Introduction of the Client
For proper patient assistance and diagnosis, it is necessary to take into account all the internal and external factors that influenced the current state of the patient. Kathy, a divorced patient, is a forty-five-year-old woman of Caucasian descent. The patient is a well-educated person who has taken a nursing course. She admits that she practiced nursing for 20 years because of her passion for working with patients.
Kathy married a man 10 years her senior at the age of 21, right after graduating from the nursing school. The couple had two children, Tommy and Betty, aged 14 and 12. Kathy is proud of her children and praises herself daily for raising responsible, disciplined and well-mannered teenagers. The doctors of the Family Counseling Center describe the patient as a well-groomed, polite and dedicated person. However, her state changed after the client developed a mental disorder. Kathy’s symptoms are indicative of Major Depressive Disorder (MDD), which was formed due to a failed marriage, the death of her mother, and her father’s illness.
DSM-5 Diagnosis
Major Depressive Disorder
Associated Symptoms
Sadness and Emptiness
The patient was diagnosed with major depressive disorder (F33.1) after the common signs and symptoms she had exhibited over the past two weeks. The DSM-5 diagnostic criteria used in patient evaluation required the patient to have more than five symptoms associated with MDD. Firstly, the patient was depressed due to her parents’ health problems and her failed marriage. The sadness and emptiness seen in Kathy’s life demonstrates the depressive mood associated with a mental illness diagnosis.
Weight Loss
Secondly, weight loss helps clinicians reconsider the diagnosis of DSM-5 in patients with MDD. According to Zimmerman et al. (2020), significant weight loss without dieting is a leading symptom in the diagnosis of depression, as it shows a strong relationship between the patient’s past and present levels of appetite. Kathy presents similar symptoms based on her claim of losing twenty pounds of weight over the course of a year.
Loss of Pleasure
The third aspect of the diagnosis included in Kathy’s case was the loss of pleasure from her work. Permanent loss of interest and pleasure in certain activities are subjective criteria for the diagnosis of major depressive disorder (Fabiano & Haslam, 2020). The patient lost her enjoyment of working for her four nephrologists, which she reportedly enjoyed for the past twenty years. She fears providing substandard services at the medical clinics she is assigned to due to her current mental condition.
Sleep Loss
The fourth criterion for diagnosing major depressive disorder is sleep loss. According to Mohammadkhani et al. (2020), insomnia is a sleep disorder that prevents people from getting enough sleep, or waking up early and not falling asleep again. Kathy stated that it was difficult for her to get up to complete her tasks in preparation for a productive day. The condition persisted for six months, which attracted the attention of doctors who diagnosed her with depression.
Fatigue and Impaired Cognitive Function
Fatigue, delusional thoughts, and decreased concentration are a fifth reason to support a diagnosis of MDD according to the DSM-5 criteria. Kathy has been lacking energy for several days because she is tired and at one point a medical examiner asked her to exercise to increase her strength. Vai et al. (2020) emphasize that fatigue causes a persistent feeling of weakness in people diagnosed with major depressive disorder. Patients screened for depression feign fatigue because they have lost self-esteem in coping with their day-to-day problems or causes of stress. Delusional thoughts about wanting to protect one’s image destroy the patient’s emotional intelligence. Kathy wants to please her friends but can no longer connect with them because they share the same thoughts due to their marriage. The patient cannot balance her mood because she focuses more on what people say about her.
Specifiers
Specifiers play a critical role in the diagnosis of MDD. The doctor assigned to Kathy must classify the specifiers into the classes to help her regain her mental health and personality. Fabiano and Haslam (2020) recognize seasonal pattern specifiers when examining clients with suspected major depressive disorder because depression coincides with a particular season. Judging by the history of the disease in the hospital, the patient is sometimes happy even with constant life difficulties, but her mood changes over the years. This means that its condition is influenced by seasonal patterns and changes.
