Psychosocial Pathology - Case Studies

Acute Stress Disorder

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 and half weeks earlier. On the day of the accident, Dylan was riding in the front passenger seat when he was struck by an oncoming SUV. The rolled over once and then came to rest right-side up. The collision of metal on metal made an extremely loud noise. The driver of the car, a 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. All three were transported to a local emergency room, where they were attended to. At release from the hospital, Dylan had a broken arm and bruises on his back and shoulder. 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. He stopped showing up to school every day and was running the risk of not passing his finals. 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. He reported feeling embarrassed and disappointed in himself for being reluctant to practice driving. He stated that about 5 years earlier, he had witnessed the near-drowning of one of his younger sisters. Also, he mentioned that this past month was the first anniversary of his grandfather's death.

Post Traumatic Stress Disorder

Eric a 45-year-old married man who referred himself to the Veterans Affairs outpatient mental health clinic for a chief complaint of having "a short fuse" and "relationship issues." Eric was in a combat zone while serving in Operation Iraqi Freedom (OIF). After 8 years' service Eric was discharged from the Army 6 years ago but only just sought treatment with the clinic 1 year ago. Mr. Reynolds has been in treatment off and on for several decades. He first received treatment about 20 years ago when he was mandated for anger management services. He assaulted a stranger on the bus after the stranger bumped him on the crowded bus. At the time he reported "feeling angry all the time" and often "fighting in relationships. Sometimes I think I just push them away first so I do not have to deal with them leaving me." He often reported getting into fights "it is always their fault. They provoke me and I just go zero to 60." He said he would fight because it is all he has ever known since he was a kid. "when I was a kid I would get into fights with other kids on the playground. They would tease me and say 'I was a shrimp, I was dirty and I smelled bad.'" Several years later Eric was in treatment again. This time he reported, "never being able to get a good night's sleep and severe anxiety." Eric reported he was always worried about "being assaulted or someone getting him." He could rarely get a full nights sleep because he was restless, having nightmares and would often wake up in cold sweats. At the time of treatment he could not identify what triggered these behaviors. After meeting with his Clinician for about a year he was finally able to talk more outside of his symptoms of anger and anxiety. As far as he could remember he was angry and "relationships always seemed to end because I am no good." He was seeking support now because his wife was reporting their "marriage was at stake if Eric did not get help to manage his emotions." Mr. Reynolds's symptoms included uncontrollable rage when unexpectedly startled. He could not sit in a restaurant with his back to the entrance. When he was in crowded spaces his anxiety would heighten and he would be constantly looking over his shoulder and on alert at all times. He would "snap on anyone without control of himself or what was happening." 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. Eric stated he also still wakes up in the middle of the night. He stated he has nightmares of past events in his life. "Sometimes it is my father and he has a machine gun and he is killing everyone while I stand there and watch people dying without being able to help. The only thing I am left with is the dead and the wounded screaming for help. I cannot speak or move. Sometimes I do not sleep at all or I am afraid to sleep because I do not know what will happen. I sleep on the couch and my wife and I stopped being intimate." "I cannot walk down the street without looking around. I am constantly on edge. My brain just cannot turn off. It does not help I have tinnitus and the ringing in my ears just won't stop. I am always in operation mode. Thoughts of my life just come flooding at me without warning. Or I will be walking and get a smell of burnt rubber. I am reminded of the bodies I would smell when I was in Iraq." Eric was not working at this time and his wife and kids would leave for the day Eric would spend most of his time alone except for going to the VA for appointments. He no longer participates in activities he liked such as playing baseball with his son. He was constantly distracted and his wife reported, "I am talking to him and I don't even know if he is listening. Is he even with me? It's like his body is but his mind is somewhere else constantly. Then when you call his name I have to yell and when I do he snaps back at me." Mr. Reynolds had difficulty talking about his childhood. He diverted the conversation often and reported "it was what it was." At times when he did mention things, he made little eye contact, difficulty formulating his thoughts and pressured speech. At age 31, Mr. Reynolds felt he needed to serve his country and enlisted, not long after he was sent to Iraq. He described himself as having been a jokester and the one to always make people laugh but after deployment things just got really bad. He said he enjoyed basic training and his first few weeks in Iraq, until one of his comrades was killed. At that point, all he cared about was getting his best friend and himself home alive. His personality changed, he said, from that of a jokester to a terrified, overprotective soldier. Something he just could not shake, even after being out. Upon returning to civilian life, he worked as a self-employed plumber for a while and then had to stop working altogether. He had a legal history but something he identified as "the past." He had married to his wife for 15 years and was a father. Although he stated their relationship has had its up and downs as well. His face lit up when talking about his kids and their accomplishments, "I am a proud father." Mr. Reynolds had tried marijuana during his early adulthood and used excessive alcohol intermittently; however, he had not consumed excessive alcohol or used marijuana during the past decade. On examination, Mr. Reynolds was a well-groomed African American man who appeared anxious and somewhat protective. 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, often having little affect even when describing disturbing events. 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.

Schizophrenia (F20.9)

Felicia Allen was a 45-year-old woman brought to the emergency room (ER) by police after she apparently tried to steal a bus as a result 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 due to a laceration from the crash. 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.More information was elicited from a psychiatrist who had come to the ER soon after the accident. He said that Ms. Allen and her friend were longtime residents at the state psychiatric hospital where he worked. They had just begun to take passes every week as part of an effort toward social remediation; it had been Ms. Allen's first bus ride without a staff member.According to the psychiatrist, Ms. Allen started hearing voices by age 25. Big, strong, intrusive, and psychotic, she had been hospitalized almost constantly since age 30. 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 said that he was not sure what had caused her to pull out the knife. She had not been hallucinating lately and had been feeling less paranoid, but he wondered if she had been experiencing more psychotic symptoms than she expressed. It was possible that she was just anxious and irritated. The psychiatrist also believed that she had spent almost no period of life developing typically and so had very little experience with the "real world."Ms. Allen had been taking Haldol for 1 year, with good resolution of her auditory hallucinations. She had gained 35 pounds during that time, but she had less trouble getting out of bed in the morning, was hoping that she could eventually get a job and live more independently, and had insisted on continuing to take the Haldol. She also experienced frequent urination in the middle of the night and had swollen ankles. The bus trip to the shopping mall was intended to be a step in that direction.

