Danial’s Case Study
Part One
Case summary
From the case scenario provided in part one, Danial is a seven-year-old boy whom his parents brought him in. Upon sitting down, Daniel sat close to his mother, clinging on her. His older brother is named Salim. Furthermore, in the family setting, Danial resides with Yalda, his mother, and Nasir, his father, an owner of three convenience stores. Religion-wise, the family are Pakistan-Muslims who, ten years ago, moved to the United States. Despite their origin, the parents are very well conversant with English, a language they very well speak. Furthermore, they firmly believe in their culture, which has made it quite difficult for them to transition to the American culture. Although he is young, Danial makes movements that make them possible for him to be mistaken for a girl. He is, however, currently in his second grade besides being an A-B student in school.
The concern with Danial’s parents is because they have been experiencing lousy stomach aches since their son’s commencement of the school year. In their explanation, they think that their child wants to stay home with the mother since he has been displaying similar behaviors in the past. As a result, Yalda has been working all through in his Kindergarten class. The son’s stomach complaints are much worse this year than the other years. Furthermore, he has trouble sleeping and waking up, which he frequently does throughout the night. Due to the circumstances surrounding these problems, Danial needs someone to stay with him every time he falls asleep each night, although his father puts a stop to that regardless of the child’s crying due to such decisions.
The parents explain how their son can be found sleeping outside their room due to his nightmares about their mother’s kidnapping. Moreover, they describe how they are only capable of leaving their son with Yalda’s parents as a way of avoiding his cry whenever the child is left with other people. After observing that Danial is very tightly held to his mother, his fear is affirmative. Such is because he describes that he is much fearful that something terrible could happen to his mother. Moreover, the child never wants to talk alone beside his clinging onto his mother more when asked to do so. Despite the affection that the child seems to be having with his mother, such is not the case as the father continually rolls his eyes at Danial’s behavior. The son does not have any family or personal history due to mental concerns. Moreover, there is no existing history of substance or physical abuse in the family lineage. Danial appears to be developmentally normal other than other behavioral concerns with his father because he likes to play more with dolls and girls.
Clinical impression and diagnosis
309.21 (F93.0) Separation Anxiety Disorder
302.6 (F64.8) Other Specified Gender Dysphoria
309.28 (F43.23) Adjustment Disorder with mixed anxiety and depressed mood
Other factors are,
V61.20 (Z62.820) Parent-Child Relational Problem
995.52 (T76.32XA) Child Psychological Abuse, Suspected
V62.3 (Z55.9) Educational Problem
Recommendations
After reading the first part of the case study, I recommend that Danial starts therapy with a counselor well-versed in the family’s diversity and cultural awareness. Furthermore, I would recommend a male therapist in this case as he will be capable of adhering to the family’s cultural customs since the child under the subject is also male. Additionally, Danial’s mother is supposed to attend the therapy sessions with him until the treatment stage for their son is reached as by the time he will be much comfortable with his mother’s absence. The therapy session should again be focused on trust issues areas and healthy parent-child relationships. It will be acceptable if the clinician remains sure of gauging treatment in ways that aim at preventing unhealthy client-therapist dependency or relationship. The father should also be involved in the therapy sessions to work through their obvious trust issues and relationship. There is a great need to carry out medical testing, which will enable healthcare professionals to rule out any stomach diseases in the child. Having more information on Danial’s education history will help gain insights into the boy’s social interactions with his peers.
Questions
Question 1. What are your diagnostic hypotheses for Danial in this scenario? Justify your conclusions.
Response: In part one, the diagnostic hypotheses for Danial are Separation Anxiety Disorder, Other Specified Gender Dysphoria, and Adjustment Disorder with mixed anxiety and depressed mood. The reason for choosing separation anxiety disorder is due to the child’s unhealthy attachment to his mother. Others are the fears that her mother will be taken away from him. In this diagnosis, the factors that are considered include the child’s difficulty and reactions to being away from the child during school time and while at sleep. Furthermore, another specified gender dysphoria was included in the diagnosis because the child did not meet the requirements for gender dysphoria. The inclusion of adjustment disorder was due to a diagnostic possibility due to the parents’ cultural difficulty in adjusting to life in the United States. Such difficulty, as well as the cultural views, significantly impact the way they treat and view Danial.
