Psychology Assignment: DSM-5 Diagnosis Of A Patient
Question
The Case of Barry
Summary
Mr Barry Morrison is a 45-year-old Ambulance Officer who works full time for NSW Ambulance Service. Over the past 10 years, he has attended over 500 critical incidents as a first responder. He is well regarded in his role and widely viewed as an expert in the work he does.
In December 2015, Barry was an ambulance officer responding to a fatal car accident involving a number of young teenagers in Sydney’s Circular Quay. He was first on the scene to provided medical attention to the surviving victims including three who subsequently lost their lives. In the past 2 months, Barry has had difficulty sleeping most nights of the week. Most days, he is also experiencing visual flashbacks of the event and reports hearing screams and sirens. He cannot block out these sensations from his mind, though they do seem to subside a little if he has a couple of glasses of whiskey in the evening to get to sleep.
Context
Barry has been referred to the mental health team for assessment of his mental state, his sleeping difficulty and his alcohol consumption. He is also concerned about events in the last week (4 separate experiences) where all of a sudden, his environment seems distant, dreamlike and distorted to him.
Barry’s symptoms are preventing him from attending to his duties as a fulltime ambulance officer. He is skipping work on a regular basis, attending no more than 3 of 5 days. Barry enjoys his role saying his job gives him the opportunity to “make a contribution to society and help those in need”. Barry has never been “a drinker”, having only the occasional beer at the end of a long week, but recently he has been drinking more heavily in an attempt to block out the memories and recurrent dreams of the accident that wake him during the night. When people ask how he’s coping, Barry becomes very irritable and angry, screaming that he wished they would “leave it alone; the world is a dangerous place and that’s all there is to it”. Although these outbursts are rare, they are becoming more frequent.
Background and Medical History
Barry has been an ambulance officer for many years. He has seen some “pretty difficult situations”, including attending to other fatal road accidents and dealing with very violent and aggressive individuals affected by the drug methamphetamine (street name, ICE).
Barry is taking medication for high blood pressure and heart palpitations. His appetite is poor but he is eating well and has not lost any weight recently. While his drinking has increased recently, he doesn’t believe he has an issue with it as he doesn’t experience cravings and has the occasional week off from drinking when the flashbacks are subdued. He is also concerned about not being under the influence when he is at work so manages his consumption accordingly.
For the last 2 months Barry has woken up several times a night on most nights, has a restless sleep when he finally gets to sleep, and wakes early every morning and is unable to go back to sleep. He believes he is having problems concentrating during the day. He also thinks he should not go to work or administer medical attention to patients while he is fatigued and not sleeping properly, because his decision making may be impaired. He has also recently asked for a job transfer to lighter duties, as working around the streets of Sydney’s Circular Quay instantly raises his blood pressure and triggers intense psychological distress, anxiety, fear, worry, unease, tension, and nervousness on a daily basis. He tries to avoid this part of Sydney as much as he can.
Social History
Barry has a supportive family life. He is married to Brenda, a primary school teacher and has two small children. Barry used to attend regular local social events with his local rugby club, but has no plans to catch up with his friends as he is starting to feel estranged from them. Although, he still has interest in social events and is almost always able to experience positive emotions and loving feelings. He enjoys his relationships, but he feels his friends and family just can’t understand what he is going through, so he feels somewhat detached.
Concerns
Barry is worried that he may not be able to return to work. He says he isn’t sleeping well and that it is starting to become concerning. He is concerned that the flashbacks he is having about the accident in Circular Quay will not subside and he will not only be unable to concentrate on his job because of them, but that he might also lose the job due to significant absenteeism.
Students are required to read the above case study and write a psychology assignment providing a DSM-5 diagnosis, along with a rationale for the labels considered, rejected, and applied.
Assessment measures that should be utilised in the assessment include:
- The DSM-5 Cross-Cutting Level 1 and 2 Symptom Measures.
- The World Health Organisation Disability Assessment Schedule.
