AnnaTruttier_u05a1_DiagnosticSkillApplication

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1 Diagnostic Skill Application Anna Truttier School of Counseling; Capella University COUN5107 Principles of Psychopathology Dr. Thomas February 12, 2023

2 Unit 5 Diagnostic Skill Application Throughout this paper, two cases will be presented; Jenny and Marisol. Each of these women is experiencing debilitating symptoms that interfere with their daily lives. Jenny parted ways with her boyfriend and moved back in with her mother. She is presenting issues of having low energy, loss of interest in things that she once loved, lack of motivation, feelings of hopelessness, and like there is a dark cloud hanging over her, and she feels like no matter what she does, it is never enough. Marisol’s presenting issue is panic, especially when in large crowds. It feels as if everyone is judging her. She fears what people think of her, gets anxious and excited, and can not seem to think straight. She passed up on a promotion because she feared what her colleagues would say. To begin treatment for Jenny and Marisol, a few things must occur. Identifying both Jenny and Marisols presenting concerns, including biological and neurological impact, examining methods used for their differential diagnoses, identifying assessments that correspond best with them, relating to the DSM and ICD codes to support their findings, and a medical referral if necessary. Presenting Concerns: Case of Jenny Jenny is experiencing many abnormalities that would qualify as dysfunction. According to Nolen-Hoeksema (2019), the four D’s explain a person’s abnormalities; dysfunction, distress, deviance, and dangerousness. This means that when a person’s thoughts and feelings begin to interfere with their daily life and are debilitating from completing mundane tasks, the term dysfunction begins to arise. In Jenny’s case, she presents many symptoms that would concern any professional counselor. Throughout Jenny’s first session, she used the terms “what is the point,” “why even bother,” and “hopelessness.” These three words might seem minor, but they provide much

3 insight into a person's mental health. Jenny tries many things to feel better about herself, but nothing seems to work for her. She once enjoyed being outside and enjoying the sunshine, but that even feels useless. Jenny recently amicably parted ways with her partner and moved back into her mother’s home. She sleeps a lot, thinks that there is a dark cloud hanging over her head, and everything goes wrong no matter what she does; she has no energy, lacks the motivation to interact with friends, and tries to eat but lacks an appetite. As mentioned above, dysfunction is identified when the person’s symptoms impede their life. Jenny’s symptoms are doing just that. Many contributing factors could help understand Jenny’s symptoms. Two leading proponents could be Biological and Neurological causes. Biologically it is known that those with a family history of depression puts them at a higher predisposition. According to Nolen-Hoeksema (2019), family history studies find that the first- degree relatives of people with a major depressive disorder are two to three times more likely to have depression than the first-degree relatives of people without the condition. However, we do not have enough information to ultimately say that Jenny’s first-degree family has a history of mood disorders. Although it is essential to keep this in mind as the therapeutic process continues. With this knowledge, it is also critical to look at our brain and its functions. It is safe to say that multiple genetic abnormalities play a role in a person’s depression. Several studies suggest that abnormalities in the serotonin transporter gene could lead to dysfunction in the regulation of serotonin, which contributes to a person’s mood stability (Nolen- Hoeksema, 2019). Jenny’s presenting symptoms could explain her feelings of “hopelessness” and the fact that she feels like “always a dark cloud” is hanging over her head. Mood disorders are complex and need appropriate tools to help proceed. Tools like the DSM-5 and the Differential diagnosis by the Trees are used to help make concrete decisions on a person’s diagnosis.

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4 Differential Diagnosis: Case of Jenny Using the Differential diagnosis by the Trees helps to identify treatment plans and the foundation of any clinical process. For Jenny, it is essential to rule out and understand leading candidates, eliminate others, and not jump to any hasty diagnoses. According to recent research, clinicians conclude in the first five minutes of interacting with a client. Then they spend the remainder trying to justify their diagnoses (Differential Diagnosis by the Trees, 2013). That is why using the differential diagnosis by the Trees is essential. To provide accurate and appropriate care for her needs, examine her presenting symptoms and work backward. The appropriate decision tree in Jenny’s case is using the decision tree for depressed mood. This tree was chosen not on a whim but with thought, Jenny’s symptoms and well-being in mind. Understand that her symptoms do show signs of being depressed, but it is also essential to know and recognize that these symptoms could be a result of a period in Jenny’s life that she is struggling to regulate. Using the differential diagnosis tree will flow through the chart to understand it more clearly. She is starting with the symptoms assessing that Jenny’s presenting issues do not stem from any form of medications or medical conditions. Confirming that her symptoms are not contingent on these, continuing to flow through the chart next, we observe that for at least two weeks, Jenny has experienced a depressed mood and diminished interest in weight loss and gain. Jenny also does not meet the requirements for manic episodes. So progressing and flowing through the chart, the following symptom to observe on the tree is a depressed mood, more days than not, for at least two years with associated symptoms. Moving along the chart, it is not conclusive that these symptoms have been going on for an extended time. Jenny states it has been going on for “awhile” If these symptoms have been going on for more than two weeks of depressed mood or diminished interest plus symptoms

