Review the case study for this week. Start by familiarizing yourself with the disorders from the DSM-5-TR found in the Learning Resources this Week.
- Review the case study for this week.
- Start by familiarizing yourself with the disorders from the DSM-5-TR found in the Learning Resources this Week.
- Look within the noted sections for symptoms, behaviors, or other features the client presents within the case study.
- If some of the symptoms in the case study cause you to suspect an additional disorder, then research any of the previous disorders covered so far in the course.
- This mirrors real social work practice where you follow the symptoms.
- Review the correct format for how to write the diagnosis noted below. Be sure to use this format.
- Remember: When using Z codes, stay focused on the psychosocial and environmental impact on the client within the last 12 months.
- Submit 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/diagnoses.
- 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.
- American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (DSM-5-TR) (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787
Week :8 Case of ALEM
CASE PRESENTATION – ALEM
INTAKE DATE: July xxxx
IDENTIFYING/DEMOGRAPHIC DATA: Alem is 24-year-old African American male. He resides in Virginia with his parents. Alem is the oldest child of two children from his parents’ union. Alem has one younger brother, aged 20.
Alem recently received an Honorable Discharge from the United States Army.
CHIEF COMPLAINT/PRESENTING PROBLEM: “I have been having trouble sleeping over the past 6 months”. I am very jumpy inside and have trouble calming down.
HISTORY OF PRESENT ILLNESS: Alem was discharged 5 months ago after spending four years in the Army. He had several tours of duty in the Middle East over the past four years but chooses not to discuss the time overseas. Alem chose not to resign and decided to leave service and return to school. He has been having trouble “kick starting” his attempt at registering for classes. “This is because I don’t get enough sleep,” Not sleeping is impacting his ability to function as well as ability to concentrate. He struggles to get to sleep and often wakes up startled. He reports being so tired during the day “it interferes with everything”. Alem noted that at times over the past few months he has very strange experiences of being overwhelmed with fear. At these times he begins sweating, has chest pains and chills, and thinks he is going crazy. It concerns him terribly that these may happen at inappropriate times. They started happening when he was deployed which is why he was sent to therapy. These symptoms did not last all day and dissipates after a short time.
PAST PSYCHIATRIC HISTORY: Alem attended some therapy right before discharge.
SUBSTANCE USE HISTORY: Alem drinks on weekends. Alem denies a problem with alcohol. He stated he has trouble sleeping some nights without a taking a drink.
PAST MEDICAL HISTORY: Alem reports normal childhood illnesses. He has not had any major illnesses.
CURRENT FAMILY ISSUES AND DYNAMICS: Alem’s childhood was otherwise unremarkable. Alem’s dad was a career service member and retired right before Alem joined the army. He reports being very close to both parents. Alem has always worked hard at school and generally was an “A” student through high school. He ran track and was involved in many activities, socializing with a wide friendship circle. He reported no particular difficulties with his parents although since he has been home Alem has been very irritable. His mood varies over the week, and he admits to chronic anxiety and some tendency to get into “arguments” with his friends and parents.
Alem always enjoyed bonding with his Dad about the military and they would binge watch military movies. Alem found that since he has been back he just is not comfortable watching the movies, it is too distressing. He feels more detached from his Dad now and does not enjoy this any longer.
MENTAL STATUS EXAM: Alem is a well-dressed young man who looks his stated age. His mood is depressed, and he lacks eye contact. His affect is anxious. Motor activity is appropriate. Speech is clear. Thoughts are logical and organized although there seems some confusion at times. There is no evidence of delusions or hallucinations. On formal mental status examination, Alem is found to be oriented to three spheres.
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