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Respond to at least two colleagues who presented a different diagnosis. Discuss the differences and similarities in your choice of criteria, focusing in particular on Other Conditions that may be a Focus of Clinical Attention.
Colleague 1: Jonathan
300.4 [F34.1] Persistent Depressive Disorder (Dysthymia) with anxious distress is what I would diagnose Sam with. Sam meets many of the diagnostic criteria for this, moreso than major depressive disorder. According to American Psychiatric Association (2013), the criteria for Dysthymia include depressed mood for most of the day for at least two years continuously, presence of at least two options in section B, including low self-esteem and poor concentration, not having been without symptoms for more than two months at a time, not being explained by any type of schizophrenia or schizoaffective disorder, not attributed to a substance or medical condition, and the symptoms of which cause social impairment. The anxious distress, according to American Psychiatric Association (2013), is defined by having a presence of a minimum of two symptoms, such as feeling keyed up or tense, and difficulty concentrating because of worry.
Sam has not presented with any episodes that would be considered “psychotic” since his original discharge from the social worker that could not be explained by an external reason, as the facts of the case seem to show that his recent hospitalization happened only due to taking discontinued medications (Plummer, Makris, & Brocksen, 2014). Sam has been seeing his psychiatrist for the last 10 years, taking Depakote, Abilify and Wellbutrin to manage his depression and previously diagnosed psychotic features (Plummer, Makris, & Brocksen, 2014). According to Plummer, Makris, & Brocksen (2014), Sam has talked about several occasions of anxiety, such as due to living alone. Also, Sam has discussed his increased feelings of depression and difficulty to adjusting to living alone. Last, Sam has no history of alcohol or substance abuse issues, which removes any possibility of the diagnosis being skewed due to substances.
While reviewing the “Other Conditions That May Be A Focus of Clinical Attention” section of the DSM-V, a ICD-10-CM code that I may include in Sam’s diagnosis would be Z62.29 – Upbringing Away from Parents (American Psychiatric Association, 2013). Since Sam was seven years old, he had been placed in foster care and had very limited contact with his extended family. This could possibly create an issue which has extended through the loss of his wife, and only having his daughter as solace. While exact times and dates and ages are not particularly stated, I wonder if the events of 9/11 had a stressful effect which brought about symptoms due to his daughter being an EMT. Maybe, if she was an EMT who had participated in the events of 9/11, Sam’s depression and psychotic features could have been symptoms from the stress of feelings of the possibility of loss of family from early childhood?
Assessment measures, according to American Psychiatric Association (2013), are the ability of the DSM to allow the clinician to add dimensional approaches to diagnostic criteria that would not normally be present when utilizing a diagnostic criteria. There are two types of measures, and an assessment schedule. These assessment measures would be vitally important to helping in the treatment of Sam. Sam has a long history of mental health, but has been doing very well for over ten years. In ten years’ time, the previous diagnoses may no longer fit, and his current symptoms may not necessarily fit in current diagnostic criteria. These assessment measures would help Sam to receive a more accurate diagnosis for where he is currently.
The Cross-cutting symptom measure utilizes the medical review of systems to pick out behaviors or symptoms that may not necessarily fit into the diagnosis, but would be important to the individual’s care (American Psychiatric Association, 2013). There are two levels of cross-cutting symptom measures: level 1 is a survey of 13 symptom domains for adults and 12 domains for minors, whereas level 2 provides a more in-depth assessment of these domains (American Psychiatric Association, 2013). The Severity Measures are utilized to assess individuals who might meet most aspects of a diagnosis, but may fall short clinically of certain aspects of a specific disorder, and do not necessarily fit any other diagnosis (American Psychiatric Association, 2013). The World Health Organization Disability Assessment Schedule version 2.0 assesses a client’s ability to perform activities in six different areas that are important to track changes in a patient’s disabilities, utilizing the WHO International Classification of Functioning, Disability and Health (American Psychiatric Association, 2013).
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Plummer, S.-B., Makris, S., & Brocksen S. M. (2014). Social work case studies: Concentration year. Baltimore, MD: Laureate Publishing.
