undergoing.
Observation
Observation is another instrument that we will use to gather more information about our
client. It entails the observation and description of specific or random behaviours that
the subject displays. We will make two kinds of observation techniques
Ad Libitum observation

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At first we will carry out an Ad Libitum technique, which is to mainly observer any
behavior that our client makes in certain environments, days of the week or hours. We
will use this technique in order to search for any concerning behavior that Susan may
display.

Self report on which she will have to describe her behavior at work, when
being alone and with her father.

Her father will also have to report her behavior but at home in a normal day and
weekends.

Systematic observation
After the Ad libitum observation we will carry out a Systematic observation. This
observation is carried out when we know which behaviors you want to observe, these
behaviors are fixed and concrete.
In the case of Susan we will focus on her mood swings, specifically in her choleric
episodes. The self report observation will give us more information about this
episodes (when they happen, what she is thinking after and during)

Choleric episodes, self report on what happens when these episodes occur
(precipitating factor, intensity of the episode, etc.) and how many times does it
happen in a week.

SESSION 3: Testing Hypothesis

The main objective for this session is to test our hypothesis using different assessment
techniques, and to come up with a Case Formulation that will describe the persons
presenting problems and use a theory to make explanatory inferences about the causes
and maintaining factors of those problems. At the end of this session a diagnosis would
have been reached and we can start developing the treatment.
After gathering and the information from sessions one and two, we defined both a list of
problems and two hypothesis in order to carry out the Functional Analysis. During this
session, a triangulation was done in order to tests our hypothesis and, with the results
that were obtained, a Case Formulation following Hayness model and a Multiaxial
Diagnosis were developed.

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List of problems
Suicidal & Self Cutting behaviors: Act of deliberately cutting her wrists with a
razor. Not meant as a suicide attempt (although she has put her life in danger and
has been hospitalized on three occasions), but as a way to cope with emotional
pain, intense anger and frustration.
Susan has scored 9 on Becks Suicide Intent Scale. However, and even though
we will not focus our analysis and future treatment on this issue, it is important
to have in mind this problem while formulating the case and for future follow up
and treatment plan.
Drug use: history of consumption of Marihuana (everyday) and LSD (once a
week), since she was 16. This problem is successfully being treated. Nowadays,
Susan smokes small doses of Marihuana during the weekends.
Given that Susan scored 11 on the EAG (Escala de Adiccin General) and the
therapy she is going through seems to be effective, we will not get involved on
this issue. However we will follow up on the process and have this issue in mind
for the diagnosis and therapy plan.
Emotional instability:
Impulsivity: acting suddenly while ignoring the consequences of her
behavior. For instance, drug use, destroying property when angry
(throwing things), self-harm behavior, acting out sexually (multiple

sexual partners).
High levels of guilt: experience of conflict at having feeling or doing
things she feels she should not have done, such as in the occurrence of

impulsive behaviors described above.

Anxiety: worrying and ruminating thoughts, rapid heartbeat, insomnia.
Dramatic mood swings: depressive and aggressive behaviors. This is
related to her low tolerance to frustration. Any event that goes slightly
wrong causes Susan to either get angry, yell or throw things around, or to

withdraw from everybody and feel sad, empty and worthless.

Identity disturbance: unstable self-image and sense of self. Incoherent and
inconsistent behaviors which are sometimes healthy, sometimes self-destructive;
lack of commitment to the job, confusion of own feelings when in a relationship,
emotional highs and lows depending on circumstances.
Choleric episodes: become enraged over tiny mistakes or events that dont go as
plan. Become physically and verbally aggressive and throwing nearby objects.