Paranoid Personality Disorder (F.60)

Frazier is a 34-year-old single man living in a group home for people needing support with daily living and functioning. He has been living in this group home for the past 15 years and prior to that spent several years on a locked inpatient unit. Incident upon admission was a physical altercation with his then girlfriend that escalated quickly when he believed she was cheating on him. Although records note mental health diagnosis it is unclear if they are accurate. Frazier has medical health complications with COPD and obesity. Frazier is at his weekly meeting with his mental health clinician and describing to him some of what has been going on for him this last week. Frazier reports regular, almost daily situations in which he is sure he is being "lied to or deceived." He reports that house staff are not being "straight with me, they are manipulating me to make me believe they are poor and have no money. They want me to give them money, I know they do." When questioned more about this Frazier could not provide concrete examples he continued to say "I just know they want to see me without, I know they are lying to me. You cannot trust a single person in that house." "I will tell you something, when I first moved here Sally would look at her phone when I walked by, I know she was recording things about me. One time she refused to give me a ride for an errand. I knew from then on she could not be trusted. One day I came for meds and she just stopped coming to work. I still think about her and how she was out to get me." In session Frazier would often complain about the staff and other tenants in the house. He reported when he is in a good mood or to avoid certain staff talking to him for long periods of time he "would smile and nod and keep it moving," but he did not identify with any friends in the house. His relationships often were minimal and without substance. When asked, if Frazier thought his own behavior contributed to any of the stress, he quickly became defensive and felt his clinician was on the house's side. He would shut down and end the session or he would get very loud, yelling at the clinician in defense of his behaviors. At around age 22 Frazier reports things in his life started to turn against him. During this time he was fired from his job as a Postman for becoming verbally aggressive with his boss. He had held numerous jobs over the years, but he was quick to add, "I've quit as often as I've been fired." During the interview, he defended his behavior, asserting that unlike many people, he understood the value of quality over productivity. Mr. Archer's wariness had contributed to his "bad temper" and emotional "ups and downs." He socialized only "superficially" with a handful of acquaintances and could recall the exact moments when previous "so-called friends and lovers" had betrayed him. He spent most of his time alone. Mr. Archer denied any significant history or current problems with substance use, and any history of head trauma or loss of consciousness. He did not report any voices, or other hallucinations, he was always orientated times 3 (person, place, time). It was difficult for the clinician to know more because Frazier was often protective of his information believing it would be used against him. His tone also changed significantly when he discussed situations that had made him angry, and many of his responses were lengthy, digressive, and vague. However, he seemed generally coherent and did not evidence perceptual disorder. His affect was occasionally inappropriate (e.g., smiling while crying) but generally constricted. He reported apathy as to whether he lived or died but did not report any active suicidal ideation or homicidal ideation.

Schizoid Personality Disorder (F60.1)

Grzegorz "Greg" is an 87-year-old man who was brought to the psychiatric emergency room (ER) by paramedics after they had been called to his apartment by neighbors when they noticed an odd smell. Apparently, his 90-year-old sister had died some days earlier after a lengthy illness. Greg delayed reporting her death for several reasons. He had become increasingly disorganized as his sister's health worsened, and he was worried that his landlord would use the apartment's condition as a pretext for eviction. He tried to clean up, but his attempts consisted mainly of moving items from one place to another. He said he was about to call for help when the police and paramedics showed up. When being evaluated in the ER Greg reported asthma and a lesion on his right arm. In the ER, Greg recognized that his actions were odd and that he should have called for help sooner. At times, he became tearful when discussing the situation and his sister's death; at other times, he seemed aloof, speaking about these in a calm, factual way. He also wanted to clarify that his apartment had indeed been a mess but that much of the apparent mess was actually his large collection of articles on bioluminescence, a topic he had been researching for decades. A licensed plumber, electrician, and locksmith, Greg worked until age 65. He described his late sister as having been always "a little strange." She had never worked and had been married once, briefly. Aside from the several-month marriage, she and Greg lived in the family's two-bedroom Manhattan apartment their entire lives. Neither of them had ever seen a psychiatrist. When questioned, Greg stated that he had never had a romantic or sexual relationship and had never had many friends or social contacts outside his family. He explained that he had been poor and Polish and had had to work all the time. He had taken night classes to better understand "the strange world we live in," and he said his intellectual interests were what he found most gratifying. He said he had been upset as he realized that his sister was dying, but he would call it "numb" rather than depressed. He also denied any history of manic or psychotic symptoms. After an hour with the psychiatric trainee, Greg confided that he hoped the medical school might be interested in some of his papers after his death. He said he believed that bioluminescent and genetic technologies were on the verge of a breakthrough that might allow the skin of animals and then humans to glow in subtle colors that would allow people to more directly recognize emotions. He had written the notes for such technology, but they had grown into a "way-too-long science fiction novel with lots of footnotes." On examination, Greg was a thin, elderly man dressed neatly in khakis and a button-down shirt. He was meticulous and much preferred to discuss his interests in science than his own story. He made appropriate eye contact and had a polite, pleasant demeanor. His speech was coherent and goal-directed. His mood was "fine," and his affect was appropriate though perhaps unusually cheerful under the circumstances. He denied all symptoms of psychosis, depression, and mania. Aside from his comments about bioluminescence, he said nothing that presented as delusional. He was cognitively intact, and his insight and judgment were considered generally good, although historically impaired in regard to his delay in calling the police about his sister.

Avoidant Personality Disorder

Harriet was a 23-year-old woman referred for psychiatric consultation to help her "break out of her shell." She had recently moved to a new city to take classes to become an industrial lab technician and had moved in with an older cousin, who was also a psychotherapist and thought she should "get out and enjoy her youth." Although she had previously been prescribed medications for anxiety and blood pressure, Ms. Herbert said that her real problem was "shyness." School was difficult because everyone was constantly "criticizing." She avoided being called on in class because she knew she would "say something stupid" and blush and everyone would make fun of her. She avoided speaking up or talking on telephones, worried about how she would sound. She dreaded public speaking. She was similarly reticent with friends. She said she had always been a people pleaser who preferred to hide her feelings with a cheerful, compliant, attentive demeanor. She had a few friends, whom she described as "warm and lifelong." She felt lonely after her recent move and had not yet met anyone from school or the local community. She said she had broken up with her first serious boyfriend 2 years earlier. He had initially been "kind and patient" and, through him, she had a social life by proxy. Soon after she moved in with him, however, he turned out to be an "angry alcoholic." She had not dated since that experience. Ms. Herbert grew up in a metropolitan area with her parents and three older siblings. Her brother was "hyperactive and antisocial" and took up everyone's attention, whereas her sisters were "hypercompetitive and perfect." Her mother was anxiously compliant, "like me." Ms. Herbert's father was a very successful investment manager who often pointed out ways in which his children did not live up to his expectations. He could be supportive but tended to disregard emotional uncertainty in favor of a "tough optimism." Teasing and competition "saturated" the household, and "it didn't help that I was forced to go to the same girls' school where my sisters had been stars and where everyone was rich and catty." She developed a keen sensitivity to criticism and failure. Her parents divorced during her senior year of high school. Her father married another woman soon thereafter. Although she had planned to attend the same elite university as her two sisters, she chose to attend a local community college at the last minute. She explained that it was good to be away from all the competition, and her mother needed the support. Ms. Herbert's strengths included excellent work in her major, chemistry, especially after one senior professor took a special interest. Family camping trips had led to a mastery of outdoor skills, and she found that she enjoyed being out in the woods, flexing her independence. She also enjoyed babysitting and volunteering in animal shelters, because kids and animals "appreciate everything you do and aren't mean." During the evaluation, Ms. Herbert was a well-dressed young woman of short stature who was attentive, coherent, and goal directed. She smiled a lot, especially when talking about things that would have made most people angry. When the psychiatrist offered a trial comment, linking Ms. Herbert's current anxiety to experiences with her father, the patient appeared quietly upset. After several such instances, the psychiatrist worried that any interpretive comments might be taken as criticism and had to check a tendency to avoid sensitive subjects. Explicitly discussing his concerns led both the patient and psychiatrist to relax and allowed the conversation to continue more productively.

