Case Analysis Evaluation-35-Year-Old Male
The case study involves Sam, a 35-year-old male who visited the clinic accompanied by his wife. Before the current visit, Sam’s wife had previously taken him to see the primary care provider after he repeatedly complained of lethargy and depression. During the current visit, Sam noted that he has been getting easily irritable and has been feeling depressed, especially when his wife discards any items in his possession. He further states that the irritability and feelings of depression get worse when his wife discards items he deems valuable and necessary. Some of the things his wife has thrown out that he deems valuable include mail, magazines, clothing, snacks, cooking supplies, and tissue rolls. He is currently exhibiting symptoms of excessive acquisition behavior, hoarding various items throughout his home, as highlighted by his behavior of ordering things in bulk; he argues that he might need them later on and that he has plenty of room to keep these items around his house. Sam has a history of psychiatric issues, as he was diagnosed with generalized anxiety disorder when he was 20 years old. He has no significant past medical or surgical history. There are also no recorded psychiatric issues or history of psychiatric problems in his family. Sam is a high school graduate and a trained mechanic. His work behavior in the last year has been poor as he has missed more work this year as compared to other years. He has a nice home in a nice neighborhood where he lives with his wife. They are yet to have children. He has had a good childhood, noting that he grew up in a nice home with loving and caring parents. His mother was a housewife, and his father was a banker. Sam denies having any manic or psychotic symptoms. He also has never had any suicidal thoughts. He is currently not using any medications and has no known allergies. A test of his vitals showed that his blood pressure was at 122/80 mmHg. His heart rate is at 82bpm, his temperature is at 97.6F, his respiratory rate is 18, and his weight is at 152lbs as at the time of the visit.
Differential Diagnosis
The three possible differential diagnoses applicable to Sam’s case are hoarding disorder, with excessive acquisition with poor insight, obsessive-compulsive disorder, and major depressive disorder/episode.
Differential Diagnosis #1: Hoarding Disorder, with Excessive Acquisition with Poor Insight
Hoarding disorder, with excessive acquisition with poor insight, refers to a mental issue characterized by having persistent difficulties in letting go of one’s possessions regardless of whether they are valuable or not. It further relates to the individual acquiring items without any notable or specific reasons and having difficulties parting with such acquired items. Having poor insight when one has a hoarding and acquisition behavioral issue means that they do not actually understand how severe their behavior is or how it affects their life and other relationships, as in the case of Sam. The diagnosis of hoarding disorder, with excessive acquisition with poor insight, is evidenced by Sam’s continuously buying things, especially in bulks, regardless of whether he needs them at the moment or not, storing them around the house, and being irritated and depressed when his wife discards items without actually being aware he has a hoarding problem.
Differential Diagnosis #2: Obsessive-Compulsive Disorder
Obsessive-compulsive disorder (OCD) is a mental condition that causes a person to have frequent and uncontrollable recurring thoughts and engage in repetitive behaviors (Stein et al., 2019). The obsessions and compulsions in OCD are intrusive and have the potential to interfere with an individual’s daily functioning. The diagnosis of OCD is evidenced by Sam’s behaviors in which he is preoccupied with possessions and collecting them and his fears of losing them. However, OCD may be ruled out based on the absence of specific OCD symptoms, including Sam not having rituals related to intrusive thoughts of hoarding.
Differential Diagnosis #3: Major Depressive Disorder/Episode
Major depressive disorder (MDD) is a mental and mood disorder that involves the patient having persistent feelings of low and depressed moods, feelings of worthlessness, sadness, hopelessness, loss of interest or pleasure in activities, and feelings of guilt, as well as a lack of energy (Bains & Abdijadid, 2022). The diagnosis of MDD is suggested by Sam having worsening depression, irritability, and lethargy, as reported by his wife. However, MDD can be ruled out since the major concern is Sam’s hoarding and possessive behaviors. Besides, there is also the absence of other MDD-specific symptoms besides low energy and irritability, such as prolonged periods of low and depressed moods, suicidal thoughts, and feelings of worthlessness.
