Case Analysis Evaluation

Symptoms: anger, stress, depression, anxiety, suspicious of authority figures, low self-esteem, low confidence, inflicting self-harm, broken relationships with family, sexually active, chronic feelings of emptiness, high consumption of alcohol, cannot maintain a job for more than one year, lacks many friends, feelings of loneliness and unhappiness.

a. Identify appropriate history questions to be asked to discriminate critical characteristics or attributes about the presenting complaint.

Character: Does the patient have a history of anxiety and or depression? Is there any medication prescribed based on a diagnosis of anxiety or depression? Does the patient have a history of a lack of trust in authority figures? Does the patient recognize historical instances of inflicting self-harm? Is the patient aware of her drug abuse problem? Is the patient sexually active? Does the patient take sexual protection measures against sexually transmitted diseases? Does the patient have an existing relationship with family and friends? From family history, what are the mental health issues in the family? What is the patient’s character in sustaining current employment? Does the patient live alone? How does the patient feel about themselves based on esteem and confidence, happiness and loneliness?

The client is legally bound to receive the best evaluation and treatment of ailment. The client’s rights for assessment require prior information about the process, what is required, what are the expected outcomes and how the process will be carried out. The client is also entitled to an assessment location that is suitable and comfortable for them. Any information that that patient asks is provided to them upon request, including preventative measures and accuracy of the test. In general, the client can request for professional assessment from an individual they are comfortable with during the evaluation.

Onset: does the patient recall when her anxieties, depression and feeling of loneliness, as well as unhappiness, begun? Does she remember when her suicidal thoughts began and when consequential self-harm started? Does the patient remember her journey toward alcoholism and being sexually active? Does the patient often feel lonely or unhappy? What times trigger the need to purchase alcohol? Why is the patient suspicious of authority figures? Is it related to her past or present events? Does this occur only in the presence or also the absence of authority figures? Does the lack of need to sustain relationships make the patient feel lonely and unhappy? Does it make her feel unloved? What effect does the medication she takes to have on controlling anxiety or depression?

Location: Does the feeling of anxiety, depression and lack of authority figure trust occur during work or outside work? Does the feeling of loneliness, unhappiness, feeling unloved, and anxiety occur when they are home alone? The need to consume alcohol, does it occur when feelings of overwhelmed loneliness and depression occur?

Severity: Does the feeling of loneliness and unhappiness occur at certain periods or as a result of specific thoughts? Does it trigger anxiety? For how long does the patient experience anxiety? Does it make her consume more alcohol? What is the trigger for alcohol consumption? How bad are the symptoms from 1-10 (with one being barely noticeable) and ten being highly noticeable). Does the patient show signs of restlessness and unwillingness to cooperate? Is the patient less likely to engage in answering the questions? Is the patient honest in their answers?

Pattern: does the medication prescribed, fluoxetine 20 mg, reduce the occurrence of the symptoms of anxiety and depression since you started? Fluoxetine 20 mg is a drug that allows patients to feel better based on the symptoms of anxiety. For instance, it can make the patient feel less anxious and reduce thoughts of being unloved and unfriendly to others.

Associated factors: will the patient present comfort and ease during the evaluation and treatment phase? Is there a need for an additional supervisory nurse or psychiatric professional needed? Further information on previous medical history is required.

b. Delineate four hypotheses (differential diagnosis) that could support the above symptoms in relation to pertinent answers given in history. Most include DSM 5 diagnostic code and provide a rationale for each choice based on the presenting case.

Differential 1	Family history of mental and behavioural disorders (ICD-10-CM diagnosis code Z 81.8) as the patient indicates a history of her sister having anxiety and depression.
Differentials 2	Somatoform Disorder (ICD-10-CM code F45.9) since the patient has a history of alcoholism which may be an unexplained contributing factor to impairment in functioning especially forgetfulness.
Differential3	Major depressive disorder (ICD-10-CM Code F33.9) as shown by the patient in having long-term depression.
Differential 4	Social Anxiety disorder (ICD-10-Cm code F40.11) given that the patient records a high level of social awkwardness and the history of isolation.

c. What would mental status exam findings be associated with each listed hypothesis above? What subjective data might the patient report? Use all seven component of MSE- Appearance, Behavior, Speech, Affect, Thought process, Thought content, Cognitive examination (level of awareness, Attention and Concentration, Memory, Orientation, etc.).

