Diagnostic Case Study
One page each:
After reviewing the case vignette you will write-up the correct diagnosis and justify your conclusions. You may choose to do this activity on your own or work within a group (no more than five to a group and each person of the group needs to be listed on the case study).
•Read the Case Study Vignette.
•Review your material for this week.
•Follow the steps for writing out the diagnosis for each case.
•Justify your diagnosis by explaining the steps you took to arrive at your decision.
Case Study Vignette
Alejandra is a 62-year-old retired corporate executive who had been meeting with a Licensed Clinical Social Worker (LCSW) due to the suicide of her partner, Mari. Alejandra’ and her partner had been together for almost 43 years. Mari had struggled with major depression when she was in her mid 30s and self-medicated with alcohol. After a fall, she was prescribed a benzo for the pain and she became addicted to prescription painkillers. Mari entered into a substance abuse treatment hospital and remained sober until a year ago when she got in a car accident and was given pain medication for cracked pelvis.
After Mari’s death, Alejandra began blaming herself because she was the one driving the car when they got in the accident. She is insistent that if the accident had not occurred, Mari would not have started taking painkillers again, and she would not have become so severely depressed. Alejandra felt crushed and as if her life had no purpose anymore. For the past 2 weeks she has become “obsessed” with how she could have prevented all this from happening. She is always sad and has withdrawn from all of her friends and social organizations that she has been involved with over the last 20 years. She is unable to concentrate and has increased her alcohol intake from a social drink every now and then to a half bottle of wine each night. At the time, Alejandra’s LCSW told her she was grieving and that the difficulties she was having were normal. They agreed to meet for support and to assess the ongoing-clinical situation.
Alejandra returned to see her LCSW weekly and about eight weeks after the suicide her symptoms worsened. Instead of thinking about what she could have done differently, she became preoccupied with the thought that she should have been the one to die, not Mari. She continued to have problems falling asleep, but was also waking up at 4:00 am and just lying there feeling exhausted, sadness and feelings of worthlessness. Her symptoms improved during the day but she felt a persistent and uncharacteristic loss of self-confidence and enthusiasm. She asked her LCSW if she still had normal grief or if she was suffering from major depression.
Alejandra herself has a history of a major depressive episode, which was resolved with therapy and an antidepressant when she was 29 years old. She has not had any episodes since then. She denied any history of alcohol or substance abuse. Both of her parents suffered from bouts of depression when they were alive. No one in her family has ever committed suicide.
Case Study II
Jeffery is a 29-year-old freelance editor who was brought to his long-time HIV clinic by his partner who is worried about him. As Jeffery entered the clinic waiting room, he announced, “God has cured me! I can stop my antivirals!” While Jeffery fidgeted in the chair and was furiously writing on a note pad, his partner reported that Jeffery had been doing well until about a month ago. At that point, he began an unusually intense editing project. After about 11 days of little sleep, Jeffrey seemed edgy, a little pressured, and “glassy-eyed.” That night, the two of them went to a party to celebrate the completion of the work project. Despite several years of Narcotics Anonymous meetings and abstinence from illicit substances, Jeffery took a stimulant, crystal methamphetamine. Acutely anxious and paranoid that they were being followed, he drank three martinis but still did not fall asleep that night. Over the ensuing days Jeffery became less paranoid, but he appeared increasingly distracted and his speech was more pressured.
Jeffry’s work project was returned with multiple negative comments and requests for corrections. Instead of focusing on his editing however, he stayed up late every night, intent on finding a cure for HIV. He made inappropriate, hypersexual advances toward other men at the gym, where he spent much of the day. He lost 5 pounds after deciding he should take vitamin supplements instead of food and his antiretroviral medication. He refused to go to the emergency room but finally agreed to come to his routine AIDS clinic appointment to show his doctors how well had done despite not having taken his medications in over a month.
Jeffry’s psychiatric history was without a prior episode of clear-cut mania, but he had been depressed as a teenager during the early phase of his coming-out process. That episode was punctuated by a purposeful overdose and a 2-week psychiatric hospitalization. He was treated with antidepressant medication and psychotherapy. He discontinued the medication because it made him “hyper and edgy,” and he stopped the psychotherapy because “it was pointless.” He used methamphetamine frequently for several years, which led to recurrent unprotected intercourse with strangers.
Jeffry was diagnosed with HIV at age 22, at which point he went to an outpatient substance abuse rehabilitation center and discontinued his use of stimulants and alcohol. His partner was unsure when Jeffry discontinued his antiretrovirals but thought it might have been months earlier. He also wondered if Jeffry cognitive faculties have declined this past year. An MRI scan of Jeffrey’s brain revealed mild cortical atrophy and periventricular white matter disease in excess of what would be expected for his age. His CD4 lymphocyte count 6 months ago were 526cells/mm3, at which time his viral load was undetectable. He had suffered fatigue but had not had any AIDS-defining illnesses.
Jeffry’s family psychiatric history was significant for a maternal aunt who had received lithium and several courses of electroconvulsive therapy, but her diagnosis is unknown. Upon evaluation, the LCSW noted Jeffry was sloppily dressed and told a pressured, disjointed story of events over the prior month. He was difficult to direct and was uncharacteristically irritable and devaluing. He was preoccupied with having discovered a cure for HIV though multivitamins and exercise. He denied hallucinations, or any suicidal or homicidal ideation. He refused cognitive testing, and his insight and judgment appeared poor.
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