Differential Diagnosis Mental Status Examination
Hoarding disorder, with excessive acquisition with poor insight, presents with mental examination findings consistent with the following:
- Appearance: Sam appeared well-dressed, but his hair was a bit disheveled.
- Speech: His speech is fluent.
- Mood & Affect: He has a depressed mood and an anxious affect.
- Behavior & Motor Activity: Increased motor activity
- Thought Process: Preoccupation with possessions and acquisitions.
- Thought Content: Preoccupied with possessions and has poor insight into behaviors
- Attention & Concentration: Attention is impaired
- Memory: Sam’s memory is intact
- Orientation: Intact.
- Insight: Limited insight into the excessive nature of acquiring and collecting items.
Obsessive-compulsive disorder presents with mental examination findings consistent with the following:
- Appearance: Sam is well-dressed for the occasion
- Speech: Fluent but with bits of intrusive thoughts
- Mood & Affect: He has a depressed mood and an anxious affect.
- Behavior & Motor Activity: Increased motor activity
- Thought Process: Preoccupied by intrusive thoughts
- Thought Content: Thoughts are highlighted intrusive thoughts and compulsions
- Orientation: Intact
- Insight: Limited insight into obsessions and compulsions
Major depressive disorder/episode presents with mental examination findings consistent with the following:
- Appearance: He appears withdrawn
- Speech: His speech is fluent but a bit slow.
- Mood & Affect: Depressed mood and decreased interest in activities.
- Attention & Concentration: Sam has difficulties concentrating and is indecisive
- Orientation: Intact
- Insight: Poor insight of the depressive symptoms
- Judgment: Impaired judgment and poor decision-making of Form
Differential Diagnosis Etiology
Diagnosis #1: Hoarding Disorder with Excessive Acquisition, with Poor Insight
According to the American Psychiatric Association (2022), the major risk and prognostic factors for hoarding disorder with excessive acquisition with poor insight are environmental, temperamental, genetic, and psychological. The condition may result from having a family history of the disorder, genetic predispositions, stressful living environments, and traumatic experiences, as well as a learned behavior (Nakao & Kanba, 2019).
Diagnosis #2: Obsessive-Compulsive Disorder
Obsessive-compulsive disorder development involves abnormalities in the cortico-striatal-thalamic-cortical (CSTC) circuitry and dysregulation of neurotransmitters within this circuitry, such as serotonin, dopamine, glutamate, and γ-aminobutyric acid (GABA) (Stein et al., 2019).
Diagnosis #3: Major Depressive Disorder/Episode
Major depressive disorder/episode development is multifactorial, involving biological, genetic, environmental, and psychosocial factors that contribute to the dysregulation of neurotransmitters such as GABA and serotonin, leading to further mood dysregulation (Bains & Abdijadid, 2022).
Differential Diagnosis Diagnostic Screening Tools
The screening tools that would be utilized to support the differential diagnosis of the hoarding disorder with excessive acquisition with poor insight include the Hoarding Rating Scale, Saving Inventory-Revised (SI-R), and the Diagnostic and Statistical Manual of Mental Disorders 5th Edition. Next, OCD can specifically be diagnosed using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and the Diagnostic and Statistical Manual of Mental Disorders 5th Edition. Lastly, major depressive disorder/episode can be specifically diagnosed using the Structured Clinical Interview for DSM-5 (SCID) for mood disorders.
Case Analysis
The most likely diagnosis in this case is hoarding disorder with excessive acquisition, with poor insight. The diagnosis is supported by Sam’s behaviors, as reported by his wife. For instance, Sam is persistently buying things in bulk and finds it difficult to discard possessions. He gets significantly depressed and irritable when his wife discards these items. He is also unaware of his hoarding problem, as he notes he can keep buying things because he has plenty of room in his house.
