Lisa Trembly, a 33-year-old female, visited a detox facility thinking about long-term rehabilitation. She presented her case to the healthcare service provider, who was responsible for evaluating her case and finding out how to help. The paper, in this context, refers to the patient.
Subjective Information
Chief Complaint
Lisa’s chief complaint was that she had been suffering from addiction. She mentioned that she had been considering going to rehab because she didn’t want people to continue calling her an addict. A symptomology to derive a differential diagnosis is that Lisa worries about losing her business with Jeremy after learning that Jeremy was in love with another lady.
Duration and Severity of the Symptoms
Lisa did not mention for how long she has been abusing drugs, but she said that Jeremy started messing her up 4 months ago. From the information provided, the symptoms were so severe that she found it wise to visit a health center. The severity of her symptoms made her even more tired of talking about her feelings.
How the Symptoms are Impacting Lisa’s functioning in Life
Lisa’s symptoms affected her functioning in life, including how she thinks and talks. She feels like having more alcoholic drinks and is also using foul language despite being in the presence of a professional.
Objective
Observations during the Assessment
At the time of assessment, it was noted that Lisa had given up on most things. It was also found that she has low self-esteem, suicidal thoughts, and distorted thinking. Lisa does not think straight like a rational human being. Her concentration was also low, and sometimes could not listen to important points.
Physical Exam Documentation
Lisa appeared tired and weak. She cannot even speak well or look straight. One would think Lisa is sleepy, yet that is not the case. She was also getting irritated quickly and did not like repeating statements.
Diagnostic Results to Develop Differential Diagnoses
From interaction with Lisa, it was clear that Lisa was suffering from mental health issues. It was, therefore, important to assess whether she had mood changes, whether she had problems sleeping, and whether she had difficulty coping.
Assessment
Patient’s Mental Status Results
The patient had difficulty in sleeping, difficulty coping, as well as mood changes. The signs indicated that the patient was suffering from a mental health disorder, and she needed to address her issue before the condition worsened.
Differential Diagnoses
The differential diagnoses include depression, generalized anxiety disorder, and borderline personality disorder. The three diagnoses are considered because the symptoms noted in the patient are linked to the disorders. According to Lagana et al. (2017), experiencing sleep disturbances, feeling sad, lacking interest in activities that give pleasure, and tiredness, among others, are signs of depression (2); the signs of depression were noted in Lisa. On the other hand, signs of a generalized anxiety disorder include having sleep problems, feeling restless, being fatigued, having headaches, and worrying a lot (Jordan et al., 207, p. 5). Signs of borderline personality disorder according to Paris (2018) include unstable relationships with others, emotional instability, and distorted thinking patterns.
DSM-5 TR Diagnostic Criteria
The DSM-5 TR criteria for diagnosis of depression state that the patient must have experienced at least 5 signs of depression for more than two weeks (Truschel, 2022). DSM-5 criteria for borderline personality disorder (BPD) include a pattern of instability in relationships, impulsivity, and unstable self-image (Guile et al., 2018). DSM-5 TR criterion for generalized anxiety disorder (GAD) includes the existence of the symptoms of GAD for more than 6 months. The accurate diagnosis, in this case, is therefore depression because Lisa experienced more than 5 depressive symptoms for more than 2 weeks.
Critical Thinking that Resulted in the Primary Diagnosis
Lisa’s depressive symptoms started to appear when she found her boyfriend cheating; this means that she had no issues in the relationship until the cheating case arose. The pertinent positives are the signs of depression that have existed for more than two weeks. Pertinent negatives include a pattern of instability in relationships and the existence of symptoms of GAD for more than 6 months; these are pertinent negatives because they ruled out the possibility of the patient suffering from BPD and GAD.
Reflection
What I would do differently with the client is explore other disorders and engage another healthcare professional so that she can get evidence-based care. The ethical consideration I made was not telling the patient all the differential diagnoses. I ensured she was given treatment for the specific condition that stood out.
References
Guile, J. M., Boissel, L., Alaux-Cantin, S., & de La Rivière, S. G. (2018). Borderline personality disorder in adolescents: prevalence, diagnosis, and treatment strategies. Adolescent health, medicine, and therapeutics, 9, 199.
Jordan, P., Shedden-Mora, M. C., & Löwe, B. (2017). Psychometric analysis of the Generalized Anxiety Disorder scale (GAD-7) in primary care using modern item response theory. PloS one, 12(8), e0182162.
Lagana, A. S., La Rosa, V. L., Rapisarda, A. M. C., Valenti, G., Sapia, F., Chiofalo, B., … & Vitale, S. G. (2017). Anxiety and depression in patients with endometriosis: impact and management challenges. International journal of women’s health, 9, 323.
Paris, J. (2018). Differential diagnosis of borderline personality disorder. Psychiatric Clinics, 41(4), 575-582.
Truschel, J. (2022). Depression Definition and DSM-5 Diagnostic Criteria. https://www.psycom.net/depression/major-depressive-disorder/dsm-5-depression-criteria.
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