EPPP: Part 2, Skills Quiz: Diagnostic Formulation

A 28-year-old client has a well-documented, 6-year history of schizophrenia, characterized by persistent auditory hallucinations and flat affect. For the past five months, he has also met the full symptomatic and duration criteria for a major depressive episode. His records indicate that outside of this current mood episode, and one previous 4-month depressive episode two years ago, he has consistently experienced psychotic symptoms for the entire 6-year duration of his illness.

What is the most accurate diagnostic formulation for this client's presentation?

An 8-year-old boy is evaluated for severe temper outbursts that occur, on average, four times per week. During these outbursts, he screams, throws objects, and is verbally aggressive. Between outbursts, his parents and teacher describe his mood as consistently irritable and angry most of the day, nearly every day. These symptoms have been present for 18 months and are observed in both home and school settings.

Which diagnosis best accounts for this child's symptoms?

A couple seeks therapy to address escalating arguments and feelings of emotional distance. They report these issues began after a significant financial setback a year ago and have not improved. Neither partner reports symptoms that meet the criteria for a formal mood or anxiety disorder, but they both state the relational problems are causing significant distress and impacting their co-parenting.

Which diagnostic code should the psychologist use to identify the primary focus of clinical attention?

A 20-year-old was in a severe car accident two weeks ago. Since the accident, he reports recurrent, intrusive memories of the crash, distressing nightmares about it, and intense physiological reactivity when he hears screeching tires. He has been avoiding driving and feels detached from his friends and family. He also reports persistent irritability and difficulty sleeping. The symptoms cause significant impairment in his ability to attend classes.

What is the most accurate diagnosis at this time?

A 29-year-old woman is evaluated due to a pattern of behavior that includes impulsivity in spending and sexual encounters, affective instability with intense mood shifts lasting hours, and frantic efforts to avoid perceived abandonment by her partner. She also reports a chronic feeling of emptiness and an unclear sense of self. This pattern has been present since her late teens and has damaged multiple relationships.

This clinical picture is most indicative of which diagnosis?

A 45-year-old man, a military veteran, meets all symptomatic criteria for Posttraumatic Stress Disorder (PTSD) related to combat exposure. He has been experiencing these symptoms for three years. However, he reports that he did not experience any significant symptoms until approximately one year after he returned from his last deployment.

Which specifier is required for this client's PTSD diagnosis?

A 30-year-old is hospitalized after intentionally contaminating his own wound to produce a severe infection. His medical history is notable for two dozen prior hospitalizations for a variety of self-induced illnesses. When interviewed, he seems pleased with the medical attention. There is no evidence of external incentives such as financial gain or avoidance of legal responsibilities.

What is the most likely diagnosis?

A psychologist is evaluating a 10-year-old child for inattention and restlessness. The parents report the child has difficulty sustaining attention in school and at home, is constantly fidgeting, and often loses things. The teacher confirms these observations. The parents also mention the child has several elaborate routines that must be followed exactly, becomes extremely distressed by minor changes, and has an encyclopedic knowledge of train schedules, a topic he discusses at length without regard for listener interest.

In formulating a diagnosis, the psychologist must primarily consider that the child's inattentive symptoms could be a manifestation of which co-occurring condition?

A 19-year-old is seen for an intake appointment, reporting a 4-week history of symptoms that meet the full criteria for a major depressive episode. He is a poor historian and cannot reliably state whether he has had past episodes of elevated or irritable mood. The psychologist plans to gather collateral information from the client's parents next week.

Given the current uncertainty about the client's psychiatric history, what is the most appropriate initial diagnosis?

A 48-year-old man reports that for the past 15 years he has experienced an intense, recurrent sexual arousal from observing an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity. He reports feeling significant shame and distress about these urges. He has never acted on them due to fear of being caught. His distress over the urges is interfering with his ability to form intimate relationships.

Which of the following is the most accurate diagnosis?

A 40-year-old architect is referred for treatment due to problems at work. His supervisor describes him as being so preoccupied with details, rules, and schedules that he frequently misses deadlines. The client confirms this, stating that projects must be 'perfect' before he can submit them. He is devoted to work to the exclusion of leisure activities and is described by colleagues as rigid and stubborn. This pattern is stable and has been present since early adulthood.

This presentation is most consistent with which diagnosis?

A 70-year-old woman is brought for an evaluation by her son, who reports she has shown a gradual decline in memory over the past two years. More recently, in the last six months, she has started having vivid, recurrent visual hallucinations of small children playing in her living room. She has also developed motor symptoms consistent with parkinsonism, such as a tremor and slowed movement. Her cognitive abilities tend to fluctuate significantly throughout the day.

This combination of cognitive decline, visual hallucinations, and parkinsonism is most suggestive of which diagnosis?

A 34-year-old man presents with a six-month history of preoccupation with the fear that he has colon cancer. This fear persists despite multiple negative colonoscopies and reassurance from his gastroenterologist. He reports no significant gastrointestinal symptoms other than occasional, mild stomach upset, which he interprets as evidence of the tumor. He spends at least two hours a day checking his body and researching symptoms online.

Which diagnosis best captures this clinical presentation?

A psychologist evaluates a client who presents with clinically significant depressive symptoms that cause impairment in her work functioning. The client reports a persistently low mood and two other symptoms from the Major Depressive Episode criteria. The symptoms have been present for three weeks. This presentation does not meet the full criteria for Major Depressive Disorder or Persistent Depressive Disorder. The psychologist documents that the reason criteria are not met is the subthreshold number of symptoms.

What is the most precise diagnosis for this presentation?

A client is diagnosed with a Major Depressive Episode. During the clinical interview, the psychologist notes that for the majority of days in the past two weeks, the client has felt keyed up, has been unusually restless, and has expressed worry that something awful might happen. The client also reports significant difficulty concentrating because of this persistent worry.

What is the most appropriate specifier to add to the diagnosis of Major Depressive Disorder?

A psychologist reviews the intake paperwork for a new client. The client endorsed symptoms consistent with a major depressive episode. On the form's medical history section, the client wrote, 'diagnosed with hypothyroidism 3 months ago, not yet on medication.' The client's primary symptoms are fatigue, depressed mood, weight gain, and difficulty concentrating.

Which diagnostic step is most critical before assigning a diagnosis of Major Depressive Disorder?

A 42-year-old client presents with a history of recurrent mood swings. He reports a distinct one-week period six months ago where he felt euphoric, needed only two hours of sleep per night, had racing thoughts, and was exceptionally talkative. During this week, he impulsively bought a sports car he could not afford, leading to significant financial distress and conflict with his spouse. He also reports several 4- to 5-day periods of milder elevated mood and energy, as well as two separate episodes of major depression in the past five years.

Based on this clinical history, which diagnosis is the most accurate formulation?

A 50-year-old client reports a pervasive, lifelong pattern of social and interpersonal deficits marked by acute discomfort with close relationships, as well as cognitive and perceptual distortions and eccentricities of behavior. He describes odd beliefs, such as feeling he can read others' minds, and his speech is often vague and metaphorical. He has few friends and experiences excessive social anxiety that does not diminish with familiarity.

This presentation is most consistent with which personality disorder?