Schizotypal Personality Disorder

Henry, a 19-year-old college sophomore, was referred to the student health center by a teaching assistant who noticed that he appeared "odd, worried, preoccupied and that his lab notebook was filled with bizarrely threatening drawings." Henry appeared on time for the psychiatric consultation. Although suspicious about the reason for the referral, he explained that he generally "followed orders" and would do what he was asked. He agreed that he had been suspicious of some of his classmates, believing they were undermining his abilities. He said they were telling his instructors that he was "a weird guy" and that they did not want him as a lab partner. The referral to the psychiatrist was, he said, confirmation of his perception. Henry described how he had seen two students "flip a coin" over whether he was gay or straight. Coins, he asserted, could often predict the future. He had once flipped a coin and "heads" had predicted his mother's illness. He believed his thoughts often came true. Henry had transferred to this out-of-town university after an initial year at his local community college. The transfer was his parents' idea, he said, and was part of their agenda to get him to be like everyone else and go to parties and hang out with girls. He said all such behavior was a waste of time. Although they had tried to push him into moving into the dorms, he had refused, and instead lived by himself in an off-campus apartment. With Henry's permission, his mother was called for collateral information. She said Henry had been quiet, shy, and reserved since childhood. He had never had close friends, had never dated, and had denied wanting to have friends. He acknowledged feeling depressed and anxious at times, but these feelings did not improve when he was around other people. He was teased by other kids and would come home upset. His mother cried while explaining that she always felt bad for him because he never really "fit in," and that she and her husband had tried to coach him for years without success. She wondered how a person could function without any social life. She also noted that Henry had a heart murmur since a young age. She added that ghosts, telepathy, and witchcraft had fascinated Henry since junior high school. He had long thought that he could change the outcome of events like earthquakes and hurricanes by thinking about them. He had consistently denied substance abuse, and two drug screens had been negative in the prior 2 years. She mentioned that her grandfather had died in an "insane asylum" many years before Henry was born, but she did not know his diagnosis. On examination, Henry was tall, thin, and dressed in jeans and a T-shirt. He was alert and wary and, although nonspontaneous, he answered questions directly. He denied feeling depressed or confused. Henry denied having any suicidal thoughts, plans, or attempts. He denied having any auditory or visual hallucinations, panic attacks, obsessions, compulsions, or phobias. His intellectual skills seemed above average, and his Mini-Mental State Examination score was 30 out of 30.

Antisocial Personality Disorder

Ike Crocker is a 32-year-old man referred for a mental health evaluation by the human resources department of a large construction business that had been his employer for 2 weeks. At his initial job interview, Mr. Crocker presented as very motivated and provided two carpentry school certifications that indicated a high level of skill and training. Since his employment began, his supervisors had noted frequent arguments, absenteeism, poor workmanship, and multiple errors that might have been dangerous. When confronted, he was reportedly dismissive, indicating that the problem was "cheap wood" and "bad management" and added that if someone got hurt, "it's because of their own stupidity." When the head of human resources met with him to discuss termination, Mr. Crocker quickly pointed out that he had both attention-deficit/hyperactivity disorder (ADHD) and bipolar disorder. He said that if not granted an accommodation under the Americans with Disabilities Act, he would sue. He demanded a psychiatric evaluation. During the mental health evaluation, Mr. Crocker focused on unfairness at the company and on how he was "a hell of a better carpenter than anyone there could ever be." He claimed that his two marriages had ended because of jealousy. He said that his wives were "always thinking I was with other women," which is why "they both lied to judges and got restraining orders saying I'd hit them." As "payback for the jail time," he refused to pay child support for his twochildren. He had no interest in seeing either of his two boys because they were "little liars" like their mothers. Mr. Crocker said he "must have been smart" because he had been able to make Cs in school despite showing up only half the time. He spent time in juvenile hall at age 14 for stealing "kid stuff, like tennis shoes and wallets that were practically empty." He left school at age 15 after being "framed for stealing a car" by his principal. Mr. Crocker pointed out these historical facts as evidence that he was able to overcome injustice and adversity. In regard to substance use, Mr. Crocker said he smoked marijuana as a teenager and started drinking alcohol on a "regular basis" after he first got married at age 22. He denied that use of either substance was a problem. Although he did mention that one time he fell while drinking and hit his head. When he woke up he had a broken arm. Since the accident he has had pain in his elbow and tendentious. Mr. Crocker concluded the interview by demanding a note from the examiner that he had "bipolar" and "ADHD." He said that he was "bipolar" because he had "ups and downs" and got "mad real fast." Mr. Crocker denied other symptoms of mania. He said he got down when disappointed, but he had "a short memory" and "could get out of a funk pretty quick." Mr. Crocker reported no difficulties in his sleep, mood, or appetite. He learned about ADHD because "both of my boys got it." He concluded the interview with a request for medications, adding that the only ones that worked were stimulants ("any of them") and a specific short- acting benzodiazepine. Mr. Crocker presented casually dressed white man who made reasonable eye contact and was without abnormal movements. His speech was linear, coherent, goal directed, and of normal rate. There was no evidence of any thought disorder or hallucinations. He was preoccupied with blaming others, but these comments appeared to represent overvalued ideas rather than delusions. He was cognitively intact. His insight into his situation was poor. The head of human resources did a background check during the course of the psychiatric evaluation. Phone calls revealed that Mr. Crocker had been expelled from two carpentry training programs and that both his graduation certificates had been falsified. He had been fired from his job at one local construction company after a fistfight with his supervisor and from another job after abruptly leaving a job site. A quick review of their records indicated that he had provided them with the same false documentation.