Colleague 2: Jennifer
Sam is a 62-year-old African American male, wife is diseased, he is currently residing alone in his own apartment unemployed (Plummer, Sara-Beth, Makris, & Brocksen, 2013). Sam was adopted when he was 7 years old. Sam has a 28year old daughter who he has a positive relationship with although he isolates, during the times he should be asking her for help. Sam developed depression and psychotic features after 9/11 and was not able to return to work due to multiple psychiatric hospitalizations (Plummer, Sara-Beth, Makris, & Brocksen, 2013). There is not enough information that specifies if this was a traumatic event during that time or what triggered Sam’s depression. Sam has continued to struggle with psychiatric symptoms. Sam has been reported to be med compliant for 10 years and was prescribed by the psychiatrist certain medications such as, Depakote®, Abilify, and Wellbutrin (Plummer, Sara-Beth, Makris, & Brocksen, 2013). After 10 years Sam expressed concerns about increased feelings of depression and anxiety to a social worker. Later on the social worker recognized that Sam begin to appear disorganized and confused. He reported to the social worker that he has been feeling “foggy” and time seems to be “missing” (Plummer, Sara-Beth, Makris, & Brocksen, 2013).
Sam has no history of substance abuse or criminal background, Sam was previously diagnosed with major depression with psychotic features along with medical conditions such as high blood pressure, and migraines (Plummer, Sara-Beth, Makris, & Brocksen, 2013). Sam denied any other medical problems but he mentioned that he recently collapsed in the street and was in the hospital. Sam has not presented any psychotic features or symptoms. Sam expressed that they ran several tests and there are no medical issues that are of concern at this time. The social worker verified this information with Mellissa (daughter) to confirm that this information is accurate due to his state of confusion and to rule out what is really going on with Sam. The social worker discovered that Sam was consuming his discontinued medication and was mixing his discontinued medications with his current medications.
Sam continues to struggle with depression, anxiety, feelings of loneliness and isolates. Sam is struggling with loneliness as evidenced by he has been having issues with adjusting living alone. Sam has a history of prior diagnosis of major depression with psychosis. As the social worker in this case Sam, he would be diagnosed with Persistent Depressive Disorder (Dysthymia) code 300.4 (F34.1) with anxiety. According to the American Psychiatric Association. (2013),
A. “Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others for at least 2 years
B. Presence, while depressed, of two (or more) of the following:
1. Poor appetite or overeating
2. Insomnia or hypersomnia
3. Low energy or fatigue
4. Low self-esteem
5. Poor concentration or difficulty making decisions
6. Feelings of hopelessness
A. During the 2 year period (1 year for children or adolescents of the disturbance, the individual has never been without symptoms in Criteria A and B for more than 2 months at a time”. p 168
Z codes such as Z60.2 code ICD-10-CM, problem related to living alone can be associated with Sam’s diagnosis. Sam reported that he has increased feelings of depression due to his daughter moving out after many years of her and his daughter’s boyfriend residing with him (Plummer, Sara-Beth, Makris, & Brocksen, 2013). This relates to some of Sam’s issues that he has been experiencing that caused his depression and anxiety to increase.
The Severity Measures are utilized to assess individuals that corresponds to the criteria that correlates with the disorder definition (American Psychiatric Association, 2013). The level of assessment measures provides adequate information regarding the severity of the individuals mental health diagnosis. On the VII depression domain Sam meets the present and moderate due to his symptoms.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Plummer, Sara-Beth, Makris, S., Brocksen, S. (2013). Social Work Case Studies: Concentration Year. Laureate Publishing,VitalBook file.
Respond to at least two colleagues in one of the following ways:
· Offer an alternative suggestion that has not been previously discussed for how your colleagues, as social work professionals, might respond to clients with suicidal ideations.
· Explain any gaps in the action plans your colleagues described for working with clients who express suicidal ideations.
Colleague 1: Jennifer
The article I chose to review for this discussion is “Ethical and Competent Care of Suicidal Patients: Contemporary Challenges, New Developments and Considerations for Clinical Practice,” by Jobes, Overholser, Rudd, and Joiner (2008). This article addresses the increasing challenges in recent years regarding clinical work with suicidal patients including providing sufficient informed consent to patients and using empirically supported treatments and interventions, and suitable risk assessment and management techniques (Jobes et al., 2008). The article also defines additional clinical issues such as improvements in the standard of care, resistance to changing practices, alterations to models of health care delivery, and the role of research and issues of diversity (Jobes et al., 2008). Lastly, the article examines acute versus chronic suicide risk, effective documentation, training, professional competence, perceptions of medical versus mental health care, fears of dealing with suicide risks, suicide myths and stigma related to suicide (Jobes et al., 2008).
