Diagnostic Formulation - Eppp Skills

1. Which diagnostic step is most critical before assigning a diagnosis of Major Depressive Disorder?
   Answer: Determine if the symptoms are a physiological consequence of the client's untreated hypothyroidism. The most critical step is to determine if the depressive symptoms are attributable to the physiological effects of another medical condition, in this case, untreated hypothyroidism. The symptoms of hypothyroidism (fatigue, depressed mood, weight gain, concentration difficulties) significantly overlap with those of Major Depressive Disorder. A diagnosis of MDD cannot be made if the symptoms are better explained by a medical condition. Therefore, ruling out 'Depressive Disorder Due to Another Medical Condition' is the priority.
2. Which of the following is the most accurate diagnosis?
   Answer: Voyeuristic Disorder The correct diagnosis is Voyeuristic Disorder. According to DSM-5-TR, a paraphilic disorder can be diagnosed if a paraphilia (an intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners) causes clinically significant distress or impairment to the individual, OR has been acted upon with a non-consenting person. In this case, even though the client has not acted on his urges, his voyeuristic interest is causing him clinically significant distress and impairment in his social functioning, thus meeting the criteria for a disorder.
3. In formulating a diagnosis, the psychologist must primarily consider that the child's inattentive symptoms could be a manifestation of which co-occurring condition?
   Answer: Autism Spectrum Disorder The child's insistence on sameness, extreme distress at changes in routine, and highly restricted, fixated interests (train schedules) are core features of Autism Spectrum Disorder (ASD). In individuals with ASD, apparent inattention may result from focusing on their internal thoughts or restricted interests rather than the task at hand. It is critical to differentiate between inattention due to ADHD and inattention secondary to the core features of ASD, as the two disorders frequently co-occur but require distinct diagnostic consideration.
4. This presentation is most consistent with which diagnosis?
   Answer: Obsessive-Compulsive Personality Disorder The diagnosis is Obsessive-Compulsive Personality Disorder (OCPD). The client's presentation is characterized by a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency. This is ego-syntonic (the client sees his way as the right way) and differs from Obsessive-Compulsive Disorder (OCD), which involves ego-dystonic, intrusive thoughts (obsessions) and repetitive behaviors (compulsions) aimed at reducing anxiety.
5. Which diagnosis best accounts for this child's symptoms?
   Answer: Disruptive Mood Dysregulation Disorder The correct diagnosis is Disruptive Mood Dysregulation Disorder (DMDD). The hallmark features of DMDD are present: severe recurrent temper outbursts that are grossly out of proportion in intensity or duration to the situation, occurring frequently (3+ times per week), and a persistently irritable or angry mood between the outbursts that is observable by others. The duration and presence in multiple settings criteria are also met. DMDD cannot be diagnosed alongside ODD, and it takes diagnostic precedence if criteria for both are met.
6. Which specifier is required for this client's PTSD diagnosis?
   Answer: With delayed expression The correct specifier is 'With delayed expression.' This specifier is used if the full diagnostic criteria for PTSD are not met until at least 6 months after the traumatic event(s), although some symptoms may appear sooner. Since the client's full symptoms did not manifest until a year after his deployment, this specifier is required. 'Complex PTSD' is a clinically used term but is not a formal DSM-5-TR diagnosis or specifier. 'Chronic' is a course descriptor, but 'With delayed expression' is the required formal specifier.
7. This presentation is most consistent with which personality disorder?
   Answer: Schizotypal Personality Disorder This presentation is most consistent with Schizotypal Personality Disorder. Key features described include cognitive or perceptual distortions (odd beliefs, magical thinking), eccentric behavior, odd thinking and speech, and a lack of close friends, coupled with acute discomfort in social situations. While Schizoid and Avoidant Personality Disorders involve social isolation, they lack the prominent cognitive and perceptual distortions characteristic of Schizotypal Personality Disorder.
8. This clinical picture is most indicative of which diagnosis?
   Answer: Borderline Personality Disorder The described symptoms are hallmark features of Borderline Personality Disorder (BPD). The pattern includes frantic efforts to avoid abandonment, unstable and intense interpersonal relationships, identity disturbance, impulsivity, affective instability, chronic feelings of emptiness. While Bipolar II Disorder involves mood shifts, they are distinct episodes of hypomania and depression lasting days to weeks, unlike the rapid, reactive shifts in BPD. HPD and DPD do not typically include the identity disturbance, emptiness, and specific pattern of impulsivity seen here.
9. This combination of cognitive decline, visual hallucinations, and parkinsonism is most suggestive of which diagnosis?
   Answer: Major Neurocognitive Disorder with Lewy Bodies The correct diagnosis is Major Neurocognitive Disorder with Lewy Bodies. The core diagnostic features include fluctuating cognition, recurrent visual hallucinations that are typically well-formed and detailed, and spontaneous features of parkinsonism. The temporal sequence is also important; in Lewy Body dementia, the cognitive decline often occurs before or concurrently with the motor symptoms. In Parkinson's Disease dementia, the motor symptoms are established for at least a year before cognitive decline begins.