Schizoaffective disorder, depressive type (F25.1) Alcohol use disorder, moderate, in remission (F10.20) Marijuana use disorder, mild in remission (F12.10)

John Evans was a 25-year-old single, unemployed white man who had been seeing a psychiatrist for several years for medication management of mental health concerns. After an apparently typical 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 unmotivated. His school performance declined around tenth grade and remained marginal through the rest of high school. He did not attend college as his parents had expected him to, but instead lived at home and did odd jobs in the neighborhood.Around age 20, Mr. Evans experienced 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. He had also been adherent to his antidepressant medication and supportive psychotherapy, although his dysphoria, irritability, and amotivation never completely resolved.Mr. Evans's history was significant for marijuana and alcohol use that began at age 15. Before the onset of psychosis at age 20, he smoked several joints of marijuana almost daily and binge drank on weekends, with occasional blackouts. After the onset of the psychosis, he decreased his marijuana and alcohol use significantly, with two several-month-long periods of abstinence, yet he continued to have psychotic episodes up through age 22. He started attending Alcoholics Anonymous and Narcotics Anonymous groups, achieved sobriety from marijuana and alcohol at age 23, and had remained sober for 2 years. In addition he experienced some medical concerns including diabetes and high blood pressure.

Obsessive Compulsive Personality Disorder

Judd and his boyfriend, Peter Kleinman, presented for couples therapy to address escalating conflict around the issue of moving in together. Mr. Kleinman described a several-month-long apartment search that was made "agonizing" by Judd's rigid work schedule and his "endless" list of apartment demands. They were unable to come to a decision, and eventually they decided to just share Judd's apartment. As Mr. Kleinman concluded, "Judd won." Judd refused to hire movers for his boyfriend's belongings, insisting on personally packing and taking an inventory of every item in his boyfriend's place. What should have taken 2 days took 1 week. Once the items were transported to Judd's apartment, Mr. Kleinman began to complain about Judd's "crazy rules" about where items could be placed on the bookshelf, which direction the hangers in the closet faced, and whether their clothes could be intermingled. Moreover, Mr. Kleinman complained that there was hardly any space for his possessions because Judd never threw anything away. "I'm terrified of losing something important," added Judd. Over the ensuing weeks, arguments broke out nightly as they unpacked boxes and settled in. Making matters worse, Judd would often come home after 9:00 or 10:00 p.m., because he had a personal rule to always have a blank "to-do" list by the end of the day. Mr. Kleinman would often wake early in the morning to find Mr. Judd grimly organizing shelves or closets or sorting books alphabetically by author. Throughout this process, Judd appeared to be working hard at everything while enjoying himself less and getting less done. Mr. Kleinman found himself feeling increasingly detached from his boyfriend the longer they lived together. Judd denied symptoms of depression and free-floating anxiety. He said that he had never experimented with cigarettes or alcohol, adding, "I wouldn't want to feel like I was out of control." He denied a family history of mental illness. He was raised in a two-parent household and was an above average high school and college student. He was an only child and first shared a room as a college freshman. He described that experience as being difficult due to "conflicting styles—he was a mess and I knew that things should be kept neat." He had moved mid-year into a single dorm room and had not lived with anyone until Mr. Kleinman moved in. Judd was well liked by his boss, earning recognition as "employee of the month" three times in 2 years. Feedback from colleagues and subordinates was less enthusiastic, indicating that he was overly rigid, perfectionistic, and critical. On examination, Judd was a thin man with eyeglasses and gelled hair, sitting on a couch next to his boyfriend. He was meticulously dressed. He was cooperative with the interview and sat quietly while his boyfriend spoke, interrupting on a few occasions to contradict. His speech was normal in rate and tone. His affect was irritable. There was no evidence of depression. He denied specific phobias and did not think he had ever experienced a panic attack. At the end of the consultation, Judd remarked, "I know I'm difficult, but I really do want this to work out."

Histrionic Personality Disorder

Karmen Fuentes was a 50-year-old married Hispanic woman who presented to the psychiatric emergency room (ER) at the urging of her outpatient psychiatrist after telling him that she had been thinking about overdosing on Advil. In the ER, Ms. Fuentes explained that her back had been "killing" her since she fell several days earlier at the family-owned grocery store where she had worked for many years. The fall had left her downcast and depressed, although she denied other depressive symptoms aside from a poor mood. She spoke at length about the fall and about how it reminded her of a fall that she had sustained a few years earlier. At that time, she had gone to see a neurosurgeon, who told her to rest and take nonsteroidal anti-inflammatory drugs. She described feeling "abandoned and not cared about" by him. The pain had diminished her ability to exercise, and she was upset that she had gained weight. While relating the events surrounding the fall, Ms. Fuentes began to cry. When asked about her suicidal comments, she said they were "no big deal." She reported that they were "just a threat" aimed at her husband to "teach him a lesson" because "he has no compassion for me" and had not been supportive since the fall. She insisted her comments about overdosing did not have other meaning. When her ER interviewer expressed concern about the possibility that she would kill herself, she exclaimed with a smile, "Oh wow, I didn't realize it's so serious. I guess I shouldn't do that again." She then shrugged and laughed. She went on to talk about how "nice and sweet" it was that so many doctors and social workers wanted to hear her story, calling many of them by their first names. She was also somewhat flirtatious with her male resident interviewer, who had mentioned that she was the "best- dressed woman in the ER." According to her outpatient psychiatrist of 3 years, she had never before expressed suicidal ideation until this week, and he would be unable to check in on her until after he left on vacation the next day. Ms. Fuentes's husband reported that she talked about suicide "like other people complain about the weather. She's just trying to get me worried, but it doesn't work anymore." He said he would never have suggested she go to the ER and thought the psychiatrist had overreacted. Ms. Fuentes initially sought outpatient psychotherapy at age 47 because she was feeling depressed and unsupported by her husband. During 3 years of outpatient treatment, Ms. Fuentes had been prescribed adequate trials of sertraline, escitalopram, fluoxetine, and paroxetine. None seemed to help. Ms. Fuentes described being "an early bloomer." She became sexually active with older men when she was in high school. She said dating had been the most fun thing she had ever done and that she missed seeing men "jump through hoops" to sleep with her. She lived with her 73- year-old husband. Her 25-year-old son lived nearby with his wife and young son. She described her husband as a "very famous" musician. She said that he had never helped around the house or with child-rearing and did not appreciate how much work she put into taking care of their son and grandson.

