Psychopathology and Diagnostic Reasoning

SUBJECTIVE
CC (chief complaint): The patient complains of “sadness and fear” after learning that they “have
to all return to Iraq for another tour.”
HPI: Ralph Newsome is a 19-year-old male who presents for a psychiatric examination with
complaints of “sadness” and “fear” after learning two months ago that he was activated with the
Navy reserves after the stop-loss policy was sanctioned. He fears returning to Iraq and living as a
gay soldier in the Arab nation. The patient also reveals “lying” about his sexuality to colleagues.
He fears people will feel uncomfortable around him – in the showers, patting him on the back,
guy hugs, and sleeping in close quarters – if he reveals his sexuality. He fears “coming out of the
closet as a gay” and does not know how to start or end. He is “terrified” of rejection and losing
people close to him forever. He is confused between sexual relations and friendships; he enjoys
close friendships with both male and female colleagues and does not know if his feelings toward
male colleagues are sexual. He has been worried in the past about his sexuality and has had
suicidal thoughts. He values friendship and unity. He confesses that “men” in his unit are all he
has “day after day.” They are right there and do not want to feel like being on the outside. The
patient is optimistic about “coming out of the closest” and doing fine like others he has seen on
TV, the internet, or had stories about. He is willing to attend two other sessions before leaving
for Iraq to discuss his sexuality (Symptom Media, 2017).
Past Psychiatric History: The patient worries about his “rejection” and harbors suicidal
thoughts. He also used to dream that what he shared with his colleagues in the unit was “real”
because he was living a lie by not revealing his sexuality. Despite his sexuality, the patient has
been a team player, valuing unity and friendship.

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 General Statement: The patient expresses excessive anxiety and worry about reporting
back to duty and coming out as gay.
 Caregivers (if applicable): None.
 Hospitalizations: No history of hospitalizations.
 Medication trials: No medication trials.
 Psychotherapy or Previous Psychiatric Diagnosis: No previous psychiatric diagnosis
or psychotherapy.
Substance Current Use and History: No history of alcohol use, smoking, or substance/drug
abuse.
Family Psychiatric/Substance Use History: He lives with his dog Chance (the only child) in
Colombus, Ohio. Parents live around. He works part-time as a construction worker. He is not in
any relationship currently. There is no past known psychiatric history.
Psychosocial History: The patient reveals being gay and slightly attracted to men. He has
thoughts of wanting to be close to a male partner and often harbors sexual thoughts. He has a
“mild curiosity maybe about what others look like when undressed.” He reports enjoying close
friendships with women too. He has never been in an ongoing relationship.
Medical History:
 Current Medications: Not on any medications.
 Allergies: No known allergies; sleeps eight hours; appetite is good.
 Reproductive Hx: The patient is single and has not been in any sexual relationship. No
children. He is sexually active and admits to being gay but has never openly talked to
anyone about their sexuality.
ROS:

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 GENERAL: No fever, chills, fatigue, weight loss, or weakness.
 HEENT: Head: appears symmetrical without tenderness, lumps, or lesions. Eyes: No
redness, swelling, blurred vision, yellow sclerae, discharge, double vision, or visual loss.
Ears, Nose, & Throat: No inflammation, hearing loss, wax buildup, infection,
inflammation, tonsilitis, redness, and swelling. The buccal mucosa, tongue, teeth, lips,
and gums are normal without lesions.
 SKIN: No rashes, scaling, discoloration, dryness, jaundice, cyanosis, and parlor. Skin
turgor and elasticity are normal.
 CARDIOVASCULAR: No abnormal thrills, pulsations, or abnormalities. No edema,
palpitations, chest pain, pressure, or discomfort. No jugular distention or edema in the
lower extremities, and capillary refill is normal.
 RESPIRATORY: No respiratory distress, shortness of breath, palpations, wheezing,
crackling, cough, or sputum. Normal oxygen saturation, breath sounds, respiratory rate,
and symmetrical chest wall motion.
 GASTROINTESTINAL: No visible changes in bowel movement, abdominal pain,
vomiting, nausea, diarrhea, blood, anorexia, nausea, or organ tenderness & enlargement.
 GENITOURINARY: No changes in urine odor/color, hematuria, urinary incontinence,
urgency, frequency, or pain.
 NEUROLOGICAL: Motor, sensory, and reflex functions are normal. Gait and balance
are coordinated and steady. Executive functions, attention, memory, and orientation are
normal. There is no tingling in extremities, numbness, ataxia, paralysis, syncope,
dizziness, or headache.

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 MUSCULOSKELETAL: No back and muscle pain and joint stiffness, pain, movement
limitations, tenderness, deformities, swelling, redness, or effusion. Walking gait is
coordinated and steady.
 HEMATOLOGIC: No bruising, weakness, fatigue, dizziness, and anemia.
 LYMPHATICS: No evidence of enlarged, inflamed, palpable, and tender lymph nodes or
past splenectomy. No swelling in the extremities or edema and lymphedema. No history
of wound healing problems.
 ENDOCRINOLOGIC: No history of heat & cold intolerance, sweating, polydipsia, and
polyuria.
OBJECTIVE:
Physical exam:
Vitals: Temp 97.0; P 70; R 18 ; BP 116/68; Ht 5’9; Wt 175lbs
Diagnostic results:
 Complete blood count (CBC) to examine underlying infections and medical conditions
 A brain scan (MRI, fMRI, PET, or EEG) to rule out potential brain damage
 Psychiatric rating scales (BDI, HAM-A, & BSI) to evaluate symptoms severity, including
anxiety and depression.
ASSESSMENT:
Mental Status Examination: The patient is oriented to time, person, and place and looks at his
stated age (19 years). He is straightforward, neatly and appropriately groomed and dressed, and
cooperative during the examination. He displays no abnormal motor activity, and his volume and
tone are normal. His speech is also coherent and clear. His affect and mood are appropriate, and
he denies hallucinations and delusions. His memory, insight, and concentration are good and

