Dsm5 Case Studies Supa, Exams of Integrated Case Studies

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Read the case studies in this packet and use the “DSM-S Student Abridged Version” to make your diagnoses. The names of the disorders are highlighted in yellow. The “Diagnostic Criteria” are all you are required to pay attention to. However, the narrative information about the disorder (“Diagnostic Features,” “Prevalence,” “Development and Course,” “Risk and Prognostic Factors,” “Culture- and Gender-related Diagnostic Issues,” “Differential Diagnosis,” “Comorbidity.” etc.) may help you narrow down a diagnosis and/or understand a disorder a little better. A glossary is included at the end of the document. Once you have made your diagnosis, type the name of the disorder next to the title of the case study. Then copy and paste the criteria from the “DSM-5 Student Abridged Version” and insert them after each corresponding example in the case study. Whatever you insert into the case study should be in another color so it stands out. See the next page for a sample of what I’m looking for. JESSICA — Major Depressive Disorder Jessica is a 28 year-old married female. She has a very demanding, high stress job as a second year medical resident in a large hospital. Jessica has always been a high achiever. She graduated with lop honors in both college and medical school, She has very high standards for herself and can be very self-critical when she fails to meet them. ately, she has struggled with significant feelings of worthlessness and shame due to her inability to perform as well as she always has in the past. A7. leelings worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) For the past few weeks Jessica has fell unusually fatigued A6. Fatigue or loss of energy nearly every day and found it increasingly difficul to concentrate at work. A8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either hy subjective account or as observed by others) Her coworkers have noticed that she is often irritable and withdrawn, which is quite different from her typically upbeat and friendly disposition, Al. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (c.g., appears tearful) She has called in sick on several occasions, which is completely unlike her. On those days, she stays in bed all day, watching TV or sleeping. B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. At home, Jessica’s husband has noticed changes as well. She’s had difficulties falling asleep at night, and her insomnia has been keeping him awake as she tosses and turns for an hour or two after they go to bed. 4. Insomnia or hypersommia nearly every day; AS. Psychomotor agitation or retardation nearly every day; (observable by others, not merely subjective feelings of restlessness or being slowed down) He’s overheard her having frequent tearful phone conversations with her closest friend, which have him worried. When he trics to gct her to open up about what’s bothcring her, she pushes him away with an abrupt “everything’s finc”. A1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful) Although she hasn’t ever considered suicide, Jessica has found herself increasingly dissatisfied with her life. She’s been having frequent thoughts of wishing she was dead. A9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide She gets frustrated with herself because she feels like she has every reason to be happy, yet can’t scem to shake the sense of doom and gloom that has been clouding cach day as of lalc. B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. ‘A physical exam performed by her primary care doctor one week prior was normal. All laboratory testing was normal, including complete blood count, electrolytes, blood urea nitrogen, creatinine, calcium, glucose, thyroid function tests, folate, and vitamin B12. She denied any illicit drug use and reported an occasional glass of wine with dinner. C. The episode is not attributable to the physiological effects of a substance or to another medical condition. DEAR DOCTOR Myrna Field, a 55-year-old woman, was a cashier in a hospital coffee shop 3 years ago when she suddenly developed the belief that a physician who dropped in regularly was intensely in love with her. She fell passionately in love with him, but said nothing to him and became increasingly distressed each time she saw him. Casual remarks that he made were interpreted as cues to his feclings, and she believed he gave her significant glances and made suggestive movements, though he never declared his {eclings openly. She was sure this was because he was married. After more than 2 two years of this, she became so agitated that she had to give up her job; she remained at home, thinking about the physician incessantly. Eventually she went to her family doctor, who found her so upset he referred her to a male psychiatrist. She was too embarrassed to confide in him, and it was only when she was transferred to a female psychiatrist that she poured forth her story. Myrna was an illegitimate child whose stepfather was excessively strict. She was a slow learner and was always in trouble at home and at