Case Studies in Assessment
Prior to beginning work on this discussion, read the assigned chapters from the text. It is highly recommended that you review each of the brief Blumenfeld (2012) video clips demonstrating the administration of a mental status examination. These are listed in the recommended resources and may require that you download Quicktime in order to view them. Although not required, these videos show the administration of a mental status exam and may prove helpful in this discussion.
USE THE CASE STUDY Case 17.3 Depressed and Withdrawn
Peter V. Rabins, M.D., M.P.H. see at the bottom of page
You must assess the client using one or more of the assessment instruments discussed in this week's reading.
For this discussion, you will take on the role of a psychology intern at a mental health facility working under the supervision of a licensed psychologist. In this role, you will conduct a psychological evaluation of a client referred to you for a second opinion using valid psychological tests and assessment procedures. The case study you select from the textbook will serve as the information provided to you from the professional who previously evaluated the client (e.g., the psychologist or psychiatrist).
In your initial post, begin with a paragraph briefly summarizing the main information about the case you selected. Evaluate and describe the ethical and professional interpretation of any assessment information presented in the case study. Devise an assessment battery for a psychological evaluation that minimally includes a clinical interview, mental status exam, intellectual assessment, observations of the client, and at least two assessment instruments specific to the diagnostic impressions (e.g., attention deficit/hyperactivity disorder, post-traumatic stress disorder, autism spectrum disorder, etc.). The assessment battery must include at least one approach to assessing your client which is different from the assessments previously administered. The assessment plan must be presented as a list of recommended psychological tests and assessment procedures with a brief sentence explaining the purpose of each test or procedure. Following the list of tests and assessment procedures you recommend for your client, compare the assessment instruments that fall within the same categories (e.g., intellectual or achievement), and debate the pros of cons of the instruments and procedures you selected versus the instruments and procedures reported by the referring professional.
Case 17.3 Depressed and Withdrawn
Peter V. Rabins, M.D., M.P.H.
Arthur Cullman, a 71-year-old man, was referred to a psychiatrist by his primary care physician for evaluation of depressive symptoms that had not responded to medication trials. His wife reported that Mr. Cullman had begun to change at age 68, about a year after his retirement. He had gradually stopped playing golf and cards, activities he had enjoyed "for decades." He had explained that seeing his friends was no longer "fun," and he generally refused to socialize. Instead, he sat on the couch all day, worrying about finances and the future. He denied sadness, however, and any suicidal or homicidal ideation. His wife said he was sleeping 10-12 hours a day instead of his customary 7 hours and that he had, uncharacteristically, gained 8 pounds in less than 1 year.
His wife had become worried that retirement had left Mr. Cullman depressed, and she had mentioned her concerns to their primary care physician. Their physician agreed and prescribed sertraline (titrated to 100 mg/day for 8 months) and then sustained-release venlafaxine (titrated to 150 mg twice daily and maintained at that level for over 1 year). Mr. Cullman's symptoms gradually worsened during these medication trials, and the internist ultimately referred him for a psychiatric evaluation.
Mr. Cullman's past psychiatric history was notable for an episode in his 20s when he had difficulty at work, felt apathetic and unconnected, and had difficulty concentrating. These symptoms persisted for several months and resolved without treatment as his work situation improved.
Mr. Cullman's family history was positive for a single episode of major depression in one of his two younger brothers; the depression responded well to psychotherapy and an antidepressant medication. His mother had developed dementia in her 70s.
Mr. Cullman's personal history revealed unremarkable development and childhood, graduation from college with a degree in business, a successful career as a corporate manager, and retirement at age 67. He and his wife had been married for 45 years, denied significant discord, and had three children and four grandchildren who were in good health. Premorbidly, he had been outgoing, energetic, and well organized.
Mr. Cullman's medical history was notable for hypertension, hyperlipidemia, and type 2 diabetes mellitus. He was taking lisinopril, metformin, simvastatin, and venlafaxine.
