Elise Schmidt
Differential Diagnosis
LP10
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The following is a case study about Henry who is a 45-year-old male who is in
search of treatment due to his wife’s’ insistence. Using the accepted diagnostic by the
American Psychiatric Association referred to as The Diagnostic and Statistical Manual
of Mental Disorders or DSM I will analyze his symptoms both physical and
psychological to determine what criteria if any he meets.
When considering the differential diagnosis, the first step is to determine if the
symptoms the client is explaining are real or if they are being deceptive whether it is
consciously or unconsciously. In the case of Henry I would conclude that he is telling
the truth about his symptoms because he does see that they are a problem and his
information is consistent.
The next step is to see if a substance is affecting the central nervous system and
if there is a correlation between the substance use and psychiatric symptoms. The first
thing considered was Henrys’ psychological problems and the time line with his
substance use of alcohol. Henrys’ alcohol abuse may result from his problems that have
escalated because of his obsessive compulsive disorder but his obsessive compulsive
behavior and poor social skills were earlier in his timeline than his substance use. In
consideration in the second step Henrys’ family as far as we know does not have a
history with substance use.
Step three is to determine if Henry has a medical condition. He does not appear to have
a general medical condition that could be affecting his psychiatric problems. Step four of
the dual diagnosis is determining the primary DSM VI that fits the client.
Elise Schmidt
Differential Diagnosis
LP10
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The primary DSM VI or the Axis I is the clinical syndrome, which for Henry I
believe would be DSM 305.00 Alcohol Abuse (Wikipedia, 2013). The DSM IV criteria for
Alcohol abuse is a maladaptive pattern of drinking leading to clinically significant
impairment or distress manifested by a minimal of one of the following; regular use of
alcohol that leads to failure to fulfill major obligations at work or home, recurrent alcohol
use in hazardous situations, recurrent alcohol related legal problems, and continued
alcohol use even though there are persistent social and/or interpersonal problems as
consequences of the alcohol. The individual must also never have met the criteria for
alcohol dependence. (Office of the Surgeon General (US); National Institute on Alcohol
Abuse and Alcoholism (US); Substance Abuse and Mental Health Services
Administration (US)., 2007) Henry has not met the DSM IV criteria for alcohol
dependence but his drinking to “relax” has interfered with his work and his marriage.
Although his drinking has continued to have negative effects on the institution of family
and his work Henry is still persistent in his use of alcohol which is why the Axis I for
Henry would be alcohol abuse.
The first pattern within the case that is clear to see for myself is Henrys’ constant
need for perfection and planning. Henry is behind in work because of his need to perfect
his work or redo it if someone else tried to, has rigid demands towards his wife, is
complained about at work because of his constant detail to work making him impossible
to work with and reducing his efficiency, and makes plans for all the members of his
family and becomes outraged if they do not follow his directions precisely. These
characteristic traits would classify Henry as having Obsessive Compulsive Personality
Elise Schmidt
Differential Diagnosis
LP10
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Disorder. DSM 300.3 Obsessive Compulsive Disorder is an Axis II in the category of
Anxiety Disorders. (Wikipedia, 2013)
For an individual to be diagnosed with DSM 300.3 Obsessive compulsive
disorder an individual must meet four of the following symptoms; preoccupied with
details, lists, order, organization, rules, or schedules, perfectionism that interferes with
the completion of tasks, excessive devotion to work, excessive devotion and inflexible
with ethics, morals, or values, cannot throw out useless or worthless objects, insist
others do tasks exactly like them, view money as something to hoarded, and our
stubborn and rigid (PsyWeb, 2013). Henry meets at least four of these criteria by being
preoccupied with details and lists at work and with his family, his perfectionism
interferes with his tasks at work, his rigid behavior is problematic at home and at work,
and he is devoted with work by working fifteen plus hours and going on frequent
business trips.
Axis III for DSM IV are where medical conditions that maybe relevant to
the individuals psychological problems are listed. (Seigan, Walker, & Rosenhan, 2001)
In Henrys’ case there are no medical problems that relevant to the psychological
problems.
Psychosocial and environmental problems that Henry has that may affect his
treatment, diagnosis, and prognosis would first of all be his problems with his primary
support group. Henrys’ primary support group would be his wife and children. This may
be problematic because his wife is why he is seeking treatment, she is fed up with their
marriage, she feels he is emotionally cold towards her and acts with bullying behavior,
Elise Schmidt
Differential Diagnosis
LP10
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has sexual disinterest, and places rigid demands on her. Occupational problems that
Henry has are numerous because of his alcohol abuse and obsessive compulsive
disorder. Some of the occupational problems are alcohol negatively affecting his work
relationships, he is unable to keep up at work, and his alcohol has lowered his
productivity. Henry also has problems related to social environment. Henry has limited
social environment outside of work and business trips. Even as a child Henry had a
problem in social situations because he was awkward and unpopular; focusing mainly
on his academic work.
Axis V is the Global Assessment of functioning or GAF. Here we look at an
individuals’ adaptive functioning with the consideration of social relations with family and
friends, occupational functioning, and use of leisure time on a scale that ranges 1
through 100. (Seigan, Walker, & Rosenhan, 2001) Henry would fall in the GAF 41 to 50
range. In this range individuals have serious symptoms or serious impairment in social,
occupational, or school functioning. (Edward Pierce, 2013) In Henrys’ particular case I
would place Henry at a 47 on the GAF scale due to how his alcohol abuse and OCD
negatively affecting his social and occupational functioning.