school. She grew up anxious and afraid, and during her adult life consulted many doctors because of hypochondriacal concerns, She was always insecure in company. Myrna married, but the marriage was asexual, and there were no children. Although her husband appeared long-suffering, she perceived him as overly critical and demanding. Throughout their married life she hud periodically abused uleohol and, during the past 3 ycurs, had been drinking morc heavily and steadily to lry to cope with her distress. She could not confide in her husband about her "love" affair. When she was interviewed, Myrna was very distressed and talked under great pressure. Her intelligence was limited and many of her ideas appeared simple; but the only clear abnormality was the unshakable belief that her physician "lover" was passionately devoted to her. She could not be persuaded otherwise. EASILY TRIGGERED Eric Reynolds was a 56-year-old married Vietnam War veteran who referred himself to the Veterans Affairs outpatient mental heulth clinic for the chief complaint of baving "a short fuse" and being "casily triggcred." Mr. Reynolds's symptoms began more than three decades earlier, soon after he left the combat zone in Vietnam, where he served as a field radio operator. He had never sought help for his symptoms, apparently because of his strong need to be independent An early retirement led to greater recognition of symptoms and a stronger desire to seek help. Mr. Reynolds's symptoms included uncontrollable rage when unexpectedly startled; recurrent intrusive thoughts and memories of dcath-related experiences; weekly vivid nightmares of combat operations that led to nighttime fight and insomnia; isolation, vigilance, and anxiety; loss of interest in hobbies that involve people; and excessive distractibility. Althongh all of these symptoms were very distressing, Mr. Reynolds was most worried about his uncontrollable aggression Examples of his "hair-trigger temper” included confrontations with drivers who cut him off, curses directed at strangers who stood too elose in checkout lines, and shifts into "attack mode" when coworkers inadvertently surprised him. Most recently, as he was drifling off to sleep on his physician's cxamination table a nursc touched his fool and he leapt up, cursing and threatening. [lis involuntary reaction scared the nurse as well as the patient. Mr. Reynolds said that no words, thoughts, or images intervened between the unexpected stimulation and his aggression. These moments reminded him of a time in the military when he was on guard at the front gate and, while he was dozing, an incoming mortar round stunned him into action. Although he kept a handgun in the console of his car for self-protection, Mr. Reynolds had no intention of harming others, He was always remorseful afler a threatening incident and had long been worried that he might inadvertently hurt someone. Mr. Reynolds was raised in a loving family that stmggled financially as Midwestern farmers. At age 20, Mr. Reynolds was drafted into the U.S. Army and deployed to Vietnam. He described himself as having been upbeat and happy prior to his army induction. He said he enjoyed basic training and his first few weeks in Vietnam, until one of his comrades got killed. At that point, all he cared about was getting his best friend and himself home alive, even if it meant killing others. His personality changed, he said, from that of a happy-go-lucky farm boy to a terrified, overprotective soldier. Upon returning to civilian life, he managed to get a college degree and a graduate business degree, but he chose to work as a self employed plumber because of his need to stay isolated in his work. He had no legal history. He had married to his wife for 25 years and was the father of two college-age students. In his retirement, he looked forward to woodworking, reading, and getting some "peace and quiet.” Mr. Reynolds had tried marijuana during his carly adulthood and used excessive alcohol intermittently; however, he had nol consumed excessive alcohol or used marijuana during the past decade. On examination, Mr. Reynolds was a well-groomed African American man who appeared anxious and somewhat guarded, He was coherent and articulate. His speech was at a normal rate, but the pace accelerated when he discussed disturbing content, He denied depression but was anxious. His affect was somewhat constricted but appropriate to content. His thought process was coherent and lincar. He denied all suicidal and homicidal ideation. He had no psycholic symptoms, delusions, or hallucinations. He had very good insight. He was well oriented and scemed to have above average intelligence. TEMPER TANTRUMS Brandon was a 12-year-old boy brought in by his mother for psychiatric evaluation for temper tantrums that seemed to be contributing lo declining school performance. The mother became cmotional as she reported thal things had always been difficult bul had become worse afler Brandon cntered middle school. Brandon's sixth-grade teachers reported that he was academically capable but that he had little ability to make friends. He seemed to mistrust