Answer Key

Question 1

The correct answers are: Sarah's relationship with her husband, Sarah's physical health, Sarah and her husband's employment status, Mental status, Sarah's relationship with her mother's deceased husband, Administer a Beck Depression Inventory

a. Sarah's relationship with her husband

Sarah says her mother is ruining her marriage, that her husband does not talk to her but just sits and does nothing. She says, "He's as bad to live with as my mother." It would be important to assess how the psychosocial stressor of adding Sarah's mother to the household is impacting the spousal relationship.

b. Sarah's physical health

"I haven't been to a doctor in some time. I might need to go to get something to help me sleep so I do not miss any more work." Learning about Sarah's physical health from her perspective would be important to determine if she needs a referral.

c. Sarah and her husband's employment status

Charlie works in construction and I am an actuary. This is the only answer choice that could give you some insight into this couple's financial health.

d. Sarah's future plans for the family's living arrangements

Not relevant at this time The question is asking about initial assessments.  You would likely learn this as counseling progresses.

e. Mental status

Mental status is good. Notable: Lability is fixed. Affect contextually appropriate. She expressed more frustration than anger, which seems to be based upon current situation. The case presentation does not directly state Sarah's reasons for seeking counseling.  It says, "... she comes to see you complaining ..."  The balance of the simulation is devoted to her complaints. A mental status examination would reveal these missing pieces. This is an important initial assessment step and the results could indicate if you need to refer her for a psychiatric evaluation.

g. Sarah's siblings

Not relevant at this time The question is asking about initial assessments.  You would likely learn this as counseling progresses.

h. Sarah's relationship with her mother's deceased husband

"I only met him once. Mama was only married to him for 4 years." This answer choice is helpful in determining if Sarah might be grieving a loss.

i. Administer a Beck Depression Inventory

Sarah's score of 16 indicates a mild depression. Sarah may be feeling depressed due to this stressor in her life, and she says she cannot sleep which is one symptom that may be associated with depression.

Question 2

d. 

·         Normalize the distress and symptoms being experienced by everyone in the family;

·         Refer to culturally sensitive community services; and 

·         Recommend marriage counseling

Normalize the distress and symptoms being experienced by everyone in the family: The sudden addition of Sarah's mother to the household has created tension. It would be helpful for the counselor to frame this as predictable and not a sign of pathology.
Refer to culturally sensitive community services: Stressed family systems often respond well to more contacts in their community. 
Recommend marriage counseling: This may be helpful, but working on their marriage will not directly help with managing the psychosocial stressor.

Question 3
The correct answers are: Major Depressive Disorder, Unspecified Depressive Disorder, Z-Code Phase of Life Problem, Z-Code Relationship Distress with Spouse or Intimate Partner, Adjustment Disorder

a. Major Depressive Disorder
Sarah reports symptoms over the last three months consistent with a depressive disorder. You refer her for a psychiatric evaluation. She mentions a sleep disturbance, and in a previous section, an answer choice revealed that she scored as having a mild depression.

e. Z-Code Phase of Life Problem
Having her mother move in and require care, has put Sarah into a new phase of life. The presenting issue features psychological symptoms triggered by this phase.

f. Z-Code Relationship Distress with Spouse or Intimate Partner 
Sarah speaks of difficulty between herself and her husband. Z-codes are found under other conditions that may be a focus of clinical attention in the DSM-5. Conditions in these categories may be the focus of clinical attention but are not mental disorders (p.715). However the DSM says there may be a coexisting mental disorder, which may be true for Sarah.

i. Adjustment Disorder
This is the best option. For Adjustment Disorder, there is an identifiable stressor that occurs within 3 months of the onset of symptoms as in this simulation.