DSM Diagnosis

Dean Winchesters diagnosis is as follows:

300.4 (F34.1) Persistent Depressive Disorder with at!pical feat"res earl! onset with inter#ittent
#a$or depressive episodes with c"rrent episode severe
303.%0 (F10.&0) Preli#inar! 'lcohol (se Disorder #oderate
)*1.&0 (+*&.,&0) Parent-.hild /elational Pro0le#
)*1., (+*&.,%1) 1i0ling /elational Pro0le#
%%2.21 (344.0&5D) .hild 6eglect .onfir#ed
)*0.% (+2%.%) (nspecified 7o"sing or 8cono#ic Pro0le#
Background and Presenting Information
Dean Winchester is a &4 !ear old single #ale whose onl! living relative is his !o"nger 0rother
1a# Winchester. When Dean was 4 !ears old he resc"ed a *-#onth old 1a# fro# a ho"se fire
that too9 the life of their #other :ar!. ;n the after#ath of their #others death their father
<ohn set o"t on the road with the 0o!s traveling across co"ntr! to wor9 odd $o0s never sta!ing
in one place for #ore than a few wee9s. 3he 0o!s were forced to live o"t of #otel roo#s to
irreg"larl! attend school in their c"rrent location and were often left alone for wee9s to fend for
the#selves. Dean was forced to ass"#e the role of careta9er and father fig"re soon after :ar!s
death as a res"lt of repeated incidents of <ohn disappearing for da!s or wee9s on end in order to
h"nt in new locations. Dean was forced to steal food and necessities for their s"rvival on #ore
than one occasion d"ring his adolescence and often went witho"t #eals to ens"re that 1a# was
well cared for. ;n the after#ath of :ar!s death <ohn fell into deep into depression and
alcoholis#. D"ring the ti#e he spent with the 0o!s he was distant and cold toward the#. <ohns
interactions with Dean were predo#inantl! 0ased in teaching hi# how to h"nt and how to protect
hi#self and his little 0rother. <ohn ha0it"all! re#inded Dean that nothing was #ore i#portant
than 1a# not even his own life.
Prior to his #others death Dean was a livel! tal9ative 0o! who thrived off ph!sical affection
fro# his parents. 'fter :ar!s death Dean spo9e ver! little for !ears and never so"ght ph!sical
co#fort fro# his father. <ohn never disc"ssed :ar!s death with the 0o!s. :ar! 0eca#e a ta0oo
topic 0eca"se <ohn never wished to spea9 of her and 1a# was too !o"ng to re#e#0er her.
Deans change in 0ehavior also incl"ded irrita0ilit! that persists to this da!. 3hro"gho"t his
adolescence and earl! ad"lthood Dean reports often feeling hopeless and sad 0"t lac9s the will
to show or to disc"ss his feelings with 1a#. 7e reports persistent inso#nia restlessness and
agitation if he sits still for too long as well as feelings of g"ilt for the deteriorating condition of
their fa#il!. =ver the !ears Dean and 1a# 0egan to grow apart d"e to disagree#ents with <ohn
that lead to fights 0etween 1a# and <ohn. Dean felt it was his $o0 to #ediate and to protect 1a#
fro# <ohn which in t"rn ca"sed 1a# to p"sh hi# awa! as well. 1a# "lti#atel! #ade the
decision to leave to attend college after receiving a f"ll-ride scholarship to 1tanford.
1i> #onths ago <ohn died in an alcohol-related car crash. 1ince then Dean reports that the
persistent feelings of g"ilt and worthlessness have 0een e>acer0ated 0eca"se he feels responsi0le
for his fathers death. 7e feels that he co"ld have done #ore to help <ohn and to fi> their fa#il!.