Other diagnostic factors are Suspected Child Psychological Abuse, Parent-Child Relational Problems, and potential educational problems. The additional elements are evident in the information and interactions that Danial’s parents give during the interview. The reason for choosing suspected child abuse was noticing Danial and his father’s interaction during the meeting. Because of the mentioning of the female mannerisms of the child, such could result in discord between the child and the family. In Muslim families, women and men who act like or relate like the opposite genders often find themselves much isolated from their families. Therefore understanding such a cultural background, it is worth considering psychological abuse a possibility until more information is obtained.
Question 2. Describe what further diagnostic information you need (what further diagnostic evaluation is warranted) at the end of this scenario.
Response: The other information that will be needed will be to learn more about Danial’s relationship with his peers, brother, and other members of the family. Knowing this will thus allow for information for the diagnosis of the attachment disorder. More observations on Danial’s relationship with his father will be required to understand the way his father treats him in various settings. Furthermore, the provision of information on the history of his female tendencies would also help understand the degree of dysphoria. It is hence necessary and helpful to know the reactions of his father for his feminine behaviors and the impact it has on other people. The medical setting will be of much essence in ruling out any possible medical disorders.
Question 3: From a diathesis-stress perspective, what impact do the cultural, ethnic, and psychosexual issues have on Danial and his family in this scenario, and what other issues may play a role?
Response: Because Danial comes from a Muslim family, there should be consideration of cultural and ethnic influences. Because of the high disapproval of gender dysphoria in the Muslim religion and culture, the presence of such a diagnosis in the child would explain other factors that add to Danial’s anxiety. Furthermore, it would also help address the stress that his family experiences as they would not want to be looked down upon by others in the Muslim culture. Regarding attachment issues, the attachment theory might help predict whether a child who is anxiously attached, is more prone to develop separation anxiety as compared to one who is securely attached (Wilmshurst, 2011). Therefore, learning more about Danial’s attachment style will be of much importance.
Part Two
Case Summary
In part two of the case study, Danial is currently aged 16 years. According to the previous medical records, he is a Muslim who completed his therapy at the age of seven. He is therefore brought in by his mother and thus believes that she is being tricked into coming. The report from his mother is that Danial’s behavior improved after the previous treatment he had as a child. However, the child has begun isolating himself from friends and family members. Report from the mother also indicates that Danial has always been too sensitive, although his behaviors have lately changed, making him be very irritable and mean to other people. The boy has quick forgetfulness besides the fact that he has lost weight six weeks because of his loss of appetite.
During the interview, Danial sits far away from his mom, where he appears much annoyed every time she converses. However, his family and medical history do not indicate any instances of abuse. The only psychological note availed is on his treatment at the age of seven years. Furthermore, the mother reports that the son has not been sleeping well for the previous seven months, where strict no manic behavior is evident. Having conversing with Danial, more information regarding his social life emanates. Such happens as he talks of how he only has one guy acquaintance where he mainly hangs out with females. He describes other guys that are similar to his brother and friends as a bunch of jocks who think that he is much worthless. Danial comments on how he is less than the dirt on his brother’s shoes besides asking the father reasons for treating the brother like the star of the family. The nails that Danial wears are elegant with a clear coat of polish on them.
Furthermore, he significantly denies any reason to withdraw his small group of family and friends. The only comment he gives is that he never wants to be around any individual, including the clinician. Again, Danial denies any suicidal feelings. He is, however, quick to mention that he recently played with his father’s muzzle to his head besides clicking the trigger in the pretense of killing himself. Danial’s only comment to such is that everyone will eventually die and that his actions were only an existential dream. He also briefly mentions that he gets vodka from someone, although he is never willing to expand on such information.
Clinical impression and diagnosis
296.23 (F32.2) Severe Major Depressive Disorder with Melancholic features
300.23 (F40.10) Social Anxiety Disorder
302.85 (F64.1) Adolescent Gender Dysphoria
Other factors are,
V61.8 (Z62.891) Sibling Relational Problem
V61.20 (Z32.820) Parent-Child Relational Problem
305.00 (F10.10) Alcohol Use Disorder, Mild
Recommendations
It is recommended that denial be entered into Danial’s therapy immediately to help in treatment for his family issues and emotional instability. He also needs to be screened for possible suicidal risk. After assessing the severity of his suicidal risk, the clinician must determine whether or not Danial needs to be admitted for treatment to reduce the self-harm risk. There is also a need for the family to be informed of his habits of playing with a gun, which will enable them to be aware hence taking the necessary precautions. However, such should be done in ways that ensure the reduction of strain on the relationship within the family.
