CASE ANALYSIS

A Paper
Presented to
MARINEL JUNE PALER, RGC, MA
Faculty of Graduate Studies
Father Saturnino Urios University
Butuan City

In Partial Fulfillment
of the Requirements for the Course
GUID 513 A (Abnormal Psychology)
SY 2017 – 2018, Second Semester

by

BERYL P. ABUCEJO, LPT, RPm

March 2018
I. Personal Information

Name: Amanda Siegel Sex: Female

Age: 19 years old Civil Status: Single
Educational Attainment: High School
Birth Order: Eldest

II. Background Information

Amanda is a daughter of a divorce parents. She is the eldest in the family of two. Her
parents had a divorce when she was 6 years old, leaving her and her sister in their mother’s
custody. Her father remarried soon afterward and was generally unavailable to their family. Due
to this occurrence, their family had a financial difficulty as her father provided little child support.
To sustain their needs, her mother began working as a waitress when she was 7 old. This left
Amanda and her sister, Megan largely unattended. At a very early age, Amanda took the
responsibility of taking care of her younger sister, and took on a number of household
responsibilities, such as regular meal preparation and shopping. Amanda did not complain
about the situation and she behave well at home and in school. However, she remained
distressed about the absence of her father and wondered how much better her life would have
been if her father was with her.
Her mother remarried to Arthur Siegel when she was 13 years old. Her stepfather had a
son, Mike who joined the household on a sporadic basis. Mike had been moving back and forth
between his parents’ houses because his mother could not manage his abusive and aggressive
behaviors. Amanda resented the intrusion of her stepfather and stepbrother into the household
because she still secretly hoped that her parents would remarry. She was also upset when her
mother changed their last name into Siegel and resented the loss of her caregiving
responsibilities, which were now shared with her mother and stepfather.
Soon after the marriage of her mother with Arthur, Mike (her stepbrother) began sexually
abusing her. She were raped several times and were threatened that if she ever told anyone, he
would tell all her friends that she was a slut. This pattern of abuse continued whenever Mike
was living with his father. Amanda was traumatized by the abuse yet unable to tell anyone. Her
behavior began to deteriorate. She had been doing very well academically in the seventh grade
and then began to skip classes. She started spending time with peers who were experimenting
with alcohol and street drugs, and became a frequent user of these drugs, even though she
experienced frightening symptoms after taking them. Her grades were so poor by the end of the
eight grade and was recommended for psychological evaluation to see if she should be held
back for a year. She was a given an extensive battery of intelligence, achievement, and
projective tests. Results revealed that she was extremely intelligent with an IQ of 130, and
projective test results (Rorschach and TAT) show a significant degree of underlying anger,
which was believed to be contributing to Amanda’s behavioural problems. The psychologist,
although have no knowledge of Amanda’s home life, recommended family therapy at a local
community mental health center as she suspected that Amanda’s problem may have reflected
from her difficulties at home.
Amanda, her mother, and sister began a family therapy with a social worker (Mr. Siegel,
her stepfather refused to attend the therapy) at the mental health center. During the therapy, the
social worker took a detailed family history and she noticed that Amanda was very guarded and
reluctant to share any feelings about or perceptions of the events of her life. The whole process
of therapy sessions still left Amanda unable to disclosed the sexual abuse which made her felt
depressed and guilty, with a very low opinion of herself.
Her mother and Mr. Siegel divorced when she was 15 years old, ending the sexual
abuse. When Amanda began high school, she continued her association with the same peer
group she had known in junior high who regularly abused drugs. She experience feelings of
being unreal and dissociation from her surroundings. She also began a pattern of promiscuous
sexual activity engaging in sadomasochistic activities to either both men and women,
particularly when she was under the influenced of drugs. By the time she was 16 years old, she
never wanted to be alone and was often bored and depressed when she had no one to spend
her time with. She experienced being pulled over by the police because the car they used while
cruising was stolen by one of her friends. Street drugs was also found in the car. Her
progressive deterioration continued and was recommended by the judge who heard the case to
undergo inpatient treatment in order to gain some control over her impulses and prevent future
legal and psychological problems.
During her first hospitalization, Amanda’s mood swings seemed to intensify. She
vacillated between outburst of anger, feelings of emptiness and depression, and showed signs
such as lack of appetite and insomnia. She spent most of her time in the hospital with a male
patient, and had idealized and fantasized of marrying him. When she was discharged, she had
her first nondrug – induced episode of feeling unreal (derealization) and subsequently cut
herself with a kitchen knife in order to feel real. She began making suicide threats over the
telephone to the former patient, saying that if he did not take her back, she would kill herself.
She was given her first trial of psychotic medication but it was ineffective.
While in the hospital, Amanda started individual psychotherapy, which was continued
after her discharged. It was psychodynamically oriented and focused on helping Amanda to
establish a trusting relationship with a caring adult. The therapist also attempted to help
Amanda understand the intrapsychic conflicts that had started very early in her life. However,
despite therapy sessions, Amanda continued to experience problems with drug abuse,
promiscuity, depression, feelings of boredom, episodes of intense anger, suicide threats,
derealization, and self-injurious behavior, such as cutting herself. Several hospitalizations were
required when Amanda‘s threats and self-injurious behavior became particularly intense or
frequent. These were usually precipitated by stressful interpersonal events, such as breaking up
with her boyfriend, or discussing emotionally charged issues, such as the sexual abuse by Mike,
in psychotherapy. Most of the hospitalizations were brief, lasting 1 to 2 weeks, and Amanda was
discharged after the precipitating crisis had been resolved.
Moreover, during one of the hospitalizations, Amanda decided to change therapist, and
after careful consideration, her treatment team decided to grant her request. She was 19 years
old when she was introduced to Dr. Swenson, a psychologist, and began individual behaviorally
oriented psychotherapy.
III. Evaluation Report

