Case A: Nonaxial Diagnosis Practice Case The client is a 48 year old man who came to therapy for a fear of flying. Although he states that he recognizes that his fear of flying is irrational, excessive and unreasonable, just the thought of being in an airport provokes intense anxiety. According to the man, he is a geologist who is expected to fly to various conferences. In the past, he has been able to avoid taking trips that would require him to fly; however, recently his supervisor has been pressuring him to attend these conferences and this has been causing him considerable distress. In other aspects of the job his work is adequate and he has received acceptable yearly evaluations. Interpersonally, he has always been passive and shy. He reported that he frequently looks to others for guidance and has difficulty making decisions on his own due to a lack of confidence. He lives with his girlfriend and relies on her to provide support and reassurance. He will frequently call her from work to seek her opinion or just to get approval for his decisions. As a result, he often subordinates his needs to those of others and volunteers to do unpleasant tasks to get people to like him. He reported that he would do anything for his girlfriend and that he is frequently concerned that she might leave him. Although he has never been married, he has never been alone and quickly enters a new relationship as soon as a previous relationship has ended. The thought of being on his own is extremely anxiety-provoking to him, and he worries that he would not be able to function. He reported that it is the feeling of terror when he thinks of getting into an airplane and the possibility that it might crash that brought him in for treatment. He denied a history of drug or alcohol use and stated that he is generally healthy, with the exception of mitral valve prolapse (i.e., mild heart condition).
Case A: Nonaxial Diagnosis Practice Case DSM-IV Axis I 300.29 Specific Phobia, Situational Type Axis II 301.6 Dependent Personality Disorder Axis III 924.0 Axis IV Axis V Mitral valve prolapse (patient report) work difficulties GAF = 65 (current) DSM-5 300.29 Specific Phobia, Situational 301.6 Dependent Personality Disorder 924.0 Mitral valve prolapse (patient report)
CASE B: DSM-IV AND DSM-5 AUTISM SPECTRUM CASES Case B.1 John is a 6-year old male referred due to aggressive behavior at school. He reportedly is aggressive towards peers and occasionally staff at school, hitting and biting on occasion, mostly when asked to stop one activity to move to another or when another child takes a toy he is playing with. His mother reports a normal pregnancy/delivery and did not report any developmental delays with the exception of a delay in speech; John did not begin talking in sentences until he was 3 ½. John displays a great deal of hyperactive and impulsive behavior both at home and at school. He tends to make minimal eye contact with others, in part due to his high activity level. John s mother reports that he enjoys playing with a range of toys and will often include his younger brother in imaginary play, however he is often aggressive towards his younger brother. John is currently receiving speech services at school to help him to expand his vocabulary and to work on pronunciation difficulties. John seems to prefer to play by himself at school and other children tend to avoid him due to his history of aggressive behavior.
CASE B1: AUTISTIC DISORDER SPECTRUM CASE DSM-IV Axis I 299.80 Pervasive Developmental Disorder- Not Otherwise Specified Axis II Axis III Axis IV 314.01 Attention Deficit/ Hyperactivity Disorder, Combined Type (Provisional) 315.31 Expressive Language none none Axis V GAF = 65 Disorder (Provisional) interpersonal difficulties DSV-5 315.39 Social (Pragmatic) Communication Disorder 314.01 Attention Deficit/Hyperactivity Disorder, Combined (Provisional)
CASE B: DSM-IV AND DSM-5 AUTISM Case B.2 SPECTRUM CASES Anthony is a 6-year old male referred for evaluation due to difficulties adjusting to kindergarten. His mother reports that Anthony dislikes going to school and will often cry or say he is sick in order to avoid going to school. Anthony s mother did not report any pregnancy or delivery complications and reported that Anthony met all developmental milestones at an average or faster than average rate. She reported that he has always been a very picky eater and is also fussy about his clothing (e.g., doesn t like to have tags on his clothes, won t wear shirts that aren t soft cotton). She noted that Anthony began speaking at an early age (1 ½) and that he is a very verbal child who likes to talk about his interest in cars. She noted with pride that Anthony can talk for hours about different types of cars and car engines. She noted that his favorite activity is to play with matchbox cars at home and that he spends hours lining up his cars and building small cities and gets upset if his play is disrupted (i.e., his younger brother picks up a car without permission). Anthony s teacher has noted that Anthony tends to play by himself, seldom engages with other children, and gets agitated if other children attempt to engage in play with him. She noted that he is doing well academically but seems disinterested in participating in class activities. For example, when asked a question in class he will either remain silent or respond with a comment that is minimally related to the question. Anthony s mother reports that she feels he is bored at school since he is already starting to read and other children are still learning their numbers and colors.
