UBC Makayla DSM 5 Diagnosis Case Study Report

User Generated

Wraan1821

Humanities

University of British Columbia

Description

Provide the full DSM-5 diagnosis for the client. Remember, a full diagnosis should include the name of the disorder, ICD-10-CM code, specifiers, severity, and the Z codes (other conditions that may be a focus of clinical attention). Keep in mind a diagnosis covers the most recent 12 months.     Explain the diagnosis by matching the symptoms identified in the case to the specific criteria for the diagnosis.     Discuss other disorders you considered for this diagnosis and eliminated (the differential diagnoses).     Describe an evidence-based assessment scale that would assist in ongoing validation of your diagnosis.     Recommend a specific intervention and explain why this intervention may be effective in treating the client. Support your recommendation with scholarly references and resources.

To prepare: Read the case provided by your instructor for this  week’s Discussion. Review the decision trees for anxiety and OCD in the  Morrison (2014) text and the podcasts on anxiety. Then access the Library and research interventions for anxiety.

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CASE PRESENTATION – MAKAYLA INTAKE DATE: May 2019 IDENTIFYING/DEMOGRAPHIC DATA: Makayla is a 29-years-old, single, heterosexual, African American female. Makayla lives with her boyfriend, Dion, of 4 years. She wants to get married ,but her boyfriend does not believe he is ready yet since he is three years younger than her. Makayla is a Certified Public Accountant, who loves her job. Dion is a manager for a gym franchise. CHIEF COMPLAINT/PRESENTING PROBLEM: “My job is flexible and I can work from home often but lately my focus has been in other areas and I just have trouble getting to work” HISTORY OF PRESENT ILLNESS: Makayla concerns herself about many things, which is not new to her and she finds that by scrubbing her home clean is her best therapy to ease her concerns. Makayla reports that germs have been a regular concern of hers since adolescence, when she learned in health classes about the risks of serious diseases including sexual transmittable disease. There are times when she looks at the house and it triggers her and within minutes she has intense discomfort feeling dizzy, sweating, feels nauseous, and trouble breathing. She is able to calm herself down in a few minutes. Makayla presented with meticulous grooming. She is challenged by her time management sometimes, when she finds herself scrubbing the house clean daily. This worries her in case she gets a visitor and the house is not in order as she would like it. She sometimes has arguments with Dion to help more around the house. The amount of time it takes to scrub the house clean delays her daily schedule. PAST PSYCHIATRIC HISTORY: Makayla has never been for therapy before and decided to attend now because her life seems to be spinning out of control. She has always been organized and liked a clean home, for as long as she can remember. Dion is not as invested in that. She remembers always keeping her room clean as a teen which was very different than her friends. She remembers sometimes going to friends homes that had messy rooms. She would get dizzy and nauseous at their homes also when she saw that. There was a time that she actually was so concerned about getting dizzy and throwing up that she stopped visiting friends for months and would only meet them in public areas. SUBSTANCE USE HISTORY: Makayla reports drinking socially. She tried marijuana in college several times but did not like it. She denies any other drug use PAST MEDICAL HISTORY: Makayla had the usual childhood illnesses but has not had any severe illnesses in adulthood. FAMILY MEDICAL AND PSYCHIATRIC HISTORY: Makayla shared that when she was 2-years-old her mother died from cancer. She denies any psychiatric history in the family although she does not know her mothers’ family very well. CURRENT FAMILY ISSUES AND DYNAMICS: Makayla shared that she was raised in the military; her father is an army officer. Makayla’s father remarried and she gets along well with her stepmother. She has two half brothers from that union. She has travelled all over the world living on military bases mostly. She has a very close relationship with her father. She knows they were raised in the “military” fashion but believes it has benefitted her over the years. MENTAL STATUS EXAM: Makayla is oriented to time, place, and person. She is professionally dressed, and her stated age. She presents with some anxiety in the interview. Motor activity is appropriate. Speech is clear. There is no evidence of delusions or hallucinations. Makayla’s intelligence appears above average.
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Explanation & Answer

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Running head: MAKAYLA DSM-5 DIAGNOSIS

MAKAYLA DSM-5 DIAGNOSIS
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MAKAYLA DSM-5 DIAGNOSIS

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MAKAYLA DSM-5 DIAGNOSIS
ICD-10-CM code: F42.9
Disorder: Obsessive-Compulsive Disorder
Disorder Class: Obsessive-Compulsive and Related Disorders
Severity: obsessions 2 that prompts the patient to indulge their compulsion
Makayla exhibits symptoms that indicate she is a patient suffering from obsessivecompulsive disorder. People under this threshold experience similar behavior to Makayla which
include; anxiety and a compulsion to clean as germs are concern such individual. In Makayla’s
case, the nuance of germs, or the possibility thereof may trigger bouts of intense cleaning. In
some instances, OCD may result in sweating, dizziness, nausea, as well as ...


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