Comprehensive Client Family Assessment And Genogram

Comprehensive Client Family Assessment And Genogramthe Client Is A 24

Comprehensive Client Family Assessment and Genogram The client is a 24-year-old female, single, African American active duty service member (SM). She resides in the barracks and reports a history of homelessness before enlisting in the Army National Guard. The client’s military occupational specialty (MOS) is 25U, Signal Support Specialist (IT). She recently completed basic training and Advanced Individual Training (AIT). Prior to enlisting, she worked as a Computer Specialist. She is accompanied by an escort during her medical visit. Her presenting problem includes expressing confusion about her presence at the facility, stating, "I do not know why I am here; I do not need to be here."

The client appears slightly disheveled, tired, and generally irritable both in the lobby with nursing staff and in the consultation room. She is accompanied by an escort who remains present throughout the assessment. Her history indicates insomnia; otherwise, she reports no significant medical conditions or substance use, denying alcohol or drug consumption. She notes a history of trauma, including two episodes of sexual harassment in 2012 and 2013, but declines to provide additional details. No prior psychiatric treatments or hospitalizations are reported, and family psychiatric history is negative, although her maternal grandmother reportedly used marijuana, and her paternal grandmother has been incarcerated.

During the mental status examination, the client is alert and oriented to person but disheveled in appearance with mild body odor. She shows irritable and restless behaviors, with pressured and frenzied speech. Her mood is euthymic but her affect is irritated. Thought processes are illogical and irrational, and she demonstrates distractibility. She denies hallucinations, suicidal or homicidal ideation, and delusions. She does not report any perceptual disturbances, though her thought content includes paranoid beliefs and delusional ideation, such as suspicions that her food is being poisoned and accusations against the president. Her judgment appears delayed and her insight and judgment are fragmented.

Reviewing her symptoms and history suggests differential diagnoses of schizophrenia, bipolar disorder, and delusional disorder. Schizophrenia is characterized by positive symptoms such as hallucinations, delusions, disorganized speech, and behavior, typically emerging in late adolescence or early adulthood (Bertolucci et al., 2018). Negative symptoms include emotional flatness, social withdrawal, and decreased motivation, accompanied by cognitive deficits affecting attention, working memory, and executive functioning (Kahn et al., 2018). The client’s presentation of paranoid delusions, disorganized thought, and social withdrawal supports the possibility of schizophrenia.

Bipolar disorder is characterized by periods of depression and mania, with manic episodes including elevated mood, irritability, pressured speech, grandiosity, decreased need for sleep, and distractibility, often lasting at least one week (Grande et al., 2016). The client reports irritability and pressured speech but lacks other features of mania such as grandiosity or risk-taking behaviors, making bipolar disorder a less likely primary diagnosis.

Delusional disorder involves persistent delusions lasting at least one month without other psychotic symptoms or significant impairment in functioning (Skelton et al., 2015). The client’s paranoid and referential delusions could fit into this diagnosis, especially considering the absence of hallucinations and disorganized speech, although her history suggests more complex psychosis.

A case formulation indicates that her symptoms—paranoid delusions, disorganized thought, and social withdrawal—point toward a diagnosis of schizophrenia spectrum disorder. She exhibits some negative and cognitive symptoms, which impair her functioning and judgment. Her history of trauma and stressors may act as triggers or exacerbators of her current presentation.

Treatment strategies focus on establishing trust, ensuring medication adherence, and providing psychotherapy to help surface symptoms and improve insight. Pharmacological interventions often involve antipsychotic medications, which help control positive symptoms—including delusions and hallucinations—while psychosocial support addresses cognitive, emotional, and social functioning (Jauhar et al., 2019). For this client, a combined approach involving medication management by psychiatrists or clinical psychologists, along with case management and psychoeducation, appears most appropriate.

Continuing therapy with a Licensed Clinical Social Worker (LCSW) or psychiatrist is critical for monitoring symptoms, medication effects, and mood stabilization. Engagement strategies include setting personalized goals, psychoeducation about her condition, and involving her support system to enhance adherence. Early intervention and ongoing support are essential for improving prognosis and functional recovery, especially considering her age and military environment (Jennings et al., 2016).

Furthermore, addressing her trauma history through trauma-informed care could help reduce the severity of symptoms and improve her coping mechanisms. Psychoeducation about her diagnosis may help reduce her paranoia and mistrust, fostering greater cooperation with her treatment plan. Given her military background, incorporating structured routines, peer support groups, and vocational counseling can bolster her recovery and social integration.

In conclusion, this client’s presentation aligns strongly with a diagnosis of schizophrenia spectrum disorder, considering her paranoid delusions, disorganized thinking, and social withdrawal. A multidisciplinary treatment plan involving antipsychotic medication, psychotherapy, trauma-informed care, and social support offers the best chance for symptom management and functional improvement. Her case underscores the importance of early diagnosis and comprehensive, individualized care within both military and civilian mental health settings.

Paper For Above instruction

The case of this 24-year-old female military service member highlights several critical aspects of mental health assessment and diagnosis in young adults presenting with psychosis-like symptoms. The client's history, behavioral presentation, and mental status examination all provide vital clues toward constructing an accurate diagnosis and effective treatment plan. Through this analysis, the complex nature of psychotic disorders, especially schizophrenia, is explored, emphasizing the importance of multidimensional assessment, including family history, psychosocial context, and symptomatology.

