DSM case studies

Dissociative Disorders: Dissociative Amnesia

Which diagnosis? Irene Upton was a 29-year-old special education teacher who sought a psychiatric consultation because "I'm tired of always being sad and alone." The patient reported chronic, severe depression that had not responded to multiple trials of antidepressants and mood stabilizer augmentation. She reported greater benefit from psychotherapies based on cognitive-behavioral therapy and dialectical behavior therapy. Electroconvulsive therapy had been suggested, but she had refused. She had been hospitalized twice for suicidal ideation and severe self-cutting that required stitches. Ms. Upton reported that previous therapists had focused on the likelihood of trauma, but she casually dismissed the possibility that she had ever been abused. It had been her younger sister who had reported "weird sexual touching" by their father when Ms. Upton was 13. There had never been a police investigation, but her father had apologized to the patient and her sister as part of a resultant church intervention and an inpatient treatment for alcoholism and "sex addiction." She denied any feelings about these events and said, "He took care of the problem. I have no reason to be mad at him." Ms. Upton reported little memory for her life between about ages 7 and 13 years. Her siblings would joke with her about her inability to recall family holidays, school events, and vacation trips. She explained her amnesia by saying, "Maybe nothing important happened, and that's why I don't remember." She reported a "good" relationship with both parents. Her father remained "controlling" toward her mother and still had "anger issues," but had been abstinent from alcohol for 16 years. On closer questioning, Ms. Upton reported that her self-injurious and suicidal behavior primarily occurred after visits to see her family or when her parents surprised her by visiting. More specific questions led Ms. Upton to deny that she had ongoing amnesia for daily life, particularly denying ever being told of behavior she could not recall, unexplained possessions, subjective time loss, fugue episodes, or inexplicable fluctuations in skills, habits, and/or knowledge. She denied a sense of subjective self-division, hallucinations, inner voices, or passive influence symptoms. She denied flashbacks or intrusive memories, but reported recurrent nightmares of being chased by "a dangerous man" from whom she could not escape. She reported difficulty concentrating, although she was "hyperfocused" at work. She reported an intense startle reaction. She reported repeated counting and singing in her mind, repeated checking to ensure that doors were locked, and compulsive arranging to "prevent harm from befalling me."

Schizophrenia Spectrum and other psychotic disorders: Brief Psychotic Disorder

Which diagnosis? Lara Gonzalez, a 51-year-old divorced freelance journalist, brought herself to the emergency room requesting dermatological evaluation for flea infestation. When no corroborating evidence was found on skin examination and the patient insisted that she was unsafe at home. Her concerns began around 1 week prior to presentation. To contend with financial stress, she had taken in temporary renters for a spare room in her home and had begun pet sitting for some neighbors. Under these conditions, she perceived brown insects burrowing into her skin and walls and covering her rugs and mattress. She threw away a bag of clothing, believing she heard fleas "rustling and scratching inside." She was not sleeping well, and she had spent the 36 hours prior to presentation frantically cleaning her home, fearing that her tenants would not pay if they saw the fleas. She showered multiple times using shampoos meant to treat animal infestations. She called an exterminator who found no evidence of fleas, but she did not believe him. She was upset about the infestation but was otherwise not troubled by depressive or manic symptoms, or by paranoia. She did not use drugs or alcohol. No one in the family had a history of psychiatric illness. Ms. Gonzalez had had depression once in the past and was briefly treated with an antidepressant. She had no relevant medical problems. On mental status examination, Ms. Gonzalez was calm and easily engaged, with normal relatedness and eye contact. She offered up a small plastic bag containing "fleas and larvae" that she had collected in the hospital while awaiting evaluation. Inspection of the bag revealed lint and plaster. Her speech had an urgent quality to it, and she described her mood as "sad right now." She was tearful intermittently but otherwise smiling reactively. Her thoughts were overly inclusive and intensely focused on fleas. She expressed belief that each time a hair fell out of her head, it would morph into larvae. When crying, she believed an egg came out of her tear duct. She was not suicidal or homicidal. She expressed an unshakable belief that lint was larvae, and that she was infested. She denied hallucinations. Cognition was intact. Her insight was impaired, but her judgment was deemed reasonably appropriate. Dermatological examination revealed no insects or larvae embedded in Ms. Gonzalez's skin. Results of neurological examination, head computed tomography scan, laboratory tests, and toxicology data were normal. She was discharged on a low-dose antipsychotic medication and seen weekly for supportive psychotherapy. Her preoccupation improved within days and resolved entirely within 2 weeks.

Ms. Gonzalez's delusions with quick return to full premorbid functioning suggest a diagnosis of brief psychotic disorder with marked stressors.

Which symptoms? Lara Gonzalez, a 51-year-old divorced freelance journalist, brought herself to the emergency room requesting dermatological evaluation for flea infestation. When no corroborating evidence was found on skin examination and the patient insisted that she was unsafe at home. Her concerns began around 1 week prior to presentation. To contend with financial stress, she had taken in temporary renters for a spare room in her home and had begun pet sitting for some neighbors. Under these conditions, she perceived brown insects burrowing into her skin and walls and covering her rugs and mattress. She threw away a bag of clothing, believing she heard fleas "rustling and scratching inside." She was not sleeping well, and she had spent the 36 hours prior to presentation frantically cleaning her home, fearing that her tenants would not pay if they saw the fleas. She showered multiple times using shampoos meant to treat animal infestations. She called an exterminator who found no evidence of fleas, but she did not believe him. She was upset about the infestation but was otherwise not troubled by depressive or manic symptoms, or by paranoia. She did not use drugs or alcohol. No one in the family had a history of psychiatric illness. Ms. Gonzalez had had depression once in the past and was briefly treated with an antidepressant. She had no relevant medical problems. On mental status examination, Ms. Gonzalez was calm and easily engaged, with normal relatedness and eye contact. She offered up a small plastic bag containing "fleas and larvae" that she had collected in the hospital while awaiting evaluation. Inspection of the bag revealed lint and plaster. Her speech had an urgent quality to it, and she described her mood as "sad right now." She was tearful intermittently but otherwise smiling reactively. Her thoughts were overly inclusive and intensely focused on fleas. She expressed belief that each time a hair fell out of her head, it would morph into larvae. When crying, she believed an egg came out of her tear duct. She was not suicidal or homicidal. She expressed an unshakable belief that lint was larvae, and that she was infested. She denied hallucinations. Cognition was intact. Her insight was impaired, but her judgment was deemed reasonably appropriate. Dermatological examination revealed no insects or larvae embedded in Ms. Gonzalez's skin. Results of neurological examination, head computed tomography scan, laboratory tests, and toxicology data were normal. She was discharged on a low-dose antipsychotic medication and seen weekly for supportive psychotherapy. Her preoccupation improved within days and resolved entirely within 2 weeks.

- began when she was a child (early onset) - the symptoms are highly disruptive, they deprived her of early life experiences such as social earning and cognitive development - hallucinations: mumbles and talks to herself suggesting auditory hallucinations - negative symptoms - disorganized or abnormal behavior: stealing the bus - functioning in mayor areas of life is impaired (she is in a psychiatric hospital) - Duration 6+ months

Felicia Allen was a 32-year-old woman brought to the emergency room (ER) by police after she apparently tried to steal a bus. Because she appeared to be an "emotionally disturbed person," a psychiatry consultation was requested. According to the police report, Ms. Allen threatened the driver with a knife, took control of the almost empty city bus, and crashed it. A more complete story was elicited from a friend of Ms. Allen's who had been on the bus but who had not been arrested. According to her, they had boarded the bus on their way to a nearby shopping mall. Ms. Allen became frustrated when the driver refused her dollar bills. She looked in her purse, but instead of finding exact change, she pulled out a kitchen knife that she carried for protection. The driver fled, so she got into the empty seat and drove the bus across the street into a nearby parked car. On examination, Ms. Allen was a handcuffed, heavyset young woman with a bandage on her forehead. She fidgeted and rocked back and forth in her chair. She appeared to be mumbling to herself. When asked what she was saying, the patient made momentary eye contact and just repeated, "Sorry, sorry." She did not respond to other questions. She had started hearing voices by age 5 years. Big, strong, intrusive, and psychotic, she had been hospitalized almost constantly since age 11. Her auditory hallucinations generally consisted of a critical voice commenting on her behavior. Her thinking was concrete, but when relaxed she could be self-reflective. She was motivated to please and recurrently said her biggest goal was to "have my own room in my own house with my own friends." The psychiatrist also believed that she had spent almost no period of life developing normally and so had very little experience with the real world.

Schizophrenia Spectrum and other psychotic disorders: schizophrenia disorder

Felicia Allen was a 32-year-old woman brought to the emergency room (ER) by police after she apparently tried to steal a bus. Because she appeared to be an "emotionally disturbed person," a psychiatry consultation was requested. According to the police report, Ms. Allen threatened the driver with a knife, took control of the almost empty city bus, and crashed it. A more complete story was elicited from a friend of Ms. Allen's who had been on the bus but who had not been arrested. According to her, they had boarded the bus on their way to a nearby shopping mall. Ms. Allen became frustrated when the driver refused her dollar bills. She looked in her purse, but instead of finding exact change, she pulled out a kitchen knife that she carried for protection. The driver fled, so she got into the empty seat and drove the bus across the street into a nearby parked car. On examination, Ms. Allen was a handcuffed, heavyset young woman with a bandage on her forehead. She fidgeted and rocked back and forth in her chair. She appeared to be mumbling to herself. When asked what she was saying, the patient made momentary eye contact and just repeated, "Sorry, sorry." She did not respond to other questions. She had started hearing voices by age 5 years. Big, strong, intrusive, and psychotic, she had been hospitalized almost constantly since age 11. Her auditory hallucinations generally consisted of a critical voice commenting on her behavior. Her thinking was concrete, but when relaxed she could be self-reflective. She was motivated to please and recurrently said her biggest goal was to "have my own room in my own house with my own friends." The psychiatrist also believed that she had spent almost no period of life developing normally and so had very little experience with the real world.

Criteria A: development of angry and depressed feelings, withdrawn behaviour and problems school in response to stressors of breakup and discovering identity father. Criteria B: Symptoms are clinically significant because: - They cause significant impairments in both his social (relation to roommates) and school areas Criteria C: Stress related disturbances don't meet criteria for others mental disorders and not merely an exacerbation of an preexisting disorder

Franklin Sims was a 21-year-old single African American man who sought treatment at a university-affiliated community mental health clinic because he felt "stressed out," withdrawn from friends, and "worried about money." He said he had been feeling depressed for 3 months, and he attributed the "nosedive" to two essentially concurrent events: the end of a 3-year romantic relationship and the accidental and disappointing discovery of his father's identity. Mr. Sims had supported himself financially since high school and was accustomed to feeling nervous about making ends meet. He had become more worried after breaking up with his longtime girlfriend, so he approached a "family friend" for financial help. He was turned down and then discovered that this man was his biological father. This disappointment revived long-standing anger and sadness about not knowing his father's identity. His roommates taunted him for "falling apart" with this discovery. At the time of this discovery, Mr. Sims was a full-time undergraduate who also worked full-time as a midnight-shift warehouse worker. When he finished his early-morning shift, he found it hard to "slow down," and he had trouble sleeping. He was often frustrated with his two roommates due to their messiness and frequent socializing with friends in their small apartment. His appetite was unchanged and his physical health was good. His grades had recently declined, and he had become increasingly discouraged about money and about being single. He had not previously sought any type of mental health services, but a supportive cousin suggested seeing a therapist at the student mental health clinic. Mr. Sims was raised as an only child by his mother and her extended family. He was a self-described "good student and popular kid." High school was complicated by his mother's 3-year period of unemployment and his experimentation with alcohol and marijuana. He recalled several heavy drinking episodes at age 14 and first use of marijuana at age 15. He smoked marijuana daily for much of his junior year and stopped heavy use under pressure from a girlfriend. At the time of the evaluation, he had "an occasional beer" and limited marijuana use to "being social" several times a month. On examination, Mr. Sims was punctual, cooperative, pleasant, attentive, appropriately dressed, and well groomed. He spoke coherently. He appeared generally worried and constricted, but he did smile appropriately several times during the interview. He had a quiet, dry sense of humor. He denied suicidality, homicidality, and psychosis. He was cognitively intact, and his insight and judgment were considered good.

Alcohol use disorder

Matthew Tucker, a 45-year-old white plumber, was referred for a psychiatric evaluation after his family did an intervention to express their concern that his alcohol problems were getting out of hand. Mr. Tucker denied having had a drink since making the appointment 3 days earlier. For 20 years after high school, Mr. Tucker typically drank 3-5 beers per evening, 5 times per week. Over the last 7 years, he had consumed alcohol almost daily, with an average of 6 beers on weeknights and 12 beers on weekends and holidays. His wife repeatedly voiced her concern that he was "drinking too much," but despite his efforts to limit his alcohol intake, Mr. Tucker continued to spend much of the weekend drinking, sometimes missing family get-togethers, and often passed out while watching TV in the evening. He remained productive at work, however, and never called in sick. In many ways, his history represents what is likely to be seen in the "typical alcoholic." Mr. Tucker had achieved two month-long periods of abstinence in the prior 4 years. Both times, he said he had gone "cold turkey" in response to his wife's concerns. He denied having had symptoms of alcohol withdrawal either time. In the 6 months prior to the evaluation, Mr. Tucker had become uncharacteristically irritable, fatigued, dysphoric, and worried. He was unable to enjoy his usual activities, including food and sex, and had difficulty concentrating. He also reacted more emotionally to stresses and expressed unsubstantiated concern about the future of his business. The patient often awoke at 2:00 a.m. and had trouble getting back to sleep. Mr. Tucker and his wife indicated that although this period of sadness had lasted 6 months, he had experienced several similar episodes in the prior 5 years, lasting 4-6 weeks each. They denied any such episodes earlier in his life. Mr. Tucker had been married for 18 years, and he and his wife had one 17-year-old daughter. He was a high school graduate with 2 years of community college who currently owned a successful plumbing company. The patient denied any other history of psychiatric or medical problems, as well as any history of mania or suicide attempts. He had never seen a psychiatrist before. At a recent annual checkup, Mr. Tucker's internist noted a mildly elevated blood pressure (135/92), a γ-glutamyltransferase value of 47 IU/L, and a mean corpuscular volume of 92.5 μm3. All other laboratory results were in the normal range. At the time of his first visit, Mr. Tucker was neatly dressed, maintained good eye contact, and showed no evidence of confusion or psychotic symptoms. His eyes teared up when he talked about the future, and he admitted to feeling sad for most or all of the day on a regular basis for the last 6 months, but he denied suicidal ideation or plans. His cognition was intact, and he demonstrated an understanding of the effects that the alcohol was having on him. A physical examination by the psychiatrist revealed a normal pulse rate, no tremor or sweating, and only a slightly elevated blood pressure.

