Diagnosis: Major Depressive Disorder, Recurrent, with Psychotic Features

Posted: September 10th, 2023

Diagnosis and Treatment Plan for Mr. Soprano

Diagnosis

Based on the case study, Mr. Soprano’s symptoms align most closely with Major Depressive Disorder, Recurrent, with Psychotic Features. He exhibits a depressed mood, significant weight loss, insomnia, fatigue, feelings of guilt, and recurrent thoughts of death. Additionally, he experiences auditory hallucinations, which are indicative of psychotic features tied to his depression. These symptoms have persisted for more than two weeks, fulfilling the criteria for this diagnosis (American Psychiatric Association, 2013).

Rationale for Excluding Other Diagnoses

Bipolar I Disorder: Mr. Soprano does not display the distinct episodes of mania required for this diagnosis. His symptoms are more consistent with depression rather than the elevated mood or grandiosity seen in mania.

Antisocial Personality Disorder: While Mr. Soprano’s criminal behavior might suggest this disorder, his primary symptoms are mood-related, and he expresses guilt and remorse, which are atypical for antisocial personality disorder.

Erectile Disorder: Although Mr. Soprano reports a loss of sexual interest, this is likely a symptom of his depression rather than a standalone sexual dysfunction.

Therapeutic Interventions

Psychotropic Medication: Antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs), can help alleviate depressive symptoms. Antipsychotic medications may also be necessary to address the psychotic features (Keks et al., 2016).

Cognitive Behavioral Therapy (CBT): CBT is effective in treating depression by helping patients identify and change negative thought patterns and behaviors. It can also assist in managing guilt and improving coping strategies (Cuijpers et al., 2016).

IQ Assessment

Full Scale IQ: Mr. Soprano’s Full Scale IQ is calculated as the average of his subtest scores: (96 + 92 + 102 + 102) / 4 = 98.

Full Scale Range: The 95% confidence interval for his Full Scale IQ is 93-103.

Percentile Explanation: A Full Scale IQ at the 45th percentile means Mr. Soprano scores higher than 45% of the population, indicating average intellectual functioning.

Potential Resources

Individual Therapy: Provides personalized support to address Mr. Soprano’s specific emotional and psychological needs, such as guilt and depression.

Group Therapy: Offers a supportive environment where Mr. Soprano can share experiences and learn from others facing similar challenges, which can be beneficial for social support and reducing isolation.

Inpatient Hospital Facility: Given the severity of his symptoms, including psychotic features and suicidal thoughts, inpatient care may be necessary for stabilization and intensive treatment.

Case Summary

Mr. A. Soprano, a 55-year-old male, presents with symptoms indicative of Major Depressive Disorder, Recurrent, with Psychotic Features. He reports a depressed mood, significant weight loss, insomnia, fatigue, guilt, and auditory hallucinations. These symptoms have persisted for several weeks, impacting his daily functioning. His Full Scale IQ is 98, placing him in the average range. Treatment recommendations include psychotropic medication and Cognitive Behavioral Therapy. Resources such as individual therapy, group therapy, and possibly inpatient care are suggested to address his complex emotional and psychological needs.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Cuijpers, P., Karyotaki, E., Weitz, E., Andersson, G., Hollon, S. D., van Straten, A., & Ebert, D. D. (2016). The effects of psychotherapies for major depression in adults on remission, recovery and improvement: A meta-analysis. Journal of Affective Disorders, 202, 511-515.

Keks, N., Hope, J., & Keogh, S. (2016). Switching and stopping antidepressants. Australian Prescriber, 39(3), 76-83.

=========================

Provide/identify the diagnosis

o Major Depressive Disorder, Recurrent, with Psychotic Features

o Bipolar I Disorder

o Antisocial Personality Disorder

o Erectile Disorder

Explain, in detail, your choice of diagnosis?

