Case Study - Psychodiagnostics And Mental Disorder Treatment
Lydia is a divorced 63-year-old Caucasian female whose local surgeon referred her to the mental health clinic. For the past 8 years, Lydia has visited plastic surgeons across the country to find one who will perform surgery to reduce the size of her hands, which she perceives as "too fat." Until she has this surgery, she will not leave her house without wearing gloves. The plastic surgeon con- curs with Lydia's family members and friends that Lydia's perception of her hands is distorted and that plastic surgery would be inappropriate and irresponsible.
Body Dysmorphic Disorder
Anastasia is a single 28-year-old Caucasian heterosex- ual woman. She works as an account executive, and at the office her co-workers view her as intensely moody and unpredictable. On some days she is pleasant and high spirited, but on other days she exhibits uncontrolla- ble anger. People are often struck by her inconsistent attitudes toward her supervisors. She may boast about the brilliance of a supervisor one day, only to deliver a burning criticism the next. Her co-workers keep their distance from her because they have become annoyed with her constant demands for attention. Anastasia has also gained a reputation in the office for her promiscu- ous relationships with a variety of people, male and female. On several occasions, colleagues have repri- manded her for becoming inappropriately entangled in the personal lives of her clients. One day, after losing one of her accounts, she became so distraught that she slashed her wrists. This incident prompted her supervi- sor to insist that Anastasia obtain professional help.
Borderline Personality Disorder
I never really feel 'happy and content' inside. I can feel excited, temporarily happy, angry, aggressive, loving, depressed and empty, extremely sad, charitable, obsessive, jealous, hopeless, worthless and confused. I can feel any of these emotions at any time, and often they are temporary (a few hours up to a day or so). The main emotion that stays with me most of the time is anxiety and I have trouble relaxing and dealing with the smallest of things sometimes. I can switch from one good emotion to another in a flash, and no-one can understand why - even though I have reasons of my own at the time. Everything is either black or white - I can switch from liking someone a lot, to disliking them completely, just through one individual incident. This hurts those people if I confront them with it, but most of all, it hurts me and my relationship. Because I moan about so many things, when I have something that really means something to me, it is not taken notice of. I feel 'needy' in relationships and I crave lots of attention. I don't really trust anyone.
Borderline Personality Disorder
Mary is a 26-year-old African-American woman who presents with a history of non-suicidal self-injury, specifically cutting her arms and legs, since she was a teenager. She has made two suicide attempts by overdosing on prescribed medications, one as a teenager and one six months ago; she also reports chronic suicidal ideation, explaining that it gives her relief to think about suicide as a "way out." When she is stressed, Mary says that she often "zones out," even in the middle of conversations or while at work. She states, "I don't know who Mary really is," and describes a longstanding pattern of changing her hobbies, style of clothing, and sometimes even her job based on who is in her social group. At times, she thinks that her partner is "the best thing that's ever happened to me" and will impulsively buy him lavish gifts, send caring text messages, and the like; however, at other times she admits to thinking "I can't stand him," and will ignore or lash out at him, including yelling or throwing things. Immediately after doing so, she reports feeling regret and panic at the thought of him leaving her. Mary reports that before she began dating her current partner she sometimes engaged in sexual activity with multiple people per week, often with partners whom she did not know.
Borderline Personality Disorder
Tia met Jay and it seems as though she "fell" for him hard. The couple had sex on their second date, and subsequently Tia told Jay that she was in love with him. Tia would call Jay several times throughout the day, often telling him that she wanted to see him. After three weeks, Tia was a frequent overnight guest at Jay's house and already began leaving clothes there. They had sex often, with Tia frequently telling Jay that he was special, and she couldn't imagine life without him. Jay noticed that at times Tia slept in late and did little during the day. He also noticed little fresh cuts on her arm, but Tia's response was usually that she fell. After two months, Tia began to seem cold and distant. She stopped spending nights at Jay's house and would often ignore his phone calls. One day she sent an email to Jay telling him that she's not in love with him anymore and she prefers not to see him again.
