Pathology Schizophrenia DSM 5 Diagnoses Case Study

Pathology Schizophrenia DSM 5 Diagnoses Case Study

Case Presentation Alex is a 67-year-old white widower and retired accountant. He was referred for psychosocial evaluation at the diabetes clinic after an emergency room (ER) visit to a local hospital. He arrived at the ER with confusion and a severe hypoglycemic episode after taking an overdose of insulin. He denied suicidal intent or alcohol abuse and claimed to have mistakenly taken insulin lispro rather than his insulin glargine dose. The ER staff was suspicious about his claim because there had been eight similar ER visits for severe hypoglycemia within the last 2 years. He explained these previous events as a result of mixing up the types of insulin he injected. Generally, his blood glucose levels have displayed wide swings. He explained that high blood glucose levels made him feel more apathetic about eating and depressed about his diabetes self-management. Personal history As a child, Alex attained developmental milestones at expected times. His father was in the Army, and as a result, Alex had moved 32 times before he graduated from high school. He was an excellent student throughout high school but only managed mediocre grades in college because of family conflict, which he has resisted describing in greater detail. Alex dropped out of college in his junior year and moved to a South Pacific island for one year. He has not maintained a relationship with his father since that time. After returning to the southwestern United States, Alex earned an undergraduate degree in English and then a second degree in accounting. After graduation, he married and worked for 20 years as an accountant in a group practice. Later, Alex started his own accounting firm, but he had difficulty keeping organized and recalls being constantly late for business meetings and failing to complete projects on time. He first recalls feeling depressed after his diagnosis with diabetes 36 years ago. He felt more depressed after he lost his 47-year-old sister to colon cancer in 1988, and then his 74-year-old father died from heart disease in 1991. But, he says his life “really fell apart” when his 54-year-old wife died from lung cancer in 1995. He contemplated suicide for 3 months but never acted, and heard his wife’s voice on several occasions, all while at their shared home. During this desperate period, he marginally functioned, lost many business clients, and was forced to close his company. Overwhelmed by depression, he moved to the West Coast to live with his mother and worked at unskilled jobs, during which time he also started smoking cannabis on a regular basis. He reports hearing his wife’s voice on at least two more occasions during this period. Diabetes complicated his emotional struggles, with blood glucose control fluctuating wildly and ranging from episodes of ketoacidosis that required hospitalization to severe hypoglycemic events that resulted in car crashes. Depression complicated his diabetes management, and after a hypoglycemia-related auto accident in which he ran over several pedestrians, he decided to stop working and was approved for social security because of psychiatric disability. Alex came to the East Coast in 1998 to briefly visit his younger brother and decided to stay. Although he still lives near his brother, he says they have had only sporadic contact since a falling out after Alex “passed out” during a severe hypoglycemic episode. In 2000, Alex got engaged, but his fiancée left him to marry the father of her child. He says he felt devastated by the loss of yet another woman who had “become everything” to him. Since then, he has withdrawn socially and does not leave his apartment unless it is necessary. He has trouble managing his money, keeping his apartment neat and orderly, taking medications on time, and maintaining any structure in his day. He also has sleep apnea, and his sleep patterns are highly erratic. Alex feels that he has been singled out for bad luck and suffering and believes that at some point he will be rewarded for his endurance. He does not smoke and reports only rarely drinking alcohol. https://spectrum.diabetesjournals.org/content/19/4/212 FINAL EXAM INSTRUCTIONS: 1) Please do not discuss the final exam questions with your classmates until after the semester. Don’t hesitate to email me directly with any questions, large or small…I will be very happy to respond. 2) Your response to each question should be roughly ½ to one page in length. For all of our sakes, no response can be longer than one page. 3) You can cite the DSM-5 as “DSM-5”, our primary textbook as “Barlow”, and the Clinical Psychopharmacology text as “Preston”. Please give page numbers when you’re drawing from a particular piece of text or (obviously) when you quote. 