Medical Assignment: Diagnosing Individual’s Illness Through Counselling

Question

Task:
Danny is a 22-year-old college student, who has been brought into your office by his parents. Danny has agreed to let his parents be involved in his counselling. You first meet with Danny’s parents who explain to you that Danny has never been involved in counselling prior to this incident. They stated they felt his problems were not serious enough to bring him into counselling. 

His mother reports that Danny can be the real life of the party and that most people find him very charismatic. She says there was one incident in which Danny tired to harm himself due to a girlfriend cheating on him. She said that her husband fell that it was a pretty typical response for an adolescent. She said lately he has been staying up late playing video games and getting on the average of 2-3 hours of sleep per night. She said she worries about his lack of sleep but he doesn’t seem to show any signs that the lack of sleep is impacting his ability to function normally. He is currently getting all A’s in his college courses, but his recent incident has jeopardized his place at the university. 

Danny comes into the office and explains to you that the whole incident is a big misunderstanding. He said to you that he doesn’t want to come to counselling because he is not crazy. He said his parents and the college administrations are requiring that he comes in for evaluation and commits to the recommendations of the counsellor regarding if there is a need for therapy. 

You ask him to tell you a little bit about the incident that caused him to come into your office. He explains to you that he really likes fast cars, but his parents don’t have a lot of money. He said he received a scholarship to a private university due to his outstanding grades. He said the only problem is that the other kids have a lot of money and can afford the items that he desperately wants but can’t afford. He said he saw another student leave his car running in the parking lot and went into the student center building. He said he was feeling like he was on top of the world and this was his golden opportunity to take that car for a spin. He said he had no plans for stealing the car, he was merely taking it for a test drive. When Danny came back to the building, campus security was interviewing the owner of the car. When he tried to explain to the other student and campus security, he was taking it for a quick test drive, he was escorted into the building to talk to the administration. Since, it is a small private university, the student and administration agreed not to press charges but he was placed on probation and had to commit to psych evaluation as well as following any recommendations made regarding therapy. 

When you were speaking to Danny, you asked him if he was really trying to steal the car. He replies to you how dumb would he be to the car back to the scene of the crime if he really had intended to steal the car. Then you ask him if he ever feels depressed. He says of course he does but he believes everyone has weeks or months where they just feel sad. You try to get him to engage further in the discussion, but he says he’s not here for you to diagnose him with depression. The session ends, now you need to figure out his diagnosis and treatment recommendations. 

Analyse the above clinical scenario and prepare a medical assignment addressing the following parts:

Part 1: Please use the DSM-5 to research further about each disorder below and choose one diagnosis that would best fit the scenario provided above and explain why? Support your answer using information from the DSM-5 and the scenario.

• Bipolar Disorder 1
• Major Depressive Disorder (MDD)
• Obsessive Compulsive Disorder (OCD)
• Anti-social Personality Disorder 

Part 2: Based on the diagnosis you made in part 1, please also address the following questions: 

• What differential diagnosis do you need to consider in this scenario?
• What further questions would you want to ask Danny to make a proper diagnosis?
• What type of treatment recommendations would you make for Danny and why? Please support your answer with information from DSM-5.

Answer

Part 1: Identification of diagnosis for the provided scenario
Based on the scenario analysed within this medical assignment, Danny (22 years, Male) is a college student who has been put forward and brought for counselling as he tried to hurt himself due to his girlfriend cheating on him. His mother has reported that he used to play video games late at night and getting sleep for 2 to 3 hours daily. She has also added that Danny is a charismatic person and lack of sleep did not impact his functional ability yet. Based on DSM-5, Danny is suffering from bipolar and depressive disorder (manic depression) for which during the depression he feels hopeless and tries to find pleasure in every activity (Paris & Phillips, 2013). However, in other time, he stays energized, judgemental, feel euphoric, behave properly and think reasonably. As commented by Carvalho, Firth & Vieta (2020), the mood swing episodes gradually impact his sleep-wake cycle that is the main symptom of bipolar disorder and he needs psychological counselling (psychotherapy). According to the scenario, this is the first time, Danny has tried to harm himself and hence he had experienced one major depressive episode followed by a hypomanic episode and was diagnosed with Bipolar II disorder.

