Reference no: EM133407371

Case: Eric Reynolds was a 56-year-old married Vietnam War veteran who referred himself to the Veterans Affairs outpatient mental health clinic for a chief complaint of having "a short fuse" and being "easily triggered."

Mr. Reynolds's symptoms began more than three decades earlier, soon after he left the combat zone in Vietnam, where he served as a field radio operator. He had never sought help for his symptoms, apparently because of his strong need to be independent. An early retirement led to greater recognition of symptoms and a stronger desire to seek help.

Mr. Reynolds's symptoms included uncontrollable rage when unexpectedly startled; recurrent intrusive thoughts and memories of death-related experiences; weekly vivid nightmares of combat operations that led to nighttime fright and insomnia; isolation, vigilance, and anxiety; loss of interest in hobbies that involve people; and excessive distractibility.

Although all of these symptoms were very distressing, Mr. Reynolds was most worried about his uncontrollable aggression. Examples of his "hair-trigger temper" included confrontations with drivers who cut him off, curses directed at strangers who stood too close in checkout lines, and shifts into "attack mode" when coworkers inadvertently surprised him. Most recently, as he was drifting off to sleep on the physician's examination table a nurse touched his foot and he leapt up, cursing and threatening. His involuntary reaction scared the nurse as well as the patient.

Mr. Reynolds said that no words, thoughts, or images intervened between the unexpected stimulation and his aggression. These moments reminded him of the time in the military when he was on guard at the front gate and, wile he was dozing, an incoming mortar round stunned him into action. Although he kept a handgun in the console of this car for self-protection, Mr. Reynolds had no intention of harming others. He was always remorseful after a threatening incident and had long been worried that he might inadvertently hurt someone.

Mr. Reynolds was raised in a loving family that struggled financially as midwestern farmers. At age 20, Mr. Reynolds was drafted into the U.S. Army and deployed to Vietnam. He described himself as having been upbeat and happy prior to his army induction. He said he enjoyed basic training and his first few weeks in Vietnam, until one of his comrades got killed. At that point, all he cared about was getting his best friend and himself home alive, even if it meant killing others. His personality changed, he said, from that of a happy-go-lucky farm boy to a terrified, overprotective soldier.

Upon returning to civilian life, he managed to get a college degree and a graduate business degree, but he chose to work as a self-employed plumber because of his need to stay isolated in his work. He had no legal history. He had been married to his wife for 25 years and was the father of two college-age students. In his retirement, he looked forward to woodworking, reading, and getting some "peace and quiet."

Mr. Reynolds had tried marijuana during his early adulthood and used excessive alcohol intermittently; however, he had not consumed excessive alcohol or used marijuana during the past decade.

On examination, Mr. Reynolds was a well-groomed African American man who appeared anxious and somewhat guarded. He was coherent and articulate. His speech was at a normal rate, but the pace accelerated when he discussed disturbing content. He denied depression but was anxious. His affect was somewhat constricted but appropriate to content. His thought process was coherent and linear. He denied all suicidal and homicidal ideation. He had no psychotic symptoms, delusions, or hallucinations. He had very good insight. He was well oriented and seemed to have above average intelligence.

Question 1. Based on the information available, what is the most appropriate DSM-5 diagnosis for Mr. Reynolds?

Question 2. How long must symptoms be present in order to meet criteria for the disorder?

Question 3. How long has Mr. Reynolds been experiencing symptoms?

Question 4. Does the disturbance caused by Mr. Reynolds' symptoms result in clinically significant distress or impairment in social, occupational, or other important areas of functioning?

Question 5. Name another diagnosis you considered, but ultimately did not select, for Mr. Reynolds:

Question 6. Describe one reason that you went with the diagnosis you did, instead of the other diagnosis you considered:

Question 7. Based on what you know about the disorder you selected as well as the information presented about Mr. Reynolds, which aspects of the multipath model do you think have contributed most to the development of Mr. Reynolds' disorder?

Question 8. Rank the factors (Social, Psychological, Biological, Sociocultural) according to the amount of evidence, from most to least (1 = most evidence; 4 = least evidence).

Question 9. Explain in a few (2-5) sentences why you ordered the factors in this way