It is not uncommon for people who experience trauma to use substances to moderate psychological or emotional pain. Trauma can easily add to the strain that people already feel. In this Discussion, you diagnose and plan treatment for a case provided by your instructor.

To prepare: Review the Learning Resources on trauma treatment for veterans, and conduct research in the Walden Library for additional resources on the topic. Then read case provided by your instructor for this week’s Discussion.

*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.

* Identify the first area of focus you would address as client’s social worker, and explain your specific treatment recommendations. Support your recommendations with research.

*Explain how you would manage client’s diverse needs, including his co-occurring disorders.

*Describe a treatment plan for client, including how you would evaluation his treatment.

Support your post with specific references to the resources. Be sure to provide full APA citations for your references.

Case Study

Week 9

INTAKE DATE: July 6, 2019 

IDENTIFYING/DEMOGRAPHIC DATA:  Minji is 48-year-old, married, Korean female.  Minji immigrated from South Korea 28 years ago with her new husband.  They have 4 children who are all currently out of the house.  Minji lives in San Francisco. 

CHIEF COMPLAINT/PRESENTING PROBLEM:   Minji presented to the emergency room reporting that she had overdosed on a handful of antihistamines shortly before she arrived.  She described her problems as having started 2 months earlier, soon after her husband unexpectedly requested a divorce. She felt betrayed after having devoted much of her 28-year marriage to being a wife, mother, and homemaker.  After medically clearing Minji, the hospital referred her for outpatient treatment. 

HISTORY OF PRESENT ILLNESS:  Minji reports being sad and tearful at times, and she occasionally has difficulty sleeping. There are no vegetative symptoms.  She felt desperate and suicidal after she realized that “he no longer loved me, this is not supposed to happen in my culture.” 

PAST PSYCHIATRIC HISTORY:  Minji  reports no previous psychiatric difficulties. 

SUBSTANCE USE HISTORY:  Minji denies any drug or alcohol use.   

PAST MEDICAL HISTORY:  Minji reports being in good health.  She has not had any major illnesses. 

CURRENT FAMILY ISSUES AND DYNAMICS:  Minji loves being a wife and mother.  Her family is “her world”.  She enjoys time with family and friends. Minji’s childhood was unremarkable.   She married her husband in South Korea and he immediately was offered a job in the United States working in technology so they immigrated to the U.S.  The move was challenging at first since she did not speak the language but once the children started to be born she acculturated to the American way.  She has a variety of friends and accommodated her husband to be successful in his career.  She was involved in many activities at the children’s  school where she met a wide friendship circle. She reported no particular difficulties in her marriage.  Her mood has varied these past two months, she admitted to anxiety and depression.  

MENTAL STATUS EXAM:  Minji is a well-dressed woman who looks her stated age.  Her mood is depressed, and she lacks eye contact.  Her affect is anxious. Motor activity is appropriate. Speech is clear. Thoughts are logical and organized.  There is no evidence of delusions or hallucinations.  On formal mental status examination, Minji is found to be oriented to three spheres.   When asked how she sees her future she responded “I need to come to terms with the possibility of life after divorce and need to explore my best options under the circumstances.”