- Any DSM-5 Level 2 or Symptom Severity Measures that may be required.
Answer
Final Diagnosis
Post Traumatic Stress Disorder (Ptsd)
Case History
The current psychology assignment is focused on the case of Mr. Barry Morrison who is an ambulance officer in his middle age. He is used to watching difficult situations as a part of his duty. He often deals with violent and aggressive people for the same reason of his profession. He is under medication for high blood pressure and palpitations in his cardiac rhythm. He is facing loss of appetite but no serious disorder in eating habit is present. He is maintaining a certain healthy weight for some time now. He has a healthy capacity to control his alcohol consumption that increased recently after he has been deeply moved by a site of accident he visited for his professional duty. However, he is not a drinker, in the typical sense of the word. Barry is experiencing troubled sleep for last two months following the visit to the road accident site. According to him, he is facing problems in concentrating in his work. He is married and is the father of two kids. He is fond of attending social events, but at the same time feels little detached from the happenings around him recently.00
Assessment And Diagnostic Process
|
Symptom Domain |
CCM L1 Highest domain score |
CCM L2 Raw or Prorated score |
T-score or other relevant score |
Comments. Key justification |
|
Anxiety (DSM-5) |
4 |
20 |
57.9 |
High. He finds facing similar situations of accidents difficult. The experience of facing the accident haunts him leading to serious troubles in his everyday activities and perceptions of reality. His current situation refers to Post Traumatic Stress Disorders accompanied with panic occasional attack. |
|
Psychosis |
4 |
20 |
N/A |
He has moderate psychosis with schizophrenic attacks of hearing sounds and visualizing the accident spot without external triggers. Mr. Morison often visualizes the incident in odd hours and gets to hear the chaos of the accident site s during trauma attacks. |
|
Repetitive thoughts |
4 |
15 |
3 |
Moderate (intrusive and uncontrollable thoughts about professional career, ability to perform his duty properly, concerns of mixing up well in social gatherings are recurrent in his mind. He also feels left out in the crowd, as others cannot understand his trouble. He is also fidgeting on his job position and performance requirements.) |
|
Sleep Problems
|
4 |
15 |
57.9 |
High. (Mr. Morrison has difficulties in sleeping since he witnessed the fatal incident. He wakes up in the middle of his sleep.) |
|
Dissociation |
3 |
10 |
N/A |
Moderate. (Mr. Morrison is facing issues of dissociation from his immediate surroundings.Though he feels good with his family and relatives, he realizes that none of them can understand what he is undergoing. ) |
|
Personality Functioning |
4 |
20 |
59 |
High. (The gentleman has been facing troubles in managing his everyday activities including professional duty, eating, sleeping and keeping balance in behavior. He is seeking different posting and positioning in his professional career, despite being proud of his service as a social contributor throughout his career. ) |
|
Substance Use |
2 |
10 |
N/A |
Moderate. (The gentleman has become more dependent on alcohol consumption to blur out the horrific experience haunting his mind. However, he still has necessary control on the consumption limit.) |
Considered Disorders
Rejected Domains
Depression: The patient does not feel any persistent sadness, hopelessness, emptiness or similar other emotions. He has not lost his interests in profession and social gathering completely. He can still perform his daily activities with necessary precision. Hence, depression is ruled out.
Anger: Mr. Morrison does not show any symptom of anger outburst like losing calm or throwing objects on any occasion. Hence, this domain is also eliminated from his diagnosis.
Mania: There is no sign of maniac disorder like obsession over any particular object, event or activity. Mr. Morrison only shows symptoms of anxious response to the repetitive image of disaster he has been through during his duty to the accident site. Hence, the domain of mania has been eliminated from the diagnosis.
Somatic Symptoms: There is absolutely no symptom of somatic disorder in the patient as he is not concerned with appearance or physical wellbeing related to his recent conditions of mental health.
