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Task: Review the 3 case studies provided (one for each DSM-V section covered in the module). Determine the correct DSM-V diagnosis including any applicable specifiers. Provide a brief rationale for your specific diagnosis (see example below). Here is an example of a case study and also an example of the DSM-V diagnosis and rationale for the diagnosis which includes the letters and numbers associated with the diagnosis in DSM-V. Example Case Study: “Carl Estel, a 74-year-old right-handed man, was brought for a neuropsychiatric evaluation after a multi-year decline marked by stiffness, forgetfulness, and apathy. His wife had been trying to get him in for an evaluation for years and had finally become desperate enough to enlist his brothers to bring him for the evaluation. Mrs. Estel described her husband’s problems as starting when he retired at age 65. He had seemed “out of sorts” almost immediately, and she had wondered at the time whether he was getting depressed. He became uncharacteristically forgetful, misplacing items and neglecting to pay bills. He had trouble with appointments, medications, and calculations. He had declined to see a physician at her urging until he was involved in a traffic accident a few years prior to this evaluation. While evaluating him for minor injuries, a physician had said that the accident was caused by inattention and diminished depth perception, that Mr. Estel should stop driving, and that he might have early dementia. Over the past year, things had gotten worse. Mr. Estel often could not recall the outcome of sporting events that he had just watched on television, although his memory improved with cues. He resisted activities such as travel and socializing that he had previously enjoyed. A former athlete, he quit taking walks around the neighborhood after several falls. He quit playing cards with neighbors because the rules had become confusing. He looked depressed and acted apathetic but generally said he was fine. His judgment and problem-solving skills were rated as poor. A retired plumbing contractor who had completed 4 years of college, Mr. Estel sometimes seemed unable to operate household appliances. All of these cognitive problems seemed to fluctuate, so that his wife reported that sometimes he was “almost like his old self,” whereas at other times it was “like living with a zombie, a depressed zombie.” She described his excessive daytime drowsiness and frequent staring spells. She also reported that she felt exhausted. When asked specifically about sleep, Mrs. Estel reported that neither of them slept well. Mainly, she said, it was because of her husband “acting out his dreams.” He punched and screamed and would occasionally fall out of bed. She was bruised the morning after these episodes and decided it was safer to sleep on the couch. These episodes occurred several times per month. She recalled that these sleep episodes began just before he retired; she recalled wondering at the time whether he had posttraumatic stress disorder, but she did not think he had suffered any particular trauma. A few years earlier, a friend had offered a “sleeping pill” that had helped her own husband with dementia. Mr. Estel had responded to it with extreme rigidity and confusion, and his wife had nearly taken him to the emergency room in the middle of the night. Mrs. Estel denied that her husband had ever had any psychiatric illness. When asked about psychotic symptoms, she said he often seemed to swat at invisible things in the air. This happened about twice a month. Mr. Estel’s medical history was pertinent for hypercholesterolemia, cardiovascular disease with a stent, and possible transient ischemic attacks. His family history was positive for his mother having developed dementia in her mid-70s. On examination, Mr. Estel was a stooped, stiff man who shuffled into the office. While listening to his wife present the history he often stared into space, seeming to pay no attention to the content of the conversation. His right hand was tremulous. He appeared depressed but when asked, he said he felt fine. His voice was so quiet that words were often unintelligible even when the interviewer leaned close. He drooled at times and did not notice until his wife wiped his chin. When asked to do cognitive testing, he shrugged his shoulders and said, “I don’t know.”” Example Student Response: Diagnosis is Major neurocognitive disorder with Lewy bodies Major neurocognitive disorder with Lewy bodies Diagnostic Criteria A – meeting criteria for major neurocognitive disorder. Major Neurocognitive Disorder Criteria A – Mr. Estel experienced significant cognitive decline (A) since retirement Major Neurocognitive Disorder Criteria B – Cognitive deficits interfere with his independence and he is unable to pay bills and drive Major Neurocognitive Disorder Criteria C – There are no indication of delirium for Mr. Estel. Major Neurocognitive Disorder Criteria D – Mr. Estel has not history of mental illness and symptoms do not seem related to another mental disorder Major neurocognitive disorder with Lewy bodies Diagnostic Criteria B – gradual onset – Mr. Estel has had worsening of symptoms over time. Major neurocognitive disorder with Lewy bodies Diagnostic Criteria C – core diagnostic features and suggestive diagnostic features Major neurocognitive disorder with Lewy bodies Core Diagnostic Features – fluctuating cognition (A)- wife reports he is sometimes a “zombie”, recurrent visual hallucinations (B) – although the specifics are not clear, wife reports he waves in the air, spontaneous features of parkinsonism (C) – sleeping pill caused extreme rigidity and confusion, Major neurocognitive disorder with Lewy bodies Suggestive Diagnostic Features – rapid eye movement sleep behavior disorder (A) – Mr. Estel meets criteria for this disorder which wife describes as “acting out his dreams” and she now sleeps on the couch. It is unclear if the Mr. Estel has severe neuroleptic sensitivity (B), but if the sleeping pill was an antipsychotic like Seroquel, then he would also meet this criteria These are the 3 case studies that has be written Somatic Symptom and Related Disorders Case Study: Paulina Davis, a 