Psychiatric Diagnosis
What is Psychopathology, and what is its relation to psychiatric diagnosis? Put simply, psychopathology is essentially the study of mental disorders, mental distress, or manifestations of behavior(s) that might indicate possible psychological impairment and/or illness. Through this form of scientific investigation, professionals within this field are able to come to both provisional and definitive diagnoses, and are subsequently able to come up with and provide effective forms of treatment. In this psychiatric diagnosis, the case study being examined is Case 19 – You Decide: The Case of Fred in the Gorenstein and Comer (2015) textbook, Case Studies in Abnormal Psychology.
To begin, let’s review some background information/history for the patient. The patient, Fred, is a male in his late 60’s. He has been married to his wife, Maggie, for about 35 years and they have one adult son, Mark. The patient has worked in the construction business for a little over 30 years and has worked for the same company all those years. Prior to the onset of the patient’s current issues, the patient has been in relatively good health.
The patient has been experiencing issues with his memory and overall cognitive functioning. The patient presents with issues of memory loss, language impairment, misplacing objects, difficulty performing basic tasks (e.g. driving), delusions, agitation, and depression. The patient’s issues have reportedly been taking place over the estimated course of eight years and instead of improving, they have become more severe, debilitating, and progressive as time has passed.
In accordance with the Diagnostic and Statistical Manual, Fifth edition (DSM-5), the patient’s symptoms can be attributed to disorders of major depressive disorder, possible stroke, dementia or Alzheimer’s, or simply the natural progression of aging. A provisional diagnosis of a major neurocognitive disorder due to Alzheimer’s disease is being given, which is believed to have late onset. However, from further investigation and review of symptoms, a definitive diagnosis of AD is being given due to prevailing symptoms like substantial diminishment and impairment in memory and learning processes, language ability, and the inability to carryout everyday basic tasks. Due to the following criteria, it is strongly believed that the patient is dealing with Alzheimer’s disease (AD). As maintained in the Diagnostic and Statistical Manual, Fifth edition (DSM-5):
At the mild NCD phase, Alzheimer’s disease manifests typically with impairment in memory and learning, sometimes accompanied by deficits in executive function. At the major NCD phase, visuoconstructional /perceptual-motor ability and language will also be impaired, particularly when the NCD is moderate to severe (APA, 2013, section 2).
According to the aforementioned criteria, the patient is a good candidate for Alzheimer’s disease. Each area of functioning outlined within the DSM-5 criteria is severely impaired in this patient. Fred has extreme memory impairment, loss of motor function, suffers from delusions, agitation, and depression.
In regards to the diagnostic manual being employed, the diagnostic manual being utilized and chosen to guide the diagnosis of this case is the Diagnostic and Statistical Manual, Fifth edition (DSM-5). This manual was selected over all others due to its comprehensiveness in terms of use in diagnosing mental health disorders. Though it is not without its limitations, this diagnostic manual provides relevant and detailed information in the diagnosis of neurocognitive disorders. Moreover, this diagnostic manual is largely important and highly useful as it provides a common language, as well as a diagnosis framework.
Alzheimer’s disease is reported and believed to be a highly genetic/biological disorder. It is a rather progressive, degenerative neurological disease that consists of the buildup of atypical quantities of the chemical substance known as amyloid in a number of areas within the brain. Many of these areas directly impact domains within the brain that are critical to memory processes. Approximately 10 percent of Alzheimer’s cases are attributed to genetics, while the remaining cases have yet to harness any known causes; however, genetic risk factors have been identified in these remaining cases (Gillick, n.d.). Because Alzheimer’s has not been capable of being explained from multiple perspectives, this case and the symptoms present in the patient are being viewed through a biological/genetic lens. AD is a devastating disease that is steadily on the rise within our aging population(s). Though this disorder’s definitive etiology is yet to be uncovered, it is largely held that it is caused by genetics/biological makeup (Bali et al., 2010; Howe, 2010; Morgan, 2011; Keltner, Zielinski, & Hardin, 2001). The biological perspective maintains that humans are a consequence of our distinct genetics and physiology (McLeod, 2015); thus, feeling, thoughts, behaviors, etc. are examined through a physical/biological lens. Many of the symptoms that the patient is experiencing are seemingly due to neurodegeneration of cells and damage to certain regions of the brain. Not only does the patient have difficulty with his memory and language ability, his motor functioning has been severely impacted, which makes it extremely hard for him to get around. Because of the diminishment in motor functioning, the patient’s wife has reported that the patient had a brutal fall that resulted in a broken hip. During his recovery time, the patient suffered from acute delusions, depression, and a healthy dose of agitation. The patient often times refused to speak as he was not sure if family visitors (like his son Mark) were real or hallucinations. There were reported periods of short bouts of lucidity; however, for the most part the patient did not recognize his visitors.
Because Alzheimer’s disease is the leading form of dementia worldwide, it is easy to listen to a patient’s symptoms, consider their age, and make a knee-jerk diagnosis; however, this is also highly unethical. Luckily, there are a number of ways to verify and validate a diagnosis. For this patient, the diagnosis of Alzheimer’s disease can be validated through comparing current firsthand experiences and witnessed accounts of symptoms, to years of research and diagnostic criteria that explicitly outline established symptoms and behaviors of the disease. For instance, as maintained by Hsu et al. (2015), “In AD, the earliest prominent cognitive symptoms can be characterized as either amnestic or non-amnestic dysfunction… In addition, 75-90% of AD patients develop “non-cognitive” behavior and psychological symptoms of dementia (BPSD)” (p. 2). Moreover, Stori, Quintino, Silva, Kusumota and Marques (2016) further explain what the terminology “behavioral and psychological symptoms of dementia” entails; it refers to symptoms such as “agitation, depression, hallucinations, delusions, and other psychopathological changes” (para. 2), all of which have been severely experienced and witnessed in our current patient. Such behaviors and psychological symptoms are consistent with criteria outlined within the DSM-5 as stated previously.