A. altered voluntary motor of convulsive episodes B. Clinical findings provide evidence of incompatibility between the comvulsive episodes and recognized neurological or medical conditions (not associated with epileptiform EEG findings) lthough patients may become angry upon learning of a diagnosis of conversion disorder, the focus of discussion should be on the good news: that they will not be exposed to unnecessary medication or studies, and that treatment—in the form of psychotherapy—is available.

Paulina Davis, a 32-year-old single African American woman with epilepsy first diagnosed during adolescence and no known psychiatric history, was admitted to an academic medical center after her family found her convulsing in her bedroom. Before she was taken to the emergency room (ER), emergency medical services had administered several doses of lorazepam, with no change in her presentation. On her arrival in the ER, a loading dose of fosphenytoin was given that successfully stopped the convulsive activity. Laboratory studies of samples obtained in the ER revealed therapeutic levels of her usual antiepileptics and no evidence of any infection or metabolic disturbance. Urine toxicology screens were negative for use of illicit substances. Ms. Davis was subsequently admitted to the neurology service for further monitoring. During her admission, a routine electroencephalogram (EEG) was ordered. Shortly after the study began, Ms. Davis began convulsing; this prompted administration of intravenous lorazepam. When the EEG was reviewed, no epileptiform activity was identified. Ms. Davis was subsequently placed on video-EEG (vEEG) monitoring while her antiepileptics were tapered and discontinued. In the course of her monitoring, Ms. Davis had several episodes of convulsive motor activity; none were associated with epileptiform activity on the EEG. Psychiatric consultation was requested. On interview, Ms. Davis denied prior psychiatric evaluations, diagnoses, or treatments. She denied having depressed mood or any disturbance of sleep, energy, concentration, or appetite. She reported no thoughts of harming herself or others. She endorsed no signs or symptoms consistent with mania or psychosis. There was no family history of psychiatric illness or substance abuse. Her examination revealed a well-groomed woman, sitting on her hospital bed with EEG leads in place. She was pleasant and easily engaged and made good eye contact. Cognitive testing revealed no deficits. Ms. Davis noted that she had recently moved to the state to start graduate school; she was excited to start her studies and "finally get my career on track." She denied any recent specific psychosocial stressors other than her move and stated, "My life is finally where I want it to be." She was future oriented and concerned about the impact that her seizures might have on her long-term health and was worried that a protracted hospitalization might cause her to miss the first day of classes (only a week away from the time of the interview). Moreover, she was quite concerned about the costs of her hospitalization because her health insurance coverage did not begin until the school semester commenced and the payment for extended benefits coverage from her previous employer would have a significant impact on her budget. When the findings of the vEEG study were discussed with Ms. Davis, she quickly became quite irritable, asking, "So, everyone thinks I'm just making this up?" She was not calmed by her treaters' attempts to clarify that they did not believe her to be faking her symptoms or by their reassurance that her symptoms might be helped by psychotherapy. Ms. Davis pulled her EEG leads from her scalp, dressed herself, and left the hospital against medical advice.

Criteria A: recurrent panick attacks (5 in past 3 months) meets criteria Panick attack since 4+ of the 13 symptoms (palpitations, sweating, trembling, smothering, chest pain, and a persistent fear of dying) Criteria B: attacks where followed by: - persistant concerns about additional attacks happening (e.g. having a heart attack despite medical reassurance) - maladaptive changes in behaviour related to the attack (e.g. avoid exercise, driving and coffee)

Which symptoms? Maria Greco was a 23-year-old single woman who was referred for psychiatric evaluation by her cardiologist. In the prior 2 months, she had presented to the emergency room four times for acute complaints of palpitations, shortness of breath, sweats, trembling, and the fear that she was about to die. Each of these events had a rapid onset. The symptoms peaked within minutes, leaving her scared, exhausted, and fully convinced that she had just experienced a heart attack. Medical evaluations done right after these episodes yielded normal physical exam findings, vital signs, lab results, toxicology screens, and electrocardiograms. The patient reported a total of five such attacks in the prior 3 months, with the panic occurring at work, at home, and while driving a car. She had developed a persistent fear of having other attacks, which led her to take many days off work and to avoid exercise, driving, and coffee. Her sleep quality declined, as did her mood. She avoided social relationships. She did not accept the reassurance offered to her by friends and physicians, believing that the medical workups were negative because they were performed after the resolution of the symptoms. She continued to suspect that something was wrong with her heart and that without an accurate diagnosis, she was going to die. When she had a panic attack while asleep in the middle of the night, she finally agreed to see a psychiatrist. On examination, the patient was an anxious-appearing, cooperative, coherent young woman. She denied depression but did appear worried and was preoccupied with ideas of having heart disease. She denied psychotic symptoms, confusion, and all suicidality. Her cognition was intact, insight was limited, and judgment was fair.

Criteria A: high preoccupation with having or triggering a chronic lyme disease Criteria B: Somatic symptoms are very mild (fatigue), and usually feels healthy Criteria C: He has a very high anxiety about triggering the illness, and shows a hypersensitivity towards any indications of worsening health Criteria D: seeks out lots of psychiatry sessions to check health, and took multiple Lyme disease test

Which symptoms? 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 disease. He explained that he had been fatigued for a month and bedridden for a week. Saying he was too tired and confused to give much information, he asked the ER team to call his psychiatrist. The psychiatrist reported that he had treated Mr. Capek for more than two decades. He first saw Mr. Capek for what appeared to be a panic attack. It resolved quickly, but Mr. Capek continued to see him for help coping with his chronic illness. Initially a graduate student pursuing a master's degree in accounting, Mr. Capek dropped out of school over worries that the demands of his studies would exacerbate his disease. Since then, his wife, 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 doses (e.g., one-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 Lyme disease for discussion and was active in a local Lyme disease support group. Mr. Capek's symptoms would occasionally worsen. This occurred less than yearly, and these "exacerbations" usually related to some obvious stress. The worst was 1 year earlier when his wife briefly left him following his revelation of an affair. Mr. Capek expressed shame about his behavior toward his wife—both the affair and his inability to support her. He subsequently 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 disease testing. Eventually, the internist and psychiatrist had agreed on a conservative treatment approach with a neutral stance regarding the disease's validity. 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.

Bipolar and related disorders: Bipolar I current episode manic

Which Diagnosis? An African American man who appeared to be in his 30s was brought to an urban emergency room (ER) by police. The referral form indicated that he was schizophrenic and an "emotionally disturbed person." One of the police officers said that the man offered to pay them for sex while in the back seat of their patrol car. He referred to himself as the "New Jesus" and declined to offer another name. He refused to sit and instead ran through the ER. He was put into restraints and received intramuscularly administered lorazepam 2 mg and haloperidol 5 mg. Despite being restrained, he remained giddily agitated, talking about receiving messages from God. When asked when he last slept, he said he no longer needed sleep, indicating that he had "been touched by Heaven." His speech was rapid, disorganized, and difficult to understand. A complete blood count, blood chemistries, and a toxicology screen were drawn. A review of his electronic medical record indicated that he had experienced a similar episode 2 years earlier. At that time, a toxicology screen had been negative. He had been hospitalized for 2 weeks on the inpatient psychiatric service and given a discharge diagnosis of "schizoaffective disorder." He made poor eye contact, instead looking at nearby people, a ticking clock, the examiner, a nearby nurse—at anything or anyone that moved. His speech was disorganized, rapid, and hard to follow. His leg bounced rapidly up and down, but he did not get out of his chair or threaten the interviewer. He described his mood as "not bad." His affect was labile. He often laughed for no particular reason but would get angrily frustrated when he felt misunderstood. His thought process was disorganized. He had grandiose delusions, and his perceptions were significant for "God talking to me." He denied other hallucinations as well as suicidality and homicidality. When asked the date, he responded with an extended discussion about the underlying meaning of the day's date, which he missed by a single day. The patient's sister arrived an hour later, after having been called by a neighbor who had seen her brother, Mark Hill, taken away in a police car. The sister said her brother had seemed strange a week earlier, uncharacteristically arguing with relatives at a holiday gathering. She said he had claimed not to need sleep at that time and had been talking about his "gifts." She had tried to contact Mr. Hill since then, but he had not responded to phone, e-mail, or text messages. Over the next 24 hours, Mr. Hill calmed significantly. He continued to believe that he was being misunderstood and that he did not need to be hospitalized. He spoke rapidly and loudly. His thoughts jumped from idea to idea. He spoke of having a direct connection to God and having "an important role on Earth," but he denied having a connection to anyone called the "New Jesus." He remained tense and jumpy but denied paranoia or fear. Historical information—much of which became available only toward the end of Mr. Hill's day in the ER—indicated he was a 34-year-old math teacher who had just finished his teaching semester.

Trauma and related disorders: Post traumatic stress disorder

Which diagnosis? Eric Reynolds was a 56-year-old married Vietnam War veteran who referred himself to the Veterans Affairs outpatient mental health clinic for a chief complaint of having "a short fuse" and being "easily triggered." 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 death-related experiences; weekly vivid nightmares of combat operations that led to nighttime fright and insomnia; isolation, vigilance, and anxiety; loss of interest in hobbies that involve people; and excessive distractibility. Although 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 close in checkout lines, and shifts into "attack mode" when coworkers inadvertently surprised him. Most recently, as he was drifting off to sleep on his physician's examination table a nurse touched his foot and he leapt up, cursing and threatening. His 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 after a threatening incident and had long been worried that he might inadvertently hurt someone. Mr. Reynolds was raised in a loving family that struggled 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." 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 linear. He denied all suicidal and homicidal ideation. He had no psychotic symptoms, delusions, or hallucinations. He had very good insight. He was well oriented and seemed to have above average intelligence.

Neurodevelopmental: Autism Spectrum Disorder

Which diagnosis? She was able to dress herself, but she was not able to shower independently or be left alone in the house. She was able to decode (e.g., read words) and spell at a second-grade level but understood little of what she read. Changes to her schedule and heightened functional expectations tended to make her irritable. When upset, xx would often hurt herself (e.g., biting her wrist) and others (e.g., pinching and hair pulling). xx knew hundreds of single words and many simple phrases. She had long been very interested in license plates and would draw them for hours. Her strongest skill was memory, and she could draw precise representations of license plates from different states. xx had always been very attached to her parents and sisters, and although affectionate toward babies, she showed minimal interest in other teenagers xx had a nonverbal IQ of 39 and a verbal IQ of 23, with a full scale IQ of 31. Her adaptive scores were somewhat higher, with an overall score of 42 (with 100 as average). xx first received services at age 9 months after her parents noticed significant motor delays. She walked at 20 months and was toilet trained at 5 years. She spoke her first word at age 6. She received a diagnosis of developmental delay at age 3 and of autism, obesity, and static encephalopathy at age 4. An early evaluation noted possible facial dysmorphology; genetic tests at that time were noncontributory. xx an overweight young woman who made inconsistent eye contact but often peered out the corner of her eye. She had a beautiful smile and would sometimes laugh to herself, but most of the time her facial expressions were subdued. She did not initiate joint attention by trying to catch another person's eyes. She frequently ignored what others would say to her. To request a preferred object (e.g., a shiny magazine), xx would rock from foot to foot and point. When offered an object (e.g., a stuffed animal), she brought it to her nose and lips for inspection. xx spoke in a high-pitched voice with unusual intonation. During the interview, she used multiple words and a few short phrases that were somewhat rote but communicative, such as "I want to clean up," and "Do you have a van?" parents noticed that she had become increasingly apathetic.

Neurodevelopmental: Attention-deficit/hyperactivity disorder

Which diagnosis? xx, a 19-year-old Hispanic college student, presented to a primary care clinic for help with academic difficulties. Since starting college 6 months earlier, he had done poorly on tests and been unable to manage his study schedule. His worries that he was going to flunk out of college were leading to insomnia, poor concentration, and a general sense of hopelessness. After a particularly tough week, he returned home unexpectedly, telling his family that he thought he should quit. before at the age of 9, xx had been in trouble at school for not following instructions, not completing homework, getting out of his seat, losing things, not waiting his turn, and not listening. He had trouble concentrating except in regard to video games, which he "could play for hours." xx had apparently been slow to talk, but his birth and developmental histories were otherwise normal. He repeated first grade because of behavioral immaturity and difficulty learning to read. Since starting college, xx reported that he had frequently been unable to remain focused while reading and listening to lectures. He was easily sidetracked and therefore had difficulty handing in his written assignments on time. He complained of feeling restless, agitated, and worried. He described difficulty falling asleep, poor energy, and an inability to "have fun" like his peers. He reported that the depressive symptoms went "up and down" over the course of the week but did not seem to influence his problems with concentration. He denied substance use.

Trauma and related disorders: Acute stress disorder

Which diagnosis? Dylan, a 15-year-old high school student, was referred to a psychiatrist to deal with the stress from being involved in a serious automobile accident 2 weeks earlier. On the day of the accident, Dylan was riding in the front passenger seat when, as the car was pulling out of a driveway, it was struck by an oncoming SUV that was speeding through a yellow light. The car he was in was hit squarely on the driver's side, which caused the car to roll over once and come to rest right side up. The collision of metal on metal made an extremely loud noise. The driver of the car, a high school classmate, was knocked unconscious for a short period and was bleeding from a gash in his forehead. Upon seeing his injured friend, Dylan became afraid that his friend might be dead. His friend in the back seat of the car was frantically trying to unlatch her seat belt. Dylan's door was jammed, and Dylan feared that their car might catch fire while he was stuck in it. After a few minutes, the driver, Dylan, and the other passenger were able to exit through the passenger doors and move away from the car. They realized that the driver of the SUV was unharmed and had already called the police. An ambulance was on its way. All three were transported to a local emergency room, where they were attended to and released to their parents' care after a few hours. Dylan had not had a good night's sleep since the accident. He often awoke in the middle of the night with his heart racing, visualizing oncoming headlights. He was having trouble concentrating and was unable to effectively complete his homework. His parents, who had begun to drive him to and from school, noticed that he was anxious every time they pulled out of a driveway or crossed an intersection. Although he had recently received his driving permit, he refused to practice driving with his father. He was also unusually short-tempered with his parents, his younger sisters, and his friends. He had recently gone to see a movie but had walked out of the theater before the movie started; he complained that the sound system was too loud. His concerned parents tried to talk to him about his stress, but he would irritably cut them off. After doing poorly on an important exam, however, he accepted the encouragement of a favorite teacher to go to a psychiatrist. When seen, Dylan described additional difficulties. He hated that he was "jumpy" around loud noises, and he could not shake the image of his injured and unresponsive friend. He had waves of anger toward the driver of the SUV.