the intentions of classmates who tried to be nice to him, and then trusted others who laughingly feigned interest in the toy cars and trucks that he brought to school. The teachers noted that he often cried and rarely spoke in class, In recent months, multiple teachers had heard him screaming at other boys, generally in the hallway but sometimes in the middle of class. The leachers had not identified a cause but gencrally had not disciplined Brandon because they assumed he was responding to provocation. When interviewed alone, Brandon responded with nonspontaneous mumbles when asked questions about school classmates, and his family. When the examiner asked if he was interested in toy cars, however, Brandon lit up. He pulled several cars, trucks, and airplanes from his backpack and, while not making good eye contact, did talk at length about vehicles, using their apparently accurale names (¢.g., front-end loader, B-52, Jaguar), When asked again about school, Brandon pulled out his eel! phone and showed a string of text messages: "dumbo!!!!, nr stutter, LoSeR, Leak!, EVERYBODY HATES YOU." While the cxamincr read the long string of texts that Brandon had saved but apparently not previousty revealed, Brandon added that other boys would whisper "bad words" to him in class and then scream in his ears in the hall. "And I hate loud noises." He said he had considered munning away, but then had decided that maybe he should just run away to his own bedroom. Developmentally, Brandon spoke his first word al age 11 months and began to use short sentenees by age 3. He had always been very focused on trucks, cars, and tains. According lo his mother, he had always been "very shy" and had never had a best friend, Ile struggled with jokes and typical childhood banter because "he takes things so literally." Brandon's mother had long seen this behavior as "a little odd" but added that it was not much different from that of Brandon's father, a successful attorney, who had similarly focused interests. Both of them were "sticklers for routine” who "lacked a sense of humor." On examination, Brandon was shy and generally nonspontaneous. He made below-average eye contact. His speech was coherent and goal directed. At times, Brandon stumbled over his words, paused excessively, and sometimes rapidly repeated words or parls of words. Brandon said he fell okay but added he was scared of school. He appeared sad, brightening only when discussing his toy cars. Ile denied suicidality and homicidality. Ile denied psychotic symptoms. Ie was cognitively intact. ON STAGE Harry is a 33-year-old man who lives in Seattle with his wife. He has been employed as a salesperson for an insurance company since graduating from college. He came to a privale psychiatrist, recommended by a friend, complaining of "anxicty al work." larry describes himself as having been outgoing and popular throughout his adolescence and young adulthood, with no serious problems until his third year of college. He then began to become extremely tense and nervous when studying for tests and writing papers. His heart would pound; his hands would sweat and tremble. Consequently. he often did not write the required papers or, when he did, would submit them after the date due. He could not understand why he was so nervous about doing papers and taking cxams when he hud always done well in these tasks in the past. As a result of his failure to submit certain papers and his late submission of others, his college grades were scriously affected. Soon after graduation, Harry was employed as a salesperson for an insurance firm. His initial training (attending lectures, completing reading assignments) proceeded smoothly. However, as soon as he began to take on clients, his anxiety retumed. He became extremely nervous when anticipating phone calls from clients. When his business phone rang, he would begin to tremble and sometimes would not even answer it. Eventually, he avoided becoming anxious by not scheduling appointments and by not conlucting clients whom he was expected to sev. When asked what it was about these situations that made him nervous, he said that he was concerned about what the client would think of him: "The client might sense that I am nervous and might ask me questions that I don't know the answers to, and I will feel foolish." As a result, he would repeatedly rewrite and reword sales scripts for telephone conversations because he was "so concerned about saying the right thing. I guess I'm just very concerned about being judged." Although never unemployed, Harry estimates that he has bcen functioning at only 20% of his work capacity, which his cmployer tolerates because a salesman is paid only on a commission basis. Vor the last several years, Iarry has had to borrow large sums of money to make ends meet. Although financial constraints have been a burden, Harry and his wife entertain guests at their home regularly and enjoy socializing with friends at picnics, purtics, and formal affairs. Hurry lamented, "It's just when I'm expected lo do something. Then it's like I'm on stage, all alone, wilh everyone watching m THE SAILOR Psychiatric