Additionally, there should be evaluations for alcohol and substance use, which should be treated through coping skills that deal with anxiety and cessation of alcohol consumption. Because alcohol can result in a worse state of depression, such an area should be addressed immediately. Upon being emotionally stable, there will be a need for him to commence family therapy sessions with an experienced therapy on Muslim families. Furthermore, working through such relationship issues with the family members will help in providing strategies on better ways of repairing his relationships with other people. Because of the boy’s relationship with his brother and father seems to be at the root of relationship concerns, it is essential to attempt repairing and creating an understanding. Psychological assessment is also critical in assessing the behavior as well as the level of depression. More information on whether Danial has gender dysphoria will also be helpful. Eventually, a medical evaluation will be of much significance in ruling out any possible medical situations and problems with other substance use issues.
Questions
Question 1: What are your diagnostic hypotheses for Danial in this scenario? Justify your conclusions.
Response: In part two, the diagnostic hypothesis is Social Anxiety Disorder, Severe Major Depressive Disorder, and Adolescent Gender Dysphoria. The reason for choosing Severe Major Depressive Disorder is because Danial meets nine of the disorder’s criteria. It is, therefore, his depressed mood and suicidal intentions that influenced Danial’s diagnostic decision. Additionally, Adolescent Gender Dysphoria was a diagnostic possibility due to the information provided from the medical report at the age of seven years. He also notes that he feels more comfortable and as himself around females than when he does with males. Interestingly, adolescents who have gender dysphoria meet the criteria for a depressive disorder (Megeri and Khoosal, 2007).
On the other hand, social anxiety is included because he has very few friends and relationships with others. Hence, the condition can be either confirmed or disputed after more information is provided about Danial’s major depressive disorder. Other diagnostic factors that should be considered are parent-child relational issues, sibling relational problems, and a potential alcohol use disorder. For the sibling relational problem, such as a factor because there is an apparent rivalry between Danial and his brother. On the other hand, the parent-child relationship is evident in how Danial’s father treats him in comparison to his brother, together with his interactions with the mother during the interview session. There is again a potential of alcohol use disorder because of Danial’s mention of consuming vodka. Gaining more information on alcohol use will thus be of much help in understanding whether it is a factor that contributes to Danial’s anxiety and depression symptoms.
Question 2: Describe what further diagnostic information you need (what further diagnostic evaluation is warranted) at the end of this scenario.
Response: There is a need for more information on whether Daniel experienced a traumatic social encounter, which could have added to Danial’s relational issues with others and his social anxiety. Additional information on the way he gets the vodka is that his degree of consumption is also vital in understanding if it adds to his symptoms of depression. There is a great need for a more understanding of Danial’s suicidal intentions, which should be the priority for further diagnostic information. It should also be known how the family’s cultural beliefs impact the relationship the teen has with both his brother and father for a proper treatment plan. Again, Danial needs to be evaluated for the potential use of other substances. Eventually, there should be psychological evaluations for depression, including the conduction of the Beck Depression Inventory.
Question 3: From a diathesis-stress perspective, what impact do the cultural, ethnic, and psychosexual issues have on Danial and his family in this scenario, and what other issues may play a role?
Response: By learning more of the Muslim perspective on gender dysphoria and how it plays a role in Danial’s relationship with other members of the family is of much significance. Such is a diathesis-stress model that provides a discussion on the potential connection between the critical cause of depression and the degree to which an individual is susceptible. In the case of Danial, his cultural influences might be playing a massive role in his vulnerability for the development of depression. Therefore, an assessment of his probability of depression can be compared to other successful events in his entire life.
Part three
Case summary
In the third part of the case study, Danial is now aged 25 years. Here, he now works as a draftsman for a large architectural organization, with his uncle as the firm’s head boss. After being required to bring himself to interview by his boss, he has attended. Before meeting with Danial, I had the opportunity to review his previous records, which had his treatment information from seven to sixteen years of age. The reports indicated that he displays a long history of anxiety besides showing signs of dysphoria at a tender age. He also has a history of adverse treatment by his father due to his feminine preference, which negatively impacted him in several ways. He also has a history of putting a gun in his head at the age of sixteen and drinking vodka. Presently, Danial has returned to treatment as a mandatory request by his boss in the event he wants to retain his job.
