1. Please give a beginning diagnosis, including any specifiers required.
2. Indicate in writing a rationale for your diagnosis and use specific case data to support your diagnosis.
3. Identify two other potential diagnoses and why you would reject these in favor of the one you chose.
4. What further information would you need to make a more definitive diagnosis?
Tim is a 27-year-old male who approached a social service agency seeking treatment due to “extreme marital and occupational stress.” Client is slight in body stature with dramatic gestures and rapid speech.
Tim reported that he and his wife of three years recently separated after a year of constant physical and verbal fighting. This fighting often escalated to the point where police were called and both engaged in loud disputes with their neighbors. Tim reported that his wife tried to run him over with their car, threw him down the stairs and often hit him. He also reported that he struck her as well as engaged in loud arguments with her that would last for hours. In recounting these events with his wife, Tim gives the impression that his behaviors were justified by extreme provocation and that no one could possibly understand the uniqueness of his situation.
Tim recounted his occupational troubles as well during the first interview. He stated that he is probably the most talented electrical design engineer in the area, but he has had trouble finding and keeping a job due to the incompetence of his bosses. He believes they have all been jealous of his talent. He is currently free-lancing in designing electrical circuitry and states that he prefers this as he does not have to deal with “stupid bosses.”
Tim further states that he is a guitar player of some renown, although he could give no specific evidence of his fame. He stated that he has auditioned for several well-known musical groups, but he was “too good for them and they were afraid they would be shown up” so he was not hired by these bands. Tim also stated that he had amassed a fortune in musical equipment and is now forming his own band.
Tim admitted to habitual use of cocaine in the past several years, stating he was able to finance his drug use from the inheritance left him by his father upon his death four years ago. He says that he went through the entire inheritance and that he can no longer support his cocaine habit so he rarely uses now.
Tim is the older of two sons. His parents were divorced when he was 10. He states that his family was quite wealthy, perhaps “German aristocracy,” and that he always had a maid while growing up. There is some indication that someone other than his mother or father did much of the parenting when he was young. Tim further states that he was given every opportunity as a child, including painting and music lessons. He states that he is a very good artist and could have made that his career but was discouraged by his father who only wanted him to “make money.”
His mother is currently living in California with his younger brother. Tim expressed great hostility for this brother who is described as “Mother’s favorite.” His mother has recently remarried a man with whom she has been involved for the past 5 to 6 years. Tim’s contact with his mother seems limited and characterized by alternating hostility and dependence.
Tim presents himself as a confident person, while almost continually seeking validation of his statements, e.g. “That’s pretty good for a guy my age, right?” After the first interview he stated that he was really seeking treatment because of legal troubles and needed an evaluation to present to the court. He stated that he was picked up for speeding and the encounter soon turned violent when he was asked to accompany the officer to the station. Tim saw this as a threat and proceeded to “tear up” the station. He state that he was just distraught by seeing his wife with another man at a class reunion and that the officer should have realized this.
In discussing the evaluation, it became clear that Tim wanted a “clean bill of health” that he could use in his defense. He became angry when informed that such an evaluation would have to be done in conjunction with the agency psychiatrist. He stated that he had seen enough “shrinks” in his lifetime and would not see another. He revealed that when he was 8 years old he had been “hospitalized” by his mother and still considered this an outrage, wanting to know how she could have done this to him. Tim stated that he never knew why he was hospitalized except that he was involved in a lot of physical fighting and had accidently started a fire in his garage that was responsible for its destruction.
Tim reported that he wanted to enlist in the marines but knew they would not take him because of his criminal record. He then revealed that he had been convicted for armed robbery of a gas station when he was 17 and served one year in prison. He was indignant that the marines would not take him, even though he had “paid his debt to society.” He alluded to the possibility that he may have murdered someone in a barroom fight, but could give no details. He does report, however, a bizarre behavior at this time in which he puts on army fatigues and with another friends, conducts “commando raids” on neighbors gardens and has shot ducks in forest preserves. He stated that he needs to learn survival skills and is using the food to live.
Tim says that he is “not all bad” as he is involved in “charity work.” He states that he tries to work with youth who think that guns and violence can be a way of life, and regularly gives money to a friend with two small children who is out of work.
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