304.90 (F19.20) Other (or Unknown) Substance-use disorder, Moderate

A problematic pattern of use of an intoxicating substance not able to be classified within the
alcohol; caffeine; cannabis; hallucinogen (phencyclidine and others); inhalant; opioid; sedative,
hypnotic, or anxiolytic; stimulant; or tobacco categories and leading to clinically significant
impairment or distress, as manifested by the following symptoms:
1. The substance is often taken in larger amounts or over a longer period than was intended.
The client became a frequent user of street drugs. It was not stated in the case though
that she used the substance in a larger amount yet it was clear that she remained a user
of drugs for a longer period of time (from 8 th grade and continued to experience
problems with drug abuse).
2. Recurrent use of the substance resulting in a failure to fulfill major role obligations at work,
school, or home.
As presented in the case, Amanda became a frequent user of street drugs, and began
skipping classes which significantly affect her school performance. Use of the substance
continued despite progressive deterioration of academic performance and social
functioning.
3. Continued use of the substance despite having persistent or recurrent social or interpersonal
problems caused or exacerbated by the effects of its use.
Amanda experienced being pulled over by the police because the car they used while
cruising had been stolen by one of her friends. Also, during the incident, street drugs
were found in the car. The Judge who heard her case recommended inpatient treatment
yet at the end of her psychological case (as presented), she was unable to gain control
over her problems with drug use.
4. Recurrent use of the substance in situations in which it is physically hazardous.
Amanda engaged in sadomasochistic sexual activity particularly when she is under the
influence of drugs. She continued using drugs and was sometimes physically abused by
her sexual partners during sex.
5. Use of the substance is continued despite knowledge of having a persistent or recurrent
physical or psychological problem that is likely to have been caused or exacerbated by the
substance.
The client continually used the substance despite her experienced of frightening
symptoms after taking them (e.g., vivid visual hallucinations and strong feelings of
paranoia).