Schizophrenia Spectrum and other psychotic disorders: Delusional disorder

Which diagnosis? Itsuki Daishi was a 23-year-old engineering student from Japan who was referred to his university student mental health clinic by a professor who had become concerned about his irregular school attendance. When they had met to discuss his declining performance, Mr. Daishi had volunteered to the professor that he was distracted by the "listening devices" and "thought control machines" that had been placed in his apartment. While initially wary of talking to the psychiatrist, Mr. Daishi indicated that he was relieved to finally get a chance to talk in a room that had not yet been bugged. He said that his problems began 3 months earlier, after he returned from a visit to Japan. He said his first indication of trouble was that his classmates sneezed and grinned in an odd way when he entered the classroom. One day when returning from class, he noticed two strangers outside his apartment and wondered why they were there. Mr. Daishi said that he first noticed that his apartment had been bugged about a week after the strangers had been standing outside his apartment. When he watched television, he noticed that reporters commented indirectly and critically about him. This experience was most pronounced when he watched Fox News, which he believed had targeted him because of his "superior intelligence" and his intention to someday become the prime minister of Japan. He believed that Fox News was trying to make him "go mad" by instilling conservative ideas into his brain, and that this was possible through the use of tiny mind-control devices they had installed in his apartment. Mr. Daishi's sleep became increasingly irregular as he became more vigilant, and he feared that everyone at school and in his apartment complex was "in on the plot." He became withdrawn and stopped attending classes, but he continued to eat and maintain his personal hygiene. He denied feeling elated or euphoric. He described his level of energy as "okay" and his thinking as clear "except when they try to put ideas into my head." He admitted to feeling extremely fearful for several hours on one occasion during his recent trip to Japan. At that time, he had smoked "a lot of pot" and began hearing strange sounds and believing that his friends were laughing at him. He denied any cannabis consumption since his return to the United States and denied ever having experimented with any other substances of abuse, saying that he generally would not even drink alcohol. He denied all other history of auditory or visual hallucinations. On examination, Mr. Daishi was well groomed and cooperative, with normal psychomotor activity. His speech was coherent and goal directed. He described his mood as "afraid." The range and mobility of his affective expression were normal. He denied any ideas of guilt, suicide, or worthlessness. He was convinced that he was being continuously monitored and that there were "mind-control" devices in his apartment. He denied hallucinations. His cognitive functions were grossly within normal limits. He appeared to have no insight into his beliefs. On investigation, Mr. Daishi's laboratory test results were normal, his head computed tomography scan was unremarkable, and his urine drug screen was negative for any substances of abuse.

Dissociative disorders: Depersonalisation/derealisation disorder

Which diagnosis? Jason Vaughan, a 20-year-old college sophomore, was referred by his dorm's resident adviser to the school's mental health clinic after appearing "strange and out of it." Mr. Vaughan told the evaluating therapist that he had not been his "usual self" for about 3 months. He said his mind often felt blank, as if thoughts were not his own. He had felt increasingly detached from his physical body, going about his daily activities like a "disconnected robot." At times, he felt uncertain if he were alive or dead, as if existence were a dream. He said he almost felt like he had "no self." These experiences left him in a state of terror for hours on end. His grades declined, and he began to socialize only minimally. Mr. Vaughan said he had become depressed over the breakup with a girlfriend, Jill, a few months earlier, describing sad mood for about a month with mild vegetative symptoms but no impairment in functioning. During this time, he began to notice some feelings of numbness and unreality, but he did not pay much attention at first. As his low mood resolved and he found himself becoming increasingly disconnected, he began to worry more and more until he finally sought help. He told the counselor that his 1-year romantic relationship with Jill had been very meaningful to him and that over the holidays he had planned to introduce her to his mother for the first time. Mr. Vaughan described a time-limited bout of extreme anxiety in tenth grade. At that time, panic attacks had begun and then escalated in severity and frequency over 2 months. During those attacks, he had felt very detached, as if everything were unreal. The symptoms sometimes lasted for several hours and were reminiscent of his current complaints. The onset appeared to coincide with his mother's entry into a psychiatric hospital. When she was discharged, all his symptoms cleared fairly rapidly. He did not seek treatment at that time. Mr. Vaughan also described several days of transient unreality symptoms in elementary school, just after his parents divorced and his father left young Jason living alone with his mother, who had paranoid schizophrenia. His childhood was significant for pervasive loneliness and the sense that he was the only adult in the family. His mother was only marginally functional but generally not actively psychotic. His father rarely returned for visits but did provide enough money for them to continue to live in reasonable comfort. Jason often stayed with his grandparents on weekends, but in general he and his mother lived a very isolated life. He did well in school and had a few close friends, but he largely kept to himself and rarely brought friends home. Jill would have been the first girlfriend to meet his mother. Mr. Vaughan denied using any drugs, in particular cannabis, hallucinogens, ketamine, or salvia, and his urine toxicology was negative. He denied physical and sexual abuse. He denied any history of depression, mania, psychosis, or other past psychiatric symptoms. He specifically denied amnesia, blackouts, multiple identities, hallucinations, paranoia, and other unusual thoughts or experiences. Results of routine laboratory tests, a toxicology screen, and a physical examination were normal, as were a brain magnetic resonance imaging scan and electroencephalogram. Consultations with an otorhinolaryngologist and a neurologist were noncontributory.

Anxiety disorders: Panic disorder

Which diagnosis? Maria Greco was a 23-year-old single woman who was referred for psychiatric evaluation by her cardiologist. In the prior 2 months, she had presented to the emergency room four times for acute complaints of palpitations, shortness of breath, sweats, trembling, and the fear that she was about to die. Each of these events had a rapid onset. The symptoms peaked within minutes, leaving her scared, exhausted, and fully convinced that she had just experienced a heart attack. Medical evaluations done right after these episodes yielded normal physical exam findings, vital signs, lab results, toxicology screens, and electrocardiograms. The patient reported a total of five such attacks in the prior 3 months, with the panic occurring at work, at home, and while driving a car. She had developed a persistent fear of having other attacks, which led her to take many days off work and to avoid exercise, driving, and coffee. Her sleep quality declined, as did her mood. She avoided social relationships. She did not accept the reassurance offered to her by friends and physicians, believing that the medical workups were negative because they were performed after the resolution of the symptoms. She continued to suspect that something was wrong with her heart and that without an accurate diagnosis, she was going to die. When she had a panic attack while asleep in the middle of the night, she finally agreed to see a psychiatrist. On examination, the patient was an anxious-appearing, cooperative, coherent young woman. She denied depression but did appear worried and was preoccupied with ideas of having heart disease. She denied psychotic symptoms, confusion, and all suicidality. Her cognition was intact, insight was limited, and judgment was fair.

Criterion A: somatic symptom of persistent back pain which is ditressing and caused significant disruptions in her daily life (going around in a wheel chair, not being able to work, and friends think she is lying so contact has been severed) Criterion B: Excessive thoughts/feelings/behaviour related to the back pain have been done, including: - disproportionate persistant thoughts about the seriousness of the symptoms - persistent high anxiety about the back pain - excessive time spend going to different clinicians and doctors

Which diagnosis? Michelle Adams, a 51-year-old former hairdresser, came to a psychiatric clinic at the urging of her primary care doctor. A note sent ahead revealed that she had been tearful and frustrated at her last medical appointment, and her doctor, who had been struggling to control her persistent back pain, felt that an evaluation by a psychiatrist might be helpful. Greeting Ms. Adams in the waiting room, the psychiatrist was struck by both her appearance and her manner: here was a woman with shaggy silver hair and dark sunglasses, seated in a wheelchair, who offered a limp handshake and a plaintive sigh before asking the psychiatrist if he would mind pushing her wheelchair into his office. She was tired from a long commute, and, she explained, "Nobody on the street offered to help me out. Can you believe that?" Once settled, Ms. Adams stated that she had been suffering from unbearable back pain for the last 13 months. On the night "that changed everything," she had locked herself out of her apartment and, while trying to climb in through a fire escape, had fallen and fractured her pelvis, coccyx, right elbow, and three ribs. Although she did not require surgery, she was bed-bound for 6 weeks and then underwent several months of physical therapy. Daily narcotic medication was only moderately helpful. She had seen "a dozen" doctors in various specialties and tried multiple treatments, including anesthetic injections and bioelectric stimulation therapy, but her pain was unrelenting. Throughout this ordeal and for years prior, Ms. Adams smoked marijuana daily, explaining that a joint enjoyed in hourly puffs softened her pain and helped her to relax. She did not drink alcohol or use other illicit drugs. Prior to the accident, Ms. Adams had worked at a neighborhood salon for more than 20 years. She was proud to have a number of devoted clients, and she relished the camaraderie with her colleagues, whom she referred to as "my real family." She had been unable to return to work since her accident on account of the pain. "These doctors keep telling me I'm good to go back to work," she said with visible anger, "but they don't know what I'm going through." Her voice broke. "They don't believe me. They think I'm lying." She added that although friends reached out after the accident, lately they had seemed less sympathetic. She let the calls go to voice mail most of the time because she just did not feel up to socializing on account of the pain. In the last month, she had stopped bathing daily and gotten slack about cleaning her apartment. Without the structure of work, she often found herself up until 5:00 a.m., and pain woke her several times before she finally got out of bed in the afternoon. As for her mood, she said, "I'm so depressed it's ridiculous." She often felt hopeless of any possibility of living without pain but denied ever thinking of suicide. She explained that her Catholic faith prevented her from considering taking her own life. Ms. Adams had never seen a psychiatrist before and did not recall ever having felt depressed prior to her accident, although she described a "hot temper" as a family trait. She spoke of only one meaningful romantic relationship, years ago, with a woman who was emotionally abusive. When asked about any legal difficulties, she revealed several arrests for theft in her 20s. She was "in the wrong place at the wrong time," she said, and was never convicted of a crime.

Somatic symptom and related disorders: Somatic symptom disorder

Which diagnosis? Michelle Adams, a 51-year-old former hairdresser, came to a psychiatric clinic at the urging of her primary care doctor. A note sent ahead revealed that she had been tearful and frustrated at her last medical appointment, and her doctor, who had been struggling to control her persistent back pain, felt that an evaluation by a psychiatrist might be helpful. Greeting Ms. Adams in the waiting room, the psychiatrist was struck by both her appearance and her manner: here was a woman with shaggy silver hair and dark sunglasses, seated in a wheelchair, who offered a limp handshake and a plaintive sigh before asking the psychiatrist if he would mind pushing her wheelchair into his office. She was tired from a long commute, and, she explained, "Nobody on the street offered to help me out. Can you believe that?" Once settled, Ms. Adams stated that she had been suffering from unbearable back pain for the last 13 months. On the night "that changed everything," she had locked herself out of her apartment and, while trying to climb in through a fire escape, had fallen and fractured her pelvis, coccyx, right elbow, and three ribs. Although she did not require surgery, she was bed-bound for 6 weeks and then underwent several months of physical therapy. Daily narcotic medication was only moderately helpful. She had seen "a dozen" doctors in various specialties and tried multiple treatments, including anesthetic injections and bioelectric stimulation therapy, but her pain was unrelenting. Throughout this ordeal and for years prior, Ms. Adams smoked marijuana daily, explaining that a joint enjoyed in hourly puffs softened her pain and helped her to relax. She did not drink alcohol or use other illicit drugs. Prior to the accident, Ms. Adams had worked at a neighborhood salon for more than 20 years. She was proud to have a number of devoted clients, and she relished the camaraderie with her colleagues, whom she referred to as "my real family." She had been unable to return to work since her accident on account of the pain. "These doctors keep telling me I'm good to go back to work," she said with visible anger, "but they don't know what I'm going through." Her voice broke. "They don't believe me. They think I'm lying." She added that although friends reached out after the accident, lately they had seemed less sympathetic. She let the calls go to voice mail most of the time because she just did not feel up to socializing on account of the pain. In the last month, she had stopped bathing daily and gotten slack about cleaning her apartment. Without the structure of work, she often found herself up until 5:00 a.m., and pain woke her several times before she finally got out of bed in the afternoon. As for her mood, she said, "I'm so depressed it's ridiculous." She often felt hopeless of any possibility of living without pain but denied ever thinking of suicide. She explained that her Catholic faith prevented her from considering taking her own life. Ms. Adams had never seen a psychiatrist before and did not recall ever having felt depressed prior to her accident, although she described a "hot temper" as a family trait. She spoke of only one meaningful romantic relationship, years ago, with a woman who was emotionally abusive. When asked about any legal difficulties, she revealed several arrests for theft in her 20s. She was "in the wrong place at the wrong time," she said, and was never convicted of a crime.

Somatic Symptom and Related Disorders: Illness Anxiety Disorder

Which diagnosis? 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 disease. He explained that he had been fatigued for a month and bedridden for a week. Saying he was too tired and confused to give much information, he asked the ER team to call his psychiatrist. The psychiatrist reported that he had treated Mr. Capek for more than two decades. He first saw Mr. Capek for what appeared to be a panic attack. It resolved quickly, but Mr. Capek continued to see him for help coping with his chronic illness. Initially a graduate student pursuing a master's degree in accounting, Mr. Capek dropped out of school over worries that the demands of his studies would exacerbate his disease. Since then, his wife, 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 doses (e.g., one-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 Lyme disease for discussion and was active in a local Lyme disease support group. Mr. Capek's symptoms would occasionally worsen. This occurred less than yearly, and these "exacerbations" usually related to some obvious stress. The worst was 1 year earlier when his wife briefly left him following his revelation of an affair. Mr. Capek expressed shame about his behavior toward his wife—both the affair and his inability to support her. He subsequently 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 disease testing. Eventually, the internist and psychiatrist had agreed on a conservative treatment approach with a neutral stance regarding the disease's validity. 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.

Bipolar and related disorders: Bipolar II, current depressive episode

Which diagnosis? 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 6-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 returned." She had also begun to think often of death but had never attempted suicide. Pamela said her memory about her history of depressions 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, anergia, amotivation, hypersomnia, hyperphagia, 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, irritability, 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 "different 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 seemed to be including her good periods as part of her illness, he had not been complaining when she had her longest such episode (about 6 days) when they first started dating in college On examination, Pamela 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. Her insight and judgment were intact.

