Applying differential diagnosis to depressive and bipolar disorders-CASE OF RONALD

Discussion: Applying Differential Diagnosis to Depressive and Bipolar Disorders 

What is it truly like to have a mental illness? By considering clients’ lived experiences, a social worker becomes more empathetic and therefore better equipped to treat them. In this Discussion, you analyze a case study focused on a depressive disorder or bipolar disorder using the steps of differential diagnosis. 

To prepare: View the TED Talk “Depression, the Secret We Share” (TED Conferences, LLC, 2013) and compare the description of Andrew Solomon’s symptoms to the criteria for depressive disorders in the DSM-5. Next review the steps in diagnosis detailed in the Morrison (2014) reading, and then read the case provided by your instructor for this week’s Discussion, considering the client against the various DSM-5 criteria for depressive disorders and bipolar disorders. 

Andrew Solomon: Depression, the secret we share | TED Talk https://www.ted.com/talks/andrew_solomon_depression_the_secret_we_share  

Morrison, J. (2014). Diagnosis made easier (2nd ed.). New York, NY: Guilford Press. 

• Chapter 11, “Diagnosing Depression and Mania” (pp. 129–166 

BY DAY 3 

Post a 450-word response in which you address the following: 

• Provide the full DSM-5 diagnosis for the client. For any diagnosis that you choose, be sure to concisely explain how the client fits that diagnostic criteria. Remember, a full diagnosis should include the name of the disorder, ICD-10-CM code, specifiers, severity, medical needs, and the Z codes (other conditions that may be a focus of clinical attention). Keep in mind a diagnosis covers the most recent 12 months. 

• Explain the diagnosis by matching the symptoms identified in the case to the specific criteria for the diagnosis. 

• Recommend a specific evidence-based measurement instrument to validate the diagnosis and assess outcomes of treatment. 

• Describe your treatment recommendations, including the type of treatment modality and whether or not you would refer the client to a medical provider for psychotropic medications. 

Requirements: 450 words 

Subject:  
Masters Social Science 

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CASE OF RONALD 

Intake Date: March 15, 2021 

IDENTIFYING/DEMOGRAPHIC DATA: This is a 39-year-old white Jewish male's first admission to a psychiatric hospital. Client’s wife is age 40.   They have three children - a son (15), daughter (12), and a second son (9).  Ronald is currently employed as a Certified Public Accountant in Wisconsin.   Ronald has been married for 16 years. 

CHIEF COMPLAINT/PRESENTING PROBLEM:  I am anxious and depressed.   

HISTORY OF PRESENT ILLNESS: Ronald states that last year has been very trying for him.  His mother-in-law-died suddenly from covid, and the three children have been sick.  Ronald has been moody and depressed since late Fall and reports in November he had the flu.  His age 40 physical was coming up and he was very worried about it. This past summer Ronald claimed he was getting "rougher" with the kids and being "grouchy."    

Ronald described being plagued with bad habits.   He said that his habits included: having to bang up against the refrigerator door 4 times each time he closed it; having to look under all the living room furniture each evening for dust and if he found any dust having to vacuum the whole living room; having to count the cans of food in his kitchen cabinets, making sure there were always an even number of cans in the cabinets.   He said he would think about these things until he did his "bad habit" and then he would feel better. 

PAST PSYCHIATRIC HISTORY: Ronald was hospitalized in August at a general hospital's psychiatric unit for three weeks, but according to Ronald, he was released prematurely.  He was treated with Lotronex and Desyrel which did not seem to help him too much. He was also given Xanax.  He wasn’t ready to go home, and once home, he gradually, again, got rough with the kids.   He was taken by ambulance back to the general hospital's emergency room, where he was, according to his wife, "paranoid."   His wife also said that Ronald was "psychotic" in the ambulance, thinking there was a plot against him and reeling he was poisoned.  Ronald said he "couldn't cope" after discharge from the general hospital and that he was still "depressed."   He said his concentration was off, he lost 24 lbs. quickly, was always anxious and was suspicious of people.   He equates this to job stress, being that he was a managerial accountant in charge of a large food processing corporation. Due to the pandemic, he worked from home which increased his stress.  He blames the start of the whole episode of "depression" on the flu and aggravation of his inflammatory bowel disease.   He said this also caused marital difficulties.   Another problem was that he always worried about his job and possibly being fired.   

SUBSTANCE USE HISTORY: Ronald denies use of illicit drugs and reports drinking rarely 

PAST MEDICAL HISTORY:  Ronald has recently been treated with Erythromycin for chronic colitis. In August he was also treated with Lotronex.  Ronald had all the childhood diseases including chickenpox.   He denied high fevers, seizures or head injuries.   He denied medical or surgical hospitalizations. His only significant medical problem was chronic colitis.    

FAMILY HISTORY INCLUDING MEDICAL AND PSYCHIATRIC:  Ronald was also worried because his father had a history of mood swings and depression and was treated with electroconvulsive therapy (ECT).  Ronald described his childhood as pleasant, growing up in Brooklyn, and commuting to Manhattan to a private school.  Ronald attended college in Wisconsin and decided to stay there for a quieter life.  Ronald was able to discuss many of his childhood traumas.   His mother died just before his 11th birthday and this made him very sad.   His father remarried for the 3rd time, and Ronald did not like his stepmother.   She was apparently very compulsive and always on him to clean his room, etc.  Ronald claims he was always shy, even as a teenager.   He blamed this on his stepmother.   He was interested in stamp collecting. 

CURRENT FAMILY ISSUES AND DYNAMICS:      Ronald describes his adulthood as constantly worrying about losing his job.   He also constantly worries about his mortgage payment and the fact that his wife doesn't work.   He said they have a new luxury car and that he has to work very hard to keep this lifestyle. He commuted 1 1/4 hours to work before the pandemic and now he works from home.  He misses the alone time in the car where he had time to think.  He worries that his job will be in jeopardy if the company does not think all the employees are necessary.   Ronald claims that the reason he was hospitalized is that he was "out of hand" yelling at his kids and "pushing them."   He also said he was depressed and suspicious.   He said he would watch TV, never get much exercise and do very little when not working, which is a change from his previously active life before last year.  He was, however, very proud of his education obtaining a bachelor's degree, following immediately with a master's degree. 

MENTAL STATUS EXAM: Ronald is oriented to time, place and person and has an excellent fund of knowledge.   He could do serial 7's and all memory tests.   Since Ronald is a college graduate, fund of knowledge would be that high.   Short and long-term memory seem adequate, but concentration is impaired.   Patient denies homicidally but is ambivalent about suicidality.   His affect was flat, and his mood was dysphoric. He has not made a suicide attempt since his hospitalization at the general hospital but while at the general hospital he banged his head and tried to choke himself, allegedly with a toothbrush.   He indicated that prior to and after his suicide attempt, he was only sleeping 2-3 hours per night, waking up and worrying. He could hardly function the next day since he was exhausted.  Proverb interpretation is correct and if he had three wishes they would be "to leave here, go home, and back to my job." When asked how he sees himself in five years, he said "in a good career position, only healthier."  When asked what he would change about himself, he said "my personality."  Ronald appeared to be very suspicious and was at times afraid something bad was going to happen to him.  He also was markedly anxious about losing his job or his wife and family because he thought the newspapers were preparing a story about him and how sick he was. Ronald thought the social workers were FBI agents observing him for the newspapers.