After reviewing the facts and assessing Henrys’ case his multiple axis diagnosis
would look like; Axis I 305.00 Alcohol Abuse, Axis II 300.3 Obsessive Compulsive
Personality Disorder, Axis III None, Axis IV Primary support group, social environment,
and occupational, and Axis V 47.
Elise Schmidt
Differential Diagnosis
LP10
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Case of Study
The Workaholic
Henry, a 45-year-old attorney seeks treatment at his wife’s insistence. She is fed up
with their marriage; she can no longer tolerate his emotional coldness, rigid demands,
bullying behavior, sexual disinterest, long work hours, frequent business trips and
excessive drinking which is his way to “relax”. Alcohol use as negatively impacted the
attorney's marriage and work relationships. The patient feels o particular distress in his
marriage, and has agreed to the consultation only to humor his wife.
It soon develops, however, that the patient is troubled by problems at work. He is known
as the hardest – driving member of a hard – driving law firm. He was the youngest full
partner in the firm’s history, and is famous for being able to handle many cases at the
same time. Lately, he finds himself increasingly unable to keep up. He is too proud to
turn down a new case, and too much of a perfectionist to be satisfied with the quality of
work performed by his assistants. His drinking has also impacted his ability to
concentrate and his productivity. Displeased by the writing of his assistants, he finds
himself constantly correcting their briefs and therefore unable to stay abreast of his
schedule. People at work complain that his attention to details and inability to delegate
responsibility are reducing his efficiency. He has had two or three secretaries a year for
15 years. No one can tolerate working for him for very long because he is so critical of
any mistakes made by others. When assignments get backed up, he cannot decide
which to address first, starts making schedules for himself and his staff, but then is
unable to meet them and works 15 hours a day. He finds it difficult to be decisive now
that his work has expanded beyond his own direct control.
The patient discusses his children as if they were mechanical dolls, but also with a clear
underlying affection. He describes his wife as a “suitable mate” and has trouble
understanding why she is dissatisfied. He is punctilious in his manners and dress and
slow and ponderous in his speech, dry and humorless, with a stubborn determination to
get his point across.
The patient is the son of two upwardly mobile, extremely hard working parents. He grew
up feeling that he was never working hard enough, that he had much to achieve and
very little time. He was a superior student, a bookworm, awkward and unpopular in
adolescent social pursuits. He has always been competitive and a high achiever. He
has trouble relaxing on vacations, develops elaborate activities schedules for every
family member, and becomes impatient and furious if they refuse to follow his plans. He
likes sports, but has little time for them and refuses to play if he can’t be at the top of his
form. He is a ferocious competitor on the tennis courts and a poor loser.
Elise Schmidt
Differential Diagnosis
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Reference Page
Edward Pierce. (2013). Axis V: Global Assessment of Functioning. Retrieved from Edward Pierce:
http://www.edwardpierce.net/super/Axis5.htm
Office of the Surgeon General (US); National Institute on Alcohol Abuse and Alcoholism (US); Substance
Abuse and Mental Health Services Administration (US). (2007). Appendix B: DSM-IV-TR
Diagnostic Criteria for Alcohol Abuse and Dependence. In O. o. (US), N. I. (US), & S. A. (US)., The
Surgeon General's Call to Action To Prevent and Reduce Underage Drinking. Rockville: Office of
the Surgeon General (US). Retrieved from NCBI:
http://www.ncbi.nlm.nih.gov/books/NBK44358/
PsyWeb. (2013). Obsessive Compulsive Disorder. Retrieved from PsyWeb:
http://www.psyweb.com/mdisord/jsp/ocpd.jsp
Seigan, M. E., Walker, E. F., & Rosenhan, D. L. (2001). Abnormal Psychology. New York: W. W. Norton &
Company, Inc.
Wikipedia. (2013). DSM-VI Codes. Retrieved from Wikipedia: http://en.wikipedia.org/wiki/DSMIV_Codes
Elise Schmidt
Differential Diagnosis
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Learning Plan 10: Scoring Guide 1
- Differential Diagnosis
Scoring Standards:
10/5 = Excellent quality; criteria is fully demonstrated; no errors are evident; all key
concepts of theory are addressed 8/4 = Acceptable quality; minor flaws or errors exist or
are omitted; Information is correct 4/2 = Criterion attempted but needs improvement;
response shows minimal understanding of concepts; details and support are lacking 0 =
Criterion is unacceptable or not completed - response is incorrect, irrelevant or missing.
10 = Criterion is met 0 = Criterion is not met
5 = Criterion is met 0 = Criterion not met
Criteria
Written case analysis applies the process of
differential diagnosis.
Written case analysis determines the
diagnosis of the case.
Written case analysis identifies the
appropriate diagnostic codes.
Written case analysis applies the multiaxial
diagnostic process.
Written case analysis justifies conclusions.
Written case analysis is completed according
to prescribed deadlines.
Written case includes reflections on the
process of differential diagnosis.
Learner distinguishes between fact and
opinion.
Learner synthesizes information from a
variety of sources.
Learner uses problem-solving and decisionmaking strategies.
Written case analysis uses bias free
language.
Written case analysis applies standard rules
of language structure including grammar,
spelling and punctuation.
Written case analysis is consistent with
established criteria.
Learner organizes information.
Learner produces evidence of learning.
Values
10 8 4 0
10 8 4 0
10 8 4 0
10 8 4 0
10 8 4 0
10 0
10 8 4 0
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5420
5420
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5420