DSM-IV-TR Hypotheticals - Questions and Answers

A 29-year-old single woman presents for psychotherapy.  She states she has been under stress due to a chaotic work environment, which sometimes prevents her from finishing her work.  She says she is experiencing insomnia, fatigue and irritability, feels overwhelmed and “can’t enjoy anything.”  She adds she has withdrawn from family and friends and sometimes feels there is no point in “going on.”

1. What are at least two diagnoses to consider for this woman and why?

ANSWER: The first diagnosis to consider is generalized anxiety disorder (“GAD”), which is defined at DSM-IV-TR §300.02.  The second diagnosis to consider is cyclothymic disorder (“CD”), which is defined at DSM-IV-TR §301.13.  In support of GAD: Px reports she feels “overwhelmed” and “can’t enjoy anything.”  She experiences “insomnia, fatigue and irritability.”  These anxiety symptoms track those set forth at §300.03(c), in particular: (2) being easily fatigued; (3) difficulty concentrating; (4) irritability and (6) sleep disturbance.  In support of CD: Px reports depressive symptoms such as withdrawal from family and friends.  She sometimes feels “there is no point in going on.”  Px also reports hypomanic symptoms such as insomnia and distractibility.  Px does not appear however to meet the DSM criteria for major depressive disorder (“MDD”).

2. What additional information would be useful before making a diagnosis?

ANSWER: Consider requiring the following additional information:

(a) Not due to a general medical condition.

(b) Not due to substance abuse.

(c) When was the onset?  GAD requires at least six months and CD requires at least two years.

(d) What is the frequency?  GAD requires “more days than not” and CD requires “numerous periods” and symptoms not absent for more than two months at a time.

(e) What is her previous psychological history?  GAD requires a hierarchy of rule-outs such as panic attack, social phobia and obsessive-compulsive disorder (“OCD”).  CD requires rule-outs such as major depressive episode, manic episode or mixed episode; and also that symptoms are not better accounted for by more differentiated Axis I pathologies such as schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder or psychotic disorder NOS.

(f) Also discern specifics of impairment in social and occupational functioning and obtain a more detailed description of Px subjectively-experienced distress.

3. What information would be useful in order to determine the level of severity of this woman’s presenting problem?

ANSWER: The first and primary concern with Px is she “sometimes feels there is no point in going on.”  This proto-suicidal ideation must be assessed immediately by clarifying the specificity of her intention, if she has devised an operational plan and if she has the means to implement it.  This information should be obtained at intake interview and if indicated Px should be referred for suicide-prevention measures ASAP.

The second concern is the texture and quality of Px lived experience.  GAD and CD (as well as most other DSM diagnoses) have a “subjective” component that can be evaluated only by exploring the Px phenomenological world.  Examples: GAD requires “excessive” anxiety and worry; CD requires sensitivity and specificity to distinguish symptoms and arrive at a clinically-accurate differential diagnosis.  Many of Px complaints have this personal affective dimension, e.g. she “feels overwhelmed.”  What exactly does this mean?

The third concern is the precise extent of her social and occupational dysfunction.  Px reports her work environment is “chaotic” and she can’t finish her work.  She has “withdrawn” from family and friends.  What does this mean operationally?  A baseline level of functioning should be established and Px experience then should be probed carefully to tease out the empirical meaning of these vaguely-reported symptoms.  Only then could their severity be correctly assessed.

4. Identify three treatment goals for this woman.

ANSWER: a. To deter Px from trying to kill herself or further refining her nascent proto-suicidal ideations.

b. To reduce Px somatic complaints such as insomnia, fatigue and irritability.

c. To restore a sense of balance to Px life by (i) promoting a realistic attitude towards job demands; (ii) developing coping skills to deal with adversity; and (iii) devising strategies to enable more facile personal and social interactions with family and friends.

5. What are appropriate interventions to address the treatment goals?

ANSWER: a. Suicidal ideations: immediately escalate Px case profile, consult with supervisor and refer to specialized suicide prevention center.

b. Somatic complaints: refer to a medical doctor for a physical examination to rule out possible medical causes, especially for insomnia, which could have a non-psychological cause.  Also refer to a psychiatrist to prescribe a mild anti-anxiety medication, which should assist Px to focus without distraction on her cognitive and behavioral issues.

c. Accept the reality of Px symptoms as reported and discern if Px should find other less-stressful employment.

d. If not, introduce a classical conditioning model to systematically desensitize Px to the stressful and worrisome aspects of her workplace environment using progressive relaxation techniques.

e. Also consider CBT to challenge Px beliefs and reasoning process and why she “feels overwhelmed” by what may be ordinary life stressors.  Px may be catastrophizing the dynamics and exigencies of a modern, fast-paced work environment (assuming c. supra is inapplicable).

f. Also embark on a program of psychoeducation to inform Px about her symptoms and sensitize her to prevention and coping skills.

