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Listing the key issues through priority, rationale, and documenting possible treatment options will help limit misdiagnosis. Prioritizing the issues will help a counselor to focus on the most accurate diagnosis while presenting the most probable treatment outcomes.
- History of Depression
- Smoking despite medical diagnosis of Congested Heart Failure
- She is non-compliant with taking her prescribed medications
- She has become manic and forgetful
- She has shown erratic behavior including excessive spending
- She holds grandiose ideas about her self-worth and intelligence
- Challenges with maintaining stable relationships and employment
Roberta is a 53-year old female who is experiencing several challenges. The rationale for the order was based on the severity of the critical challenges. Of all the things she is battling with the most important thing to address is to maintain Roberta’s safety and functioning. Depression is one of the main issues the client is facing. An assessment of her family history will be completed. This will help to establish the main causes of her depression and to assist with understanding issues she is facing in her life. This will be addressed first because it has impacted her life in a negative way.
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The second key issue will need to be addressed is Roberta’s medical component. Her noncompliance with medication and smoking with her illness may lead to increased cardiovascular complications. Additionally, an inquiry whether the client abuses any alcohol or drugs. That will assist with understanding issues she is facing in her life also to provide the right medication together with good guidance and counseling for her (De Hert et al., 2011).
Most important features and why?
The first three issues are the most important because safety is of utmost importance. Even though client has not expressed a plan, ideation or intent, one must consider that this client has been receiving treatment for a long time with several admissions. It would be beneficial to evaluate this deeply. Then having the client to take her medication and understanding the importance of consistency in medication treatment is important as well.
Outcome of Treatment
First, alleviate manic mood and return Roberta to a level of effective functioning. Then, return her to usual activities, good judgement, stable mood, more realistic expectations, and goal-oriented behavior. The client needs to be stabilized and a medication management schedule needs to be put in place that will contribute to the wellbeing of the client to maintain her functioning in the community. A medical plan for her to take care of her medical condition and program that will assist client in reducing or to stop smoking should be implemented. Roberta will learn how to find and maintain a job. Also, she will reestablish communication with her daughter.
Client’s Key Issues List
The client might express that she prefers a different order of priority of key issues. This is because she may be confused as she is undergoing a great deal of stress in her life. She may provide the following list:
- I want to work on communication with my daughter.
- I want to have a good job.
- I want to have a good relationship.
- I want to work on my mental health.
- I want to work also in my physical health
- Finally, I would like to stop smoking.
This counselor will try to obtain more information about her abuse history and her family members’ history. Also, to inquire the clients sleeping habits as depressive disorders often disrupt sleeping habits which may result in being unable to sleep or staying asleep. A spiritual assessment of the client will be very beneficial.
Based on the shared and documented assessment information my clinical diagnosis would be that Roberta is suffering from Bipolar I disorder (F31.81). Individuals with this type of Bipolar also may lose interest in activities they previously enjoyed doing such as their jobs and also have thoughts of suicide (Cuijpers, Hofmann & Anderson, 2010).
Even though the case study does not go into details about a manic episode it does explain that Roberta has become manic which is criteria A. Criteria B. First, she meets criteria in inflated self-esteem or grandiosity. Second, in increase in nongoal-directed activity for instance in not taking care of her medical condition. Finally, Excessive involvement in activities that have a potential for painful consequences like excessive spending. Criteria C the mood disturbance is sufficiently severe to cause market impairment in social or occupational functioning like her not being able to maintain jobs. Criteria D the episode is not attributable to the physiological effects of a substance abuse, a medication or another medical condition.
In review all differential diagnosis listed in the DSM-5 and there is no other co-occurring disorder that applies to Roberta at this time.Roberta has been hospitalized several times in the past for depression, but in this case study there is not enough evidence to support a major depressive disorder. Neither do Roberta’s symptoms apply to a Bipolar II disorder, generalized anxiety disorder, panic disorder, posttraumatic stress disorder, substance/medication induced bipolar disorder, attention-deficit/hyperactivity disorder, personality disorder or other.