Narcissistic Personality Disorder

Larry Goranov was a 57-year-old single unemployed white man who was asking for a review of his treatment at the psychiatric clinic. He had been in weekly psychotherapy for 7 years with a diagnosis of dysthymic disorder. He complained that the treatment had been of little help and he wanted to make sure that the doctors were on the right track. Mr. Goranov reported a long-standing history of low-grade depressed mood and decreased energy. He had to "drag" himself out of bed every morning and rarely looked forward to anything. He had lost his last job 3 years earlier, had broken up with a girlfriend slightly later, and doubted that he would ever work or date again. He was embarrassed that he still lived with his mother, who was in her 80s. He denied any immediate intention or plan to kill himself, but if he did not improve by the time his mother died, he did not see what he would have to live for. He denied disturbances in sleep, appetite, or concentration. Clinic records indicated that Mr. Goranov had been adherent to adequate trials of fluoxetine, escitalopram, sertraline, duloxetine, venlafaxine, and bupropion, as well as augmentation with quetiapine, aripiprazole, lithium, and levothyroxine. He had some improvement in his mood while taking escitalopram but did not have remission of symptoms. He also had a course of cognitive-behavioral therapy early in his treatment; he had been dismissive of the therapist and treatment, did not do his assigned homework, and appeared to make no effort to use the therapy between sessions. He had never tried psychodynamic psychotherapy. Mr. Goranov expressed frustration at his lack of improvement, the nature of his treatment, and his specific therapy. He found it "humiliating" that he was forced to see trainees who rotated off his case every year or two. He frequently found that the psychiatry residents were not especially educated, cultured, or sophisticated, and felt they knew less about psychotherapy than he did. He much preferred to work with female therapists, because men were "too competitive and envious." Mr. Goranov previously worked as an insurance broker. He explained, "It's ridiculous. I was the best broker they had ever seen, but they won't rehire me. I think the problem is that the profession is filled with big egos, and I can't keep my mouth shut about it." After being "blackballed" by insurance agencies, Mr. Goranov did not work for 5 years, until he was hired by an automobile dealer. He said that although it was beneath him to sell cars, he was successful, and "in no time, I was running the place." He quit within a few months after an argument with the owner. Despite encouragement from several therapists, Mr. Goranov had not applied for a job or pursued employment rehabilitation or volunteer work; he strongly viewed these options as beneath him. Mr. Goranov has "given up on women." He had many partners as a younger man, but he generally found them to be unappreciative and "only in it for the free meals." The psychiatric resident notes indicated that he responded to demonstrations of interest with suspicion. This tendency held true in regard to both women who had tried to befriend him and residents who had taken an interest in his care. Mr. Goranov described himself as someone who had a lot of love to give, but said that the world was full of manipulators. He said he had a few buddies, but his mother was the only one he truly cared about. He enjoyed fine restaurants and "five-star hotels," but he added that he could no longer afford them. He exercised daily and was concerned about maintaining his body. Most of his time was spent at home watching television or reading novels and biographies. On examination, the patient was neatly groomed, had slicked-back hair, and wore clothing that appeared to be by a hip-hop designer generally favored by men in their 20s. He was coherent, goal directed, and generally cooperative. He said he was sad and angry. His affect was constricted and dismissive. He denied an intention to kill himself but felt hopeless and thought of death fairly often. He was cognitively intact.

Alcohol use disorder Severe (F10.20) Alcohol-induced depressive disorder, moderate (F10.24)

Matthew Tucker, a 45-year-old plumber, was referred for a psychiatric evaluation after his family did anintervention to express their concern that his alcohol problems were getting out of hand. Mr. Tucker deniedhaving 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 thelast 7 years, he had consumed alcohol almost daily, with an average of 6 beers on weeknights and 12 beers onweekends and holidays. His wife repeatedly voiced her concern that he was "drinking too much," but despitehis 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 remainedproductive at work, however, and never called in sick. In many ways, his history represents what is likely to beseen in the "typical alcoholic." Mr. Tucker had achieved two month-long periods of abstinence in the prior 4years. Both times, he said he had gone "cold turkey" in response to his wife's concerns. He denied having hadsymptoms 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 difficultyconcentrating. He also reacted more emotionally to stresses and expressed unsubstantiated concern aboutthe 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 hadexperienced several similar episodes in the prior 5 years, lasting 4-6 weeks each. denied any suchepisodes 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 highschool graduate with 2 years of community college who currently owned a successful plumbing company. Thepatient denied any other history of psychiatric or medical problems, as well as any history of mania or suicideattempts. He had never seen a psychiatrist before.At a recent annual checkup, Mr. Tucker's internist noted a mildly elevated blood pressure (135/92), aγ-glutamyltransferase value of 47 IU/L, and a mean corpuscular volume of 92.5μm3.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 noevidence of confusion or psychotic symptoms. His eyes teared up when he talked about the future, and headmitted to feeling sad for most or all of the day on a regular basis for the last 6 months, but he deniedsuicidal ideation or plans. His cognition was intact, and he demonstrated an understanding of the effects thatthe alcohol was having on him.A physical examination by the psychiatrist revealed a normal pulse rate, no tremor or sweating, and only aslightly elevated blood pressure.

Dependent Personality Disorder

Nate Irvin was a 31-year-old white man who sought outpatient psychiatric services for "lack of self-confidence." He reported lifelong troubles with assertiveness and was specifically upset by having been "stuck" for 2 years at his current "dead-end" job as an administrative assistant. He wished someone would tell him where to go next so that he would not have to face the "burden" of decision. At work, he found it easy to follow his boss's directions but had difficulty making even minor independent decisions. The situation was "depressing," he said, but nothing new. Mr. Irvin also reported dissatisfaction with his relationships with women. He described a series of several-month-long relationships over the prior 10 years that ended despite his doing "everything I could." His most recent relationship had been with an opera singer. He reported having gone to several operas and taken singing classes to impress her, even though he did not particularly enjoy music. That relationship had recently ended for unclear reasons. He said his mood and self-confidence were tied to his dating. Being single made him feel desperate, but desperation made it even harder to get a girlfriend. He said he felt trapped by that spiral. Since the latest breakup, he had been quite sad, with frequent crying spells. It was this depression that had prompted him to seek treatment. He denied all other symptoms of depression, including problems with sleep, appetite, energy, suicidality, and ability to enjoy things. Mr. Irvin initially denied taking any medications, but he eventually revealed that 1 year earlier his primary care physician had begun to prescribe alprazolam 0.5 mg/day for "anxiety." In addition he was drinking ensures daily to increase weight gain as he was underweight. Mr. Irvin denied any prior personal or family psychiatric history, including outpatient psychiatric appointments.