An important question to ask is: Who gets Alzheimer’s disease? Alzheimer’s impacts approximately 25 million worldwide, with an estimated 4 million in the United States alone. This disorder is not biased in terms of favored demographics. However, worth noting, it typically occurs in most people who are in their mid-sixties and women tend to be diagnosed more than men. Moreover, it has been stated that Latinos and African-Americans may be more at risk to developing this condition, but the divergence between races is unknown (Alzheimer’s Association, 2017). Also worth noting is the fact that some individuals endure early onset, which takes place before 65 years of age (Allan, Behrman, & Ebmeier, 2013), and individuals who suffer from early onset typically have the type of disease known as “familial Alzheimer’s disease.” This form of AD is the type that runs in families. Thus, people with this type often have parent and/or grandparent who developed AD early on (Graff-Radford, 2017). Additionally, another important question to ask is: What are the risk factors for this condition? There are a few risk factors associated with the diagnosis of AD. The leading risk factor for this condition is age. Women tend to be at a higher risk of being diagnosed, as they typically live longer. Social isolation can be a risk factor in that it can produce depression. Moreover, head trauma is a risk factor for Alzheimer’s, as well as biological make-up/genetics. (Cure Alzheimer’s, 2017). However, in recent years, more and more research is starting to point towards largely genetic biomarkers. As stated previously, in the cases that have a known cause, genetics is the primary link, and even in the majority of cases that do not have a distinct known cause, there are still strong implications for/of genetic biomarkers. Because of such implications, it may be beneficial to inquire about Fred’s parents and/or grandparents to see if there is perhaps a familial link to his disorder.
The next question is probably one of the most common when it comes to any disorder: How do we treat it? There are a slew of treatments for Alzheimer’s disease, both evidence-based and non-evidence based. When we talk about evidence-based treatments, we are referring to well-established, efficacious, and experimental treatments. Non-evidence based treatments tend to be more holistic and steer away from more conventional treatments like pharmacological interventions. Evidence-based treatment for AD include five main interventions: cholinesterase inhibitors (ChEIs), memantine, antipsychotic agents, antioxidants, and ginkgo biloba (Vardi, 2010, p. 1). Non-evidence-based interventions like exercise, increased social interactions and cognitive stimulation may be beneficial for patients with Alzheimer’s disease (Howe, 2009); however, they are not without the possibility of adverse responses and thus, before being implemented should be discussed at length with both the patient and the patient’s caregiver. Both evidence-based and non-evidence-based treatments hold merit; however, are not without limitations.
The well-established treatments for AD, such as cholinesterase inhibitors, memantine, and antioxidants work to provide symptomatic relief from cognitive and functional symptoms, whereas ginkgo biloba works to help with behavioral symptoms (Vardi, 2010). While there is no cure for AD, interventions such as these can slow its overall progression. Due to their being no cure for AD, non-evidence based interventions may be beneficial in creating a platform for an overall better quality of end-of-life care. Such interventions could alleviate symptoms of depression, agitation, anxiety and stress, etc. Exercise is a non-evidence based treatment that is well-known to harness benefits to the overall health and well-being of all individuals, both healthy and those afflicted with myriad conditions. It is common knowledge that exercise releases endorphins, which produce that “feel good” sensation and enables us to be more alert and energized. In patients with Alzheimer’s disease, exercise could possibly help reduce functional diminishment. It could also assist in decreasing the risk of falling, and symptoms of agitation and depression (Primary Psychiatry, 2017), all of which have been experienced by our current patient in this case study. Cognitive/brain stimulation is another non-evidence based treatment that has potential benefits. Programs that promote healthy brain longevity and aging, like cognitive/brain stimulation therapy, could ultimately reduce risks to the development of Alzheimer’s disease and/or additional dementias. However, perhaps the best form of treatment for Alzheimer’s disease comes from integrating both evidence-based and non-evidence based therapies.
For our patient, it would be recommended that Fred undergo a combination of therapies. Due to the progressiveness of his condition and the prominent symptoms he is exhibiting, it is recommended that Fred partake in therapies of cognitive behavioral therapy to help with his depression, agitation, and delusions. Moreover, moderate exercise would be a beneficial non-conventional therapy that would help our patient strengthen functional processes, as well as give the added benefit of decreasing his chances for repeated falls and helping reduce the severity and extent of his symptoms of depression and agitation.
To conclude, we understand the unique role psychopathology plays in the understanding of and subsequent diagnosis of mental health disorders. In this case, through the careful evaluation of background history, past and current symptoms and exhibited behaviors, and reports from the patient’s wife, it is clear that the patient is suffering from a major neurocognitive disorder due to the late onset of Alzheimer’s Disease (AD). This diagnosis was made based upon presenting issues and through the utilization of the Diagnostic and Statistical Manual, Fifth edition (DSM-5) to verify and validate the patient’s symptoms and behaviors. Additionally, while there are a number of treatments that can slow the progression of this disease, it is not curable. Thus, for Fred, and because of the progressiveness of his disease, pharmacological interventions do not seem like they would have any benefits, which is why it is recommended that the patient undergo cognitive behavioral therapy to help with his depression, agitation, and delusions and a moderate exercise routine to help with strengthening motor function and symptoms of depression and agitation. Ultimately, improving the patient’s quality of life, along with the support and encouragement to the patient’s primary caregiver, through supportive end-of-life care and appropriate therapies is the supreme goal.
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