3he g"ilt Dean e>periences is overwhel#ing often res"lting in diffic"lt! concentrating on an!
tas9 for a long period of ti#e and an increase in the restlessness that #a9es hi# often ta9e to the
road and avoid an! se#0lance of sta0ilit!. Dean reports great diffic"lt! sleeping despite feeling
tired #ost da!s. 1a# and Dean 0oth state that Dean goes thro"gh periods of positive affect in
light of positive events s"ch as prolonged positive interaction 0etween the two 0rothers. ;n the
ti#e since <ohn passed awa! 1a# reports that Dean has 0eco#e ?cling!@ and often e>presses his
fears that 1a# will leave hi# li9e their parents did. 7e 0elieves that Dean has 0een co#pensating
for his g"ilt for <ohns 0ehavior 0! acting li9e his father since the! were 9ids and that 0ehavior
has onl! increased in light of <ohns death. 1a# shares that Dean has told hi# that he doesnt feel
li9e he has a p"rpose 0e!ond ta9ing care of 1a# and that Dean wo"ldnt 0e a0le to live witho"t
hi# if #isfort"ne fell "pon hi#.
Dean reports that he has so#e da!s where his #ood is elevated d"e to positive interactions with
1a# 0"t it never lasts for long. :ore often than not Dean feels irrita0le and down on hi#self for
the circ"#stances of his life. Dean reports that recentl! his alcohol inta9e has increased 0"t he
does not feel as tho"gh it is pro0le#atic. 1a# enco"raged Dean to see9 treat#ent after Dean
0egan e>pressing tho"ghts that dist"r0ed hi# in ter#s of Deans carelessness for his own life
co#0ined with a noticea0le and #ar9ed increase in his alcohol cons"#ption leading to long
stretches of ti#e where Dean dran9 e>cessivel! 0"t never achieved a dr"n9en state. Dean
e>pressed to 1a# that he feels e#pt! e>cept for the g"ilt that is ?9illing hi#@ and e>plained that
he feels li9e 1a# doesnt care or love hi# as #"ch as he loves 1a# citing 1a#s decision to
wal9 awa! fro# Dean and <ohn to attend college. Dean saw this as 1a# leaving hi# 0ehind to
carr! o"t his own life witho"t hi# and thats not so#ething that Dean co"ld ever do. 1a#
e>pressed that Deans dependence on hi# was part of his reason for leaving 0"t in light of <ohns
death and Deans descent into #ore freA"ent depressive episodes hes too afraid to leave Dean
alone for fear that he #a! 0e a danger to hi#self.
Explanation for Diagnosis
; have diagnosed Dean Winchester with Persistent Depressive Disorder with at!pical feat"res
earl! onset with inter#ittent #a$or depressive episodes with c"rrent episode severe 0ased "pon
the preponderance of evidence of s!#pto#s of #a$or depressive disorder that have persisted for
considera0l! longer than the & !ear reA"ire#ent for diagnosis. Persistent depressive disorder is
characteriBed 0! depressed #ood for #ost of the da! for #ore da!s than not that #eets the
criteria of chronic #a$or depressive disorder. ;n accordance with the Diagnostic Statistical
Manuel of Mental Disorders 2
th
ed. Dean #"st #eet five or #ore of the criteria for #a$or
depressive disorder persisting for at least & !ears to 0e diagnosed with persistent depressive
disorder. Dean #eets the following criteria of #a$or depressive disorder: depressed #ood #ost of
the da! nearl! ever! da! as indicted 0! s"0$ective report (e.g. feeling sad e#pt! hopeless)
inso#nia ps!cho#otor agitation and restlessness that is o0serva0le 0! others fatig"e despite
inso#nia feelings of worthlessness and e>cessive and inappropriate g"ilt nearl! ever! da!
