Demographic information
- Name: M. S.
- Age: 46
- Sex: Male
- Ethnicity: Caucasian American
- Date of Interview: 10/12/2021
Introduction
The evaluation process was self-referred by Mr. S. He is a 46-year old single male whose primary issues lie in the area of personal and work relationships and anxiety. He complains that his anxiety in the last five months has become highly disruptive of his work and personal life. The given assessment is conducted in order to identify the appropriate diagnosis and options of treatment.
Family background
Mr. S. was born and raised in Scranton, Pennsylvania, by his two biological parents, who later divorced. The client reports that he has a half-brother and half-sister from his biological father, but he has never contacted them. Mr. S. describes his relationship with his parents as “problematic” due to having a “difficult childhood” because of their inattentiveness and indifference towards him. His mother was a nurse who was constantly busy at work, whereas his father worked at an oil rig with a work schedule based on a rotation of 28 days.
Mr. S. currently does not have a family of his own and lives alone at his condo. He reports dating a 38-year-old woman but describes it as “challenging” due to her being his superior at the company in which he works. Mr. S. has no children and does not plan to have one in the near future.
Significant medical/Counseling history
Mr. S claims that he never used counseling services, and he is not taking any medications at the moment. His previous physical examination was a year ago, and there are no substantially important points in his medical history.
Educational and vocational history
Mr. S. graduated from the University of Scranton in Business Administration in Scranton, PA, and has completed four years of college. Mr. S. is currently working at a paper company as a regional manager and has held this position for 11 years, with prior positions being a sales manager. The current employer was his first employer as well. He had a short period of unemployment due to entrepreneurial pursuits but was able to return to his old position.
Mental status exam
Mr. S. was well-dressed and well-groomed for the interview by wearing a dark blue suit. He appeared to have no abnormalities and irregularities, and the appearance matched the reported age. Eye contact and other facial expressions were within the norm, and he demonstrated average intelligence. There were no indications of homicidal and suicidal thoughts or tendencies. However, Mr. S. communicated a grandiose sense of self-importance and reported constantly seek praise and admiration.
Assessment results
The client was administered a semi-structured clinical interview and mental status exam. Results were unremarkable. No additional tests were administered.
Diagnosis
DSM-5 301.81 (F60.81) – Narcissistic Personality Disorder.
Summary and conclusion
Mr. S. is a 46-year old single male whose primary issues lie in the area of personal and work relationships and anxiety. He was raised by his two biological parents but experienced indifference and inattentiveness as a child. Currently, he experiences difficulties in building and maintaining personal and work relationships and is dating his superior.
Recommendations
- Utilize psychotherapy or talk therapy.
- Conduct weekly CBT.
- Determine the treatment objectives.