DSM Social Work Diagnosis

CASE PRESENTATION – NEVILLE

INTAKE DATE: July 6, 2019

IDENTIFYING/DEMOGRAPHIC DATA: Neville is 24-year-old African

American male. He resides in Virginia with his parents. Neville is the oldest child

of two children from his parents’ union. Neville has one younger brother, aged 20.

Neville recently received an Honorable Discharge from the United States Army.

CHIEF COMPLAINT/PRESENTING PROBLEM: “I have been having

trouble sleeping over the past 6 months”. I am very jumpy inside and have trouble

calming down.

HISTORY OF PRESENT ILLNESS: Neville was discharged 5 months ago

after spending four years in the Army. He had several tours of duty in the Middle

East over the past four years but chooses not to discuss the time overseas. Neville

chose not to resign and decided to leave service and return to school. He has been

having trouble “kick starting” his attempt at registering for classes. “This is

because I don’t get enough sleep,” Not sleeping is impacting his ability to function

as well as ability to concentrate. He struggles to get to sleep and often wakes up

startled. He reports being so tired during the day “it interferes with everything”.

Neville noted that at times over the past few months he has very strange

experiences of being overwhelmed with fear. At these times he begins sweating,

has chest pains and chills, and thinks he is going crazy. It concerns him terribly

that these may happen at inappropriate times. They started happening when he

was deployed which is why he was sent to therapy. These symptoms did not last

all day and dissipates after a short time.

PAST PSYCHIATRIC HISTORY: Neville attended some therapy right before

discharge.

SUBSTANCE USE HISTORY: Neville drinks on weekends. Neville denies a

problem with alcohol. He stated he has trouble sleeping some nights without a

taking a drink.

PAST MEDICAL HISTORY: Neville reports normal childhood illnesses. He

has not had any major illnesses.

CURRENT FAMILY ISSUES AND DYNAMICS: Neville’s childhood was

otherwise unremarkable. Neville’s dad was a career service member and retired

right before Neville joined the army. He reports being very close to both parents.

Neville has always worked hard at school and generally was an “A” student

through high school. He ran track and was involved in many activities, socializing

with a wide friendship circle. He reported no particular difficulties with his parents

although since he has been home Neville has been very irritable. His mood varies

over the week, and he admits to chronic anxiety and some tendency to get into

“arguments” with his friends and parents.

Neville always enjoyed bonding with his Dad about the military and they would

binge watch military movies. Neville found that since he has been back he just is

not comfortable watching the movies, it is too distressing. He feels more detached

from his Dad now and does not enjoy this any longer.

MENTAL STATUS EXAM: Neville is a well-dressed young man who looks his

stated age. His mood is depressed, and he lacks eye contact. His affect is anxious.

Motor activity is appropriate. Speech is clear. Thoughts are logical and organized

although there seems some confusion at times. There is no evidence of delusions or

hallucinations. On formal mental status examination, Neville is found to be

oriented to three spheres.