di#inished a0ilit! to concentrate for long periods of ti#e and e>plicit tho"ghts of s"icide. ;n
addition Deans depressive s!#pto#s lasting longer than & !ears d"ring a depressive episode he
e>periences the following criteria of persistent depressive disorder: overeating inso#nia low
energ! low self-estee# poor concentration and feelings of hopelessness. Dean does not report
ever having a #anic or h!po#anic episode and does not present s!#pto#s significant to a
diagnosis of a schiBophrenia spectr"# disorder or other ps!chotic disorder. 6one of Deans
s!#pto#s are attri0"ta0le to a pree>isting #edical condition and his s"0stance a0"se occ"rred
after the #ar9ed e>acer0ation of s!#pto#s since his fathers death. Deans s!#pto#s have
ca"sed hi# significant distress since his childhood and have i#paired his social and occ"pational
f"nctioning in ter#s of creating new #eaningf"l relationships and #aintaining health! fa#ilial
relationships and in the ina0ilit! to settle into a ho#e environ#ent and hold a stead! $o0. 3he
severit! of Deans diagnosis was categoriBed as severe 0eca"se the n"#0er of s!#pto#s he
e>periences d"ring episodes and on a dail! 0asis are in e>cess of the reA"ire#ents for the
diagnosis and the intensit! of his e>perience with his s!#pto#s have ca"sed #ar9ed interference
with social and occ"pational f"nctioning and are reported as distressing and "n#anagea0le
leading to tho"ghts of s"icide.
; specified Deans persistent depressive disorder diagnosis as having at!pical feat"res 0eca"se
the #a$orit! of da!s Dean e>periences additional s!#pto#s incl"ding: #ood reactivit! in which
his #ood 0rightens in response to act"al or potential positive events increase in appetite and ?a
long-standing pattern of interpersonal re$ection sensitivit!@ that is not e>cl"sive to an episode
and that res"lts in significant social or occ"pational i#pair#ent. Dean e>presses irrational fear of
1a# 0eing in danger or of 1a# choosing to a0andon hi# which has ca"sed significant strain in
their relationship especiall! after <ohns death.
Persistent depressive disorder with inter#ittent #a$or depressive episodes with c"rrent episode
was specified 0eca"se the f"ll criteria for a #a$or depressive episode are c"rrentl! #et 0"t Dean
reports periods of at least eight wee9s within the last two !ears with s!#pto#s 0elow the
threshold for a f"ll #a$or depressive episode d"ring which he was a0le to settle in one place and
wor9 for #"ltiple #onths for a stead! inco#e witho"t the restless need to travel and d"ring
which 1a# reported i#prove#ents in their relationship.
;n addition to persistent depressive disorder ; preli#inaril! diagnosed Dean with 'lcohol (se
Disorder characteriBed 0! s!#pto#s that ca"se clinicall! significant distress or i#pair#ent in
social occ"pational or other real#s of f"nctioning 0"t do not #eet the f"ll criteria of alcohol "se
disorder. ;n order for Dean to 0e diagnosed with alcohol "se disorder his s!#pto#s #"st 0e
present for at least a 1&-#onth period. Civen the *-#ont ti#efra#e since his increase in alcohol
"se and dependence he will not #eet the f"ll criteria and preventative #eas"res can still 0e ta9en
to defer pathological dependence. Deans self-report on his alcohol "se presents an increased
tolerance defined 0! a need for #ar9edl! increased a#o"nts of alcohol to achieve into>ication
as well as contin"ed "se of alcohol despite his 9nowledge that it is not onl! negativel! affecting
his health 0"t leading to an increase in his feelings of g"ilt and hopelessness. Dean reports that
he often ingests a #"ch larger A"antit! of alcohol than originall! intended and craves alcohol
when hes 0een witho"t it for #ore than a few ho"rs at a ti#e. 1a# reports that Dean often "ses
alcohol in sit"ations that are potentiall! ph!sicall! haBardo"s s"ch as while wor9ing or h"nting.