Atypical features form part of the specifiers that are given priority in the diagnosis of major depressive disorder. Kathy’s psychological symptoms can be analyzed using atypical trait specifiers. The patient may exhibit unusual weight loss depending on her current dietary choices. Workplace stress may have contributed to the patient’s loss of appetite for homemade food. Therefore, an addiction to processed foods or fast food from McDonald’s restaurants may have reduced the patient’s weight by twenty pounds due to poor eating behavior. The mood changes noted in her medical record may be a result of her unusual feelings at certain times. Mohammadkhani et al. (2020) state that mood changes do not confirm the diagnosis of patients with MDD. On the contrary, changing social conditions at work, at home, and in hospitals can cause mood swings that affect people’s psychological fitness.
Borderline Personality Disorder
Symptoms
Impairment of Personality Functioning
The doctor handling Kathy’s case may diagnose the patient with borderline personality disorder (BPD) (F60.3). When evaluating patients with BPD, a number of criteria and specifiers are included in the revised DSM-5. In Kathy’s case, the patient must have more than five symptoms to improve the accuracy of developing an alternative to the existing problem. Firstly, the patient must have severe impairment of personality functioning. Zimmerman et al. (2020) emphasize that in order for a person to qualify for a diagnosis of borderline personality disorder, they must indicate a self-functioning identity that affects the functioning of their psyche. In particular, patients with borderline personality disorder must suffer from emotional emptiness, alienation from people, unstable self-image, and self-criticism (Fabiano & Haslam, 2020). Kathy experienced these identities after failing to acknowledge her attempts to survive outside of a failed marriage.
Uncertainty of Personal Goals and Career Direction
Kathy developed borderline personality issues when she tried to live a fake life. She thought that her friends would judge her for the fact that she actually suffered from a mental disorder. The instability of Kathy’s values, aspirations, and career plans is the second indicative factor of borderline personality disorder. Perrotta (2020) emphasizes that the vulnerability and selective bias inherent in people in the same social setting can be used to monitor the perceptions and interpersonal hypersensitivity associated with borderline personality disorder.
Negative Feelings Towards Past Interests
Kathy experienced negative urges from things and activities she once enjoyed, which may be the third criteria. Mohammadkhani et al. (2020) note that when diagnosing Kathy, doctors should consider signs of unstable self-perception. The patient cannot understand herself and the needs of others due to her psychological state.
Negative Affectability and Disinhibition
Negative affectability and disinhibition formulate primary grounds for diagnosing borderline personality disorder using the DSM-5 criteria. For negative affectability, doctors observe emotional liability, separation insecurity, anxiousness, and depression to diagnose borderline personality disorder patients, which are present in the case, indicating the fourth factor for diagnosis.
Unstable Emotional Condition
Vai et al. (2020) echoes those unstable emotional experiences in people’s lives that characterize such individuals to psychological diseases like BPD. Kathy experienced frequent mood swings that deprived her of happiness and a stable relationship, which is the fifths factor, which may indicate BPD. Thus, on a par with major depressive disorder, Kathy has reasons to be diagnosed with borderline personality disorder.
Differential Diagnosis
Correct differential diagnosing requires considering all the symptoms and separating them from similar disorders factors. Kathy expresses apathy, loss of interest in life, anxiety, inability to perform social and work responsibilities, weight loss, and trouble sleeping. The potential cause of such conditions may be a different spectrum of disorders: anxiety-depressive disorder (F41.8), generalized anxiety disorder (F41.1), obsessive-compulsive disorder (F 42), bipolar disorder (F 31.9) or post-traumatic stress disorder (F 43.10). Major depressive disorder and borderline personality disorder become the most likely causes of Kathy’s mental condition due to the presence of all associated symptoms and the absence of key features of other similar syndromes.
Bipolar Disorder
Although the comorbidity of supposed disorders, the enumeration of the underlying problem was facilitated by the observed symptoms from the DSM-5 guidelines. Bipolar disorder can be easily confused with major depressive disorder due to the similarity of symptoms (Morishita et al., 2020). Since Kathy did not exhibit typical manic episodes, this disorder can be ruled out. Obsessive-compulsive disorder is an independent psychological illness that can lead to major depressive disorder (Perrotta, 2020). Kathy cannot be diagnosed with obsessive-compulsive disorder, as there are no references to rituals or possessions in her anamnesis.