Borderline Personality Disorder
Albert is a 33-year-old single, Caucasian male who reports experiencing pervasively depressed mood following the dissolution of a six-month romantic relationship. Albert describes feeling overwhelmed with feelings of "emptiness" and is convinced that he will be "alone forever." He additionally reports being "in and out" of psychosocial treatment for suicidal thoughts though denies ever having made any suicide attempts. He also denies engagement in non-suicidal self-injurious behaviors. Albert reports chronic difficulty managing his strong emotions and recognizes that others would describe him as "moody." He further recognizes that he can quickly escalate with inappropriate and/or intense anger over minor transgressions, which subsequently results in feelings of guilt and embarrassment. His anger makes it difficult to sustain both platonic and romantic relationships. To cope, Albert frequently seeks reassurance from others (e.g., calling in desperation to make sure they still care about him) and drinks excessively (i.e., six or more drinks per sitting). Due to the heaviness and frequency of his drinking in the recent weeks, Albert has called out sick a few times from work to recover from drinking the night before. Albert is looking for a treatment that will help him manage/regulate intense emotions in an adaptive manner. In addition, he hopes to learn strategies to better navigate interpersonal relationships (e.g., effective communication)
Borderline Personality Disorder with Comorbid Alcohol use
Anthony is a 22-year-old Caucasian heterosexual male. He is a senior at a prestigious small college. His family has traditionally held high standards for Anthony, and his father had every expectation that his son would go on to study at Harvard Law School. Anthony often felt intensely pressured as he worked day and night to maintain a high grade-point average, while diligently preparing for the national examination for admission to law school. His social life became devoid of any meaningful contact. He even began skipping meals, because he did not want to take time away from studying. When Anthony received his scores on the law school admission exam, he was devastated, because he knew they were too low to allow him to get into any of the better law schools. He began crying uncontrollably, wandering around the dor- mitory hallways, screaming obscenities, and telling peo- ple there was a plot on the part of the college dean to keep him from getting into law school. After 2 days of this behavior, Anthony's resident advisor convinced him to go to the infirmary, where clinicians diagnosed and treated his condition. After a week of rest and medica- tion, Anthony returned to normal functioning and was able to assess his academic situation more rationally.
Brief Psychotic Disorder
Maria is a single 21-year-old Caucasian, heterosexual female. She is a junior in college who has been psychiat- rically hospitalized for a month. The resident assistant in Maria's dormitory notified the campus police because she had grown increasingly concerned about Maria's deterio- rating behavior over the course of the semester. When Maria returned to college in September, her roommate told others, including the resident assistant, that Maria's behavior seemed odd. For example, she had a habit of repeating other people's words, she stared listlessly out the window, and she ignored her personal hygiene. As the semester's end approached, Maria retreated more and more into her own world, until her behavior reached a point at which she was completely unresponsive to others. Eventually, her resident assistant had to call the police, because Maria had not been seen outside her room for about a week. The police found Maria in a trancelike state, unable to respond to any of their questions or attempts to engage with her. She was sent to the hospital for a psychiatric eval- uation and was admitted because she was deemed unable to take care of herself. In the hospital, Maria main- tains rigid posturing of her body, while staring blankly most of the time. The staff members treating her are in a quan- dary about what intervention to use because of her hyper- sensitivity to most medications. At present, the clinicians are attempting to determine whether she has another medical condition or a psychological disorder, but because they cannot identify any, for the moment they have diag- nosed her as having unspecified catatonia.
Catatonia
Brian is a 24-year-old Caucasian man who identifies as gay. He is pursuing a PhD in engineering and constantly feels stressed by his rigorous academic workload. He has always thought of himself as a person to whom weird things happen and has commonly made more of situations than was warranted. Driving on a snowy night, he accidentally hit an elderly man who was walking on the side of the road, causing the man a near-fatal injury. In the months that followed, Brian became caught up in lengthy legal proceedings, which distracted him from his work and caused him tremendous emotional stress. On awakening one Monday morning, he found himself staggering around, unable to see anything other than the shadows of objects in the room. At first he thought he was just having a hard time waking up. As the morn- ing progressed, however, he realized that he was losing his vision. He waited 2 days before going to the emergency clinic on campus. When he did go, he was oddly unconcerned about what seemed like such a serious physical condition.
