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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. The three cases Substance-Related and Addictive Disorders Case Study # 1: Tomás Zambrano was a 36-year-old married first-generation Hispanic man who presented to the gambling clinic at a major medical center for evaluation and treatment. A football coach at a suburban high school, Mr. Zambrano had a 5-year-old son. He denied having any prior psychiatric or substance abuse history. He was appropriately dressed and groomed, expressed himself fluently in both English and Spanish, spoke in normal tone and volume, and on examination presented with intact cognitive function and average intelligence. Mr. Zambrano had been betting on sports and playing cards since childhood, noting in the evaluation that gambling “is part of our culture.” His own father’s favorite hobby and stress reliever had been to play poker with friends at night, and Mr. Zambrano remembered with affection the father-son moments they shared. Poker became for him a familial activity that he increasingly used to relieve work-related stress. He relished the excitement as well as the intellectual challenge and competition. Card games did not, however, remain a benign pastime for Mr. Zambrano. He had begun to lose more money than he could afford. Over the prior 2 years, he had gradually increased the frequency and stakes of his poker nights. When he lost, he placed even larger bets, convinced that the odds would favor him the next time. When he won, he felt great and would continue to play, convinced he was “on a streak.” Although losses made him feel unworthy, stupid, and irritable, he believed success would come if he could fine-tune his strategy. He felt a powerful, almost constant impulse to increase the tempo of his gambling and recover the money he had lost. When he tried to cut back on gambling, he felt irritable and preoccupied, and quickly returned to his poker nights. By the time Mr. Zambrano presented to the gambling clinic, he felt desperate. Nightly poker had led to daytime fatigue and poor performance at his coaching job, which he had previously loved. He was consumed with thoughts about his next poker game. His wife and son had long resented his time away from the family, but his wife had just found out that he had used up his son’s college fund plus accumulated $30,000 in credit card debt. When his wife threatened to file for divorce, he felt sad and depressed and decided to seek treatment. Substance-Related and Addictive Disorders Case Study # 2: Oliver Vincent never saw himself as an addict. He had always been “on top of things.” At age 35, he was independently wealthy as the owner of several clothing franchises, lived with an ex-partner in a more-than-comfortable apartment in New York City, worked out every day, enjoyed the company of a group of loving friends, and, although single, had not given up on the idea of someday (preferably soon) finding the perfect man to share his life with. Mr. Vincent came out to his Irish Catholic family when he was 19. His parents had already guessed that Mr. Vincent was gay long before he told them, and they took the non-news fairly well. Their main concern had been that their son might be discriminated against because of his sexuality, get hurt, and live a lonely life. Nothing could be farther from the way things turned out: Mr. Vincent was “out and proud” and living it up. When Mr. Vincent found himself with a substance use problem, he addressed it the same way he had dealt with pretty much everything else: head on. For the first time in his life, he decided to see a psychiatrist. Mr. Vincent described a pattern that revolved around weekend “party and play” activities. On Friday and Saturday evenings—and occasionally during the week—he would go out to dinner with friends and then to a club or a private party. He tended to drink two or three cocktails and four to five glasses of wine during the evening. Without the alcohol, he found he could easily say “no” to substances, but “after a good buzz, if someone has coke—and there is always someone around who has coke—I use. And then my heart starts to race, and then I do everything I can to hook up. I used to go online, but these days, it’s all on Grindr.” Party and play are code words for drugs and sex, respectively. The term is sometimes abbreviated PNP. Grindr is a smartphone application that uses GPS to identify and connect similarly inclined individuals in a person’s geographical vicinity. Overall, Mr. Vincent drank alcohol and used cocaine three to four times a week and “occasionally used tina and bath salts.” He could hardly attend Monday morning meetings, much less prepare for them, and had been trying to cut down on his cocaine use for the prior 6 months without success. Tina is slang for crystal methamphetamine. Bath salts is slang for a powder that contains a variety of synthetic stimulants. Since Mr. Vincent had started using cocaine regularly, he had lost weight and had trouble sleeping. He worried that his effort at the gym was going to waste. His business continued to succeed, but his own effectiveness had decreased. Most importantly, he did not practice safer sex when high on stimulants, and he worried about HIV seroconversion. Substance-Related and Addictive Disorders Case Study # 3: Nicholas Underwood, a 41-year-old software engineer, entered an alcohol treatment program with this chief complaint: “I need to stop drinking or my wife will divorce me.” At the time of admission, Mr. Underwood stated that he was drinking approximately 1 liter of vodka per day, every day, and had not had an alcohol-free day in over 2 years. For many years, Mr. Underwood had drunk alcohol only after work, but about a year prior to the evaluation he had begun to routinely drink in the morning whenever he had the day off. More recently, he had begun to feel “shaky” every morning and would sometimes treat that sensation with a drink, followed by more alcohol during the day. Mr. Underwood experienced a number of problems related to drinking. His wife was “at the end of her rope” and considering divorce. His diminished ability to concentrate at work was “sinking” his once-promising career. He was spending more time trying to recover from the effects of drinking and found himself both planning strategies both for abstinence and for surreptitiously taking his next drink. Mr. Underwood first tried alcohol in high school and said that he had always been able to hold his liquor more than his friends could. In college, he was one of the heaviest drinkers in a fraternity known as “Animal House” around campus. Through his 30s, he gradually increased the frequency of his drinking from primarily on weekends to daily. Over the prior year, he had switched from being exclusively a beer drinker to drinking vodka. He had gone to many Alcoholics Anonymous meetings over the years but tended to drink as soon as the meeting ended. He had received no formal treatment. The patient denied recent use of other substances; he had smoked marijuana and snorted cocaine several times during college but never since. He had used no other illicit drugs and took no medications. He did not smoke cigarettes. He had experienced blackouts on several occasions during college but not since then. He had no history of seizures and no other medical problems. Family history was significant for alcohol dependence in his father and paternal grandfather. Mr. Underwood entered the alcohol treatment program at approximately 3:00 p.m., having not had a drink since the evening before. He was diaphoretic and exhibited significant tremulousness in his hands. He complained of anxiety, restlessness, irritability, nausea, and recent insomnia. Clinical evaluation revealed a casually groomed, diaphoretic man who was cooperative but anxiously pacing and who immediately said, “I’m getting ready to jump out of my skin.” Speech was of normal rate, rhythm, and tone. He denied depression. There was no evidence of psychotic thinking, and he denied auditory, visual, or tactile hallucinations. He was alert and oriented to person, place, and date. He had no gross memory deficits, but his attention and concentration were noted to be reduced. Notable features of his physical examination were marked diaphoresis, a blood pressure of 155/95, a heart rate of 104 beats/minute, severe tremulousness in his upper extremities, and hyperactive deep tendon reflexes throughout. Laboratory tests were within normal limits except for aspartate aminotransferase and alanine aminotransferase, which were approximately 3 times normal.
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DNP 650

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