Reference no: EM133681435
Assignment:
Practice open-ended questions to gain understanding. What are 3 different open-ended questions you could ask to help you determine the following?
In summary, Victor meets the criteria for Major Depressive Disorder, Recurrent, Moderate, based on the presence of multiple depressive episodes accompanied by significant distress and impairment in functioning.
Adjustment Disorder and other mood disorders have been ruled out or considered for further evaluation based on the clinical presentation and course of Victor's symptoms.
Abnormalities observed in the MSE checklist align with the diagnosis of major depressive disorder, providing additional support for the assessment.
Further evaluation and monitoring are recommended to refine the diagnosis and develop an appropriate treatment plan for Victor.
Explanation:
Diagnostic Justification for Victor N.
DSM-5 Diagnosis: Major Depressive Disorder, Recurrent, Moderate (F33.1)
Criteria Met/Observed Supporting the Diagnosis:
- Victor has experienced two or more major depressive episodes characterized by a depressed mood and loss of interest or pleasure in activities, lasting for at least two weeks.
- He exhibits significant weight loss and insomnia, which are associated features of depression.
- Victor reports feelings of worthlessness and excessive guilt, as well as diminished ability to think or concentrate.
- His symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Similar Diagnosis Ruled Out: Adjustment Disorder with Depressed Mood (F43.21) has been ruled out because Victor's symptoms persist beyond the expected duration of stressor-related reactions. Additionally, his symptoms are severe and impairing, exceeding the criteria for an adjustment disorder.
Rule Outs (R/O):
- Bipolar Disorder (F31.9) - Victor's history and current presentation do not indicate any manic or hypomanic episodes. Further assessment is needed to rule out bipolar disorder.
- Dysthymic Disorder (F34.1) - Although Victor's depressive symptoms have persisted for over two years, his current episode meets the criteria for major depressive disorder rather than dysthymic disorder. However, dysthymic disorder should be considered if his symptoms persist after the resolution of the current episode.
Abnormal/Concerning Items from MSE Checklist Relevant to the Diagnosis:
- Affect: Victor's affect is consistently sad and dysphoric, reflecting his depressed mood.
- Thought Content: He reports recurrent thoughts of worthlessness and guilt, indicative of depressive cognitions.
- Insight: Victor acknowledges his depressive symptoms and their impact on his life, demonstrating insight into his condition.
- Psychomotor: Victor displays psychomotor agitation, as evidenced by restlessness and fidgeting during the evaluation.
In summary, Victor meets the criteria for Major Depressive Disorder, Recurrent, Moderate, based on the presence of multiple depressive episodes accompanied by significant distress and impairment in functioning. Adjustment Disorder and other mood disorders have been ruled out or considered for further evaluation based on the clinical presentation and course of Victor's symptoms. Abnormalities observed in the MSE checklist align with the diagnosis of major depressive disorder, providing additional support for the assessment. Further evaluation and monitoring are recommended to refine the diagnosis and develop an appropriate treatment plan for Victor.