The Competency-Based Assessment: Case Studies

Case Study 1

Diagnostic Assessment

Joshua comes to the office at the advice of his wife. The reason for the appointment was his lack of energy, feeling down, and loss of interest in his job, hobbies, and relationships. He has lost weight and was on sick leave from work. The client’s recent history includes suicidal thoughts, difficulty completing tasks, poor concentration, high energy, talkativeness – in the last week, however, Joshua has been inactive, depressed, sleepless, and disinterested. It is unclear what event was an antecedent of an episode, but the consequence was a complete change of behavior from highly-energetic to depressed.

The client’s usual cognitive functioning is defined by a lack of attention, poor memory, racing thoughts, high energy, and low focus. Currently, he has slowed down, but Joshua remains bored and unconcentrated. His emotions are mostly negative, as he reports to hearing a voice that talks about suicide. Behaviorally, Joshua has become inactive in life, wanting to vegetate and sleep at most times. He has difficulty sleeping and lays awake for hours at night.

His primary roles are of an employee (police officer) and a husband – he fails to perform both of them and distances himself from engagement. Joshua is married, and his relationship seems stable, although he admits that he has lost interest in it. His current relationship with his parents is unclear, but they saw him as a bad kid when he was young. At work, Joshua’s usual behavior is the cause of conflict as coworkers think that he talks too much. Potential support comes from his marriage, while his job may be an obstacle as the environment seems tense. Risks may include substance abuse, suicidal ideations, and the degradation of personal relationships. The client does not have any apparent cultural or economic problems.


The childhood and adult history of being disorganized, inattentive, overly energetic, and bored point to a diagnosis of attention deficit hyperactivity disorder (ADHD). ADHD is common in children, but it also occurs in adults. Such signs as poor memory, reckless driving, and restlessness confirm this suggestion (Katzman et al., 2017). Joshua’s family did not seek a therapist in his childhood, which left his condition untreated. The client’s current state also points to a depressive episode – a mood disorder that is a common comorbidity to ADHD (Katzman et al., 2017). Thus, one can conclude that the client experiences depression enhanced by untreated ADHD.

Case Study 2

Diagnostic Assessment

Sally came to the appointment to talk about personal problems related to feelings of abandonment. Before the referral, she had met with several therapists whom she deemed insensitive. Her history shows many relationships that ended because the client did not trust people or found them unreliable. She frequently felt irritated, angry, confrontational, and impulsive. At the same time, she expressed feelings of emptiness, loneliness, dissociation, disinterest, and abandonment. Her reactions and mood changes appear intense, frequent, and rapid.

Currently, Sally’s cognitive functioning is defined by dissociation and inability to think clearly. She shifts between irritation and emptiness, and her actions also change from reckless behavior to inactivity and back. The client engages in drinking alcohol, which has led her to lose several jobs and a driver’s license. Her mental status is not stable, and she responds aggressively to criticism. Sally is not in a relationship, and her mother is the only known family member. The client dislikes her mother and compares her to the devil – most past friendships are viewed in a similarly negative tone. Her current role as an employee is unknown, but she seems to have an overall poor experience with peers.

The client’s environment does not have meaningful relationships that could become her support structure. Thus, her main vulnerability is the lack of connections and her negative perception of people as untrustworthy. Nevertheless, Sally seeks therapy and is ready to come for another appointment. She is also open about her past experiences and feelings, which creates a basis for discussions. There are no apparent cultural considerations at the time.


Sally’s irritability, black-and-white thinking, impulsivity, and intense emotional reactions suggest borderline personality disorder (BPD) as the primary diagnosis. The mentioned above symptoms are present and consistent in the client, as Sally reports substance abuse, reckless spending and driving, aggressiveness, and dissociation (Gunderson et al., 2018). Moreover, BPD is related to feelings of abandonment, which moves people to react negatively to criticism or end relationships based on imagined adverse reactions. The client talks about her mother and past friends and partners in a way that suggests that she cut off ties out of fear of abandonment. Finally, substance abuse and BPD are connected as well – individuals with BPD are more vulnerable to an elevated rate of alcohol consumption (Carpenter et al., 2017).