300.6 (F48.1) Depersonalization / Derealization Disorder

A. The presence of persistent or recurrent experiences of depersonalization, derealization, or
both:
1. Derealization: Experiences of unreality or detachment with respect to surroundings (e.g.,
individuals or objects are experienced as unreal, dreamlike, foggy, lifeless, or visually
distorted).
 She began her nondrug – induced episode of feeling unreal after her discharged from
first hospitalization. The continuing symptoms of derealization was still presented after
several therapy sessions.
B. During the depersonalization or derealization experiences, reality testing remains intact.
During derealization episodes, her reality testing remained intact – cuts herself with a
knife to feel real shows that Amanda is aware that her experiences are unreal.
C. The symptoms cause clinically significant distress or impairment in social, occupational, or
other important areas of functioning.
The disturbance impaired the client in important areas of functioning (i.e., interpersonal).
After her first non – drug episode of derealization, she began making suicide threats
over the telephone to a former patient whom she fantasized of marrying. She was a
given a short trial of antipsychotic medication but it was ineffective.
D. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of
abuse, medication) or another medical condition (e.g., seizures).
Nondrug – induced episode of derealization was mentioned.
E. The disturbance is not better explained by another mental disorder, such as schizophrenia,
panic disorder, major depressive disorder, acute stress disorder, posttraumatic stress
disorder, or another dissociative disorder.
- None Specified

301.83 (F60.3) Borderline Personality Disorder

A. A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and
marked impulsivity, beginning by early adulthood and present in a variety of contexts, as
indicated by the following:
1. Frantic efforts to avoid real or imagined abandonment.
Amanda never wanted to be alone and she was often bored if she had no plans for
spending time with anyone else.
2. A pattern of unstable and intense interpersonal relationships characterized by alternating
between extremes of idealization and devaluation.
Amanda had idealized a patient during her first hospitalization. She even fantasized of
marrying him. They watched TV together, ate together, and played various games that
were available on the ward. There was no physical contact or romantic talk involved, and
to any observer, their relationship don’t have a romantic component. However, when she
was discharged and broke off the relationship, she began making suicide threats over
the telephone to the former patient. Also, she had an unstable interpersonal relationship
even with her therapist and shows sign of trust issues (change of therapists).
3. Impulsivity in areas that are potentially self-damaging (i.e., sex, and substance abuse).
She engaged in sexual promiscuity, unable to refuse sexual advances from either men
or women, and participated in sadomasochistic sexual activities. Also, Amanda became
a frequent user of drugs which are potentially damaging.
4. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
Cuts herself with a kitchen knife. She also made suicide threats to a former patient,
saying that if he won’t take her back, she would kill herself.
5. Affective instability due to a marked reactivity of mood.
 Her first hospitalization showed signs of intense mood swings. She vacillated between
outburst of anger, feelings of emptiness, and depression.
6. Feelings of emptiness.
The symptoms were observed during her first hospitalization.
7. Difficulty controlling anger
Episodes of intense anger was presented as one of the key symptoms of her case.
 V61.29 Z62.898 Child affected by parental relationship distress
During her childhood, she was affected by the disruption of her parent’s marriage. Her
parents got divorced when she was 6 years old and her sister, Megan was 4 years old.
She behave well at school and home, and assumes caregiver responsibilities for her
younger sister. However, she remained distress about the absence of her father.
 V15.42 Z62.812 Personal history (past history) of neglect in childhood
The client experienced neglect and abandonment of his father after the divorce of her
parents. Her father never remembered important dates of her life, such as birthdays and
holidays. Their family experienced financial difficulty as her father provided little child
support and completely unavailable for them because he remarried soon afterward. She
often wonder how better her life would have been if her father was with her.
 V62.3 Z55.9 Academic or educational problem (reason for recommendation of
psychological evaluation when she was in the 8th grade)
Amanda was found to be extremely intelligent with an IQ of 130. However, her school
performance deteriorated as she began skipped classes and spent time with peers who
were experimenting with street drugs.
 V61.21 Z69.020 Encounter for mental health services for victim of nonparental child
sexual abuse
She was sexually abuse by her stepbrother, Mike when she was 13 years old. When this
occurred, she had not been sexually active with anyone. However, she was unable to tell
anyone even with the social worker during her first appointment together with her mother
and sister. On the other hand, later stage of her case showed that several
hospitalizations were required when her threats and self – injurious behavior became
intense and frequent which precipitated by stressful interpersonal events, such as
discussing emotionally charged issue of Mike’s sexual abuse to her.
 V62.5 Z65.3 Problems related to other legal circumstances (reason for first inpatient
treatment)
Amanda and her friends were pulled over by the police one night while cruising in a car
with her friends because the car had been stolen by one of her friends. Street drugs
were also found in the car. The Judge who heard the case was concerned about the
deterioration of Amanda’s academic performance and social functioning. He
recommended inpatient treatment to help Amanda gain some control over her impulses
and prevent future legal and psychological problems.

