INSTRUCTIONS: Read the case study information provided below. Based on the information provided here, decide what the diagnosis for this individual is and then list it in the appropriate formats of DSM-IV and 5. Below each axis, include a listing of the criteria that you are noting from the case that you are using to support your diagnosis (unless you selected None for any of the diagnostic areas). For the DSM-IV section, if you believe that any of the axes do not have anything to list, then state None (rather than N/A or rather than leaving it blank – think of it as a legal document in which you would not leave anything blank).
NOTE: Considering yourself in the role of a therapist (not a MD). So, if you list any medical issues, you must stick with the language of the case as it is described here. (For example, if you see a listing of information that makes you think the person might have diabetes, you must list the information, not diabetes – as you are not a medical doctor and cannot make that particular diagnosis.)
A 27-year-old married electrician complains of dizziness, sweating palms, heart palpitations, and ringing of the ears of more than 18 monthsâ€™ duration. He has also experienced dry mouth and throat, periods of extreme muscle tension, and a constant â€œedgyâ€ and watchful feeling that has often interfered with his ability to concentrate. These feelings have been present most of the time over the previous 2 years; they have not been limited to discrete periods. Although these symptoms sometimes make him feel â€œdiscouraged,â€ he denies feeling depressed and continues to enjoy activities with his family.
Because of these symptoms, the patient had seen a family doctor, a neurologist, a chiropractor, and an ear-nose-throat specialist. He had been placed on a nutritious diet including many small meals per day, received physical therapy for a pinched nerve, and was told that he might have â€œan inner ear problem.â€
He also has many worries. He constantly worries about the health of his parents. His father, in fact, had a myocardial infarction (heart attack) 2 years previously, but is now feeling well. He also worries about whether he is â€œa good father,â€ whether his wife will ever leave him (there is no indication that she is unhappy with the marriage), and whether co-workers at his job like him. Although he recognizes that his worries are often unfounded (have no basis in truth), he canâ€™t stop worrying.
For the past 2 years, he has had few social contacts because of his nervous symptoms. Although he has sometimes had to leave work when the symptoms became intolerable, he continues to work for the same company he joined for his apprenticeship following high-school graduation. He tends to hide his symptoms from his wife and children, to whom he wants to appear â€œperfect,â€ and reports few problems with them as a result of his nervousness. â€¨
For the case study described below, create a multi-axial diagnosis. List what you would diagnose for each of the 5 axes & briefly explain (with examples) your reasoning for each selection you make:
AXIS I: ______________________
If you listed anything on Axis I, explain your reason for this specific choice by listing and discussing the criteria for the disorder you selected as well as the symptoms or details from the case here that you felt exemplified this criteria and disorder.
AXIS II: ______________________
If you listed anything on Axis II, explain your reason for this specific choice by listing and discussing the criteria for the disorder you selected as well as the symptoms or details from the case here that you felt exemplified this criteria and disorder.
AXIS III: ______________________
If you listed anything on Axis III, explain your reason for this specific choice by listing the details from the case that you believe are clear medical issues (remember to not “diagnose” medical issues – stick to the details within the case only).
AXIS IV: ______________________
Explain your reason for this specific choice (Note: Think of axis IV as within the past 6-12 months):
AXIS V: ___________________
Explain your reason for this specific choice (briefly describe why you selected the particular GAF score that you did, by discussing the indicators of severity – or lack of severity).
NOW, also record your diagnosis for this case in the format of a DSM-5 diagnosis (there is an example of DSM-IV and DSM-5 diagnosis in the powerpoint from the class section on Classification & Diagnosis).