The differential diagnoses of Paranoid Personality disorder are:
• Paranoid traits associated with physical handicaps
• Anxiety disorder due to another medical condition
• delusional disorder
• major depressive disorder
• obsessive-compulsive disorder
• alcohol and substance-related disorders
• schizoid personality disorder
• schizotypal personality disorder
• narcissistic personality disorder
• avoidant personality disorder
• borderline personality disorder
The essential diagnostic features of this disorder are present and more consistent than the features of other closely related comorbid disorders such as schizophrenia, bipolar or depressive disorder with psychotic features or another psychotic disorder (American Psychiatric Association, 2013). The key feature for the diagnoses eliminating the other disorders had to do with the level and history of suspiciousness followed by continued nurture and elevation of distrust as is the nature and defined features of the disorder. This diagnostic impression and finding are based on shared information from the client and diagnostic and statistical criteria as outlined, defined, and featured per the DSM-5.
Treatment options will vary according to the patient and the illness. The patient will need to participate in any treatment plans the counselor and client form together. Allowing the client to participate in the discussion and help choose from the approved methods could help build a strong counselor patient alliance.
- Group counseling,
- Medications (SSRI’s, minor tranquilizers, anxiolytics, benzodiazepines, and antidepressants).
- Relaxation techniques, and
- Cognitive behavioral therapy.
- Cognitive Behavioral Therapy (CBT) would be the best way to treat Mr. Doyle because of his faulty beliefs.
- Mr. Boyle counseling sessions will be a minimum of one time a week since psychotherapy has proven to provide positive changes even if in small amounts. (Kring et al., 2016, pp. 474-475).
- Specifically assessing his obsessive-compulsive personality disorder, treatment would include digging into Mr. Boyle’s childhood to find out where the need for perfection and compulsive nature began. (Kring et al., 2016, p. 475)
- CBT will be helpful in assisting Mr. Boyle to “become more aware of his negative beliefs and then to challenge maladaptive cognitions”. (Kring et al., 2016, p. 475)
- Helping Mr. Boyle understand that his obsessive-compulsive personality disorder are just thoughts. (Kring et al., 2016, p. 475)
- When dealing with Mr. Boyle’s paranoid personality disorder, it is important that the correct treatment is chosen so that it will be effective. The primary approach to treatment of people with paranoid personality disorder is psychotherapy (Haycock, 2003). It is recommended that Mr. Boyle seeks therapy for his disorder. Therapy treatments can range from behavior therapy, which is problem solving and education to traditional psychoanalytic treatment (Bateman, 2015). This may be difficult for him because people with paranoid personality disorder often do not readily offer enough trust to counselors for it to be effective (Haycock, 2003). Therefore, the therapist must make sure they do not show any hostility on their part to cause Mr. Boyle to should more hostility. Transparency is important with the client – counselor relationship (Haycock, 2003). The first goal should be to help Mr. Boyle learn to analyze his problems in dealing with other people (Haycock, 2003). Over time trust will be gained by Mr. Boyle. Once this happens the therapy will become more effective because he will be able to listen and trust what the therapist is saying.
- Also, a part of that therapy Mr. Boyle receives should be marriage counseling. His marriage has taken a blow with the way he has been acting and his wife has thought about leaving him. Marriage counseling is a strong suggestion to help them rebuild what was destroyed.
- Family therapy is suggested so that Mr. Boyle’s wife and children can become educated on Mr. Boyle’s diagnosis and his family can also attest if Mr. Boyle is improving after treatment begins. “Psychoeducation emphasizing the biological nature of psychosis, the need for medication, risk factors, and importance of communication” (Jongsma, Jr, Peterson, & Bruce, 2014, p. 347) is important so that the family can be aware and involved.
- Another form of treatment from Mr. Boyle can be medication. Although at this time it is not recommended medication can be used to because behavioral traits related to personality disorders might be associated with neurochemical abnormalities (Bateman, 2015). Clinicians have suggested that low doses of neuroleptics should be used however, medications are not normally part of long-term treatment for paranoid personality disorder (Haycock, 2003). Medication can be used in addition to therapy. However, it is not recommended for Mr. Boyle at this time because some medication like antidepressants can actually make his symptoms worse (Haycock, 2003).
Discussing the options for treatment with Donald will allow him to be active and participate in his therapy plan of action. This will allow Mr. Boyle to feel more in control of the treatment itself instead of allowing paranoia or distrust interfering with the outcomes of therapy.
Considering the biopsychosociospiritual aspects of this case, Mr. Boyle seems to be experiencing many suspicions and distrust. Therapy will be used to help with his mistrust and suspicions of others. Group therapy with his family and marriage counseling with his wife will help with the problems he has socially. As for the spiritual part, prayer should become a major part of Mr. Boyle’s life. It seems as though he has some anxiety and lacks peace. The bible says, “do not let your heart be troubled”. It is important that Mr. Boyle prays for peace and understanding.
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