Assessing and Diagnosing Patients with Mood Disorders
The clinical assessment involves the application of the instruments such as the DSM-V to determine the clinical and psychological needs of a patient. This assessment entails looking at the patient’s stressors, and the impact of such stressors on the patient’s wellbeing. There are various factors which may alter the emotional wellbeing of the patient, and these factors range from the social factors within the patient’s surroundings, and fear or uncertainty.
When examining a patient for psychological issues, a psychologist needs to consider the primary and secondary diagnoses. This is necessary so that they can provide an intervention that comprehensively meets the patients’ physiological and emotional needs (American Psychiatric Association, 2013a). During the assessment, a psychologist may look at aspects of the patient such as their sexual orientation, sleep patterns, and behaviors when in the presence of others. This information can form the basis for the clinical intervention as described in this study.
Patient: The patient’s name is Mr. David Jackson, and he is a 19-year old male, and the only child in his family.
Subjective:
CC: He is concerned about his friends’ reaction if they learn that he is sexually queer. He feels that his friends will isolate him if he shares the details of his sexuality.
HPI: The 19-year old is worried about the possibility of being isolated by his friends if they learn about his sexual preferences, and he feels uncomfortable when his friends talk ill about gays.
The patient states that he has had suicide ideations because he feels he is different. Still, he is worried about his rejection, and this makes him feel like he wants to die (American Psychiatric Association, 2013b). According to the patient, he is sad and he has fear, and he is shocked to learn that he will be acted with the Navy Reserves.
Past Psychiatric History: David denies psychiatric history. The patient is mentally sound considering that he can differentiate between reality and non-real stuff. He denies ever using a drug to treat psychiatric condition.
Substance Current Use and History: The patient denies substance abuse.
Family Psychiatric/Substance Use History: There is no substance and psychiatric history for the patient’s family.
Psychosocial History: There is no history of psychological and psychiatric problems.
Medical History:
History and Present Illness: The results of the clinical assessment shows that the patient’s temperature is 98.8o F, which is within the normal temperature range. The patient’s respiratory rate is normal, and he seems to be having hypertension given his 110/62 blood pressure. He is concerned about rejection, and this is his main stressor. His symptoms began appearing one and half months ago when he learned that he was being enlisted.
History and Current Use of Substance: The patient denies using any behavior-altering substance.
Medication Trials and Current Medications: David’s family does not currently use any substance.
Psychotherapy or psychiatric Diagnosis for the family: David’s family has no history of psychiatric problems.
Allergies: The patient does not have any history of allergy.
ROS:
- GENERAL: The patient denies fatigue, fever, and nausea. The patient positive for weight History and Current Use of Substance: The patient denies using any behavior-altering substance.
- Medication Trials and Current Medications: David’s family does not currently use any substance.
- Psychotherapy or psychiatric Diagnosis for the family: David’s family has no history of psychiatric problems.
- Allergies: The patient does not have any history of allergy.
Objective:
Physical exam
General: David shows sign of fear and is moody when being interviewed. He speaks coherently and clearly, and he can be head clearly. He seems to respond to the interview questions in an appropriate manner.
Vital Signs: The patient’s temperature is 98.8 and weighs 133 lbs. His height is 5”7. He does not have enough sleep considering that he sleeps for 6.5 hours. His appetite is good, and he has a 110/62 of blood pressure. This shows that his blood pressure is above the normal level.
Diagnostic results:
The results for the psychological assessments, based on the Kessler Psychological Distress Test, are pending.
Assessment:
The patient seems to orient to time and the place, and he cooperates with the person who is conducting the interview. He looks worried about rejection, and he shows sign of fear. He reasons logically, and he is coherent in the way he answers questions (MedEasy, 2017).
Differential Diagnoses:
Primary diagnosis:
David has depression, and this is the primary diagnosis for the patient. For one to have this disorder, one has to feel worthless, guilt and develop self-hate. A person with this disorder also experiences restlessness, and depressive mood. This mood seems to occur because he is fearful of rejection if his discloses to his friend the information about his sexuality.
These symptoms match the signs of depression described under the DSM-V assessment tool. He feels that he is responsible for his plight because he has failed to be real (American Psychiatric Association, 2013). He also feels guilty because he has not been able to disclose to his unit that he has queer sexual preferences.
Secondary Diagnosis
- Social Phobia. This condition is characterized by an individual’s fear to socialize because of the way they perceive how others might feel about them.
- The other potential secondary disorder for the patient is anxiety disorder. This is because he feels uneasy, and he does not get enough sleep.
- The third secondary diagnosis for David is stress because his has more than normal blood pressure. The diagnosis for David, therefore include social phobia, anxiety disorder and stress (Sadock, Sadock, & Ruiz, 2015).
Reflections:
Reflecting on the patient’s symptoms and analyzing the manifestations based on the DSM-V framework, it is apparent that the main condition that David seems to suffer from is depression. This is because depression is associated with symptoms such as the lack of sleep, restlessness and fear. I would make changes in the way I conduct the assessment if I were to work with the patient again.
For instance, I would ask the patient to talk more about his strengths. Knowing the patient’s strengths is important because it can help develop an intervention that can help optimize the patient therapy outcomes (Classroom Productions, 2015). This implies that the strengths can be utilized to meet David’s psychological and emotional needs.
In conclusion, the use of the tool such as the DSM-V can help diagnose a patient’s illness because the tool can match the patient’s symptoms with those linked to the various DSM disorders. When assessing a patient for psychiatric issues, a psychiatrist may look at patient-based factors, and the family health background.
This information is pertinent to the diagnosis process because it helps identify the patient’s behaviors and how the patient responds to the events in their life. Looking at David’s symptoms from the perspective of the tool, shows a possible depression. It also shows that the patient may be suffering from anxiety disorder.
References
American Psychiatric Association. (2013). Trauma- and stressor-related disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.9780890425596.dsm07