Vignette Analysis: Case Study

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And answer the following in APA format:
Mood Disorders, Medications Recommended, and Reasons Why
The patient is a 45-year-old African American male. He was referred to you by his primary care physician after an emergency room visit, where he was evaluated for chest pains, low energy, headaches, problems sleeping, constipation, and poor appetite. He also has hypertension and high cholesterol.
Social issues include that his wife recently left him, and he has not been promoted for over three years on his job. Finances are tight, and he has been dealing with overdue bills. He says he feels there is not much to live for, but he denies any active suicidal thoughts. He says he has felt this way for the last three months since all the pressures built to this point. He does admit to drinking a six pack a day for the last month.
He is suspicious about being referred for counseling and seems reluctant to discuss things with you. He seems resistant to the idea of counseling/therapy. Finally, he admits that his father and both uncles were treated for depression and gained a lot of weight and had sexual issues.
What is your diagnostic impression on all five axes? What are your best practices treatment recommendations? His primary care physician (PCP) says she will prescribe medication but would like your diagnostic impressions and recommendations in this regard.
Write your diagnostic findings and recommendations in a Microsoft Word document.
All written assignments and responses should follow APA rules for attributing sources.
Assignment 2 Grading Criteria Maximum Points
Provided a sound multiaxial diagnosis. 8
Provided your best practices treatment recommendations. 12
Provided your recommendation to PCP on prescribing medication. 8
Reviewed and critiqued the analysis done by at least one of your classmate. 4
Highlighted any areas that you believe might have been missed or added suggestions for treatment recommendations. 4
Wrote in a clear, concise, and organized manner; demonstrated ethical scholarship in accurate representation and attribution of sources, displayed accurate spelling, grammar, and punctuation. 4
Total: 40
Here is an example of what one student completed: (Please do not copy, but this is a great guideline and the format in which you should follow exactly). Include 5-6 references and write at minimum 2 pages.
Mood Disorders, Medication Recommended, and Reasons Why
Multi-axis Diagnosis
Axis I R/o Panic Attack
R/o 305.00 Alcohol Abuse
296.22 Major Depressive Disorder, Single Episode
Axis II V71.09 None
Axis III ICD-10 CM 401 Essential Hypertension
ICD-10 CM E78.0 Pure hypercholesterolemia
Axis IV Problems with primary support group: separation.
Occupational problems: job dissatisfaction, lack of promotion.
Economic problems: debts.
Axis V GAF 60
The information provided in the vignette indicated that client visit an emergency room with some physiological discomforts. Since client visited PCP after emergency incident, one can assume that no physical conditions other than hypertension and hypercholesterolemia were noted. Panic attacks present in a fashion mimicking physical distress similar to the ones described in his history. With that in mind, and in consideration that panic attack is not a codable disorder, a valid recommendation for close monitoring of similar incidents to rule out the presence of panic attacks that can lead to a panic disorder diagnosis is noted at this time (APA, 2000).
In addition, client’s alcohol self-reported history of alcohol consumption does not meet criteria for substance abuse. However, it is not unusual that clients suffering from substances related disorders do not report everything at first. Further assessment is needed to determine the severity and duration of the same. At this time, the Alcohol Use Inventory (AUI), the Substance Abuse Subtle Screening Inventory (SASSI), or the Alcohol Use Disorders Identification Test (AUDIT). These tests are short and easy-to-administer psychometric instruments design to assist in the diagnosis and treatment implementation of alcohol and other substance abuse (Carey, Carey, and Chandra, 2003; Miller, 1999). It is relevant for treatment planning and recommendations to have a clear picture of client’s presentation and how different factors might interact.
The current client’s presentation grants diagnosis for major depressive disorder, single episode with moderate severity and with out the presence of psychotic features. Duration and presence of symptoms characteristic of major depressive episode are met almost in its totality, granting more than sufficient evidence for the diagnosis. There is no evidence that symptoms are due to substance use or any other mental disorder, and the is no mention of manic episodes. Additionally, a family history indicating presence of depression may indicate a higher predisposition for the disorder (APA, 2000). Further assessment for suicidal tendencies and/or ideation is recommended. The Scale for Suicide Ideation (SSI) is a psychometric test that might prove helpful for this client. This test has a high face, convergent, and constructed validity making it a reliable psychometric test to quantify intensity of suicide ideators (Beck, Kovacs, and Weissman, 1979).
Treatment Recommendations
At this time, treatment would be based on the provisional diagnosis awaiting for more information in order to rule out the presence of panic attacks and substance related disorders. As a cognitive-behavioral therapist, I would initiate treatment for depression with the understanding that once the psychometric testing is completed, we may add some features to the treatment. Cognitive behavioral treatment for depression includes the development of a list of factors (cognition and behaviors) that affect the client’s mood. The treatment continues aspiring to re- formulate present cognitions by proving the unfounded reason for the false ones. The same applies for behaviors, where in order to affect mood, cognitive-behavioral therapists with the client work on restructuring maladaptive patterns and in the substitution of the same for healthy ones (Ledley, Marx, and Heimberg, 2005).
Recommendation to PCP on prescribing medication
Considering that the client was referred from the primary care physician before making any decision on the prescription of psychotropic drugs, a thorough report should be send to the same. The report should include the diagnostic and clinical impressions, as well as the interpreted results of psychometric testing. The particular recommendations would be as follow:
1. Cognitive-behavioral therapy for depression full treatment (16 weeks) followed by
2. Re-evaluation of symptoms and diagnosis
3. Pharmacological consult if client does not show improvement with psychotherapy alone. For this situation, therapist recommends a collaborative work integrating psycho-pharmacological and therapeutic treatment that in addition to therapeutic treatment would include:
a. Monitor of psychotropic drug compliance and effects
b. Discussion of side effects, doubts, concerns, and expectations of medications
c. Discussion of how medication work and why sometimes is necessary to switch drugs or adjust present dosage.
d. Incorporate client’s concerns on libido and weight gain with the use of certain medications.
Overall and at this point, recommendations are based on offer psychotherapy as a first line of action with the understanding that a pharmacological consult may be necessary further on. However, if client declines psycho-therapeutic services, is recommended to contemplate the pharmacological treatment option from the beginning.
Reference
American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, 4th Ed (Text Revision). (DSM-IV-TR). Washington, DC: American Psychiatric Publishing.
Beck, A.T., Kovacs, M., & Weissman, A. (1979). Assessment of suicidal ideation: The scale for suicide ideation. Journal of Consulting and Clinical Psychology. 47, 343-352.
Carey, K.B., Carey, M.P., & Chandra, P.S. (2003). Psychometric evaluation of the Alcohol Use Disorders Identification Test and Short Drug Abuse Screening Test with psychiatric patients in India. Journal of Clinical Psychiatry.
64(7):767-774
Miller, G.A. (1999). The Substance Abuse Subtle Screening Inventory (SASSI) Manual. 2nd Ed. IN: The SASSI Institute.
Ledley, D.R., Marx, B.P., & Heimberg, R.G. (2005). Making Cognitive-Behavioral Therapy Work: Clinical Process for New Practitioners. The Guildford Press: N.Y.
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