-A: 1+ current Mayor depressive episode and past episodes of hypomania and depression -B: Never any manic episodes (no longer than 7 days) Hypomania episode: - A: irritable mood - B: pressured speech, flight of ideas, needing less sleep, increased goal directed activity (becoming really productive) Duration: max 6 days Depressive episode: - depressed mood (watch tv, sleep excessively) - significant weight gain - hypersomnia - loss of energy - thoughts of death Duration: 3+ weeks

Which symptoms? 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 6-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 returned." She had also begun to think often of death but had never attempted suicide. Pamela said her memory about her history of depressions 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, anergia, amotivation, hypersomnia, hyperphagia, 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, irritability, 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 "different 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 seemed to be including her good periods as part of her illness, he had not been complaining when she had her longest such episode (about 6 days) when they first started dating in college On examination, Pamela 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. Her insight and judgment were intact.

Bipolar and related disorders: Cyclothymic Disorder

Which diagnosis? Rachel, a 15-year-old girl, was referred for a psychiatric evaluation because of worsening difficulties at home and at school over the prior year. The mother said her chief concern was that "Rachel's meds aren't working." Rachel said she had no particular complaints. In meetings with the patient and her mother, both together and separately, both reported that Rachel's grades had dropped from As and Bs to Cs and Ds, that she had lost many of her long-standing friends, and that conflicts at home had escalated to the point that her mother characterized her as "nasty and mean." At around age 14, however, Rachel became "moody." Instead of being a "bubbly teenager," she would spend days by herself and hardly speak to anyone. During these periods of persistent sadness, she would sleep more than usual, complain that her friends didn't like her anymore, and not seem interested in anything. At other times, she would be a "holy terror" at home, frequently yelling at her sister and parents to the point that everyone was "walking on eggshells." At about that time, Rachel's grades plummeted, and her pediatrician increased the dosage of her ADHD medication. In exploring the periods of irritability, dysphoria, and social isolation, the clinician asked whether there had been times in which Rachel was in an especially good mood. The mother recalled multiple periods in which her daughter would be "giddy" for a week or two. She would laugh at "anything" and would enthusiastically help out with and even initiate household chores. Because these were the "good phases," the mother did not think these episodes were noteworthy. On examination while alone, Rachel was a casually groomed teenager who was coherent and goal directed. She appeared wary and sad, with some affective constriction. She did not like how she had been feeling, saying she felt depressed for a week, then okay, then "hilarious" for a few days, then "murderous," like someone was "churning up my insides." She did not know why she felt like that, and she hated not knowing how she would be feeling the next day. She denied psychotic symptoms, confusion, and suicidal and homicidal thoughts. She was cognitively intact.

Obsessive compulsive and related disorders: Body Dysmorphic disorder

Which diagnosis? Vincent Mancini, a 26-year-old single white man, was brought for an outpatient evaluation by his parents because they were distressed by his symptoms. Since age 13, he had been excessively preoccupied with his "scarred" skin, "thinning" hair, "asymmetrical" ears, and "wimpy" and "inadequately muscular" body build. Although he looked normal, Mr. Mancini was completely convinced that he looked "ugly and hideous," and he believed that other people talked about him and made fun of him because of his appearance. Mr. Mancini spent 5-6 hours a day compulsively checking his disliked body areas in mirrors and other reflecting surfaces such as windows, excessively styling his hair "to create an illusion of fullness," pulling on his ears to try to "even them up," and comparing his appearance with that of others. He compulsively picked his skin, sometimes using razor blades, to try to "clear it up." He lifted weights daily and regularly wore several layers of T-shirts to look bigger. He almost always wore a cap to hide his hair. He had received dermatological treatment for his skin concerns but felt it had not helped. Mr. Mancini missed several months of high school because he was too preoccupied to do schoolwork, felt compelled to leave class to check mirrors, and was too self-conscious to be seen by others; for these reasons he was unable to attend college. He became socially withdrawn and did not date "because no girl would want to go out with someone as ugly as me." He often considered suicide because he felt that life was not worth living "if I look like a freak" and because he felt isolated and ostracized because of his "ugliness." His parents expressed concern over his "violent outbursts," which occurred when he was feeling especially angry and distressed over how he looked or when they tried to pull him away from the mirror.

Persistent Depressive Disorder (Dysthymia)

Which disorder? Diane Taylor, a 35-year-old laboratory technician. Her supervisor had referred Ms. Taylor to the EAP after she had become tearful while being mildly criticized during an otherwise positive annual performance review. Somewhat embarrassed, she told the consulting psychiatrist that she had been "feeling low for years" and that hearing criticism of her work had been "just too much." She left graduate school before completing her doctorate and began work as a laboratory technician. She felt frustrated with her job, which she saw as a "dead end," yet feared that she lacked the talent to find more satisfying work. As a result, she struggled with guilty feelings that she "hadn't done much" with her life Despite her troubles at work, Ms. Taylor felt that she could concentrate without difficulty. She denied ever having active suicidal thoughts, yet sometimes wondered, "What is the point of life?" When asked, she reported that she occasionally had trouble falling asleep. However, she denied any change in her weight or appetite. Although she occasionally would go out with coworkers, she said that she felt shy and awkward in social situations unless she knew the people well. She did enjoy jogging and the outdoors. Although her romantic relationships tended to "not last long," she felt that her sex drive was normal. She noted that her symptoms waxed and waned but had remained consistent over the past 3 years. She had no symptoms suggestive of mania or hypomania. Ms. Taylor became depressed for the first time in high school when her father was repeatedly hospitalized after developing leukemia. At that time she was treated with psychotherapy and responded well.After several months of treatment, she revealed that she had been sexually abused by a family friend during her childhood. It also emerged that she had few women friends and a persistent pattern of dysfunctional and occasionally abusive relationships with men.

Criteria A: feelings of depersonalisation (detachment of his physical body, mind, and emotions, and persasive sense of "no self" feeling like a robot). Criteria B: during the depersonalisation experience, the reality testing remains intact.

Which symptom? Jason Vaughan, a 20-year-old college sophomore, was referred by his dorm's resident adviser to the school's mental health clinic after appearing "strange and out of it." Mr. Vaughan told the evaluating therapist that he had not been his "usual self" for about 3 months. He said his mind often felt blank, as if thoughts were not his own. He had felt increasingly detached from his physical body, going about his daily activities like a "disconnected robot." At times, he felt uncertain if he were alive or dead, as if existence were a dream. He said he almost felt like he had "no self." These experiences left him in a state of terror for hours on end. His grades declined, and he began to socialize only minimally. Mr. Vaughan said he had become depressed over the breakup with a girlfriend, Jill, a few months earlier, describing sad mood for about a month with mild vegetative symptoms but no impairment in functioning. During this time, he began to notice some feelings of numbness and unreality, but he did not pay much attention at first. As his low mood resolved and he found himself becoming increasingly disconnected, he began to worry more and more until he finally sought help. He told the counselor that his 1-year romantic relationship with Jill had been very meaningful to him and that over the holidays he had planned to introduce her to his mother for the first time. Mr. Vaughan described a time-limited bout of extreme anxiety in tenth grade. At that time, panic attacks had begun and then escalated in severity and frequency over 2 months. During those attacks, he had felt very detached, as if everything were unreal. The symptoms sometimes lasted for several hours and were reminiscent of his current complaints. The onset appeared to coincide with his mother's entry into a psychiatric hospital. When she was discharged, all his symptoms cleared fairly rapidly. He did not seek treatment at that time. Mr. Vaughan also described several days of transient unreality symptoms in elementary school, just after his parents divorced and his father left young Jason living alone with his mother, who had paranoid schizophrenia. His childhood was significant for pervasive loneliness and the sense that he was the only adult in the family. His mother was only marginally functional but generally not actively psychotic. His father rarely returned for visits but did provide enough money for them to continue to live in reasonable comfort. Jason often stayed with his grandparents on weekends, but in general he and his mother lived a very isolated life. He did well in school and had a few close friends, but he largely kept to himself and rarely brought friends home. Jill would have been the first girlfriend to meet his mother. Mr. Vaughan denied using any drugs, in particular cannabis, hallucinogens, ketamine, or salvia, and his urine toxicology was negative. He denied physical and sexual abuse. He denied any history of depression, mania, psychosis, or other past psychiatric symptoms. He specifically denied amnesia, blackouts, multiple identities, hallucinations, paranoia, and other unusual thoughts or experiences. Results of routine laboratory tests, a toxicology screen, and a physical examination were normal, as were a brain magnetic resonance imaging scan and electroencephalogram. Consultations with an otorhinolaryngologist and a neurologist were noncontributory.

- This was his second manic episode Criteria A: he had 1+ week of elevated, irritable, expansive mood Criteria B: - grandiosity ("New Jesus") - decreased need sleep - more talkative, pressured speech (e.g. to his family about his new gifts, or about the days of the week) - racing thoughts (e.g. days of the week) - distractibility - agitation - sexually inappropriate behaviours (asking the police for sex) - dehydration and blisters from constantly being on the move Criteria C: mood disturbances caused marked impairments on his social/occupational functioning and required restrainment for 24hrs Not schizophrenia because they very rarley are abe to keep high demaniding jobs like teaching, whilst Bipolar illness people remain quite functional between episodes. Also, he had another episode before.

Which symptoms? An African American man who appeared to be in his 30s was brought to an urban emergency room (ER) by police. The referral form indicated that he was schizophrenic and an "emotionally disturbed person." One of the police officers said that the man offered to pay them for sex while in the back seat of their patrol car. He referred to himself as the "New Jesus" and declined to offer another name. He refused to sit and instead ran through the ER. He was put into restraints and received intramuscularly administered lorazepam 2 mg and haloperidol 5 mg. Despite being restrained, he remained giddily agitated, talking about receiving messages from God. When asked when he last slept, he said he no longer needed sleep, indicating that he had "been touched by Heaven." His speech was rapid, disorganized, and difficult to understand. A complete blood count, blood chemistries, and a toxicology screen were drawn. A review of his electronic medical record indicated that he had experienced a similar episode 2 years earlier. At that time, a toxicology screen had been negative. He had been hospitalized for 2 weeks on the inpatient psychiatric service and given a discharge diagnosis of "schizoaffective disorder." He made poor eye contact, instead looking at nearby people, a ticking clock, the examiner, a nearby nurse—at anything or anyone that moved. His speech was disorganized, rapid, and hard to follow. His leg bounced rapidly up and down, but he did not get out of his chair or threaten the interviewer. He described his mood as "not bad." His affect was labile. He often laughed for no particular reason but would get angrily frustrated when he felt misunderstood. His thought process was disorganized. He had grandiose delusions, and his perceptions were significant for "God talking to me." He denied other hallucinations as well as suicidality and homicidality. When asked the date, he responded with an extended discussion about the underlying meaning of the day's date, which he missed by a single day. The patient's sister arrived an hour later, after having been called by a neighbor who had seen her brother, Mark Hill, taken away in a police car. The sister said her brother had seemed strange a week earlier, uncharacteristically arguing with relatives at a holiday gathering. She said he had claimed not to need sleep at that time and had been talking about his "gifts." She had tried to contact Mr. Hill since then, but he had not responded to phone, e-mail, or text messages. Over the next 24 hours, Mr. Hill calmed significantly. He continued to believe that he was being misunderstood and that he did not need to be hospitalised. He spoke rapidly and loudly. His thoughts jumped from idea to idea. He spoke of having a direct connection to God and having "an important role on Earth," but he denied having a connection to anyone called the "New Jesus." He remained tense and jumpy but denied paranoia or fear. Historical information—much of which became available only toward the end of Mr. Hill's day in the ER—indicated he was a 34-year-old math teacher who had just finished his teaching semester.

Criteria A: Exposure to threatened death (as soldier in army to oneself and friends), and exposure to actual death of comrade, and repeated witnessing/learning/exposure to details of death, threatened death, and severe injuries Criteria B (Intrusions): intrusive memories, distressing dreams, psychological and physiological stress at exposure to cues, etc. Criteria C (Avoidance): took job plumber and early retirement to avoid external reminders/memories/thoughts events Criteria D (Alterations): negative beliefs about self, negative emotional state, diminished interest/participation in significant activities like family events, etc. Criteria E (Arousal): irritable behaviour and angry outburst with very little startling, exaggerated startle response, sleep disturbances

Which symptoms? Eric Reynolds was a 56-year-old married Vietnam War veteran who referred himself to the Veterans Affairs outpatient mental health clinic for a chief complaint of having "a short fuse" and being "easily triggered." 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 death-related experiences; weekly vivid nightmares of combat operations that led to nighttime fright and insomnia; isolation, vigilance, and anxiety; loss of interest in hobbies that involve people; and excessive distractibility. Although 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 close in checkout lines, and shifts into "attack mode" when coworkers inadvertently surprised him. Most recently, as he was drifting off to sleep on his physician's examination table a nurse touched his foot and he leapt up, cursing and threatening. His 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 after a threatening incident and had long been worried that he might inadvertently hurt someone. Mr. Reynolds was raised in a loving family that struggled 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." 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 linear. He denied all suicidal and homicidal ideation. He had no psychotic symptoms, delusions, or hallucinations. He had very good insight. He was well oriented and seemed to have above average intelligence.

Criterion A - unable to form friendships (A3. developing, maintaining and understanding relationships) - does not engage in interactive play - struggles with reading social cues (A1&2: deficits social-emotional reciprocity + nonverbal communication) criterion B: - fixated interest in cars and trains, little interest in anything else, no apparent insight that other children might not share his enthusiasms (B3: Highly restricted, fixated interest that are abnormal in intensity or focus) - He requires "sameness," with distress arising if his routine is altered. (B2: Insistence of sameness, inflexible adherence to routines, or ritualised patters of (non)verbal behaviour)

Which symptoms? xx 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 teachers had not identified a cause but generally had not disciplined xx because they assumed he was responding to provocation. 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 running away, but then had decided that maybe he should just run away to his own bedroom. xx spoke his first word at age 11 months and began to use short sentences by age 3. He had always been very focused on trucks, cars, and trains. According to his mother, he had always been "very shy" and had never had a best friend. He struggled with jokes and typical childhood banter because "he takes things so literally." was shy and generally nonspontaneous. He made below-average eye contact. His speech was coherent and goal directed. At times, xx stumbled over his words, paused excessively, and sometimes rapidly repeated words or parts of words. xx said he felt okay but added he was scared of school. He appeared sad, brightening only when discussing his toy cars. He denied suicidality and homicidality. He denied psychotic symptoms. He was cognitively intact.

