Question: XXXXXXX is a middle-aged, married, Caucasian male who has two grown children. XXXXXXX father passed away when XXXXXXX was in college, and this loss still pains him. He held his father in extremely high regard and at times referred to him as "brilliant XXXXXXX even though his father did not graduate from high school. His father worked at a skilled trade until he suffered a fatal illness in his late 40s or early 50s. XXXXXXX laments the loss of his father and, in particular, the guidance he thought his father could have provided during turbulent times in XXXXXXX life.

According to the pattern of alcohol use that XXXXXXX describes, it is likely that XXXXXXX father had a serious drinking problem, if he was not actually an alcoholic. XXXXXXX mother, who is also deceased, is described by XXXXXXX as a strong woman and the matriarch of the family. While XXXXXXX states that he had much respect for her, it seems that his respect was also tinged with fear of her disapproval. She never accepted or understood why XXXXXXX chose the college he did and why he had an interest in an Army career.

XXXXXXX states that his mother never used alcohol. He describes her as a very critical and judgmental person. His family of origin was devout in their religious beliefs, and this appears to play a significant role in XXXXXXX life. He is close to his siblings, but they do not talk often, and he feels guilt for not initiating calls to them. His hesitation to call them is due in part to a fear that they will reject him. It is for this reason that he also tries to keep conversations with them at a superficial level. His extended family includes people who have achieved at the highest levels of government and their professions.

XXXXXXX graduated from a prestigious college and embarked on a military career, which was his lifelong ambition. A "vindictive" superior officer who gave him poor performance evaluations cut XXXXXXX career short. It turns out that XXXXXXX may have had much more of a role in this than he is aware of or initially admits. He acknowledges a lengthy period of indecision and marginal adherence to military standards at the beginning of his career, but relates that he eventually got over that “down time.” Nonetheless, XXXXXXX developed the persona of hero in both military matters and civilian jobs, and to this day, he compares himself with heroic figures from antiquity and sees himself on the verge of doing something great, “if,” he says, “I can ever get over this serious case of the blues I’ve been experiencing for the past months.” He indicates that he has felt this way, “empty, really,” nearly all day every day for at least two to three months. As he says this he appears tearful. He relates that there was no particular incident or event that started him feeling this way. “It just came over me,” he says.

He reports that he has, in fact, lost interest in any kind of work or activities over the last months, and finds XXXXXXX in literally nothing. He has no energy and reports that others have been asking him why he’s so plodding and slow about everything lately. He has great difficulty getting out of bed in the morning and constantly thinks about suicide. While he feared death as a young man, he now says he would welcome it. He has been on Prozac “and things” for years and questions whether it is working.
XXXXXXX is awash in guilt. He feels guilt for things he has done and for things he has not done. He has a disarming smile that belies the pain he feels and keeps people from prying into his life. He has one or two drinks of XXXXXXX Daniels, neat, each night. Psychotherapy is difficult with him because of the chronic nature of his problems and his fear of alienating people who are close to him. He seems to genuinely believe that his expectations of other people are fair and reasonable, but he is so disappointed in “everything” that he doesn’t know what there is to live for.
XXXXXXX places unrealistic importance on the support available from his nuclear family. Yet, he says he is cautious around them because if he says or does the wrong thing, they might leave him or tell him to leave. He is, he adds, feeling pretty worthless and guilty about ridiculous little things he’s done and said to his family. He knows he has been emotionally “fragile” the last few months; in particular, he has found himself increasingly irritable. He expresses anger at his adult children because they do not appear as devoted to him as he was and still is to his late father. However, XXXXXXX keeps this anger to himself for fear of rejection. He has also recently experienced conflict with his wife of many years. It is not possible for her to XXXXXXX his expectations for support, so he becomes angry with her, but withholds the expression of his anger for fear of alienating her.

Here is my AXIS diagnosis….

Axis I: V62.82 Bereavement, 309.00 Adjustment Disorder with depressed mood, 305.00 Alcohol abuse

Axis II: 309.81 Post Traumatic Stress Disorder.

Axis III: None to Report

AXIS IV: Social, employment, family, suicidal ideation

Axis V: 10

1.     Would there be a different in the diagnosis if we were to use the ICD-10 to arrive at these diagnoses?

2.     What would be the three primary issues that need to be addressed in the treatment for XXXXXXX?

His bereavement, substance abuse, and suicidal ideation issues. I'm on the correct track?

3.     Keeping the diathesis-stress model in mind, what etiological factors do you think are relevant in this case, and why?

XXXXXXX has several stressors that are present and may be the cause of these diagnosed disorders including the death of his father, fearing the rejection of his mother, his feelings of anxiety at losing his parental figure of his mother, he also feels stressed by his children in that they don’t look up to him as much as he continues to look up to his late father. I’m I on the correct track?

I would say....296.23 Major Depressive Disorder, Single Episode, Severe Without Psychotic Features

Or did I still miss the boat?

Thank you so much...I'm slowly getting a better understanding of everything. One last question, What kind of questions would you ask to help you diagnose this person?
Is there any other additional information you would need? Thanks