32-year-old single African American woman with epilepsy first diagnosed during adolescence and no known psychiatric history, was admitted to an academic medical center after her family found her convulsing in her bedroom. Before she was taken to the emergency room (ER), emergency medical services had administered several doses of lorazepam, with no change in her presentation. On her arrival in the ER, a loading dose of fosphenytoin was given that successfully stopped the convulsive activity. Laboratory studies of samples obtained in the ER revealed therapeutic levels of her usual antiepileptics and no evidence of any infection or metabolic disturbance. Urine toxicology screens were negative for use of illicit substances. Ms. Davis was subsequently admitted to the neurology service for further monitoring. During her admission, a routine electroencephalogram (EEG) was ordered. Shortly after the study began, Ms. Davis began convulsing; this prompted administration of intravenous lorazepam. When the EEG was reviewed, no epileptiform activity was identified. Ms. Davis was subsequently placed on video-EEG (vEEG) monitoring while her antiepileptics were tapered and discontinued. In the course of her monitoring, Ms. Davis had several episodes of convulsive motor activity; none were associated with epileptiform activity on the EEG. Psychiatric consultation was requested. On interview, Ms. Davis denied prior psychiatric evaluations, diagnoses, or treatments. She denied having depressed mood or any disturbance of sleep, energy, concentration, or appetite. She reported no thoughts of harming herself or others. She endorsed no signs or symptoms consistent with mania or psychosis. There was no family history of psychiatric illness or substance abuse. Her examination revealed a well-groomed woman, sitting on her hospital bed with EEG leads in place. She was pleasant and easily engaged and made good eye contact. Cognitive testing revealed no deficits. Ms. Davis noted that she had recently moved to the state to start graduate school; she was excited to start her studies and “finally get my career on track.” She denied any recent specific psychosocial stressors other than her move and stated, “My life is finally where I want it to be.” She was future oriented and concerned about the impact that her seizures might have on her long-term health and was worried that a protracted hospitalization might cause her to miss the first day of classes (only a week away from the time of the interview). Moreover, she was quite concerned about the costs of her hospitalization because her health insurance coverage did not begin until the school semester commenced and the payment for extended benefits coverage from her previous employer would have a significant impact on her budget. When the findings of the vEEG study were discussed with Ms. Davis, she quickly became quite irritable, asking, “So, everyone thinks I’m just making this up?” She was not calmed by her treaters’ attempts to clarify that they did not believe her to be faking her symptoms or by their reassurance that her symptoms might be helped by psychotherapy. Ms. Davis pulled her EEG leads from her scalp, dressed herself, and left the hospital against medical advice. Feeding and Eating Disorders Case Study: Uma, an 11-year-old girl in a gifted and talented school, was referred to an eating disorder specialist by a child psychiatrist who was concerned that Uma had drifted below the 10th percentile for weight. The psychiatrist had been treating Uma for perfectionistic traits that caused her significant anxiety. Their sessions focused on anxiety, not on eating behavior. Uma’s eating difficulties started at age 9, when she began refusing to eat and reporting a fear that she would vomit. At that time, her parents sought treatment from a pediatrician, who continued to evaluate her yearly, explaining that it was normal for children to go through phases. At age 9, Uma was above the 25th percentile for both height and weight (52 inches, 58 pounds), but by age 11, she had essentially stopped growing and had dropped to the 5th percentile on her growth curves (52.5 inches, 55 pounds). The only child of two professional parents who had divorced 5 years earlier, Uma lived with her mother on weekdays and with her nearby father on weekends. Her medical history was significant for her premature birth at 34 weeks’ gestation. She was slow to achieve her initial milestones but by age 2 was developmentally normal. Yearly physical examinations had been unremarkable with the exception of the recent decline of her growth trajectory. Uma had always been petite, but her height and weight had never fallen below the 25th percentile for stature and weight for age on the growth chart. Uma was a talented student who was well liked by her teachers. She had never had more than a few friends, but recently she had stopped socializing entirely and had been coming directly home after school, reporting that her stomach felt calmer when she was in her own home. For the prior 2 years, Uma had eaten only very small amounts of food over very long durations of time. Her parents had tried to pique her interest by experimenting with foods from different cultures and of different colors and textures. None of this seemed effective in improving her appetite. They also tried to let her pick restaurants to try, but Uma had gradually refused to eat outside of either parent’s home. Both parents reported a similar mealtime pattern: Uma would agree to sit at the table but then spent her time rearranging food on her plate, cutting food items into small pieces, and crying if urged to eat another bite. When asked more about her fear of vomiting, Uma remembered one incident, at age 4, when she ate soup and her stomach became upset and then she subsequently vomited. More recently, Uma had developed fear of eating in public and ate no food during the school day. She denied any concerns about her appearance and only became aware of her low weight after her most recent visit to the pediatrician. When educated about the dangers of low body weight, Uma became tearful and expressed a clear desire to gain weight.
SCIENCE
HEALTH SCIENCE
NURSING
DNP 650

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