Neurodevelopmental: Autism spectrum disorder (if her deficits were due solely to limited intellectual abilities, she would be expected to have the social and play skills of a typical 3- to 4-year-old child. Ashley's social interaction is not at all like that of a typical preschooler, however, and never has been. She has limited facial expressions, poor eye contact, and minimal interest in peers. Compared to her "mental age," Ashley demonstrates significant restriction in both her range of interests and her understanding of basic human emotions. Furthermore, she manifests behaviors that are not seen commonly at any age.)

Which symptoms? xx 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 teachers had not identified a cause but generally had not disciplined xx because they assumed he was responding to provocation. 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 running away, but then had decided that maybe he should just run away to his own bedroom. xx spoke his first word at age 11 months and began to use short sentences by age 3. He had always been very focused on trucks, cars, and trains. According to his mother, he had always been "very shy" and had never had a best friend. He struggled with jokes and typical childhood banter because "he takes things so literally." was shy and generally nonspontaneous. He made below-average eye contact. His speech was coherent and goal directed. At times, xx stumbled over his words, paused excessively, and sometimes rapidly repeated words or parts of words. xx said he felt okay but added he was scared of school. He appeared sad, brightening only when discussing his toy cars. He denied suicidality and homicidality. He denied psychotic symptoms. He was cognitively intact.

he has five different inattentive symptoms and two symptoms related to hyperactivity-impulsivity. Inattentive: 1. Often avoids/dislikes/reluctant to engage in tasks requiring sustained mental effort 2. often has difficulty sustaining attention in tasks or play activities 3. often does not follow through on instructions and fails to finish schoolwork/chores/duties in the workplace 4. Often has difficulty organising tasks/activities 5. easily distracted by extraneous stimuli Hyperactivity/impulsivity 1. often fidgets/squirms in seat 2. often on the go, acting as if driven by a motor 3. Unable to play/engage in leisure activities quietly

Which symptoms? xx, a 19-year-old Hispanic college student, presented to a primary care clinic for help with academic difficulties. Since starting college 6 months earlier, he had done poorly on tests and been unable to manage his study schedule. His worries that he was going to flunk out of college were leading to insomnia, poor concentration, and a general sense of hopelessness. After a particularly tough week, he returned home unexpectedly, telling his family that he thought he should quit. before at the age of 9, xx had been in trouble at school for not following instructions, not completing homework, getting out of his seat, losing things, not waiting his turn, and not listening. He had trouble concentrating except in regard to video games, which he "could play for hours." xx had apparently been slow to talk, but his birth and developmental histories were otherwise normal. He repeated first grade because of behavioral immaturity and difficulty learning to read. Since starting college, xx reported that he had frequently been unable to remain focused while reading and listening to lectures. He was easily sidetracked and therefore had difficulty handing in his written assignments on time. He complained of feeling restless, agitated, and worried. He described difficulty falling asleep, poor energy, and an inability to "have fun" like his peers. He reported that the depressive symptoms went "up and down" over the course of the week but did not seem to influence his problems with concentration. He denied substance use.

A: depressed mood most days for 2+ years B: whilst depressed also: - depressed mood - low energy - low self esteem (not good enough for more satisfying jobs)

Which symptoms? Diane Taylor, a 35-year-old laboratory technician. Her supervisor had referred Ms. Taylor to the EAP after she had become tearful while being mildly criticized during an otherwise positive annual performance review. Somewhat embarrassed, she told the consulting psychiatrist that she had been "feeling low for years" and that hearing criticism of her work had been "just too much." She left graduate school before completing her doctorate and began work as a laboratory technician. She felt frustrated with her job, which she saw as a "dead end," yet feared that she lacked the talent to find more satisfying work. As a result, she struggled with guilty feelings that she "hadn't done much" with her life Despite her troubles at work, Ms. Taylor felt that she could concentrate without difficulty. She denied ever having active suicidal thoughts, yet sometimes wondered, "What is the point of life?" When asked, she reported that she occasionally had trouble falling asleep. However, she denied any change in her weight or appetite. Although she occasionally would go out with coworkers, she said that she felt shy and awkward in social situations unless she knew the people well. She did enjoy jogging and the outdoors. Although her romantic relationships tended to "not last long," she felt that her sex drive was normal. She noted that her symptoms waxed and waned but had remained consistent over the past 3 years. She had no symptoms suggestive of mania or hypomania. Ms. Taylor became depressed for the first time in high school when her father was repeatedly hospitalized after developing leukemia. At that time she was treated with psychotherapy and responded well.After several months of treatment, she revealed that she had been sexually abused by a family friend during her childhood. It also emerged that she had few women friends and a persistent pattern of dysfunctional and occasionally abusive relationships with men.

Duration: 2 weeks Criteria A: exposure to threatened death of self and freinds, and severe injuries Criteria B: intrusive memories (triggered by e.g. loud noises, intersections, etc.), intense psychological and physiological distress (e.g. in cinema, efforts to avoid thinking or having feelings about what happened, recurrent distressing dreams, avoidance external reminders of what happened, irritable behaviour, problems concentration, exaggerated startle response, etc.

Which symptoms? Dylan, a 15-year-old high school student, was referred to a psychiatrist to deal with the stress from being involved in a serious automobile accident 2 weeks earlier. On the day of the accident, Dylan was riding in the front passenger seat when, as the car was pulling out of a driveway, it was struck by an oncoming SUV that was speeding through a yellow light. The car he was in was hit squarely on the driver's side, which caused the car to roll over once and come to rest right side up. The collision of metal on metal made an extremely loud noise. The driver of the car, a high school classmate, was knocked unconscious for a short period and was bleeding from a gash in his forehead. Upon seeing his injured friend, Dylan became afraid that his friend might be dead. His friend in the back seat of the car was frantically trying to unlatch her seat belt. Dylan's door was jammed, and Dylan feared that their car might catch fire while he was stuck in it. After a few minutes, the driver, Dylan, and the other passenger were able to exit through the passenger doors and move away from the car. They realized that the driver of the SUV was unharmed and had already called the police. An ambulance was on its way. All three were transported to a local emergency room, where they were attended to and released to their parents' care after a few hours. Dylan had not had a good night's sleep since the accident. He often awoke in the middle of the night with his heart racing, visualizing oncoming headlights. He was having trouble concentrating and was unable to effectively complete his homework. His parents, who had begun to drive him to and from school, noticed that he was anxious every time they pulled out of a driveway or crossed an intersection. Although he had recently received his driving permit, he refused to practice driving with his father. He was also unusually short-tempered with his parents, his younger sisters, and his friends. He had recently gone to see a movie but had walked out of the theater before the movie started; he complained that the sound system was too loud. His concerned parents tried to talk to him about his stress, but he would irritably cut them off. After doing poorly on an important exam, however, he accepted the encouragement of a favorite teacher to go to a psychiatrist. When seen, Dylan described additional difficulties. He hated that he was "jumpy" around loud noises, and he could not shake the image of his injured and unresponsive friend. He had waves of anger toward the driver of the SUV.

Criteria A: Inability recall important events from when she was 7-13 yrs old, (including family vacations, trips, etc.) (and DA is associated with with physical and sexual abuse, and its extent seems to increase with increased severity, frequency, and violence of the abuse) inconsistent with normal forgetting.

Which symptoms? Irene Upton was a 29-year-old special education teacher who sought a psychiatric consultation because "I'm tired of always being sad and alone." The patient reported chronic, severe depression that had not responded to multiple trials of antidepressants and mood stabilizer augmentation. She reported greater benefit from psychotherapies based on cognitive-behavioral therapy and dialectical behavior therapy. Electroconvulsive therapy had been suggested, but she had refused. She had been hospitalized twice for suicidal ideation and severe self-cutting that required stitches. Ms. Upton reported that previous therapists had focused on the likelihood of trauma, but she casually dismissed the possibility that she had ever been abused. It had been her younger sister who had reported "weird sexual touching" by their father when Ms. Upton was 13. There had never been a police investigation, but her father had apologized to the patient and her sister as part of a resultant church intervention and an inpatient treatment for alcoholism and "sex addiction." She denied any feelings about these events and said, "He took care of the problem. I have no reason to be mad at him." Ms. Upton reported little memory for her life between about ages 7 and 13 years. Her siblings would joke with her about her inability to recall family holidays, school events, and vacation trips. She explained her amnesia by saying, "Maybe nothing important happened, and that's why I don't remember." She reported a "good" relationship with both parents. Her father remained "controlling" toward her mother and still had "anger issues," but had been abstinent from alcohol for 16 years. On closer questioning, Ms. Upton reported that her self-injurious and suicidal behavior primarily occurred after visits to see her family or when her parents surprised her by visiting. More specific questions led Ms. Upton to deny that she had ongoing amnesia for daily life, particularly denying ever being told of behavior she could not recall, unexplained possessions, subjective time loss, fugue episodes, or inexplicable fluctuations in skills, habits, and/or knowledge. She denied a sense of subjective self-division, hallucinations, inner voices, or passive influence symptoms. She denied flashbacks or intrusive memories, but reported recurrent nightmares of being chased by "a dangerous man" from whom she could not escape. She reported difficulty concentrating, although she was "hyperfocused" at work. She reported an intense startle reaction. She reported repeated counting and singing in her mind, repeated checking to ensure that doors were locked, and compulsive arranging to "prevent harm from befalling me."

he has one or more delusions that persist for greater than 1 month but no other psychotic symptoms. Most of Mr. Daishi's delusions are persecutory and related to monitoring devices. He has delusions of reference (classmates sneezing and grinning at him), persecution ("trying to make me go mad," monitoring devices), and thought insertion ("machines trying to put ideas into my head"). He warrants the "mixed" specifier because the apparent motivation for his having been targeted appears to be grandiose (his "superior intelligence" and plans to be the prime minister of Japan), but he has no other symptoms of mania.

Which symptoms? Itsuki Daishi was a 23-year-old engineering student from Japan who was referred to his university student mental health clinic by a professor who had become concerned about his irregular school attendance. When they had met to discuss his declining performance, Mr. Daishi had volunteered to the professor that he was distracted by the "listening devices" and "thought control machines" that had been placed in his apartment. While initially wary of talking to the psychiatrist, Mr. Daishi indicated that he was relieved to finally get a chance to talk in a room that had not yet been bugged. He said that his problems began 3 months earlier, after he returned from a visit to Japan. He said his first indication of trouble was that his classmates sneezed and grinned in an odd way when he entered the classroom. One day when returning from class, he noticed two strangers outside his apartment and wondered why they were there. Mr. Daishi said that he first noticed that his apartment had been bugged about a week after the strangers had been standing outside his apartment. When he watched television, he noticed that reporters commented indirectly and critically about him. This experience was most pronounced when he watched Fox News, which he believed had targeted him because of his "superior intelligence" and his intention to someday become the prime minister of Japan. He believed that Fox News was trying to make him "go mad" by instilling conservative ideas into his brain, and that this was possible through the use of tiny mind-control devices they had installed in his apartment. Mr. Daishi's sleep became increasingly irregular as he became more vigilant, and he feared that everyone at school and in his apartment complex was "in on the plot." He became withdrawn and stopped attending classes, but he continued to eat and maintain his personal hygiene. He denied feeling elated or euphoric. He described his level of energy as "okay" and his thinking as clear "except when they try to put ideas into my head." He admitted to feeling extremely fearful for several hours on one occasion during his recent trip to Japan. At that time, he had smoked "a lot of pot" and began hearing strange sounds and believing that his friends were laughing at him. He denied any cannabis consumption since his return to the United States and denied ever having experimented with any other substances of abuse, saying that he generally would not even drink alcohol. He denied all other history of auditory or visual hallucinations. On examination, Mr. Daishi was well groomed and cooperative, with normal psychomotor activity. His speech was coherent and goal directed. He described his mood as "afraid." The range and mobility of his affective expression were normal. He denied any ideas of guilt, suicide, or worthlessness. He was convinced that he was being continuously monitored and that there were "mind-control" devices in his apartment. He denied hallucinations. His cognitive functions were grossly within normal limits. He appeared to have no insight into his beliefs. On investigation, Mr. Daishi's laboratory test results were normal, his head computed tomography scan was unremarkable, and his urine drug screen was negative for any substances of abuse.

Criteria A: Preoccupation with "scarred skin", "thinning hair", "asymmetrical" ears, and "wimpy/inadequate' muscular body" (though looks normal) Criteria B: spends 5-6hrs a day checking reflection, excessively try style hair, used razor to try clear up skin, and excessively picks at it, pulls ears. Impairment with functioning since months of school delay due to preoccupation with looks

Which symptoms? Vincent Mancini, a 26-year-old single white man, was brought for an outpatient evaluation by his parents because they were distressed by his symptoms. Since age 13, he had been excessively preoccupied with his "scarred" skin, "thinning" hair, "asymmetrical" ears, and "wimpy" and "inadequately muscular" body build. Although he looked normal, Mr. Mancini was completely convinced that he looked "ugly and hideous," and he believed that other people talked about him and made fun of him because of his appearance. Mr. Mancini spent 5-6 hours a day compulsively checking his disliked body areas in mirrors and other reflecting surfaces such as windows, excessively styling his hair "to create an illusion of fullness," pulling on his ears to try to "even them up," and comparing his appearance with that of others. He compulsively picked his skin, sometimes using razor blades, to try to "clear it up." He lifted weights daily and regularly wore several layers of T-shirts to look bigger. He almost always wore a cap to hide his hair. He had received dermatological treatment for his skin concerns but felt it had not helped. Mr. Mancini missed several months of high school because he was too preoccupied to do schoolwork, felt compelled to leave class to check mirrors, and was too self-conscious to be seen by others; for these reasons he was unable to attend college. He became socially withdrawn and did not date "because no girl would want to go out with someone as ugly as me." He often considered suicide because he felt that life was not worth living "if I look like a freak" and because he felt isolated and ostracized because of his "ugliness." His parents expressed concern over his "violent outbursts," which occurred when he was feeling especially angry and distressed over how he looked or when they tried to pull him away from the mirror.