Conversion Disorder
Larry is a divorced 60-year-old Caucasian heterosexual male who works as a bank cashier. For much of his adult life, co-workers, family, and friends have repeatedly told him he is very moody. He acknowledges that his mood never feels quite stable, although at times others tell him he seems more calm and pleasant than usual. Unfortu- nately, these intervals are quite brief, lasting for a few weeks and usually ending abruptly. Without warning, he may experience either a somewhat depressed mood or a period of elation. During his depressive periods, Larry's confidence, energy, and motivation are very low. During his hypo- manic periods, he willingly volunteers to extend his workday and to undertake unrealistic challenges at work. On weekends, he might decide to put in long shifts at a homeless shelter without getting any sleep. Larry disregards the urging of his family members to get professional help, insisting that it is his nature to be high-energy at times. He also states that he doesn't want some "shrink" to steal away the periods during which he feels on top of the world.
Cyclothymic Disorder
"I know I won't actually die, but it often feels like it." - says Mona and nervously pats her auburn hair - "I can't live without him, that's for sure. When he is gone, it's like life switching from Technicolor to black and white. There is no excitement, this electricity in the air that seems to constantly surround him." She misses him so much that it physically hurts. Sometimes she feels like throwing up at the mere thought of separating or being abandoned by him. She is helpless without him: "He is so masterful and knows how to fix things around the house." He is gorgeous and a great lover. Is he intellectually stimulating? Do they talk a lot? She moves uncomfortably in her seat: "He is more the silent strong type." She is supporting him financially. "He is studying". In the last seven years he had switched from psychology to political science to physical therapy. How long will she underwrite his quest for self-realization? "As long as it takes. I love him".
Dependent Personality Disorder
Betty is a married 52-year-old Caucasian heterosexual woman. She has never lived on her own; even while a college student 30 years ago, she commuted from home. Betty was known by her classmates as someone who was dependent on others. Relying on others to make choices for her, she did whatever her friends advised, whether it choosing courses or selecting the clothes she should wear each day. The week after grad- uation, she married Ken, whom she had dated all senior year. She was particularly attracted to Ken because his domineering style relieved her of the responsibility to make decisions. As she has customarily done with all the close people in her life, Betty goes along with what- ever Ken suggests, even if she does not fully agree. She fears that he will become angry with her and leave her if she rocks the boat. Although she wants to get a job outside the home, Ken has insisted that she remain a full-time homemaker, and she has complied with his wishes. However, when she is home alone, she calls friends and desperately pleads with them to come over for coffee. The slightest criticism from Ken, her friends, or anyone else can leave her feeling depressed and upset for the whole day.
Dependent Personality Disorder
Robert is a 49-year-old heterosexual African American male. He entered the psychiatrist's office in a state of extreme agitation, almost panic. He described the terrifying nature of his "nervous attacks," which began several years ago but had now reached catastrophic proportions. During these "attacks," Robert feels as though he is floating in the air, above his body, watching everything he does but feeling totally disconnected from his actions. He reports that he feels as if his body is a machine controlled by outside forces: "I look at my hands and feet and wonder what makes them move." However, Robert's thoughts are not delusions. He is aware that his altered perceptions are not normal. The only relief he experiences from his symptoms comes when he strikes himself with a heavy object until the pain finally penetrates his consciousness. His fear of seriously harming himself adds to his main worry that he is losing his mind.
Depersonalization/Derealization Disorder
Troy is a 39-year-old heterosexual Caucasian man. He entered the mental health crisis center in a daze, tears streaming down his face, and wearing only a T-shirt despite the frigid temperatures outside. "I have no idea where I live or who I am! Will somebody please help me?" The crisis team asked Troy to search his pockets for an ID or other identifying information, but the only thing he had on him was a picture of a little blonde- haired girl. Troy appeared exhausted and was taken to a bed, where he promptly fell asleep. The crisis team called the local police to find out whether there was a report of a missing child. As it turned out, the little girl in the photograph was Troy's daughter. She had been hit by a car in a shopping center parking lot. Although she had suffered a broken leg, the child was resting comfort- ably in a hospital pediatrics ward. Her father, however, had disappeared. Troy had apparently been wandering around the hospital for several hours, leaving his wallet and cell phone with the hospital social worker in the emergency room. When he awoke, he was able to recall who he was and the circumstances of the accident, but he remembered nothing of what had happened since.