V. Conclusion

Amanda satisfied the criteria for Other (Unknown) Substance Use Disorder. As
presented in the case, the client had been a frequent user of street drugs and had shown
symptoms that characterized the substance use disorder. It was not otherwise specified on what
type of street drugs she used. It is difficult to put a specification on the substance used as there
are different classifications of street drugs which includes Uppers or Stimulants (e.g., Cocaine,
Crack, Crystal Methamphetamine, Ecstasy), Downers or Depressants (e.g., Heroin, Mandrax)
and Hallucinogens (e.g., Cannabis, LSD). However, this diagnosis may be reclassified when the
unknown type of substance is identified. The factors that contributed on the development of this
disorder was her exposure to peers who were using street drugs. A teenage years is tough and
her vulnerability to copy the behaviors of those around her was at its peak. Also, her father’s
absence in her childhood and teenage years may contribute to her drive of using drugs to cover
up her longings of his absence, particularly, when nobody on their household can protect her
against the sexual abuse of her stepbrother.
The client also showed features of Depersonalization / Derealization Disorder. It was
mentioned in her case that she experienced nondrug – induced episode of feeling unreal and
subsequently cut herself with a kitchen knife in order to feel real. Her action of cutting herself
may signify that her reality testing was still intact as she was able to distinguished reality from
her unreal experienced. She was given a trial of antipsychotic medication but it was ineffective.
Further, the diagnosis is not due to his consumption of drugs as it did not occur exclusively as
part or direct physiological effects of a substance. Moreover, at the later part of her case,
derealization was still present despite several therapy sessions.
Moreover, Amanda also had satisfied the criteria for Borderline Personality Disorder
showing symptoms of impulsivity, suicide threats, episodes of intense anger, feelings of
emptiness, promiscuity, and self – injurious behavior, such as cutting herself. Her functioning
was normal and was able to fight distress of her parent’s divorce before the onset of the
disturbance. She was found to be extremely intelligent but her history of sexual abuse by her
stepbrother, Mike may have triggered the situation. She was a productive daughter as she
behave well in school and in home prior to the intrusion of Mr. Siegel and his son to their
household. Her sufferings began when Mike started to raped her and threatened her that if she
would tell anyone, Mike would tell all her friends that she is a slut. This threats made her felt
helpless and unable to make a move on how to get away from the abused and physical
advances. This event may have play a role in the development of her BPD.
In addition, looking into the background of the client, it can be inferred that she had a
history of Adjustment disorder with mixed disturbances in emotion and conduct. However, it had
been ruled out from present diagnosis as the present functioning of the client (mentioned in the
later part of background information after her multiple hospitalizations) no longer satisfied the
criteria of the mentioned disorder.
Lastly, appropriate intervention is needed to successfully help Amanda in her
disturbances. Some of the symptoms may not be completely eliminated, but, with the proper
medication, psychotherapy, family support, and lifestyle management, Amanda will eventually
gain control over her life and may be able to restore good functioning in different areas.
VI. Treatment Plan