Moreover, Danny has received a scholarship for his outstanding grade in university that indicates he is a meritorious student but his episodic tearful mood impacts his daily social activities. Danny has told to the counsellor that he likes fast cars but due to the low economic status of his parents he is unable to get desired things which gradually put him in a jeopardize condition. As asserted by Rowland & Marwaha (2018), though the feeling of euphoria can make the bipolar patients more productive still emotional crush and unmet desires can result in depression as well. He has stated that after seeing a running car in the parking lot of the students’ center building in his university he has felt ecstatic and did not miss the opportunity to spin the car as a test drive. He was escorted to this event he has explicit that he did not have any intention to steal the car that is why he came back with the car. As per DSM-5, this condition indicates he is suffering from moderate Bipolar II disorder with partial remission and hypomanic-like features (Paris & Phillips, 2013). As opined by Birmaher et al. (2018), hypomania does not result from unhealthy behavior hence it remains unnoticed and untreated. The counsellor proposed to undergo psychotherapy sessions to minimize the risk of developing future hypomania or depressive episodes by controlling warning signs and stabilizing mood. The counsellor has stated that this therapy is not only beneficial for developing community and social functioning but also builds self-esteem. As asserted by Rowland & Marwaha (2018), depression often results from sleep problems and after any hypomanic episode, the patient used to feel apathy. Here, through the therapy, the counsellor can explore the behavior and mood of Danny along with furnish an unspoiled perspective for understanding his emotions.

Part 2 : Differential diagnosis for Danny with treatment recommendations
In this scenario, the differential diagnosis for Bipolar II disorder includes mania, depression, and irritability. As opined by Ogasawara et al. (2018), adolescence is not good reporters about any events or are unable to understand abstract concepts as racing thought as well as euphoria. According to the administrator of Danny’s university, though he is motivative and creative still is encountering prevailing mood and behavior change due to the post-pubertal youth depression. The counsellor is examining that if he is having Pragmatic communication disorders or secondary social difficulties as that also result from mood swings along with hypomanic episodes. As per probationary diagnosis, he is not suffering from any kind of language disorders or sensory impairments therefore he is recommended to undertake psychological counselling to withdraw manic and psychotic episodes. For bipolar II disorder, less differentiating attributes involve active instability, borderline personality disorders, and impulsivity that requires medication along with therapies for withdrawing acute behavioral emergency (Goldstein et al. 2018). As per the response of Danny, he is having depression due to his gloominess and unmet desires and he is not willing to undergo diagnosis for episodic depression, rumination, and lack of sleep. The counsellor has provided mild medication to balance his mood and therapies for mood stabilizing.

Along with mood stabilizer therapies, counsellors recommended Danny to take anti-anxiety medication to improve the sleep-wake cycle and reduce the chances of manic episodes. Moreover, Danny is recommended for ‘Interpersonal and social rhythm therapy (IPSRT) for stabilizing daily rhythms such as waking, sleeping, and mealtime (Goldstein et al. 2018). It will be beneficial for the social domains (such as improve awareness) and personal domains (such as life-setting, personal care, and self-management) of Danny and supremacy adaptive functioning. The counsellor has suggested ‘Family-focused therapy’ as a bipolar II disorder treatment plan that requires loved ones to recognize as well as manage warning signs (Rosenblat & McIntyre, 2017). Based on DSM-5, this therapy can make parents realize about the rationale, chances of changes, awaited impacts as well as clinical management of Bipolar II disorder (Paris & Phillips, 2013). Danny is also suggested to undergo ‘Psychoeducation’ to understand what is going on with him, identify issues and take support from the counsellor for making a plan to prevent relapse together with stick with direction. As commented by Goldstein et al. (2018), therapies include medical care with patient education can improve somatic presentation, control sleep disorders with depressive mood episodes. The counsellor said that he must receive ‘Dialectical Behavior Therapy’ as it deals with mindfulness along with acceptance skill that is vital to control moment to moment emotions through judgment. As per DSM-5, for both manic and hypomanic episodes, prophylactic treatment is essential with a mild dosage of antidepressant medication as it is helpful to control sub-diagnosis symptoms too (Paris & Phillips, 2013). Counsellors have discussed few matrix questions (to access his mood swings) and activity-related questions to examine if a change of response is there (Luty, 2020). Apart from that, Danny was given a close-ended questionnaire for further clinical investigation to identify if he is suffering from any major unexpressed disorders (like schizophrenia, OCD, or dementia) (Refer to appendix).