CASE B2: AUTISTIC DISORDER SPECTRUM CASE DSM-IV Axis I 299.80 Asperger s Disorder Axis II none DSM-5 299.00 Autism Spectrum Disorder, Level 1, without language impairment Axis III none Axis IV peer interaction difficulties Axis V GAF = 65
CASE C: PSYCHOTIC DISORDER CASE A 23 YO man came to an outpatient clinic for symptoms of psychosis. He has always been a loner who shows very little emotion and prefers not to become involved with people. Since high school, he has had no close friends and prefers solitary tasks. He chose computers as a major in junior college because he feels that "computers are more rational and easier to deal with than people" and after graduation obtained employment as a computer programmer. He has no friends or hobbies, except working on his computer, and has little contact with co-workers or his family. Eight months ago, his performance at work, which was marginal but adequate, began to decline. About this same time, he began to believe that his computer was trying to communicate with him. Several times, he heard a voice that he is convinced was the computer talking to him. This did not disturb him at first until he began to believe that the computer was trying to control his thoughts. He was referred for inpatient admission, was treated with antipsychotic medication, but showed little improvement. Currently, it has been four months since the onset of his overt psychotic symptoms; he continues to take antipsychotics on an outpatient basis but still believes that his computer is trying to communicate with him. He has not returned to work and his parents have been paying his bills for him. He presents as a quiet, shy, and aloof young man who shows little if any emotion. Although it was suggested that he also start individual therapy to work on establishing relationships and learning to express feelings, he refused. There are no medical problems or history of substance abuse.
CASE C: PSYCHOTIC DISORDER CASE DSM-IV Axis I 295.30 Schizophrenia, Paranoid Type Axis II 301.20 Schizoid Personality Disorder (premorbid) Axis III Axis IV Axis V None reported Unemployment, inadequate social support GAF = 30 (current) DSM-5 295.90 Schizophrenia 301.20 Schizoid Personality Disorder (premorbid)
CASE C: DSM-5 SCHIZOPHRENIA Optional Severity Specifiers From Clinician Rated Dimensions of Psychosis Symptom Severity Delusions Hallucinations Disorganized speech Abnormal psychomotor behaviors Negative symptoms SCALE: 0-4 0 Not present 1 Equivocal 2 Present, but mild 3 Present and moderate 4 Present and severe With optional severity specifiers 295.90 Schizophrenia 301.20 Schizoid Personality Disorder (premorbid)
CASE D: MOOD DISORDER CASE A 30 year old man was transferred to a long term facility for longstanding feelings of depression. History reveals that he first experienced a depressive episode at age 23. At that time, he was dysphoric, hopeless, lost considerable weight due to lack of appetite, withdrew from all social contacts, and heard voices, which he believed came from God, telling him he was being punished for past sins. His condition was so severe that he was hospitalized for 2 months. He was tried on various antidepressants with little success and was eventually given a course of ECT. He showed some partial improvement for 6 months or so, and his psychotic symptoms remitted. However, he became depressed again and has been depressed on and off ever since. Currently, he has been depressed for at least 3 years without any periods of remission of his symptoms. He has been experiencing severe depressed mood, insomnia, poor appetite, fatigue, and feelings of worthlessness almost every day. He feels hopeless, has recurrent suicidal ideation, although with no specific plan nor intent to act on his ideation, has little interest in anything, and has no energy. He has not worked since age 23 and is receiving social security disability benefits. Apparently, the man has never really been happy. History reveals that he felt dysphoric throughout high school, long before he experienced the more severe depression in adulthood. He has never had much energy, has always suffered from insomnia, and has had chronic feelings of low selfesteem. As a result, his functioning was always somewhat marginal; he had few friends, rarely dated, and never established a career. There is no history of periods of elevated or irritable mood or history of substance abuse. He has no significant medical problems.
