• Describe your case in 100–150 words.
  • Identify the red flags in your case study to be evaluated.

CASE OF AERA

Intake Date: February 2021

IDENTIFYING/DEMOGRAPHIC DATA:

Aera is a 27-year-old, single Korean female. She has never been married. Aera has a 9-year-old son from a prior relationship. Aera did not graduate from high school but returned to school to get her G.E.D. She is presently a first year student at a community college. She is working in the college library in conjunction with a work-study program. Aera’s goal is to become a teacher. Aera identifies herself as lesbian which does create some conflict with her family.

CHIEF COMPLAINT/PRESENTING PROBLEM:

“I find it hard to concentrate, and have difficulty sleeping. I wonder if I’m going crazy.”

HISTORY OF PRESENT ILLNESS:

The intake was precipitated by Aera’s inability to concentrate and stay focused. Aera reports she has felt like this since she was a teenager. She also states that one year ago, she began to develop what she described as a panic attack. She is always worried about something and her heart beats very fast and she has sweaty palms, often throughout the day. She reports that she does not want to go to class because she fears that “I’ll say something stupid.” She often has to re-read class material several times before she can absorb it and often thinks about leaving school. Aera thinks that these symptoms may be due to her son’s placement in special education classes. Aera reports that she does not go out as much anymore because she likes to stay home with her son. Aera reports she sleeps for a few hours every night, with difficulty falling asleep and waking up in the middle of the night with an inability to fall back a sleep. She reports no change in appetite.

SUBSTANCE USE HISTORY:

She denies all substance abuse. She reports she will have only one drink on a special occasion or if she goes out, which is rare. Aera tried marijuana once when she was a teenager, but states she never tried it again because “I didn’t like the way it made me feel.”

PAST PSYCHIATRIC HISTORY:

Aera denies any past psychiatric history. She reports this is the first time she has ever seen a therapist. Aera states she has always worried due to her family issues when growing up. The worry has become so normal she no longer tries to stop it.

PAST MEDICAL HISTORY:

Aera denies any significant medical history. She states she has had normal childhood illnesses. There is no significant weight gain or loss.

FAMILY MEDICAL AND PSYCHIATRIC HISTORY:

Aera states her parents never married. Her parents’ relationship was on again/off again, but her dad left for good when Aera was 14-years-old. Aera was pleased when her father left for good, stating he was a “bad man.” He drank a lot. Her parents fought frequently, an

F90.2   Attention deficit hyperactivity disorder combined presentation moderate  Z81.8 Family history of mental disorder

Explanation of the diagnosis by matching the symptoms identified in the case to the specific criteria for the diagnosis

According to DSM-5 criteria, for an individual to be diagnosed with inattention and/or hyperactivity-impulsivity disorder, that individual must meet six or more symptoms of each inattention criteria and hyperactivity-impulsivity criteria to be diagnosed as having attention deficits hyperactivity disorder combined. The ADHD symptoms Bryan demonstrates are restlessness, constant running, requiring reminders to stay in the task, difficulty listening and following instructions, destructive behavior both at home and in school to name a few. 

· Hyperactivity: The scenario states that Bryan is constantly running, has difficulty sitting in class, listening, and following through with instruction, and requires reminders to stay on task and focus.

· Impulsive: Bryan blurts out answers and interrupts other students in class, is emotionally impulsive, has confrontational behaviors, inappropriate behaviors, cries, gets upset when he does not receive recognition or feels that he has been ignored, is socially immature, and often demonstrates attention-seeking behavior. In addition, Bryan is said to be easily frustrated and emotionally impulsive. 

· Opposition defiant behavior: Bryan demonstrates confrontational behavior both at home and at school. He has trouble listening to his parents and teachers and has incidents of destructive behavior in the classroom, often loses his temper, hits others, lies, and is argumentative.  

Identification of diagnoses I initially considered in the case using the DSM-5 diagnostic criteria

F84.0 Autism spectrum disorder: According to American Psychiatric Association (2013), to diagnose autism, there are five areas or criteria to look at to have an appropriate diagnosis. These include the client’s social interaction and communication. In the scenario, Bryan enjoys spending time with his friends and participating in physical activities and other social events like swimming, play dates, and birthday parties. It was also stated that Bryan is argumentative, thus showing Bryan has no issues with communication. Therefore, with average social interaction and communication, this diagnosis of autism was ruled out because Bryan did not meet the criteria specified for autism disorder to be diagnosed. 

F780.5 Unspecified insomnia disorder: It was stated in the scenario that Bryan had challenges falling asleep and difficulty maintaining sleep. According to American Psychiatric Association (2013), insomnia disorder can be diagnosed in children. This issue was a red flag in Bryan’s case scenario. It needs further assessment because