As a professional, I have had to respond to clients who have expressed suicidal ideation, and agency protocol dictated emergency response representatives be contacted when clients became a risk to themselves or others. Prior to these events, clients were informed of confidentiality and informed consent rules and regulations. Clients with a history of suicide were frequently assessed through both self and clinician assessments to not only establish baselines for their behaviors but serve as an adequate assessment of the risk. Clients with long histories of depression were referred to psychiatrists and medication regulation was a client goal.
In working with those with suicidal ideation it is important to not only utilize hospital or medications but empirically informed treatments that will help aid in redirecting the negative thoughts associated with suicide (Jobes et al., 2008). Cognitive therapies and psychosocial interventions are both noted as providing effective treatments for such clients (Jobes et al., 2008). In addition, crisis response plans developed with the patient provide the tools necessary for the patient to cope differently through self-soothing, outreach, and support, or through the use of new adaptive skills (Jobes et al., 2008). Role-playing scenarios that use one or more of these features can aid in reducing suicide among patients (Jobes et al., 2008).
It is difficult for me to hear clients report their suicide plans and ideation’s because my heart breaks and my first instinct is to leap out of my seat and hug the person until their feelings of sadness disappear, which is not only unprofessional but presumably ineffective. To aid clients in future self-helping tasks, my supervisor encourages me (when possible) to walk the client through their feelings and thoughts to help them recognize that/when emergency personnel should be notified. Sometimes this works, and sometimes it doesn’t. In my experience when I have had to call emergency personnel without the client’s approval, it isn’t initially a positive experience. Often they feel violated and are angry that you have ‘wronged’ them, however in most cases after hospitalization they are grateful for the services. Each client is different, and I quickly learned that there isn’t one successful ‘cookie cutter’ method that works for everyone.
Jobes, D, Overholser, J., Rudd, M., & Joiner, T. (2008). Ethical and competent care of suicidal patients: Contemporary challenges, new developments, and considerations for clinical practice. Professional Psychology: Research and Practice 39(4): 405-413. Retrieved from Walden Library databases.
Colleague 2: Brittany
Suicidality in Bipolar Disorder and Other Related Disorders
Evidence suggests that suicide is the leading cause of death in individuals with bipolar disorder and/or other significant mood disturbances, with the highest rates occurring in those with bipolar II disorder (Saunders & Hawton, 2013; Balazs, et al., 2006). “Standardized suicide mortality rates between 120 and 200 per 100000 have been reported, which equates to 15-20 times the rates seen in the general population. These may, however, be an overestimate, as followed-up samples usually include both first-episode cases and/or those admitted to hospital. Given that suicidality is often a reason for admission, such samples are inherently biased. They are also likely to exclude those individuals with less severe illness” (Saunders & Hawton, 2013, p. 575). Risk factors cannot be adequately represented in terms of magnitude, but most frequently encompass sociodemographic and clinical features. These include: gender (male), family history of suicide, previous suicide attempt(s), recent hospital admission (increased risk the first week following admission to the hospital and the week following discharge), mixed mood state, rapid cycling, depression, hopelessness, and comorbid anxiety disorder (Saunders & Hawton, 2013, p. 575-7).
Suicide Risk Assessment and Management
Clinical assessment and screening for suicide risk are of utmost importance and should occur at the earliest possible opportunity (Saunders & Hawton, 2013; Balazs et al., 2006). Unfortunately, however, Saunders & Hawton (2013) highlight: “At present, there are no validated suicide risk assessment tools specifically for bipolar disorder in primary or secondary care, and the screening of bipolar disorder for risk factors has uncertain predictive power [as there is no] set of criteria [found] to predict risk in an individual patient. Although more general risk assessment tools [e.g., The Tools for Assessment of Suicide Risk (TASR)] may allow clinicians to identify potentially higher-risk individuals and target interventions effectively, these should never be viewed as an alternative to thorough [BP1] clinical assessment” (p. 578). Additionally, worth noting is that the experience of bipolar disorder has the potential to “…fluctuate between elated mastery and paralyzed, anxious isolation (Rusner et al., 2009, p. 160) and denial of suicidality may occur in one mood state whereas it may be present in the other pole (APA, 2013; Saunders & Hawton, 2013, 578).