Alcohol withdrawal (F10.239) Alcohol use disorder Severe (F10.20)

Nicholas Underwood, a 41-year-old software engineer, entered an alcohol treatment program with this chiefcomplaint: "I need to stop drinking or my wife will divorce me." At the time of admission, Mr. Underwoodstated that he was drinking approximately 1 liter of vodka per day, every day, and had not had an alcohol-freeday in over 2 years. For many years, Mr. Underwood had drunk alcohol only after work, but about a year priorto the evaluation he had begun to routinely drink in the morning whenever he had the day off. More recently,he had begun to feel "shaky" every morning and would sometimes treat that sensation with a drink, followedby more alcohol during the day.Mr. Underwood experienced a number of problems related to drinking. His wife was "at the end of her rope"and considering divorce. His diminished ability to concentrate at work was "sinking" his once-promisingcareer. He was spending more time trying to recover from the effects of drinking and found himself bothplanning strategies both for abstinence and for surreptitiously taking his next drink.Mr. Underwood first tried alcohol in high school and said that he had always been able to hold his liquor morethan his friends could. In college, he was one of the heaviest drinkers in a fraternity known as "Animal House"around campus. Through his 30s, he gradually increased the frequency of his drinking from primarily onweekends to daily. Over the prior year, he had switched from being exclusively a beer drinker to drinkingvodka. He had gone to many Alcoholics Anonymous meetings over the years but tended to drink as soon asthe meeting ended. He had received no formal treatment.The patient denied recent use of other substances; he had smoked marijuana and snorted cocaine several times during college but never since. He had used no other illicit drugs and took no medications. He did notsmoke cigarettes. He had experienced blackouts on several occasions during college but not since then. Hehad no history of seizures and no other medical problems. Family history was significant for alcoholdependence in his father and paternal grandfather.Mr. Underwood entered the alcohol treatment program at approximately 3:00 p.m., having not had a drinksince the evening before. He was diaphoretic and exhibited significant tremulousness in his hands. Hecomplained of anxiety, restlessness, irritability, nausea, and recent insomnia.Clinical evaluation revealed a casually groomed, diaphoretic man who was cooperative but anxiously pacingand who immediately said, "I'm getting ready to jump out of my skin." Speech was of normal rate, rhythm,and tone. He denied depression. There was no evidence of psychotic thinking, and he denied auditory, visual,or tactile hallucinations. He was alert and oriented to person, place, and date. He had no gross memorydeficits, but his attention and concentration were noted to be reduced.Notable features of his physical examination were marked diaphoresis, a blood pressure of 155/95, a heartrate of 104 beats/minute, severe tremulousness in his upper extremities, and hyperactive deep tendonreflexes throughout. Laboratory tests were within normal limits except for aspartate aminotransferase andalanine aminotransferase, which were approximately 3 times normal.

Traumatic Brain Injury, moderate

Only upon the repeated and fervent insistence of her parents did 19-year-old Emily reluctantly agree to see a psychiatrist. "It's not me you want to see," Emily proclaimed emphatically. "It's my insane parents who need your help." Emily did not offer a chief complaint, aside from the concern that her parents were driving her "crazy." She added, "Everything is going great in my life. I have plenty of friends, go out almost every night, and always have lots of fun." While Emily was taking some time away from "the so-called real world," her sister was attending Duke University, her younger brother was excelling at a competitive private high school, and both her parents seemed to enjoy their careers as radiologists. She asked, "Don't you think that's enough strivers for one family?" Emily agreed to have her parents join the session, and they told a different story. They tearfully disclosed that their daughter had become irritable, unproductive, and oppositional. She drank to intoxication almost every night, often not returning home for an entire weekend. In searching her room, they had found small amounts of marijuana, alprazolam (Xanax), cocaine, and prescription stimulants. The parents described the changes in Emily's personality as "an adolescent nightmare" and described her friends as "losers who do nothing but dye their hair, get tattoos, and hate everything." Emily's attitudes and behavior contrasted markedly with those of her parents and siblings. "We don't mind that she is doing her own thing and that she isn't conservative like the rest of us," her father said, "but it's like we don't even recognize who she's become." According to her parents, Emily's "adolescent nightmare" began 4 years earlier. She had apparently been a studious 15-year-old girl with a lively sense of humor and a wide circle of "terrific friends." "Almost overnight," she began to shun her longtime friends in favor of "dropouts and malcontents" and began to accumulate traffic tickets and school detentions. Instead of her former bright-eyed curiosity, Emily manifested a lack of interest in all her academic subjects, and her grades dropped from As to Ds. The parents were at an absolute loss to explain the sudden and dramatic change. The abrupt change in performance led the psychiatrist to ask Emily to take a battery of neuropsychological tests so the results could be compared with those of tests that she had taken when she had applied to a private high school several years earlier. In particular, Emily retook two high school admissions tests: the System for Assessment and Group Evaluation (SAGE), which measures a broad array of academic and perceptual aptitudes, and the Differential Aptitude Tests (DAT), which focus on reasoning, spelling, and perceptual skills. On the SAGE, her average percentile scores dropped from the upper 10% for a 13-year-old to the bottom 10% for an adult (and the bottom 20% for a 13-year-old). When Emily took the DAT at age 13, she scored in the highest range for ninth graders across almost all measures. Her worst result had been in spelling, where she scored at the second-highest level. Upon repeating the test at age 19, she scored below the high school average in all measures. EEG, brain CT, and T2-weighted brain MRI images did not show evidence of structural brain damage. However, fluid-attenuated inversion recovery (FLAIR) T2-weighted MRI displayed a clear lesion in the left frontal cortex, highly suggestive of previous injury to that region. Upon further questioning about the crucial period in which she seemed to have changed, Emily admitted to being in a traffic accident with her now ex-boyfriend, Mark. Although Emily did not recall much from this episode, she remembered that she hit her head and that she had bad headaches and still continues to do so but thought it was from the hangovers. Because Emily was not bleeding and there was no damage to the car, neither Mark nor Emily reported the incident to anyone. With Emily's permission, the psychiatrist contacted Mark, who was away at college but a willing and excellent historian. He remembered the incident well. "Emily hit her head very, very hard on the dashboard of my car. She was not totally unconscious but very dazed. For about 3 hours, she spoke very slowly, complained that her head hurt badly, and was confused. For about 2 hours she didn't know where she was, what day it was, and when she had to get home. She also threw up twice. I was really scared, but Emily didn't want me to worry her parents since they're so overprotective. And then she broke up with me, and we've hardly spoken since."