Differential 1

(Keeley et al., 2016)

Family history of mental and behavioural disorders (ICD-10-CM diagnosis code Z 81.8) as the patient indicates a history of the sister having anxiety and depression.

Appearance	Behaviour	Speech	Affect	Thought-process	Thought content
Anxiety Depression	Allows feeling alone Feeling unloved.	Deviation	Uncooperative Dos does not understand changes in her body Change in sex drive	Overly stressed about her relations	evasion
Level of awareness	Attention	Concentration	Memory	Orientation	Abstraction
Too alert	Limited focus	Condensed dimensions to focus	Evasion	Failure to recall Losses memory after alcohol drinking	High interest in surroundings Derealisation

differential 2

(Kampfer et al., 2016)

Somatoform Disorder (ICD-10-CM code F45.9) since the patient has a history of alcoholism which may be an unexplained contributing factor to impairment in functioning especially forgetfulness.

Appearance	Behaviour	Speech	Affect	Thought-process	Thought content
Weak Anxious	Distressed Tense	Slow	Miserable	Unresponsive Overly stressed about emotions	Insufficient Incoherent
Level of awareness	Attention	Concentration	Memory	Orientation	Abstraction
Lack of awareness	Easily distracted Blocking	Weariness	Incapable of recall	Aware	Incapacitated

Differential 3

Otte et al. (2016)

Major depressive disorder (ICD-10-CM Code F33.9) as shown by the patient in having long-term depression.

Appearance	Behaviour	Speech	Affect	Thought-process	Thought content
Loss of weight Chronic fatigue Excessive sweating	Depression	Avoids answer questions	Moody Anger Stress	Lack of trust Has no association with others.	Suicidal thoughts
Level of awareness	Attention	Concentration	Memory	Orientation	Abstraction
Reduced desire	Reduced capability Unresponsive	Irrational Over-expressive	Limited Dimensional	Lacks proper responses to answers	Stress Anger

Differential 4

Hofman and Otto (2017)

Social Anxiety disorder (ICD-10-Cm code F40.11) given that the patient records a high level of social awkwardness and a history of isolation.

Appearance	Behaviour	Speech	Affect	Thought-process	Thought content
Distracted Unresponsive	Variations in awareness	Limited replies	Anger Anxiety	Feel unloved Lack of relations with others	Suicidal thoughts Depression
Level of awareness	Attention	Concentration	Memory	Orientation	Abstraction
Reduced awareness	Inconclusiveness	Difficult to handle	Impaired	Inadequate liveliness	Moderate aptitude

d. What is the etiology associated with each of the four differential diagnosis? Include psychological factors and past experiences that may be contributing to current symptoms.

Differential 1

(Keeley et al., 2016)

(NIMH » Any Anxiety Disorder, 2020)

Keeley et al. (2016)

Family history of mental and behavioural disorders

Etiology

Family history of the mental and behavioural disorder is regarded as a genetic disorder that is passed on down to the offspring. Genetic factors have a strong role in the development of psychopathology, including anxiety disorders and depression. Specific disorders, including anxiety, can develop from childhood, whereas; depression is an onset symptom of adulthood.

An estimated 19.1% of adults in America have an anxiety disorder. It is more prevalent in females (23.4%) than in males (14.3%). It is estimated that 31.1% of adults experience anxiety at one point in their lives. Further, more than 22.8% of adults have a severe impairment, while 33.7% have mild impairment.

Psychological factors

Inherited factors and environmental exposures. There has to be a history of mental illness from a blood relative either parent or sibling. Stressful environments can also be a trigger for mental disorder synonymous with family-oriented mental disorders.

Past experiences/ risk factors

Genetics can be a strong contributor to family-based mental disorders which prompts anxiety and depression. The following factors can be considered

– Absentee parent

– Trauma

– Depression

– Self-harm

– Personality

– Constant stress

– Substance abuse

– Loneliness

– Physical illness

– Gender

Differential 2

Kampfer et al. (2016)

(NIMH » Any Anxiety Disorder, 2020)

Somatoform Disorder

Etiology

Susceptibility to alcoholism is inherited. Inheritance factors include different rates of tolerance, routes of alcohol metabolism, taste and preferences, signalling mechanism in the peripheral brain and aversion on qualities of alcohol. There is also the possibility of environmental interactions. Psychological and emotional influences can lead to alcohol problems increasing vulnerability to alcohol dependence.