Dissociative Amnesia with Dissociative Fugue
Maya is a 26-year-old Latina heterosexual woman. She is single, lives with two roommates, and works as a store clerk at a department store. She rarely leaves her apart- ment except to go to work and to see her family who live close by. She is known at work for being rather quiet and shy, even around customers. As a teenager, she was in an intimate relationship for about 2 years with a middle-aged man who was physically and emotionally abusive toward her. Although others often remind her of this troubled relationship, Maya claims to remember very little about that time and has no recollection of the physical abuse she endured. Currently, she says she is totally uninterested in pursuing any romantic relation- ships. Those to whom Maya is closest know different versions of her personality or "alters" that go by different names and behave in ways that are totally incongruous with Maya's personality. Whereas Maya is quiet and reserved, her main alter "Rita" is flamboyant, outgoing, and hypersexual. A second alter, "Joe," occasionally emerges from Maya's apartment dressed in men's cloth- ing and speaking in deep tones. Maya's alters are oblivious to the details of her life.
Dissociative Identity Disorder
Kai is 34 years old and has been dating the same woman for more than a year. This is his first serious relationship, and the woman is the first person with whom he has been sexually intimate. During the past 6 months, they have frequently tried to have intercourse, but each time they have become frustrated by Kai's inability to maintain an erection for more than a few minutes. Every time this happens, Kai becomes very upset, despite his girlfriend's reassurance that things will work out better next time. His anxiety level heightens every time he thinks about the fact that he is in his midthirties, sexually active for the first time in his life, and encountering such frustrating difficulties. He fears he is "impotent" and will never have a normal sex life.
Erectile Disorder
Ernie is a 28-year-old single African American hetero- sexual male. He is in jail for the fourth time in the past 2 years for public exposure. As Ernie explained to the court psychologist who interviewed him, he has "flashed" much more often than he has been apprehended. In each case, he has chosen as his victim an unsuspecting college-age woman, and he jumps out at her from behind a doorway, a tree, or a car parked at the sidewalk. He has never touched any of these girls, instead fleeing the scene after having exposed himself. On some occasions, he masturbates immediately after the exposure, fantasiz- ing that his victim was swept off her feet by his sexual prowess and pleaded with him to make love to her. This time, his latest victim responded by calling the police to track him down. Ernie felt crushed and humiliated by an overwhelming sense of his sexual inadequacy.
Exhibitionistic Disorder
Johann is a 45-year-old single Caucasian heterosexual male. For several years, Johann has been breaking into cars and stealing boots or shoes, and he has come close to being caught on several occasions. Johann takes great pleasure in the excitement he experiences each time he engages in the ritualistic behavior of pro- curing a shoe or boot and going to a secret place to fondle it and masturbate. In his home, he has a closet filled with dozens of women's shoes, and he chooses from this selection the particular shoe with which he will masturbate. Sometimes he sits in a shoe store and keeps watch for women trying on shoes. After a woman tries on and rejects a particular pair, Johann scoops the shoes from the floor and takes them to the register, explaining to the clerk that the shoes are a gift for his wife. With great eagerness and anticipation, he rushes home to engage once again in his masturbatory ritual.
Fetishistic Disorder
Bruce is a 40-year-old married Caucasian heterosexual male. As a delivery messenger in a large city, he rides crowded subways throughout the day. He thrives on this opportunity to become sexually stimulated by rubbing up against unsuspecting women. Having developed some cagey techniques, Bruce is often able to take advantage of women without their realizing what he is doing. As the day proceeds, his level of sexual excitation grows, so that by the evening rush hour he targets a par- ticularly attractive woman and only at that point allows himself to reach orgasm.