Furthermore, he was referred to me by his medical doctor, who is also the person that provided me with his past treatment records. After inquiring why he thought that his boss was interested in firing him, he explained how his boss, together with other employees, made jokes, which implied they had a pact against him. He describes himself as a star and an astounding draftsman who is both underpaid and unappreciated. After such insights, he shares his opinion that I am siding with his boss because of reporting everything that has happened to him so that his boss could fire him. He again explains his rationale for why his boss pays me. After telling Danial that I no longer knew his boss and that he had the right to choose the therapist of his want, he decides to stay because he feels that I would report that he left the therapy session.
Afterward, we made a verbal agreement that everything was confidential unless he had intentions of harming himself and others around him. I later signed a note of confidentiality as a way of putting his mind at ease and then discussing his previous emotional concerns with the scenario with his father’s firearm. He responds that he is never depressed and that he is ever happy. Furthermore, he claims to not have trust in people and not losing weight. He also claims to be able to sleep. The only reason why Danial is here is to get his uncle and boss off his back. Furthermore, he mentions that he wanted to learn, figuring if his boyfriend was having an affair. He is also very reluctant to answer questions but then says that he drinks an average of three to five highballs a day during weekends and even more sometimes. He also describes his relationship with the family as a hostage situation where they need him to keep to their Muslim traditions. Danial never maintains much contact with his parents and intentionally changes his mobile phone to ensure minimal contact. He, however, ends the session with a sarcastic note regarding every individual at his job place being gay, he included besides a sly remark on his father’s opinion of gay people.
Clinical Impression and Diagnosis
301.0 (F60.0) Paranoid Personality Disorder
R/O 301.83 (F60.3) Borderline Personality Disorder
Other factors are
V61.29 (Z62.898) Child Affected by Parental Relationship Distress
V62.29 (Z56.9) Other Problems Related to Employment.
V61.10 (Z63.0) Relationship Distress with Intimate Partner
V62.89 (Z65.8) Other Problems Related to Psychosocial Circumstances
Recommendations
Based on the conducted interview and other past medical health records, I recommend that Danial engages in therapy. The reason is that participating in the said therapy will be of much help in learning the effective ways of managing his thoughts that involve the way others perceive the social interactions, him, and his ideas that others are conspiring against him. Again, the therapy session will aid in recognizing the way his paranoid thoughts act as an influence on Danial’s perception of others. Such a move will also bring awareness of how his behaviors are the reason the boss’s job security threatened him if he failed to seek counseling. Other options for the treatment would also include sending him to a psychiatrist to receive medication to stabilize his emotional activity. It will also be important in retrieving reports from the boss and intimidating partners on his behaviors to help with the provision of a clear picture of his deeds in both professional and social settings. Finally, it will be recommended that Danial be evaluated and assessed for any substance abuse to rule out, such as an influence for the paranoid and erratic behavior.
Questions
Question 1: What are your diagnostic hypotheses for Danial in this scenario? Justify your conclusions.
Response: For the third part, the diagnostic possibilities are Borderline Personality Disorder or Paranoid Personality Disorder. In this case, paranoid Personality Disorder is listed as the primary hypothesis due to the paranoia that Danial has while thinking that individuals around him are conspiring against him. He believes that his boss, as well as other coworkers, are conversing behind his back. Again, he has paranoid thoughts that the boss and I are conspiring behind his exposure. Other paranoid aspects are evident in his thoughts that his partner is cheating on him behind his back despite having no proof for such claims. In this case, also, a borderline personality disorder is an alternative diagnosis. The evidence here includes his unstable relationships, self-image issues, and other criteria for diagnosis. In this case, gender dysphoria was never added because Danial reported his homosexuality, so the diagnosis did not apply. Other factors that impacted the mental state include parental relationships, relational distress with partner and employment, and different circumstances. All the other factors played a huge part in this paranoid personality disorder that Danial was diagnosed with. Because of his homosexuality, his relationship with parents and family members is much impacted as he never trusts the cultural traditions they hold. Danial is paranoid about his partner’s affair. It is worth noting that most of the issues he has are due to paranoia and the need for therapy to keep his position.