Prevalence of substance abuse and mental disorder is rampant in the country. At least 20.2 million are diagnosed with substance abuse. Alcohol deaths are reported to be at 6 per day.

Psychological factors

Family history of alcoholism or drug abuse can establish variations of alcoholism in members. Mental and behavioural disorders, family environments and psychologic responses can trigger alcoholism.

Past experiences/ risk factors

Risk factors associated with alcoholism include:

– depression

– anti-social behaviour

– anxiety disorder

– isolation

– heightened sensitivity

– deviance proneness

– emotional distress

– alcohol dependence

Differential 3

Otee et al. (2016).

(NIMH » Any Anxiety Disorder, 2020)

Otee et al. (2016).

Major depressive disorder

Etiology

Depression can occur as early as the pre-adolescent years. It is estimated that 1/3 of teenagers born in America can have early-onset depression. It can also occur in early adulthood. There are greater chances of recurrence can impair judgment and functionality, and worse, can factor in psychosocial behaviour.

An estimated 17.3 million adults (17.1%) have at least one major depressive episode. Prevalence of depression is higher in females (8.7%) than in males (5.3%). Depressive disorder can occur in more than one episode and in adults; it is estimated to occur often at 11.8%.

Psychological factors

Depression can be noted as a result of an acute stressor, inability to seek treatment, impairment in judgment and cognition and vulnerability to stress and anger. Genetic factors can also contribute. Early-onset of depression is linked to the parental transfer of the disorder to children.

Past experiences/ risk factors

– acute life events including undesirable or negative events

– Stressful events, such as loss or deprivation.

– Race, culture and ethnicity can be risk factors as well.

Differential 4

Hofman and Otto (2017)

(NIMH » Any Anxiety Disorder, 2020)

Hofman and Otto (2017)

Social Anxiety disorder

Etiology

Genetic factors play a contributory role in social anxiety disorders. Family history can be a risk factor in which a parent can transfer genes to the child. Also, it can be initiated due to a traumatic social experience or through social skill deficit. Hypersensitivity reaction can cause increased social anxieties.

An estimated 7.1% of adults have the disorder. Prevalence is higher in females (8%) compared to males at 6.1%. It is also estimated that adults experience the social disorder at least once in their lives.

Psychological factors

Cognitive factors are contributors to the disorder. The CBT (cognitive-based therapy) model indicates that increased perception of social standards, poorly defined social goals and differential social apprehensions. In most cases, individuals perceive negatively, have low emotional control and anticipate social mishaps.

Past experiences/ risk factors

Environmental risk factors are great contributors.

– Biological

– Psychological

– Social

– Environmental disturbances

e. What diagnostic screening tool would you use for each of the four differential diagnosis?

Differential 1

Rahm et al. (2017)

Family history of mental and behavioural disorders

– General psychosocial screening tests

– Ages and stages questionnaire

– Substance abuse CRAFFT (Car, relax, alone, forget, friends and trouble)

– Family screening

– Trauma or exposure

Differential 2

Lee et al. (2015)

Somatoform Disorder

– PHQ-15

– WI-7

– SAIB

– DSM-V

Differential 3

Rahm et al. (2017)

Major depressive disorder

– Intellectual and cognitive impairments

– Co-morbid psychiatry

– Concurrent substance abuse

– Other illnesses (anxiety)

– Age-specific issues

– Beck anxiety inventory

Differential 4

Lee et al. (2015)

Social Anxiety disorder

– Social phobia inventory

– Liebowitz social anxiety disorder scale

– Brief social phobia scale

– Social avoidance and distress scale

– Beck anxiety inventory

f. Analysis

The client displays diverse responses to her aggression and behaviour—the diagnostic criteria of disorders, either social or psychological factors in clinical practice and research. Criteria on the evaluation of the presence of disorders have to factor in false-positive, which may imply recognition of errors in criteria of diagnosis. The validity in assessment challenges the ability to pick mental disorders without any disputes with the knowledge that there is always an underlying shared symptom across disorders. It is, therefore, critical to distinguish between disorder and non-disorder. Common tests used include statistical deviance, family history, genetics, factor analysis and guides on disorders and non-disorders.

First et al. (2015).

Factors on environmental contributors such as insomnia, positive or negative sentiments, and seasonal affective disorders should also be factored. Measures of the association on identity are significant, including physical exam, laboratory tests and psychological examination.

