Margaret is a 28-year-old woman who went to her primary care physician with a chief complaint of not getting enough sleep and feeling fatigued for the past 4 months. She says that she has a problem falling asleep and often wakes up numerous times during the night as well.
Margaret reports that her sleep problems began after she had an argument over the phone with her boyfriend. After she hung up, she states she felt “all keyed up”, and could not go to sleep that night. Subsequently, she faces every night with dread because she is preoccupied with getting enough sleep. She reports she has not had a full night’s sleep since the argument with her boyfriend. She has become very frustrated with her inability to sleep, which seems to make the problem worse.
Margaret has no other signs or symptoms other than the fatigue caused by failure to get her usual 8 hours of sleep each night. She reports that her mood is “okay, except for this sleep thing”. She is still seeing her boyfriend, and their relationship has been stable. They have not had any more arguments. Despite her daytime sleepiness, she is not having any trouble completing her tasks at work. She has no medical problems, denies the use of drugs, and drinks alcohol only rarely. She has not had a drink since she began having problems sleeping.
Harriet, 54, makes an appointment with you because her MD sent her after her third visit to the ER the past four weeks. She reports that she just feels overwhelmed with these terrible physical pains that her doctor reports are not physical. She states she is not crazy but this feeling that she can’t breathe and even that she must be having a heart attack are very real. Harriet reports that she and her husband of 17 years have just separated. She becomes tearful when she describes this change. She also reports that until recently she was doing very well at work and was being considered for a promotion, “but now I just don’t know what will happen.”
1. List the signs and symptoms of the client
2. Give a complete DSM-5 diagnosis.
a. Give the complete DSM-5 Code Number
b. Give the complete ICD-10 Code Number
c. Write out the complete diagnosis
3. In no more than one page, justify your final diagnosis.
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