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Case of Seo-Jun




Intake Date: November 2021




IDENTIFYING/DEMOGRAPHIC DATA: Seo-Jun is 23 years old and the oldest child of two working-class parents. Her father is a heating and air conditioning technician, and her mother is an administrative assistant at a local community college. Both parents immigrated from Korea as children. Seo-Jun has one younger brother, aged 17, who she reports worring about what direction he is going in. Seo-Jun appeared normally dressed and is 5’2” tall. Her current weight was reported at 104 pounds.



CHIEF COMPLAINT/PRESENTING PROBLEM:  She struggles to get to sleep and would wake up often.  She also reported being so tired during the day “it interfers with everything”. Seo-Jun reports she hadn’t been interested much in food since mid-sophomore year.  Her roommates insisted she get some help, which has now worried her, as she has gotten thinner. Seo-Jun admitted that she often has no time for meals and at times has “no appetite.” Her mood varies over the week, and she admitted to chronic anxiety and some tendency to get into “arguments” with her roommates, her body gets so tense when she gets irritated.

HISTORY OF PRESENT ILLNESS: As a freshman, Seo-Jun lived off campus with three other roommates. She has been waitressing in Tampa since freshman year at a bar/restaurant to supplement financial aid for tuition. She had very good grades (B+ to A) in her first semester of college. The next semester her grades started slipping and she began missing classes. She reported not having interest in school at that time but wanted to graduate for her parents.  She had to drop at least one course (and is retaking it now) due to nonattendance. “This is because I don’t get enough sleep,” Seo-Jun said, and she stated that she was simply unable to wake up in time for that course.

PAST PSYCHIATRIC HISTORY: Seo-Jun does not report any past psychiatric history before the reports in the intake.



SUBSTANCE USE HISTORY: Seo-Jun drinks on weekends with her college friends. Seo-Jun reports beer bloats her so she now drinks vodka and cranberry juice mixed drinks. She rarely gets drunk. She rarely used alcohol in high school, due to her status as a varsity athlete which motivated her to limit her use.



PAST MEDICAL HISTORY: Seo-Jun reports receiving all the childhood vaccines.

 



FAMILY HISTORY INCLUDING MEDICAL AND PSYCHIATRIC: Seo-Jun’s childhood was otherwise unremarkable. She reported that she has always worked hard at school and generally was an “A” student through high school. She ran track and was involved in many activities, socializing with boyfriends and her wide friendship circle. She reported no particular difficulties with her parents other than fighting with them over her decision to leave the state for college. She worries often about how they are getting along since they still hold onto values and behaviors from their country of origin. After delaying admission for a year and working, Seo-Jun left her home in New Hampshire at 20 to attend college in Florida.

 



CURRENT FAMILY ISSUES AND DYNAMICS: Seo-Jun is now a junior. She still works long hours, and she recently took a course in bartending so she can serve drinks and make more money. She struggles to maintain a B grade point average while studying juvenile justice. She reports a high degree of worry about her grades failing.

MENTAL STATUS EXAM: Seo-Jun looks younger than her stated age. Her mood appeared depressed although she did seem anxious often. Seo-Jun states she is anxious and worries but it has been present for so long there is no sense in trying to control it anymore.

To prepare: View the TED Talk “Depression, the Secret We Share” (TED Conferences, LLC, 2013) and compare the description of Andrew Solomon’s symptoms to the criteria for depressive disorders in the DSM-5. Next review the steps in diagnosis detailed in the Morrison (2014) reading, and then read the case provided by your instructor for this week’s Discussion, considering the client against the various DSM-5 criteria for depressive disorders and bipolar disorders.

Post a 300- to 500-word response in which you address the following:

· Provide the full DSM-5 diagnosis for the client. For any diagnosis that you choose, be sure to concisely explain how the client fits that diagnostic criteria. Remember, a full diagnosis should include the name of the disorder, ICD-10-CM code, specifiers, severity, medical needs, 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.

· Recommend a specific evidence-based measurement instrument to validate the diagnosis and assess outcomes of treatment.

· Describe your treatment recommendations, including the type of treatment modality and whether or not you would refer the client to a medical provider for psychotropic medications.

Andrew Solomon: Depression, the secret we share | TED Talk

https://www.ted.com/talks/andrew_solomon_depression_the_secret_we_share