4) There is no need to reference the above sources, and there is no need to formally cite or reference the CCP trainings/assessments, nor the attached appendix, case study, or suicide assessment tool. If you draw upon any other materials, you will need to cite and reference using APA style (or close enough that I can easily locate your source). 5) I will not be allocating points specifically for clarity or presentation, but writing that impacts a response’s clarity will be reflected in its score. Beyond that, APA style will not be considered. 6) I will be carefully reviewing Turnitin reports…DO NOT PLAGIARIZE!!! FINAL EXAM QUESTIONS: 1 (30 pts). How would you diagnose Alex in the attached case study? [NOTE: This case study is substantially modified from a published paper. Please do not search for it online! First, that would be cheating. Second, I have altered the clinical picture in such a way that it would do you more harm than good.] Include the following: 1) DSM-5 diagnoses (if any), with specifiers and rationale 2) DSM-5 provisional diagnoses (if any), with rationale 3) DSM-5 differential diagnoses you seriously considered but ultimately rejected, with rationale 4) Information you would want/need to confirm or reject your provisional diagnoses 2 (10 pts). Briefly describe the etiological factors contributing to the development of schizophrenia. 3 (10 pts). What are the risks involved in taking atypical/2nd-generation antipsychotics? Which atypical antipsychotics, if any, reduce those risks? 4 (15 pts). How do you think a counselor should advise a person with an addictive disorder regarding participation in 12-step recovery groups (encourage, discourage, share information, say nothing, etc.), and why? 5 (15 pts). How do you think a counselor can best work with a person with an active addictive disorder who is participating in 12-step recovery groups, and why? 6 (10 pts). Briefly describe the etiological factors contributing to the development of addictions and addictive behaviors. 7 (10 pts). What evidence-based practice(s) and/or technique(s) might you use when working with a person correctly diagnosed with comorbid obsessive-compulsive disorder and major depressive disorder, and why? 8 (15 pts). What do you see as the strengths and weaknesses of the SAFE-T Protocol with C-SSRS (attached), and why? 9 (15 pts). What do you see as the strengths and weaknesses of the CCP approach to crisis counseling, and why? 10 (10 pts). What long-term impact, if any, do you think the COVID-19 pandemic has had/will have on the counseling profession, and why? 11 (15 pts). How would you address potential cross-cultural issues if a 1st-generation immigrant from an isolated ethnic group you had never heard of presented for counseling, and why? 12 (15 pts). What do you see as the pros and cons of remote (telephone/video) counseling services, and why? What part, if any, do you expect remote services to play in your counseling practice? 13 (15 pts). What are the strengths and weaknesses of Aetna’s behavioral health documentation requirements, as reflected in items 1-17 on Appendix A of the company’s provider manual (attached)? 14 (15 pts). What type of person/problem/etc. would you personally find the most challenging/problematic as/in a client, and why? How would you handle the situation if your worstpossible case were assigned to you or requested your assistance? Appendix A: The Aetna Behavioral Health treatment record review criteria and best practices STANDARD BEST PRACTICE INSTRUCTIONS A. TREATMENT RECORD-KEEPING PRACTICES 1. Is the record legible to someone other than the writer, that is, doesn’t cause a problem to read some or a majority of record? (If the answer is “No,” mark all questions “N” and end review.) The handwriting should be easy to read, and the reviewer shouldn’t have to make more than two attempts to read documentation within the medical record. 2. Is the patient’s personal data documented: address, gender, date of birth, home phone number, emergency contact, marital/legal status and guardianship (if relevant)? Self-explanatory 3. Is the member’s name or unique identifier on every page? Self-explanatory 4. Do all entries in the record contain the author’s signature or electronic identifier with title (if applicable) and degree? Self-explanatory 5. Are all entries dated? Self-explanatory B. ASSESSMENT AND TREATMENT PLAN 24 6. Is there a presenting problem, including history and current symptoms and behaviors, including behavior onset and development? Self-explanatory 7. Is there documentation of a thorough risk assessment, including presence or absence of suicidal or homicidal thoughts? Self-explanatory 8. Is there a complete mental status examination, including affect, mood, thought content, insight, judgment, speech, attention, concentration and impulse control? This may be documented on an assessment tool or in a progress note and will include most of the nine elements in the standard. 