· Please Identify the two most appropriate therapeutic interventions & explain why they are appropriate in this instance

o Psychotropic medication

o Cognitive Behavioral Therapy (CBT)

o Electroconvulsive Therapy (ECT)

· Calculate Mr. Soprano’s Full Scale IQ ____________________

· Describe the Full Scale range of scores ___________ – ___________

· Mr. Soprano’s full-scale IQ falls at the 45th percentile; please explain what this means.

· Of those listed, please select three potential resources for a client such as Mr. Soprano, and explain why based on emotional/psychological needs.

o Grief support groups

o MHMR (Helen Farabee Mental Health and Mental Retardation Center)

o Individual therapy

o Inpatient hospital facility

o Group therapy

· Please write a summary for the provided case study

==========

Signature ASSIGNMENT

The following is a brief, highly incomplete case study of a fellow who presents with symptoms of a specific psychiatric illness. He is interviewed and given some IQ testing. IQ testing would not be the best test to understand his problems, in fact it might be contraindicated in his current state but for the purposes of the assignment, IQ testing provides the clearest example of data and its use in a critical thinking exercise which is one of the goals of this assignment.
CASE STUDY
Mr. A. Soprano is a 55-year-old white male who presented as an “emergency” to a psychologist at a local ER. After establishing rules of confidentiality he revealed he was a high level crime boss; essentially a mobster. Throughout the interview he spoke in a rather pronounced Brooklyn accent. He preferred to call himself “a highly creative business man.” The client’s chief complaint was a concern over a vague desire to “hurt” himself, sleep problems and was experiencing disturbing “thoughts that don’t make any sense.” He stated his thinking had become very negative, “and weighs heavy on me”, where he doesn’t see anything good or positive in his life, “and I’m normally a positive kinda guy.” Dr. Psychologist proceeded to request the client cooperate with psychological testing to help determine potential causes for the client’s reported problems. This included a clinical interview.
Mr. Soprano began his interview by telling a story about ordering a fellow mobster killed, “a couple months ago.” He said, “I liked the guy. He was my right hand man, but he screwed up Doc and coulda’ got me whacked so ahh, ya know, he had to go but I felt really bad about it. Hey ‘fergit’ about it, it was a business decision. Sometimes ya make those tough one’s but this one really bothered me ya know.” He stated he noticed in the days following, his thoughts would race and be dominated by feelings of guilt. In the last seven weeks, he went through periods of sleeping much more than normal or suffering from insomnia when he felt “stressed out and I don’t get stressed out, Doc. Normally I sleep like a baby.” He also related in the last month, he had been battling with the strong desire to stay home and “hibernate” and would struggle to fight the fatigue and loss of interest through these times “but I have a business to run. So I get out but most days I don’t wanna.” On the days where he simply couldn’t bring himself to leave home he said he sometimes hears voices telling him he is a “bad man” and deserves to die. He added he finds himself peering out the curtains fearing the cops will come arrest him at any moment. He added he’s noticed other changes that cause him concern, “I don’t know Doc, I used to really enjoy roughin’ people up a little. You know, gettin’ their attention, a busted finger or a knee, but here lately I don’t enjoy it so much.” He said these changes in his feelings, thoughts and behaviors had been going on for “a couple months.” When asked if he had any thoughts of suicide he said, “I’ve thought about wanting to die a couple times, here lately when whoever this is talking to me in my head, but I don’t think I’d actually do it. I don’t want my kids livin’ with that, ya know. I just sometimes feel like hurtin’ myself for what I’ve done, but I’m not sure what that would be.”
Two days prior to this interview, Mr. Soprano said he was very disturbed when his wife came up to the restaurant table he was sharing with his girlfriend and called him a, “cheater and a murderer.” He added, “First time in a while since I went to restaurant ‘cause my appetite’s been off for weeks. I’ve lost about 30 pounds.” He said his wife knew he had a girlfriend but had never confronted him. His wife stormed out and he cut the evening short because of intense feelings of guilt and the sudden onset of deprecating voices that led to a brief consideration of suicide but he said he had no plan, just fleeting “thoughts of dying or deserving to die. But it went away.” He added that he has noticed frequent mood changes, ”Doc, these ‘blue moods’ just come over me. I ain’t no crier but suddenly I’m sad and ballin’ like a baby and I don’t even know why.” He also reported a loss of sexual interest, “My girlfriend is a real good lookin’ broad Doc, ya know buddaboom(!) but she’s frustrated with me cause I ain’t really interested lately, if ya know what I mean. And that really ain’t like me.”
The client reported a very similar episode at age 28, with most of the same symptoms, many years ago after he began his life of crime. After killing his first victim, a “business” associate, Mr. Soprano recalled becoming withdrawn and emotional and hearing a similar voice repeatedly speaking to him that he was “a bad man.” At that time, Mr. Soprano’s wife actually considered having him committed but decided against doing so. After several weeks his symptoms subsided without treatment. “I just threw myself into my work and got over it.” He also reported that he never wanted to be in this life. He said he was “a good kid”. Until he was 24 he worked for a second cousin in a successful chain of shoe stores and looked forward to becoming a partner but his father was killed and he was enlisted to “take over the family business. “Just like in the godfather movie Doc. I’m like a real life version of Michael Corleone.”
After assurances that he would not try to harm himself he agreed to come in for testing.

