Assignment task:
Your diagnosis for the client in the case. Follow the guidelines below.
The diagnosis should appear on one line in the following order.
Note: Do not include the plus sign in your diagnosis. Instead, write the indicated items next to each other.
Code + Name + Specifier (appears on its own first line)
Z code (appears on its own line next with its name written next to the code)
Then, in 1-2 pages, respond to the following:
Explain how you support the diagnosis by specifically identifying the criteria from the case study.
Describe in detail how the client's symptoms match up with the specific diagnostic criteria for the disorder (or all the disorders) that you finally selected for the client. You do not need to repeat the diagnostic code in the explanation.
Identify the differential diagnosis you considered.
Explain why you excluded this diagnosis.
Explain the specific factors of culture that are or may be relevant to the case and the diagnosis, which may include the cultural concepts of distress.
Explain why you chose the Z codes you have for this client.
Remember: When using Z codes, stay focused on the psychosocial and environmental impact on the client within the last 12 months.
The Case of Tiana
Intake Date: August xxxx
DEMOGRAPHIC DATA: This was a voluntary intake for this 16-year-old single African American female. Tiana lives with her family in New York City, where she was born. She is currently in the 10th grade. Her dad works in the garment district and her mom works for a major hotel as the front desk manager. Tiana has an older brother and sister and one younger brother.
CHIEF COMPLAINT: "My mom wanted me to go to therapy. She thinks I should be more social like my older sister was at this age. I do not agree. I can handle my life. I am doing fine. My grades are good."
HISTORY OF PRESENT ILLNESS: Tiana admitted to throwing up when she overeats several times per week. She finds herself eating a lot of sweets when she is under stress and is concerned about gaining weight. She found websites on the Internet describing ways to keep her weight down. Tiana reports that she was much heavier when younger and wants to confirm she doesn't get like that again. Her fear of gaining weight contributes to her not engaging in social interaction with others. If her peers see what she eats, they may judge her so she chooses not to socialize a lot.
Tiana reported that she is stressed in school trying to get good grades. She doesn't want to socialize, it makes her anxious and she needs to focus on her school. She has attempted to attend school activities, but they just brought up a lot of anxiety with all the students looking at each other. She thinks her behavior and anxiety would be prominent. She did not mind attending parties as a young child but once she got in her teen years, it became uncomfortable. Tiana noted that at times over the past year she has very strange experiences of being overwhelmed with fear. A couple of times when she tried to attend a social situation she began sweating and had chest pains and chills. Reluctantly, Tiana admitted to bingeing to calm her down from these episodes.
PAST PSYCHIATRIC HISTORY: Tiana denies any history of psychiatric problems in the past. Tianadenies any alcohol or drug use.
MEDICAL HISTORY:Tiana is allergic to penicillin and has a lactose intolerance. She wears glasses for reading.
PSYCHOSOCIAL AND DEVELOPMENTAL HISTORY: Tiana's parents were married when her mother was 19-years-old. Tiana's sister was born the following year. Two years later, her brother was born. Tiana was born one year after that, then 4 years later her younger brother was born. Tiana reports her mother started worrying about her when she began high school. Tiana's mother said that Tiana began isolating. Tiana states she "adores her father" because he was never the disciplinarian.
Tiana reports that when she was in junior high school, her maternal aunt, who was dying of cancer, came to live with the family and this was very stressful for the family. Tiana reports she was always an above-average student. She said she was always very focused on school and wants to get into a good college. She is concerned that she may move away to college and would have to connect with people she does not know. This thought builds anxiety in her.
Currently, Tiana is friendly with a student that sits next to her in chemistry class. She does not talk much about herself since she does not want her classmate to know of her behaviors. Tiana works during summer vacation in the library. She does not have to interact with many people in her work so this makes her comfortable. Tiana also babysits.
MENTAL STATUS EXAMINATION: Tiana presented as a slightly overweight, somewhat disheveled, African-American female. She was anxious during the interview. Her facial expression was mobile. Her affect during the initial interview was constricted and her mood dysphoric. Tiana's speech was normal. Her thinking was logical. Tiana denied hallucinations. She denied suicidal and homicidal ideation.
Tiana was oriented to person, place, and time. Her fund of knowledge was excellent for her age. Tiana was able to calculate serial sevens easily and accurately. Tiana repeated 7 digits forward and 3 in reverse. Her recent and remote memory was intact, and she recalled 3 items after five minutes. Tiana was able to give appropriate interpretations for 3 of 3 proverbs. Her social and personal judgment was appropriate. When asked how she sees herself in 5 years, Tiana replied, "Hopefully graduating from college ." If Tiana could change something about herself, she would "try to be more comfortable around people."