Diagnosis and Management Across the Lifespan I

Jessica Ruiz

MN663 PMHNP Diagnosis and Management Across the Lifespan I

Purdue Global University

03/08/2023

Case Study

The client is a 45-year-old male with a history of depression, anxiety, and substance use disorder. He has a history of childhood trauma, including physical and emotional abuse, and has struggled with addiction since his teenage years. He has been in and out of rehab programs with varying degrees of success. He is currently unemployed and living with his sister.

Psychiatric History: The client reported having a history of depression, anxiety, and substance use disorder. He reported that he had been struggling with addiction since his teenage years and had been in and out of rehab programs with varying degrees of success. He reported a history of childhood trauma, including physical and emotional abuse.

Physical History: The client reported no physical illnesses or injuries. He stated that he had not had any recent medical checkups. He reported that he had a normal diet and was not taking any medications.

Social History: The client reported being unemployed and living with his sister. He reported that he had no close friends due to his struggles with addiction. He reported that he had been in a few relationships in the past, but they did not last.

Family History: The client reported having a difficult relationship with his parents since his teenage years. He reported that his father was an alcoholic, and his mother was emotionally distant. He reported having two siblings, an older brother and a younger sister.

Work History: The client reported that he had worked in various jobs but had difficulty maintaining employment due to his struggles with addiction. He reported that he had been unemployed for the past six months.

Diagnostic Aids: The client was assessed using the Structured Clinical Interview for DSM-5 (SCID-5), which revealed the presence of major depressive disorder, generalized anxiety disorder, and substance use disorder. The client was also given the Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI), which revealed moderate levels of depression and anxiety, respectively.

The client was assessed using the Structured Clinical Interview for DSM-5 (SCID-5), a semi-structured clinical interview for diagnosing mental disorders that are used to assess for the presence of mental disorders and to provide information for developing a DSM-5-compliant diagnosis. The SCID-5 assesses for the presence of symptoms, their severity, and the duration of the symptoms. The SCID-5 provides information on the client’s personal and family history of mental disorders. The client was also given the Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI), both self-report scales that measure the severity of depression and anxiety symptoms, respectively. The results of the BDI and BAI revealed moderate levels of depression and anxiety, respectively.

The client underwent a physical examination to assess his overall health and well-being. The physical examination included vital sign measurements such as blood pressure, pulse, and respiration rate, as well as an assessment of the client’s height and weight. Additionally, the physical examination included an assessment of the client’s head and neck, lungs, heart, abdomen, and extremities. The physical examination revealed no physical illnesses or injuries. The physical examination also revealed that the client was of normal weight and height, and had normal vital signs.

Based on the information gathered during the evaluation, the client was diagnosed with Major Depressive Disorder (F32.9), Generalized Anxiety Disorder (F41.1), and Substance Use Disorder (F19.10). The diagnosis of MDD is based on the presence of five or more of the following symptoms, which the client reported experiencing during the evaluation: depressed mood, diminished interest or pleasure in activities, significant weight loss or gain, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or excessive guilt, diminished ability to think or concentrate, and recurrent thoughts of death. The diagnosis of GAD is based on the presence of three or more of the following symptoms, which the client reported experiencing during the evaluation: restlessness, easily fatigued, difficulty concentrating, irritability, muscle tension, and sleep disturbance. The diagnosis of SUD is based on three or more of the following symptoms, which the client reported experiencing during the evaluation: impaired control over substance use, social impairment, risky use, and pharmacological criteria, as well as tolerance and withdrawal. The client’s verbal reports, observations of the client during the evaluation, and the results of the SCID-5, BDI, and BAI all support the diagnosis of MDD, GAD, and SUD. The client reported experiencing symptoms such as depressed mood, diminished interest or pleasure in activities, restlessness, easily fatigued, difficulty concentrating, irritability, muscle tension, and sleep disturbance. Additionally, the SCID-5, BDI, and BAI results all revealed moderate levels of depression, anxiety, and substance use disorder. Based on these findings, it is reasonable to conclude that the client meets the criteria for MDD, GAD, and SUD diagnosis.

The client’s plan of care should include evidence-based interventions for treating MDD, GAD, and SUD. The plan of care should also address the client’s underlying psychological issues, such as his history of childhood trauma and his struggles with addiction.

For MDD, the client should be offered evidence-based psychotherapeutic interventions, such as cognitive-behavioural therapy (CBT), interpersonal psychotherapy (IPT), and problem-solving therapy (PST). For GAD, the client should be offered evidence-based psychotherapeutic interventions, such as CBT and mindfulness-based stress reduction (MBSR). For SUD, the client should be offered evidence-based psychotherapeutic interventions, such as motivational interviewing (MI) and cognitive-behavioural therapy for substance use disorders (CBT-SUD). Additionally, the client should be offered medication management as indicated.

In addition to these evidence-based interventions, the client should be offered interventions to address his underlying psychological issues. The client should be referred for trauma-informed care, which includes therapies such as cognitive-processing therapy (CPT), prolonged exposure therapy (PE), and eye movement desensitization and reprocessing (EMDR). The client should also be referred for substance abuse treatment, which includes individual counselling, group therapy, medication-assisted treatment (MAT), and 12-step programs.

Finally, the client should be referred to other professionals, such as a pain specialist and social services, to address any physical and social issues contributing to his poor psychological functioning. The client should also be encouraged to engage in healthy lifestyle activities like exercise, healthy eating, and adequate sleep.

Conclusion

In conclusion, this case study highlights the importance of a comprehensive psychiatric assessment for clients with a history of depression, anxiety, and substance use disorder. A full psychiatric, physical, social, family, and work history was collected, and a diagnosis of MDD, GAD, and SUD was formulated. Additionally, evidence-based interventions for treating these disorders were proposed, as well as interventions to address the client’s underlying psychological issues. The client should also be referred to other professionals and encouraged to engage in healthy lifestyle activities.

References

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