Assessment and diagnosis
Date identification
Initial assessment date: 4/17/2022
Presenting the Problem
The patient is a 61-year-old male who speaks Portuguese and has a history of depression. The patient is self-referred, has reported feelings of loneliness, is medicated by a psychiatrist, and has been suicidal once. Throughout the patient’s life, he has always sought to be in relationships as he believes they give him a sense of purpose. The patient is co-dependent and states he only feels motivated when he is with someone else.
The patient has signed the HIPAA and the informed consent forms. I told the patient the terms of the confidentiality policy and informed him that privacy and confidentiality of the session would be maintained between him and me. Before the session, I reminded the patient of the agreement concerning privacy signed for the significance of videotaping and recording the session. The agreement included deleting the record after the end of the assessment. The patient gave consent to the use of recordings during the assessment.
Information sources: The information was collected during a previous biopsychosocialspiritual assessment of the patient. The patient was requested to complete the DSM-5 measure and Cultural Formulation Interview (CFI).
Summary
The patient is a 61-year-old male who has a history of depression. The present state started at an early age in his youth, which was a result of losing both of his parents to an accident and the same time, his divorce from his current fiancé. Since then, the patient started feeling lonely, resulting in anxiety symptoms. After the death of his parents, he was poor and was forced to live on the streets, where he got involved in criminal acts such as theft and selling drugs to sustain himself. The patient worked in strip clubs and, at some point forced to engage in sexual acts for money. These challenges resulted in his self-esteem issues and living this kind of lifestyle for eleven years.
The patient was initially found to be suicidal, a likely indication of loss of hope associated with the previous history of depression. At this point in his life, he had lost hope and felt that he had no purpose. Although any suicide attempt was unsuccessful, his depressive state did not change. He was never married but has had multiple relationships in his life in an attempt to create meaning for his life. He does not like being alone and moves from one relationship to another. In another episode, the patient was involved in a car accident which left him with a need to use one crutch, which has added to his self-esteem issues.
The patient has visited a psychiatrist and is under medication for depression. He, however, continues to experience sadness, loneliness, emptiness, and a lack of meaning in life. Based on the DSM-5 level 1 measure, the patient scored more than a 2 on the depression domain. On the DSM-5 level 2, the patient recorded a t-score of 67. The state of depression was evaluated using BDI at a score of 27. The elevation was due to comments such as “feels lonely all the time,” “lost hope,” and “no interest in anything.” During the CFI, the patient stated that he continues to have self-esteem issues due to his condition. The patient stated that he does not have many friends apart from his partners and feels lonely most of the time. The patient continues to state that in the presence of other people, he continues to feel sad even in happy moments and has a feeling of heaviness in his heart all the time. The patient feels left out most of the time and lacks to recognize love and care from people around him.
The patient stated that he is not very religious but had been forced to attend Catholic Church throughout his young age due to his parent’s religiousness. He does not believe much in religion but goes to church sometimes when he feels despaired and needs interactions. The patient indicated that he is bisexual and enjoys the company of both men and women. However, he is forced to be with women more and hide his sexuality due to his community and parents’ religion. The patient has a history of being suicidal and substance abuse from an early age, where he had to attend rehab due to addiction.
The patient seemed articulate and answered questions effectively with great attention. He seemed worried about the idea of lacking control over his life and feeling sad constantly. However, it was clear that the client was willing to get assistance and overcome the challenges. Throughout the conversation, it emerged that the client avoided questions that seemed personal and only twisted answers to avoid providing crucial details about life difficulties. The challenges in treatment include his fear of trusting the counselor with significant details that could highly assist in the intervention.
DSM-5 Diagnosis
F33.1 Major Depression Disorder
Rationale
According to the diagnosis, the patient is experiencing a major depressive episode. The patient’s symptoms have characterized a series of a feeling of emptiness, hopelessness, and loss of interest in almost everything. The patient is experiencing a depressed mood characterized by persistent sadness. His t-score is elevated at 67, which designates a depressive state. He expressed a wish for the need to be with other people indicating co-dependence. He experiences fatigue and a lack of interest in things that used to be fun to him before and has difficulty sleeping. The patient’s symptoms are moderate and recurrent, with a persistent low mood accompanied by self-esteem issues.
Conceptualization
Step 1: Identification of concerns and problems
- Suicidal feelings
- feeling sad
- sleeping problems
- low self-esteem
- lack of interest in anything
- feelings of loneliness
- hopelessness
- low motivation
- co-dependence
Step 2: Descriptive diagnostics
- Major Depressive Disorder
Step 3 Theoretical inferences that attach the descriptive diagnosis or inferred area of difficulty
Maladaptive Thinking (CBT):
- Low self-esteem
- The feeling of lack of purpose
Maladaptive behavior (CBT):
- Co-dependence
- Sleeping problems
Step 4: Narrowed inferences and more significant difficulties
- Deepest Negative Distortion
- Feelings of hopelessness
Narrative of the Case Conceptualization
The objective of case conceptualization is to comprehend and elucidate the situation of the client clinically. In reference to CBT, the patient shows behavioral patterns such as sadness, avoidance, seclusion, low self-esteem, and lack of interest which are signs of major depressive disorder. The client’s problems can be linked to a defectiveness schema that creates a belief that one is internally flawed, resulting in low self-esteem (Herts & Evans, 2021). The defect makes an individual fear rejection if others discover their weakness; hence they will always complain having loneliness. For instance, the patient claims to have a history of codependency and “feels lonely all the time. Such statements indicate the clients have issues with the ability to act and do things that make them happy confidently.
Treatment plan
Integration of faith
I integrate my practice with the Christian faith. Christ’s rule over all aspects of human nature can be challenged in biblical or Christian psychology that incorporates biblical and Christian teachings. Several clients I see may have a solid connection to religion or spirituality in their lives. They have religious and spiritual concerns that influence their values, beliefs, lifestyles, and behaviors, even if they are not the primary focus of treatment. These individuals believe that treatment should be based on a biblical worldview and the truth revealed in Scripture. Christian counseling is informed by the truth that all creation is affected by sin, and the human mind and body are in a fallen state. Persons are composed of both body and soul. Individuals may seek treatment because of religious or spiritual concerns. There are many examples, including disagreements over religious views and practices, spiritual crises, and feelings of disconnection from one’s faith. It is a common practice in psychotherapy for clients to draw strength and support from their own religious and spiritual beliefs.
Model of Counseling
My guiding theory involves aligning personal beliefs and values with theoretical approaches. I am working towards mastery of CBT as a foundation to navigate my counseling process. I include patients’ conceptualization based on their maladaptive behavior and thinking, leading to state anxiety and disorder. CBT-based interventions have been helpful when assisting my patients; however, I need a continuous reference to processes, interventions, and concepts. I plan to do further research and take classes to master the process and seek help and consultation from professionals who are more conversant with using CBT. Occasionally, I will ensure successful treatment for the patient is my main goal by doing more research on similar cases to maximize my effectiveness in treatment and quality of healthcare.
Reference
Herts, K. L., & Evans, S. (2021). Schema Therapy for Chronic Depression Associated with Childhood Trauma: A Case Study. Clinical Case Studies, 20(1), 22-38. Web.
López-López, J. A., Davies, S. R., Caldwell, D. M., Churchill, R., Peters, T. J., Tallon, D. & Welton, N. J. (2019). The process and delivery of CBT for depression in adults: A systematic review and network meta-analysis. Psychological medicine, 49(12), 1937-1947. Web.