Reference
Birmaher, B., Merranko, J. A., Goldstein, T. R., Gill, M. K., Goldstein, B. I., Hower, H., ... & Keller, M. B. (2018). A risk calculator to predict the individual risk of conversion from subthreshold bipolar symptoms to bipolar disorder I or II in youth. Journal of the American Academy of Child & Adolescent Psychiatry, 57(10), 755-763. Retrieved on 16th October 2021. Retrieved from https://www.sciencedirect.com/science/article/pii/S0890856718312279

Carvalho, A. F., Firth, J., & Vieta, E. (2020). Bipolar disorder. New England Journal of Medicine, 383(1), 58-66. Retrieved on 14th October 2021. Retrieved from https://www.nejm.org/doi/full/10.1056/NEJMra1906193

Goldstein, T. R., Merranko, J., Krantz, M., Garcia, M., Franzen, P., Levenson, J., ... & Frank, E. (2018). Early intervention for adolescents at-risk for bipolar disorder: A pilot randomized trial of Interpersonal and Social Rhythm Therapy (IPSRT). Journal of affective disorders, 235, 348-356. Retrieved on 16th October 2021. Retrieved from https://www.sciencedirect.com/science/article/pii/S016503271732699X

Luty, J. (2020). Bordering on the bipolar: a review of criteria for ICD-11 and DSM-5 persistent mood disorders. BJPsych Advances, 26(1), 50-57. Retrieved on 17th October 2021. Retrieved from https://www.cambridge.org/core/journals/bjpsych-advances/article/bordering-on-the-bipolar-a-review-of-criteria-for-icd11-and-dsm5-persistent-mood-disorders/D73A8F4F22A635353B17DFF36AB9301B

Ogasawara, K., Nakamura, Y., Kimura, H., Aleksic, B., & Ozaki, N. (2018). Issues on the diagnosis and etiopathogenesis of mood disorders: reconsidering DSM-5. Medical assignment Journal of Neural Transmission, 125(2), 211-222. Retrieved on 17th October 2021. Retrieved from https://link.springer.com/article/10.1007/s00702-017-1828-2

Paris, J., & Phillips, J. (Eds.). (2013). Making the DSM-5. New York: Springer. Retrieved on 14th October 2021. Retrieved from https://link.springer.com/content/pdf/10.1007/978-1-4614-6504-1.pdf

Rosenblat, J. D., & McIntyre, R. S. (2017). Treatment of mixed features in bipolar disorder. CNS spectrums, 22(2), 141-146. Retrieved on 17th October 2021. Retrieved from https://www.cambridge.org/core/journals/cns-spectrums/article/treatment-of-mixed-features-in-bipolar-disorder/903D69FD837B852BCABEF60748405FBD

Rowland, T. A., & Marwaha, S. (2018). Epidemiology and risk factors for bipolar disorder. Therapeutic advances in psychopharmacology, 8(9), 251-269. Retrieved on 15th October 2021. Retrieved from https://journals.sagepub.com/doi/abs/10.1177/2045125318769235

Appendix : Matrix Questions