Anxiety Disorders
Anxiety-depressive disorder could be a suitable diagnosis for Kathy, but she does not express unreasonable anxious thoughts and does not talk about panic attacks. Generalized anxiety disorder also cannot be confirmed, since the patient expresses justified anxiety caused not by a psychological state, but by external life factors. Post-traumatic stress disorder is predominantly accompanied by the presence of triggers in response to trauma, but Kathy did not express such reactions.
Major Depressive Disorder
Despite the similarity of symptoms, Kathy’s tentative diagnosis should predominantly sound like MDD. Kathy does not show the lack of self-control and socialization that is typical of BPD patients. This disease could have developed as a consequence of MDD, but additional testing and anamnesis taking is required to make such a diagnosis. The most probable diagnosis remains MDD, diagnosed by the criteria of apathy, loss of interest in life, inability to perform duties, and physiological factors.
Conceptualization of the Client
The patient is a middle-aged woman going through a severe depressive period due to social factors. From a biological point of view, the patient is entering an age when life changes can meet with strong internal resistance. The mental aspect demonstrates a strong personality who was not afraid to talk about her problem and coped with the fear of judgment. This is a patient who has strong self-reflection skills and is able to provide the medical staff with complete and objective information about her own emotions that contribute to the correct diagnosis. Social factors were predominantly the cause of Kathy’s condition. Having experienced a painful divorce, the death and illness of her parents, the patient’s psyche was not able to cope with these life circumstances. Cultural affiliation did not play a significant role in the course of the disease and the patient’s symptoms.
The strength of the patient is the spiritual component of her personality. Mahase (2019) advises patients to accept their health condition for faster recovery because such thoughts help victims forget the painful events that led to their mental illness. Kathy showed great confidence and was optimistic about her recovery, which will greatly contribute to the success of her treatment. The client’s problem may be difficulty in accepting her own position, since Kathy previously demonstrated herself as a wonderful mother and successful worker, which is now difficult for her.
Kathy’s story presents a typical picture of the development of MDD as a result of significant stress experienced due to social factors. The spiritual and psychological aspects of the client’s personality indicate that she readily accepts treatment and believes in recovery. The psychological factor of middle age can be a barrier to successful therapy as the client has difficulty accepting change. The main focus of the therapy sessions should be carried out to help Kathy adjust to the new social environment.
Suggested Treatment Care Recommendations to Consider
MDD is treatable and manageable, and in Kathy’s case, a successful recovery is possible and achievable. Attending therapy sessions and taking medication allows clinicians to control symptoms of major depressive disorder (Mahase, 2019). An effective treatment result is achieved by a combination of appropriate medical therapy, constant monitoring and sessions with the attending physician. The regimen and treatment plan prioritizes antidepressants, anxiolytics, selective serotonin reuptake inhibitors, and antipsychotics. Forms of medication will help the patient cope with the effects of MDD and improve her mood.
In this case, selective serotonin reuptake inhibitors can be used to relieve symptoms of mild depression. The patient should be given one to three tablets of sertraline, citalopram, and fluoxetine for two weeks. In addition, the patient can be introduced to cognitive behavioral therapy to change the negative thoughts seen in Kathy’s medical record. Mahase (2019) claims that psychotherapy treats MDD by correcting behavioral and mental disorders through self-help talk and therapy. Therapy may be transferred for better patient management to other referral hospitals of her choice.
Care Plan Form
Medications
According to the above treatment plan, Kathy’s main medications will be antidepressants, which are serotonin reuptake inhibitors. Taking drugs of this type will help get rid of apathy and anxiety. The patient’s mood will improve, which will contribute to a better performance of daily duties and reduce the level of self-criticism. Medication is a necessity in Kathy’s case as she is unable to come out of her mental state on her own and needs additional stimulation.
Serotonin reuptake inhibitors have side effects that must be communicated to the client in order to make a decision to accept such therapy. Physiological consequences, which may include adverse gastrointestinal reactions, must be considered. Symptoms of individual drug intolerance may include nausea, diarrhea and vomiting. Serotonin reuptake inhibitors can have a depressing effect on the patient’s psyche, especially during the first time from the start of the intake, when the body may not be adapted to the medication. The depressing effect can manifest itself in the form of a growing sense of anxiety. Finally, the client must be made aware of the possibility of a withdrawal syndrome in which anxiety, apathy and depressive thoughts may return.
