Psychiatric Diagnosis Assignment Paper

CASE 19

You Decide: The Case of Fred

This case is presented in the voices of Fred and his wife, Margaret. Throughout the case, you are asked to consider a number of issues and to arrive at various decisions, including diagnostic and treatment decisions. You can find Fred’s probable diagnosis, the DSM-5 criteria, clinical information, and possible treatment directions in Appendix B.

Margaret “My Husband’s Brain Stopped Working Properly” About 8 years ago, my life changed completely. The reason? My husband’s brain stopped working properly. We had been married 34 years and Fred was 67 years old. He had worked for the same construction company in New Jersey for 32 years, first as a laborer, then as a security supervisor and union leader. He was a big strong man, a good husband, and a good father to our son, Mark. Together, we had managed to make a decent living with him in construction and me an actress in television commercials—the original Odd Couple, our friends would call us. Life was good. And then Fred’s brain went downhill, taking the whole family down with it.

The problems seemed small at first, hardly noticeable really. Sometimes, when telling me about his day at work, Fred would talk about the foreman, Jimmy, driving a “tractor” when he meant “bulldozer,” or he’d say that he had made a “revision” instead of “decision.” Little stuff. And he’d catch himself. I didn’t worry too much about it, but it was odd. It doesn’t sound like much, but it wasn’t like him. I even thought, “Oh, well, the old boy’s slipping,” and would laugh to myself. But when he forgot the anniversary of our first date, well. . . I knew something was wrong. I gave him all kinds of hell for that—I accused him of having an affair, I cried, I really let him have it. But I was also scared. I mean, maybe an anniversary like that doesn’t mean much to other people, but for us—well, over the years, he’d taken me to Atlantic City for shows and to dinners in expensive restaurants. Once, after Mark was grown, he even got us a hotel room in the Catskills for a weekend. There was always some sort of surprise. So, 8 years ago, in anticipation of a special evening, I got all dressed up. When he got home from work that night and sat down on the sofa, I knew he’d forgotten; and when he saw the disappointment in my eyes, he realized the same thing pretty quickly. In fact, he felt terrible about it, and took me out to a very fancy Italian restaurant after I calmed down. But it was a bad sign. That year turned out to be a rough one. Psychiatric Diagnosis Assignment Paper

Forgetfulness is universal, and increases in forgetfulness are a normal part of aging. How might we distinguish normal forgetting or normal aging from the symptoms of a clinical disorder?

It wasn’t as if he suddenly forgot everything, but it seemed like he was forgetting a bunch of things that he’d never forgotten before. I had always been the one with my head in the clouds, forgetting dates and losing car keys. Fred would be the one telling me, “Maggie, you’ve got to stay more on the ball. If you forget to pay the bills, they’re gonna shut off our electricity.” Or he’d chew me out about forgetting to make a doctor’s appointment for Mark. Of course, I’d joke, “Why don’t we switch jobs and you’ll see who’s got it tougher,” but he definitely had a sharper head, no denying that. Now, suddenly, he was losing his wallet and we’d find it later in the study, where he’d sworn he hadn’t been in days. Or he would leave half-full glasses of juice on the floor of the living room, and when I’d chide him about it he’d say, “Oh, I’m sorry,” and change the subject. This was Mr. Neat Freak who, in the past, couldn’t stand it if a dirty dish sat on the kitchen table more than a half hour after dinner.

What might be the most difficult aspects of observing a spouse, parent, or other close relative gradually lose their memory or other cognitive faculties?

He also had little accidents, spilling food on himself, or knocking over a pile of papers or the jar of pencils from the counter. Then he started asking me to drive him to work all the time. He said that he’d caught himself veering off the road a few times and had just barely avoided an accident. “It’s all the stress,” he’d tell me. “We’ve got a new contract coming up and I don’t think it’s gonna go our way. I’ve just got too much on my mind.”

As the forgetfulness and unusual behavior mounted, it couldn’t be ignored any more. Yet somehow I found a way to do just that. I wanted to believe that he was fine. Then, one day, he missed a meeting with an important contractor—just didn’t show up. Instead, he went to his office like it was any other day. The company lost the contract and a lot of money, and it also was bad for their image. Actually, by that point in time, I wasn’t all that surprised by his error. This strong and organized man, who had taken care of everything for so many years, was by then becoming a different person, and I was now taking care of him. That’s when I told him that he must see a doctor. And Fred did something I’d never seen him do: He burst into tears.

Despite his emotional outpouring that evening, Fred managed to put off medical treatment for nearly a year. Eventually, however, the incidents caught up with him—for example, leaving his glasses in the mailbox or mowing only half the lawn—and he went for a neuropsychological exam. The results of a battery of tests revealed some significant problems, and the neuropsychologist, Dr. Schoenfeld, broke the news to us that he was suffering from a neurocognitive disorder. He explained to us that we would be facing a very difficult battle— that Fred would become less and less able to take care of himself. He also told us that very little could be done to stem the progress of Fred’s condition. Fred was going to have to rely on the support of his loved ones, particularly me, to see him through this.

Neurocognitive disorders include a group of organic syndromes, marked by major problems in cognitive functioning, such as memory and learning, attention, visual perception, planning and decision making, language ability, or social awareness. Based on your reading of either the DSM-5 or your textbook, what form of neurocognitive disorder might Fred be displaying? Which of his symptoms suggest this diagnosis?

Fred had already planned to retire, as his position in the company had been scaled down drastically after the contract debacle. The doctor’s diagnosis simply made it official in our minds. Within 3 months, he was thrown a retirement party by his coworkers, many of whom he had mentored. By then he was having trouble remembering people’s names, but that party meant a lot to him. He knew just how lucky he was to have so many caring friends and colleagues. He was still embarrassed about having lost that contract, but everybody tried their best to show him that they had nothing but gratitude for his years of service. He wasn’t walking too well by then, either, so I helped him to a chair, where he sat for most of the party, sometimes crying quietly to himself because he no longer had full control of his emotions. I think that was really his last great experience, the last time he had a really special night out. Psychiatric Diagnosis Assignment Paper

At the party, Fred gave a short talk to his coworkers, thanking them for the event. He had been worried about this speech for days. He feared attempting to reminisce or trying to be too specific, because he’d been having so much trouble remembering things. But he didn’t want to read

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