5 associated with loss of appetite, changes in sleep behavior, fatigue, etc. (Differential Diagnosis by the Trees, 2013) then the flow chart would bring us to “Major Depressive Disorder.” Different checklists and assessments of Jenny will allow for a more conclusive understanding. Symptom Checklists: Case of Jenny The Beck Depression Inventory-Second Edition is a twenty-one self-report item constructed to quantify a person’s depressive symptoms. While this is a widely used assessment, it is essential to denounce that this checklist is primarily used as a baseline or a screening instrument. According to Erford et al. (2016), the BDI-II is a depression screening instrument and should not be used alone to diagnose depression. The reason for choosing BDI-II is that it has significant signs of validity across the board for those that show symptoms of depression. Multiple studies have found an 80% accuracy rate in assisting in diagnosis and treatment (Erford et al., 2016). As stated above, BDI-II is a twenty-one self-reported item assessment. Jenny and her counselor can do this together. This scale is set on a four-point scale from 0(not at all) to 3(severely). This assessment will help further focus on issues that Jenny has presented, such as loss of interest, “hopelessness,” “what is the point,” and “why even bother,” which can be interpreted as symptoms of depression. Furthermore, administering this assessment to Jenny will help her counselor with a proper treatment plan, give Jenny a baseline, and see if further or additional interventions are necessary. Systemic Assessments: Case of Jenny A person’s family system plays an essential role in an individual’s life. The family is a framework of how individuals see the world. A person can learn how to trust others, how to form bonds and friendships, how to socialize, how to cope, how to build emotional skills, etc. If these foundational blocks are damaged, it can emotionally damage the family system. Family

6 counseling works to direct emotionality back into the family (Butler & Butler, 2016). It would be beneficial if Jenny and her mom were present together throughout treatment. Family support throughout treatment can also positively affect Jenny and her mother. During Jenny’s first session, she voiced that her mother thought she was just lazy, giving up, and needed to snap out of it. Having Jenny’s mom there can help her understand that her words affect the family’s functioning. Jenny does want to “snap out of it,” but it is not that easy; it takes time, flexibility, cohesion, and understanding. A reliable family systems assessment that could be administered is The Family Adaptability and Cohesion Scale IV(FACES-IV). This scale is used for families to learn and understand how they work together as a family unit. The Family Adaptability and Cohesion Scale IV were developed to capture how well- adjusted and unstable levels of cohesion and flexibility are in families (Priest et al., 2020). FACES-IV is a self-administered assessment that contains 62 items, and it has eight levels. It assesses adaptability, cohesion, and satisfaction (Everri et al., 2016). It would be imperative for Jenny and her mom to take these assessments independently. Once these have been administered and results are in from both Jenny and her mom, their counselor can walk them through the results and understand their family functioning. The results from FACES-IV will better serve Jenny and her treatment, better serve their family system and help them learn more adaptive implementation. DSM and ICD Diagnosis: Case of Jenny As mentioned above, the Differential Diagnosis by the Trees brought us to Major Depressive Disorder. With further assessments with Becks’ Depression Inventory-II and the FACES-IV. Major Depressive Disorder presents itself as the leading diagnosis for Jenny. Although we do not have a definitive time frame for her symptoms to begin, consulting with the DSM-5, Jenny fits the criteria for F33.1, Major Depressive Disorder. Jenny meets the five or

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7 more symptom criteria according to the DSM-5. She states that she has depressed moods most of the day, diminished interest in things that once brought her joy, decreased appetite, hypersomnia, fatigue and energy loss, and impairment in social and occupational functioning (American Psychiatric Association, 2022). With a diagnosis of Major Depressive Disorder, it is essential to also look at other conditions that are important and deserves clinical attention. Although V and Z codes are not diagnoses in the DSM-5, they play an essential role in the therapeutic process and goals of a client like Jenny. The V and Z codes to be cognizant of are; Parent-Child Relational Problems V61.29(Z62.820) and Problems of Adjustment to Life-Cycle Transitions (Z60.0) (American Psychiatric Association, 2022). Each of these considerations affects and plays a role in Jenny’s life. Jenny has had a problematic relationship with her mom throughout the years, and Jenny is currently transitioning from being in a relationship to moving back in with her mom. These considerations are significant in assuring Jenny gets the most out of her treatment. Medication Referral/Consultation: Case of Jenny An abundance of information was gained from assessments and talking with Jenny and her mother. They did not mention moving forward with medication or any referrals to mental health professionals that could prescribe Jenny any medications. Anti-depressants such as Selective Serotonin Reuptake Inhibitors are the most commonly used pharmacotherapy for treating depression and anxiety, with 12.7% of persons over age 12 in the U.S . (Hughes et al., 2021). In the beginning stages of treatment, any medication is not considered. Some medications have adverse side effects, some more manageable than others. SSRIs are not more effective in treating depression than the other available antidepressants, but they have fewer difficult-to-tolerate side effects (Nolen-Hoeksema, 2019). Jenny presents many symptoms and dysfunction, and adding potential side effects might do more harm than good for

