Question

To complete each assignment, you will need to read the case study. Assume that the client described in each case study meets criteria for a DSM-5 disorder. You will then consult the DSM-5 criteria and write 1-2 detailed paragraphs in which you assign a primary diagnosis for the client and justify that diagnosis. In this section you should reference EACH of the DSM-5 criteria for the diagnosis you are assigning and provide evidence from the case study for or against the presence of that criterion. If you have no information for a particular criterion you should specify this. For example, if the DSM-5 criteria specify that the symptoms cannot be accounted for by a medical condition and you have no evidence that the client has a medical condition that would explain their symptoms, you should state this. Next, write a paragraph in which you provide an example of at least one related diagnosis that you are ruling out based on the information you have. This is a process called “differential diagnosis.” As you know, the categories provided in the DSM-5 do not represent “true” categories in nature, and often clients will often have symptoms in multiple categories. As a clinician, you need to rule out other categories or explanations for the symptoms. For example, if someone is experiencing panic attacks in the wake of a traumatic event, you might consider the diagnoses of Posttraumatic Stress Disorder, Acute Stress Disorder, or Panic Disorder. The DSM-5 criteria will help you figure out which is the most appropriate diagnosis, and you should specify why you are ruling out another disorder, providing specific justification for ruling it out. The best disorders to rule out are those that share features or symptoms described in the case but are not the best diagnosis for the client. Finally, you will write one paragraph in which you may specify the use of a psychosocial treatment, a psychoactive medication, or both. You must briefly describe how this treatment works and you must justify your choice of treatment based on the research evidence for the efficacy of the treatment.

Case Study #1

Linda is a 36-year old, Afro-Latina, married insurance executive living in the Northeast United States. She has been experiencing symptoms of anxiety since she was in high school, but they have recently become much worse after the birth of her second child, a son, 4 months ago, prompting her to seek treatment. She says that for the last 4 months she has felt keyed up, anxious, and “on alert” almost constantly. She has difficulty sleeping, significantly diminished concentration, and is irritable. In addition, several times a day she has “attacks” that involve involve “full terror.” The episodes last for about 10-15 minutes each, and usually involve profuse sweating, muscle tension, increased heart rate, feelings of dizziness, trembling, intense fear, and crying. When asked what triggers these episodes, Linda says that they usually occur when she is at home alone with her infant son or when she has memories of his delivery, during which she suffered a rare complication (she learned after delivering that both she and her baby could have died during the delivery). She tries very hard not to think about the delivery, but images and memories of it pop into her head frequently. In addition to these episodes of “terror,” Linda says that since her son’s birth she feels worthless, ashamed, and guilty for not “bringing him into a safe world.” She also states that she feels sad much of the time, and is detached from her son (she does not feel she has bonded well with him). Linda has started to sometimes call out sick from work when she has the sense that she is “having a bad day” and might have an episode, and she says she is increasingly withdrawing from her son because she finds that being with him triggers her anxiety. She says that she feels “utterly alone” and avoids hanging out with other mothers of infants because she finds they cannot relate to her experiences. Linda does not use any substances or have any medical conditions that could explain these episodes.

Answer 1

Primary diagnosis : Posttraumatic Stress Disorder 309.81

A. Exposure to actual death, serious injury, in one (or more) of the following ways:

1. Learning that the traumatic event occurred to a close family member.. She learned after delivering that both she and her baby could have died during the delivery

B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s) that symbolize or resemble an aspect of the traumatic event(s).... when she is at home alone with her infant son or when she has memories of his delivery. She tries very hard not to think about the delivery, but images and memories of it pop into her head frequently.

2. Intense or prolonged psychological distress at exposure to internal or external cues .... several times a day she has “attacks” that involve involve “full terror.” and the episodes last for about 10-15 minutes each. These usually occur when she is at home alone with her infant son.

3. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).... The terror attacks usually involve profuse sweating, muscle tension, increased heart rate, feelings of dizziness, trembling, intense fear, and crying.

C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:

1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)..... She tries very hard not to think about the delivery.

2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)....she is increasingly withdrawing from her son because she finds that being with him triggers her anxiety. She says that she feels “utterly alone” and avoids hanging out with other mothers of infants because she finds they cannot relate to her experiences.

D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

1. Persistent and exaggerated negative beliefs or expectations about oneself.... She says that for the last 4 months she has felt keyed up, anxious, and “on alert” almost constantly.

2. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.... Linda says that since her son’s birth she feels worthless, ashamed, and guilty for not “bringing him into a safe world.”

3. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).... Linda says that since her son’s birth is ashamed of having not brought the child into a safe world. She feels sad much of the time. She has intense fear.

4 . Markedly diminished interest or participation in significant activities... She avoids hanging out with when mothers of infants are present.

5. Feelings of detachment or estrangement from others.... she does not feel she has bonded well with her baby and avoids hanging out with other mothers of infants because she finds they cannot relate to her experiences. She says she is increasingly withdrawing from her son because she finds that being with him triggers her anxiety.

E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects..... Case history sayssshe is irritable

2. Hypervigilance. ... She is “on alert” almost constantly.

3. Problems with concentration. .. She has significantly diminished concentration.

4. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).... She has difficulty sleeping.

F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month. .. She is facing the problems for past 4 months.

G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.... Linda has started to sometimes call out sick from work when she has the sense that she is “having a bad day” and might have an episode.

H. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.....Linda does not use any substances or have any medical conditions that could explain these episodes.

Differential diagnosis 1. Panic Disorder

Several times a day she has “attacks” that involve involve “full terror.” The episodes last for about 10-15 minutes each, and usually involve profuse sweating, muscle tension, increased heart rate, feelings of dizziness, trembling, intense fear, and crying. But these symptoms are better explained by PTSD here in her condition.

Differential diagnosis 2: post partum depression..... Irritability sadness, worthlessness, guilt, pleasure associated with hanging out with others avoided (social withdrawal) , unable to bond with the child etc.... Here too symptoms better explained by PTSD since the trauma is caused by learning about delivery complication in which both mother and child could have died.

Treatment

Pharmacotherapy is needed for immediate sessation of anxiety attacks and for preventing the worsening of already present mood symptoms. CBT can be used as preferred psychotherapy intervention to challenge the cognition associated with guilt, avoidance etc . Behavioural techniques of systematic desensitization to external and internal cues can be done with carefully chosen SUD (subjective units of distress ), also biofeedback maybe employed to handle physiological responses . Relaxation techniques can be taught so that it can be used when anticipation of anxiety attacks occur. Practice of positive psychology techniques may be suggested to prevent relapse .