Case Study 3

Diagnostic Assessment

The client is a young man who has been experiencing mood swings for the last two years. The reason for referral is the increasing intrusiveness of the changes. “High” moods last for 9-11 days, and “low” periods are much longer, spanning months. During high periods, he is talkative, overly energetic, unfocused, and reckless. Outside of these times, he loses interest and energy; Jose does not eat; he is anxious and suicidal.

Jose’s cognitive, emotional, and behavioral functioning is influenced by the period. During high times, he feels confident, aggressive, distracted, and adventurous. He engages in gambling and traveling without sufficient funds. Currently, Jose is depressed – he participates in smoking marijuana in such periods and avoids social situations. The client’s roles are a son, a boyfriend, a friend, and an employee, although he may not have a job at the moment. His parents support him financially, but his romantic relationship is at risk of ending.

Jose’s environment has both support and risks, and his main resource is his parents. They are supportive, but their financial stability is also an increased risk for the client who engages in gambling. Jose’s girlfriend is a source of possible support if she stays in a relationship. The client’s vulnerability is his reliance on distractions, such as marijuana and gambling. The client’s family and readiness for therapy are among the main strengths. Some cultural considerations include the client’s young age and ethnicity – Jose is a young Latino man. Thus, he may experience racial prejudice; he also does not have financial independence.


The client has two distinct periods that have their own moods and behaviors. The first one is short (9-11 days) and is defined by agitation, increased activity, talkativeness, and poor decision making – a description that fits episodes of mania and hypomania (Vieta et al., 2018). The second type of episode is depressive – the client feels empty and worthless, loses interest in usual hobbies, and seeks substances that would ease his anxiety (Vieta et al., 2018). The combination of these episodes points to bipolar disorder I as the primary diagnosis. Furthermore, the client has several addictions, such as gambling and marijuana (Stokes et al., 2017). He seeks both activities and perceives them as helpful in mitigating his moods, which creates an unhealthy dependence on potentially dangerous substances and behaviors.

Case Study 4

Diagnostic Assessment

Johnathan is referred to the clinic because of his worsening memory. He has a history of ADHD, and his memory was always one of the related issues. However, the memory loss and the lack of concentration have increased in the last four weeks; Johnathan has also been feeling down during this period. The client has signs of social anxiety that can be traced as far as his student years. Currently, he experiences trouble sleeping, loss of interest, as well as feelings of worthlessness and sadness. These feelings seem to be new, and the memory loss is described as rapid and sudden.

The client’s cognitive functioning has declined in the last month. He has trouble remembering some events and gets frustrated often. Emotionally, Johnathan is down – he is sad and disinterested in usual hobbies. His physiology changed as well since Johnathan lost interest in food and lost weight. His avoidance of social situations is not novel, and it had a significant influence on his life. The client is married; he has adult children and grandchildren. Johnathan is employed as an accountant, but he is taking some days off to rest.

Overall, Johnathan has a positive environment, a family, and a job. While he is anxious about social situations, he has a small number of friends and a very supportive wife who knows about his challenges. His principal vulnerabilities are the potential reluctance to ask for help, a long history of ADHD, and his current depressive state. Nonetheless, as he knows about his ADHD and has a trusting relationship with his wife, his awareness is also a source of strength.


In this case, several conditions comprise the diagnosis, as the history of ADHD can impact the client’s mental health with age. First, his memory loss may pertain to such issues as ADHD, anxiety, depression, and mild cognitive impairment (MCI). According to Callahan et al. (2017), the symptoms of ADHD closely resemble those of prodromal dementia or MCI, especially in individuals older than 50. Moreover, the combination of newly developing depression and ADHD can coincide with increased memory loss, as both disorders put increased stress on one’s cognitive abilities (Freire et al., 2017). The diagnosis of depression is explained by the client’s loss of interest, weight loss, insomnia, and the feeling of sadness (Freire et al., 2017). As a result, Johnathan’s memory problems are a result of ADHD and depression. However, the diagnosis of dementia has to be considered if the treatment for depression does not produce results.

