1. What would you diagnose the client with? Please provide justification and ensure you use proper specifiers if applicable.

2. Are there any differentials that you would consider? If so, what are they?

3. What would your treatment recommendations be? (is there a certain theory you'd use? Would you suggest individual, family, couples, etc? Would you suggest medication and if so what would you think a prescriber would prescribe?). Please ensure you explain why you chose the recommendations you did.

4. Include DSM5-TR codes for each Diagnosis

Larry Goranov was a 57-year-old single unemployed white man who was asking for a review of his treatment at the psychiatric clinic. He had been in weekly psychotherapy for 7 years with a diagnosis of dysthymic disorder. He complained that the treatment had been of little help and he wanted to make sure that the doctors were on the right track.

Mr. Goranov reported a long-standing history of low-grade depressed mood and decreased energy. He had to "drag" himself out of bed every morning and rarely looked forward to anything. He had lost his last job 3 years earlier, had broken up with a girlfriend slightly later, and doubted that he would ever work or date again. He was embarrassed that he still lived with his mother, who was in her 80s. He denied any immediate intention or plan to kill himself, but if he did not improve by the time his mother died, he did not see what he would have to live for. He denied disturbances in sleep, appetite, or concentration.

Clinic records indicated that Mr. Goranov had been adherent to adequate trials of fluoxetine, escitalopram, sertraline, duloxetine, venlafaxine, and bupropion, as well as augmentation with quetiapine, aripiprazole, lithium, and levothyroxine. He had some improvement in his mood while taking escitalopram but did not have a remission of symptoms. He also had a course of cognitive-behavioral therapy early in his treatment; he had been dismissive of the therapist and treatment, did not do his assigned homework, and appeared to make no effort to use the therapy between sessions. He had never tried psychodynamic psychotherapy.

Mr. Goranov expressed frustration at his lack of improvement, the nature of his treatment, and his specific therapy. He found it "humiliating" that he was forced to see trainees who rotated off his case every year or two. He frequently found that the psychiatry residents were not especially educated, cultured, or sophisticated, and felt they knew less about psychotherapy than he did. He much preferred to work with female therapists, because men were "too competitive and envious."

Mr. Goranov previously worked as an insurance broker. He explained, "It's ridiculous. I was the best broker they had ever seen, but they won't rehire me. I think the problem is that the profession is filled with big egos, and I can't keep my mouth shut about it." After being "blackballed" by insurance agencies, Mr. Goranov did not work for 5 years, until he was hired by an automobile dealer. He said that although it was beneath him to sell cars, he was successful, and "in no time, I was running the place." He quit within a few months after an argument with the owner. Despite encouragement from several therapists, Mr. Goranov had not applied for a job or pursued employment rehabilitation or volunteer work; he strongly viewed these options as beneath him.

Mr. Goranov has "given up on women." He had many partners as a younger man, but he generally found them to be unappreciative and "only in it for the free meals." The psychiatric resident's notes indicated that he responded to demonstrations of interest with suspicion. This tendency held true in regard to both women who had tried to befriend him and residents who had taken an interest in his care. Mr. Goranov described himself as someone who had a lot of love to give but said that the world was full of manipulators. He said he had a few buddies, but his mother was the only one he truly cared about. He enjoyed fine restaurants and "five-star hotels," but he added that he could no longer afford them. He exercised daily and was concerned about maintaining his body. Most of his time was spent at home watching television or reading novels and biographies.

On examination, the patient was neatly groomed, had slicked-back hair, and wore clothing that appeared to be by a hip-hop designer generally favored by men in their 20s. He was coherent, goal-directed, and generally cooperative. He said he was sad and angry. His effect was constricted and dismissive. He denied an intention to kill himself but felt hopeless and thought of death fairly often. He was cognitively intact.