Opioid use disorder, severe (F11.20), Tobacco use disorder, mild (z72.0), Alcohol use disorder, mild, in sustained remission (F10.10), Major depressive disorder in partial remission (F32.5)

Peter Winters, a 46-year-old white minister, was referred to the psychiatry outpatient department by his primary care doctor for depressive symptoms and opioid misuse in the setting of chronic right knee pain.Mr. Winters injured his right knee playing basketball 17 months earlier. His mother gave him several tablets of hydrocodone-acetaminophen that she had for back pain, and he found this helpful. When he ran out of the pills and his pain persisted, he went to the emergency room. He was told he had a mild sprain. He was given a 1-month supply of hydrocodone-acetaminophen. He took the pills as prescribed for 1 month, and his pain resolved.After stopping the pills, however, Mr. Winters began to experience a recurrence of the pain in his knee. He saw an orthopedist, who ordered imaging studies and determined there was no structural damage. He was given another 1-month supply of hydrocodone-acetaminophen. This time, however, he needed to take more than prescribed in order to ease the pain. He also felt dysphoric and "achy" when he abstained from taking the medication, and described a "craving" for more opioids. He returned to the orthopedist, who referred him to a pain specialist.Mr. Winters was too embarrassed to go to the pain specialist, believing that his faith and strength should help him overcome the pain. He found it impossible to live without the pain medication, however, because of the pain, dysphoria, and muscle aches when he stopped the medication. He also began to "enjoy the high" and experienced intense craving. He began to frequent emergency rooms to receive more opioids, often lying about the timing and nature of his right knee pain, and even stole pills from his mother on two occasions. He became. He endorsed low mood, especially when contemplating the impact of opioids on his life, but denied any other mood or neurovegetative symptoms. Eventually, he told his primary care doctor about his opioid use and low mood, and that doctor referred him to the outpatient psychiatry clinic.Mr. Winters had a history of two lifetime major depressive episodes that were treated successfully with escitalopram by his primary care doctor. He also had a history of an alcohol use disorder when he was in his 20s. He managed to quit using alcohol on his own after a family intervention. He smoked two packs of cigarettes daily. His father suffered from depression, and "almost everyone" on his mother's side of the family had "issues with addiction." He had been married to his wife for 20 years, and they had two school-age children. He had been a minister in his church for 15 years. Results of a recent physical examination and laboratory testing performed by his primary care physician had been within normal limits.On mental status examination, Mr. Winters was cooperative and did not exhibit any psychomotor abnormalities. He answered most questions briefly, often simply saying "yes" or "no." Speech was of a normal rate and tone, without tangentiality or circumstantiality. He reported that his mood was "lousy," and his affect was dysphoric and constricted. He denied symptoms of paranoia or hallucinations. He denied any thoughts of harming himself or others. Memory, both recent and remote, was grossly intact.(Memory intact is a good indicator that the use of alcohol has not led to more severe brain damage.)

Borderline Personality Disorder

Terra, a single, unemployed Hispanic woman, sought therapy at age 33 for treatment of depressed mood, chronic suicidal thoughts and social isolation. All of this she recognized as impacting her personal hygiene. She had spent the prior 6 months isolated in her apartment, lying in bed, eating junk food, watching television, and doing more online shopping than she could afford. Multiple treatments had yielded little effect. Ms. Delgado is the middle of three children, in an upper-middle-class, immigrant family in which the father reportedly valued professional achievement over all else. She felt isolated throughout her school years and experienced recurrent periods of depressed mood. Within her family, she was known for "angry outbursts." She had done well academically in high school but dropped out of college because "of frustrations with a roommate and a professor." She attempted a series of internships and entry-level jobs with the expectation that she would return to college, but she kept quitting because "bosses are idiots. They come across as great and they all turn out to be twisted." These "traumas" always left her feeling terrible about herself ("I can't even succeed as a clerk?") and angry at her bosses ("I could run the place and probably will"). She had dated men when she was younger but never let them get close physically because she became too anxious when any intimacy began to develop. Ms. Delgado's history included cutting herself superficially on a number of occasions, along with persistent thoughts that she would be better off dead. She said that she was generally "down and depressed" she had difficulty identifying a trigger to her depression often blaming others for her depression. She quickly reported, "I have about a dozen of manias, they last about a day" in which she was energized and edgy. She tended to "crash and the next day and I sleep for 12 hours." She had been in psychiatric treatment since age 17 and had been psychiatrically hospitalized three times after overdoses. Treatments consisted primarily of medication: mood stabilizers, low-dose neuroleptics, and antidepressants that had been prescribed in various combinations in the context of supportive psychotherapy. She was currently taking medications to help with the rash on her arm and the swelling in her legs. When asked about how past therapy went she reported, "Well you know therapists are all nice in the beginning because they want you to just tell them everything but then something inevitably happens and they leave you behind." Her medical history During the interview, she was a casually groomed and somewhat unkempt woman who was cooperative, coherent, and goal directed. She was generally dysphoric with a constricted affect but did smile appropriately several times. She described shame at her poor performance but also believed she was "on Earth to do something great." She described her father as a spectacular success, but he was also a "Machiavellian loser who was always trying to manipulate people." She described quitting jobs because people were disrespectful. For example, she said that when she worked as a clerk at a department store, people would often be rude or unappreciative ("and I was there only in preparation to become a buyer; it was ridiculous"). Toward the end of the initial session, she became angry with the interviewer after he glanced at the clock "Are you bored already?". She said she knew people in the neighborhood, but most of them had "become frauds or losers." There were a few people from school who were "Facebook friends," doing amazing things all over the world. Although she had not seen them in years, she intended to "meet up with them if they ever come back to town."

