Case Presentation: Intake Date May 2019 Identifying Demo

Case Presentation Lanelleintake Date May 2019identifyingdemographi

CASE PRESENTATION – LANELLE INTAKE DATE: May 2019 IDENTIFYING/DEMOGRAPHIC DATA: Lanelle is a 29-year-old, single, heterosexual, African American female. Lanelle lives with her boyfriend, Dion, of 4 years. She wants to get married, but her boyfriend does not believe he is ready yet since he is three years younger than her. Lanelle is a Certified Public Accountant, who loves her job. Dion is a manager for a gym franchise.

CHIEF COMPLAINT/PRESENTING PROBLEM: I am worried about my job since charges were pressed against me from Grants Department store for not paying for a lipstick.

HISTORY OF PRESENT ILLNESS: Lanelle has admitted that she has taken small things previously that “the store doesn’t care much about.” She realizes she can afford these small items, but the excitement she experiences and tension right before taking an item is fun when she gets away with the item. “Everyone takes a lipstick or so,” she expresses. Lanelle states she concerns herself about many things, which is not new to her. Since she could remember she was the concerned person in her family about her siblings, her parents, family finances.

Her mom used to tell her not to concern herself with things beyond her control. Lanelle reports that germs have been a regular concern of hers since adolescence, when she learned in health classes about the risks of serious diseases including sexual transmittable disease. There are times when she worries it triggers her and within minutes she knows intense discomfort is coming, feeling dizzy, sweating, feeling nauseous, and having trouble breathing. She can tell when the discomfort is coming and is able to calm herself down in a few minutes. Lanelle and Dion entertain often and Lanelle worries she may get visitors and the house is not in order as she would like it.

She sometimes has arguments with Dion to help more around the house. PAST PSYCHIATRIC HISTORY: Lanelle has never been for therapy before and decided to attend now because her life seems to be spinning out of control. She states the restlessness, trouble sleeping and anxiety has always been a part of who she is which is why she never needed to go to therapy. She admits that all this is distressing and sometime interferes with her life especially with Dion. SUBSTANCE USE HISTORY: Lanelle reports drinking socially. She tried marijuana in college several times but did not like it. She denies any other drug use.

PAST MEDICAL HISTORY: Lanelle had the usual childhood illnesses but has not had any severe illnesses in adulthood. FAMILY MEDICAL AND PSYCHIATRIC HISTORY: Lanelle reports no significant family medical or psychiatric history.

CURRENT FAMILY ISSUES AND DYNAMICS: Lanelle shared that she was raised in the military; her father is an army officer. She has two brothers. She has travelled all over the world living on military bases mostly. She has a very close relationship with her father. She knows they were raised in the “military” fashion but believes it has benefitted her over the years. MENTAL STATUS EXAM: Lanelle presented with meticulous grooming. Lanelle is oriented to time, place, and person. She is professionally dressed and looks her stated age. She presents with some anxiety in the interview as well as restlessness. She states that this is normal for her so she is used to it. Motor activity is appropriate. Speech is clear. Lanelle does report being irritable due to her restlessness. There is no evidence of delusions or hallucinations. Lanelle’s intelligence appears above average.

Sample Paper For Above instruction

The case of Lanelle offers a comprehensive illustration of the complex interplay between individual, familial, and cultural factors influencing mental health. A 29-year-old African American woman, Lanelle presents with concerns that encompass anxiety, restlessness, and behaviors that could suggest underlying mood or anxiety disorders. Her psychiatric profile underscores the importance of culturally sensitive assessment tools, such as the Cultural Formulation Interview (CFI), to capture nuances that might be overlooked through standard diagnostic procedures.

Lanelle’s psychosocial context reveals significant insights. Raised in a military environment with a close relationship with her father, her upbringing likely provided resilience and discipline, which can serve as protective factors. However, her concerns related to germophobia, perfectionism about household order, and her internal conflict about her relationship and marriage readiness suggest underlying anxiety symptoms possibly compounded by stressors such as her recent legal issues and social worries. These stressors align with findings in psychiatric literature emphasizing how socio-cultural stress impacts mental well-being, especially among minority populations (Kirmayer, 2014; Lewis-Fernández et al., 2017).

Her history of petty theft (stealing small items) might indicate a diagnostic consideration of impulsive behaviors or compulsive tendencies, yet it’s essential to evaluate within her cultural context and personal history. Her prior avoidance of therapy due to perceiving her traits as intrinsic rather than pathological echoes a common barrier in mental health engagement, especially among minority groups where stigma and mistrust disrupt service utilization (Corrigan, 2004). Her social drinking and experimentation with marijuana during college suggest a generally mild substance use profile, but ongoing assessment is necessary to identify if these behaviors co-occur with her anxiety symptoms or serve as maladaptive coping mechanisms.

Psychiatric evaluation must focus on her current presentation: high-functioning, meticulous grooming, and insight into her symptoms. Her affect appears anxious; thought process intact with no evidence of psychosis. Her intellectual abilities seem above average, which can facilitate engagement in therapy and comprehension of interventions. An essential aspect of her assessment involves understanding her cultural background to tailor interventions effectively. The CFI could elucidate her cultural values around family, religion, and social roles—factors that influence her help-seeking behaviors and perceptions of mental health. For instance, her close relationship with her father and military upbringing might inform strength-based approaches emphasizing resilience and structure.

Treatment planning for Lanelle should include psychoeducation about anxiety, potentially incorporating culturally adapted cognitive-behavioral therapy (CBT) approaches that acknowledge her background and beliefs. Addressing her perfectionism and germophobia may involve exposure therapy and mindfulness strategies. Building trust remains critical, considering her prior avoidance of therapy and her concerns about social stigma. Incorporating community resources, such as faith-based organizations, and engaging culturally competent providers can foster trust and improve adherence.

In conclusion, Lanelle’s case exemplifies the importance of integrating cultural competence into mental health assessments and interventions. The use of tools like the CFI enriches understanding of individual experiences within their cultural framework, leading to more effective and respectful care. Recognizing the influence of familial, cultural, and social factors enhances clinicians’ ability to design personalized treatment plans that resonate with patients’ values and life context, ultimately improving mental health outcomes among diverse populations.

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