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The diagnosis of the patient in the case scenario is done based on the five different dimensions of the DSM-IV-TR (fourth edition, text revision).
Available literature demonstrates that the five-part ‘axis’ system of the DSM-IV-TR is the mostly used criteria for diagnosing mental illnesses in the United States as it provides a more comprehensive assessment of a client’s level of functioning, based on the premise that mental illnesses often affect many different life areas (Warelow & Holmes, 2011). The diagnosis of the patient is made as follows:
This axis illustrates clinical syndromes that cause considerable impairment to the patient (Warelow & Holmes, 2011). One of the most prevalent clinical syndromes demonstrated by the patient is 296.4 Bipolar 1 Disorder. The justification for diagnosing the patient as having this syndrome is based on the fact that the primary symptom presentation of Bipolar 1 Disorder is manic, characterized by a distinct period of an elevated mood, which often assumes the form of euphoria (American Psychiatric Association, 2000).
It is indeed true that the patient meets the full criteria for a manic episode not only due to her abnormally and persistently elevated, expansive, and irritable mood (extremely angry at her sons and the psychiatrist), but also due to the fact that she demonstrates these symptoms:
- Inflated self-esteem and grandiosity (asked the psychiatrist if she was attractive enough to capture a 25-year old man),
- Decreased need for sleep (patient felt refreshed after only 3 hours of sleep,
- More talkative than usual (patient was over talkative and repeatedly refused the psychiatrist to disrupt her with questions), and
- Excessive involvement in pleasurable activities that have a high potential for painful ramifications (patient engaged in spending sprees, sexual indiscretions with a 25-year old man) (American Psychiatric Association, 2000; Gray, 2011; Yatham et al., 2009).
It is important to note that the manic-like episode demonstrated by the patient is evidently not triggered by somatic antidepressant drugs or therapies since the patient was not on any medication. Additionally, the patient does not have a history of drug or alcohol abuse (Gray, 2011). Consequently, the manic-like episode demonstrated by the patient counts toward a valid diagnosis of Bipolar 1 Disorder.
Available literature demonstrates that this axis assesses permanent problems that are often overlooked in the presence of Axis I disorders, such as mental retardation and personality disorders (Warelow & Holmes, 2011). The patient cannot be diagnosed with mental retardation as she does not exhibit any cognitive impairment, not mentioning that she does not show marked deficits in other critical spheres of life, such as self-care and interpersonal skills (Yatham et al, 2009).
However, the patient can be diagnosed with antisocial personality disorder, characterized by the presence of irritability and impulsivity. Indeed, it can be argued that her frequent mood disturbance is considerably severe to trigger a marked impairment in her social functioning, particularly in terms of her social relationships with others (American Psychiatric Association, 2000).
This extensive axis includes physical and medical conditions (e.g., diabetes, hypertension, HIV/AIDS, physical injury and brain damage) that may manipulate or aggravate Axis 1 and Axis II disorders noted in the patient (Warelow & Holmes, 2011). The patient has no physical or medical conditions that can be reported under Axis 3 criteria since she appears correctly oriented in all areas.
Available literature demonstrates that any non-clinical, albeit medically significant, stressors that have the capacity to impact Axis 1 or Axis II disorders are included and evaluated in this axis (American Psychiatric Association, 2000). The fact that the patient lost her husband six months ago is a psychosocial problem that could have triggered the frequent mood disturbance exhibited by the patient, leading to the clinical syndrome of Bipolar 1 Disorder.
This axis, which is commonly referred to as the Global Assessment of Functioning (GAF) in DSM-IV-TR, basically serves as an indication of the evaluating psychiatrist’s opinion of the patient’s capability to function in daily life.
Extant literature demonstrates that the GAF is calibrated on a 100 point scale, which evaluates the functioning of the patient on three important spheres of life – psychological, social and occupational (American Psychiatric Association, 2000). The patient’s GAF is at 49 “current”, implying that the demonstrated symptoms lead to antisocial behavior and social dysfunction (Warelow & Holmes, 2011).
The allocated GAF score is reached at based on the following justifications. The patient is still functional occupationally as can be seen by her volunteer work in the local hospital. However, her normal psychological functioning is hampered by her inflated self-esteem, irritable mood, grandiosity, and anger.
Her social functioning is also hampered by the presence of antisocial personality disorder as well as excessive involvement in pleasurable activities that have a high probability for inflicting painful consequences (Yatham et al., 2009). These observations, in my view, demonstrate marked culpability in antisocial behavior and social dysfunction, necessitating a GAF score of 49 “current”.
