Differential diagnosis process

The sign of an effective clinician is the ability to identify the criteria that distinguish the diagnosis from any other possibility (otherwise known as a differential diagnosis). An ambiguous clinical diagnosis can lead to a faulty course of treatment and hurt the client more than it helps. In this Assignment, using the DSM-5 and all of the skills you have acquired to date, you assess a client.

This is a culmination of learning from all the weeks covered so far.

To prepare: Use a differential diagnosis process and analysis of the Mental Status Exam in the case provided by your instructor to determine if the case meets the criteria for a clinical diagnosis.

Submit a 4- to 5-page paper in which you:

  • Provide the full DSM-5 diagnosis. 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 need clinical attention).
  • Explain the full diagnosis, matching the symptoms of the case to the criteria for any diagnoses used.
  • Identify 2–3 of the close differentials that you considered for the case and have ruled out. Concisely explain why these conditions were considered but eliminated.
  • Identify the assessments you recommend to validate treatment. Explain the rationale behind choosing the assessment instruments to support, clarify, or track treatment progress for the diagnosis.
  • Explain your recommendations for initial resources and treatment. Use scholarly resources to support your evidence-based treatment recommendations.
  • Explain how you took cultural factors and diversity into account when making the assessment and recommending interventions.
  • Identify client strengths, and explain how you would utilize strengths throughout treatment.
  • Identify specific knowledge or skills you would need to obtain to effectively treat this client, and provide a plan on how you will do so.

Resources

Morrison, J. (2014). Diagnosis made easier (2nd ed.). New York, NY: Guilford Press.

  • Chapter 15, “Diagnosing Substance Misuse and Other Addictions” (pp. 238–250)

https://dsm-psychiatryonline-org.ezp.waldenulibrary.org/doi/10.1176/appi.books.9780890425596.dsm16

https://ajp-psychiatryonline-org.ezp.waldenulibrary.org/doi/pdf/10.1176/appi.ajp.2017.16101180

https://ajp-psychiatryonline-org.ezp.waldenulibrary.org/doi/pdf/10.1176/appi.ajp.2017.1750101

https://www-ncbi-nlm-nih-gov.ezp.waldenulibrary.org/pmc/articles/PMC5447061/

https://eds-a-ebscohost-com.ezp.waldenulibrary.org/eds/detail/detail?vid=0&sid=a52aa701-4f47-4178-b16b-98eb4ca9608e%40sdc-v-sessmgr03&bdata=JnNpdGU9ZWRzLWxpdmUmc2NvcGU9c2l0ZQ%3d%3d#AN=000368510100003&db=edswss

CASE of HERMOSA

Intake Date: April 2020

PRESENTING PROBLEM:

Hermosa indicated that since her husband died suddenly of a Myocardial Infarction (MI) on Christmas Day in 2018, she has progressively become “more and more depressed.” During the week prior to this assessment, she indicated becoming progressively dysphoric, crying uncontrollably for several hours and had suicidal thoughts of taking an overdose.  Patient presented in the Emergency Department (ED) on a voluntary basis.  She denied wanting to kill herself on admission to the ED.

PSYCHOLOGICAL DATA:

Hermosa is a 43-year old, Hispanic widowed female.  Hermosa reports being of Christian faith. She completed her BS in Education and one semester in graduate school in Special Education.  She has been voluntarily unemployed since 6/19.  She lives with her 18-year old daughter who is a college student.  She also has a son, age 20, who is a college student in California.  She has two step-daughters who are identical twins, age 22.  They are college students and living on campus in Indiana. Prior to being widowed, Hermosa was married twice.  Her first marriage ended in 2003, and she remarried in 2007.  Hermosa also has a brother, age 40, and a sister, age 38, both of whom live within a two-hour drive of Hermosa.  Her father & mother, ages 69 and 65 respectively, are both retired and living within a four-hour drive of Hermosa.

MEDICAL HISTORY:

Menses are irregular and accompanied by severe dysmenorrhea.  Hermosa previously took birth control pills at ages 17 to 27 for hormone imbalance and severe dysmenorrheal, when she was not focused on getting pregnant.  Her last menstrual period began 3/30/20.  Hermosa has had two pregnancies and given birth to two children.  She is allergic to spores, mold, dust, cigarette smoke, Penicillin and Demerol.  She has previously had hyposensitization shots which ended in 6/19 (History taken from ED chart).

SUBSTANCE ABUSE HISTORY:

Hermosa denies consumption of alcohol/drugs.

PSYCHIATRIC HISTORY:

Hermosa has been in outpatient individual psychotherapy with Dr. W since 6/19.  In addition, her family physician, Dr. A prescribed Prozac in 6/19.  Hermosa indicated seeing a psychiatrist, whose name she could not recall, from 2001-2003.  She said that she was put on Seroquel, because she was hearing things and couldn’t sleep, but could not recall the dosage. Once everything become better she was weaned off the medication.