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Isolation & Problematic Relationships: difficulty being in a long-term

relationship, no long-term friends, conflicts are a common thing in the
relationship with others.
Formulating hypothesis
After considering the information obtained during sessions one and two, we will
contemplate two diagnostic hypothesis:
1- Mood disorder: Susans inability to discriminate, label, monitor and control her
emotions; her emotional instability in the form of impulsiveness and depressive
and aggressive behaviors, and her feelings of emptiness and dissatisfaction, lead
us to believe that the disturbance in Susans mood might be an underlying
feature of her problems. Given her symptomatology (insomnia, difficulties in
concentration, negative thoughts, irritability, etc.) we will consider a Major
Depressive Disorder.
2- Personality disorder: Given Susans enduring pattern of psychological
experience and behaviour that differs from cultural expectations, as shown in
cognition (disturbed perception of self), affect (inappropriate emotional
responses), problematic interpersonal relationships, and lack of impulse control,
we will consider a personality disorder, and more specifically, bipolar
personality disorder.
Testing for Major Depressive Disorder: Triangulation.
In order to test our hypothesis for Major Depressive Disorder we have obtained three
measures using three different diagnostic tools.

The SCDI-1: Structured interview.

Becks Depression Inventory (BDI): self-administered questionnaire
Hamilton Depression Rating Scale (HRSD): scale filled out by the therapist
based on his own observations.
(See Appendix VII & VIII for the BDI and HRSD)

SCDI I
Affective Episodes Module A
We applied the SCDI I on major mental disorders on the third session, this structured
interview tell us if our client has any major disorder relaying on her answers.

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The results of the test shows that according to the SCDI I Susan shouldnt be
diagnosed with Major Depression despite our previous assumptions, she doesnt fulfil
all the required parameters for this disease.
Susan is having a (A1) depressive mood for more than 2 weeks but she has not had any
(A2) decreased interest of pleasure neither an alteration on appetite or weight (A3).
She does have troubles to sleep because of insomnia (A4). Susan has no agitation,
psychomotor problems (A5) or fatigue (A6). But she does feels a great feeling of
worthlessness and guilt (A7) She does not have problems on concentration (A8)
neither memory. Concerning her suicidal ideation, she had it but currently she says to
have overcome it, nevertheless she keeps on thinking about death daily (A9)
As we know at least 5 out of the 9 items on Major depression need to be positive to
diagnose Susan with Depression, but in our case she just got 4 positive items on the test
and therefore it seems that she has no depression. Further tests will be perform so to be
clear about this fact.
BDI:
Becks Depression Inventory is a 21 question, self-administered questionnaire that
evaluates a wide array of depressive symptomatology.
Susans score is 17, which is within the range of mild depression (between 10-18).
HRSD:
Hamiltons Depression Rating Scale is a scale to be filled out by the therapist from his
own observations of the patient.
Susan scored a 9, within the range of minor depression (between 7-17).
Conclusion: Susan is most likely to have a mild case of depression.
Testing for Borderline Personality Disorder: Triangulation
In order to test our hypothesis for Borderline Personality Disorder we have obtained two
measures using three different diagnostic tools.

The SCDI-II: Structured interview.

Zarini Rating Scale for Borderline Personality Disorder: brief clinician-

administered interview to assess severity and change in BPD symptoms.

MMPI-II: Standardized test of adult personality and psychopathology.
(See appendix IX for Zarinis rating Scale)