A GAF score of between 41 and 60 demonstrates that the relational unit has occasional times of satisfying and competent functioning together, but obviously the relationship is dysfunctional and the unproductive social, psychological or occupational relationships appear to prevail (American Psychiatric Association, 2000)
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Possible uses and Misuses of Diagnosis
One of the most important uses of the diagnostic manual is that it leads to proper treatment. The symptoms presented by the patient can lead to a misdiagnosis if proper care is not taken to classify them and note their variations. Owing to the classification done in Axis 1, it is clear that the patient suffers from Bipolar I disorder due to the manic episodes.
Such a diagnosis will ensure that the patient is given the correct treatment for the variant of Bipolar Disorder she is suffering from instead of generalizing the symptoms (Gray, 2011).
The second use of the diagnostic manual in this case scenario is that it helps clinicians and psychiatrists define societal limits for acceptable behavior. The elevated behaviors exhibited by the patient, particularly the sexual indiscretions with a 25-year old man and unchecked spending habits, have been clearly labeled as socially unacceptable and valid symptoms of a clinical disorder (Yatham et al., 2009).
Third, it can be argued that the diagnostic manual assists clinicians and psychiatrists to advance research, particularly in the broad area of mental illnesses and their comorbid conditions (Gray, 2011).
For instance, the axial categorization done on the case scenario has demonstrated that there is a possibility for antisocial personality disorder occurring together with the primary condition of Bipolar I disorder. Extant literature demonstrates that such knowledge will lead to better treatment outcomes for patients suffering from psychiatric and mental disorders (Gray, 2011).
Furthermore, it can be argued that the use of the diagnostic manual helps clinicians and psychiatrists to communicate with each other and achieve validity in their diagnosis. For instance, it is possible for another psychiatrist evaluating the patient using the DSM-IV-TR to come up with the same diagnosis due to standardization of routines and processes.
This is a plus for the medical profession as it does not only create standardized procedures and processes for handling medical problems, but also provides the capacity for the development of common language that can be used by professionals to discuss diagnoses (Gray, 2011).
In disadvantages, it is evident that the bias of the assessing psychiatrist or clinician can lead to wrong diagnosis. There always exist the twin challenges of possible stigmatization and stereotyping of individuals with mental or psychiatric conditions. For instance, the society can view the patient in the case negatively for engaging in sexual activities with people young enough to be her children.
Cultural beliefs and taboos also trigger the stigmatization and stereotyping of people with mental/psychiatric conditions (Gray, 2011). Lastly, the diagnostic manual has been criticized for lack of reliability, particularly in situations where symptoms for various medical conditions overlap (Gray, 2011).
Most patients suffering from Bipolar 1 Disorder with demonstrated manic episodes are exposed to ‘mood stabilizers’, especially lithium and sodium valproate, to prevent relapses of further episodes. The anticonvulsants sodium valproate and valproate semisodium are more effective than lithium and have marketing authorization in most Western countries for the treatment of manic episodes in the context of Bipolar I Disorder.
The major ingredient which makes the anticonvulsants effective in the treatment of manic episodes is the valproate ion, but studies demonstrate that the element is associated with an enhanced risk of neural tube defects and fetus developmental problems during pregnancy (The British Psychological Society, 2006).
However, it can be administered safely to the patient since she is in her post-menopausal age. Other interventions, including social support, family interventions, psychoeducation and cognitive behavior therapy, should also be used.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, fourth edition: DSM-IV-TR. Washington, DC: American Psychiatric Association.
Gray, S.W. (2011). Competency-based assessments in mental health practice: Cases and practical applications. Hoboken, NJ: Wiley.
The British Psychological Society. (2006). Bipolar disorder: The management of bipolar disorder in adults, children and adolescents, in primary and secondary care. London: Alden Press. Retrieved from https://www.nice.org.uk/guidance/CG38
Warelow, P., & Holmes, C.A. (2011). Deconstructing the DSM-IV-TR: A critical perspective. International Journal of Mental Health Nursing, 20(6), 383-391.
Yatham, L.N., Kauer-Sant’Anna, M., Bond, D.J., Lam., R.W., & Torres, I. (2009). Course and outcome after the first manic episode in patients with Bipolar Disorder: Prospective 12-month data from the systematic treatment optimization program for early mania project. Canadian Journal of Psychiatry, 54(2), 105-112.