6. Would this woman benefit from a medication evaluation and a trial of psychotropic medications?

ANSWER: Yes.  As previously reported a course of mild anxiolytics or mood stabilizers is appropriate.  Individuals presenting as this Px frequently are unable to deal with psychiatric symptoms until their neurochemistry has been properly regulated.  Among other positive effects this will stabilize Px mood, eliminate ruminative symptoms characteristic of mild depression and better enable Px to focus on the important cognitive and behavioral tasks confronting her.  It also is important for Px to have an overall physical examination to rule out any contributory medical conditions.

After eight weeks of treatment this woman cancels several sessions in a row.  When she resumes treatment she informs you she just left an inpatient detoxification program for abuse of alcohol and prescription sleeping pills.  She indicates that since being discharged she has felt even more depressed, hopeless and helpless.  She adds that prior to detoxification she used alcohol excessively for “a few years” to cope with stress but that she never had attended a substance abuse program (before her recent detoxification).

7. What information would be desirable in order to acquire better understanding of her substance abuse problems?

ANSWER: Px is suffering from alcohol dependence, DSM-IV-TR §303.90 and sedative dependence, DSM-IV-TR §304.10.  In order to evaluate the nature, scope and extent of these issues, assess: (a) Was the inpatient detoxification program successful, or has Px relapsed?  (b) What are the frequency, duration and onset of her substance abuse problem?  (c) Where did she get the sleeping pills?  If they were prescribed, obtain medical release and consult with the physician re: recommended dosage, number of refills and similar issues.  (d) What were Px prior social/environmental stressors that precipitated earlier substance abuse?  (e) Why does Px now feel “even more depressed, hopeless and helpless”?  Is this a reaction to detoxification or does Px have genuine psychological difficulty reacclimating to a world where substance abuse is not a viable option for coping with personal/occupational life stressors?  (f) An important component of (d) and (e) is to arrive at a precise, operationalized definition of Px symptoms, subjective experience and behavior.

8. In what ways does the information presented above change relevant diagnostic considerations?

ANSWER: The primary way in which it changes the initial diagnostic information (see Answer # 1) is that it complicates the issue by introducing new complex neurochemical variables, i.e. substances of abuse.  Px symptoms may not be due to subtler or refined cognitive/behavioral issues but rather due to gross biochemical malfunction caused by substance abuse.  Substance abuse is a major contributor to many DSM diagnoses including GAD and CD.  These cannot be addressed proactively until substance abuse has been resolved.  At the very least substance abuse is a confounding variable making it more difficult to define treatment goals and establish a therapeutic treatment regimen.

9. What new treatment goals emerge?

ANSWER: To detoxify Px from substance of abuse prior to/contemporaneous with working on more complex psychological/behavioral issues.  Px substance abuse issue is an obstacle preventing further meaningful progress towards any of the other therapeutic objectives/treatment goals previously outlined.

10. How should these goals be addressed?

ANSWER: (a) Assess and evaluate Px previous inpatient treatment.  Was it successful or has Px relapsed; or does Px still crave the substance of abuse?  (b) Speak with Px MD to insure no more sleeping pills are prescribed; and consider an anti-alcohol medication such as anabuse.  (c) Although its efficacy is mixed refer Px to group therapy such as AA.  (d) Consider a program of classical aversive conditioning to counteract Px substance dependence, possibly by pairing Px maladaptive habit with something unpleasant to reassociate the experience of substance dependency with some other cognition in Px frame of reference.

11. What are other professionals/treatment settings to whom you may need to refer her on an adjunctive basis in order to have a comprehensive treatment plan?

ANSWER: Px would benefit from (a) an overall medical examination/physical to rule out possible physiological causes for her distress.  (b) A psychiatric evaluation with a view towards assessing suitability of a mild anxiolytics or mood stabilizer.  (c) Group therapy, particularly to address issues of substance abuse.  (d) Px also might benefit from a psychoeducation program e.g. at a community college to identify potential stressors in advance of their occurrence thus enabling her to take suitable prophylactic measures.