8 Jenny at this stage in her treatment. According to Huges et al. (2021), given the possible harms and questionable efficacy of antidepressant use, an urgent need exists to develop alternatives that might shift trajectories for young people away from potentially unnecessary or harmful practices. Presenting Concerns: Case of Marisol Marisol’s presenting conditions are panic and anxiousness. During Marisol’s session, she explained that she gets panicked and anxious when going out with friends. She gets very excited and anxious and can not think straight. She feels as if everyone is staring at her and is afraid of what everyone thinks. Marisol was up for a vital promotion but passed on because she feared her colleagues' thoughts. She even explained that she could not make it out of her car before she made it into her session because she knew people would be in the lobby. These symptoms impede Mariel’s daily; like Jenny, these abnormalities need to be understood. A lot of Marisol’s presenting concerns are surrounded by social settings. These anxieties can be caused by a few things, such as biological or neurological basis. Although we do not have enough information about Marisol and her family history, according to Nolen-Hoeksema (2019), it is essential to understand that individuals like Marisol who present with these forms of anxiety also put an extraordinary amount of pressure on themselves during social settings stating “they should be like everyone else.” Twin studies suggest that these forms of anxiety have genetics not towards social settings per se but instead a more general tendency toward the anxiety of disorders. The area of the brain that controls these anxieties are the amygdala, hippocampus, and prefrontal cortex (Nolen-Hoeksema, 2019). The DSM-5 and Differential Diagnosis by the Trees will be implemented to understand these symptoms thoroughly. Differential Diagnosis: Case of Marisol The Differential Diagnosis by the Trees was used to facilitate Marisol’s understanding of her presenting symptoms. The Tree that will be used is the Decision Tree for Anxiety. We ruled

9 out that no medications, substances, or preexisting medical conditions lead to these symptoms. That said, navigating through the tree and looking at each branch ensures no haste is made. Starting with occurring in the context of an abrupt panic surge that reaches a peak within minutes (Differential Diagnosis by the Trees, 2022). This could be “yes,” but we do not know the severity of her panic and how fast she reaches her “peak.” Marisol also does not demonstrate unexpected panic attacks; this would be “no.” Moreover, the next branch of the decision tree is anxiety about being in places that might be hard to escape from in the event of a panic attack. This branch could also be a “yes”; again, with limited information, it does not seem as if her panic stems from the possibility of escape from being in social situations. It is more so that she is putting pressure on herself. Marisol also does not show signs of attachment disorder from parental figures. The next branch to consider is “anxiety or worry about social situations in which the person is exposed to the scrutiny of others without more generalized worried” (Differential Diagnosis by the Trees, 2022). This seems like a probable diagnosis for Marisol, leading us to Social Anxiety Disorder. Although this seems like a probable diagnosis, further information needs to be gathered. Symptom Checklists: Case of Marisol The next step is to fully understand and obtain more information on Marisol’s presenting symptoms using a reliable assessment. The assessment that will be used is Becks’ Anxiety Inventory. The Becks Anxiety Inventory is a self-report used to measure a person’s severity of anxiety in the population (Becks, 1988). This scale has a total of 21 questions that respondents rate how much he or she has been bothered by each symptom over the past week. Using a four- point scale ranging from 0 (not at all) to 3 (severely I could barely stand it) (Becks, 1988). Once the assessment is complete, the total score will be accumulated. This assessment allows for

