DSM-5 Diagnosis and Ethics in Psychiatric Nursing Practice

Client Presentation and Case Background

The client is a 36-year-old male of Hispanic origin who came to the United States as a teenager and currently resides with his mother in a mid-income neighborhood.

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

History of Current Illness: The client has no history of traumatic childhood experiences or abuse. He does, however, have a history of major depressive disorder, for which he previously received treatment. There is no history of psychiatric illness in the client's family, and previous medical workup indicates that his depression has no organic basis. His depression is attributable to the bullying and discrimination he experienced in high school due to his immigrant status. An EKG performed today is normal and his BMI is within normal range. From the mental status examination, he appears alert and oriented, with judgment and insight intact, and a broad affect throughout the interview. He denies experiencing paranoid thought processes, hallucinations, or suicidal ideation.

Allergies: NKDA

Psychiatric History: Major depressive disorder

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

Social History: The client lost his father at a young age and has been living with his mother since. He shares a strong relationship with her and reports that she has always been present to help him confront his fears and adequately manage his emotions.

Case Formulation: Since high school, the client has been a victim of discrimination based on 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, stable employment has been difficult to obtain. Aged 36 and still living with his mother, the client feels stagnated, worthless, and sad.

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 depressed mood or loss of pleasure/interest:

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

DSM-5 Criteria for Major Depressive Disorder

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 every day

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

vi) Loss of energy or fatigue every day

vii) Feelings of excessive guilt or worthlessness occurring nearly every day

viii) Indecisiveness and diminished ability to concentrate nearly every day

Differential Diagnosis: Bipolar II Disorder

The symptoms must cause clinically significant impairment in occupational and social functioning, and must not be attributable to the use of substances or other medication (APA, 2013).

The DSM-5 criteria for bipolar II disorder (Code 296.89 [F31.81]) require the patient to have experienced at least one hypomanic episode and at least one major depressive episode (APA, 2013). For a hypomanic episode, the patient must demonstrate a period of persistently irritable, expansive, or elevated mood and persistently or abnormally increased energy or activity lasting four consecutive days, present all day or most of the day. In addition, during the period of mood disturbance, the patient must experience at least three of the following symptoms:

i) Inflated grandiosity or self-esteem

ii) Insomnia and decreased need for sleep

iii) Pressure to keep talking or to be more talkative than usual

iv) Distractibility as observed or reported

v) Psychomotor agitation

vi) Excessive involvement in activities with high potential for painful consequences, such as sexual indiscretion or unrestrained buying sprees

The mood disturbance need not be severe enough to cause marked impairment in occupational or social functioning, and the episodes must not be attributed to another medical condition or to the physiological effects of substance use (APA, 2013). For the major depressive episode component, the patient must demonstrate the symptoms of major depressive disorder described above (APA, 2013). The hypomanic and major depressive episodes must not be due to another medical condition, and must cause clinically significant impairment in occupational and social functioning (APA, 2013).