Subjective
The patient provided valuable details regarding complaints and symptomology, which required asking questions related to the patient’s experience with motherhood. Ultimately, the patient expressed several complaints related to the recent birth of Jessica, her daughter. She complained about feeling terrible as a mother, feeling disgusted when her daughter cries or when she needs to carry her. Additionally, the patient talked about her dissatisfaction with her being overweight and the constant lack of energy to exercise. Finally, the patient admitted having suicidal ideation and experiencing anger outbursts. These symptoms have been present for two months since the patient’s daughter’s birth. The patient’s condition significantly impairs her social functioning and relationships with her husband, friends, and Jessica.
Objective
I made several observations during the initial psychiatric assessment, which allowed me to create a rationale for three differential diagnoses. Firstly, I noticed the sense of anxiety and guilt in the patient. In particular, she was anxious because Jessica disrupted her everyday routines and activities, such as going out with her friends. The patient looked worried, potentially because she was expecting interruptions from her daughter, whom she did not like to touch or carry around. However, the inability to be a good mother to Jessica made the patient experience constant feelings of guilt. The difficulty of navigating between an irrational disdain toward the baby and the necessity to be a good mother caused severe distress to the patient. I realized that the emotional toll of the situation on the patient was heavy since she looked exhausted. My initial assumption was confirmed by the patient, who admitted having fits of anger mixed with feelings of guilt.
Assessment
Evaluation of the symptomology through the criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) yielded three differential diagnoses. These diagnoses are provided in the order from the most to the least probable ones, depending on the overlaps between the patient’s symptoms and DSM-5 criteria. A subsequent application of specifiers made it possible to derive the primary diagnosis of the patient’s mental health condition.
Differential Diagnosis 1: Major Depressive Disorder, 296.22 (F32.1)
Given the evidence from the initial assessment, major depressive disorder was the first-priority differential diagnosis. According to the American Psychiatric Association (APA, 2013), a major depressive episode is represented by three criteria: A, B, and C, respectively. The complex criterion A requires the presence of five or more specific symptoms during the same 2-week period. Out of these symptoms, the patient exhibited or claimed to have a depressed mood, loss of pleasure from activities, fatigue, feelings of guilt, and suicidal ideation. Criterion B requires symptoms to cause significant distress and impairment in social or other functions. The patient’s words showed that she could not normally interact with her husband and friends. Finally, criterion C requires the episode not to be attributable to the effects of substances or medical conditions (APA, 2013). Since the patient’s case history does not mention such factors, all pertinent positives of major depressive disorder are matched. However, an additional application of specifiers is necessary for more precise coding and diagnosing.
Differential Diagnosis 2: Bipolar I Disorder 296.7, (F31.81)
The bipolar I disorder diagnosis was ruled out due to only a partial matching of symptoms. Specifically, the bipolar I disorder diagnosis requires the patient to exhibit symptoms both of hypomanic and major depressive episodes (McIntyre, 2020). While the symptoms of a major depressive episode were present, the patient did not exhibit distinctive hypomanic symptoms, such as inflated self-esteem and unusual involvement in social activities (APA, 2013). As such, the evidence of bipolar I disorder diagnosis is insufficient.
Differential Diagnosis 3: Posttraumatic Stress Disorder, 309.81 (F43.10)
Lastly, posttraumatic stress disorder was initially considered one of the differential diagnoses. The patient experienced her brother’s death, who had committed suicide after she denied him access to methamphetamines. According to APA (2013), exposure to a family member’s violent or accidental death acts as one of the potential PTSD criteria. However, the patient did not demonstrate intrusive memories, a symptom essential in PTSD diagnosis (Mayo Clinic, 2022a). Therefore, PTSD had to be ruled out due to the presence of the strong pertinent negative.
Primary Diagnosis: Severe Major Depressive Disorder With Peripartum Onset, 296.22 (F32.1)
Ultimately, applying specifiers makes it possible to finalize the first-priority differential diagnosis of major depressive disorder. Most importantly, the patient’s symptomology matches the description of peripartum onset, particularly a postpartum mood episode (APA, 2013). According to Mayo Clinic (2022b), postpartum depression symptoms may include frequent crying, anger, thoughts of suicide, and fear of being a bad mother. The patient exhibited all of these symptoms, leading me to the inclusion of peripartum onset into the primary diagnosis. Finally, the patient’s episode is not recurring, but the symptoms are severe enough to cause serious impairment of social functioning and threaten the patient’s life if left unmanaged. Therefore, the patient’s case should be diagnosed as a severe major depressive disorder with peripartum onset, DSM-5 coding 296.22 (F32.1).
Reflection Notes
If I could redo the session from the start, I would demonstrate more sympathy as a pure professional instead of documenting history and symptoms. In particular, I would inform the patient that she should not be ashamed of herself, as she did the right thing by seeking help. It must be traumatizing and horrifying for a 27-year-old woman to view herself as a monster who hates her child. In this regard, I believe that practitioners dealing with postpartum depression issues should commend them for seeking therapy. According to Walker (2018), postpartum depression affects up to 20% of women, so providers should reassure patients of their normality. Ultimately, support from providers would promote health, as women would begin seeking professional help more willingly.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5). American Psychiatric Publishing.
Mayo Clinic. (2022a). Post-traumatic stress disorder (PTSD). Web.
Mayo Clinic. (2022b). Postpartum depression. Web.
McIntyre, R. S., Berk, M., Brietzke, E., Goldstein, B. I., López-Jaramillo, C., Kessing, L. V., Malhi, G. Nierenberg, A. A., Rosenblat, J. D., Majeed, A., Vieta, E., Vinberg, M., S., Young, A. H., & Mansur, R. B. (2020). Bipolar disorders. The Lancet, 396(10265), 1841-1856. Web.
Walker, M. (2018). Post-partum depression: A clinical, not legal, issue. MedPage Today. Web.