Nicole Pough

Module 14 Assignment

Title: A Mental Status Exam of Precious Jones

Demographic Info:
Precious Jones is a 16-year-old African-American girl who lives in Harlem with her abusive
mother and is pregnant with her second child. She dropped out of school in the eighth grade
and struggles with reading and writing. She has a history of physical, sexual, and emotional
abuse, as well as neglect.

Mental Status Exam:

During the Mental Status Exam, Precious appeared disheveled and unkempt, with unwashed
hair and clothes. She avoided eye contact and slouched in her chair, displaying poor posture.
Her speech was slow and hesitant, with long pauses between words. Precious exhibited
tangential and circumstantial thought processes, frequently losing her train of thought and
jumping from topic to topic. She often circled back to previous topics and repeated herself. Her
thought content was dominated by her traumatic experiences and negative self-image, with
frequent expressions of hopelessness and helplessness. Precious exhibited a depressed mood,
with a constricted affect and tearfulness. Her intellectual functioning appeared below average,
with difficulty comprehending and answering simple questions. She was oriented to person and
place but had difficulty recalling the current date.

Psychosocial Factors:
Several environmental, situational, and personal factors impact Precious' daily functioning and
symptoms. Her living situation, which involves physical, emotional, and sexual abuse from her
mother, has contributed significantly to her traumatic experiences and negative self-image.
Precious' lack of education and limited literacy skills also affect her ability to navigate the world
and access resources. Additionally, her pregnancy and the responsibilities of motherhood at a
young age further complicate her situation, leading to feelings of overwhelm and hopelessness.
The lack of a supportive social network exacerbates her struggles.

Clinically Significant Info & DSM-5 Symptoms & Diagnostic Criteria:

Precious presents with several clinically significant symptoms and experiences. She
experiences recurrent, intrusive, and distressing memories of her traumatic experiences, which
meet the diagnostic criteria for Post-Traumatic Stress Disorder (PTSD) in the DSM-5. She also
exhibits symptoms of Major Depressive Disorder, including a depressed mood, anhedonia,
feelings of worthlessness, and hopelessness. Her difficulty concentrating and low intellectual
functioning are consistent with a diagnosis of Intellectual Disability. Precious' history of sexual
abuse also increases her risk for developing a Substance-Related and Addictive Disorder, as
she has used marijuana and alcohol to cope with her trauma. Finally, her social isolation and
limited support network suggest a diagnosis of Social Anxiety Disorder.
Diagnosis(es):
Based on the DSM-5 criteria, Precious meets the diagnostic criteria for several mental
disorders. She meets the criteria for Post-Traumatic Stress Disorder (PTSD), Major Depressive
Disorder (MDD), Intellectual Disability (ID), Substance-Related and Addictive Disorders, and
Social Anxiety Disorder (SAD).

Precious' PTSD diagnosis is based on her recurrent, intrusive, and distressing memories of her
traumatic experiences. Her symptoms of MDD, including her depressed mood, anhedonia,
feelings of worthlessness, and hopelessness, are significant enough to warrant a diagnosis. Her
low intellectual functioning and difficulty concentrating meet the criteria for ID. Her history of
using marijuana and alcohol to cope with her trauma suggests a Substance-Related and
Addictive Disorder. Finally, her social isolation and limited support network suggest a diagnosis
of SAD.

Precious' experience of her disorders and symptoms is severe, as her symptoms significantly
impact her daily functioning and quality of life. She experiences frequent flashbacks and
nightmares related to her trauma, which interfere with her ability to function. Her depression is
pervasive, and she often feels hopeless and helpless. Her intellectual functioning is significantly
below average, which affects her ability to access resources and navigate the world. Her
substance use exacerbates her symptoms, and her social isolation contributes to her anxiety.

Given her severe symptoms and the complexity of her situation, a comprehensive psychological
assessment tool, such as the Structured Clinical Interview for DSM-5 (SCID), would be
appropriate to gather additional information and refine her diagnosis.

Treatment Plan:
Given the severity of Precious' symptoms and her complex psychosocial factors, a
comprehensive treatment plan is necessary. The treatment plan will include a combination of
Cognitive Behavioral Therapy (CBT), Trauma-Focused Cognitive Behavioral Therapy (TF-CBT),
and psychopharmacology. CBT will be used to address her negative thought patterns and help
her develop coping skills, while TF-CBT will be used to address her PTSD symptoms.
Psychopharmacology, such as Selective Serotonin Reuptake Inhibitors (SSRIs), will be
considered to manage her depression and anxiety symptoms.

In therapy sessions, we will focus on building a trusting therapeutic relationship with Precious,
establishing safety, and creating a supportive environment. We will work on identifying and
challenging negative thoughts, developing coping skills, and processing her traumatic
experiences. We will use TF-CBT techniques to help her manage her symptoms and develop a
sense of mastery and control. We will also work on developing healthy relationships and a
support network, including connecting her with community resources.

Prognosis:
Precious' prognosis is fair with appropriate treatment. While her symptoms are severe, she is a
resilient individual who has demonstrated a strong desire to improve her life. With the right
treatment plan, she can manage her symptoms, develop coping skills, and improve her daily
functioning. However, her prognosis is dependent on several factors, including her ability to
access resources, her support network, and the consistency of her treatment. The ongoing
presence of environmental stressors, such as her abusive mother and limited resources, may
also pose challenges to her recovery.