Speaking the same language: Diagnosis Case Study :Reflective Journal

Scenario 1

Dear colleague,

May I please request an assessment, diagnosis and treatment plan for my patient Sarah Smith? She is a 19-year-old shop assistant registered with our practice. She has two young children, Stephen 6 months and Mark, 2-years-old. She lives alone in a rented flat and has frequent money worries. She has Irritable Bowel Syndrome and recurrent migraines. She was a well child but family life was strained growing up as her father was physically abusive to her and her mother abused alcohol. She attended local schools but was bullied and became shy and withdrawn. 

She repeatedly attends the surgery complaining of low mood, tearfulness and of having no energy. She reports having dark thoughts about herself, the world and the future and admitted at the most recent visit to having thoughts of suicide. She is sleeping quite poorly and her appetite is reduced but sometimes she can binge on food and make herself sick.

This period has lasted almost three weeks and appears to have come out of nowhere. Usually with Sarah you can pin the low mood on a recent stressful event, such as falling out with her friends or a new partner. One recent breakup involved Sarah having stitches to her forearm after cutting herself with a bathroom razor to deal with the stress.  Most often she reports being 'empty but OK' and we do not see her for months on end. Interestingly, last year she attended the surgery asking for travel vaccinations as she planned to travel around India for six months and was found by my colleague to be very chatty, upbeat and made one or two worrying comments that she was 'destined for greatness' but this settled after several days.

She frequently drinks over the recommended limits for alcohol and this has caused her problems with work and the police in the past. She’s come this morning to know what's wrong with her and I’d be very grateful for your opinion. In clinic you’ll find that she is shy, finds eye contact difficult and can take things quite literally. Her children are strong protective factors and she loves collecting stamps. 

Many thanks,

Dr R Keen, GP

• Using the referral letter as a basis and utilising the ICD-10 criteria, can you list and justify potential psychiatric diagnoses that Sarah may have?
• Imagine that you were asked to make ONE ICD-10 diagnosis based on the referral letter alone - how would you do this and do you have any comments on the process you would use?
• How confident are you that you would have reached the same diagnosis as other members of your study cohort? If you suggested different diagnoses when you have the same referral letter and the same ICD-10 criteria to refer to, why might these differences occur?
• Is it possible to have more than one diagnosis?

Scenario 2

You are a locum GP working in a small town surgery. Your next patient is Patricia Smith. You have not met her before so check her file. She is a 50-year-old childminder, non-smoker and occasional alcohol drinker. She has two children, the youngest of which attends the practice regularly for a methadone script. Patricia is well known in the practice as 'a worrier' and being fearful to have her flu vaccination and always asks for her blood pressure to be checked, even if she visits for a minor ailment. She visits the practice several times a year. 

As Patricia and her husband, John, enter the clinic room they are bickering about their money worries. John is off work at the moment with a bad back and the local steel works are threatening the older workers like John with redundancy so you assume this is causing a strain. After their GP visit they plan to visit the bank and renegotiate their house payments. 

Patricia walks with a limp and sits on the chair, rubbing her left knee. 'Oh my arthritis is just not getting any better doctor!' she complains but then becomes tearful. She is not sleeping well, feels exhausted all the time and isn’t meeting friends for coffee as she has 'lost interest'. This has been going on for three weeks. She has poor concentration, feels bad about herself and feels guilty that she should be a better mother to her son, who had always worried about her. She feels 'really fed up' and it’s a struggle to get out of bed sometimes. She has taken a week off sick with 'stress'. She is finding it a problem to look after her home but is managing to take care of herself.

She is not suicidal and has hopes for the future. Other than her knee she is physically well.

Patricia wants to know what's wrong with her. To help make the diagnosis you ask her to complete the PHQ-9 questionnaire.

Using the vignette above, please provide a diagnosis using:

• The ICD-10 criteria 
• The DSM-IV multi-axial evaluation
• Classification systems in psychiatry can be criticised for taking a reductionist approach to complex human experiences and interactions. With reference to the DSM-IV do you find this criticism is valid?
• Given the experiences you had using the ICD-10 criteria for the last scenario (Sarah Smith), can you comment on which diagnostic system you prefer? Are they mutually exclusive or can they be combined? 
• Are you going to tell her she has a moderate depressive episode or share your multi-axial evaluation?
• Are rating scales helpful?