The understanding difference in factor contribution including neurodevelopmental, depressive, anxiety, obsessive-compulsive, trauma, stressor and feeding and eating disorders can provide a better understanding of the symptoms and diagnosis of the patient.

g. What is the appropriate treatment plan for this patient? Treatment should include specific psychological therapeutic modalities and the focus, social interventions (support or self- help groups, mobilization of family resources, vocational rehabilitation, financial planning) and identification of strengths.

Specific psychological therapy modalities

Social interventions

Identification of strengths

– Cognitive-behavioural therapy

CBT is ideal for the patient in treating symptoms of anxiety, depression, anti-social behaviour, stress, alcohol dependence, high sexual activity and lack of trust in others.

The method is established for efficiencies in improving unhappiness, alcoholism and complications on psychological tendencies.

Crane (2017)

– Mindfulness training. Where the patient will be taught on how to handle negative interpretations, especially for social-based skills.

– Systemic exposure: limiting stressor or trigger environments for alcohol consumption, anxiety and depression. Cognitive skill boost on mindfulness.

– Medication including selective serotonin reuptake inhibitors (Paroxetine or Prozac) (Crane, 2017)

– Beta-blockers for anxiety reduction.

(Crane, 2017)

– Seeking help to better outcomes in life.

– Increased social skills

– Reduced anxiety and panic

– Reduced stress

– Improved relationships

– Reduce alcoholism

– Improve health

Heineman (2015)

– Acceptance and commitment therapies: these therapies are methods that promote specific behaviour in patients to avoid stigma. It includes cognitive re-structuring similar to CBT but will be handled separately. It is ideal for emotional distress.

Harris (2019).

– Therapy: The patient will be placed under strict psychological counselling. The aim will help uncover any childhood trauma or memories that may act as triggers.

Harris (2019)

– Increased social skills

– Reduced anxiety and panic

– Reduced stress

– Improved relationships

– Reduce alcoholism

– Improve health

Heineman (2015)

h. References

1. NIMH » Any Anxiety Disorder. (2020). https://www.nimh.nih.gov/health/statistics/any-anxiety-disorder.shtml

2. Keeley, J. W., Reed, G. M., Roberts, M. C., Evans, S. C., Robles, R., Matsumoto, C., … & Gureje, O. (2016). Disorders specifically associated with stress: A case-controlled field study for ICD-11 mental and behavioural disorders. International Journal of Clinical and Health Psychology, 16(2), 109-127.

3. First, M. B., Reed, G. M., Hyman, S. E., & Saxena, S. (2015). The development of the ICD‐11 clinical descriptions and diagnostic guidelines for mental and behavioural disorders. World Psychiatry, 14(1), 82-90.

4. Kämpfer, N., Staufenbiel, S., Wegener, I., Rambau, S., Urbach, A. S., Mücke, M., … & Conrad, R. (2016). Suicidality in patients with somatoform disorder–the speechless expression of anger?. Psychiatry research, 246, 485-491.

5. Otte, C., Gold, S. M., Penninx, B. W., Pariante, C. M., Etkin, A., Fava, M., … & Schatzberg, A. F. (2016). Major depressive disorder. Nature reviews Disease primers, 2(1), 1-20.

6. Hofmann, S. G., & Otto, M. W. (2017). Cognitive-behavioural therapy for a social anxiety disorder: Evidence-based and disorder-specific treatment techniques. Routledge.

7. Rahm, A. K., Boggs, J. M., Martin, C., Price, D. W., Beck, A., Backer, T. E., & Dearing, J. W. (2015). Facilitators and barriers to implementing Screening, Brief Intervention, and Referral to Treatment (SBIRT) in primary care in integrated health care settings. Substance abuse, 36(3), 281-288.

8. Lee, S. M., Yoon, J. R., Yi, Y. Y., Eom, S., Lee, J. S., Kim, H. D., … & Kang, H. C. (2015). Screening for depression and anxiety disorder in children with headache. Korean Journal of paediatrics, 58(2), 64.

9. Crane, R. (2017). Mindfulness-based cognitive therapy: Distinctive features. Routledge.

10. Harris, R. (2019). ACT made simple: An easy-to-read primer on acceptance and commitment therapy. New Harbinger Publications.

11. Heinemann, A. (2015). The importance of the detail complexity (symptoms) and dynamic complexity (emotional flexibility) for the description, diagnosis and therapy of mental disorders (shown by the example of phobic and schizoid personality disorders). Psychiatria, 12(4), 213-237.

Case Analysis Evaluation

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