MENTAL STATUS:

Hermosa presented as a casually dressed, meticulously groomed woman who appeared her stated age of 43. She lay on her bed during the interview.  She had a fixed, mood congruent expression on her face.  Motor activity was normal.  Mood was dysphoric. Affect was constricted.  Speech was guarded and soft with some evidence of stuttering. Content was adequate, however.  Thought processes were goal-directed, logical and abstract.  There was no evidence of delusions.  Hermosa acknowledged auditory hallucinations in the form of two men sitting on her shoulder telling her self-depreciating thoughts.  Hermosa was oriented in three spheres.  Concentration was markedly impaired.  Digit span was 7 forward and 4 in reverse.  She was unable to calculate serial 7’s.  Recent and remote memory appeared intact.  Intelligence appeared above average and fund of knowledge was excellent.  All factual questions were answered correctly.  Hermosa was able to abstract similarities and proverbs with detail and accuracy.  Ordinary social and personal judgment was appropriate.  Hermosa’s three wishes were that “my family stays well, that I am able to get on with my life, and that I am close to my family and kids.”   Five years from now, Hermosa sees herself in “graduate school, getting a doctorate in social work.” If Hermosa could change something about herself, she would “feel better about myself, more secure more confident.”

SUICIDAL ASSESSMENT:

Hermosa admitted to recurring thoughts about “taking an overdose and ending my life.” She said that “I would be better off dead, then I would no longer be in pain.”   Hermosa denied any concrete plan about taking an overdose, vis-s-vis the type of medication or the amount.  Hermosa also denied intent.  Hermosa admitted to a prior suicide attempt in 2001, in which she took an overdose of Valium and Alcohol.  Hermosa denied any other attempts.

HOMICIDAL ASSESSMENT:

Hermosa denied any homicidal thoughts, plan or intention.  Hermosa denied any previous homicidal history.

SUMMARY NOTE:

Hermosa thought she has been depressed since her husband died suddenly of an MI on Christmas Day in 2015.  Initially she felt “numb” and in shock, but later became increasingly dysphoric and tearful and unable to carry on every day tasks.  At the end of the school year, 6/19, Hermosa resigned her position as special education teacher and began outpatient treatment with Dr. W, 3x/week.  Hermosa hears two male voices commenting on her activities, telling her to hurt herself when she is upset and telling her she “shouldn’t be here.”   They come at various times during the day and night, but are worse in the late afternoon.  Hermosa shows no sign of delusional thinking.  Immediately prior to her presentation at the ED, Hermosa’s therapist went on vacation.  She had recently decreased her individual therapy sessions to twice a week and she joined a group therapy run by her therapist once a week.  Hermosa complains of difficulty falling asleep because she fears she will not wake up. She feels her mood has improved as a result of being on Prozac but has still experienced hallucinations despite the Seroquel.

During the week prior to her admission to the ED, Hermosa became increasingly dysphoric, cried uncontrollably for several hours and had suicidal thoughts of taking an overdose.  She has felt increasingly anxious, has sat for hours at a time at home, just staring out a window.  Hermosa said she is unable to concentrate, feels responsible for her husbands’ death, hates herself, is anhedonic, fatigued, unable to make decisions, and had decreased libido.  A friend called Hermosa on the Saturday prior to admission, while Hermosa was distraught, and Hermosa confided to her friend her suicidal thoughts.  Hermosa had also told her therapist of her suicidal thoughts and her therapist encouraged a voluntary inpatient admission.  An additional stressor for Hermosa was the physical and sexual abuse she experienced during her first marriage.  She still has nightmares about this and if awakened suddenly, she covers her face with her arms as if to protect herself.  She is unable to talk about what happened during her marriage, because she does not trust anyone and fears that she will be blamed if she confides in staff or peers.  Prior to her leaving her first marriage, she was losing weight and had difficulty concentrating.  Her husband would abuse her about her disheveled appearance.  One day she suddenly packed a suitcase and took her children, who were then ages 2 and a newborn and left.  She has never fully told her parents why she left.  Hermosa has applied and has been accepted at a graduate school for social work and hopes to be a therapist.

COLLATERAL CONTACT: 

Hermosa’s daughter and Hermosa’s friend were interviewed by telephone by the intake social worker.  Each of the persons interviewed described relief in having Hermosa in the hospital.  Her friend stated she may have diverted Hermosa’s plan of suicide by making a call to Hermosa at just the right time.  Hermosa said to the friend, “I just don’t know how I can go on.”   When the friend asked Hermosa how she could help her, Hermosa replied, “Please just shoot me.”  According to daughter and friend, Hermosa’s sadness began at the time to her second husband’s death two years ago, and has extended beyond the “normal grieving period.” Her friend stated, “I have watched her get worse and worse,” indicating that Hermosa has changed from a capable detail oriented person with strong conviction, to a depressed, nonfunctional person, with an inability to cope with life.  Daughter states that her mother never smiles…”Hermosa thinks she is not worth anything, that she is undesirable and that she is not capable.”  Daughter describes her mother’s recent behavior as sad and tearful, “staring into space.”   Hermosa lives with her daughter, who indicates that she and her mother have become friends since her step-father died.  Daughter states she is confused by her mother’s behavior and feels sad for her.  She also experiences fear that her mother will kill herself.  Friend indicates that Hermosa has made new friends since her husband’s death, but states Hermosa is “terrified of long-lasting male relationships, intimacy and any physical contact.” According to friend, Hermosa maintains a close relationship with her parents who have always required a strong sense of stability from Hermosa.  Although Hermosa has been a teacher for the past 13 years, she currently is not gainfully employed.

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