consultation is requested by an emergency room physician for an 18-year-old male who has been brought into the hospital by the police. The youth appears exhausted and shows cvidenee of prolonged exposure to the sun. He identifies the current date incorrectly, giving it as September 27 instead of October 1. It is difficult to get him to focus on specific questions, but with encouragement he supplies a number of facts. Ile recalls sailing with friends, apparently about September 25, on a weekend cruise, off the Florida coast, when bad weather was encountered. He is unable to recall any subsequent events and does not know what became of his companions. He has to be reminded several times that he is in a hospital, as he expresses uncertainty as to his whereabouts. Each time he is told, he seems surprised. There is no evidence of head injury or dehydration, Electrolytes and cranial nerve examination are unremarkable. Because of the patient's apparent exhaustion, he is permitted to sleep for 6 hours. Upon awakening, he is much more attentive, but is still unable to recall events after September 25. including how he came to the hospital. There is no longer any doubt in his mind that he is in the hospital, however, and he is able to recall the contents of the previous interview and the fact that he had fallen asleep. He is able to remember that he is a student at a southern college, maintains a B average, has a small group of close friends, and has a good relationship with his family. He denies any previous psychiatric history and says he has never abused drugs or alcohol. Because of the patient's apparently sound physical condition, a sodium amytal interview is performed. During this interview he relates that neither he nor his companions were particularly experienced sailors capable of coping with the ferocity of the storm they encountered, Although he had taken the precaution of securing himself to the boat with a life jacket and tie line, his companions had failed to do this and had been washed overboard in the heavy seas. He completely lost control of the boat and felt he was saved only by virtue of good hick and his lifeline. He had been able to consume a small supply of food that was stowed away in the cabin over a 3-day period, He never saw cither of his sailing companions again. He was picked up on October 1 by a Coast Guard cutter and brought to shore, and subscqucally the police had brought him to the hospital. EPISODIC DEPRESSIONS Pamela was a 43-year-old married librarian who presented to an outpatient mental health clinic with a long history of episodic depressions. Most recently, she described depressed mood during the month since she began a new job. She said she was preoccupied with concerns that her new boss and colleagues thought her work was inadequate and slow and that she was unfriendly. She had no energy and enthusiasm at home, either, and instead of playing with her children or talking to her husband, she tended to watch television for hours, overeat, and sleep excessively. This had led to a -pound weight gain in just 3 weeks, which made her feel even worse about herself. She had begun to cry several times a week, which she reported as the sign that she "knew the depression had retuned." She had also begun to think oficn of death but had never atlempicd suicide. Ms. Kramer said her memory about her history of depression was a little fuzzy, so she brought in her husband, who had known her since college. They agreed that she had first become depressed in her teens and that she had experienced at least five discrete periods of depression as an adult. These episodes generally included depressed mood, amotivation, hypersomnia, deep feelings of guilt, decreased libido, and mild to moderate suicidal ideation without plan. Her depressions were also punctuated by periods of “too much" energy, ixritability, pressured speech, and flight of ideas. These episodes of excess energy could last hours, days, or a couple of weeks. The depressed mood would not lift during these periods, but she would "at least be able to do a few things.” When specifically asked, Ms. Kramer's husband described distinctive times when Ms. Kramer seemed unusually excited, happy, and self-confident, and like a "ditferent person." She would talk fast. seem energized and optimistic, do the daily chores very efficiently, and start (and often finish) new projects. She would need little sleep and still be enthusiastic the next day. Ms. Kramer recalled these periods but said they felt "normal." In response to a question about hypersexuality, Ms. Kramer smiled for the only time during the interview, saying that although her husband scemed to be ineluding her good periods as part of her illness, he bad not been complaining when she had her longest such episode (about 6 days) when they first started dating in college. Since then, she reported that these episodes were "fairly I frequent" and lasted 2 or 3 days. Because of her periodic low mood and thoughts of death, she had seen various psychiatrists since her mid-teenage years Psychotherapy tended to work "okay" until she had another depressive