10. Which diagnosis best captures this clinical presentation?
    Answer: Illness Anxiety Disorder The diagnosis that best fits is Illness Anxiety Disorder. The core feature is a preoccupation with having or acquiring a serious illness. Somatic symptoms are not present or, if present, are only mild in intensity. The client's mild stomach upset fits this criterion. His preoccupation is clearly excessive and is accompanied by high anxiety and excessive health-related behaviors (checking, researching). The belief is not of delusional intensity, as he continues to seek medical testing, suggesting some doubt.
11. Based on this clinical history, which diagnosis is the most accurate formulation?
    Answer: Bipolar I Disorder The correct diagnosis is Bipolar I Disorder. The key diagnostic feature is the presence of at least one lifetime manic episode. The client's one-week period of elevated mood with decreased need for sleep, racing thoughts, and impulsive behavior that caused marked functional impairment (significant financial distress) meets the criteria for a manic episode. The presence of even one manic episode is sufficient for a Bipolar I diagnosis, regardless of any history of hypomanic or major depressive episodes.
12. What is the most accurate diagnostic formulation for this client's presentation?
    Answer: Schizoaffective Disorder, Depressive Type. The correct diagnosis is Schizoaffective Disorder, Depressive Type. The essential criterion for Schizoaffective Disorder is an uninterrupted period of illness during which there is a major mood episode (depressive or manic) concurrent with Criterion A of schizophrenia. Crucially, delusions or hallucinations must be present for 2 or more weeks in the absence of a major mood episode during the lifetime duration of the illness. This client meets these criteria, as his psychotic symptoms are persistent even when he is not depressed. Since he only has a history of major depressive episodes, the Depressive Type specifier is appropriate.
13. What is the most precise diagnosis for this presentation?
    Answer: Other Specified Depressive Disorder The most precise diagnosis is Other Specified Depressive Disorder. This category is used in situations where the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific depressive disorder. In this case, the psychologist has identified the reason as an insufficient number of symptoms for a major depressive episode. 'Unspecified Depressive Disorder' would be used if the clinician did not specify the reason. 'Subsyndromal Depression' is a descriptive term, not a formal DSM-5-TR diagnosis.
14. What is the most appropriate specifier to add to the diagnosis of Major Depressive Disorder?
    Answer: With anxious distress The correct specifier is 'With anxious distress.' This specifier is applied when at least two of the following symptoms are present during a major depressive episode: feeling keyed up or tense, feeling unusually restless, difficulty concentrating because of worry, fear that something awful may happen, and feeling that the individual might lose control. The client's report of feeling keyed up, restless, having difficulty concentrating due to worry, and fearing something awful will happen meets the criteria.
15. Which diagnostic code should the psychologist use to identify the primary focus of clinical attention?
    Answer: Z63.0 (V61.10) Relationship Distress with Spouse or Intimate Partner The correct code is Z63.0 (V61.10) Relationship Distress with Spouse or Intimate Partner. This 'Z-code' is used when a pattern of interaction between spouses or partners is associated with clinically significant distress or impairment in functioning, and it becomes a focus of clinical attention. Since neither partner meets criteria for a mental disorder and the problem is explicitly relational, this code accurately captures the reason for seeking treatment. An Adjustment Disorder diagnosis is not appropriate because the problem is defined as relational rather than an individual's maladaptive response to a stressor.
16. What is the most likely diagnosis?
    Answer: Factitious Disorder Imposed on Self The most likely diagnosis is Factitious Disorder Imposed on Self. The key features are the intentional falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception. The individual presents themself to others as ill or injured. The deceptive behavior is evident even in the absence of obvious external rewards. This distinguishes it from Malingering, where the motivation is an external incentive (e.g., money, avoiding work).
17. Given the current uncertainty about the client's psychiatric history, what is the most appropriate initial diagnosis?
    Answer: Major Depressive Disorder, single episode, moderate (provisional) The most appropriate initial diagnosis is Major Depressive Disorder, single episode, moderate (provisional). The client currently meets the criteria for an MDE. However, because a history of manic or hypomanic episodes cannot be definitively ruled out due to the client being a poor historian, the diagnosis is provisional. The 'provisional' specifier indicates that there is a strong presumption that the full criteria will ultimately be met for the disorder, but not enough information is available to make a firm diagnosis. This is the most precise way to capture the current clinical picture while acknowledging the diagnostic uncertainty.
18. What is the most accurate diagnosis at this time?
    Answer: Acute Stress Disorder The correct diagnosis is Acute Stress Disorder (ASD). The client is experiencing characteristic post-traumatic symptoms (intrusion, avoidance, negative mood, arousal) following a traumatic event. The key diagnostic factor here is the duration. ASD is diagnosed when the duration of the disturbance is from 3 days to 1 month after trauma exposure. Since the symptoms have been present for two weeks, ASD is the appropriate diagnosis. If the symptoms were to persist for more than one month, the diagnosis would be changed to PTSD.

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