Criteria A: recurring periods of mood changes, from a week or two of hypomania followed by a week or two of sadness followed by a couple of weeks of irritability. Duration is 1+ year (since still an adolescence) with no more than 2-months stretches without symptoms

Which symptoms? Rachel, a 15-year-old girl, was referred for a psychiatric evaluation because of worsening difficulties at home and at school over the prior year. The mother said her chief concern was that "Rachel's meds aren't working." Rachel said she had no particular complaints. In meetings with the patient and her mother, both together and separately, both reported that Rachel's grades had dropped from As and Bs to Cs and Ds, that she had lost many of her long-standing friends, and that conflicts at home had escalated to the point that her mother characterized her as "nasty and mean." At around age 14, however, Rachel became "moody." Instead of being a "bubbly teenager," she would spend days by herself and hardly speak to anyone. During these periods of persistent sadness, she would sleep more than usual, complain that her friends didn't like her anymore, and not seem interested in anything. At other times, she would be a "holy terror" at home, frequently yelling at her sister and parents to the point that everyone was "walking on eggshells." At about that time, Rachel's grades plummeted, and her pediatrician increased the dosage of her ADHD medication. In exploring the periods of irritability, dysphoria, and social isolation, the clinician asked whether there had been times in which Rachel was in an especially good mood. The mother recalled multiple periods in which her daughter would be "giddy" for a week or two. She would laugh at "anything" and would enthusiastically help out with and even initiate household chores. Because these were the "good phases," the mother did not think these episodes were noteworthy. On examination while alone, Rachel was a casually groomed teenager who was coherent and goal directed. She appeared wary and sad, with some affective constriction. She did not like how she had been feeling, saying she felt depressed for a week, then okay, then "hilarious" for a few days, then "murderous," like someone was "churning up my insides." She did not know why she felt like that, and she hated not knowing how she would be feeling the next day. She denied psychotic symptoms, confusion, and suicidal and homicidal thoughts. She was cognitively intact.

It is not another Schizophrenia Spectrum and other psychotic disorders because the 3 month duration to long brief psychotic disorder (Max 1 month), and too short for schizophrenia (at least 6+ months). It does match schizophreniform time frame, but no second symptom (hallucinations, negative symtom , catatonic disorganization present).

Why not another Schizophrenia Spectrum and other psychotic disorder? Itsuki Daishi was a 23-year-old engineering student from Japan who was referred to his university student mental health clinic by a professor who had become concerned about his irregular school attendance. When they had met to discuss his declining performance, Mr. Daishi had volunteered to the professor that he was distracted by the "listening devices" and "thought control machines" that had been placed in his apartment. While initially wary of talking to the psychiatrist, Mr. Daishi indicated that he was relieved to finally get a chance to talk in a room that had not yet been bugged. He said that his problems began 3 months earlier, after he returned from a visit to Japan. He said his first indication of trouble was that his classmates sneezed and grinned in an odd way when he entered the classroom. One day when returning from class, he noticed two strangers outside his apartment and wondered why they were there. Mr. Daishi said that he first noticed that his apartment had been bugged about a week after the strangers had been standing outside his apartment. When he watched television, he noticed that reporters commented indirectly and critically about him. This experience was most pronounced when he watched Fox News, which he believed had targeted him because of his "superior intelligence" and his intention to someday become the prime minister of Japan. He believed that Fox News was trying to make him "go mad" by instilling conservative ideas into his brain, and that this was possible through the use of tiny mind-control devices they had installed in his apartment. Mr. Daishi's sleep became increasingly irregular as he became more vigilant, and he feared that everyone at school and in his apartment complex was "in on the plot." He became withdrawn and stopped attending classes, but he continued to eat and maintain his personal hygiene. He denied feeling elated or euphoric. He described his level of energy as "okay" and his thinking as clear "except when they try to put ideas into my head." He admitted to feeling extremely fearful for several hours on one occasion during his recent trip to Japan. At that time, he had smoked "a lot of pot" and began hearing strange sounds and believing that his friends were laughing at him. He denied any cannabis consumption since his return to the United States and denied ever having experimented with any other substances of abuse, saying that he generally would not even drink alcohol. He denied all other history of auditory or visual hallucinations. On examination, Mr. Daishi was well groomed and cooperative, with normal psychomotor activity. His speech was coherent and goal directed. He described his mood as "afraid." The range and mobility of his affective expression were normal. He denied any ideas of guilt, suicide, or worthlessness. He was convinced that he was being continuously monitored and that there were "mind-control" devices in his apartment. He denied hallucinations. His cognitive functions were grossly within normal limits. He appeared to have no insight into his beliefs. On investigation, Mr. Daishi's laboratory test results were normal, his head computed tomography scan was unremarkable, and his urine drug screen was negative for any substances of abuse.

Depressive disorders: Mayor depressive disorder

Yvonne Perez was a 23-year-old woman who presented for an outpatient psychiatric evaluation 2 weeks after giving birth to her second child. She was referred by her breast-feeding nurse, who was concerned about the patient's depressed mood, flat affect, and fatigue. Ms. Perez said she had been worried and unenthusiastic since finding out she was pregnant. She and her husband had planned to wait a few years before having another child, and her husband had made it clear that he would have preferred that she terminate the pregnancy, an option she would not consider because of her religion. He had also been upset that she was "too tired" to do paid work outside of the home during her pregnancy. She had then become increasingly dysphoric, hopeless, and overwhelmed after the delivery. Breast-feeding was not going well, and she had begun to believe her baby was "rejecting me" by refusing her breast, spitting up her milk, and crying. Her baby had become very colicky, so she felt forced to hold him most of the day. She wondered whether she deserved this difficulty because she had not wanted the pregnancy. Her husband was gone much of the time for work, and she found it very difficult to take care of the new baby and her lively and demanding 16-month-old daughter. She slept little, felt constantly tired, cried often, and worried about how she was going to get through the day. Her mother-in-law had just arrived to help her care for the children. On mental status examination, Ms. Perez was a casually dressed, cooperative young woman. She made some eye contact, but her eyes tended to drop to the floor when she spoke. Her speech was fluent but slow, with increased latency when answering questions. The tone of her speech was flat. She endorsed low mood, and her affect was constricted. She denied thoughts of suicide and homicide. She also denied any hallucinations and delusions, although she had considered whether the current situation was punishment for not wanting the child.She was fully oriented and could register three objects but only recalled one after 5 minutes.

criteria A: - depressed mood - insomnia - psychomotor retardation - loss energy - inappropriate feelings of guilt (towards child since child reject breastfeeding so punishment since she didn't want child) - poor concentration (as shown by task with objects) Duration: 2+ weeks

Yvonne Perez was a 23-year-old woman who presented for an outpatient psychiatric evaluation 2 weeks after giving birth to her second child. She was referred by her breast-feeding nurse, who was concerned about the patient's depressed mood, flat affect, and fatigue. Ms. Perez said she had been worried and unenthusiastic since finding out she was pregnant. She and her husband had planned to wait a few years before having another child, and her husband had made it clear that he would have preferred that she terminate the pregnancy, an option she would not consider because of her religion. He had also been upset that she was "too tired" to do paid work outside of the home during her pregnancy. She had then become increasingly dysphoric, hopeless, and overwhelmed after the delivery. Breast-feeding was not going well, and she had begun to believe her baby was "rejecting me" by refusing her breast, spitting up her milk, and crying. Her baby had become very colicky, so she felt forced to hold him most of the day. She wondered whether she deserved this difficulty because she had not wanted the pregnancy. Her husband was gone much of the time for work, and she found it very difficult to take care of the new baby and her lively and demanding 16-month-old daughter. She slept little, felt constantly tired, cried often, and worried about how she was going to get through the day. Her mother-in-law had just arrived to help her care for the children. On mental status examination, Ms. Perez was a casually dressed, cooperative young woman. She made some eye contact, but her eyes tended to drop to the floor when she spoke. Her speech was fluent but slow, with increased latency when answering questions. The tone of her speech was flat. She endorsed low mood, and her affect was constricted. She denied thoughts of suicide and homicide. She also denied any hallucinations and delusions, although she had considered whether the current situation was punishment for not wanting the child.She was fully oriented and could register three objects but only recalled one after 5 minutes.

Schizophrenia Spectrum and other psychotic disorders: schizophreniform disorder

what diagnosis? Hakim Coleman was a 25-year-old U.S. Army veteran turned community college student who presented to the emergency room (ER) with his girlfriend and sister. On examination, he was a tall, slim, and well-groomed young man with glasses. He spoke softly, with an increased latency of speech. His affect was blunted except when he became anxious while discussing his symptoms. He said he could use a "general checkup" because of several days of "migraines" and "hallucinations of a spiritual nature" that had persisted for 3 months. His headache involved "sharp, shooting" sensations in various bilateral locations in his head and a "ringing" sensation along the midline of his brain that seemed to worsen when he thought about his voices. he had joined an evangelical church 4 months earlier in the context of being "riddled with guilt" about "all the things I've done." Three months earlier, he began "hearing voices trying to make me feel guilty" most days. The last auditory hallucination had been the day before. During these past few months, he had noticed that strangers were commenting on his past sins. Mr. Coleman believed that his migraines and guilt might be due to alcohol withdrawal. He had been drinking three or four cans of beer most days of the week for several years until he "quit" 4 months earlier after joining the church. He still drank "a beer or two" every other week but felt guilty afterward. He denied alcohol withdrawal symptoms such as tremor and sweats. He had smoked cannabis up to twice monthly for years but completely quit when he joined the church. He denied using other illicit drugs except for one uneventful use of cocaine 3 years earlier. He slept well except occasional nights when he would sleep only a few hours in order to finish an academic assignment. Otherwise, Mr. Coleman denied depressive, manic, or psychotic symptoms and violent ideation. He denied posttraumatic stress disorder (PTSD) symptoms. A physical examination of the patient, including a neurological screen, was unremarkable, as were routine laboratory testing, a blood alcohol level, and urine toxicology. A noncontrast head computed tomography (CT) scan was normal.

Hakim seems most likely to fit a DSM-5 schizophreniform disorder, a diagnosis that differs from schizophrenia in two substantive ways: the total duration of schizophreniform illness—including prodrome, active, and residual phases—is greater than 1 month but less than 6 months. In addition, there is no criterion that mandates social or occupational impairment. For both schizophreniform disorder and schizophrenia, the patient must meet at least two of five symptomatic criteria. Mr. Coleman describes hallucinations ("hearing voices trying to make me feel guilty") and negative symptoms (blunted affect, avolition, social isolation). The case report does not mention delusions or disorganization of either speech or behavior. And it lasted 4-5 months Not schizoaffective or medical cause because: Mr. Coleman denies pertinent mood symptoms. The diagnosis of schizophreniform disorder also requires exclusion of a contributory general medical condition or substance use disorder. Mr. Coleman appears to have no medical complaints, and both his physical examination and laboratory testing are noncontributory. After cuttback of alcohol symptoms persisted.

what symptoms? Hakim Coleman was a 25-year-old U.S. Army veteran turned community college student who presented to the emergency room (ER) with his girlfriend and sister. On examination, he was a tall, slim, and well-groomed young man with glasses. He spoke softly, with an increased latency of speech. His affect was blunted except when he became anxious while discussing his symptoms. He said he could use a "general checkup" because of several days of "migraines" and "hallucinations of a spiritual nature" that had persisted for 3 months. His headache involved "sharp, shooting" sensations in various bilateral locations in his head and a "ringing" sensation along the midline of his brain that seemed to worsen when he thought about his voices. he had joined an evangelical church 4 months earlier in the context of being "riddled with guilt" about "all the things I've done." Three months earlier, he began "hearing voices trying to make me feel guilty" most days. The last auditory hallucination had been the day before. During these past few months, he had noticed that strangers were commenting on his past sins. Mr. Coleman believed that his migraines and guilt might be due to alcohol withdrawal. He had been drinking three or four cans of beer most days of the week for several years until he "quit" 4 months earlier after joining the church. He still drank "a beer or two" every other week but felt guilty afterward. He denied alcohol withdrawal symptoms such as tremor and sweats. He had smoked cannabis up to twice monthly for years but completely quit when he joined the church. He denied using other illicit drugs except for one uneventful use of cocaine 3 years earlier. He slept well except occasional nights when he would sleep only a few hours in order to finish an academic assignment. Otherwise, Mr. Coleman denied depressive, manic, or psychotic symptoms and violent ideation. He denied posttraumatic stress disorder (PTSD) symptoms. A physical examination of the patient, including a neurological screen, was unremarkable, as were routine laboratory testing, a blood alcohol level, and urine toxicology. A noncontrast head computed tomography (CT) scan was normal.

criteria A: fear/anxiety of 2+ situations: - open spaces (e.g. reading in park) - leaving home alone criteria B: avoided situations since escaping difficult and embarrassed that as a 15yr old she will develop symptoms and can't leave house criteria C: situations almost always provoke fear Criteria D: situations are avoided by not leaving the house criteria E: the fear is out of proportion to actual danger posed by e.g. talking to neighbours

which Agoraphobia symptoms? Nadine was a 15-year-old girl whose mother brought her for a psychiatric evaluation to help with her long-standing shyness. Although Nadine was initially reluctant to say much about herself, she said she felt constantly tense. She added that the anxiety had been "really bad" for several years and was often accompanied by episodes of dizziness and crying. She was generally unable to speak in any situation outside of her home or school classes. She refused to leave her house alone for fear of being forced to interact with someone. She was especially anxious around other teenagers, but she had also become "too nervous" to speak to adult neighbors she had known for years. She said it felt impossible to walk into a restaurant and order from "a stranger at the counter" for fear of being humiliated. She also felt constantly on her guard, needing to avoid the possibility of getting attacked, a strategy that really only worked when she was alone in her home. Nadine tried to conceal her crippling anxiety from her parents, typically telling them that she "just didn't feel like" going out. Feeling trapped and incompetent, Nadine said she contemplated suicide "all the time." Nadine had always been "shy" and had been teased at recess since she started kindergarten. The teasing had escalated to outright bullying by the time she was in seventh grade. For 2 years, day after difficult day, Nadine's peers turned on her "like a snarling wolf pack," calling her "stupid," "ugly," and "crazy." Not infrequently, one of them would stare at her and tell her she would be better off committing suicide. One girl (the ringleader, as well as a former elementary school chum) hit Nadine on one occasion, giving her a black eye. Nadine did not fight back. This event was witnessed by an adult neighbor, who told Nadine's mother. When Nadine's mother asked her about the incident, Nadine denied it, saying she had "fallen" on the street. She did, however, mention to her mother "in passing" that she wanted to switch schools, but her delivery was so offhand that at the time, her mother casually advised against the switch. Nadine suffered on, sobbing herself to sleep most nights. Full of hope, Nadine transferred to a specialty arts high school for ninth grade. Although the bullying ceased, her anxiety symptoms worsened. She felt even more unable to venture into public spaces and felt increasingly embarrassed by her inability to develop the sort of independence typical of a 15-year-old. She said she had begun to spend whole weekends "trapped" in her home and had become scared to even read by herself in the local park. She had nightly nightmares about the bullies in her old school. Her preoccupation with suicide grew. Her parents had thought she would outgrow being shy and sought psychiatric help for her only after a teacher remarked that her anxiety and social isolation were keeping her from making the sort of grades and doing the sort of extracurricular activities that were necessary to get into a good college. Nadine described her mother as loud, excitable, aggressive, and "a little frightening." Her father was a successful tax attorney who worked long hours. Nadine described him as shy in social situations ("He's more like me"). Nadine said she and her father sometimes joked that the goal of the evening was to avoid tipping the mother into a rage. Nadine added that she "never wanted to be anything like her mother."