Anorexia nervosa, restricting type (F50.01)

Valerie Gaspard was a 20-year-old single black woman who had recently immigrated to the United States from West Africa with her family to do missionary work. She presented to her primary care physician complaining of frequent headaches and chronic fatigue. Her physical examination was unremarkable except that her weight was only 78 pounds and her height was 5 feet 1 inch, resulting in a body mass index (BMI) of 14.7 kg/m2, and she had missed her last menstrual period. Unable to find a medical explanation for Ms. Gaspard's symptoms, and feeling concerned about her extremely low weight, the physician referred Ms. Gaspard to the hospital eating disorders program. Upon presentation for psychiatric evaluation, Ms. Gaspard was cooperative and pleasant. She expressed concern about her low weight and denied fear of weight gain or body image disturbance: "I know I need to gain weight. I'm too skinny," she said. Ms. Gaspard reported that she had weighed 97 pounds prior to moving to the United States and said she felt "embarrassed" when her family members and even strangers told her she had grown too thin. Notably, everyone else in her extended family was either of normal weight or overweight. Despite her apparent motivation to correct her malnutrition, Ms. Gaspard's dietary recall revealed that she was consuming only 600 calories per day. The day before the evaluation, for example, she had eaten only a small bowl of macaroni pasta, a plate of steamed broccoli, and a cup of black beans. Her fluid intake was also quite limited, typically consisting of only two or three glasses of water daily.Ms. Gaspard provided multiple reasons for her poor intake. The first was lack of appetite: "My brain doesn't even signal that I'm hungry," she said. "I have no desire to eat throughout the whole day." The second was postprandial bloating and nausea: "I just feel so uncomfortable after eating." The third was the limited choice of foods permitted by her religion, which advocates a vegetarian diet. "My body is not really my own. It is a temple of God," she explained. The fourth reason was that her preferred sources of vegetarian protein (e.g., tofu, processed meat substitutes) were not affordable within her meager budget. Ms. Gaspard had not completed high school and made very little money working at a secretarial job at her church.Ms. Gaspard denied any other symptoms of disordered eating, including binge eating, purging, or other behaviors intended to promote weight loss. However, with regard to exercise, she reported that she walked for approximately 3-4 hours per day. She denied that her activity was motivated by a desire to burn calories. Instead, Ms. Gaspard stated that because she did not have a car and disliked waiting for the bus, she traveled on foot to all work and leisure activities.Ms. Gaspard reported no other notable psychiatric symptoms apart from her inadequate food intake and excessive physical activity. She appeared euthymic and did not report any symptoms of depression. She denied using alcohol or illicit drugs. She noted that her concentration was poor but expressed hope that a herbal supplement she had just begun taking would improve her memory. When queried about past treatment history, she reported that she had briefly seen a dietitian about a year earlier when her family began "nagging" her about her low weight, but she had not viewed the meetings as helpful.

Bulimia nervosa (F50.2) Major depressive disorder, moderate (F32.1)

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.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.

Binge-eating disorder, mild ((F50.81) Major depressive disorder, recurrent, in remission (F33.41)

Yasmine Isherwood, a 55-year-old married woman, had been in psychiatric treatment for 6 months for an episode of major depression. She had responded well to a combination of psychotherapy and medications (fluoxetine and bupropion), but she began to complain of weight gain. She was at her "highest weight ever," which was 140 pounds (her height was 5 feet 5 inches, so her BMI was 23.3). The psychiatrist embarked on a clarification of Ms. Isherwood's eating history, which was marked by recurrent, distressing episodes of uncontrollable eating of large amounts of food. The overeating was not new but seemed to have worsened while she was taking antidepressants. She reported that the episodes occurred two or three times per week, usually between the time she arrived home from work and the time her husband did so. These "eating jags" were notable for a sense that "she was out of control." She ate rapidly and alone, until uncomfortably full, often resulting with severe pain in her abdomen. So much so she went to her PCP about the pain who noted she would need to have her gallbladder removed in the next few weeks. She would then feel depressed, tired, and disgusted with herself. She usually binged on healthy food but also had "sugar binges" where she ate primarily sweets, especially ice cream and candy. She denied current or past self-induced vomiting, fasting, or misuse of laxatives, diuretics, or weight-loss agents. She reported exercising for an hour almost every day but denied being "addicted" to it. She did report that in her late 20s, she had become a competitive runner. At that time, she had often run 10-kilometer races and averaged about 35 miles per week, despite a lingering foot injury that eventually forced her to shift to swimming, biking, and the elliptical machine. Ms. Isherwood stated that she had binged on food "for as long as I can remember." She was "chunky as a child but stayed at a normal weight throughout high school (120-125 pounds) because I was so active." She denied a history of anorexia nervosa. At age 28, she reached her lowest adult weight of 113 pounds. At that point, she felt "vital, healthy, and in control." In her mid-30s, she had a major depressive episode that lasted 2 years. She had a severely depressed mood, did not talk, "closed down, stayed in bed, was very fatigued, slept more than usual, and was unable to function." This was one of the few times in her life that the binge eating stopped and she lost weight. She denied a history of hypomanic or manic episodes. Although she lived with frequent sadness, she denied other serious depressive episodes until the past year. She denied a history of suicidal ideation, suicide attempts, and any significant use of alcohol, tobacco, or illicit substances. The evaluation revealed a well-nourished, well-developed female who was coherent and cooperative. Her speech was fluent and not pressured. She had a mildly depressed mood but had a reactive affect with appropriate smiles. She denied guilt, suicidality, and hopelessness. She said her energy was normal except for post-binge fatigue. She denied psychosis and confusion. Her cognition was normal. Her medical history was unremarkable, and physical examination and basic laboratory test results provided by her internist were within normal limits.

Cocaine use disorder, moderate (F14.20)

ndependently wealthy as the owner of several clothing franchises, lived with an ex-partner in a more-than-comfortable apartment in New York City, worked out every day, enjoyed the company of a group of loving friends, and, although single, had not given up on the idea of someday (preferably soon) finding the perfect man to share his life with. Mr. Vincent came out to his Irish Catholic family when he was 19. His parents had already guessed that Mr. Vincent was gay long before he told them, and they took the non-news fairly well. Their main concern had been that their son might be discriminated against because of his sexuality, get hurt, and live a lonely life. Nothing could be farther from the way things turned out: Mr. Vincent was "out and proud" and living it up.When Mr. Vincent found himself with a substance use problem, he addressed it the same way he had dealt with pretty much everything else: head on. For the first time in his life, he decided to see a psychiatrist.Mr. Vincent described a pattern that revolved around weekend "party and play" activities. On Friday and Saturday evenings—and occasionally during the week—he would go out to dinner with friends and then to a club or a private party. He tended to drink two or three cocktails and four to five glasses of wine during the evening. Without the alcohol, he found he could easily say "no" to substances, but "after a good buzz, if someone has coke—and there is always someone around who has coke—I use. And then my heart starts to race, and then I do everything I can to hook up. I used to go online, but these days, it's all on Grindr."Overall, Mr. Vincent drank alcohol and used cocaine three to four times a week and "occasionally used tina and bath salts." He could hardly attend Monday morning meetings, much less prepare for them, and had been trying to cut down on his cocaine use for the prior 6 months without success..Since Mr. Vincent had started using cocaine regularly, he had lost weight and had trouble sleeping. He worried that his effort at the gym was going to waste. His business continued to succeed, but his own effectiveness had decreased. Most importantly, he did not practice safer sex when high on stimulants, and contracted HIV.