Case Study
Patient Demographic:  Initial Intake: Age: 14 Gender: Female Sexual Orientation: Heterosexual Ethnicity: Hawaiian American Relationship Status: Single Counseling Setting: School-based mental health counseling Type of Counseling: Individual
Mental Status Exam: Malik presents as well groomed, good hygiene and behavior within normal limits. She is highly anxious, evidenced by limited eye contact, tense expressions and fidgeting with her hands. Malik admits to having suicidal thoughts and has self-harmed by cutting herself in the past. She reluctantly shares that she had a traumatic event in Hawaii right before leaving but is unwilling to discuss it and begins crying. She then changes the subject and tells you moving out of Hawaii has been painful because “everything is different here, including how they do school and how people talk about each other.” She adds that she experiences at least one nightmare a week since moving.
Presenting Problem: Diagnosis: Major depressive disorder, single episode, unspecified (F32.9), Anxiety disorder, unspecified (F41.9)
 

Malik, a 14-year-old girl entering High School is referred to you for mental health counseling by her school counselor for reports of her leaving the classroom in tears and because of calls received by her mother stating that she has crying spells at home. After speaking with Malik’s mother, you learn her mother, stepfather and sisters have recently moved with her to the mainland states from the Hawaiian Islands and that she has been missing her father, friends, school, and other family members left behind. Malik spends most of her time in her room, appears depressed often, gets upset easily and is constantly on her phone. Her mother asks that you meet with her during school hours and help her understand what is going on. She says Malik has been crying since just before leaving Hawaii.
Other Contexts: Family History:
Malik’s parents divorced while she was young but had always lived in Hawaii, making it easy for her to see both sides of her family at will. Malik has several siblings, cousins, and all her grandparents are still alive. Malik has a strained relationship with her father and stepmother and feels heavily influenced by her father’s opinion of her, stating “he just wants what is best for me, but he’s really harsh about it and it sometimes hurts my feelings and stresses me out.” She is struggling to connect with her mother now because she is working full-time, and she feels “doesn’t have time for her anymore.” Malik is also forced to do most of the household chores and care for her younger siblings on top of managing her schoolwork. All of this has made her feel overwhelmed.

Question: Which factor presents as the most likely underlying issue causing Malik's depression symptoms?
(A): Cultural stress
(B): Dad's criticism
(C): Trauma
(D): Feeling "overwhelmed"

Correct Answer: Trauma
Explanation: Malik's mother reported her presentation of symptoms prior to leaving Hawaii, which follows the same timeline as Malik's report of a traumatic event occurring. Based on Malik's presentation of avoiding discussion of trauma, crying when she thinks of it and then deflecting, trauma is the best choice. Acculturation issues began after she moved, which likely exacerbated her symptoms but are not presenting as most plausible to be the primary cause. In this case, all other stressors reported are more likely contributing to her Anxiety disorder diagnosis. Therefore, the correct answer is (A)
Competency: intake, assessment, and diagnosis