Related Psychosocial and Family Issues
3he relationship 0etween Dean and his father sho"ld 0e a 9e! foc"s is his therape"tic intervention
and is incl"ded as a part the diagnosis of Parent-.hild /elational Pro0le#s. Foc"sing on the
relationship 0etween Dean and his father will provide a pict"re of the develop#ent and co"rse of
his persistent depressive disorder. 3he relevant parent-child relational pro0le#s incl"de poor
A"alit! of parenting ste##ing fro# inadeA"ate parent control s"pervision and involve#ent
e>cessive press"re fro# his father arg"#ents 0etween Deans father and his little 0rother that
escalated to threats of violence and avoidance witho"t resol"tion of pro0le#s. 6one of the iss"e
or grief fro# the death of Deans #other where ever addressed within the fa#il! nor was there
an! co##"nication 0etween <ohn and sons a0o"t the change in his 0ehavior and his
a0andon#ent.
3he e>isting 1i0ling /elational Pro0le# sho"ld also 0e a 9e! foc"s of Deans treat#ent 0eca"se
1a# is his sole s"pport. Deans 0ehavior and "nhealth! attach#ent to 1a# has ca"sed a rift
0etween the two of the# #ainl! d"e to Dean conf"sing his caregiver roles as a 0rother and as a
parent to 1a# as well as his a"g#ented fear of a0andon#ent. Dean needs to co#e to the
realiBation that it is not his responsi0ilit! to ta9e the place of his parents in 1a#s life as well as
arrive at a place where he can 0egin to let go of the attach#ent to 1a# that has 0eco#e
codependent o"t of fear of a0andon#ent.
;ntervention foc"sing on the effects of childhood neglect is critical to Deans positive progress.
<ohns actions thro"gho"t Deans childhood deprived hi# of his 0asic age-appropriate needs and
res"lted in ph!sical and ps!chological har#. 's a res"lt of <ohns a0andon#ent and fail"re to
provide necessar! no"rish#ent care and shelter Dean was forced to raise 1a# li9e a father
rather than a 0rother was forced to steal food and #one! for their s"rvival and to freA"entl! s9ip
#eals to ens"re that 1a# was well fed. F"rther inA"ir! into Deans childhood and the steps he
too9 to ens"re their s"rvival in <ohns a0sence sho"ld 0e #ade in order to ascertain the li9elihood
that Dean engaged in an! illicit #eans of o0taining #one! 0e!ond theft incl"ding prostit"tion
which #a! also 0e contri0"ting factors to his pri#ar! diagnosis that #"st 0e addressed in the
treat#ent process.
Related Vocational Issues
(nspecified 7o"sing or 8cono#ic Pro0le# was diagnosed d"e to the nat"re Deans childhood
sit"ation concerning the lac9 of a sta0le ho#e environ#ent that does not #eet the criteria )*0.0
(+2%.0) 7o#elessness and )*0.1 (+2.1) ;nadeA"ate 7o"sing. Dean and 1a# lived in #otel
roo#s across the co"ntr! thro"gho"t their childhood and were so#eti#es left to sta! with fa#il!
friends for long periods of ti#e. 3heir needs were #et 0! the sacrifice of fa#il! friends and
Dean hi#self. ."rrentl! Dean has !et to find the sta0ilit! to settle down in a ho#e environ#ent
choosing to re#ain living on the road and o"t of #otel roo#s with his 0rother. Dean has also
0een "na0le to hold a sta0le $o0 d"e to his restless need to not sta! in one place for long. 7is #ain
so"rce of inco#e is a $o0 as a #echanic for a fa#il! friend that he ret"rns to ever! few #onths
for a few wee9s at a ti#e. 3he lac9 of sta0ilit! in ho#e and career #a! 0e contri0"ting factors in
Deans feelings of lac9 of hope and worthlessness
Proposed reatment !ptions
3he #ost co##on treat#ent intervention for persistent depressive disorder is phar#acotherap!