Saunders & Hawton (2013) advise that suicide and crisis planning occur “in advance of any such crisis arising,” whenever possible (p. 578). Consistent with existing clinical guidelines, Saunders & Hawton (2013) further suggest that a crisis management plan should be created that includes the following: “…details of common precipitating factors, signs and symptoms of relapse, what action the patient should take, who they should contact, and the response they can expect from health services, as well as possible pharmacological interventions” (p. 579). However, evidence is lacking regarding the efficacy of such plans in reducing suicide risk, in individuals with bipolar disorder. “There is [also] no clear evidence for or against safety contracts, although many clinicians will make informal agreements with patients as to what they should do if they feel unsafe or things deteriorate. More formal signed agreements are not recommended as there is a lack of evidence to support their efficacy, and one study reported that patients with suicide contracts were five times more likely to attempt than those without” Saunders & Hawton, 2013, 578).
Saunders & Hawton (2013) best summarize:
“In the short term, management involves reducing the risk of a suicidal act and optimizing an individual’s mental state. Risk reduction often involves practical measures such as reducing access to means (e.g., removing stockpiles of medication, prescribing limited amounts of psychotropic medication, removing firearms), increasing the level of community support, and admission to hospital when no safe community-based option is available. Misuse of alcohol and drugs should be addressed as these are both likely to increase impulsivity and hopelessness, and, hence, risk. Acute and maintenance treatment with mood stabilizers should be optimized and balanced against the risk of toxicity and overdose. [Therefore, the] key points [are:] agree to a crisis/safety plan in advance, limit access to means, treat any relapse in illness, consider admission to hospital, ongoing monitoring, and support family and carers” (p. 579).
Professional Response and Agency Protocols
From professional experience, this writer has learned that suicide assessment is not an easy subject to discuss nor an unambiguous process. In fact, multiple risk factors may be present that suggest suicide will occur yet, in the end, it does not while no factors may be blatant and the individual successfully completes suicide. Therefore, consistent with the recommendations of Saunders & Hawton (2013), an amalgamation of assessment tools, interviews with the individual and direct supports (such as family or caretakers), and clinical judgment should be applied when evaluating suicide risk. However, this writer has also learned that even the most thorough assessment and crisis management plan do not guarantee the individual’s safety, especially in the context of the rapid cycling and/or mood volatility present in bipolar and other related disorders (APA, 2013).
Consequently, “even clinical assessment is not without its limitations as no set of criteria [exists to predict risk amidst the variability of bipolar and other related disorders]. The involvement of family/carers in the assessment process is essential to ensure that all relevant available information has been obtained. Assessment should include a thorough examination of mental state, with a particular focus on their mood as well as compliance with prescribed medication. Obtaining information relevant to assessing risk and safety is also essential. This should include establishing the nature, extent, and duration of suicidal ideation; whether the person has a plan; the method they intend to use; the extent, nature, and lethality of previous suicidal acts; as well as the patient’s access to means and the presence of possible protective factors (e.g., children, religious beliefs)” (Saunders & Hawton, 2013, p. 577). Additionally, suicide risk assessment should be ongoing and any crisis management plan that is created should be reviewed and updated frequently (Saunders & Hawton, 2013).
In approaching the subject of suicide, this writer would first be cognizant of factors that may bias perception of the client, such as: preconceived notions, opinions about what constitutes risk, and feedback from others. For example, this writer would avoid making assumptions, such as labeling someone as a risk solely because they have made a knee-jerk decision (like ended a relationship). This writer would consider all the precipitating factors, access to means or a plan, previous history of attempts, current client presentation, and nonverbal cues. These less obvious clues can provide context for the verbal reports of the client and/or their family/supports. In the event the client verbalizes suicidal intent or hopelessness, hospitalization (including involuntary admission on a 72-hour hold) would be considered if/when applicable, especially if the individual does not have proper supports at home. If safety is ambiguous, a crisis plan (in addition to the existing crisis management plan) would be created to ensure safety between visits and this writer would provide contact numbers for crisis lines and/or 24-hour supports. The individual’s supports would be involved in this plan so they know what to watch for and can adequately support their loved one to: a) reduce risk of relapse and b) ensure safety should a mental health crisis arise.
