NCMHCE Practice Test 4
10 free NCMHCE practice questions in the real exam format, covering the official content areas, with an explanation for every answer.
Question 1 of 10
Intake, Assessment, and DiagnosisCase study: Veteran with nightmares and nightly drinking
| Client | |
|---|---|
| Age | 38 |
| Gender | Male |
| Sexuality | Heterosexual |
| Ethnicity | African American |
| Relationship Status | Married |
| Counseling Setting | Community counseling agency serving veterans and families |
| Types of Counseling | Individual |
| Provisional Diagnosis | Posttraumatic stress disorder (specifiers to be determined) |
Presenting Problem
You are a licensed mental health counselor working in a community counseling agency that serves veterans and their families. Lamont, a 38-year-old Army veteran who served two deployments as a combat medic, comes to intake at his wife's urging after she found him asleep in his truck in the driveway at 3 a.m. following a night of drinking. He says, "She thinks I'm falling apart. I think I'm just tired." Lamont left the military 3 years ago. He describes a convoy attack 11 years ago in which a soldier he was treating died. He says he "held it together" for years, but over the past 14 months, since a coworker was killed in a line-work accident, his symptoms have steadily worsened. He has nightmares about the convoy four to five nights a week, wakes "soaked and swinging," and now sleeps in a recliner so he will not hit his wife. When a truck backfires, "for a few seconds I'm back on that road, and I can smell it." He avoids war movies and unit reunions, has stopped watching the news and drives long routes to avoid overpasses. He says, "I love my daughter, but the feeling's switched off. I can't get it back." He startles at slamming doors, sits facing exits and checks the door locks two or three times a night. He blames himself: "A real medic would have stopped the bleeding." Several times a month, for a few minutes at a time and including on days he has not been drinking, "everything around me looks flat and fake, like a movie set." Lamont drinks five or six beers most nights "to get to sleep" and more on weekends; his AUDIT score today is 18. He has missed four shifts in the past 2 months and received a written warning. When asked directly about suicide, he says, "Some nights I think it would be easier to just not be here anymore, but I wouldn't do that to them." He denies a plan, intent or past attempts. He keeps a loaded handgun in his nightstand "for security." He denies thoughts of harming others.
Mental Status Exam
Lamont arrives on time, casually dressed and adequately groomed, with a healing cut on his knuckles that he says came from "punching the headboard in a dream." He is oriented to person, place, time and situation. He sits with his back to the wall and scans the room when the hallway door closes. Eye contact is intermittent. His mood is "worn out"; affect is constricted and congruent with mood. Speech is normal in rate and low in volume. Thought process is linear and goal-directed, and thought content centers on guilt about the convoy and worry about his job. He denies hallucinations and describes the "movie set" episodes with reality testing intact. Memory is grossly intact, though he reports poor concentration at work. Gait is normal, and his startle response is elevated. He reports passive death wishes as described, denies intent, plan and homicidal ideation, and denies any history of mania. Alcohol use is as described; he denies other drug use.
Psychosocial and Family History
Lamont has been married for 9 years and has a 7-year-old daughter. He works as a field technician for a regional electric utility; the company's employee assistance program (EAP) gave him the agency's name after his written warning. His father, also a veteran, "drank his feelings," and Lamont says he swore he would never be like him. He was raised in the Church of God in Christ and says his faith "went quiet" after his second deployment. He texts with a few soldiers from his unit but has not seen any of them in over a year. Money is tight since the warning put his overtime on hold. He has had no prior counseling and declined mental health services when he left the Army because "it goes in your record." His trauma screen is positive, and his PCL-5 total at intake is 54. At the end of the intake, Lamont asks, "If I tell you how much I really drink, does my job or the VA find out?"
Which client report supports adding the "with dissociative symptoms" specifier to Lamont's PTSD diagnosis?