DIAGNOSIS, LEGAL AND ETHICAL ISSUES

Developing Diagnoses for Clients Receiving Psychotherapy

This weeks practicum involves making a diagnosis for a presenting client using the DSM-5 criteria and explaining the legal and ethical implications associated with counseling clients with psychiatric disorders.

The Presenting Client

The client is a thirty-six-year-old male of Hispanic origin who came into the US as a teenager and resides with his mother in a mid-income neighborhood.

The Chief Complaint

The client complains of endorsed feelings of depression, insomnia, feelings of worthlessness, loss of interest in routine activities, sudden unexplained weight loss, and inability to concentrate at work.

History of Current Illness

The client has no history of traumatic childhood experiences or abuse. He, however, has a history of major depressive disorder, for which he received treatment. There is no history of psychiatric illness in the clients family and previous medical work-up shows that his depression has no organic base. His depression is attributable to the bullying and discrimination he experienced in high school owing to his immigrant status. An EKG carried out today is normal and his BMI is within normal range. From the mental status exam, he appears alert and oriented, with judgment and insight intact, and a broad affect throughout the interview. He denies experiencing paranoid thought processes, hallucinations, and suicidal ideation.

Allergies: NKDA

Psychiatric history: major depressive disorder

Medications: Zoloft 25mg daily and Wellbutrin XR 150mg daily

Social history: client lost his dad at a young age and has been living with his mother since. He shares a strong relationship with his mother and reports that she has always been present to ensure that he confronts his fears and adequately manages his emotions.

Case Formulation: Since high school, the client has been a victim of discrimination for his immigrant status. He struggles to achieve success in a system that discriminates against racial minorities. Given the social disorganization and lack of formal institutions in most immigrant communities, a stable job has been difficult to come by. Aged 36 and still living with his mother, the client feels stagnated, worthless, and sad.

Differential Diagnosis

Major depressive disorder

The DSM-5 criteria for major depressive disorder require a client to display five or more of the following symptoms, one of which must be either loss of pleasure/interest or depressed mood:

i) Depressed mood most or all of the day, nearly everyday

ii) Markedly diminished pleasure or interest in all or almost all activities nearly all of the day or most of the day

iii) Significant weight loss without evidence of dieting or significant weight gain (such as increases of more than 5 percent in one month)

iv) Hypersomnia or insomnia nearly everyday

v) Psychomotor retardation or agitation nearly every day that are observable by others

vi) Loss...…instance, while it is paramount for the nurse to keep patient information confidential, there may be instances when disclosing the same may be part of a legal duty, such as if the spouse is at a risk of harm from the patients psychotic symptoms. In this case, the PMHNP has a duty to carefully consider relevant ethical codes and state law to determine whether to break confidentiality and warn third parties at risk of harm (Jain et al., 2017)

Another fundamental ethical issue surrounds the involvement of family members in the patients treatment (Wheeler, 2014). In most cases, a mental status examination alone may not inform a psychiatric diagnosis (Wheeler, 2014). PMHNPs will often face situations that require them to involve a clients relatives in the treatment plan to better understand the contextual factors influencing disease and to ensure adherence to medication. While such involvement may be crucial for enhancing the accuracy of diagnoses, the PMHNP has an ethical responsibility to determine the extent of the same without compromising the patients confidentiality rights (Wheeler, 2014).

The third ethical issue is involuntary treatment. Mental illness often compromises an individuals decision-making capacity and insight related to the need for treatment (Bellesheim et al., 2016). This necessitates the PMHNP to execute the principles of nonmaleficence and beneficence to treat patients, but balance the same with…