LARIOSA, HIYASMIN GABRIELA AND GUMBAN, VER LOVE

CASE DIAGNOSIS

I. Demographics
 Name: Roman
 Age: 30 y/o
 Address: N/A
 Status: Unspecified
 Religion: N/A
 Occupation: Home-based work

I. Case Overview

Roman, 30, is an introverted man. He is a brilliant student with a great family. But his life
was turned upside down beginning at the age of 18. A family problem arose, and he
blamed himself for it. With his family problem, Roman rebelled and eventually stopped
attending school. He then worked for a bank and changed jobs several times just to
keep himself busy.
Roman can't have any conversations about sensitive topics, especially about the
changes he's gone through, because it will trigger him, and when triggered, Roman will
lock himself home and refuse to speak to anyone. He is also suicidal and has low self-
esteem. He has also had insomnia, fatigue, and the feeling that he is worthless. He is
also unable to concentrate and is easily distracted. Roman had previously overeaten
but was consistently underweight. Roman is very good at concealing his problems from
others, and this trait has remained with him. He'd been having these for months without
saying anything to avoid being triggered.
Roman did not take any medication for clinically diagnosed psychological or physical
illnesses, nor did he seek professional help to have his condition evaluated. Roman felt
better in 2015-2016 and is feeling better now that he and his partner have begun
planning their family, though he is still referred to as a ticking bomb. People just need to
avoid talking to him about the usual, sensitive topics. Although he was feeling better, the
past two months of this year were difficult for him because he was awaiting work. He
was socially withdrawn, consistently sleeping, low on energy, and felt he was reliving
what had happened to him when he was younger but in tolerance.

II. Presenting Problem

Roman is suicidal and has low self-esteem. He has also experienced insomnia, fatigue,
and a sense of worthlessness. He is also unable to focus and easily distracted. Roman
had previously overeaten but was always underweight. People should avoid talking to
him about common, sensitive topics because he may become triggered. Despite feeling
better, the last two months of this year were difficult for him. He was socially withdrawn,
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slept a lot, was tired all the time, and felt like he was reliving what had happened to him
when he was younger but in tolerance.

III. Diagnosis
Present the disorder diagnosis, its code, and specifier. (Based it on DSM-V)

Roman is diagnosed with 296.31 (F33.0) Major Depressive Disorder in partial

remission.

Criteria Symptoms for Diagnosis

A.Five (or more) of the following
symptoms have been present during the  Roman would also end up with
same 2-week period and represent a irritated mood when triggered,
change from previous functioning; at least lasting for 1-2 weeks
one of the symptoms is either (1)
depressed mood or (2) loss of interest or
pleasure.

Note: Do not include symptoms that are

clearly attributable to another medical
condition.

1. Depressed mood most of the day,

nearly every day, as indicated by either
subjective report (e.g., feels sad, empty,
hopeless) or observation made by others  He is feeling worthless
(e.g., appears tearful). (Note: In children
and adolescents, can be irritable mood.)

2. Markedly diminished interest or

pleasure in all, or almost all, activities
most of the day, nearly every day (as
indicated by either subjective account or
observation). Major Depressive Disorder
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 He could also not concentrate and
3. Significant weight loss when not dieting is easily distracted. Roman overate
or weight gain (e.g., a change of more before, but was consistent in low
than 5% of body weight in a month), or weight.
decrease or increase in appetite nearly
every day. (Note: In children, consider
failure to make expected weight gain.)
 He has also experienced insomnia,
where he would not be able to

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4. Insomnia or hypersomnia nearly every
day.
5. Psychomotor agitation or retardation
nearly every day (observable by others,
not merely subjective feelings of
restlessness or being slowed
down).
6. Fatigue or loss of energy nearly every
day.
7. Feelings of worthlessness or excessive
or inappropriate guilt (which may be
delusional) nearly every day (not merely
self-reproach or guilt about being sick).
8. Diminished ability to think or
concentrate, or indecisiveness, nearly
every day (either by subjective account or
as observed by others).
9. Recurrent thoughts of death (not just
fear of dying), recurrent suicidal ideation
without a specific plan, or a suicide
attempt or a specific plan for committing
suicide
B. The symptoms cause clinically
significant distress or impairment in
social, occupational, or other important
areas of functioning.
sleep until morning comes and
eventually would just play online
games, with a certain addiction to
DoTA.
 Consistent sleeping
 He has also experienced fatigue,
loss of energy was probably
caused by his extended exposure
to personal computer all night long,
sleep when it’s already morning,
and wakes up only for work.
 He is also someone who has low
self-esteem, saying that he’s
worthless and has no purpose in
the world.
 He felt guilty about the family
problem, thinking that it was his
fault even though it is not.
 He could also not concentrate and
is easily distracted.
 Roman also has suicidal
tendencies. He thinks about and
has attempted suicide before like
hanging and cutting his wrist, that
it is fine for him to die
 He even avoided some of his
friends he had before.
 He was socially withdrawn.
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C. The episode is not attributable to the  Roman is a 30-year-old introverted

physiological effects of a substance or to man with no history of substance
another medical condition. abuse.

D. The occurrence of the major

depressive episode is not better It is not better explained with other
explained by schizoaffective disorder, disorders
schizophrenia, schizophreniform disorder,
delusional disorder, or other specified and
unspecified schizophrenia spectrum and
other psychotic disorders.

E. There has never been a manic episode

or a hypomanic episode. There has never been manic
Note: This exclusion does not apply if all episode or hypomanic episode.
of the manic-like or hypomanic-like
episodes are substance-induced or are
attributable to the physiological effects of
another medical condition.