Case Study 5

Diagnostic Assessment

In the fifth case, Winifred comes to therapy after the suggestion of her partner, who describes her as moody. Moreover, the client has a history of shifting moods – some periods are short (four days) and defined by high self-esteem, talkativeness, and poor decision-making. In contrast, others are much longer (several weeks) and are characterized by trouble sleeping, occasional suicidal thoughts, low appetite, fatigue. Apart from that, Winifred has a long history of inattentiveness and an inability to organize or follow instructions. As a consequence, her school experience was negative, but college was easier to finish.

Currently, Winifred experienced cognitive issues with memory and concentration during low periods. Her emotional functioning changes as well, but it is mostly defined by depressive episodes. She is fatigued most of the time but engages in impulsive activities when she is energized. She shifts between overeating and not eating much; her sleep patterns change between not needing much sleep or being unable to fall asleep, although she is tired. She maintains a romantic relationship, friendships, and hew job as a social worker, but her moodiness is a source of tension.

Winifred’s environment is a good fit for her – she seems interested in her current job, which supports her mental wellbeing. Her partner has some concerns, but she is supportive overall. Winifred’s friends are also open about their feelings, but the relationship remains stable. Thus, the client has a reliable system of potential supports. The client’s strengths are her career, lack of substance abuse, and a stable romantic relationship.


Currently, the client’s description of mood changes points to the diagnosis of bipolar disorder II. The second type is chosen because it is defined by shorter, less intense episodes of hypomania and stronger, more prevalent depressive periods (Vieta et al., 2018). Winifred’s hypomanic episodes last around four days, an approximate length needed for the diagnosis (Vieta et al., 2018). Furthermore, they are described mostly by self-esteem changes and poor decisions. This type of episode does not suggest mania that is much stronger than hypomania. In addition to the diagnosis of bipolar disorder, one should consider that Winifred shows signs of attention deficit disorder without hyperactivity (ADD). Here, the main symptom is inattention; Winifred has a poor memory, misplaces and loses things, gets distracted, cannot follow instructions, and loses interest. These descriptions fit the diagnosis of ADD, comorbidity to bipolar disorder (Katzman et al., 2017).


Callahan, B. L., Bierstone, D., Stuss, D. T., & Black, S. E. (2017). Adult ADHD: Risk factor for dementia or phenotypic mimic? Frontiers in Aging Neuroscience, 9, 260.

Carpenter, R. W., Trela, C. J., Lane, S. P., Wood, P. K., Piasecki, T. M., & Trull, T. J. (2017). Elevated rate of alcohol consumption in borderline personality disorder patients in daily life. Psychopharmacology, 234(22), 3395-3406.

Freire, A. C. C., Pondé, M. P., Liu, A., & Caron, J. (2017). Anxiety and depression as longitudinal predictors of mild cognitive impairment in older adults. The Canadian Journal of Psychiatry, 62(5), 343-350.

Gunderson, J. G., Herpertz, S. C., Skodol, A. E., Torgersen, S., & Zanarini, M. C. (2018). Borderline personality disorder. Nature Reviews Disease Primers, 4(1), 1-20.

Katzman, M. A., Bilkey, T. S., Chokka, P. R., Fallu, A., & Klassen, L. J. (2017). Adult ADHD and comorbid disorders: Clinical implications of a dimensional approach. BMC Psychiatry, 17(1), 302.

Stokes, P. R., Kalk, N. J., & Young, A. H. (2017). Bipolar disorder and addictions: The elephant in the room. The British Journal of Psychiatry, 211(3), 132-134.

Vieta, E., Salagre, E., Grande, I., Carvalho, A. F., Fernandes, B. S., Berk, M., Birmaher, B., Tohen, M., & Suppes, T. (2018). Early intervention in bipolar disorder. American Journal of Psychiatry, 175(5), 411-426.

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