• 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, 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.

POTENTIAL DIAGNOSIS

"Trauma and Stressor-Related Disorders" (pp. 295-328) Note:Review this entire classification.

"Dissociative Disorders" (pp. 329-348) Note:Review this entire classification.

CASE of HERMOSA

Intake Date: April xxxx

PRESENTING PROBLEM:

Hermosa indicated that since her husband died suddenly of aMyocardial Infarction (MI) on Christmas Day, two years ago, she has progressively become "more and more depressed". During the week prior to this presentation, she indicated becoming progressively dysphoric, crying uncontrollably for several hours and had suicidal thoughts of taking an overdose. Patient presented in the ER on a voluntary basis. She denied wanting to kill herself on admission to the ER.

PSYCHOLOGICAL DATA:

Hermosa is a 43-year old, Hispanic widowed female. Hermosa reports being of Christian faith. She completed her BSinEducation and one semester in graduate school in Special Education. She has been voluntarily unemployed last year. She lives with her 18-year old daughter who is a college student. She also hasa son,age 20, who is a college student in California. She has two step-daughters who are identical twins, age 22. They are college students and living on campus in Indiana. Prior to being widowed, Hermosa was married twice. Her first marriage ended seventeen years ago, and she remarried four years later. Hermosa also has a brother, age 40, and a sister, age 38, both ofwhomlive within a two-hour drive of Hermosa. Her father & mother, ages 69 and 65 respectively, are both retired and living within a four-hour drive of Hermosa.

MEDICAL HISTORY:

Menses are irregular and accompanied by severe dysmenorrhea. Hermosa previouslytookbirth control pills at ages 17 to 27 for hormone imbalance and severe dysmenorrheal, when she was not focused on getting pregnant. Her last menstrual period began last month. Hermosa has had two pregnanciesandgiven birth to two children. She is allergic to spores, mold, dust, cigarette smoke,Penicillinand Demerol. She has previously had hyposensitization shots which endedlast June(History taken from ER chart).

SUBSTANCE ABUSE HISTORY: Hermosa denies consumption of alcohol/drugs.

PSYCHIATRIC HISTORY:

Hermosa has been in outpatient individual psychotherapy with Dr. W since last June. Inaddition, her family physician, Dr. A prescribed Prozac. Hermosa indicated seeing a psychiatrist, whose name she could not recall, nineteen years ago for two years. She said that she was put onSeroquel, because she was hearing things and couldn't sleep, but could not recall the dosage. Once everything become better she was weaned off the medication.

MENTAL STATUS:

Hermosa presented as a casually dressed, meticulously groomed woman who appeared her stated age of 43. She lay on her bed during the interview. She had a fixed, mood congruent expression on her face. Motor activity was normal. Mood was dysphoric. Affect was constricted. Speech was guarded and soft with some evidence of stuttering. Content was adequate, however. Thought processes were goal-directed, logical and abstract. There was no evidence of delusions. Hermosaacknowledged auditory hallucinations in the form of two men sitting on her shoulder telling her self-depreciating thoughts. Hermosa was oriented in three spheres. Concentration was markedly impaired. 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. Hermosa was able toabstract similarities and proverbs with detail and accuracy. Ordinary social and personal judgment was appropriate. Hermosa's three wishes were that "my family stays well, that Iam able to get on with my life, and that I am close to my family and kids." Five years from now, Hermosa sees herself in "graduate school, getting a doctorate in social work." If Hermosacould change something about herself, she would "feel better about myself, more secure more confident."

SUICIDAL ASSESSMENT:

Hermosa admitted to recurring thoughts about "taking an overdose and ending my life."She said that"I would be better off dead, then I would no longer be in pain." Hermosadenied anyconcrete plan about taking an overdose, vis-s-vis the type of medication or the amount. Hermosa also denied intent. Hermosaadmitted to a prior suicide attempt nineteen years ago, in which she took an overdose of Valiumand Alcohol. Hermosa denied any other attempts.