The clinical presentation of the client—including paranoid delusions, disorganized thought processes, irritability, and social withdrawal—strongly suggests a schizophrenia spectrum disorder. Schizophrenia often manifests during late adolescence or early adulthood, which coincides with the client’s age (Bertolucci et al., 2018). The key diagnostic features include positive symptoms such as hallucinations and delusions, negative symptoms such as social withdrawal and emotional flatness, and cognitive deficits impacting attention and executive functions. This client exhibits several of these hallmark features, particularly paranoid delusions and disorganized thought processes, coupled with irritability and social withdrawal.

Her history of trauma, particularly sexual harassment, warrants consideration of trauma-related mental health conditions; however, her persistent delusions and disorganized thinking point more towards a primary psychotic disorder rather than post-traumatic stress disorder (PTSD). Nonetheless, trauma can act as a stressor that exacerbates psychotic symptoms or complicates recovery. For this reason, trauma-informed care should be integrated into her treatment plan, emphasizing safety, trust, and empowerment.

It is essential to distinguish schizophrenia from other disorders like bipolar disorder, delusional disorder, and brief psychotic episodes. Bipolar disorder involves mood episodes, including mania and depression, but the client’s presentation lacks characteristic features of mania, such as elevated mood, grandiosity, or decreased need for sleep. Delusional disorder, however, involves persistent delusions without extensive hallucinations or disorganized speech, which partially aligns with this client's clinical picture. Still, her disorganized thought pattern and irritability suggest a broader schizophrenia spectrum diagnosis rather than isolated delusional beliefs.

The importance of early and accurate diagnosis cannot be overstated, especially in populations like military personnel, where functional impairment may affect operational readiness. The client’s social and occupational functioning is compromised by her symptoms, which could lead to difficulties in military training and deployment if left untreated. Therefore, a comprehensive treatment plan should be implemented, consisting of pharmacotherapy, psychotherapy, social support, and trauma management.

Antipsychotic medications are the cornerstone of schizophrenia treatment, helping to control positive symptoms such as delusions and hallucinations. Evidence-based guidelines recommend atypical antipsychotics like risperidone, olanzapine, or aripiprazole, which have favorable side effect profiles (Howes et al., 2016). Medication adherence is often a challenge, especially in populations with paranoid delusions or mistrust of healthcare providers. To address this, psychoeducational strategies and therapeutic alliance building are critical. Psychoeducation aims to inform the client about her condition, benefits of medication, and strategies to manage side effects, fostering cooperation and adherence.

Psychosocial interventions are equally vital, addressing cognitive deficits, social skills, and vocational functioning. Cognitive-behavioral therapy (CBT) tailored for psychosis can help reduce paranoid thoughts, challenge delusional beliefs, and improve insight (Jauhar et al., 2019). Family therapy and social skills training may improve the client’s support system, while vocational rehabilitation can promote her return to productive roles, including her aspirations of attending nursing or IT college.

Addressing comorbidities such as trauma and stressors enhances the overall effectiveness of her treatment plan. Trauma-informed care emphasizes safety, trustworthiness, peer support, collaboration, and empowerment. For this client, incorporating trauma counseling can help process past experiences and reduce symptom severity. Also, given her military background, structured routines, peer support groups, and case management services within the military healthcare system can facilitate recovery and social reintegration.

In conclusion, a multidisciplinary approach is essential for managing clients with schizophrenia spectrum disorders. Accurate diagnosis guided by thorough assessment and family genogram analysis informs targeted interventions. Pharmacological treatment combined with psychotherapy, trauma care, and social supports can significantly improve her prognosis. This case illustrates the critical importance of early detection and comprehensive care in optimizing outcomes for young adults facing psychosis, especially within the military context where functional capacity is closely tied to identity and service readiness.

References

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
• Bertolucci, B., Pitta, J. C., Higuchi, C., Noto, C., Rocha, D., Joyce, D., ... & Gadelha, A. (2018). S129. Does Treatment Resistant Schizophrenia Present A Characteristic Symptomatic Signature?. Schizophrenia Bulletin, 44(suppl_1), S375-S376.
• Grande, I., Berk, M., Birmaher, B., & Vieta, E. (2016). Bipolar disorder. The Lancet.
• Howes, O. D., McCutcheon, R., Agid, O., De Bartolomeis, A., Van Beveren, N. J., Birnbaum, M. L., ... & Castle, D. J. (2016). Treatment-resistant schizophrenia: treatment response and resistance in psychosis (TRRIP) working group consensus guidelines on diagnosis and terminology. American Journal of Psychiatry, 174(3), 216–229.
• Jauhar, S., Laws, K. R., & McKenna, P. J. (2019). CBT for schizophrenia: a critical viewpoint. Psychological Medicine, 1-4.
• Jennings, K. S., Zinzow, H. M., Britt, T. W., Cheung, J. H., & Pury, C. L. (2016). Correlates and reasons for mental health treatment dropout among active duty soldiers. Psychological Services, 13(4), 356–365.
• Kahn, R. S., Sommer, I. E., Murray, R. M., Meyer-Lindenberg, A., Weinberger, D. R., Cannon, T. D., ... & Wang, Q. (2018). Schizophrenia. Nature Reviews Disease Primers, 4(1), 1-23.
• Skelton, M., Khokhar, W. A., & Thacker, S. P. (2015). Treatments for delusional disorder. Cochrane Database of Systematic Reviews, (5).