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10 almost instant results for Marisol. It is an assessment that Marisol and her counselor can use to measure her anxiety weekly, which will allow for adjustments if necessary. Systemic Assessments: Case of Marisol Just like Jenny, a person’s family system plays a vital role. Family, as mentioned in the framework of how an individual sees the world, how to trust, build friendships, and bonds, cope, and build emotional skills. Family counseling works to direct emotionality back into the family (Butler & Butler, 2016). It seems as though Marisol and her family seem to have a positive foundation. Marisol explains that her older brother and parents have always provided support and practical help for her and her child. Although her parents are supportive, it would not hurt to have them attend a session while considering Marisol and her family's culture. They are administering an assessment to show their family’s strengths and provide feedback on how they can work together as a family unit to assist Marisol better. The assessment that can be used is The Family Adaptability and Cohesion Scale IV(FACES-IV). The Family Adaptability and Cohesion Scale IV were developed to capture how well-adjusted and unstable levels of cohesion and flexibility are in families (Priest et al., 2020). FACES-IV is a self-administered assessment that contains 62 items, and it has eight levels. It assesses adaptability, cohesion, and satisfaction (Everri et al., 2016). The results from the FACES-IV can provide important information and feedback to help navigate and understand Marisol and how they function together as a family. DSM and ICD Diagnosis: Case of Marisol With the information gathered from assessments, the differential diagnosis, and the information provided by Marisol, the best diagnosis per the DSM-5 would be Social Anxiety Disorder (F40.10). According to the DSM-5, the presenting symptoms of Social Anxiety are persistent fear or anxiety about specific social situations with fear of being judged, avoiding

11 social situations, enduring them with intense fear, and excessive anxiety out of proportion (American Psychiatric Association, 2022). While Marisol presents these symptoms per the DSM- 5, it is essential to consider the V and Z codes. The V and Z codes that need to be accounted for are Adult Anti-Social Behavior V.71.01 (Z72.811), Other problems related to employment V62.29 (Z56.9), and Unspecified Problems Related to Social Environment V62.9 (Z60.9). These V and Z codes and DSM diagnoses were formulated based on all the information provided. Her experiences with anxiety and panic being in large social settings, she avoids social situations so she will not be judged; she turned down a big promotion in her career because she feared what her colleagues thought. Medication Referral/Consultation: Case of Marisol An abundance of information was gained from assessments and talking with Marisol. Marisol did not mention any interest or desire for medications or any referrals. Anti-depressants such as Selective Serotonin Reuptake Inhibitors are the most commonly used pharmacotherapy for treating depression and anxiety, with 12.7% of persons over age 12 in the U.S . (Hughes et al., 2021). While these drugs show signs of efficacy, once the medication is stopped, do these symptoms return? According to Nolen-Hoeksema (2019), symptoms tend to reappear when individuals discontinue taking these medications. Starting with counseling and implementing appropriate therapies for Marisol would be positive. They are keeping in mind that if the time did come that Marisol wanted to explore the avenue of medication, Marisol and her counselor could take that step together. Conclusion Throughout this paper, two cases were presented to us, Jenny and Marisol. Each of these women is experiencing encumbering symptoms that interfere with their day-to-day. To help

12 understand Jenny and Marisol’s concerns, understand the impact of biological and neurological contributions. Along with examining the methods used for their differential diagnoses, identifying assessments that correspond best with them, relating to the DSM and ICD codes to support their findings, and a medical referral if necessary.

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13 References American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders, Text Revision Dsm-5-tr (5th ed.). Amer Psychiatric Pub Inc. Beck, A. T., Epstein, N., Brown, G., & Steer, R. (1988). Beck Anxiety Inventory. PsycTESTS . https://doi.org/10.1037/t02025-000 Differential Diagnosis by the Trees. (2013). DSM-5® Handbook of Differential Diagnosis . https://doi.org/10.1176/appi.books.9781585629992.mf02 Hughes, S., Rondeau, M., Scott, S., Sharp, J., Ivins, G., Lee, J., Taylor, I., & Brianna, B. (2021). A Holistic Self-learning Approach for Young Adult Depression and Anxiety Compared to Medication-Based Treatment-As-Usual. Community Mental Health Journal, 57 (2), 392- 402. https://doi.org/10.1007/s10597-020-00666-9 Erford, B. T., Johnson, E. R., & Bardoshi, G. (2016). Meta-Analysis of the English Version of the Beck Depression Inventory–Second Edition. Measurement and Evaluation in Counseling and Development , 49 (1), 3–33. https://doi.org/10.1177/0748175615596783 Everri, M., Mancini, T., & Fruggeri, L. (2016). The Role of Rigidity in Adaptive and Maladaptive Families Assessed by FACES IV: The Points of View of Adolescents. Journal of Child and Family Studies, 25 (10), 2987-2997. https://doi.org/10.1007/s10826-016-0460-3 Priest, J. B., Parker, E., Hiefner, A. R., Woods, S., & Roberson, P. N. E. (2020). The Development and Validation of the FACES‐IV‐SF. Journal of Marital and Family Therapy . https://doi.org/10.1111/jmft.12423 Nolen-Hoeksema, S. (2019). Abnormal Psychology (8th ed.). McGraw-Hill Higher Education (US). https://capella.vitalsource.com/books/9781260426151

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