Develop Diagnoses for Clients Receiving Psychotherapy
Mr. W is a 48 year old single dad with a 19 year old daughter A.W who he petitioned.
Chief Compliant:
Petitioned by father who reports patient thinks she is going “crazy” and she tried to cut herself and makes threats to kill self.
History of Present Illness (HPI):
Patient says she has too much “crap” going on and she can’t take it anymore. She was in an emotionally abusive relationship with her boyfriend. She denies physical at all. He was controlling and picked on everything she did. She walked on egg shells so she wouldn’t do anything to upset him so he would not yell at her. She became really depressed an anxious. She quit going to work because she couldn’t handle it. She would break down and cry. She admitted herself into a local hospital in April. She was not suicidal but she knew she needed help. Prior to that her PCP had her on Paxil, Ativan and trazodone. The hospital did not change her medications and did not give her a follow-up. She moves out to get away from it all. She had hoped to “free herself” being here and get better. Her dad lives with his own mother and her 2 half- siblings. Her father is an alcoholic- he has no job no car and lives off his mother’s money. Pt feels she has had to become an “alcoholic watcher” and has to take care of her younger siblings because her dad is too drunk to care for them. She has been here 5 weeks now. She wants to go back to Prescott but she feels too guilty to leave her siblings alone with the father. She needs a job but can’t figure out how to get her CNA license renewal. “I’m not smart and I need help with these things and no one will help me.” She wants to go back to Prescott to be near her mom.
Allergies: NKDA
Psychiatric history: anxiety
Medical History: None
Medications: Paxil 20mg, Ativan 1 mg, Trazadone 50 mg.
Substance abuse: Marijuana, drinks occasionally, denies tobacco and denies illicit drugs
Social History: Parents divorced when she was 3. Dad remarried and has 2 kids and lives with his mother in Prescott
Dad comes in for family counseling and he presents with complaints of feeling really depressed about family situation especially his daughter. He wants therapy to help with the communication between him and his daughter. Mr W. has also complaints of weight gain, low energy, and loss of interest, decreased appetite, and insomnia. Dad is an alcoholic and does not currently have a job.
Case Formulation: 19 years old with a recent onset of depression and anxiety with prior superficial cuts to the arm.
Plan and Recommendations: Continue Paxil and raise dose.
Both Mr. W and A.W were assessed with the Questionnaire -9(PHQ-9) scales Mr. W. had MDD moderate and AW has depression and anxiety. MDD, anxiety were based on the DSM-5 criteria symptoms
Differential Diagnosis:
Depressive disorder, depressed mood
Anhedonia (diminished loss of interest or pleasure in almost all activities)
Significant weight or appetite disturbance
Sleep disturbance
Psychomotor agitation or retardation (a speeding or slowing of muscle movement)
Loss of energy or fatigue
Feelings of worthlessness (low self-esteem)
Diminished ability to think, concentrate and make decisions
Recurrent thoughts of death, dying or suicide
Longstanding interpersonal rejection ideation (others would be better off without me); specific suicide plan; suicide attempt(APA, 2013)
Anxiety Disorder disorders that share features of excessive fear and anxiety and related behavioral disturbances.
Edginess or restlessness.
Tiring easily; more fatigued than usual.
Impaired concentration or feeling as though the mind goes blank.
Irritability (which may or may not be observable to others).
Increased muscle aches or soreness.
Difficulty sleeping (due to trouble falling asleep or staying asleep, restlessness at night, or unsatisfying sleep)(APA, 2013).
DSM-5: Depressive Disorder 311, Generalized Anxiety disorder 300.02
ICD Codes:
Depressive disorder ICD 10-CM Diagnosis Code F33, mental, behavioral and neurodevelopment disorder. Anxiety Disorder ICD-10 CM Diagnosis Code F41.9 Generalized anxiety disorder. Mental, behavioral and neurodevelopment disorders
Depressive disorders as evidenced by feelings of worthlessness, diminished ability to think, concentrate and make decision, attempted to commit suicide. Anxiety disorder as evidenced by impaired concentration, fear and behavioral disturbances (APA, 2013).
The five core ethical and clinical questions counselors need to consider, when treating patients with a psychiatric illness is to first know that patient rights are within the psychology. Each patient has the right to treatment, confidentiality, competence of counselor, professional boundaries and informed consent (Howe, E.2013). This includes whether counselor should tell patients their diagnosis and what they should tell them about their suicide risk. In addition, counselors should ask whether or not are available by phone, when they should hospitalize these patients involuntarily, and how they should respond after these patients have attempted suicide and return for further care (Howe, E. 2013).
The ethical components are to optimize ethical and clinical interventions; in some cases they may overlap. These interventions may maximize the autonomy patients with mental illness disorder and, at the same time, be clinically optimal, thus increasing a sense of self-efficacy and patient-counselor trust in the patients (Howe, E. 2013. In treating these clients included an inform consent from both parties. I employed non maleficence and beneficence to Mr. W and AW. The treatment goal is to improve therapeutic communication between the two. Goal treatment was to provide therapeutic communication between the two.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Washington, DC: Author.
Howe, E. (2013). Five ethical and clinical challenges psychiatrists may face when treating
Patients with borderline personality disorder with are or may become suicidal. Retrieved
from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3579480/
Nichols, M., & Tafuri, S. (2013). Techniques of structural family assessment: A qualitative
analysis of how experts promote a systemic perspective. Family Process, 52(2), 207–215.
doi:10.1111/famp.12025. Retrieved from Walden Library databases.
Nichols, M. (2014). The essentials of family therapy (6th ed.). Boston, MA: Pearson.
Wheeler, K. (Eds.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A
how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer
Publishing Company.