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.
• 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 study

The Case of Emma

Intake Date:February xxxx

IDENTIFYING/DEMOGRAPHIC DATA: This was an emergency, voluntary admission for this 28-year-old single white female. This was herfourth psychiatric hospitalization. Emma lives with a 24-year old female roommate in New York City. She has a bachelor's degree in art history and is employed by a major New York museum. Emma is of Jewish ancestry.

CHIEF COMPLAINT/PRESENTING PROBLEM: "Mytherapist saidI was decompensatingbecause I broke my leg, and I was despondent."

HISTORY OF PRESENT ILLNESS: Emma reported that she began a special diet and, although she was supposed to be eating 600 calories a day, she wasonly eating between 200 and 400 caloriesa day. She also admittedto purging and frequent use of laxatives. Emma reported her weight was being monitored, and she had lab work done to be sure she remained healthy. In 3 months, Emma lost approximately 80 pounds.

Emma reported that she has a very stressful job. She stated that approximatelyone month priorto admission, she started to "decompensate" and had difficulty maintaining control at work. She hadseveral altercations with coworkers. One week prior to admission, Emma reported that herNA sponsor"said something nasty, andI lost it."According to her mother, the sponsor made a reference to Emma being overweight. Emma reported that she was angry and "hit everythingI knew I couldbut that did not help." She thenkicked a brick wall, fracturing her right leg. Emma also reported being under stress due to applying for her master's degree in art history and difficulties with her boyfriend.

Emma complained ofdepression with insomniaand sleeping only a few hours per night,feeling confused, decreased concentration, irritability, anger, and frustration. She admitted tosuicidal ideation. She complained offeeling paranoid over the past few weeks and believed the police were after her and that she heard them outside her door. She believed the police had her under surveillance. Emma complained of a fear of dirt, taking time to frequently bathe and brush her teeth. Emma reported she was emotionally abused as a child and thinks she suffered from post-traumatic stress disorder, but she denied a history of flashbacks or nightmares. She also thinks she had panic attacks and said she controlled them by taking Klonopin, but there wasno clear information about this. She reported ahistory of bulimiasince the age of 17.

PAST PSYCHIATRIC HISTORY:Emma's mother reported that Emma saw a clinical social worker briefly when Emma was 10 years old. Emma reported that she was hospitalized at a New York hospital 3 years ago for 3 months. Six months after that, Emma took an overdose of Halcion and was treated at the same hospital, and then was transferred to a state hospital. After discharge in the next month, Emmaattended a partial hospitalization program for drugs and alcohol every day for 5 weeks. She has been seeing a psychiatrist for the past 2 years on an outpatient basis. Emma sees a clinical social worker weekly.

SUBSTANCE USE HISTORY:Emmareported ahistory of drug and alcohol use, but she stated that she has been clean and sober for two years. Emma admitted tousing marijuana, cocaine, opiates, and hallucinogens in the past. She denied IV drug use but admitted to "skin popping" cocaine. Emma has abused alcohol in the past. According to her mother, Emma has also abusedprescription medicationsin the past. Emma reported that she has been sober for the past 2 years andattends AA and NA meetings regularly. Emma was treated for alcohol and cocaine use.

PAST MEDICAL HISTORY:At 17 years old,Emma suffered from bulimia withbingeing, purging, and the use of laxatives. She reported shehad not purged for 3 years until she began the new diet3 months ago. Although Emma is currently not bingeing, sheadmitted to purging and using laxatives.Emma is allergic to penicillin and has a lactose intolerance. She wears glasses for reading.

FAMILY HISTORY INCLUDING MEDICAL AND PSYCHIATRIC: Emma's parents were married when her mother was 19 years old, and Emma was born the following year. Emma's mother described Emma as a wonderful, even-tempered, and happy baby. Two years later, Emma's sister was born. Mother stated Emma's personality changed. She became stubborn and difficult. Emma's mother said that Emma began biting and having tempertantrums andhas been moody since then. Emma's mother stated her marriage was conflicted because she has a communication problem with her husband and he was "never an active parent." Emma's mother reported that Emma "adores her father" because he is not the disciplinarian. When Emma was 12 years old, her parents separated for 2 weeks. Emma reported her mother quit college after Emma's birth and returned to college after her sister's birth. She said her father worked all the time, and there was a housekeeper who cared for the children.

Emma reported that the family moved to Arizona when Emma was in sixth grade, where she began using marijuana that she reported stealing from her parents. The family returned to New York when Emma was in seventh grade.

Emma is currently applying for admission to graduate school and has taken some courses toward her master's degree. Emma was always an athlete (soccer) in school, and according to her mother, she was a champion.

Currently, Emma is friendly with her roommatebut doesnot have any other friends. "I don't trust anybody." Emma's mother reported that when Emma lived in Connecticut during college, Emma had many friends and was active in NA and AA.

CURRENT FAMILY ISSUES AND DYNAMICS: Emma has close contact with her parents but less contact with her sister. The family celebrates the Jewish holidays and gets together for those activities.

MENTAL STATUS EXAM: Emma presented as an overweight, somewhat disheveled, white female who had a cast on her right leg. She was relaxed but very restless during the interview. Her facialexpression was mobile. Her affect during the initial interview was constricted and her mooddysphoric. Emma'sspeech was pressuredand often circumstantial or tangential, and she spoke in a loud voice. Attimes her thinking was logical, and at other times it was illogical. Althoug Emma denied hallucinations she complained of hearing policemen outside herdoor prior to admission. She denied homicidal ideation and initiallyadmitted to suicidal ideation but then denied this.

Emma was oriented to person, place, and time. Her fund of knowledge was excellent. Emma was able to calculate serial sevens easily and accurately. Emma repeated 7 digits forward and 3 in reverse. Her recent and remote memory was intact, and she recalled 3 items after five minutes. Emma was able to give appropriate interpretations for 3 of 3 proverbs. Her social and personal judgment was appropriate. Emma's three wishes were: "To be skinny, to have a big house where I can take in all the stray cats, and for a million more wishes." When asked how she sees herself in 5 years, Emma replied, "Hopefully graduating from graduate school." If Emma could change something about herself, she would "make myself thin."