Intervention Description of Persons Means of

Date Objectives Strategies
Time Frame
Intervention Involved Verification

April 2, To be able to Medical Conducting 1 session  Client Psychiatric

2018 evaluate the History physical exam  Psychiatrist Records
patient’s present and and evaluating
symptoms, Physical medical Medical
treatment Exam history Records
previously
received, and Laboratory
possible illnesses Results
or medications
that might affect
the treatment plan.
April 9, To aid the patient Educating the 1 session  Client Organizing a
2018 in managing patient and  Family talk about
symptoms and Education her family Members substance
(mother,
preventing about the use, BPD,
sister,
complications, the nature of and
father)
patient as well as Amanda’s  Psychiatrist depersonaliz
her family needs disorder ation /
to understand the derealization
nature of dx; giving of
Amanda’s disorder informative
materials
(e.g. leaflets)
and; showing
videos about
the disorder.

April – To be able to Prescribing 6 months  Client Prescribed

August minimize the drugs to (depends on  Psychiatrist Drugs
2018 Medication
symptoms of BPD, stabilize the
Derealization Dx symptoms of response of Medical
as well as to substance the patient Records
stabilize the abuse to
withdrawal (possible medication)
symptoms of withdrawal
substance abuse. symptoms);
control
symptoms of
Derealization
Dx as well as
features of
BPD (BPD
cannot be
cure by
 medications
but can help
treat other
conditions that
accompany it
such as
depression,
impulsivity,
and anxiety)
April To help the client Psycho Conducting CBT (5  Client Behavioral
2018 – cope with the therapy psychotherapy sessions)  Family Treatment;
April difficult or sessions with Members Counseling
2019 the client Family – (mother, Sessions
uncomfortable
focused sister,
feelings, deal with  Cognitive – therapy (2 father)
stress, regulate Behavior sessions)  Psychiatrist
mood, and Therapy
manage impulsive  Family – Mindfulness
behavior. focused based
therapy therapy (5
CBT (focus on  Mindfulness sessions)
changing negative – based
thinking patterns cognitive Transference-
therapy focused
and behaviors into
(approach therapy (2
more positive
may sessions)
ways of involve
responding). meditation, 2 year follow
yoga, and – up when the
Family – focused breathing therapy and
therapy exercises) medication
(addresses issues  Transferen has been
in family and ce-focused discontinued
relationships therapy for 1 year
which works to
restore a healthy
and supportive
home
environment).

Mindfulness –
based cognitive
therapy (help fight
and prevent
depression,
manage
promiscuity,
intense anger,
agitation, feelings
of boredom and
emptiness, suicide
 threats and self-
injurious
behavior). This
therapy may help
Amanda to focus
her awareness on
the present
moment and break
negative thinking
patterns

Transference-
focused therapy is
designed to help
Amanda
understand her
emotions and
interpersonal
problems through
the relationship
between her and
her therapist.
Amanda then
apply the insights
she learned to
other situations.
Begins as To be able to Self-Care Maintaining a Lifetime  Amanda Keeping the
soon as
symptoms control symptoms Activities regular right lifestyle
are of the disorders as / exercise, good and following
stabilize
(Lifetime)
well as episodes Lifestyle sleep habits, activities that
of self-injurious Manage- nutritious diet, would
behavior ment taking reduce if not
medications eliminate the
as prescribed, appearance
avoiding of the
alcohol and symptoms.
drugs (other
than the
prescribed
medicine),
and healthy
stress
management.
May start To be able to Getting Participating Whenever  Client Widening of
once the
symptoms reach out to Involved in a substance opportunity  Support support
are totally people who are with – use support demands for groups system
controlled,
reduce, or
going through the Groups groups, and it (depends (Getting a
eliminated same of people BPD support on the solid support
experiences; and who fight groups. situation) system can
the make all the
To be able to learn disorder difference in
from others Amanda’s
people’s outlook and
experiences motivation)