Mental status examination revealed an alert, cooperative man who was neatly dressed and who had a steady but slow gait and no abnormal movements other than psychomotor slowing. Mr. Cullman's speech was soft in volume but normal in rate and rhythm, without paraphasic errors. He had a limited range of emotional expression, denied feeling sad or guilty, but felt he had retired too early. He denied self-blame, hopelessness, and suicidal thoughts or plans. He was aware that his wife was concerned and acknowledged that he was less energetic and active than in the past. He ascribed these changes to his retirement. He said he was generally satisfied with his life.
On cognitive examination, Mr. Cullman was oriented except for the date. He remembered one of three objects in 2 minutes, performed three of five serial 7 subtractions correctly, named four common objects correctly, and repeated a complex sentence accurately. He was able to draw the face of a clock and place the numbers correctly but was not able to correctly place the hands at 10 minutes after 2. His blood pressure was 142/82, and his pulse was 84 and regular. His physical examination was noncontributory. His neurological examination revealed intact cranial nerves and 1+ symmetric deep tendon reflexes.
Diagnosis
. Major neurocognitive disorder due to Alzheimer's disease
Discussion
This 71-year-old man presents with a 3-year history of gradual social withdrawal. Mr. Cullman has failed two prolonged trials of antidepressant medication, one of which did not reach maximum dose (sertraline) and one of which reached a moderately high dose (venlafaxine). He had a successful marriage and career, and the presenting apathy is a significant change from his lifelong baseline. He may have had an episode of depression in his 20s, but this is not well established. He has a family history of depression in a brother and late-life dementia in his mother. The prominent symptoms on examination are slowness, lack of self-reported sad or dysphoric mood, lack of concern about his decline, increased sleep, and a cognitive examination that indicates impairments in memory, concentration, and math, as well as impaired clock drawing.
The differential diagnosis in Mr. Cullman's case includes a primary dementia (neurocognitive disorder) and major depression with marked apathy. Favoring major depression is the presence of lack of interest in usually enjoyed activities, hypersomnia, and unhappiness with retirement.
The more likely diagnosis, however, is major neurocognitive disorder due to Alzheimer's disease, with apathy and mood disturbance. This diagnosis is supported by the presence of memory, executive function, and visuospatial function abnormalities (abnormal clock drawing) on examination. The history includes a gradual onset and slow progression, which is more consistent with a dementia than a depression, as is the lack of a patient-reported mood change. Although Alzheimer's disease is the most likely cause of the neurocognitive disorder, reversible causes of dementia should be investigated.
DSM-5 has improved the diagnostic approach to dementia in several ways. First, it no longer requires that memory be impaired, a requirement that is appropriate for Alzheimer's disease but not necessarily for frontotemporal dementia or vascular dementia. By listing a set of impairments by domain-complex attention, executive function, learning and memory, language, perceptual-motor, and social cognition-DSM-5 broadens clinician understanding of the protean manifestations of the neurocognitive disorders. Unfortunately, however, DSM-5 requires impairment in only one domain, a change not only from DSM-IV but also from most conceptualizations of dementia that require multiple impairments. In DSM-IV and ICD, impairments in a single domain, be it language, perception, or memory, were identified as focal impairments and classified separately because the differential diagnosis for them is distinct from that for multiple impairments.
A second major change is the use of neurocognitive disorder as the overarching term. This was presumably done to destigmatize cognitive impairment, because the word demented is thought to be pejorative. Time will tell whether this change is widely embraced and whether it will aid patients and families in accepting the diagnosis and lead to improved care by breaking down barriers due to stigma. The term dementia is still included as an alternative description. I favor the traditional term because neurocognitive implies that the manifestations are cognitive and "neurological," whereas changes in mood, experience (hallucinations and delusions), and behavior (agitation, wandering, apathy) can also be symptoms of dementia.
A third general change is the division into minor and major neurocognitive disorders. This change acknowledges the recognition in recent years that many neurodegenerative disorders develop so gradually that subtle impairments are present before function is impaired. This demarcation will become clinically relevant in the future when preventive strategies depend on recognizing very mild disorder.