Frotteuristic Disorder
Jin is a 32-year-old heterosexual Korean female and the single mother of two children. She is seeking profes- sional help for her longstanding feelings of anxiety. Despite the fact that her personal and financial life is relatively stable, she worries most of the time that she will develop financial problems, that her children will become ill, and that the political situation in the country will make life for her and her children more difficult.Although she tries to dismiss these concerns as excessive, she finds it virtually impossible to control her worrying. Most of the time, she feels uncomfortable and tense, and sometimes her tension becomes so extreme that she begins to tremble and sweat. She finds it diffi- cult to sleep at night. During the day she is restless, keyed up, and tense. She has consulted a variety of medical specialists, each of whom has been unable to diagnose a physical problem.
Generalized Anxiety Disorder
Phil is a 67-year-old male who reports that his biggest problem is worrying. He worries all of the time and about "everything under the sun." For example, he reports equal worry about his wife who is undergoing treatment for breast cancer and whether he returned his book to the library. He recognizes that his wife is more important than a book, and is bothered that both cause him similar levels of worry. Phil is unable to control his worrying. Accompanying this excessive and uncontrollable worry are difficulty failing asleep, impatience with others, difficulty focusing at work, and significant back and muscle tension. Phil has had a lifelong problem with worry, recalling that his mother called him a "worry wart." His worrying does wax and wane, and worsened when his wife was recently diagnosed with breast cancer.
Generalized Anxiety Disorder
Shana seems to always be involved in dramatic relationships and situations. She appears to thrive off of these situations. She is often uncomfortable within her group of friends when she is not the center of attention and will often dramatizes her stories in order to command an audience. At times she will also dress provocatively and use sexual suggestions, though when called upon her actions, will appear surprised at being called out.
Histrionic Disorder
Lynnette is a married 44-year-old African American het- erosexual female. She works as an administrator at a local college and has gained a reputation for outlandish behavior and inappropriate flirtatiousness. She often greets students with overwhelming warmth and appar- ent concern over their welfare, which leads some to find her appealing and engaging at first; however, they invariably become disenchanted when they realize her shallowness. To her colleagues, she brags about her minor accomplishments as if they were major victories, yet if she fails to achieve a desired objective, she sulks and breaks down into tears. She is so desperate for the approval of others that she will change her story to suit whomever she is talking to at the time. Because she is always creating crises and never reciprocates the con- cern of others, people have become immune and unre- sponsive to her frequent pleas for help and attention.
Histrionic Personality Disorder
Marsha visibly resents the fact that I have had to pay attention to another patient (an emergency) "at her expense" as she puts it. She pouts and bats suspiciously long eyelashes at me: "Has any of your female patients fallen in love with you?" - she suddenly changes tack. I explain to her what is transference and countertransference in therapy. She laughs throatily and shakes loose an acid blond mane: "You may call it what you want, doctor, but the simple truth is that you are irresistibly cute." I steer away from these treacherous waters by asking her about her marriage. She sighs and her face contort, on the verge of tears: "I hate what's been happening to Doug and me. He has had such a stretch of bad luck - my heart goes out to him. I really love him you know. I miss what we used to be. But his rage attacks and jealousy are driving me away. I feel that I am suffocating."
Histrionic Personality Disorder
Hannah is a 48-year-old heterosexual Japanese American woman. She is a mother of two children, both of whom have recently moved away from home. Within the past year, her menstrual periods have become much heavier and more irregular. Seeking an explanation, Hannah began to spend days reading everything she could find on uterine cancer. Although medical books specified menstrual disturbance as a common feature of menopause, one newspaper article mentioned the possi- bility of uterine cancer. Hannah immediately made an appointment with her gynecologist, who tested her and concluded that her symptoms were almost certainly due to menopause. Convinced that her physician was trying to protect her from knowing "the awful truth," Hannah visited one gynecologist after another in search of some- one who would properly diagnose what she was certain was a fatal illness. She decided to give up her job as a restaurant hostess. First, she was concerned that long hours of standing at the cash register would aggravate her medical condition. