CASE SANDRA

INTAKE DATE: July

PRESENTING PROBLEM:

Patient was brought to counseling by her mother. Following an argument with her parents, she threatened to cut her wrist. Prior to this threat Sandra's mother says she started screaming and became very angry with her after discussing her eating habits.

PSYCHOLOGICAL DATA:

Sandra is a 14 year old white female who resides in Pennsylvania with her parents and older sister. She appears to be of average intelligence as she was able to respond to numerous questions in an articulate and intelligent manner. She was well versed about world history and current affairs. Her mother confirms that she has always done pretty well in school, maintaining a "B", average, although IQ testing indicates she could do better. She has always been somewhat of a perfectionist and likes to do well, and studies hard to get good results. Sandra participates in various school activities (i.e. chorus, school newspaper). Sandra is quite shy and reserved in character, but is generally well-liked by people.

She started going out with a boy from her class and feels very happy. After a few weeks, her boyfriend dumped her and begin going out with her best friend. Sandra feels an overwhelming sense of betrayal and hurt, and tried to talk to her family about it, who tells her 'there are plenty more fish in the sea', and not to worry about it. Sandra feels ashamed and embarrassed of her feelings and very alone. Not only has she lost her boyfriend but also her best friend, and no one around her seems to understand the severity of what she is going through. To Sandra, whose life as a teenager revolves heavily around her friends, she feels she has lost everything.

In order to cope and distract herself, she plunged herself into her studies, though her concentration is off. She began eating less since she loses her appetite quickly, and within a few weeks people started commenting on how fantastic she looks with her weight loss. She went to a party one night in a tight fitted dress and received a large amount of attention from the boys. In a very difficult and painful time, Sandra finally finds she was praised for something, and began to more consciously restrict her food intake to ensure that she continues to lose weight and feel good about herself. At times Sandra finds herself eating more than she wants and goes into the bathroom and induces vomiting to rid herself of the extra calories. She has done this about 3 times over the past several months.

MEDICAL HISTORY:

Sandra had a complete physical by her doctor one month ago. The doctor identified that Sandra was thin but remained in her weight range for her age. He also confirmed that she continued to have her menses. She denied any dieting or fasting to the doctor.

More recently Sandra's family begans to worry about her, as she did not want to eat evening meals with them. Sandra's friends also comment on how thin she is getting and jokingly put her on the scale. Sandra still maintained a weight within her height and body frame. Sandra sees this as a positive thing, believing it is praise and attention from others, but she has become completely obsessed with food. She goes to bed at night counting the calories she has had in the day, and rigidly planning what she will eat the next day.

SUBSTANCE ABUSE HISTORY:

Sandra denies any drug or alcohol use. She states "I could do drugs if I wanted to. I don't want to because it's dumb".

PSYCHIATRIC HISTORY:

Sandra denies any psychiatric history.

MENTAL STATUS:

Sandra was casually dressed. She was in a lively manner with good eye contact and the conversation flowed freely. Thought and speech patterns were clear. Affect was appropriate. She was oriented in three spheres. Sandra denies feeling depressed, anxious or suicidal, although this was not a strong denial. When questioned about her family's concern of her eating habits, she suddenly became quiet, teary eyed, lowered her head and responded "you don't understand it, I don't want to hurt myself, there is nothing wrong".

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)

• 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.