episode, when she would be unable to attend sessions and would then just quit. Three antidepressant trials of adequate dosage and duration (6 months to 3 years) "were each associated with short-term relief of depression, followed by relapse. Both alone and in the presence of her husband, Ms, Kramer denied a history of alcohol and substance abuse. A matcrnal aunt and maternal grandfather had been recurrently hospitalized for mania, although Ms. Kramer was quick to point out that she was “not at all like them.” On examination, Ms. Kramer was a well-groomed, overweight woman who often averted her eyes and tended to speak very softly. No abnormal motor movements were noted, but her movements were constrained, and she did not use hand gestures, Her mood was depressed. Her affect was sad and constricted. Her thought processes were fluid, though possibly slowed. Her thought content was notable for depressive content, including passive suicidal ideation without evidence of paranoia, hallucinations, or delusions. [ler insight and judgment were intact. COMPULSIONS Alan, a 10-year-old boy, is brought for a consultation by his mother because of "severe compulsions.” The mother reports that the child at various times has to run and clear his throat, touch the doorknob twice before entering any door, till his head from side to side, rapidly blink his eyes, and suddenly touch the ground with his hands by flexing his whole body. These "compulsions" began 2 years ago. ‘Ihe first was the eye blinking, and then the others followed, with a waxing and waning course. ‘The movements occur more frequently when he is anxious or under stress. The last symptom to appear was the repetitive touching of the doorknobs. The consultation was scheduled after the child began to make the middle finger sign while saying "fuck." ‘When examined, Alan reported thal most of the lime he did not know in advance when the movements were going to occur except for the touching of doorknobs. Upon questioning, he said thal before he felt he had to touch a doorknob, he got the thought of doing it and tried to push it out of his head, but he couldn't because it kept coming back until he touched the doorknob several times: then he felt better, When asked what would happen if someone did not let him touch the doorknob, he said he would just get mad; once his tather had tried to stop him and Alan had had a temper tantrum. Alan explained that the touching of the doorknobs dida't really bother him—what did was all the "other stuff" that he couldn't control." During the interview the child grunted, cleared his throat, turned his head, and rapidly blinked his cycs several limes, Al times he tried to make it appear as if he had voluntarily been trying to perform these movements. Personal history and physical and neurological examination were totally unremarkable except for the abnormal movements and sounds. The mother reported that her youngest uncle had had similar symptoms when he was an adolescent, but she could not elaborate any farther. She stated that she and her husband had always been "very compulsive," by which she meant only that they were quite well organized and stuck to routines. UNFAIRNESS Ike Crocker was a 32-year-old man referred for a mental health evaluation by the human resources department at a construction sile. Although he presented as a very motivated and skilled worker at the inlerview with two carpentry cerlificales, in the first two weeks of employment, he has had frequent arguments, absentecism, and made many dangerous mistakes. When confronted by supervisors, he was dismissive of the problem and said if someone got hurt, “it’s because of their own stupidity.” ‘When the head of human resources met with him to discuss termination, Mr. Crocker said he would sue on the grounds of the American Disability Act: He demanded a psychiatriatric evaluation for attention-deficit/hyperactivity disorder (ADHD) and bipolar, During the mental health evaluation, Mr. Crocker focused on unfairness at the company and how he was “a hell of a better carpenter than anyone there could ever be.” Ie had been married twice and had two children. Mr. Crocker retused to pay child support, which is why he said both ex-wives “lied to judges and got restraining orders saying I'd hit them.” He was not interested in seeing his children. He said they were “little liars” like their mothers. During high school, he said he “must have been smart” because he was able to make Cs in school despite only showing up half the time, He spent time in juvenile hall at age 14 for stealing “kid stuff, like tennis shocs and wallets that were practically empty.” Ie left school at age 15 after being “framed for stealing a car.” Ile pointed this out to show how he had overcome injustice. Mr. Crocker concluded the interview by demanding a note from the examiner that said he had “bipolar” and “ADHD.” Phone calls revealed that Mr. Crocker had been expelled from two carpentry training programs and that both of his certificates had becn falsified. He got fired from his job al onc local construction company aller a fistfight with his supervisor. INCREASINGLY