Reference no: EM133033356

CASE of KAI Intake

IDENTIFYING/DEMOGRAPHIC DATA:

Kai (31) and Mira (28) are a married Japanese-American couple who live with their sons, Myles (10) and Levi (8), in a two-bedroom condominium in a middle-class neighborhood. Kai is an Iraq War veteran and employed as a human resources assistant for the military and Mira is a special education teacher in a local elementary school. Mira is in good physical condition and has recently found out that she is pregnant with their third child.

CHIEF COMPLAINT/PRESENTING PROBLEM:

Kai stated that he came to the VA for services only because his wife had threatened to leave him if he did not get help. Mira was particularly concerned about his drinking and lack of involvement in his sons' lives.  Kai admitted at times he thought he was "going crazy". 

HISTORY OF PRESENT ILLNESS:

Mira told Kai his drinking had gotten out of control and was making him mean and distant. Kai said that since his return to civilian life 10 months ago he had experienced difficulty sleeping, heart palpitations, and moodiness. He described being proud to join the army and deployed and described himself as upbeat and happy prior to his deployments. He felt that he had to "change" to stay alive there.

When Kai's options for treatment were discussed, he expressed fear of losing his job and his family if he did not get help. He said he was exhausted from being always alert and looking for potential problems around him. He noted he always felt on edge and every sound seemed to startle him when he was not drinking.

Kai shared that he often thinks about what happened "over there" but tries to push it out of his mind. The night is the worst time for Kai, as he has terrible recurring nightmares of one particular event. He said he wakes up shaking and sweating most nights. He then said drinking was the one thing that seemed to give him a little relief.

PAST PSYCHIATRIC HISTORY:

Kai had previously visited his primary care physician, Dr. Zoe, where he was given a prescription of Paxil to help reduce his symptoms of anxiety and depression. Dr. Zoe recommended that he get ongoing treatment and had given him my name as the social worker to see at the local VA.

SUBSTANCE USE HISTORY:

As teenagers, Kai and Mira used marijuana and drank. Neither uses marijuana now but they still drink. Mira drinks socially and has one or two drinks over the weekend. Kai reported he has four to five drinks in the evenings during the week and eight to ten drinks on Saturdays and Sundays.  Kai admitted to drinking heavily nearly every day.  Kai spent his evenings on the couch drinking beer and watching TV or playing video games.

Kai expressed concern that he would never feel "normal" again and said that when he drank alcohol, his symptoms and the intensity of his emotions eased.  Kai shared that he had started attending AA meetings.  He realized that drinking was being used as a way to avoid his feelings, and he attended AA meetings regularly. He has been able to not drink for a few weeks and found a sponsor who is also a veteran.

PAST MEDICAL HISTORY:

Overall, Kai is physically fit, but an injury he sustained in combat sometimes limits his ability to use his left hand. 

FAMILY HISTORY INCLUDING MEDICAL AND PSYCHIATRIC:

Neither Kai or Mira reported having criminal histories.  Kai and Mira identify as Christian and attend a local church on major holidays. Kai's parents are deceased, and he has a sister who lives outside London. He and his sister are not very close but do talk twice a year. Mira is an only child, and her mother lives in the area but offers little support. Her mother never approved of Mira marrying Kai and thinks Mira needs to deal with their problems on her own.

CURRENT FAMILY ISSUES AND DYNAMICS:

     The couple have some friends, but due to Kai's recent behaviors, they have slowly isolated themselves.  Kai continued that he and his wife had been fighting a lot and that he drank to take the edge off and to help him sleep, saying, "Nights are the hardest."  He reported that he was not engaged with his sons at all and he kept to himself when he was at home. He gave some examples of having a "hair-trigger temper" with his sons, especially if they surprised him inadvertently.

Kai works in an office with civilians and military personnel and mostly gets along with people in the office. Kai tended to keep to himself and said he sometimes felt pressured to be more communicative and social. He was also very worried that Mira would leave him. He said he had never seen her so angry before and saw she was at her limit with him and his behaviors.

Kai noted that his wife stated she wants to be able to communicate with him without feeling that she was "nagging him" or fearful that she was making him withdraw and that she would "trigger his anger." She said that she avoided asking him things or talking to him for fear it would "set him off" and make him retreat to the basement on his own. As it stood, she did not think she could talk with Kai about her concerns. She told him she missed socializing with friends and having family outings and felt isolated during their confrontation. She reported that during a fight it came out that Kai told her that just keeping his intrusive thoughts at bay took all the energy he could muster. Seeing friends and making small talk was not something he felt he could do right now. Mira admitted that she did not know that socializing affected him that way nor that loud noises, open spaces, and green lights triggered intrusive memories. She was at the "end of her rope" with Kai. 

MENTAL STATUS EXAM:

Kai was well-groomed but appeared somewhat guarded and anxious. He was coherent and articulate. Speech was at a normal rate, although the pace was noted to accelerate when he approached or discussed disturbing content. He denied depression but admitted anxiety and hyperarousal in situations, such as when strangers stand close to him in check-out lines. His affect was somewhat constricted but appropriate to content. His thought process was coherent and linear. He denied all suicidal and homicidal ideations but admitted that if startled "not much thought happens" between the event and his aggression responses. He had no psychotic symptoms, delusions, or hallucinations. He had reasonable insight, was well oriented, and seemed to have average intelligence.

Directions below: for the case of KIA

SOCW 6090: Psychopathology and Diagnosis for Social Work Practice

• Week 9
• Discussion 2: Trauma and Comorbidity
• 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.