HOMICIDAL ASSESSMENT:

Hermosa denied any homicidal thoughts, plan or intention. Hermosa denied any previous homicidalhistory.

SUMMARY NOTE:

Hermosa thought she has been depressed since her husband died suddenly of an MI onChristmas Day two years ago. Initially she felt "numb" and in shock, but later became increasingly dysphoric and tearful and unable to carry on every day tasks. At the end of the school year, last year, Hermosaresigned her position as special education teacher and began outpatient treatment with Dr. W, 3x/week. Hermosa hears two male voices commenting on her activities, telling her to hurt herselfwhen she is upset and telling her she "shouldn't be here." They come at various times during the day and night, but are worse in the late afternoon. Hermosa shows no sign of delusional thinking. Immediately prior to her presentation at the ER, Hermosa's therapist went on vacation. She had recently decreased her individual therapy sessions to twice a week and she joined a group therapy run by her therapist once a week. Hermosa complains of difficulty falling asleep because she fears she will not wake up. She feels her mood has improved as a result of being on Prozac.

During the week prior to her admission to the ER, Hermosa became increasinglydysphoric,cried uncontrollably for several hours and had suicidal thoughts of taking anoverdose. She has felt increasingly anxious, has sat for hours at a time at home, juststaring outa window. Hermosa said she is unable to concentrate, feels responsible for her husbands' death, hates herself, is anhedonic, fatigued, unable to make decisions and had decreased libido. A friend called Hermosa on the Saturday prior to admission, while Hermosa wasdistraughtand Hermosa confided to her friend her suicidal thought. Hermosa had also told hertherapistof her suicidal thought and her therapist encouraged a voluntary inpatientadmission. Anadditional stressor for Hermosa was the physical and sexual abuse she experienced during her first marriage. She still has nightmares about this and if awakened suddenly, she coversher facewith her arms as if to protect herself. She is unable to talk about what happened during her marriage, because she does not trust anyone and fears that she will beblamedif she confides in staff or peers. Prior to her leaving her first marriage, shewas losingweight and had difficulty concentrating. Her husband would abuse her aboutherdisheveled appearance. One day she suddenly packed a suitcase and tookherchildren,who werethen ages 2 and a newborn and left. She has neverfullytold her parents why she left. Hermosahas applied and has been accepted at a graduate school for socialwork and hopes tobe a therapist.

COLLATERAL CONTACT:

Hermosa's daughter and Hermosa's friend were interviewed by telephone by the intakesocialworker. Each of the persons interviewed described relief in having Hermosa in the hospital. Her friend stated she may have diverted Hermosa's plan of suicide by making a call to Hermosa atjust the right time. Hermosa said to the friend, "I just don't know how I can go on." When thefriend asked Hermosa how she could help her, Hermosa replied, "Please just shoot me." According to daughter and friend, Hermosa's sadness began at the time to hersecondhusband's death two years ago, and has extended beyond the "normal grieving period." Friend stated "I have watched her get worse and worse," indicating that Hermosa has changedfrom a capable detail oriented person with strong conviction, to a depressed, nonfunctional person, with an inability to cope with life. Daughter states that her mother never smiles..."Hermosa thinks she is not worth anything, that she is undesirable and that she is not capable." Daughter describes her mother's recent behavior as sad and tearful, "staring into space." Hermosa lives with her daughter, who indicates that she and her mother have become friends since her step-father died. Daughter states she is confused by her mother's behavior and feels sad for her. She also experiences fear that her mother will kill herself. Friend indicates that Hermosa has made friends since her husband's death, but states Hermosa is "terrified of long-lasting male relationships, intimacy and any physical contact." According to friend, Hermosa maintains a close relationship with her parents who have always required a strong sense of stability from Hermosa. Although Hermosa has been a teacher for the past 13 years, she currently is not gainfully employed.