Diagnostic Assessment Example

Client: Sophak S. (she/they), 27, second-generation Khmer American

Session type/length: Intake diagnostic interview, 60 minutes (In-Person)


Presenting concern (IC): Role overload and resentment related to family caregiving/translation; guilt about being “the good one.” Increased family conflict since brother Dara (24, he/him) came out as gay; parents minimize Dara’s depression (“He has too much freedom”). An auntie urges, “keep family problems in the family and pray to the Lord.” Sophak identifies as asexual.

Intake source: Completed by intake team - Yolandi V.

I. History & Psychosocial Summary

Brief psychosocial (expanded symptoms): Eldest adult child; primary language broker and bill-payer for parents. Reports chronic mental load and anticipatory worry centered on bills, appointments, and “what could go wrong.” Anxiety shows up as: (a) cognitive—rumination, “replaying” conversations with parents/teachers/clerks, difficulty turning off thoughts at night; (b) emotional—irritability when interrupted, quick tearfulness after conflict, guilt spikes after setting limits; (c) behavioral—over-functioning (taking tasks before asked), conflict-avoidant agreeing then regretting, late-night admin tasks, double-checking translations/forms; (d) somatic—jaw/shoulder tightness, tension headaches, chest “pressure” during family arguments, stomach fluttering before calls; and (e) sleep—initial insomnia and 1–2 nocturnal awakenings on conflict weeks. No current romantic/sexual partnerships; asexual identity is affirmed and not a source of distress. Values family obligation and also personal boundaries, which feel in tension.

Family/relationship context: Parents lean on Sophak for translation, bills, and caregiving; extended-family messaging emphasizes privacy and prayer. Parental minimization of Dara’s depression increases Sophak’s vigilance and sense of being the family “buffer.” Resentment toward the “good one” role alternates with guilt and self-blame (“If I don’t do it, who will?”). Sibling alliance is strong; Sophak often advocates for Dara while managing parents’ reactions.

Psychiatric/medical/substance: No prior psychiatric hospitalizations/meds reported. Past counseling: none/limited. Denies substance misuse. Medical: none reported. Sleep: 4–6 hrs on conflict weeks; ~6.5–7 hrs otherwise.

Strengths/protective factors: Insightful; reliable; strong sibling bond; emerging boundary skills; prosocial values; employed; asexual identity clarity; help-seeking; organizational skills that can be repurposed toward sustainable boundaries.

II. Cultural & Systemic Formulation

Second-generation role strain/parentification and language brokering intersect with collectivist norms of filial piety and privacy about family problems, constraining help-seeking and increasing hidden workload. Heteronormative stigma and mental health minimization around Dara’s depression place Sophak in a loyalty bind (care vs. self-preservation). Observed emphasis on controlled presentation (see MSE) may function as cultural “face”/respectability and a personal armor when internal state feels disorganized. Distress is driven by Z-code stressors (acculturation, role overload, caregiver burden), not by asexual identity. Treatment will validate cultural values while redistributing invisible labor, building permission for limits, and de-shaming rest.

III. Risk & Safety

Suicide/self-harm/violence: Denies current/past SI, plan, intent; denies NSSI/HI; no firearms reported.
Acute risk level: Low; monitor given insomnia, somatic strain, and overwork.
Safety steps today: Reviewed 24/7 crisis resources; identified two trusted contacts; agreed to outreach if sleep <4 hrs on 3 consecutive nights or if hopelessness escalates.

IV. Mental Status Exam

Appearance well-groomed; full-coverage makeup noted (foundation/contour, precise brows, matte finish). Behavior cooperative; eye contact good. Psychomotor WNL; mild fidgeting of hands during family topics. Speech normal rate/volume. Mood “tired and frustrated”; affect congruent, mildly constricted with brief tearfulness. Thought process linear; content without delusions/AVH; no SI/HI. Orientation x4; attention/concentration intact. Insight and judgment good.

Clinical note: Makeup is documented as an observation only; possible meanings (self-expression, cultural norm, “feeling put together” under stress) to be explored collaboratively without pathologizing.

V. Diagnostic Impressions (DSM-5-TR)

Primary (provisional): F43.23 Adjustment Disorder with Mixed Anxiety and Depressed Mood — tied to sustained caregiving/translation demands, minimization of sibling’s depression, and extended-family privacy/religious directives.

Secondary/Contextual (Z-codes):

  • Z63.8 Other problems related to primary support group

  • Z60.3 Acculturation difficulty

  • Z62.898 Other problems related to upbringing

  • Z62.891 Sibling relational problem

  • Z56.9 Work-related stressor
    Differential to monitor: GAD (F41.1) if pervasive >6 months across domains; PDD (F34.1) if low mood/sleep issues most days ≥2 years; Other Specified Trauma- and Stressor-Related Disorder if cumulative parentification yields trauma-like clusters. Asexual orientation is not pathological.

VI. Medical Necessity / Level of Care

Clinically significant anxiety/depressive symptoms (rumination, irritability, guilt cycles), functional impairment (sleep disruption, time-costly over-functioning, somatic pain), and environmental stressors (ongoing role overload) require weekly 53–60 minute outpatient psychotherapy. Goals include symptom reduction, rebalancing invisible labor, boundary acquisition, sleep restoration, and culturally responsive support for Dara while maintaining Sophak’s limits.

VII. Initial Treatment Goals (90 days)

(1) Reduce anxiety/depressive symptoms by ≥50% (weekly check-ins) and decrease rumination episodes to ≤10 minutes using cue-based skills.
(2) Rebalance roles: reduce unplanned translation/billing tasks by ≥25% through boundary scripts and alternative resources.
(3) Implement two somatic downshift skills for jaw/shoulder tension, with self-rated muscle tension dropping ≥2 points (0–10 scale) on ≥4 days/week.
(4) Improve sleep to 6.5–7.5 hrs on ≥5 nights/week; reduce sleep latency to <30 minutes.
(5) Increase values-aligned boundary statements (≥2/week) with post-boundary guilt recovery routine (self-compassion + reality-check) within 24 hours.
(6) Develop a shared plan to support Dara (identify 2 resources) without abandoning limits.
(7) Reframe “good one” narrative; increase self-validation statements (≥3/week) and reduce self-blame frequency by 50%.