Suicidal Ideation: Though Mr. Morrison is finding issues in handling his personal and professional life following the traumatizing incident, he has never shown any sign of symptom of suicidal thoughts or feeling. Absence of depression is one of the major directives in eliminating the domain of suicide from the case.
Memory: Mr. Morrison has not complained of any problem regarding memorizing things he needs to. He can clearly identify his relatives, immediate family, and acquaintances. He is very much aware about his professional needs and social roles. Hence, there is no sign of memory impairment in this case.
Anxiety Disorders
Post Traumatic Stress Disorder
PTSD was considered as Mr. Morrison showed a number of symptoms directly relating to his professional experience at the accident site. Despite being an experienced professional in this field, the accident accompanied with the death of two young people shook his to the core. This very stress is the reason why he has developed severe sleeping disorders, fear of unpleasant experiences, detachment to his immediate family, and eating disorder along with increased frequency of drinking alcohol.
Panic Attack: Though the patient does not record any history of panic attack, with his present mental condition, he can develop it if left untreated.
Obsessive Compulsive Disorder: Mr. Morrison does not show any obsession or compulsion to repetitive activities.
Schizoprenia Spectrum And Other Psychotic Disorders
Delusional Disorder
Mr. Morrison can hear or see the same traumatizing experience without any external trigger. This makes him undergo the same pain every time he hears the sounds of the to and fro at the accident site, or he remembers the faces of the victims injured and consequently died. The whole scenario of devastation keeps appearing in front of his vision and makes him delusional about his present physical state.
Hallucination: The patient, according to the record of his experience of illusion, is prone to hallucination as he becomes obsessed over the unpleasant experience he has undergone.
Brief Psychotic Disorder: The mental health problem is caused by a certain incident in the recent past. It is likely to subside after necessary treatment within a certain period. Since he does not have any pre-existing mental health condition or history of schizophrenia or psychosis, this experience can be a BPD.
Repetitive Thought Disorder
Intrusive Thoughts
The patient feels that his condition is not understandable to any of his acquaintances. He also feels that he will not be able to work like before. The delusion and hallucination caused are parts of the repetitive thought disorder originated from the experience of the accident. However, there is no physical manifestation of this thought in the patient in forms of Obsessive Compulsive Disorders (OCD). Mr. Morrison tries to find remedy of these intrusive thoughts through alcohol consumption. He believes that he still has control over his alcohol consumption limit despite becoming a more frequent drinker than he used to be. His drinking habit has changed from occasional to regular following the trauma largely owing to the intrusive thoughts.
Sleeping Problems
Insomnia
Mr. Morrison has developed clear symptoms of insomnia as he finds it difficult to fall asleep and maintain proper sleeping durations. The problem is persistent with other issues following his trauma experience. However, other kinds of sleeping disorders like restless leg, narcolepsy, obstructive sleep apnea, are sleepwalking have not been experience by the patient.
Dissociation
General Symptoms of Dissociation
Though the patient does not show any symptom of dissociative amnesia or its different variations, he has grown a certain degree of general dissociation from his immediate environment and surroundings. He feels less active in social gathering than he used to feel before the incident. The rounds of hallucination also refer to his internal urge of dissociation from the reality for the time being.
Personality Functioning Disorders
Avoidant Personality Disorder
The patient has grown avoidant personality disorder that reflects in his idea of inability to perform his previous role properly. Hence, he has asked for a less important position and posting to his employer after the trauma experience. This is also the reason behind his reduced interest over social gathering compared to his early approach. If left untreated, this disorder with the hallucination might lead to borderline personality disorder and paranoia.
