CASE PRESENTATION - NEVILLE

INTAKE DATE: July xxxx

IDENTIFYING/DEMOGRAPHIC DATA: Neville is 24-year-old African American male. He resides in Virginia with his parents. Neville is the oldest child of two children from his parents' union. Neville has one younger brother, aged 20.

Neville 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: Nevillewas discharged5 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. Neville 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". Neville 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: Neville attended some therapy right before discharge.

SUBSTANCE USE HISTORY: Nevilledrinks on weekends. Neville denies a problem with alcohol. He stated he has trouble sleeping some nights without a taking a drink.

PAST MEDICAL HISTORY: Neville reports normal childhood illnesses. He has not had any major illnesses.

CURRENT FAMILY ISSUES AND DYNAMICS: Neville's childhood was otherwise unremarkable. Neville's dad was a career service member and retired right before Neville joined the army. He reports being very close to both parents. Neville 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 Neville 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.

Neville always enjoyed bonding with his Dad about the military and they would binge watch military movies. Neville 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: Neville 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, Neville is found to be oriented to three spheres.

• Name the diagnosis and code. 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, 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.

Resources

• 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
  • "Trauma and Stressor-Related Disorders" (pp. 295-328)
  • "Dissociative Disorders" (pp. 329-348)
• Jones, P. J. (2021). What's in a trauma? Using machine learning to unpack what makes an event traumatic. Links to an external site.Journal of Affective Disorders, 294, 769-775. https://doi.org/10.1016/j.jad.2021.07.066
• American Psychiatric Association. (2022). DSM-5-TR online assessment measures. Links to an external site.https://www.psychiatry.org/psychiatrists/practice/dsm/educational-resources/assessment-measures