END OF CASE STUDY

One of the requirements of this assignment is to diagnose what psychiatric illness Mr. Soprano is suffering from. Be assured he is suffering from one of the four diagnoses listed in the answer sheet portion.
The following list of diagnostic criteria and symptoms is not comprehensive but gives sufficient information for you to determine which diagnosis best fits. Many psychiatric problems share similar symptoms and this can be confusing. What you are looking for is the best match for the largest group of symptoms that match Mr. Soprano’s story. For the most part these are the same criteria any professional would use to diagnose Mr. Soprano, only some of the wording has been simplified. Confine your consideration of symptoms to the facts of the story to determine THE BEST FIT.
The four diagnoses for you to consider are:
o Major Depressive Disorder, Recurrent, with Psychotic Features
o Bipolar I Disorder
o Antisocial Personality Disorder
o Erectile Disorder

1. These are the diagnostic criteria of Major Depressive Disorder and regardless of the other symptoms must include either depressed mood or loss of interest or pleasure.
• Must have at least 5 of the following symptoms for at least 2 weeks.
o Feels sad, hopeless, helpless and empty
o Significant decrease in interest or pleasure in all or almost all activities.
o Significant weight loss not from dieting or weight gain with decrease or increase in appetite daily.
o Sleeping too much or too little
o Fatigue or loss of energy
o Feelings of worthless or inappropriate guilt
o Decreased ability to think or concentrate or indecisiveness.
o Recurrent thoughts of death or thoughts of suicide
Sometimes the person may or may not experience psychosis (a distortion of reality in some way that can be problems with who they are, when it is or where they are, or strange thoughts that are not logical or hearing or seeing things that no one else can see or hear that reinforces their depression. Meaning, the psychosis seems somehow tied to the depression, appears driven by the depression and may make it worse. Where if the depression goes away, the psychosis goes away.
2. The diagnostic criteria of Bipolar I Disorder
Bipolar disorder is a cycling mood disorder. That means the sufferer has distinct episodes where they are markedly (very) different from their normal personality. These episodes can come frequently or may have years between. However to be considered a bipolar episode it must persist for a week or more and they come in two types: Bipolar I and Bipolar II.
Bipolar I is an episode of mood and behavior change dominated by mania. They may have also suffered from depression in the past, or prior to, or following a manic episode. Lastly, the depression portion can be like the symptoms of depression described above but episodes of depression are not necessary for the diagnosis of Bipolar I Disorder.
Bipolar II is dominated more by episodes of depression with a least one time where the person exhibited some symptoms of mania called hypomania (manic light) and is not offered for your consideration.
The symptoms of mania in Bipolar I Disorder are listed below for you to consider for Mr. Soprano.