ODD Gregory Baker was a 20-yearold African American man who was brought to the emergency room (ER) by the campus police of the university from which he had been suspended several months earlier. The police had been called by a professor who reported that Mr. Baker had walked into his classroom shouting, "I am the Joker, and Lam looking for Batman.” When Mr. Baker refused to leave the class, the professor contacted security. Although Mr. Baker had much academic success as a teenager, his behavior had become increasingly odd during the past year. He quit sccing his friends and spent most of his time lying in bed staring al the ceiling, He lived with several family members but rarely spoke lo any of them. He had been suspended from college because of lack of attendance. His sister said that she had recurrently seen him mumbling quietly to himself and noted that he would sometimes, at night, stand on the roof of their home and wave his arms as if he were "conducting a symphony." He denied having any intention of jumping from the roof or having any thoughts of self-harm, but claimed that he felt liberated and in tune with the nmsic when he was on the roof. Although his father and sister had tried to encourage him to see someone at the university's student health office, Mr. Baker had never seen a psychiatrist and had no prior hospitalizations. During the prior several months, Mr. Baker had become increasingly preoccupied with a female friend, Anne, who lived down the street. While he insisted to his family that they were engaged, Anne told Mr. Haker's sister that they had hardly ever spoken and certainly were not dating, Mr. Baker's sister also reported that he had written many letters to Anne but never mailed them: instead, they just accumulated on his desk. His family said that they had never known him to use illicit substances or alcohol, and his toxicology screen was negative. When asked about drug use, Mr. Baker appeared angry and did not answer. On examination in the ER, Mr. Baker was a well-groomed young man who was gcucrally uncooperative, He appeared constricted, guarded, inattentive, and preoccupied. Ile became enraged when the I'L staff brought him dinner. Ile loudly insisted that all of the hospital's food was poisoned and that he would only drink a specific type of bottled water. Ile was noted to have paranoid, grandiose, and romantic delusions. He appeared to be internally preoccupied, although he denied hallucinations. Mr Baker reported feeling "bad" but denied depression and had no disturbance in his sleep or appetite. He was oriented and spoke articulately but refused formal cognitive testing. His insight and judgment were deemed to be poor. Mr. Baker's grandmother had dicd ina state psychiatric hospital, where she had lived for 30 years. Her diagnosis was unknown. Mr. Baker's mother was reportedly "crazy." She had abandoned the family when Mr. Baker was young, and he was raised by his father and paternal grandmother. Ultimately, Mr. Baker agreed to sign himself into the psychiatric unit, stating, "I don't mind staying here. Anne will probably be there, so I can spend my time with her." FALSE RUMORS Bob, age 21, comes to the psychiatrist's office, accompanied by his parents, on the advice of his college counselor. He begins the interview by announcing thal he has no problems. His parents arc always overly concerned about him, and il is only to get them “off my back" that he has agreed to the evaluation. "| am dependent on them financially, but not emotionally." The psychiatrist is able to obtain the following story from Bob and his parents. Bob had apparently spread malicious and false rumors about several of the teachers who had given him poor grades, implying that they were having homosexual affairs with students. This, as well as increasingly erratic attendance at his classes over the past term, following the loss of a girlfriend, prompted the school counselor lo suggest to Bob and his parcals that help was urgently needed, Bob claimed that his academic problems were cxaggcrated, his success in theatrical productions was being overlooked, and he was in full control of the situation. Ie did not deny that he spread the false rumors, but he showed no remorse or apprehension about possible repercussions tor himself. Bob is a tall, stylishly dressed young man with a dramatic wave in his hair. His manner is distant, but charming, and he obviously enjoys talking about a variety of intellectual subjects or current affairs. However, he assumes a condescending, cynical, and bemused manner toward the psychiatrist and the evaluation process. He conveys a sense of superiority and control over the evaluation. Accounts of Bob's development are complicated by his bland dismissal of its importance and by the conflicting accounts about it by his parents. His mother was an extremely anxious, immaculately dressed, outspoken woman. She described Bob as having been a beautiful, joyful baby, who was gifted and brilliant. She recalled that after a miscarriage, when Bob was age 1, she and her husband bad become even more devoted to his care, giving him "the love for two." The