TPC-Journal-V4-Issue3

The Professional Counselor \Volume 4, Issue 3 239 At this time, Martha’s core diagnosis of major depressive disorder, recurrent remains appropriate. Upon further exploration of Martha’s symptoms, the counselor finds that seven symptoms are present; therefore, Martha’s depressive episode is considered moderate. The new specifier with moderate anxious distress is also appropriate for inclusion because of Martha’s reported stressors. Martha feels tense and restless nearly every day. She worries about her children, her health, and her mother, and has difficulty focusing on her work and household tasks. She describes the feelings of depression as present all day, every day, and the stress, worry, and tension as present nearly every day, particularly when she attempts to “face reality” and engage with others or accomplish tasks around the house. A review of Martha’s history shows that anxious distress may have always been present during her depressive episodes. It was noted during her hospitalization and during previous counseling services, but had not reached the severity level necessary for an anxiety disorder diagnosis. Noting these important symptoms using the specifier may help Martha get the treatment she needs. Using the cross- cutting symptom measures to track her symptoms of depression and anxiety may be helpful as the counselor works to find the most effective ways to facilitate progress on Martha’s goals. During Martha’s 24 years of treatment, she has had several slightly different diagnoses. Her first unspecific depression diagnosis from the family physician was further identified by the evaluation she had while an inpatient using the DSM-IV criteria for 296.33 major depressive disorder, recurrent, severe without psychotic features, with post-partum onset . Martha’s current diagnosis of 296.32 major depressive disorder, recurrent, moderate, with moderate anxious distress is reflective of both her history and current presentation. Bo: Bipolar I Disorder Bo is a 32-year-old single male. He lives alone with the support of his mother and brother. He has held numerous entry-level jobs for short time periods. Presently, he is unemployed and receiving Social Security Disability benefits. He receives treatment through a local mental health center. His current treatment program is called Program of Assertive Community Treatment (PACT; National Alliance on Mental Illness, 2014) and includes psychiatry, counseling, case management and vocational rehabilitation services. Some services occur at the local mental health center and some occur in his home or in the community. Bo was first diagnosed (per the DSM-IV-TR ) with 296.90 mood disorder, not otherwise specified when he was 24. During adolescence, Bo had a history of drug and alcohol use, academic and behavioral problems at school, and minor legal infractions. At age 22, Bo had a stable job, one year of sobriety, and lived alone for the first time. After 3 days of no returned phone calls, Bo’s brother began a search and finally found him in an apparent manic state. He was rambling enthusiastically about a new business in media promotions. He had drawings and notes scattered across his apartment with what appeared to be logos for the business. Bo told his brother that he would make millions of dollars with his connections in the music industry. Bo’s brother was concerned given that Bo had no such relationships. With just a little prodding, Bo revealed he had already spent his life savings and sold his motorcycle to get the business started and needed to borrow more money to “make it happen.” He became furious and destructive when his brother challenged his ideas. Bo’s brother was alarmed and took him to the local emergency room for an evaluation. The emergency clinician met with Bo and determined that although some of his symptoms matched those for a manic episode, his vague symptom history and relatively short duration of illness precluded diagnosis of bipolar I disorder at that time. Bo was diagnosed with 296.90 mood disorder, not otherwise specified and referred to a crisis stabilization program for treatment and further evaluation. Bo was resistant to treatment because he did not believe his behavior to be inappropriate. After 4 days in crisis stabilization, Bo’s mood changed dramatically and he entered a major depressive episode. He expressed suicidal intent and was hospitalized. His diagnosis was revised to 296.53 bipolar I disorder, most recent episode depressed, severe without psychotic features (per DSM-IV-TR at the time).