The following diagnoses are considerations. Ms. Lewis had symptoms, which may be consistent with: Schizoaffective Disorder (295.70), Posttraumatic Stress Disorder (309.81), Major Depressive Disorder (296.32), Schizophrenia (295.90), and Delusional Disorder (297.1).
295.70 Schizoaffective Disorder, Depressive type, with multiple episodes, currently in acute episode:
Ms. Lewis experiences symptoms concurrent with Major Depressive Disorder and Schizophrenia. Her symptoms were consistent with Persecutory type Delusional Disorder as evidenced by her belief that her cellmates intended to harm or steal from her. Her symptoms were consistent with a depressive disorder, and were likely not attributed to the effects of substance abuse or other medical …show more content…
Lewis was exposed throughout her childhood to physical, emotional, and verbal abuse. This abuse continued with both of her romantic relationships. Ms. Lewis stated that she actually feared her ex boyfriend finding her again. Ms. Lewis expressed having the belief that no one could be trusted and excessive guilt over her past. She appeared irritable as evidenced by her not wanting to answer the interview questions. She reported having difficulty falling asleep and lost concentration during the interview. Her symptoms caused significant distress in social functioning. This diagnosis was retained as a secondary diagnosis; however, due to her symptomology, Schizoaffective Disorder was retained as the primary diagnosis.
296.32 Major Depressive Disorder, Moderate, with anxious distress:
Ms. Lewis presented with symptoms of depression, and expressed these symptoms were ongoing. She disclosed feelings of worthlessness, guilt, and thoughts of death. She expressed a lack of pleasure in activities, sleep disruptions, and feelings of fatigue. While Ms. Lewis’ symptoms were consistent with Major Depressive Disorder, this diagnosis was not retained as a diagnosis due to being better explained by Schizoaffective Disorder.
295.90 …show more content…
Lewis expressed concern with regards to her cellmates conspiring against her. She believed that other inmates wanted to cause harm to her, or steal her possessions. She denied hallucinating. Her functioning did not appear impaired nor was it odd or bizarre. She did report several symptoms consistent with depression. Due to her history of substance abuse, it would be difficult to determine whether her symptomology is related to her substance abuse or another mental health disorder, therefore this diagnosis was not retained.
Recommendations
Ms. Lewis was diagnosed with Schizoaffective Disorder and Posttraumatic Stress Disorder. Her MMPI-2 results were congruent with a personality disorder and depressive symptoms. She would likely benefit from the following treatments:
• Pharmacotherapy: The use of antipsychotics is the first line of treatment in individuals suffering from schizophrenia (Sadock, Sadock, & Ruiz, 2014).
• Psychotherapy: Psychotherapy would augment the antipsychotic success, but also treat Ms. Lewis’ symptoms of Posttraumatic Stress Disorder.
• Group Therapy: Group programs have proven beneficial in providing a rounded treatment method to individuals (Humphreys, 1997). This would also give Ms. Lewis a better understanding that other individuals are experiencing similar diagnoses to her.
• Cognitive Behavioral Treatment might prove beneficial to Ms. Lewis.
Ms. Lewis was considered a moderate risk for suicide and
295.70 Schizoaffective Disorder, Depressive type, with multiple episodes, currently in acute episode:
Ms. Lewis experiences symptoms concurrent with Major Depressive Disorder and Schizophrenia. Her symptoms were consistent with Persecutory type Delusional Disorder as evidenced by her belief that her cellmates intended to harm or steal from her. Her symptoms were consistent with a depressive disorder, and were likely not attributed to the effects of substance abuse or other medical …show more content…
Lewis was exposed throughout her childhood to physical, emotional, and verbal abuse. This abuse continued with both of her romantic relationships. Ms. Lewis stated that she actually feared her ex boyfriend finding her again. Ms. Lewis expressed having the belief that no one could be trusted and excessive guilt over her past. She appeared irritable as evidenced by her not wanting to answer the interview questions. She reported having difficulty falling asleep and lost concentration during the interview. Her symptoms caused significant distress in social functioning. This diagnosis was retained as a secondary diagnosis; however, due to her symptomology, Schizoaffective Disorder was retained as the primary diagnosis.
296.32 Major Depressive Disorder, Moderate, with anxious distress:
Ms. Lewis presented with symptoms of depression, and expressed these symptoms were ongoing. She disclosed feelings of worthlessness, guilt, and thoughts of death. She expressed a lack of pleasure in activities, sleep disruptions, and feelings of fatigue. While Ms. Lewis’ symptoms were consistent with Major Depressive Disorder, this diagnosis was not retained as a diagnosis due to being better explained by Schizoaffective Disorder.
295.90 …show more content…
Lewis expressed concern with regards to her cellmates conspiring against her. She believed that other inmates wanted to cause harm to her, or steal her possessions. She denied hallucinating. Her functioning did not appear impaired nor was it odd or bizarre. She did report several symptoms consistent with depression. Due to her history of substance abuse, it would be difficult to determine whether her symptomology is related to her substance abuse or another mental health disorder, therefore this diagnosis was not retained.
Recommendations
Ms. Lewis was diagnosed with Schizoaffective Disorder and Posttraumatic Stress Disorder. Her MMPI-2 results were congruent with a personality disorder and depressive symptoms. She would likely benefit from the following treatments:
• Pharmacotherapy: The use of antipsychotics is the first line of treatment in individuals suffering from schizophrenia (Sadock, Sadock, & Ruiz, 2014).
• Psychotherapy: Psychotherapy would augment the antipsychotic success, but also treat Ms. Lewis’ symptoms of Posttraumatic Stress Disorder.
• Group Therapy: Group programs have proven beneficial in providing a rounded treatment method to individuals (Humphreys, 1997). This would also give Ms. Lewis a better understanding that other individuals are experiencing similar diagnoses to her.
• Cognitive Behavioral Treatment might prove beneficial to Ms. Lewis.
Ms. Lewis was considered a moderate risk for suicide and