Abnormal Psychology Midterm 1

Excoriation (Skin-Picking) Disorder

When asked what she would do if she could not find the "right" kind of hair to pull, she admitted that she would often pick at her skin or at a scab. The scab's coming off in just the right way led to a feeling of relief that was similar to that which she experienced when hair pulling. She would also sometimes chew and swallow her scabs. Ms. Oliver often picked at scabs on her back so that the lesions would not be easily visible to others.

Factitious Disorder

A hospital-based psychiatric consultation-liaison service was called to assess possible depression in Rebecca Ehrlich, a 24-year-old woman who had been hospitalized 2 days earlier for severe abdominal pain. She had been admitted through the emergency room for the latest flare-up of her underlying Crohn's disease.Ms. Ehrlich's endoscopy and colonoscopy results were normal. She spent much of the next day calling hospitals and physicians that met descriptions provided by the patient and her mother. That afternoon, one of the physicians called back and indicated that he had treated Ms. Ehrlich 6 months earlier at a hospital near her mother's home. That admission was strikingly similar: after a short hospitalization, she quickly fled from the hospital after a normal colonoscopy.

Disinhibted Social Engagement Disorder

Adriana was a 4½-year-old girl referred to an early childhood mental health clinic for evaluation of "dangerous behaviors." The parents were particularly concerned that Adriana maintained poor boundaries, was impulsive, and was too quick to trust strangers. Adriana had been adopted from an Eastern European orphanage at age 29 months. At the time of the adoption, Adriana's medical records were reviewed by a local pediatrician, who found no problems aside from growth parameters that were all below the 5th percentile. When the adoptive parents met her at the orphanage, Adriana approached without shyness and visited easily with them. The parents had been pleasantly reassured by the child's happy demeanor and her spontaneous, warm hugs.

Acute Stress Disorder (symptoms last less than a month)

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. 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.

Post-traumatic stress disorder

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.

Depersonalization/derealization disorder

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.

Panic Disorder

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

Somatic Symptom Disorder

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. 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.

Dissociative Amnesia

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."

Obsessive-Compulsive Disorder

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.

Trichotillomania (Hair-Pulling Disorder)

Ms. Oliver's hair pulling most often took place as a ritual when she returned home from work. She would search for hairs of a particular texture from the crown of her head (though she also pulled from her eyebrows, eyelashes, and pubic region). She felt intense relief if the hair came out with its root. She would then typically bite off the root of the hair and swallow the rest of the hair. She had never experienced any gastrointestinal symptoms after hair swallowing. She said the hair pulling had begun at age 12, and she had never known anyone with similar behaviors.

Agoraphobia

Nadine 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." 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.

Social Anxiety Disorder (Social Phobia)

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.

Specific Phobia (situational)

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.

Illness Anxiety Disorder

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 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.

Conversion Disorder

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.

Generalized Anxiety Disorder (GAD)

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."

Hoarding Disorder

The clinician noted that Ms. Nichols's purse was filled with bills and other papers. When asked, the patient initially shrugged it off, indicating that she "carried around my office." When the interviewer inquired further, it emerged that Ms. Nichols had had difficulty discarding important business papers, newspapers, and magazines for as long as she could remember. She felt that it all started when her mother got rid of her old toys when she was age 12. Now, many years later, Ms. Nichols's apartment had become filled with books, stationery, crafts, plastic packages, cardboard boxes, and all sorts of other things.

Body Dismorphic Disorder (BDD)

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