Detailed Diagnostic Report: Criteria, Symptoms, and Cultural Considerations

• The diagnosis should appear on one line in the following order.
  Note: Do not include the plus sign in your diagnosis. Instead, write the indicated items next to each other.

Code + Name + Specifier (appears on its own first line)
Z code (appears on its own line next with its name written next to the code)

Then, in 1–2 pages, respond to the following:

• Explain how you support the diagnosis by specifically identifying the criteria from the case study.
  • Describe in detail how the client’s symptoms match up with the specific diagnostic criteria for the disorder (or all the disorders) that you finally selected for the client. You do not need to repeat the diagnostic code in the explanation.
• Identify the differential diagnosis you considered.
• Explain why you excluded this diagnosis/diagnoses.
• Explain the specific factors of culture that are or may be relevant to the case and the diagnosis, which may include the cultural concepts of distress.
• Explain why you chose the Z codes you have for this client.
  • Remember: When using Z codes, stay focused on the psychosocial and environmental impact on the client within the last 12 months.

CASE OF ROBERT

Intake Date: May 2019

DEMOGRAPHIC DATA:

This is a voluntary intake for a 33-year-old Caucasian, Protestant male. Robert has had several psychiatric hospitalizations in the past. He has been married for 8 years and has been separated from his wife for the past ten months. He initially moved in with his parents but recently moved to his own place for the past five months. His wife lives two blocks from him. Robert has had difficulty in jobs and has not been at any job longer than two years.

CHIEF COMPLAINT:

“I miss my wife and do not want to live if I have to live without her”.

HISTORY OF ILLNESS:

Robert reports first seeking psychiatric treatment when he was seventeen years old. He was prescribed anti-depressants but does not remember what kind. The anti-depressants worked well for his depressed mood, so he remained on anti-depressants for three years until he believed he did not need them anymore since things started changing for him. He was feeling much better, happier, freer, able to get out there and conquer the world. At 21, he began drinking. His chemical use increased in his early twenties when he began using cocaine and amphetamines. His use of alcohol and pills continued throughout his late twenties. At twenty-nine-years-old, he attempted suicide after his wife left for the first time. He was hospitalized in a psychiatric unit for thirty days where he was also treated for drug and alcohol addiction. At this time, he became involved with AA and NA for a short period of time. After the reconciliation with his wife, their financial difficulties, which existed from the start of the marriage, continued. At that time, Robert was put on Vraylar with continued successful results for three years. Robert stayed clean and sober at this time.

Robert reports being in a car accident six months ago where he hurt his back and was prescribed Oxycontin. He began using the medication more often than prescribed. Shortly after the accident, he began using other medication once in a while that he would obtain from friends, such as Klonopin. He decided to return to self-help meetings to end this behavior, but it did not last long because he felt uncomfortable.

In December, 5 months ago, Robert returned to his psychiatrist because he was becoming depressed again, feeling sad, fearful, and suicidal. He was given Luvox. Soon after, the psychiatrist did not think this was working very well and added Ritalin to augment his medication regiment. During the next three months, Robert’s mania increased. He was having angry outbursts regularly. His wife asked him to leave the home. He took an overdose of Klonopin. Robert was hospitalized for 3 days until his mood was stabilized and then returned home. He reports feeling anger towards his wife believing she forced him to be hospitalized and started using amphetamines again.

Robert continued on anti-depressants and Luvox. His psychiatrist was unaware that he continued using amphetamines. Robert’s wife was getting continuously concerned about their financial state because Robert would constantly buy presents for her that she did not need or want, nor that they could afford. They would have arguments about this all the time. Robert continued his use over the fall and by the end of March was asked to leave his home again because he used pills as a suicidal gesture. He began drinking again to cope with the separation. This use continued up to his current presentation for intake.

PSYCHOSOCIAL HISTORY:

Robert is the only child from his parents union. Robert reports his childhood to be tumultuous. His mother separated from his father on several occasions and sometimes would throw Robert out of the house with the father. His mother made all the decisions and his father played a more passive role. Both parents would often have physical fights and Robert would try to break up the fighting from as early as he can remember.

Robert had very few friends growing up due to his tumultuous family system.

Robert was considered an underachiever in the early years of school. He went on to college and graduated with a bachelor’s in science with a major in computer science.

Robert denies any legal history. Robert worked for many years in the family business right after college. Although the customers liked him, he was asked to leave because of his mood swings. After his addiction recovery, he entered the computer business and was a salesperson for a major company. Robert stayed at his first job six months but did not like the company and left. He then became a director in another company. He had several jobs for a while but would not stay long at the job. He became a district coordinator at his next job. He stayed there three years.

MEDICAL HISTORY:

Robert states he has no major physical illnesses.

FAMILY ISSUES AND DYNAMICS:

Robert married at twenty five years old. He reports not loving his wife but thought he should be married. The first four years of their marriage Robert reported being happy but there was turmoil with his mood being elevated at times and depressed at other times. Over the past several years, he believed his wife was becoming more distant from him, which angered him. Their fighting increased especially over his excessive spending. Robert reports not having a lot of friends.

MENTAL STATUS EXAM:

Robert presents as a neatly dressed male who appears younger than his stated age. His hair is a bit disheveled, although he continuously takes a brush out to fix it. He discusses his weight and body image stating he wants to be thinner and return to weightlifting to build up his muscles again. His nails are neatly groomed. Facial expressions are appropriate to thought content. Motor activity is appropriate. Thoughts are logical and organized. There is no evidence of hallucinations. Robert admits to a history of suicidal ideation. Robert has some manic like symptoms, i.e. getting up, going to the men’s room, talking fast during the interview. Robert is oriented to time, place, and person. His intelligence appears normal.