SCDI - II

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We also applied the SCDI II to determine if Susana has any specific personality
disorder, we also applied this interview on the second session.
According to the results of the SCDI II Susana has to be diagnosed with a border line
personality disorder, this result are supported with the disease parameters.
Susana has a great worry about important people in her life abandoning her, she gets
furious when she feels like her father or current boyfriend is going to abandon her. (she
would score 3 in this) She has dysfunctional relationships that last for weeks (score 2)
She also has episodes identity disturbance this episodes consist on a detachment from
herself, she wont know who she really is (score 3). However she hasnt done any
abrupt changes in her job or beliefs, only her mood swings. Susan has impulsive
behaviour in her relationships, decision making and her past substance abuse. She had
made suicidal attempts in the past, three times by cutting herself, but she says that she
has overcome that symptom though she keeps on thinking about death. (score 3 ) Susan
has huge mood swings that she cannot control, she is aware of this fact (score 3). On her
mood swings she can feel hopeless, guilt, worthless and empty which causes sadness,
but on the other hand she can have choleric episodes on which she reacts aggressively.
(score 3 in both) Susan can react like this for significant issues or for minor issues. She
has no transitory paranoid.
As we can see Susan scores 3 on more than 5 items, therefore we can suggest that she
suffers from Border line personality.
Zarini Rating Scale for Borderline Personality Disorder
Susan scored 9/10, indicative of a diagnosis of Borderline Personality Disorder.
MMPI-II-RF: Summary of interpretive report
Scores on the MMPI-2-RF validity scales dont raise any concerns about possible
under/over reporting or unscorable itmes in this protocol.
Substantive Scale Interpretation
Somatic/Cognitive dysfunction: Susan doesnt show any somatic complaints.
Emotional Dysfunction Scales: Susans responses indicate a moderate to mild
level of emotional distress. Susan reports feeling unhappy, sad and dissatisfied with her
current life circumstances. She also reports experiencing various negative emotions
including anxiety and anger, low tolerance to frustration and mood instability. Susan
reports a history of suicidal ideation and /or attempts.

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Thought dysfunction Scales: Susan reports feeling useless at times, she is likely
to be unhappy with herself and prone to rumination.
Behavioral dysfunction Scales: Susan reports a significant history of antisocial
behavior. She is likely to have been involved with the criminal justice system, to fails to
conform to societal norms and expectations, to experience conflictual interpersonal
relationships, engage in substance abuse, and be interpersonally aggressive.
Interpersonal Functioning Scales: Susan reports having conflictual family
relationships and lack of support from family members. She is likely to have family
conflicts and to experience poor family functioning. She is likely to have difficulty
forming close relationships.
The MMPI-2-RF Diagnostic Considerations:
Emotional internalizing disorders:
Should be evaluated for depression, anger-related disorders and anxiety-related
disorders.
Thought disorders:
Should be evaluated for disorders associated with thought dysfunction, dysfunctional
perception of the self.
Behavioral disorders:
Should be evaluated for substance abuse disorders.
Interpersonal disorders
Should be evaluated for Antisocial Personality Disorders
With the results obtained in the MMPI-2-RF a diagnosis of Borderline Personality
Disorder is possible.
Conclusion: the hypothesis of Borderline Personality Disorder is confirmed by the
three different diagnostic tools.

MULTIAIAL DIAGNOSIS
Axis 1: Minor Depressive Disorder (Depressive Disorder not Otherwise Specified)
[311]
Axis 2: Borderline Personality Disorder [301.83]

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Axis 3: None
Axis 4: Mothers suicide, poor bonds with family and friends, conflictual relationships,
job dissatisfaction.
Axis 5: EEAG: 50.

Case Formulation (Hyaness Model)

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FUNCTIONAL ANALYSIS: One Example

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SESSION 4: Functional Hypothesis Generation

After doing the diagnosis and Case Formulation, the functional hypothesis must be
defined before developing and intervention plan.
By teaching Susan tools for emotional control- IV and by working with her to
resolve emotional issues such as grieving her mothers death or dealing with
her fear of abandonment we will expect to see an improvement in the area of
emotional instability-DV (mood swings, impulsiveness, etc.), and her feelings
of emptiness and dissatisfaction, therefore reducing the possibility of a new
suicide attempt or a relapse into drug use.
By working with Susan on modifying her cognitive style - IV (polarized
thinking, high standards, perfectionism, etc.), we will help reduce her feelings of
emptiness and dissatisfaction, her negative self-perception and the levels of
guilt, anxiety and impulsivity DV.
By working with Susan on her Social Skills IV, Susan reduce the probability
of having problematic relationships DV, and will have the chance to improve
her relationships with family members and friends.

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