Bipolar I:
• Must exhibit a period where there is a distinct episode of abnormal and persistent elevated or irritable mood. Increased focus on activities or energy for at least a week.
• During this period of elevated mood the person must exhibit at least three of the following
o Inflated self-esteem/ grandiose
o Much less need for sleep
o More talkative or a pressure to keep talking
o Racing thoughts
o Either increased focused on work, sex or other endeavors or unfocused purposeless activity
o Overly involved in activities that involve high risk of painful consequences such as spending or sex.
• These changes are sufficient to cause significant impairment in functioning.
• Not attributable to drugs. Some stimulants can cause a similar presentation as mania.

3. The diagnostic criteria for Antisocial Personality Disorder.
A personality disorder is a pervasive personality style that would describe the person. It is not a mental illness in that the person may not clearly appear psychiatrically ill. The main feature of this disorder is a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood.
Antisocial Personality Disorder:
• Does not obey the law by engaging in behaviors that are grounds for arrest.
• Is deceitful with patterns of lying, using aliases or conning others for profit or pleasure
• Impulsive with no planning
• Irritable with arguments or physical fights
• Reckless disregard for safety of self or others
• Irresponsible including failure to sustain consistent work or honor financial obligations
• Lack of remorse with indifference to hurting others or rationalizing hurting or mistreating others.
• Must be 18 or older
• Evidence of conduct problems before age 15.
• The behaviors of the disorder can’t be tied to a more severe mental illness such as schizophrenia.
4. The diagnostic criteria for Erectile Disorder.
Erectile Disorder is part of a group of Sexual Dysfunction Disorders. These are disorders where the person has a significant problem in their ability to respond sexually or to experience sexual pleasure. Erectile Disorder is essentially a problem for a man to get and/or keep an erection during sexual activity.
Erectile Disorder:
• Must have one of the three of the following on all or almost all (75%-100%) occasions of sexual activity.
o Significant difficulty obtaining an erection during sexual activity
o Or maintaining an erection until completion of sex.
o Significant decrease in erectile rigidity.
The symptoms must be for a period longer than 6 months and are distressing to the sufferer. It is not better explained by stress or relationship problems and is not the result of drugs, alcohol or a medical condition.
Test Results and Interpretations
Intelligence
The Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV) is a cognitive assessment for those aged 16-89. It provides scoring representative of intellectual functioning in specific cognitive domains, as well as a composite score representing general cognitive ability. This administration of the WAIS-IV of Mr. Soprano yielded the following results. All the ranges are calculated at the 95% confidence interval.

Factor Standard Score Percentile Description Range

Verbal Comprehension 96 42nd Average 91-101
Perceptual Reasoning 92 30th Average 87-97
Working Memory 102 51st Average 97-107
Processing Speed 102 51st Average 97-107