Scenario 3

You are a GP who has been asked to attend a 'formulation meeting' at the first-episode psychosis service for one of your patients. His name is Ryan Jones and he is 19-years-old.

Ryan was born on time to a well mother but his father had schizophrenia. At school Ryan was a quiet but polite boy and had aspirations to be an electrician. At 14-years-old his parents split up and he moved to a new town with his mum. He fell in with a bad crowd and started to smoke cannabis most days and his school work suffered. Despite this, he did manage to get a place at college and he stopped using cannabis for the next few years. 

At 16-years-old he started to fall behind with his college work and began to lose interest with his friends. Whilst quiet at school he was talkative at home but this began to diminish and he started spending more time in his room. He and his mum argued as he used to leave microwave meal packets in his bedroom but she realised he was eating more in his room than at the dinner table. Eventually, Ryan insisted on eating microwave meals that he had bought and prepared himself. 

6 months ago, Ryan became anxious in the evenings and made his mum buy him a chain for his bedroom door. His mum heard him mumbling at night to himself but he reassured her that he was well. The pair started to argue more when his mum moved her new partner into the home but she put this down to there being a new man in the house. Ryan started to use cannabis again to deal with the stress. 

6 weeks ago, Ryan had a panic attack and complained that the next door neighbours were using the Wi-Fi signal to spy on him. He was fearful of being controlled and so he ran into nearby woods and the police had to find him. He was detained by police officers when found speaking incoherently and complaining that the secret service were conspiring to have him locked into a science lab as his birth was orchestrated to ensure his genetic material would be sold on eBay.

Ryan was detained under section II of The Mental Health Act and admitted to the local psychiatric ward.The psychiatrist provides a working diagnosis of psychosis. 

Using the ICD-10 criteria, please provide a diagnosis

Using the DSM-V, please provide a multi-axial evaluation

The ICD-10 and the DSM-V both provide what we call a 'snapshot' diagnosis of varying scope. Psychiatric formulation (please see the attached article) is an essential aid to diagnosis. Using the case vignette above please provide a basic formulation using the key headings:

Diagnosis 

1. Predisposing factors
2. Precipitating factors 
3. Perpetuating factors
4. Protective factors
5. Iatrogenic factors
6. Risks
7. Prognosis 

• With reference to your formulation, how does it differ to the ICD-10 and DSM-IV diagnostic frameworks?

Post instructions:

• Make a minimum of 2 direct responses to discussion prompts scenarios delivered by your tutor, using academic language and Harvard referencing in text citation and reference list. These posts should be between 150 and 300 words it depends on Scenario (excluding references). You are cautioned against overlong posts - you will attract marks if you are concise and include critique rather than just setting out the theory.

 Write Post 1

Write Post 2

Write a reflective Journal of 150 words.

Reflective Journal 100 to 150 word

Reflection is a means by which you, as a professional, can structure your thinking to encourage personal and professional growth and meaningful change in practice. It is a personal, continuous, structured process and further details about frameworks to use were discussed on Day 3 of the Study Skills module.

When writing in your journal, write in the first person, rather than using an objective academic style of writing (e.g. ‘I felt...’ rather than ‘it is thought that...’). You may wish to use the module learning objectives and/or an experience in practice linked to your module learning as the focus for your reflection

When writing in your journal, write in the first person, rather than using an objective academic style of writing (e.g. ‘I felt...’ rather than ‘it is thought that...’). You may wish to use the module learning objectives and/or an experience in practice linked to your module learning as the focus for your reflection.

Please ensure that you:

• provide a clear focus/topic,
• are honest about your thoughts, feelings, values, strengths and weaknesses,
• address gaps in your knowledge and outline what you are going to do about them, or show what knowledge you have gained (e.g. provide references you have accessed or explain how new knowledge or insight will affect your practice in the future).

For your Week 1 entry, set out your expectations of the module and what you want to learn from this part of your programme. You may want to draw on the learning aims and outcomes set out at the top of the module page. Aim to write approximately 100 to 150 words.

For each of your entries for Weeks 2 to 5, give a short reflective progress report of approximately 50 words.

For your final, Week 6 entry, reflect on the module as a whole, perhaps using a fuller reflective cycle such as the Gibbs or Kolb methods. Aim to write approximately 200 words.