"sing tric!clic antidepressants to significantl! red"ce the patients depressive s!#pto#s. ; wo"ld
not s"ggest this intervention for Dean given his e>pressed tho"ghts related to s"icide. 3ric!clic
antidepressants are highl! to>ic and Deans s"icidal ideation p"ts hi# at ris9 of atte#pting to
overdose. 1elective serotonin re"pta9e inhi0itors (11/;s) #a! 0e the 0est phar#acotherap!
option for Dean in order to red"ce his depression s!#pto#s. 'd#inistration of dr"gs sho"ld 0e
#onitored for at least * wee9s for signs of i#prove#ent in Deans s!#pto#s. ;t will 0e i#portant
to 9eep Dean infor#ed of the nat"re of antidepressant treat#ent in regard to contin"ed
e>periences with s!#pto#s. Feelings of fail"re and hopelessness are prevalent in Deans illness
so it is critical he "nderstands that even while 0eing treated individ"als with persistent depressive
disorder are li9el! to contin"e to e>perience periods of d!sth!#ia in order to circ"#vent an!
feelings he #a! have that treat#ent is hopeless for hi#.
Civen the nat"re of Deans persistent depressive disorder with at!pical feat"res #edication will
not 0e a s"fficient co"rse of treat#ent and #"st 0e acco#panied with appropriate ps!chotherap!.
;nterpersonal therap! (;P3) wo"ld foc"s on Deans c"rrent relationship with his 0rother to help
hi# "nderstand the #aladaptive interaction patterns in which the! are engaged in order to 0egin
the change process. Deans ;P3 treat#ent plan will incl"de the following co#ponents: a positive
therape"tic relationship to #a>i#iBe the 0enefits of treat#ent and treat#ent alliances with Dean
his 0rother pri#ar! care providers and other #ental health professionals. ;n order to o0tain the
#ost positive treat#ent o"tco#e for Dean the plan #"st #a>i#iBe his cooperation in his own
treat#ent identif! and address Deans ris9 factors for relapse and #aintain a treat#ent regi#en
for as long as necessar! for Deans condition to sta0iliBe which considering his histor! and
significant ris9 of rec"rrence sho"ld incl"de a plan for #onitoring and proactive treat#ent for a
least 3 !ears. Deans treat#ent progress sho"ld 0e #onitored &-3 ti#es wee9l! for efficac! and
an! side effects fro# the ti#e of i#ple#entation for a reasona0le trial period. 3reat#ent shall 0e
a"g#ented if Deans condition fails to i#prove or sta0iliBe. ; wo"ld s"ggest that in addition to
dr"g protocol treat#ent and ;P3 Dean reg"larl! attend gro"p therap! sessions with other
individ"als str"ggling with depression and co#or0id s"0stance a0"se pro0le#s. 3his will wor9 to
e>pand his incredi0l! narrow s"pport s!ste# as well as provide ed"cation on the dangers of
s"0stance dependence and c"ltivate hope that he can co#0at his #ental illness and find p"rpose
in his life once again.
"ontinuing #ssessment
Civen the length of ti#e that Deans d!sth!#ia has persisted and the additional stress of his
fathers death that has e>acer0ated the severit! of his s!#pto#s the potential for relapse after
recover! is appro>i#atel! 41 percent. .ontin"ing assess#ent and therap! will 0e critical in
lowering the ris9 of Dean relapsing into contin"ed depression s!#pto#s and s"icidal ideation as
well as prevent alcohol dependenc! and the develop#ent of 'lcohol (se Disorder. Dean sho"ld
receive ongoing ed"cation on depression and lifest!le changes that will assist recover! and allow
hi# to re#ain #indf"l of his stressors and his s"pport s!ste#. .ontin"ing ed"cation will 0e
necessar! for Dean to #aintain the changes that he has #ade in his lifest!le and 0ehavior and to
adapt to changes in his environ#ent. ;t will also 0e i#portant to contin"all! #onitor Deans ris9
for s"icide and the ris9 for alcohol dependence considering his fathers histor! of alcoholis# and
his increased "sage as a coping #echanis# with the help of his s"pport s!ste#. Deans treat#ent
will 0e a long-ter# possi0l! life-long co##it#ent to ens"re positive growth sta0ilit! of
depressive s!#pto#s and i#prove#ent of social and occ"pational f"nctioning.