Suggested Readings
1. Blazer D: Neurocognitive disorders in DSM-5. Am J Psychiatry 170(6):585-587, 2013 PubMed ID: 23732964
2. Rabins PV, Lyketsos CG: A commentary on the proposed DSM revision regarding the classification of cognitive disorders. Am J Geriatr Psychiatry 9(3):201-204, 2011 PubMed ID: 21425503
3. Rosenberg PB, Onyike CU, Katz IR, et al: Clinical application of operationalized criteria for 'Depression of Alzheimer's Disease.' Int J Geriatr Psychiatry 20(2):119-127, 2005 PubMed ID: 15660424
Introduction
John W. Barnhill, M.D.
All of the neurocognitive disorders feature prominent, acquired cognitive deficits. These cognitive disorders can be divided into two broad groups-acute delirium and the more chronic neurocognitive disorders (NCDs)-each of which can be further characterized.
Delirium is characterized as a fluctuating disturbance of attention, awareness, and cognition that develops acutely and in the context of one or more identified physiological precipitants. Delirium can be further characterized in regard to such factors as duration, activity level, and etiology. Most often encountered among medically hospitalized and/or substance-abusing patients, delirium requires a careful search for etiology-which is often multifactorial. If the delirium is caused by substance withdrawal or intoxication, the pertinent diagnosis is delirium, comorbid with possible substance use disorders. For example, a patient might be coded as having alcohol withdrawal delirium, acute, hyperactive, along with an alcohol use disorder.
In addition to acute delirium, this chapter of DSM-5 also describes chronic neurocognitive disorders. Two aspects of the nomenclature may be confusing. First, most of the chronic neurocognitive disorders have been generally described as dementias. Although still in use, the term dementia is sometimes seen as having a pejorative connotation. In addition, this term may better fit the disorders that are progressive and most commonly affect older adults (e.g., Alzheimer's disease) rather than the abrupt and static cognitive decline related to a disorder such as traumatic brain injury (TBI).
A second issue is that the term neurocognitive implies an emphasis on cognitive deficits. All of the NCDs involve multiple deficits, however, and DSM-5 suggests that the assessment of NCD include an assessment of such executive functions as complex attention, learning and memory, language, visuoconstructional perceptual ability, and social cognition. Furthermore, all of the NCDs can have prominent personality and behavioral components that may be the most visible and dysfunctional aspect of the clinical presentation.
The neurocognitive disorders are divided into major and mild categories based on the person's cognitive functioning and level of practical independence.
Major neurocognitive disorder conforms to criteria used previously within psychiatry, medicine, and neurology, and usefully identifies clusters of people with similar deficits and care needs.
Mild neurocognitive disorder, a new category in DSM-5, represents an attempt to identify clusters of patients whose impairment may be relatively subtle but still significant. As is true throughout psychiatry, clinical judgment is required to avoid excessive pathologizing. For example, occasional "senior moments" are not mild NCD. Instead, mild NCD is intended to identify people whose deficits are impairing their quality of life to the extent that they warrant clinical attention. A second reason for creating a mild NCD diagnosis is the reality that most of the major neurocognitive disorders are inexorably progressive, and the effort to reduce their catastrophic impact will likely include recognition and treatment at an early stage of disease progression.
Suggested Readings
1. Blazer D: Neurocognitive disorders in DSM-5. Am J Psychiatry 170(6):585-587, 2013 PubMed ID: 23732964
2. Ganguli M, Blacker D, Blazer DG, et al: Classification of neurocognitive disorders in DSM-V: a work in progress. Am J Geriatr Psychiatry 19(3):205-2010, 2011 PubMed ID: 21425518
3. Weiner MF, Lipton AM (eds): Clinical Manual of Alzheimer Disease and Other Dementias. Washington, DC, American Psychiatric Publishing, 2012
4. Yudofsky SC, Hales RE: Clinical Manual of Neuropsychiatry. Washington, DC, American Psychiatric Publishing, 2012
Attachment:- require reading.rar