Treatment Plan
The treatment plan for Sam will combine pharmacological and non-pharmacological interventions to help improve his awareness of and manage his hoarding behavior, as well as the comorbid depressive and OCD symptoms. For the pharmacological option, Sam will be given antidepressants, especially a selective serotonin reuptake inhibitor (SSRI) and specifically Citalopram, to help manage the depressive symptoms. He will be started on 20mg to be taken orally once a day. The non-pharmacologic treatment will include cognitive behavioral therapy (CBT) as it effectively addresses response behaviors to intrusive and compulsive thoughts and behaviors in hoarding disorders (Rodgers et al., 2021). Family psychoeducation will also be provided to help the family work together to address Sam’s hoarding behaviors, as well as to encourage him to clean up and let go of some of his possessions. There will be no referrals in the meantime; however, a follow-up every two weeks is advised to monitor his progress. If change is not achieved within the treatment period, Sam will be referred to a therapy specialist to address his hoarding disorder and provide proper treatment.
References
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders: DSM-5-TR / American Psychiatric Association (5th ed.). American Psychiatric Association Publishing. https://lccn.loc.gov/2021051781
Bains, N., & Abdijadid, S. (2022). Major depressive disorder. Major Depressive Disorder, 1–189. https://doi.org/10.1016/C2017-0-01421-0
Nakao, T., & Kanba, S. (2019). Pathophysiology and treatment of hoarding disorder. Psychiatry and Clinical Neurosciences, 73(7), 370–375. https://doi.org/10.1111/PCN.12853
Rodgers, N., McDonald, S., & Wootton, B. M. (2021). Cognitive behavioral therapy for hoarding disorder: An updated meta-analysis. Journal of Affective Disorders, 290, 128–135. https://doi.org/10.1016/J.JAD.2021.04.067
Stein, D. J., Costa, D. L. C., Lochner, C., Miguel, E. C., Reddy, Y. C. J., Shavitt, R. G., van den Heuvel, O. A., & Simpson, H. B. (2019). Obsessive-compulsive disorder. Nature Reviews Disease Primers 2019 5:1, 5(1), 1–21. https://doi.org/10.1038/s41572-019-0102-3
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Question 
(This section should contain a summary of the presented case: History, symptoms present, etc.)
Differential Diagnosis
(This section should contain possible differential diagnoses applicable to the case presentation that was reviewed. In this section list the differential diagnosis and then define them; identify how the differential diagnosis is supported based on the information provided in the case study. Provide no less than 2 and no more than 4 differential diagnoses.)
Case Analysis Evaluation-35-Year-Old Male
Differential Diagnosis #1
Differential Diagnosis #2
Differential Diagnosis #3
Differential Diagnosis Mental Status Examination
(This section should provide the expected or provided mental exam findings for each differential diagnosis (not all criteria may be completed under each differential diagnosis).
______________ Disorder presents with mental examination findings consistent with the following:
- Appearance:
- Speech:
- Mood & Affect:
- Behavior & Motor Activity:
- Thought Process:
- Thought Content:
- Attention & Concentration:
- Memory:
- Orientation:
- Insight:
- Judgement:
(Complete this for each differential diagnosis).
Differential Diagnosis Etiology
(Provide the etiology for each of the selected Differential Diagnosis)
Diagnosis #1
Diagnosis #2
Diagnosis #3
Differential Diagnosis Diagnostic Screening Tools
(Provide the screening tools that would be utilized to support the differential diagnosis – if applicable; include examination specifics, laboratory testing, etc.)
Diagnosis #1
Diagnosis #2
Diagnosis #3
Case Analysis
(This section should include a discussion of the likely diagnosis and how the diagnosis is supported by the presented patient)
Treatment Plan
(The treatment plan should include pharmacologic treatment, non-pharmacologic treatment, patient/family education, referrals, follow-up, etc.)
References
(References should be in APA 7th edition format; must provide scholarly support for all provided information)
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