CASE OF LUCIA

INTAKE DATE: January xxxx

IDENTIFYING/DEMOGRAPHIC DATA: Lucia is a 53-years-old Hispanic female. She has two adult sons, aged 27 and 24, who both live with her. She works full-time as an executive secretary. Lucia has a live-in boyfriend, Tomaz. They have been together for 8 years.

CHIEF COMPLAINT/PRESENTING PROBLEM: "I am in constant physical pain every day and can hardly walk and move. Even at night when I am in bed I am always in pain." Lucia reports that even in the few moments the pain eases it is difficult for her to get to sleep.

HISTORY OF PRESENT ILLNESS: Lucia has been suffering from physical pain for the past 18 months (about 1 and a half years). She has been to many doctors for help. Lucia has been overly concerned about her illness and wants to understand the causes of this pain. There has never been an accurate diagnosis. She has been given medication and steroids with no relief from her physical pain. Most recently, she had a full evaluation at the Mayo Clinical which had inconclusive results. One doctor at the Mayo Clinic suggested she seek individual counseling, hoping this would help her physically as well. Lucia reports her anxiety is so high now with all the stress she is under.

PAST PSYCHIATRIC HISTORY: Lucia denies any past psychiatric history for herself. The only significant family history is her older brother's diagnosis of Intellectual Disability.

SUBSTANCE USE HISTORY: Lucia reports drinking socially and very minimally. There is no evidence of substance use disorders in her family.

PAST MEDICAL HISTORY: Lucia has been ailing over the past 18 months (about 1 and a half years) with unidentified pain. There were no previous significant medical issues in her past.

FAMILY MEDICAL AND PSYCHIATRIC HISTORY: Lucia is the third child of four from her parents' union. She has an older sister, a brother, and a younger sister. Her brother was diagnosed with intellectual disability at an early age. The family's focus has always been on taking care of her older brother. Her father died 6 years ago. Lucia lost her mother to dementia 6 months earlier than this intake. With the death of her mother, the responsibility of her brother has now been transferred to Lucia and her two sisters. Lucia reports feeling responsible for her extended family and needs to be involved with their issues. She recalls growing up and always feeling not worthy of being part of the family. She is hoping that the family will value her more than she believes they do.

CURRENT FAMILY ISSUES AND DYNAMICS: Lucia divorced 17 years ago after 12 years of marriage. The marriage was tumultuous. Her husband was addicted to pornography and had several affairs. Lucia denies any physical abuse but reports a lot of emotional abuse that she sustained from her husband. Lucia maintained the family house after the divorce but had little money to support the household and her two sons. Lucia's financial issues continued to increase her stress over the years.

Eight years ago, Lucia began a romantic relationship with Tomaz after a long-term work friendship. Tomaz divorced nine years ago. Lucia believed she was finally happy in a relationship. Tomaz moved into her home soon after their romantic relationship began. Tomaz promised he would take care of her financially for the rest of her life.

Four years ago, Tomaz was diagnosed with terminal cancer. Following the diagnosis, Tomaz became a spendthrift and purchased exceptionally large items such as trucks, motorcycles, and ATVs. Lucia was feeling increased stress with the loss of her mother, the burden of care taking her brother, Tomaz's diagnosis and his increased spending of his money. She always found herself fatigued due to this stress.

MENTAL STATUS EXAM: Lucia presented as a casually dressed, meticulously groomed woman who appeared her stated age of 53. She had a fixed, mood-congruent expression on her face. Motor activity was normal. Mood appeared depressed and was dysphoric. Affect was constricted. Speech was guarded and soft, content was adequate. Thought processes were goal-directed, logical but at times distracted. There was no evidence of delusions. Lucia was oriented to time, place, and person. During the intake, Lucia's thoughts would jump around. She noted that over the past several months she has had an inability to concentrate at work. Digit span was 7 forward and 4 in reverse. She was unable to calculate serial 7's. Recent and remote memory appeared intact. Intelligence appeared above average and fund of knowledge was excellent. All factual questions were answered correctly. Lucia was able to abstract similarities and proverbs with detail and accuracy. Ordinary social and personal judgment was appropriate.

Submit your diagnosis for the client in the case. Follow the guidelines below.

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,

• 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
• reference:

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

"Somatic Symptom and Related Disorders" (pp. 349-370)