Case Study

IDENTIFYING/DEMOGRAPHIC DATA: Aiden is a 24 year old Black English male. Aiden’s religion is Protestant. He is single and attending the University of Maine for his Masters Degree in Finance. Aiden was born and raised in Liverpool, England and came to the United States 6 months ago to attend school.

CHIEF COMPLAINT/PRESENTING PROBLEM: Over the past three months Aiden reported things were becoming strange and he cannot explain it. He heard voices of an angel. It confused him since the angels’ voice was telling him to kill his roommate by suffocation. Aiden claimed that he heard fireflies telling him the roommate is influenced by Satan.

HISTORY OF PRESENT ILLNESS: In the last several weeks, Aiden began to become socially withdrawn (keeping himself in his room) because he was suspicious of his peers in the dorm. With collateral discussion with his roommate, it was reported that Aiden had signs of disorganized speech & thought. The roommate complained about Aiden being disorganized in the dorm with papers all over. Aiden began spending his time browsing and chatting in Facebook about God and UFO’s. He would spend a lot of time online until he passed out.

PAST PSYCHIATRIC HISTORY: Aiden denies any past psychiatric history.

SUBSTANCE USE HISTORY: Aiden denies any use of illicit drugs. He does report occasional use of alcohol. He has been drunk as a teenager but prefers not to indulge that much.

PAST MEDICAL HISTORY: Aiden had been admitted to a hospital to get treatment as his wrist was injured due to a suicide attempt, six weeks ago.

FAMILY MEDICAL AND PSYCHIATRIC HISTORY: Aiden is the second from five siblings. Aiden denies any mental illness in the family.

CURRENT FAMILY ISSUES AND DYNAMICS: Aiden attends school for finance. His family continues to reside in England. His parents are very supportive of his attendance at an American school. Aiden was able to socialize with other students and professors. Before this onset he engaged in leisure activity such as surfing the Internet, kept his room tidy, did household activity such as washing clothes, and kitchen preparation.

MENTAL STATUS EXAM: Aiden appeared disheveled with poor hygiene. He was properly attired with hospital attire and had adequate eye contact. Aiden was able to cooperate during interview. There were some signs of anhedonia and inappropriate behavior. He raised his voice at one time during the interview. His mood was irritable with upset speech. He was not coherent at times. Sometimes there appeared irrelevant talk. Thoughts were preoccupied with obsessions, and persecutory delusions and ideas of reference. Perceptions showed auditory hallucinations. He was oriented: able to state person, place and time correctly. His short term memory was intact: able to retrieve game rules. His long term memory was good: able to recall previous history. Insight was good.

Briefly summarize the case of Aiden, highlighting the diagnostic symptoms seen in the case.

Describe your decision-making process for identifying the key problems in the case and the differential eliminations for the case.

Identify the diagnosis of the client in the case of Aiden. Explain the diagnosis by providing the supporting DSM-5 criteria with specific examples of how the client met those criteria.

Post a fully coded DSM-5 diagnosis for Aiden. Remember, a full diagnosis should include the name of two disorders, two ICD-10-CM codes start with the letter F, specifiers, severity, and two Z codes (other conditions that may be a focus of clinical attention)