DSM-5 Social Work Discussion Question

CASE PRESENTATION –NAHIA

INTAKE DATE: May 2019

IDENTIFYING/DEMOGRAPHIC DATA: Nahia is a 43-year-old, married,

heterosexual, African American female. Nahia lives with her husband, Dion, of 24

years. She describes being happily married. Nahia is a Certified Public

Accountant, who loves her job. She is the manager over 12 employees. Dion is a

manager of a gym franchise. They have three children, 19 years old, 17 years old

and 12 years old.

CHIEF COMPLAINT/PRESENTING PROBLEM: “My job is flexible and I can

work from home often but I get nervous if I am not in the office and lately my

focus has been in other areas and I just have trouble focusing on work”

HISTORY OF PRESENT ILLNESS: Nahia worries about many things, which is

not new to her. She describes herself as always worrying about things which has

been successful for her in her career. She loves to clean her house as therapy to

take her mind off the worry. There are times when she looks at her surroundings at

home and it triggers her and within minutes she has intense discomfort feeling

dizzy, sweating, feels nauseous, and trouble breathing. It concerns her that there

may be germs around and she must keep the house clean to keep her children

healthy. She is concerned since they are growing up and will be leaving the

household soon. She also worries that she may get a visitor and the house is not in

order. She sometimes becomes irritated with Dion and at the end of their

disagreements cannot figure out what she was annoyed about.

Nahia is concerned about her job since she is having trouble sleeping and wakes

up fatigued. On several occasions, she woke up in the middle of the night

worrying about getting to work on time which increased her anxiety.

PAST PSYCHIATRIC HISTORY: Nahia 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 but has spent most of her adult life concerned about her

children, her husband, her employees, the clients she works with. Her anxiety goes

“through the roof” often and has progressively increased over the last 10 years.

She remembers getting so anxious as a teenager visiting friends, she would get

dizzy and nauseous at their homes.

SUBSTANCE USE HISTORY: Nahia reports drinking socially. She tried

marijuana in college several times but did not like it. She denies any other drug

use.

PAST MEDICAL HISTORY: Nahia had the usual childhood illnesses but has not

had any severe illnesses in adulthood.

FAMILY MEDICAL AND PSYCHIATRIC HISTORY: Nahia 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: Nahia shared that she was

raised in the military; her father is an army officer. Nahia’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: Nahia is oriented to time, place, and person. She is

professionally dressed, and looks 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. Nahia intelligence appears above average.