Counseling psychoeducation prior to prescribing antidepressants should include communicating side effects to the patient. Kathy should be aware that her condition may change and seem unusual for her. The client must be aware of the need to continuously adhere to the treatment plan so that her symptoms do not worsen. The patient should be made responsible for the need to completely eliminate alcohol and other factors that distort the mental state. Kathy should be communicated the responsibility for her own health and the need to strictly follow the recommendations.
Self-Reflection
Establishing contact between the doctor and the patient is one of the key components of the success of the treatment. In Kathy’s case, it may be difficult for me to communicate to her the changed living conditions. In the case of such a client, it may be problematic for them to convey new realities. Divorce with her husband, death of her mother and illness of her father are factors that Kathy’s psyche could not accept, and this is the main reason for her disorder. I find it difficult to convey to a client the need to come to terms with the harsh realities of life that she is experiencing. This seems cruel and unfair, since the client does not deserve such life circumstances, and the defense mechanisms of the psyche are understandable and justified. Communicating to the client the need to continue living and adapting to new conditions is difficult to combine with empathy, since this is a rather cruel, but necessary path.
When working with me, a client may encounter an approach that may seem unnecessarily harsh in a depressed emotional state. Acceptance of reality in Kathy’s case is a key factor in the success of the treatment. However, Kathy may not realize and reject the need for this, which will lead her to assume an unnecessarily violent approach. The client may begin to look for compromises for refusing to deal with the real state of affairs. For example, Kathy may contrive to make her relationship with her ex-husband seem better than it actually is. Despite the fact that this is how the defense mechanism of the psyche works, I will need to stop such thoughts. The solution to this problem can be gradual steps towards understanding the conditions of a new life and the client’s place in it.
Conclusion
The symptomatology expressed by Kathy signals that she has a major depressive disorder. This mental state is caused in the client by difficult social circumstances. The recommendation for the patient is to take serotonin reuptake inhibitors and accept behavioral therapy aimed at reducing the severity of symptoms. The combination of psychotherapeutic and drug treatment is expected to give an effective result. A positive attitude towards treatment allows to make optimistic forecasts up to a complete recovery.
References
Fabiano, F., & Haslam, N. (2020). Diagnostic inflation in the DSM: A meta-analysis of changes in the stringency of psychiatric diagnosis from DSM-III to DSM-5. Clinical Psychology Review, 80(7), 101–889. Web.
Mahase, E. (2019). Esketamine is approved in Europe for treating resistant major depressive disorder. BMJ, 3(1), 102–135. Web.
Mohammadkhani, P., Forouzan, A. S., Hooshyari, Z., & Abasi, I. (2020). Psychometric properties of the Persian version of the structured clinical interview for DSM-5-research version (SCID-5-RV): A diagnostic accuracy study. Iranian Journal of Psychiatry and Behavioral Sciences, 14(2), 114–157. Web.
Morishita, C., Kameyama, R., Toda, H., Masuya, J., Ichiki, M., Kusumi, I., & Inoue, T. (2020). Utility of TEMPS-A in differentiation between major depressive Disorder, Bipolar I Disorder, and bipolar II Disorder. PLOS ONE, 15(5), 223–276. Web.
Perrotta, G. (2020). Suicidal risk: Definition, contexts, differential diagnosis, neural correlates, and clinical strategies. Neuroscience and Neurological Surgery, 6(2), 01–04. Web.
Vai, B., Parenti, L., Bollettini, I., Cara, C., Verga, C., Melloni, E., Mazza, E., Poletti, S., Colombo, C., & Benedetti, F. (2020). Predicting differential diagnosis between bipolar and unipolar depression with multiple kernel learning on multimodal structural neuroimaging. European Neuropsychopharmacology, 34(6), 28–38. Web.
Zimmerman, M., Thompson, J. S., Diehl, J. M., Balling, C., & Kiefer, R. (2020). Is the DSM-5 Anxious Distress Specifier Interview a valid measure of anxiety in patients with generalized anxiety disorder: A comparison to the Hamilton Anxiety Scale. Psychiatry Research, 286(13), 112–859. Web.