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intact. He denies suicidal ideation but acknowledges expressing “wanting to die” in the past.
However, he has patient has difficulty separating sexual relations from friendships. He also has
difficulty revealing to people about their sexuality (gay). He also has a problem dealing with
“rejection.” He fears telling people about his sexuality because others will walk away, feel
deceived, and may never support them. His face occasionally expresses sadness, and seems
deeply embroiled in deep thought. He worries about rejection from friends and colleagues about
his sexuality. However, he values friendship and unity. He confesses that “men” in his unit are
all he has “day after day.” They are right there and do not want to feel like being on the outside.
The patient is willing and optimistic about “coming out of the closest” and doing fine like others
he has seen on TV, the internet, or had stories about.
Differential Diagnoses:
 Adjustment disorder with mixed anxiety and depressed mood: Based on the DSM-5
criteria, it is highly likely that the patient is suffering from adjustment disorder with
mixed anxiety and depressed mood (3009.24; F43.22) (Substance Abuse and Mental
Health Services Administration, 2016). This is because the symptoms started two months
ago (within the three months stipulated under the DSM-5), and the patient exhibits signs
of both anxiety (worry) and depressed mood (sadness) at the thought of going back to
Iraq. He is worried and sad about the upcoming redeployment and uncertain about
disclosing his sexuality to the unit, as well as the protection of information disclosure by
the Constitution. The marked distress and symptoms might be caused by stressors like his
experiences in the military service and the likely impact revealing his sexual identity
might have on his relationship with peers. According to the patient, disclosing their

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sexual orientation (the stressor) might significantly impair their occupational and social
functioning, including unit teamwork and relationship-building.
 Gender dysphoria (sexual identity confusion): The patient is also likely suffering from
sexual identity confusion, a condition identified in the DSM-5 as gender dysphoria. He is
confused and uncertain about his sexuality, mainly because he is attracted to both women
and men. Although he identifies as gay, he finds difficulty separating sexual feelings
from friendship, coupled with the absence of real-life life experiences in sexual
relationships with either men or women, which may imply an ongoing questioning of and
exploration of their sexual identity. According to the DSM-5, gender dysphoria is a
clinically significant impairment or distress linked to gender incongruence or disparity
between expressed/experienced and assigned gender, lasting at least six months (Turban,
2022; Cooper et al., 2020). The patient also strongly believes he has the typical
reactions/feelings of the other gender (male).
 Generalized anxiety disorder (GAD): It is also likely that the patient fears and worries
about disclosing their sexual identity, going to Iraq, the possible rejection he might face,
and the impact disclosure might pose on their relationship with peers and work may also
align with GAD symptoms. GAD is a mental disorder characterized by excessive and
uncontrollable worry and anxiety over specific issues lasting less than six months
(Boland et al., 2016; Stein et al., 2021). However, lack of accompanying symptoms –
restlessness, fatigue, impaired concentration, irritability, increased muscle soreness/aches,
and difficulty sleeping – might disqualify GAD as a potential candidate for the patient.
Reflections:

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If presented with the same patient, I would interview his unit peers in the navy (especially
Jonhson) and parents to get an idea of their cognitive, social, mental, and behavioral symptoms,
including sexual attraction. Secondly, I will perform a comprehensive psychiatric assessment
using tools like BSI (Brief Symptom Inventory), HAM-A (Hamilton Anxiety Rating Scale), and
BDI (Beck Depression Inventory) to evaluate the symptoms’ severity and track changes weekly
or monthly. I will also dig deeper into the patient’s psychiatric history to identify other
psychological, neurological, cognitive, and motor symptoms the patient might have experienced
in the past, such as restlessness, fatigue, impaired concentration, irritability, increased muscle
soreness/aches, difficulty sleeping, and gender incongruence to support the diagnosis for gender
dysphoria and GAD.

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References

Boland, R., Verduin, M. L., & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12 th
ed.). Wolters Kluwer.
Cooper, K., Russell, A., Mandy, W., & Butler, C. (2020). The phenomenology of gender
dysphoria in adults: A systematic review and meta-synthesis. Clinical Psychology
Review, 80. doi: 10.1016/j.cpr.2020.101875
Stein, D. J., Kazdin, A. E., Ruscio, A. M., Chiu, W. T., Sampson, N. A., et al. (2021). Perceived
helpfulness of treatment for generalized anxiety disorder: A World Mental Health
Surveys report. BMC Psychiatry, 21 (392). https://doi.org/10.1186/s12888-021-03363-3
Substance Abuse and Mental Health Services Administration. (2016). Impact of the DSM-IV to
DSM-5 changes on the National Survey on Drug Use and Health [Internet]. Rockville,
MD: SAMHSA. https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t19/
Symptom Media. (Producer). (2017). Training title 15 [Video].
https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/wa
tch/training-title-15
Turban, J. (2022). Gender dysphoria. American Psychiatric Association.
https://www.psychiatry.org/patients-families/gender-dysphoria/what-is-gender-dysphoria