Case Study: Diagnosis Assignment Axis I Clinical Diagnosis: Post Traumatic Stress Disorder

Case Study: Diagnosis Assignment
Axis I
Clinical Diagnosis: Post Traumatic Stress Disorder (PTSD)
Justification:
I believe Cindy suffers from the condition called Post Traumatic Stress Disorder because of her mother's abuse to her two years ago. After the incident Cindy tends to avoid her friends, family, activities and her sports. Cindy becomes scared of anything that reminds her of the event and her mother often triggers this uncontrolled fear. She is characterized as someone who shows disinterest in friends, school and other activities that previously stimulated her to be happy. She is unattached with her family and friends and has lost sight of her future and self-image.
Axis II
Personality Diagnosis: Borderline Personality Disorder (BPD)
Justification:
Cindy has Borderline Personality Disorder in many ways. Cindy often shows an unstable relationship with friends and family especially her mother. She often sees herself going nowhere in life and her attitude toward everything is negative. This causes an unstable relationship with her family and friends. Her social life has also taken a toll because she is distant from school and activities that once suited her.
Axis III
Biomedical Concerns
Cindy's mother has a history of mental issues
Her mother burned her shoulder two years ago and she still has not recovered
Possibly suicidal
She stays out of her mother's way
Withdrawn from everything for the past month
Constantly tired and cannot sleep at night; only during the day
Previously straight "A" student, but now grades have drastically fallen
Cindy has been sad and depressed for the past six months
Lost interest in school activities and sports
Axis IV
Pyschosocial stressors
Presence of her mother
School life
Social activities and situations
Axis V
Cindy's current GAF score
I gave Cindy a GAF score of 57 because she has a difficulty in both social and school activities. Although she doesn't fight with friends and family, she does not associate herself with any of them like she used to. It is difficult to determine how many stable relationships Cindy has but, it appears to be few. I gave her this score because of her involvement in social activities and school.
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