Final Diagnosis
Post Traumatic Stress Disorder (Ptsd)
|
A. Stressor |
Mr. Morrison is threatened with direct exposure to traumatic incident through his professional need. Though the victims of the incident were not his close relatives or acquaintances as per the DSm-5 requirement, the incident left a mark in his psyche due to its violent impact.
|
|
B. Intrusion |
The patient has multiple symptoms of intrusion through flashbacks, unwanted upsetting memories, emotional distress following traumatic reminders, and hallucination. Only physical reactivity is not registered here.
|
|
C. Avoidance |
Trauma-related thoughts and feelings are predominant in the patient’s complete history of mental health disorder. He experiences hallucination, finds difficult to take part in social events, and fears returning to his previous job position. Hence, he has also asked for a less active position in his profession. However, the patient has not reported any external reminder related to the trauma.
|
|
D. Negative Alterations in Cognitions and Mood |
Mr. Morrison shows several symptoms of this criterion in PTSD according to DSM-5. He is facing inability to recall the exact incident of the trauma and it has registered as a chaos to his psyche that often reflects through his hallucinations. The trauma has caused some negative effect on his psyche leading to his feeling of incompetence and isolation from social gathering. He is also suffering from decreased interest in activities. His present condition is difficult to perceive any positive implication of experiences. |
|
E. Alterations in Arousal and Reactivity |
Mr. Morrison does not become aggressive but certainly irritable due to his hallucinations. He exhibits risky behaviour through his alcohol consumption. Difficulty sleeping is very much evident in his experience. He also finds it difficult to concentrate to the moment following his exposure to the trauma.
|
|
F: Duration |
Mr. Morrison is facing these experiences for last two months which matches the criteria of DSM-5 of PTSD. |
|
G: Functional Significance |
Mr. Morrison is explicitly suffering from functional impairment following his trauma exposure. He does not feel the same energy and vigour to join social events. He does not want to go back to his previous job position despite fairly knowing the social importance of his role to help people in distress (Duncan, 2017). He has difficulty in sleeping and he resorts to alcohol consumption to prevent his senses from repeating the trauma memory. |
|
H: Exclusion |
The symptoms shown by Mr. Morrison are not results of any medication, substance abuse and other physical illness. |
|
Specifications: Dissociative and Delayed. |
Dissociative: Mr. Morrison is suffering from depersonalization through dissociative specification of the trauma. There is no sign of Derealization in his case. Delayed Specification: The diagnosis criteria are studied after two months of the trauma exposure. However, it needs to cover at least six month of the onset of symptoms. |
Clinical Significance And Recommendations
|
WHODAS Domain
|
Score and Severity
|
Evidence/Justification/Comments |
|
Life activities— Social and Work
|
4/5 severe |
could not resume usual work-life activities
|
|
Getting along with people (mild),
|
2/5 mild |
Feels others distant and inadequate to understand his emotion. Finds social gathering less interesting. |
|
Disorder Specific Severity Score |
Score 4. It is extremely severe affecting the regular activities of the patient and changing his perception of surroundings and reality. |
|
|
Secondary clinical features? |
Monitoring changes in mood and cognitive behaviours during the treatment is crucial for secondary diagnoses related to PTSD. The patient needs to look after for the nature of appetite, cohesion in verbal and physical communication, sleep regularity etc. along with the treatment and medication for the diagnosed disorder. |
|
|
Treatment recommendation |
Adult PTSD treatment depends on cognitive behaviour therapies. In this case, Mr. Morrison requires Cognitive Processing Therapy (CPT). CPT relates to the learning of modification in unhelpful belief systems related to trauma exposure. If the symptoms persist after six months, the patient will need to undergo Eye Movement Desensitization and Reprocessing (EMDR) Therapy to reduce the vividness and emotional attachment associated with the trauma exposure. SSRIs like sertraline, paroxetine, FDA-approved medication are to be applied for treatment (Duncan, 2017). Zoloft, and Paxil are recommended for the case. The patient is on the medication of high blood sugar and palpitation. Hence, any subsequent occurrence of physical reaction must be documented and analysed for continuation of the medicines. Follow up in every fortnight is recommended. |
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References
DMS (2013). Diagnostic and Statistical Manual of Mental Disorders. 5Th Edition. APA.
Duncan G. (2017) PTSD Comorbidty. Psychology assignment Journal of General Internal Medicine.