CASE D: MOOD DISORDER CASE Axis I 296.33 300.4 DSM-IV Axis II V71.09 No diagnosis Axis III Axis IV Axis V Major Depressive Disorder, Recurrent, Severe Without Psychotic Features, Chronic, Without Full Interepisode Recovery Dysthymic Disorder, Early Onset None reported GAD = 35 (current) Unemployment, limited social support DSM-5 296.33 Major Depressive Disorder, Recurrent episode, Severe 300.4 Persistent Depressive Disorder, Early Onset, With persistent major depressive episode, Severe* *criteria for MDD met throughout past 2 years. If had periods of remission but has MDD episode now: With intermittent major depressive episodes, with current episode
CASE E: TRAUMA-RELATED DISORDER CASE A 40 YO man has recently brought by his parents for treatment at a VA hospital. The man attributes all his problems to serving in the Middle East, where he witnessed atrocities such as seeing children killed in an explosion. About 2 months ago, after seeing a car accident, he started having flashbacks and nightmares of some of the atrocities he witnessed while in the military. However, his family reported that he has had difficulties since childhood. He was a non-compliant child who had behavioral problems in early childhood, and was frequently involved in vandalism, stealing, fighting and truancy in junior high school. In high school, his misbehavior progressed to auto theft and serious fights, sometimes using weapons. His parents were hopeful when he enlisted that he would "straighten out." Since his discharge from the military, he mostly has been a "drifter," never settling down into a long term job or relationship and usually spending his pay for nonessentials. He has no close friends and usually winds up back at his parent's home asking for money and a place to live. He is tense, irritable and hypervigilant, and has an exaggerated startle response and poor concentration. With his parent's encouragement, he agreed to seek treatment at the VA hospital. A physical exam performed at the time of admission revealed hypertension.
CASE E: TRAUMA RELATED DISORDER CASE DSM-IV Axis I 309.81 Posttraumatic Stress Disorder, Acute, With Delayed Onset Axis II 301.7 Antisocial Personality Disorder Axis III 401.9 Hypertension, essential (medical records) Axis IV Axis V GAF = 40 (current) History of combat, unemployment, lack of stable home or social support DSM-5 309.9 Unspecified Trauma- and Stressor-Related Disorder 301.7 Antisocial Personality Disorder 401.9 Hypertension, essential (medical records) V62.22 Exposure to Disaster, War or Other Hostilities * Not meet the avoidance sx requirement; if met new criteria: 309.81 Posttraumatic Stress Disorder, With delayed expression
PTSD: DSM-IV vs. DSM-5 DSM-IV A: stressor: need 2 of 2: 1) experienced, witnessed, or was confronted with traumatic event and 2) intense fear, helplessness, or horror. B. traumatic reexperienced: need 1 of 5: (1) Recurrent and intrusive distressing recollections; (2) distressing dreams; (3) flashbacks; 4) Intense psychological distress at exposure to cues; (5) Physiological reactivity on exposure to cues C. persistent avoidance of stimuli associated with the trauma and numbing: need 3 of 7: (1) Efforts to avoid thoughts, feelings; (2) Efforts to avoid activities, places, or people; (3) Inability to recall an important aspect of the trauma; (4) Markedly diminished interest; (5) Feeling of detachment /estrangement; (6) Restricted affect; (7) Sense of a foreshortened future D. persistent increased arousal: need 2 of 5: (1) Difficulty falling /staying asleep; (2) Irritability/ outbursts of anger; (3) Difficulty concentrating; (4) Hypervigilance; (5) Exaggerated startle response DSM-5 A: stressor: need 1 of 4: 1) Direct exposure; 2) Witnessing,; 3) Indirectly, by learning a close relative or close friend was exposed; 4) Repeated/extreme indirect exposure in the course of professional job (not through media). B: intrusion symptoms: need 1 of 5: 1) Recurrent, intrusive memories; 2) Traumatic nightmares; 3) flashbacks; 4) Intense/prolonged distress after exposure; 5) physiologic reactivity upon exposure to cues C: persistent effortful avoidance of distressing trauma-related stimuli: need 1 of 2: 1) Trauma-related thoughts /feelings; 2) Traumarelated external reminders D: negative cognitions/ mood: need 2 of 7: 1) Inability to recall key features of the trauma; 2) negative beliefs about oneself, the world; 3) distorted blame of self, others; 4) Persistent negative traumarelated emotions; 5) diminished interest; 6) Feeling alienated, detachment/estrangement; 7) Constricted affect E: alterations in arousal and reactivity: need 2 of 6: 1) Irritable or aggressive behavior; 2) Self-destructive/ reckless behavior; 3) Hypervigilance; 4) Exaggerated startle response; 5) Problems in concentration; 6) Sleep disturbance.