Question 2: Describe what further diagnostic information you need (what further diagnostic evaluation is warranted) at the end of this scenario.
Response: The other diagnostic information that is needed would include abuse of substance and evaluation of ruling out whether the substance could be the contributor of such behaviors. Referral to a psychiatrist will also be vital for the prescription of the medication. Further information about such practice both at work and in a social setting also requires to be gathered as a way of providing a clear picture of Danial’s behavior and paranoia with others.
Question 3: From a diathesis-stress perspective, what impact do the cultural, ethnic, and psychosexual issues have on Danial and his family in this scenario, and what other issues may play a role?
Response: The opinions that Danial’s parents have on him are based on their culture and disapproval of being homosexual. Such plays a role in the mental issues Danial has. The trust issues he had as a child also play a significant role in his current paranoia.
Part 4 Questions and Issues
Question: Given Danial’s family background and his open homosexuality, what cultural and ethnic factors do you need to be aware of at the different stages of his life, and how would you deal with them in arriving at your diagnosis? Give your reasoning with supporting documentation.
Response: In arriving at the diagnosis, Danial’s family background provides a lot of ethnic and cultural factors. The family immigrated to Pakistan from America, where they obtained their Muslim beliefs as well as practices. In treating individuals who show feminine mannerisms such as Danial as a child, it is of much essence to take into consideration the view of parents in homosexuality and gender dysphoria. In part one and two of the case, gender dysphoria was one of the diagnostic hypotheses. His parents’ reaction to the diagnosis was a thing to consider since it would much impact Danial and his family. Because of the Muslim culture as well as a religious view of homosexuality a crime against the community as well as a sin to Allah, it would be advisable not to mention such a specific diagnosis to the parents (Dogan and Dogan, 2006). Homosexuality is illegal in most countries, and thus, telling the parents created more problems. It is tough for a clinician to push values and beliefs onto the clients and family in treating the client (Richards and Worthington, 2010). Such shows that there is a great need for culturally diverse treatments and approaches.
Richards and Worthington (2010) comments on the way, considering such views, helps the medical therapists create a quite vivid and complete picture of the issue. An excellent example of such would be in the third part in Danial’s adult stage, where he mentions that his father never approved his homosexuality as a Muslim. It will be essential to get both sides of the picture for a complete understanding of the perspective. Due to paranoia, a comprehensive cultural view was necessary as a way of weeding any false information. Such information could have emanated from the boss, family, and friends. Such a complete picture would ensure the accuracy of the information, for the implementation of the best diagnosis and treatment.
Question: Compare and contrast the changing roles of psychosexual diagnoses in the DSM text since the 1950s.
Response: It is of great importance to understand that in the 1950s, most of the information in the DSM was only theoretical. Most of the psychosexual information that was available never had psychiatric reasoning to back it up (Ishak, 2013). Such information came from theories including Freudian, which described issues such as castration anxiety as a way of justifying sexual deviance. Over the years, there has been an evolution of the theories and ideas up to the 1980s, where psychiatrists employed phrases such as ‘ego-dystonic homosexuality’ in describing an individual who could be distressed about homosexuality. Such was, however, quickly removed where it continually transformed. There has been an evolution of paraphilia, and psychiatrists keep on disputing on the qualifications of it being a mental disorder. DSM-5, therefore, clarifies the diagnosis besides providing a vivid understanding of the required criteria for diagnosis. Currently, DSM-5 is now inclusive of three female dysfunctions and four male dysfunctions. Further narrowing down of the disorder hence enhances the user with clarity. Although there has been a vast improvement of DSM since the 1950s due to the arising controversies and change in society, so will happen to the descriptions of the psychosexual diagnosis roles.
References
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders. (5th Ed.). Washington, DC: Author.
Dogan, S., & Dogan, M. (2006). Possible gender identity disorder in an extremely religious Muslim family. Archives of Sexual Behavior, 35(6), 645-646.
Ishak, W. (2013). DSM-5 changes in diagnostic criteria of sexual dysfunction. Reproductive System & Sexual Disorders.
Megeri, D., & Khoosal, D. (2007). Anxiety and depression in males experiencing gender dysphoria. Sexual and Relationship Therapy, 22(1), 77-81.
Richards, P., Worthington, E. (2010). The need for evidence-based, spiritually oriented psychotherapies. Professional Psychology: Research and Practices, 41(5), 363-370.