Case Study: Wealthy Widow
DSM-IV Multiaxial Evaluation
Axis I Moderate Mood Disorder NOS with single Hypomanic Episode (current)
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Axis II No formal diagnosis, frequent use of denial
Axis III None
Axis IV Problems with primary support group
Axis V GAF = 60 (current)
The client is a 72-year-old female, referred to psychiatrist against her will by her children. She is alert and oriented, although uncooperative and does not present with any signs or symptoms of dementia or psychotic behavior. In addition, no medical conditions or disabilities were reported, and the client denied the use of substances. The client currently meets DSM-IV diagnostic criteria for Moderate Mood Disorder Not Otherwise Specified with a single Hypomanic Episode, as she does not have a history of emotional disturbance or prior psychiatric diagnoses (American Psychiatric Assoc, 2000). However, her levels of functioning are sufficient to warrant a score of 60 on the Global Assessment of Functioning Scale.
The client was brought in by her sons because over the last three months her children have become concerned about significant changes in her behavior and her recent engagement to a 25-year-old male nurse she met while volunteering at a local hospital. The client’s husband is recently deceased, but client notes the bereavement was not severe and that she resumed her normal activities very shortly after the loss, which may indicate the use of denial of her feelings as a coping mechanism. Her children encouraged this behavior, but it would appear that her relationship with her sons has deteriorated since then, indicating problems with her primary support group. This is evidenced in her sons’ use of threats and intimidation to force their mother to accompany them to the psychiatrist’s office, and in the client’s assertions that they do not understand her and are only after her money. It is appropriate to note that the client is very wealthy, and most likely has complete management of her finances.
From what the client reported during the initial interview, she seems to be having a Hypomanic Episode. The DSM-IV defines a Hypomanic Episode as a period in which there is an abnormally and persistently elevated, expansive, or irritable mood lasting at least 4 days that is clearly different from the individual’s usual nondepressed mood (American Psychiatric Assoc, 2000). At the beginning of the interview, the client was very angry with her three sons and the psychiatrist, but later claimed that for the first time in her life she was feeling fulfilled and that her life was exciting. She reported no feelings that are typically associated with Major Depressive Disorder or Bereavement, and did not report or seem to be experiencing the delusions or hallucinations that would indicate a Manic Episode. In addition, the changes in the client’s mood and behavior are not severe enough to cause marked impairment in functioning, or to necessitate hospitalization, which assists in differentiating this from a Manic Episode.
The client also presented with at least five of the symptoms that must be present to indicate a Hypomanic Episode, including inflated self-esteem or grandiosity, as evidenced by her references to her ability to attract a much younger man. She refused to participate in formal testing and asserted that she will continue in her current behavior, seemingly regardless of her sons’ interference, which may be regarded as an increase in goal-oriented activity, another of the necessary symptoms. Her claims that she is finally doing something for herself instead of the men in her life may also be a form of coping, and a way of denying feelings of loss or abandonment related to her husband’s death. The client also indicated a decreased need for sleep, an excessive involvement in pleasurable activities that have a high potential for painful consequences, including her spending sprees and sexual activities, and displayed overly talkative behavior, all three of which are considered symptomatic of Hypomanic Episodes.
Despite these indications, there are several ethical concerns that the clinician must address when evaluating this case. The most obvious reason to confirm this diagnosis is to enable the client to move forward with treatment. The circumstances surrounding the changes in behavior and the relative lack of significant harm to the client or others indicates that this may be merely a reaction to underlying adjustment or bereavement issues, and therefore psychotherapy would most likely be successful in resolving the symptoms. In addition, this diagnosis may be useful in protecting the client’s finances. She indicated that she was planning to turn over her house and a large sum of money to her young fiancé, which is not necessarily problematic in itself, but the client’s age and circumstances make her vulnerable to being taken advantage of. Ethical concerns dictate that the clinician focus on what would be best for the client, and the prudent clinician would want to gain a clearer picture of the understanding between the client and her fiancé in order to assess whether the client is capable of managing her own finances.
However, the same ethical concerns regarding the client’s financial state could be applied to her children as well. The client expressed several times in the interview that she was merely asserting her freedom, having been the conventional wife and mother for most of her life, and seemed to understand how others viewed her behavior as unusual for her age and social position. Her sons’ claimed that they thought she was going “senile,” but this is clearly not the case, and the client’s statement that her children want her money must be explored. Because of the client’s age, it is possible that a diagnosis like this could be used to declare her unfit to manage her own finances at best, or to place her unnecessarily in a nursing home or retirement facility at worst. It is very possible that what the client declares about her own behavior is true, and that this change is something she actually desires and not a manifestation of a mood disorder. People are complex beings and must be looked at in context of their entire lives, not one small portion. In conclusion, psychotherapy and further evaluation should be considered in order to determine the true nature of the client’s behavior and to determine a course of action that will benefit the client, in either treating her for a Mood Disorder or helping her to make the transition to her new life and resolving some family conflict.
American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental
Disorders (4th ed., text revision). Arlington, VA: Author.
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