9. Is there a substance abuse assessment for all those For members under age 12, mark N/A. over 12 years of age and a history, including substances used, amount, frequency and prior treatment history? 10. Is there behavioral health treatment history documented? Behavioral health history could include treatment dates, providers/facilities, current treating clinicians, response to treatment, lab tests and consultation reports (if applicable), and relevant behavioral health treatment history. 11. Is there a comprehensive assessment of the family, psychosocial history and cultural variables that could also include legal and educational variables? Does it include the source(s) of the information? Self-explanatory 12. Is there a medical history that could include medical conditions and a medication history that includes medications taken (prescriptions, as well as over the counter), dosages, dates, responses to medications, allergies? Self-explanatory STANDARD BEST PRACTICE INSTRUCTIONS 13. Is there a diagnosis documented? Diagnosis should include comorbid and relevant psychosocial factors. 14. Is the diagnosis consistent with the assessment? The diagnosis should be consistent with presenting problems, history, mental status exam and/or other assessment data. 15. For children and adolescents, is there a developmental history that could include prenatal and perinatal events, physical, psychological, social, intellectual, academic, and educational history? Self-explanatory 16. For suicidal and homicidal patients, or patients who are otherwise at risk, are there risk assessments at every session? For suicidal (or homicidal) members, there should be risk assessments at every session. If the member’s condition is deteriorating, the record must indicate that more intense levels of care have been arranged, for example, intensive outpatient, partial, detox, residential or inpatient. This question will be scored N/A for members who don’t have these symptoms. 17. (For all psychotherapy) Treatment plan goals that are Is the treatment plan documentation thorough and complete? Are treatment plan and goals consistent with vague won’t be credited. assessment and diagnosis? Does each goal have an estimated time frame? (If the member is an adult, then this question will be scored N/A.) CA-only members (autism spectrum disorders): Reference California Code of Regulations Title 28 CCR 1300.67.1(d), 28 CCR 1300.80(b)(4), 28 CCR 1300.80(b)(5)(E), 28 CCR 1300.80(b)(6)(B). Non-CA residents will be scored as N/A. 18. If member is age 0–6 years, was there screening for autism spectrum disorder? This may be documented on an assessment tool or the findings summarized in a progress note. Score N/A if member is a non-CA resident. 19. If autism spectrum disorder is the diagnosis, is there documentation to support this diagnosis? The diagnosis should be consistent with presenting problems, behaviors, developmental and/or appropriate screening tool assessment data. Score N/A if member is non-CA resident. 20. Does the treatment plan show evidence-based therapies for autism spectrum disorder? Does the treatment plan reflect the outcome of the assessment and indicate plans to use evidencebased therapies? Score N/A if member is a non-CA resident. C. DOCUMENTATION AND PRACTITIONER COMMUNICATION 21. Is there documentation to show that the provider requested the member’s permission to communicate with the primary medical practitioner? 22. Did the member grant permission to communicate with This is a non-scored item. (Score N/A if Q21 = N.) the primary medical practitioner? A signed consent from the member must be obtained before the practitioner corresponds with the member’s primary medical practitioner. 25 SAFE-T Protocol with C-SSRS (Columbia Risk and Protective Factors) – Recent Step 1: Identify Risk Factors C-SSRS Suicidal Ideation Severity Month 1) Wish to be dead Have you wished you were dead or wished you could go to sleep and not wake up? 2) Current suicidal thoughts Have you actually had any thoughts of killing yourself? 3) Suicidal thoughts w/ Method (w/no specific Plan or Intent or act) Have you been thinking about how you might do this? 4) Suicidal Intent without Specific Plan Have you had these thoughts and had some intention of acting on them? 5) Intent with Plan Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? C-SSRS Suicidal Behavior: “Have you ever done anything, started to do anything, or prepared to do anything to end your life?” Lifetime Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn’t swallow any, held a gun but changed your mind or it was grabbed from your hand, went to the roof but didn’t jump; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc. Past 3 Months If “YES” Was it within the past 3 months? Activating Events: □ Recent losses or other significant negative event(s) (legal, financial, relationship, etc.) □ Pending incarceration or homelessness □ Current or pending isolation or feeling alone Treatment History: □ Previous psychiatric diagnosis and treatments □ Hopeless or dissatisfied with treatment □ Non-compliant with treatment □ Not receiving treatment □ Insomnia Other: □ ___________________ □ ___________________ □ ___________________ Clinical Status: □ Hopelessness □ Major depressive episode □ Mixed affect episode (e.g. Bipolar) □ Command Hallucinations to hurt self □ Chronic physical pain or other acute medical problem (e.g. CNS disorders) □ Highly impulsive behavior □ Substance abuse or dependence □ Agitation or severe anxiety □ Perceived burden on family or others □ Homicidal Ideation □ Aggressive behavior towards others □ Refuses or feels unable to agree to safety plan □ Sexual abuse (lifetime) □ Family history of suicide □ Access to lethal methods: Ask specifically about presence or absence of a firearm in the home or ease of accessing Step 2: Identify Protective Factors (Protective factors may not counteract significant acute suicide risk factors) Internal: External: □ Fear of death or dying due to pain and suffering □ Identifies reasons for living □ ___________________ □ ___________________ □ Belief that suicide is immoral; high spirituality □ Responsibility to family or others; living with family □ Supportive social network of family or friends □ Engaged in work or school Step 3: Specific questioning about Thoughts, Plans, and Suicidal Intent – (see Step 1 for Ideation Severity and Behavior) C-SSRS Suicidal Ideation Intensity (with respect to the most severe ideation 1-5 identified above) Month Frequency How many times have you had these thoughts? (1) Less than once a week (2) Once a week (3) 2-5 times in week (4) Daily or almost daily (5) Many times each day Duration When you have the thoughts how long do they last? (1) Fleeting – few seconds or minutes (2) Less than 1 hour/some of the time (3) 1-4 hours/a lot of time (4) 4-8 hours/most of day (5) More than 8 hours/persistent or continuous Controllability Could/can you stop thinking about killing yourself or wanting to die if you want to? (1) Easily able to control thoughts (2) Can control thoughts with little difficulty (3) Can control thoughts with some difficulty (4) Can control thoughts with a lot of difficulty (5) Unable to control thoughts (0) Does not attempt to control thoughts Deterrents Are there things – anyone or anything (e.g., family, religion, pain of death) – that stopped you from wanting to die or acting on thoughts of suicide? (1) Deterrents definitely stopped you from attempting suicide (2) Deterrents probably stopped you (3) Uncertain that deterrents stopped you (4) Deterrents most likely did not stop you (5) Deterrents definitely did not stop you (0) Does not apply Reasons for Ideation What sort of reasons did you have for thinking about wanting to die or killing yourself? Was it to end the pain or stop the way you were feeling (in other words you couldn’t go on living with this pain or how you were feeling) or was it to get attention, revenge or a reaction from others? Or both? (1) Completely to get attention, revenge or a reaction from others (2) Mostly to get attention, revenge or a reaction from others (3) Equally to get attention, revenge or a reaction from others and to end/stop the pain (4) Mostly to end or stop the pain (you couldn’t go on living with the pain or how you were feeling) (5) Completely to end or stop the pain (you couldn’t go on living with the pain or how you were feeling) (0) Does not apply Total Score Step 4: Guidelines to Determine Level of Risk and Develop Interventions to LOWER Risk Level “The estimation of suicide risk, at the culmination of the suicide assessment, is the quintessential clinical judgment, since no study has identified one specific risk factor or set of risk factors as specifically predictive of suicide or other suicidal behavior.” From The American Psychiatric Association Practice Guidelines for the Assessment and Treatment of Patients with Suicidal Behaviors, page 24. RISK STRATIFICATION High Suicide Risk Suicidal ideation with intent or intent with plan in past month (C-SSRS Suicidal Ideation #4 or #5) Or TRIAGE    Suicidal behavior within past 3 months (C-SSRS Suicidal Behavior) Initiate local psychiatric admission process Stay with patient until transfer to higher level of care is complete Follow-up and document outcome of emergency psychiatric evaluation Moderate Suicide Risk Suicidal ideation with method, WITHOUT plan, intent or behavior in past month (C-SSRS Suicidal Ideation #3)   Directly address suicide risk, implementing suicide prevention strategies Develop Safety Plan  Discretionary Outpatient Referral Or Suicidal behavior more than 3 months ago (C-SSRS Suicidal Behavior Lifetime) Or Multiple risk factors and few protective factors Low Suicide Risk W …