Criteria A: anxiety about multiple social situations (e.g. being around teenagers/adults/neighbours, etc.) fear being exposed to possible scrutiny Criteria B: In new school, fears showing anxiety will be negatively evaluated Criteria C: Social situations almost always provoke anxiety Criteria D: Social situations avoided (doesn't go out) with fear of embarrassment Criteria E: Fear is out of proportion to actual threat posed by the situations

which Social anxiety Disorder symptoms? Nadine was a 15-year-old girl whose mother brought her for a psychiatric evaluation to help with her long-standing shyness. Although Nadine was initially reluctant to say much about herself, she said she felt constantly tense. She added that the anxiety had been "really bad" for several years and was often accompanied by episodes of dizziness and crying. She was generally unable to speak in any situation outside of her home or school classes. She refused to leave her house alone for fear of being forced to interact with someone. She was especially anxious around other teenagers, but she had also become "too nervous" to speak to adult neighbors she had known for years. She said it felt impossible to walk into a restaurant and order from "a stranger at the counter" for fear of being humiliated. She also felt constantly on her guard, needing to avoid the possibility of getting attacked, a strategy that really only worked when she was alone in her home. Nadine tried to conceal her crippling anxiety from her parents, typically telling them that she "just didn't feel like" going out. Feeling trapped and incompetent, Nadine said she contemplated suicide "all the time." Nadine had always been "shy" and had been teased at recess since she started kindergarten. The teasing had escalated to outright bullying by the time she was in seventh grade. For 2 years, day after difficult day, Nadine's peers turned on her "like a snarling wolf pack," calling her "stupid," "ugly," and "crazy." Not infrequently, one of them would stare at her and tell her she would be better off committing suicide. One girl (the ringleader, as well as a former elementary school chum) hit Nadine on one occasion, giving her a black eye. Nadine did not fight back. This event was witnessed by an adult neighbor, who told Nadine's mother. When Nadine's mother asked her about the incident, Nadine denied it, saying she had "fallen" on the street. She did, however, mention to her mother "in passing" that she wanted to switch schools, but her delivery was so offhand that at the time, her mother casually advised against the switch. Nadine suffered on, sobbing herself to sleep most nights. Full of hope, Nadine transferred to a specialty arts high school for ninth grade. Although the bullying ceased, her anxiety symptoms worsened. She felt even more unable to venture into public spaces and felt increasingly embarrassed by her inability to develop the sort of independence typical of a 15-year-old. She said she had begun to spend whole weekends "trapped" in her home and had become scared to even read by herself in the local park. She had nightly nightmares about the bullies in her old school. Her preoccupation with suicide grew. Her parents had thought she would outgrow being shy and sought psychiatric help for her only after a teacher remarked that her anxiety and social isolation were keeping her from making the sort of grades and doing the sort of extracurricular activities that were necessary to get into a good college. Nadine described her mother as loud, excitable, aggressive, and "a little frightening." Her father was a successful tax attorney who worked long hours. Nadine described him as shy in social situations ("He's more like me"). Nadine said she and her father sometimes joked that the goal of the evening was to avoid tipping the mother into a rage. Nadine added that she "never wanted to be anything like her mother."

- Duration definitely 2+ weeks, with absence of the depressive mood episode at some point during the lifetime (several weeks of delusions/hallucinations without mood epsiode) - Delusions: he murdered 6 people - Hallucinations: auditory hallucinations saying he was guilty and he will be punished - symptoms of depression there for majority of total duration and concurrent with psychotic symptoms, emerging after periods of delusion and hallucinations and feature overwhelming guilt, prominent anhedonia, poor sleep, and occasional bursts of irritability. He can become suicidal when psychosis and depression reach peak intensity.

which symptoms? John Evans was a 25-year-old single, unemployed white man who had been seeing a psychiatrist for several years for management of psychosis, depression, anxiety, and abuse of marijuana and alcohol. fter an apparently normal childhood, Mr. Evans began to show dysphoric mood, anhedonia, low energy, and social isolation by age 15. At about the same time, Mr. Evans began to drink alcohol and smoke marijuana every day. In addition, he developed recurrent panic attacks, marked by a sudden onset of palpitations, diaphoresis, and thoughts that he was going to die. When he was at his most depressed and panicky, he twice received a combination of sertraline 100 mg/day and psychotherapy. In both cases, his most intense depressive symptoms lifted within a few weeks, and he discontinued the sertraline after a few months. Between episodes of severe depression, he was generally seen as sad, irritable, and amotivated. Around age 20, Mr. Evans developed a psychotic episode in which he had the conviction that he had murdered people when he was 6 years old. Although he could not remember who these people were or the circumstances, he was absolutely convinced that this had happened, something that was confirmed by continuous voices accusing him of being a murderer. He also became convinced that other people would punish him for what had happened, and thus he feared for his life. Over the ensuing few weeks, he became guilt-ridden and preoccupied with the idea that he should kill himself by slashing his wrists, which culminated in his being psychiatrically hospitalized. Although his affect on admission was anxious, within a couple of days he also became very depressed, with prominent anhedonia, poor sleep, and decreased appetite and concentration. With the combined use of antipsychotic and antidepressant medications, both the depression and the psychotic symptoms remitted after 4 weeks. Thus, the total duration of the psychotic episode was approximately 7 weeks, 4 of which were also characterized by major depression. He was hospitalized with the same pattern of symptoms two additional times before age 22, each of which started with several weeks of delusions and hallucinations related to his conviction that he had murdered someone when he was a child, followed by severe depression lasting an additional month. Both relapses occurred while he was apparently adherent to reasonable dosages of antipsychotic and antidepressant medications. During the 3 years prior to this evaluation, Mr. Evans had been adherent to clozapine and had been without hallucinations and delusions.

Schizophrenia Spectrum and other psychotic disorders: Schizoaffective disorder, depressive type

which diagnosis? John Evans was a 25-year-old single, unemployed white man who had been seeing a psychiatrist for several years for management of psychosis, depression, anxiety, and abuse of marijuana and alcohol. fter an apparently normal childhood, Mr. Evans began to show dysphoric mood, anhedonia, low energy, and social isolation by age 15. At about the same time, Mr. Evans began to drink alcohol and smoke marijuana every day. In addition, he developed recurrent panic attacks, marked by a sudden onset of palpitations, diaphoresis, and thoughts that he was going to die. When he was at his most depressed and panicky, he twice received a combination of sertraline 100 mg/day and psychotherapy. In both cases, his most intense depressive symptoms lifted within a few weeks, and he discontinued the sertraline after a few months. Between episodes of severe depression, he was generally seen as sad, irritable, and amotivated. Around age 20, Mr. Evans developed a psychotic episode in which he had the conviction that he had murdered people when he was 6 years old. Although he could not remember who these people were or the circumstances, he was absolutely convinced that this had happened, something that was confirmed by continuous voices accusing him of being a murderer. He also became convinced that other people would punish him for what had happened, and thus he feared for his life. Over the ensuing few weeks, he became guilt-ridden and preoccupied with the idea that he should kill himself by slashing his wrists, which culminated in his being psychiatrically hospitalized. Although his affect on admission was anxious, within a couple of days he also became very depressed, with prominent anhedonia, poor sleep, and decreased appetite and concentration. With the combined use of antipsychotic and antidepressant medications, both the depression and the psychotic symptoms remitted after 4 weeks. Thus, the total duration of the psychotic episode was approximately 7 weeks, 4 of which were also characterized by major depression. He was hospitalized with the same pattern of symptoms two additional times before age 22, each of which started with several weeks of delusions and hallucinations related to his conviction that he had murdered someone when he was a child, followed by severe depression lasting an additional month. Both relapses occurred while he was apparently adherent to reasonable dosages of antipsychotic and antidepressant medications. During the 3 years prior to this evaluation, Mr. Evans had been adherent to clozapine and had been without hallucinations and delusions.

Feeding and eating disorders: Bulimia Nervosa

which diagnosis? Wanda Hoffman was a 24-year-old white woman who presented with a chief complaint: "I have problems throwing up." These symptoms had their roots in early adolescence, when she began dieting despite a normal BMI. At age 18 she went away to college and began to overeat in the context of new academic and social demands. A 10-pound weight gain led her to routinely skip breakfast. She often skipped lunch as well, but then—famished—would overeat in the late afternoon and evening. The overeating episodes intensified, in both frequency and volume of food, and Ms. Hoffman increasingly felt out of control. Worried that the binges would lead to weight gain, she started inducing vomiting, a practice she learned about in a magazine. She first thought this pattern of behavior to be quite acceptable and saw self-induced vomiting as a way of controlling her fears about weight gain. The pattern became entrenched: morning food restriction followed by binge eating followed by self-induced vomiting. Ms. Hoffman continued to function adequately in college and to maintain friendships, always keeping her behavior a secret from those around her. After college graduation, she returned to her hometown and took a job at a local bank. Despite renewing old friendships and dating and enjoying her work, she often did not feel well. She described diminished energy and poor sleep, as well as various abdominal complaints, including, at different times, constipation and diarrhea. She frequently made excuses to avoid friends, and she became progressively more socially isolated. Her mood deteriorated, and she found herself feeling worthless. At times, she wished she were dead. She decided to break out of this downward spiral by getting a psychiatric referral from her internist. On mental status examination, the patient was a well-developed, well-nourished female, in no apparent distress. Her BMI was normal at 23. She was coherent, cooperative, and goal directed. She often felt sad and worried but denied feeling depressed. She denied an intention to kill herself but did sometimes think life was not worth living. She denied confusion. Her cognition was intact, and her insight and judgment were considered fair.

Obsessive compulsive and related disorders: Obsessive compulsive disorder

which diagnosis? When asked about anxiety, Mr. King said he was worried about contracting diseases such as HIV. Aware of an unusually strong disinfectant smell, the interviewer asked Mr. King if he had any particular cleaning behaviors related to the HIV concern. Mr. King paused and clarified that he avoided touching practically anything outside of his home. When further encouraged, Mr. King said that if he even came close to things that he considered potentially contaminated, he had to wash his hands incessantly with household bleach. On average, he washed his hands up to 30 times a day, spending hours on this routine. Physical contact was particularly difficult. Shopping for groceries and taking public transportation were a big problem, and he had almost given up trying to socialize or engage in romantic relationships. When asked if he had other worries, Mr. King said that he had intrusive images of hitting someone, fears that he would say things that might be offensive or inaccurate, and concerns about disturbing his neighbors. To counteract the anxiety produced by these images and thoughts, he constantly replayed prior conversations in his mind, kept diaries to record what he said, and often apologized for fear he might have sounded offensive. When he showered, he made sure that the water in the tub only reached a certain level for fear that if he were not attentive, he would flood his neighbors. He used gloves at work and performed well. He had no medical problems. He spent most of his free time at home. Although he enjoyed the company of others, the fear of having to touch something if he was invited to a meal or to another person's home was too much for him to handle. The examination revealed a casually dressed man who smelled strongly of bleach. He was worried and constricted but cooperative, coherent, and goal directed. He denied hallucinations and other strongly held ideas. He denied a current intention to hurt himself or others. He was cognitively intact. He recognized that his fears and urges were "kinda crazy," but he felt they were out of his control.

Disruptive, Impulse-Control, and Conduct Disorders: Conduct disorder,

which diagnosis? Kyle was a 12-year-old boy who reluctantly agreed to admission to a psychiatric unit after getting arrested for breaking into a grocery store. His mother said she was "exhausted," adding that it was hard to raise a boy who "doesn't know the rules." Beginning as a young child, Kyle was unusually aggressive, bullying other children and taking their things. When confronted by his mother, stepfather, or a teacher, he had long tended to curse, punch, and show no concern for possible punishment. Disruptive, impulsive, and "fidgety," Kyle was diagnosed with attention-deficit/hyperactivity disorder (ADHD) and placed in a special education program by second grade. He began to see a psychiatrist in fourth grade for weekly psychotherapy and medications (quetiapine and dexmethylphenidate). He was adherent only sporadically with both the medication and the therapy. When asked, he said his psychiatrist was "stupid." During the year prior to the admission, he had been caught stealing from school lockers (a cell phone, a jacket, a laptop computer), disciplined after "mugging" a classmate for his wallet, and suspended after multiple physical fights with classmates. He had been arrested twice for these behaviors. His mother and teachers agreed that although he could be charming to strangers, people quickly caught on to the fact that he was a "con artist." Kyle was consistently unremorseful, externalizing of blame, and uninterested in the feelings of others. He was disorganized, was inattentive and uninterested in instructions, and constantly lost his possessions. He generally did not do his homework, and when he did, his performance was erratic. When confronted about his poor performance, he tended to say, "And what are you going to do, shoot me?" Kyle, his mother, and his teachers agreed that he was a loner and not well liked by his peers. Kyle lived with his mother, stepfather, and two younger half-siblings. His stepfather was unemployed, and his mother worked part-time as a cashier in a grocery store. His biological father was in prison for drug possession. Both biological grandfathers had a history of alcohol dependence. Kyle's early history was normal. The pregnancy was uneventful, and he reached all of his milestones on time. There was no history of sexual or physical abuse. Kyle had no known medical problems, alcohol or substance abuse, or participation in gang activities. He had not been caught with weapons, had not set fires, and had not been seen as particularly cruel to other children or animals. He had been regularly truant from school but had neither run away nor stayed away from home until late at night. When interviewed on the psychiatric unit, Kyle was casually groomed and appeared his stated age of 12. He was fidgety and made sporadic eye contact with the interviewer. He said he was "mad" and insisted he would rather be in jail than on a psychiatric unit. His speech was loud but coherent, goal directed, and of normal rate. His affect was irritable and angry. He denied suicidal or homicidal ideation. He denied psychotic symptoms. He denied feeling depressed. He had no obvious cognitive deficits but declined more formal testing. His insight was limited, and his judgment was poor by history.

