Case study 2
A 56-year-old man is referred to a PMHNP from his primary care physician due to restricted affect and concern about possible depression. The patient denies that he is depressed or feeling stressed. He was doing well in his job as a security guard, working the night shift, until he was told that his position was being phased out and that in order to stay with the company, he would need to switch to the day shift. The patient agreed because he did not think that this would be a problem and did not want to lose his insurance benefits and retirement plan. However, after several months in his new position he admits he is concerned that he is not doing as well in his new position. His previous position allowed him work on his own the vast majority of his work hours, while his new job requires almost constant interaction with coworkers, clients, his supervisor, and the general public, which does not agree with him as he describes himself as “not a very sociable person. “The patient says that he has almost no friends, except for a cousin that he has been close to since childhood. He reports that he has never had a significant romantic relationship or sexual encounter, but does not miss having had these experiences or not having friends. He states that he most enjoys spending hours surfing the Internet, collecting stamps, or playing computer games by himself. He has never seen a mental health professional before and has presented today only at the insistence of his primary care doctor.

On a mental status examination, the patient appears notably detached and aloof toward the examiner. He exhibits little eye contact. His mood is reported as “stressed,” but his affect is not congruent with this. He appears calm, and his emotional range is flat. No other prominent symptoms are noted during the mental status examination.

» What is the most likely diagnosis?

» What is the best initial treatment?

» Include the 3-differential diagnosis