Additionally, this writer would gauge for presence of hope and/or mood brightening in response to the introduction of certain topics or stimuli. If the individual remains melancholic (blunted emotional response) or is unable to verbalize future-oriented thinking, hospitalization may be warranted. In the event this writer initiates hospitalization on a 72-hour involuntary hold, this writer would connect with the individual after hospitalization to attempt to repair rapport and/or suggest other colleagues/resources that the individual can utilize instead.
One resource to assist in this process would be the adult hope scale (AHS), also referred to as the future scale. Snyder et al. (1999) developed a “…cognitive model of hope which defines hope as ‘a positive motivational state that is based on an interactively derived sense of successful (a) agency (goal-directed energy), and (b) pathways (planning to meet goals).’ [The pathway and agency scores are then added together to determine the level of hope present, according to the self-report questionnaire]” (p. 287). Like the severity scales in the DSM-5 (APA, 2013), the AHS can focus this writer’s attention to specific areas of the individual’s functioning while providing context to explore issues further to explore their impact on the presentation of mental illness and risk for suicide.
Other supports would also include: “increased contact with clinicians, psychological therapy to address suicidal thinking and hopelessness, a crisis plan, an emergency contact number for the patient and relatives, and communication with and guidance for other clinicians and services involved in the patient’s care. Intensifying support for both patient and family, facilitating urgent access to clinicians, and, where necessary, hospital admission are essential components of managing the suicidal patient. In addition, addressing alcohol and drug misuse, and removing access to obvious means for suicide, may be critical. Psychological interventions are also likely to be important in managing and preventing suicidal crises, but currently there is a paucity of evidence for the prevention of suicidal acts” (Saunders & Hawton, 2013, p. 581). Therefore, as a professional, this writer would provide as many supports as possible while remaining grounded in the reality that suicide may occur regardless of safety measures. This will prevent burnout while also removing the risks of disempowering the individual (by assuming that this writer has “saved” them as opposed to them “saving” themselves). Agency policy allowing for coordination of care (on an inpatient and outpatient basis), priority to outpatients of the facility for admission to the inpatient, crisis response teams (in place), and active contracts with county social services and local providers would be beneficial in assessing risk.
This writer has a strong emotional response when speaking to others about suicide, be it past, present, or future-planning. This is somewhat grounded in personal mental health problems and direct (professional and personal) exposures to suicide attempts. This writer tends to internalize the problems of others and feel responsible when things do not go well for them. Practicing self-care and remaining grounded in reality is critical in these moments. In previous experiences with individuals who express suicidality, this writer has often felt a sense of panic, not wanting to miss anything and scared that this writer’s efforts wouldn’t suffice. However, this writer takes every step possible to ensure their safety (involving a support, making a safety plan, reviewing resources, offering additional help, addressing current symptoms, exploring hope and goals, etc. In doing this, the power is in the individual’s hands to utilize the supports.
Just as it is their choice to pursue health and well-being, it is also their right to engage in maladaptive behavior. In the presence of blatant signs, however, this writer would defer to mandated reporting legislation and a medical doctor, psychiatrist, or law enforcement to determine if a 72-hour involuntary hold is warranted to ensure safety of the individual and others. In these moments, it is difficult for this writer to hide emotion, leaving responses vulnerable to outward expression – such as tears, a sense of being overwhelmed, panic, and/or fear. This writer recognizes that such blatant expression of emotions may not be beneficial to the individual, however, and takes steps to avoid emotions undermining the ability to think critically, including: self-care, supervision, role-plays, desensitizing (such as watching shows or reading things that contain suicide), decompressing, guided meditation, relaxation techniques, confronting and/or naming the emotion, etc.). This writer accepts professional liability and mandates to ensure the safety of clients and others, but also has learned the balance of removing self-blame for decisions made by clients. A client may commit suicide regardless of the thoroughness of efforts/intervention, but it is this writer’s duty to never give up hope and to empower clients to maximize strengths and resources to reduce the risks suicide will occur. Ultimately, this writer is human and mistakes are inevitable but what matters is learning from them so that when mistakes are made, they aren’t repeated in the future. From pain, we grow. From admitting flaws, we overcome them.
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