NCMHCE Practice Test 5
10 free NCMHCE practice questions in the real exam format, covering the official content areas, with an explanation for every answer.
Question 1 of 10
Intake, Assessment, and DiagnosisCase study: Older adult after a spouse's death
| Client | |
|---|---|
| Age | 74 |
| Gender | Male |
| Sexuality | Gay |
| Ethnicity | White |
| Relationship Status | Widowed |
| Counseling Setting | Integrated primary care clinic (behavioral health in a family medicine practice) |
| Types of Counseling | Individual |
| Provisional Diagnosis | Deferred pending assessment |
Presenting Problem
You are a licensed mental health counselor working in an integrated primary care clinic, where you see patients referred by the clinic's physicians. Walter, a 74-year-old retired high school chemistry teacher, is referred by his primary care physician after his annual visit, at which he had lost 15 pounds in a year and told the nurse, "I'm just marking time until I can be with Gene." Walter's husband of 31 years, Gene, died 14 months ago of amyotrophic lateral sclerosis (ALS) after Walter cared for him at home for nearly 3 years. Walter says, "Every day I wake up, and for a second I think he's downstairs making coffee, and then it hits me again." He describes a near-constant longing for Gene and says most of his day is spent thinking about him; he still sets out two mugs and talks to Gene's photo each evening. He says, "I know he's gone, but I don't believe it, if that makes sense." He avoids the diner where they ate every Sunday and drives miles out of his way to avoid the hospice office. He stopped singing in his community choir after Gene died: "Without him in the second row, what's the point?" He describes feeling "numb at the edges" and says life "stopped meaning anything when he did." He feels intensely lonely "every single evening." He eats poorly because "Gene was the cook," and the weight loss has been gradual. He sleeps about six hours, waking once, and says his energy is "fine for an old man." He enjoys weekly visits from his grandnephew and still reads the newspaper every morning. He describes himself as "a decent person who just lost his other half" and denies feeling worthless, though he feels some guilt for "not noticing his stumbling sooner." His PHQ-9 total today is 9. When asked about suicide, Walter says, "I don't want to die, exactly. Some nights I just don't care if I wake up." He denies a plan, intent, preparatory behavior or past attempts. He denies homicidal ideation.
Mental Status Exam
Walter arrives early, neatly dressed in a pressed shirt that now hangs loosely on him; grooming is good. He is alert and oriented to person, place, time and situation. Eye contact is good, although he looks down at his wedding ring when speaking of Gene. His mood is "empty"; affect is tearful when he discusses Gene and brightens when he describes his grandnephew, congruent with content. Speech is soft and normal in rate. Thought process is logical and goal-directed; thought content focuses on Gene and the years of caregiving. He denies hallucinations and says he talks to Gene's photo but has never heard a reply. Recent and remote memory are intact. Gait is slow but steady. He reports passive death wishes as described, denies plan, intent and homicidal ideation, and denies any history of mania. He has one glass of wine with dinner "some nights" and denies other substance use.
Psychosocial and Family History
Walter and Gene met in their early 40s and married as soon as they legally could. They had no children; Walter's niece and her 10-year-old son visit weekly, and his niece drove him to today's appointment. Gene's siblings, who "never accepted us," planned the funeral in Gene's hometown church and listed Walter only as "a close friend" in the obituary. Walter says, "They erased thirty-one years in one paragraph." He lives on a teacher's pension and owns his home. He describes himself as "spiritual, not religious." Friends from the choir call now and then, but he lets the calls go to voicemail. He has never been in counseling. His trauma screen is negative. He signed the clinic's integrated-care consent form at check-in but says he "just signed where they pointed." At the end of the intake, Walter asks, "Does Dr. Okafor see everything I tell you? I don't want my doctor thinking I'm losing my marbles."
Considering Walter's symptoms and their duration since Gene's death, what diagnosis best fits his presentation?