Anxiety disorders: - Social anxiety disorder (social phobia), severe - Agoraphobia, severe (and Posttraumatic stress disorder, moderate)

which diagnosis? Nadine was a 15-year-old girl whose mother brought her for a psychiatric evaluation to help with her long-standing shyness. Although Nadine was initially reluctant to say much about herself, she said she felt constantly tense. She added that the anxiety had been "really bad" for several years and was often accompanied by episodes of dizziness and crying. She was generally unable to speak in any situation outside of her home or school classes. She refused to leave her house alone for fear of being forced to interact with someone. She was especially anxious around other teenagers, but she had also become "too nervous" to speak to adult neighbors she had known for years. She said it felt impossible to walk into a restaurant and order from "a stranger at the counter" for fear of being humiliated. She also felt constantly on her guard, needing to avoid the possibility of getting attacked, a strategy that really only worked when she was alone in her home. Nadine tried to conceal her crippling anxiety from her parents, typically telling them that she "just didn't feel like" going out. Feeling trapped and incompetent, Nadine said she contemplated suicide "all the time." Nadine had always been "shy" and had been teased at recess since she started kindergarten. The teasing had escalated to outright bullying by the time she was in seventh grade. For 2 years, day after difficult day, Nadine's peers turned on her "like a snarling wolf pack," calling her "stupid," "ugly," and "crazy." Not infrequently, one of them would stare at her and tell her she would be better off committing suicide. One girl (the ringleader, as well as a former elementary school chum) hit Nadine on one occasion, giving her a black eye. Nadine did not fight back. This event was witnessed by an adult neighbor, who told Nadine's mother. When Nadine's mother asked her about the incident, Nadine denied it, saying she had "fallen" on the street. She did, however, mention to her mother "in passing" that she wanted to switch schools, but her delivery was so offhand that at the time, her mother casually advised against the switch. Nadine suffered on, sobbing herself to sleep most nights. Full of hope, Nadine transferred to a specialty arts high school for ninth grade. Although the bullying ceased, her anxiety symptoms worsened. She felt even more unable to venture into public spaces and felt increasingly embarrassed by her inability to develop the sort of independence typical of a 15-year-old. She said she had begun to spend whole weekends "trapped" in her home and had become scared to even read by herself in the local park. She had nightly nightmares about the bullies in her old school. Her preoccupation with suicide grew. Her parents had thought she would outgrow being shy and sought psychiatric help for her only after a teacher remarked that her anxiety and social isolation were keeping her from making the sort of grades and doing the sort of extracurricular activities that were necessary to get into a good college. Nadine described her mother as loud, excitable, aggressive, and "a little frightening." Her father was a successful tax attorney who worked long hours. Nadine described him as shy in social situations ("He's more like me"). Nadine said she and her father sometimes joked that the goal of the evening was to avoid tipping the mother into a rage. Nadine added that she "never wanted to be anything like her mother."

Anxiety disorders: - Specific phobia, situational (flying on airplanes) - Specific phobia, animals

which diagnosis? Olaf Hendricks, a 51-year-old businessman, presented to an outpatient psychiatrist complaining of his inability to travel by plane. His only daughter had just delivered a baby, and although he desperately wanted to meet his first granddaughter, he felt unable to fly across the Atlantic Ocean to where his daughter lived. The patient's anxiety about flying had begun 3 years earlier when he was on a plane that landed in the middle of an ice storm. He had last flown 2 years earlier, reporting that he had cried on takeoff and landing. He had gone with his wife to an airport one additional time, 1 year prior to the evaluation, to fly to his daughter's wedding. Despite having drunk a significant amount of alcohol, Mr. Hendricks had panicked and refused to board the airplane. After that failed effort, he tended to feel intense anxiety when he even considered the possibility of flying, and the anxiety had led him to decline a promotion at work and an external job offer because both would have involved business trips. When specifically asked, he reported that as a child, he had been "petrified" that he might get attacked by a wild animal. This fear had led him to refuse to go on family camping trips or even on long hikes in the country. As an adult, he said that he had no worries about being attacked by wild animals because he lived in a large city and took vacations by train to other large urban areas.

Anxiety disorders: Generalised anxiety disorder

which diagnosis? Peggy Isaac was a 41-year-old administrative assistant who was referred for an outpatient evaluation by her primary care physician with a chief complaint of "I'm always on edge." She lived alone and had never married or had children. She had never before seen a psychiatrist. Ms. Isaac had lived with her longtime boyfriend until 8 months earlier, at which time he had abruptly ended the relationship to date a younger woman. Soon thereafter, Ms. Isaac began to agonize about routine tasks and the possibility of making mistakes at work. She felt uncharacteristically tense and fatigued. She had difficulty focusing. She also started to worry excessively about money and, to economize, she moved into a cheaper apartment in a less desirable neighborhood. She repeatedly sought reassurance from her office mates and her mother. No one seemed able to help, and she worried about being "too much of a burden." During the 3 months prior to the evaluation, Ms. Isaac began to avoid going out at night, fearing that something bad would happen and she would be unable to summon help. More recently, she avoided going out in the daytime as well. She also felt "exposed and vulnerable" walking to the grocery store three blocks away, so she avoided shopping. After describing that she had figured out how to get her food delivered, she added, "It's ridiculous. I honestly feel something terrible is going to happen in one of the aisles and no one will help me, so I won't even go in." When in her apartment, she could often relax and enjoy a good book or movie. Ms. Isaac said she had "always been a little nervous." Through much of kindergarten, she had cried inconsolably when her mother tried to drop her off. She reported seeing a counselor at age 10, during her parents' divorce, because "my mother thought I was too clingy." She added that she had never liked being alone, having had boyfriends constantly (occasionally overlapping) since age 16. She explained, "I hated being single, and I was always pretty, so I was never single for very long." Nevertheless, until the recent breakup, she said she had always thought of herself as "fine." She had been successful at work, jogged daily, maintained a solid network of friends, and had "no real complaints.

Criteria A: A repetitive and persistent pattern of behaviour in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the following: - often bullies others - initiates physical fights (punches and fights others) - stolen whilst confronting victim (mugging) - often lies to others to obtain good/avoid obligations - broken into someone elses property (breaking into grocery store) - stolen items of nontrivial value (wallet classmate, stealing from lockers) - often truant from school duration: present past 12+ months, with at least 1+ (breaking in to grocery store) in last 6 months. Note: His earlier behavior warranted a diagnosis of DSM-5 oppositional defiant disorder (ODD), which is characterized by a pattern of negative, hostile, and defiant behaviors that are usually directed at an authority figure (e.g., parent or teacher) and may cause significant distress in social or academic settings. However, ODD cannot be diagnosed if CD is present.

which symptoms? Kyle was a 12-year-old boy who reluctantly agreed to admission to a psychiatric unit after getting arrested for breaking into a grocery store. His mother said she was "exhausted," adding that it was hard to raise a boy who "doesn't know the rules." Beginning as a young child, Kyle was unusually aggressive, bullying other children and taking their things. When confronted by his mother, stepfather, or a teacher, he had long tended to curse, punch, and show no concern for possible punishment. Disruptive, impulsive, and "fidgety," Kyle was diagnosed with attention-deficit/hyperactivity disorder (ADHD) and placed in a special education program by second grade. He began to see a psychiatrist in fourth grade for weekly psychotherapy and medications (quetiapine and dexmethylphenidate). He was adherent only sporadically with both the medication and the therapy. When asked, he said his psychiatrist was "stupid." During the year prior to the admission, he had been caught stealing from school lockers (a cell phone, a jacket, a laptop computer), disciplined after "mugging" a classmate for his wallet, and suspended after multiple physical fights with classmates. He had been arrested twice for these behaviors. His mother and teachers agreed that although he could be charming to strangers, people quickly caught on to the fact that he was a "con artist." Kyle was consistently unremorseful, externalizing of blame, and uninterested in the feelings of others. He was disorganized, was inattentive and uninterested in instructions, and constantly lost his possessions. He generally did not do his homework, and when he did, his performance was erratic. When confronted about his poor performance, he tended to say, "And what are you going to do, shoot me?" Kyle, his mother, and his teachers agreed that he was a loner and not well liked by his peers. Kyle lived with his mother, stepfather, and two younger half-siblings. His stepfather was unemployed, and his mother worked part-time as a cashier in a grocery store. His biological father was in prison for drug possession. Both biological grandfathers had a history of alcohol dependence. Kyle's early history was normal. The pregnancy was uneventful, and he reached all of his milestones on time. There was no history of sexual or physical abuse. Kyle had no known medical problems, alcohol or substance abuse, or participation in gang activities. He had not been caught with weapons, had not set fires, and had not been seen as particularly cruel to other children or animals. He had been regularly truant from school but had neither run away nor stayed away from home until late at night. When interviewed on the psychiatric unit, Kyle was casually groomed and appeared his stated age of 12. He was fidgety and made sporadic eye contact with the interviewer. He said he was "mad" and insisted he would rather be in jail than on a psychiatric unit. His speech was loud but coherent, goal directed, and of normal rate. His affect was irritable and angry. He denied suicidal or homicidal ideation. He denied psychotic symptoms. He denied feeling depressed. He had no obvious cognitive deficits but declined more formal testing. His insight was limited, and his judgment was poor by history.

criteria A: fear/anxiety about flying criteria B: flying provokes instant fear (crying rakeoff and landing) Criterion C: Flying is avoided or endured with intense fear (didn't go to wedding nor took promotions with possibility of flying for trips) Criterion D: the fear/anxiety is out of proportion with actual danger of flying and the sociocultural beliefs about flying

which symptoms? Olaf Hendricks, a 51-year-old businessman, presented to an outpatient psychiatrist complaining of his inability to travel by plane. His only daughter had just delivered a baby, and although he desperately wanted to meet his first granddaughter, he felt unable to fly across the Atlantic Ocean to where his daughter lived. The patient's anxiety about flying had begun 3 years earlier when he was on a plane that landed in the middle of an ice storm. He had last flown 2 years earlier, reporting that he had cried on takeoff and landing. He had gone with his wife to an airport one additional time, 1 year prior to the evaluation, to fly to his daughter's wedding. Despite having drunk a significant amount of alcohol, Mr. Hendricks had panicked and refused to board the airplane. After that failed effort, he tended to feel intense anxiety when he even considered the possibility of flying, and the anxiety had led him to decline a promotion at work and an external job offer because both would have involved business trips. When specifically asked, he reported that as a child, he had been "petrified" that he might get attacked by a wild animal. This fear had led him to refuse to go on family camping trips or even on long hikes in the country. As an adult, he said that he had no worries about being attacked by wild animals because he lived in a large city and took vacations by train to other large urban areas.

criteria A: excessive worry/anxiety about leaving the apartment and entering supermarket (but not agrophobia since less than 6+ month requirement), Criteria B; difficult controlling worry Criterion C: 3+ of the following: - easily fatigued - restlessness/on edge (e.g. think will be attacked in alley) -Muscle tension

which symptoms? Peggy Isaac was a 41-year-old administrative assistant who was referred for an outpatient evaluation by her primary care physician with a chief complaint of "I'm always on edge." She lived alone and had never married or had children. She had never before seen a psychiatrist. Ms. Isaac had lived with her longtime boyfriend until 8 months earlier, at which time he had abruptly ended the relationship to date a younger woman. Soon thereafter, Ms. Isaac began to agonize about routine tasks and the possibility of making mistakes at work. She felt uncharacteristically tense and fatigued. She had difficulty focusing. She also started to worry excessively about money and, to economize, she moved into a cheaper apartment in a less desirable neighborhood. She repeatedly sought reassurance from her office mates and her mother. No one seemed able to help, and she worried about being "too much of a burden." During the 3 months prior to the evaluation, Ms. Isaac began to avoid going out at night, fearing that something bad would happen and she would be unable to summon help. More recently, she avoided going out in the daytime as well. She also felt "exposed and vulnerable" walking to the grocery store three blocks away, so she avoided shopping. After describing that she had figured out how to get her food delivered, she added, "It's ridiculous. I honestly feel something terrible is going to happen in one of the aisles and no one will help me, so I won't even go in." When in her apartment, she could often relax and enjoy a good book or movie. Ms. Isaac said she had "always been a little nervous." Through much of kindergarten, she had cried inconsolably when her mother tried to drop her off. She reported seeing a counselor at age 10, during her parents' divorce, because "my mother thought I was too clingy." She added that she had never liked being alone, having had boyfriends constantly (occasionally overlapping) since age 16. She explained, "I hated being single, and I was always pretty, so I was never single for very long." Nevertheless, until the recent breakup, she said she had always thought of herself as "fine." She had been successful at work, jogged daily, maintained a solid network of friends, and had "no real complaints.

Criteria A: - obsessions: fear of contamination (HIV), agression (hitting someone), scrupulosity (fear of sounding agressive/inaccurate), and symmetry - compulsion: excessive washing of hands with bleach, checking (keeping diaries), repeating (clarifying what he said repeatedly), and mental compulsion (replaying conversation in his head) Criteria B: its very time consuming

which symptoms? When asked about anxiety, Mr. King said he was worried about contracting diseases such as HIV. Aware of an unusually strong disinfectant smell, the interviewer asked Mr. King if he had any particular cleaning behaviors related to the HIV concern. Mr. King paused and clarified that he avoided touching practically anything outside of his home. When further encouraged, Mr. King said that if he even came close to things that he considered potentially contaminated, he had to wash his hands incessantly with household bleach. On average, he washed his hands up to 30 times a day, spending hours on this routine. Physical contact was particularly difficult. Shopping for groceries and taking public transportation were a big problem, and he had almost given up trying to socialize or engage in romantic relationships. When asked if he had other worries, Mr. King said that he had intrusive images of hitting someone, fears that he would say things that might be offensive or inaccurate, and concerns about disturbing his neighbors. To counteract the anxiety produced by these images and thoughts, he constantly replayed prior conversations in his mind, kept diaries to record what he said, and often apologized for fear he might have sounded offensive. When he showered, he made sure that the water in the tub only reached a certain level for fear that if he were not attentive, he would flood his neighbors. He used gloves at work and performed well. He had no medical problems. He spent most of his free time at home. Although he enjoyed the company of others, the fear of having to touch something if he was invited to a meal or to another person's home was too much for him to handle. The examination revealed a casually dressed man who smelled strongly of bleach. He was worried and constricted but cooperative, coherent, and goal directed. He denied hallucinations and other strongly held ideas. He denied a current intention to hurt himself or others. He was cognitively intact. He recognized that his fears and urges were "kinda crazy," but he felt they were out of his control.