CASE F: SUBSTANCE DISORDER CASE A 45 year old man sought treatment due to anxiety. He reported that about a year ago, he had a very frightening episode in which his heart started to race and beat very hard, he could not breathe, he had chest pains, and thought he was having a heart attack. He called 911 and was taken to the emergency room, but an EKG was normal and there was no evidence of cardiac disorder hypertension, or respiratory disorders. He was told it was anxiety, sent home with a prescription for xanax and told to take it when he started to feel increased anxiety. Since that time, he has had several similar episodes in which he experiences a sudden onset of intense fear that quickly builds to a peak. His heart pounds and races, he feels dizzy and short of breathe, and he has terrible feelings of dread, like he is going to die. He constantly worries about having one of these attacks, but the worry has not kept him from going to work or leaving his home. However, the man admitted that he has started drinking much more heavily over the past year, and reported that alcohol calms his nerves better than the xanax. Although he has not had any legal problems related to his alcohol use, he has started to frequently miss or be late for work, and his frequent hangovers have affected the quality of his work. The man is a computer analyst and head of the department. While he has always been attentive to details, his co-workers have noticed a significant decline in his performance. Medically, the man is generally healthy, although medical records indicate that he has carpal tunnel syndrome.
CASE F: SUBSTANCE DISORDER CASE Axis I 300.01 305.00 DSM-IV Panic Disorder without Agoraphobia Alcohol Abuse, rule out Alcohol Dependence* Axis II V71.09 No diagnosis Axis III 354.0 Carpal tunnel (medical records) Axis IV Axis V GAF = 60 (current) Work related problems DSM-5 300.01 Panic Disorder 305.00 Alcohol Use Disorder, Mild** 354.0 Carpal tunnel (medical records) *several symptoms are possibly present ** would be moderate if at least 4 symptoms were present Notes. He sought treatment for his anxiety symptoms so it should be listed if you considered the alcohol problem primary, you could list it first but you would have to put (reason for visit) next to the Panic Disorder. You could also list the V code: (V62.29 Other Problem Related to Employment) for the work related problems, especially in DSM-5 since there is no axis IV.
CASE G: NEUROCOGNITIVE DISORDER CASE A 55 YO man was brought to see his physician by his wife because of his increasing difficulty functioning. The man had worked as a librarian in the rare document department for the past 25 years but was being asked to take an early retirement due to memory difficulties and inability to keep the documents properly catalogued. Apparently, he was always an excellent worker because he was so orderly, organized and perfectionistic; however, in other areas of his life, this preoccupation with details often resulted in the point of the activity being lost and the task not being completed. Moreover, he was always so devoted to his work that through the years, he never had any friends and neglected his wife and all leisure pursuits. His wife had noticed that during the past year or so he seemed to be having increased difficulty expressing his thoughts, seemed forgetful and at times, and was confused. In addition, while he had always dressed meticulously, he no longer seemed to care and was neglecting his grooming. He became increasingly impaired and acted like he was lost in his own home. She became very concerned when one day he wandered out of the house in his pajamas and got lost in his own neighborhood. It was at that point that she insisted he get checked out by his physician. The physician noted that aside from his hypertension for which he had been prescribed medication, he was healthy.
CASE F: NEUROCOGNITIVE DISORDER CASE DSM-IV Axis I 294.8 Dementia Not Otherwise Specified Axis II 301.4 Obsessive Compulsive Personality Disorder (provisional) Axis III 401.9 Axis IV Axis V GAF = 30 (current) Hypertension, Essential (medical records) Mandated early retirement, limited social support DSM-5 799.59 Unspecified Neurocognitive Disorder 301.4 Obsessive Compulsive Personality Disorder (provisional) 401.9 Hypertension, Essential (medical records) *If the etiology was due to a known medical condition, list that diagnosis first including the ICD-9-CM code. You could also choose one of the possible major cognitive disorders based on history: Possible Major Neurocognitive Disorder Due to Alzheimer s Disease or Possible Major Vascular Neurocognitive Disorder