Diagnosing Somatic Symptoms and Related Disorders

The diagnosis should appear on one line in the following order.

Diagnose the client

Note: Do not include the plus sign in your diagnosis. Instead, the indicated items should be 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)

Next

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 all the disorders that you finally selected for the client. NOTE: You do not need to repeat the diagnostic code in the discussion.

Identify the differential diagnosis you considered

Please provide an in-depth explanation of 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.

CASE of SABASTON

Intake Date:September xxxx

IDENTIFYING/DEMOGRAPHIC DATA: Sabaston is an 11-year-old Hispanic male who lives with his grandmother and mother Sofia in Nogales, Arizona. Sabaston's father has not been in his life over the past two years.

CHIEF COMPLAINT/PRESENTING PROBLEM: Two years ago Sabaston stopped talking and lost his hearing and sight. The medical doctors can not find any physical reasons for his challenges. After many visits to doctors they decided to bring Sabaston to a clinical social worker.

HISTORY OF PRESENT ILLNESS: Sabaston and his family live in a gang ridden area in Nogales. Sofia's husband Juan wasprotecting Sofia from being attacked by a gang leader and Sabaston watchedhis father shoot the gang leader as he was attempting to attack Sofia. When Sofia and Juan realized that Sabaston saw this, they feared for his life and worried he may say something about this murder. Sofia violently shook Sabaston telling him he did not see or hear anything. Two months later Sabaston lost his sense of hearing, seeing and speaking.

PAST PSYCHIATRIC HISTORY: This is the first psychiatric visit for Sabaston.

SUBSTANCE USE HISTORY: There is no reported substance use for Sabaston.

PAST MEDICAL HISTORY: Sabaston had wellness checks from the time he was born. There were no medical issues other the normal childhood illnesses.

FAMILY HISTORY INCLUDING MEDICAL AND PSYCHIATRIC: No reported medical or psychiatric family issues.

CURRENT FAMILY ISSUES AND DYNAMICS: Sabaston was a good student up to 9 years old. His parents helped Sabaston stay focused on his studies, wanting more for him outside the neighborhood. Since Sofia's mother was elderly and ailing they were not prepared to leave the area yet but had future plans of doing that. Sabaston has never been in trouble at school or at home. His parents have kept him isolated, with few friends, due to their worry about Sabaston getting involved with gang activity.

After the death of the gang leader Juan decided to leave the area to protect his family. At this point it is unknown if Juan is alive or not.

Sabaston does not engage with others, including his mother and grandmother. He only responds to a man on the street who plays the guitar in the street for money. Sofia and Sabaston encounter this man when they go to the bodega. Sabaston likes to just sit there but they typically do not stay long since Sofia fears the neighborhood.

Sabaston is no longer in school.

MENTAL STATUS EXAM: The social worker was unable to engage in a full mental status exam with Sabaston since he wasmostly catatonic.