father was a rugged-looking, sofi-spoken, suecessful man, He recalled a period in Bob's carly life when they had been very close, and he had even confided in Bob about very personal matters and expressed deep feelings. Ile also noted that Bob had become progressively more resentful with the births of his two siblings. ‘The father laughingly commented that Bob "would have liked to have been the only child." Ie recalled a series of conflicts between Bob and authority figures over rules and noted that Bob had expressed disdain for his peers at school and for his siblings. In his carly school years, Bob seemed to play and interact less with other children than most others do. In Gifth grade, aller a change in teachers, he became arrogant and withdrawn and refused to participate in class. Nevertheless, he maintained excellent grades. In high school he had been involved in an episode similar to the one that led to the current evaluation. At that time he had spread false rumors about a classmate whom he was competing against for a role in the school play. In general, it became clear that Bob had never been "one of the boys." He liked dramatics and movies, but had never shown an interest in athletics. He always appeared to be a loner, though he did not complain of loneliness. When asked, he professed to take pride in "being different” from his peers. He also distanced himself from his parents and often responded with silenec to their overtures for more communication. Ilis parents felt that behind his guarded demeanor was a sad, alienated, lonely young man. ‘Though he was well known to classmates, the relationships he had with them were generally under circumstances in which he was looked up to for his intellectual or dramatic talents. Bob conceded that others viewed him as cold or insensitive. He readily acknowledged these qualities, and that he had no close friends, but he dismissed this as unimportant, This represented strength (o him, He went on to note thal when others complained about these qualities in him, it was largcly because of their own weakness. In his view, they cnvicd him and longed to have him care ahout them. Ile believed they sought to gain by having an association with him. Bob had occasional dates, but no steady girlfriends. Although the exact history remains unclear, he acknowledged that the girl whose loss seemed to have led to his escalating school problems had been someone whom he cared about, She was the first person with whom he bad had a sexual relationship. The relationship had apparently dissolved after she had expressed an increasing desire lo spend more time with her girlfriends and lo go lo school social events. THUNDERSTORMS Sheila, a 28-year-old housewife, sought psychiatric treatment for a fear of storms that had become progressively more disturbing to her. Although she had been frightened of storms since she was a child, (he foar scemcd to abate somewhat during adolescenee, but had been increasing in severity over the past few years. ‘This gradual exacerbation of her anxiety, plus the fear that she might pass it on to her children, led her to seek treatment. She is most frightened of lightning, but is uncertain about the reason for this. She is only vaguely aware of a fear of being struck by lightning and recognizes that this is an unlikely occurrence. When asked to elaborate on her fears, she imagines that lightning could sirike a ee in her yard and the tree might fall and block her driveway, thus trapping her al home. This frightens her, bul she is quite aware that her [car is irrational. She also recognizes the irrational nature of her fear of thunder. She begins to feel anxiety long before a storm arrives. A weather report predicting a storm later in the week can cause her anxiety to increase to the point where she worries for days before the storm. Although she does not express a fear of rain, her anxiety increases even when the sky becomes overcast because of the increased likelihood of a storm. During a storm, she does several things to reduce her anxiety. Because being with another person reduces her fear, she often tries to make plans lo visit friends or relatives or go to a store when a storm is threalening, Sometimes, when her husband is away on business, she stays overnight with a close relative if a storm is forecast. [During a storm she covers her eyes or moves to a part of the house far from windows where she cannot see lightning should it occur.) Sheila has three young children. She describes her marriage as a happy one and states that her husband has been supportive of her when she is frightened and has encouraged her to seek psychiatric treatment. She is in good physical health, and at the time she centered treatment there were no unusually stressful situations in her life or other motional difficulties. Her parents separated shortly afler she began treatment, Although she found this distressing, she felt her personal supports were adequate and that this occurrence did not necessitate psychiatric attention. She describes her personal history as generally unremarkable in terms of any obvious emotional problems. except for