Full Scale IQ (FSIQ) 45th Average

Assignment Assist and Guidance Sheet
This is to help you complete the assignment.
Critical Thinking: Choose the diagnosis. This is what clinical psychologists do. A clinical psychologist is provided information through interviews, outside information and assessment and then they put it together to ‘figure out’ what is going on. Those conclusions are then used to guide treatment. In explaining why you did not choose the other three diagnoses, focus on a few symptoms that are not present that caused you to rule that diagnosis out.
Interventions – pick two. There is one intervention that is not appropriate for Mr. Soprano. The other two address specific symptoms both physiologic and psychological that Mr. Soprano clearly presents. However there is one treatment that is just not indicated. One helpful hint; many studies show that two of the treatments in combination are much more effective in treating Mr. Soprano’s problem than either one alone.
Quantitative skills:
An IQ test is made up of many smaller tests. These then produce the subtest scores you see on the left. The Full Scale IQ is that one number we always hear when talking about a person’s Intelligence Quotient or IQ. For the purposes of the assignment the Full Scale IQ is an overall average of the individual subtest scores.
The column with all the “average”(s) merely means that all the scores fall in the average range of IQ scores. Meaning most people have scores like these. Not exceptionally high or low; they are average.
Understanding and calculating confidence intervals:
No one will get exactly the same score on an IQ test every time. There are variables in the person and in the administration that can introduce variance in the scores. The assumption is there is an optimal or true performance score for this person. This true IQ score would reveal itself as the most common score through multiple administrations of the test but of course you can’t keep giving the test over and over again because of something called ‘practice effect’. So you calculate using statistical methods how confident you are that the score you got would be captured in a range of scores the vast majority of the time if you could give the test repeatedly; say a hundred times. This is called a confidence interval. Another way to say it as a percentage, how confident am I, as the tester that the client’s actual, true IQ score falls in a specific range of scores most of the time on repeated administrations? In this case we are looking at ranges that capture a 95% confidence interval. Simply stated, as the tester, “I am confident that 95% of the time the person’s true IQ will be in the range of __A___ to __B____. Where A and B are the outside limit of the range of possible scores with the actual tested IQ score as the middle of that range. Or conversely there is a 5% chance their true IQ score falls above or below the range of scores given.
The percentile is where the person’s score falls, in relation to the standard distribution of scores. For instance a person with a score of 115 is at the 84th percentile, meaning about 84% of the population would score at or below below 115 and 16% at or above 115. (Average IQ is 100 at the 50th percentile).
Now, look closely at the scores and ranges. As stated these are at 95% confidence interval. It remains the same for the blank confidence interval for you to fill in for the Full Scale IQ. Again, because we don’t exactly know where the range of scores fall in relation to the person’s true IQ, we consider the score we do have as the center of the interval (with the understanding it may not be). With this information you should be able to calculate the FSIQ and the confidence interval numbers and explain Mr. Soprano’s percentile rank.
Social Responsibility: Now that you know the person a bit, what community resources would best fit Mr. Soprano needs? To do this you have to have some understanding of what those resources try to accomplish and would that be beneficial to this person and explain why. There is no singular right answer. It rests more on your explanation and educated knowledge of those listed resources.
Communication skills: This is to see if you can distill the background, interview content, test results and treatment recommendations into a short summary where the reader would still have a good understanding of the case without all the quotes or details.
Writing is a combination of aptitude and knowledge of grammar and sentence structure. As a college educated person the ability to write is essential to the appearance of competence. You don’t have to be an accomplished author but basic skills are a necessity. So here are a few rules:
• This is a professional, formal writing task. It is not writing a note or sending a text.
• Do not refer to yourself. No “I” or “me”. If you must, you are “this writer”.
• Do not use slang
• Do not use abbreviations. Texting has ruined people in this regard. IMHO 😉
• Read what you’ve written, aloud. If it sounds disjointed or doesn’t make sense then guess what?
• Do not answer with your opinion
For the case summary let’s see what a summary would look like of a similar length case study of Ms. Jane summarized in 1 paragraph as follows:
Ms. Jane is a 44 year old, white, female who presented with a complaint of anxiety. She reported experiencing anxiety in the form of severe nervousness, panic, fear and foreboding in most social situations, especially where she feels pressured to meet and speak to unfamiliar people. She is terrified she will embarrass herself by having nothing to say or humiliate herself in some way. She stated she has suffered with this for years but never sought treatment until now because her daughter is marrying in 6 months. She is terrified she will embarrass herself and her daughter. She was assessed and found to meet the criteria for Social Anxiety Disorder. IQ testing indicated that Ms. Jane’s intellectual functioning is in the average range. She was prescribed short term psychotropic medication in the form of an anxiolytic to relieve her sense of panic and nervousness. She also contracted for at least 5 sessions of Cognitive Behavioral Therapy to help her identify triggers for her anxiety and strategies to reduce her fearfulness. She was also referred to a support group of people with social phobias.
This reads very similarly to an actual summary paragraph of a psychological assessment. Note most of the details of the interview and assessment are omitted but there is enough to give you a pretty good idea what is going on with Ms. Jane and her treatment plan. Obviously Mr. Soprano’s will read differently because he has a different history and disorder but it should contain similar kinds of points.