Play a role of being a therapist (plz help)

Question

`You are playing the role of a therapist. Based on the info given, diagnose patient 1 and patient 2 using DSM5 and explain why you chose that diagnosis.  Be sure that your diagnosis matches all of the symptoms presented in the case.)

1st Client: 29yr old defense attorney (male)

The client reported that he was in a car accident 3 years ago. The accident left him with severe back and neck pain that was treated initially with narcotics. He stated that he was able to go back to work as long as he was on the medication. Over time, he stated that he began taking more than his doctor prescribed because he felt the medication wasn’t working anymore. He reported that at first it was just one pill, then it was two, and from there it snowballed. He stated that he tried to stop on multiple occasions but said he felt awful, like he had the flu (diarrhea, vomiting, aches, and fever) and the cravings were unbearable. He stated that there was a time where he thought he would never be able to quit and would probably die from an overdose. The client stated that he frequently goes to emergency rooms complaining of severe back pain in order to get a prescription. His sister threatened to file a report with the bar association if he did not seek help. The client reported that the issues began about 2 years ago, but got worse recently. The client reported that his childhood was not the best. He stated his father was an alcoholic and would rough up his mother when he was drunk, but never abused him. The client reported that he has not done a very good job of taking care of himself. He stated that without his mother and sister he would probably be dead. The client’s main goal is get sober and stay that way. He stated he wants to start a life with his girlfriend and have children someday. He also fears landing in jail and so he wants to get sober before he does something he regrets.

2nd Client (9th grade boy)

The client’s parents report that he has shown a repeated pattern of defiance and disobedience both at school and home. This started around 10 yrs old but has gotten worse. The client does not believe his actions are out of the norm. He stated that everyone should stop complaining about him and that things could be worse. During the intake session the client repeatedly clicked a pen, even after his parents asked him to stop. When his mother removed the pen, he grabbed another off the desk, looked at his mother and clicked it. He was referred for counseling by the high school’s psychologist to help him avoid being suspended or expelled while in high school. The client’s grades have been slipping since 6th grade. He does not attribute his low grades to his own inaction but rather it is everyone else’s fault. He repeatedly blamed his teachers as well as his parents for his failing grades. In his childhood he grew up in a great environment with both parents present. The client is very argumentative and will slam doors, throw things, and shout when he is angry. The client’s parents stated that while they were gone, he placed dog feces in all of their shoes, keyed both cars, and emptied every bottle of dish, laundry, and body soap in the household into the center of their bed. When confronted, the client told his parents that they should have let him go on the trip and it was their fault he got an “F” in biology and algebra. The client reported that he doesn’t hate his parents. He just wishes they would get off his back and let him live his life. The client’s maternal grandfather struggled with schizophrenia and his father with depression.

No history reported of drug or alcohol problems, neurological illness, physical/emotional/sexual abuse in the family.

Answer 1

Hi Jerr,

For the first client, I would recommend looking at the diagnostic criteria for Opioid Use Disorder per the DSM-5:

A. A problematic pattern of opioid use leading to clinically significant impairment or distress,

as manifested by at least two of the following, occurring within a 12-month period:

1. Opioids are often taken in larger amounts or over a longer period than was intended.

2. There is a persistent desire or unsuccessful efforts to cut down or control opioid use.

3. A great deal of time is spent in activities necessary to obtain the opioid, use the opioid,

or recover from its effects.

4. Craving, or a strong desire or urge to use opioids.

5. Recurrent opioid use resulting in a failure to fulfill major role obligations at work,

school, or home.

6. Continued opioid use despite having persistent or recurrent social or interpersonal

problems caused or exacerbated by the effects of opioids.

7. Important social, occupational, or recreational activities are given up or reduced because

of opioid use.

8. Recurrent opioid use in situations in which it is physically hazardous.

9. Continued opioid use despite knowledge of having a persistent or recurrent physical

or psychological problem that is likely to have been caused or exacerbated by

the substance.

10. Tolerance, as defined by either of the following:

a. A need for markedly increased amounts of opioids to achieve intoxication or desired

effect.

b. A markedly diminished effect with continued use of the same amount of an opioid.

Note: This criterion is not considered to be met for those taking opioids solely under

appropriate medical supervision.

11. Withdrawal, as manifested by either of the following:

a. The characteristic opioid withdrawal syndrome

b. Opioids (or a closely related substance) are taken to relieve or avoid withdrawal

symptoms.

As you can see, client #1 meets criteria for a diagnosis of Opioid Use Disorder given the information provided regarding his increased tolerance, unsuccessful cessation of the substance due to severity of withdrawals, and his continued usage of opioids despite the interpersonal (i.e., conflict with his sister) and occupational (i.e., potentially having a complaint filed with the bar association) harm, etc. Further, given that he has been suffering from this disorder for the past two years, he meets the prerequisite bolded above regarding duration of symptomatology.

Finally, the DSM-5 states that with this diagnosis, the clinician is to indicate the level of severity per the following criteria:

Mild: Presence of 2 -3 symptoms.

Moderate: Presence of 4-5 symptoms.

Severe: Presence of 6 or more symptoms

Since I provided all of the symptoms above, I recommend you thoroughly reread the first case study, and highlight each of the diagnostic criteria he is known to exhibit. However, if you have difficulty with regard to the level of severity, please feel free to message me.

For the second client, I will provide the DSM-5 criteria for Oppositional Defiant Disorder, and encourage you to think out the process in a similar fashion as was demonstrated above.

A. A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting

at least 6 months as evidenced by at least four symptoms from any of the following categories,

and exhibited during interaction with at least one individual who is not a sibling:

Angry/Irritable Mood

1. Often loses temper.

2. Is often touchy or easily annoyed.

3. Is often angry and resentful.

Argumentative/Defiant Behavior

4. Often argues with authority figures or, for children and adolescents, with adults.

5. Often actively defies or refuses to comply with requests from authority figures or

with rules.

6. Often deliberately annoys others.

7. Often blames others for his or her mistakes or misbehavior.

Vindictiveness

8. Has been spiteful or vindictive at least twice within the past 6 months.

Note: The persistence and frequency of these behaviors should be used to distinguish

a behavior that is within normal limits from a behavior that is symptomatic. For children

younger than 5 years, the behavior should occur on most days for a period of at least

6 months unless otherwise noted (Criterion A8). For individuals 5 years or older, the

behavior should occur at least once per week for at least 6 months, unless otherwise

noted. While these frequency criteria provide guidance on a minimal level

of frequency to define symptoms, other factors should also be considered, such as

whether the frequency and intensity of the behaviors are outside a range that is normative

for the individual’s developmental level, gender, and culture.

B. The disturbance in behavior is associated with distress in the individual or others in his or

her immediate social context (e.g., family, peer group, work colleagues), or it impacts negatively

on social, educational, occupational, or other important areas of functioning.

C. The behaviors do not occur exclusively during the course of a psychotic, substance

use, depressive, or bipolar disorder. Also, the criteria are not met for disruptive mood

dysregulation disorder.

Specify current severity:

Mild: Symptoms are confined to only one setting (e.g., at home, at school, at work, with

peers).

Moderate: Some symptoms are present in at least two settings.

Severe: Some symptoms are present in three or more settings.

Again, please feel free to contact me with any additional questions.

Sincerely,

Jessica