her fear of storms. She feels that she may have "learned" this fear from her grandmother, who also was frightened of storms. She denies panic attacks, or any other unusual or incapacitating fears. CHRONIC LYME DISEASE Oscar Capek, a 43 -year-old man, was brought by his wife to an emergency room (ER) for what he described as a relapse of his chronic Lyme discase, He explained that he bad been fatigued for a month and bedridden for a week. Saying he was too tired and confused to give much information, he asked the R team to call his psychiatrist. The psychiatrist reported that he had treated Mr. Capek for move than two decades. He first saw Mr. Capek for what appeared to bea panic attack. It resolved quickly, but Mr. Capek continued to see him for help coping with his chronic illness. Initially a graduale studcnt pursuing a master's degree in accounting, Mr. Cupck dropped oul of school over worries that the demands of bis studies would cxucerbale his discase. Since then, bis wile, a registered nurse, had been his primary support. He supplemented their income with small accounting jobs but limited these lest the stress affect his health. Mr. Capek usually felt physically and emotionally well. He deemed that his occasional fatigue, anxiety, and concentration difficulties were "controllable" and did not require treatment, He was typically averse to psychotropic medications and took a homeopathic approach to his disease, including exercise and proper nutrition. When medication was required, he used small doscs (¢.g., onc quarter of a 0.5-mg lorazepam pill). His psychiatric sessions were commonly devoted to concerns about his underlying disease; he would often bring in articles on chronic I.yme disease for discussion and was active ina local Lyme disease support group Mr. Capek's symptoms would occasionally worsen. This occurred less than yearly, and these "exacerbations" usually related to some obyious stress. The worst was | ycur earlier when bis wife bricfly left him following his revelation of an affair. Mr. Capek expressed shame about his behavior loward his wife both the affair and his inability to support her. He subscqucnlly cut off contact with the other woman and attempted to expand his accounting work. ‘The psychiatrist speculated that similar stress was behind his current symptoms. The psychiatrist communicated regularly with Mr. Capek’s internist. All testing for Lyme disease thus far had been negative. When the internist explained this, Mr. Capek became defensive and produced literature on the inaccuracy of Lyme discase testing. Eventually, the intemist and psychiatrist had agreed on a conservative lreatment approach with a ncutral stance regarding the discase’s validily. On examination, Mr. Capek was a healthy, well-developed adult male. He was anxious and spoke quietly with his eyes closed He frequently lost his train of thought, but with encouragement and patience, he could give a detailed history that was consistent with the psychiatrist’ s account. Physical examination was unremarkable, Lyme disease testing was deferred given his past negative tests. A standard laboratory screen was normal with the exception of a slightly low hemoglobin value. On hearing about the low hemoglobin, Mr. Capek became alarmed, dismissed reassurances, and insisted this be investigated further. EDGY ELECTRICIAN A27-year-old married electrician complains of dizziness, sweating palms, heart palpitations, and ringing of the ears of more than 18 months’ duration, He has also experienced dry mouth and throal, periods of extreme muscle tension, and a constant "edgy" and watchful feeling that has often interfered with his ability to concentrate. ‘These feelings have been present most of the time over the previous 2 years; they have not been limited to discrete periods. Although these symptoms sometimes make him feel "discouraged," he denies feeling depressed and continues to enjoy activities with his family. Because of these symptoms, the patient had seen a family practitioner, a neurologist, a neurosurgeon, a chiropractor, and an ear- nose-throat specialist, He had been placed on a hypoglycemic dict, received physiotherapy for a pinched nerve, and becn told he might have "an inner ear problem. He also has many worries. He constantly worries about the health of his parents. His father, in fact, had a myocardial infarction 2 years previously but is now feeling well. He also worries about whether he is "a good father," whether his wife will ever leave him (there is no indication that she is dissatisfied with the marriage), and whether co-workers on the job like him. Although he recognizes that his worries are often unfounded, he cannot stop worrying. Vor the past 2 years, the patient has had few social contacts because of his nervous symptoms. Although he has sometimes had to leave work when the symptoms became intolerable, he continues to work for the same company he joined for his apprenticeship after high school graduation. He tends to hide his symptoms from his wife and children, to whom he wants to appear "perfect," and reports few problems with them as a result of his nervousness