How to conduct a DSM 5 Diagnosis Clinical Case Summary (Solved)

How to conduct a DSM 5 Diagnosis Clinical Case Summary (Solved)

The case deals with a 41-year-old man presenting with symptoms of hopelessness, sadness, and helplessness. He explains that the symptoms began six weeks ago but has found it difficult to explain them to someone else. Apart from the stated symptoms, the patient cries for no reason, has sleeping difficulty, stopped going to work, and has been drinking more alcohol than usual. The patient reports signs of suicidal thoughts whereby he thinks of driving his car into the nearest canal. These symptoms indicate an underlying psychological disorder that needs to be treated with medication.

DSM 5 Diagnosis

The DSM-5 diagnosis for this patient is major depressive disorder (MDD). This condition causes mood changes and makes individuals have persistent feelings of sadness and hopelessness. The condition is accompanied by low mood, loss of pleasure in activities that were once enjoyed, and it can cause difficulty in performing activities of daily living (American Psychiatric Association., 2013). The symptoms of MDD typically last for two weeks or longer and they can be severe enough to interfere with work and other routine activities.

The diagnosis of MDD is based on the presence of various symptoms for a period of two or more weeks. These symptoms must either indicate a depressed mood or loss of interest in activities for the diagnosis of MDD to be made (American Psychiatric Association., 2013). Patients with MDD present with depressed mood, diminished interest in activities, significant weight loss or weight gain, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue, feelings of worthlessness or guilt, diminished ability to think or concentrate, and recurrent thoughts of death or suicide (American Psychiatric Association., 2013). The healthcare provider must ensure that these symptoms are not attributable to the psychological effects of other medical conditions or substance abuse. Of more importance, symptoms must cause significant distress or impairment in social, occupational, or other important areas of functioning.

The diagnosis of MDD is based on the presenting symptoms explained by the patient. The patient presents with MDD symptoms like hopelessness, sadness, difficulty sleeping, and suicidal thoughts. The symptoms began six weeks ago and have interfered with activities of daily living like going to work. The patient has also been drinking more alcohol than usual indicating that he is overwhelmed.

Pharmacological Treatment

Major depressive disorder is mainly treated using antidepressants and selective serotonin reuptake inhibitors (SSRIs) are the first-line choice (Clevenger et al., 2018). These drugs act by increasing the levels of serotonin in the brain, a chemical neurotransmitter that regulates mood to relieve symptoms of depression. The drug of choice for this patient is Zoloft 25 mg once daily every morning (Clevenger et al., 2018). I will consider increasing the dosage to 50 mg after two weeks after ascertaining that the patient can tolerate side effects. The reason for choosing this drug is that it has fewer side effects and more dopaminergic activity compared to other drugs in the same class.

Non-Pharmacological Treatment 

Electroconvulsive therapy (ECT) is one of the most effective non-pharmacological treatment approaches to MDD. This approach involves passing a carefully controlled electric current through the brain to stimulate brain cells and relieve symptoms of depression (Li et al., 2020). ECT is mainly recommended for individuals for whom the use of medication and psychotherapy has failed.


American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5th ed. Author.

Li, M., Yao, X., Sun, L., Zhao, L., Xu, W., Zhao, H., Zhao, F., Zou, X., Cheng, Z., Li, B., Yang, W., & Cui, R. (2020). Effects of electroconvulsive therapy on depression and its potential mechanism. Frontiers in Psychology11, 80.

Clevenger, S. S., Malhotra, D., Dang, J., Vanle, B., & IsHak, W. W. (2018). The role of selective serotonin reuptake inhibitors in preventing relapse of major depressive disorder. Therapeutic Advances in Psychopharmacology8(1), 49–58.

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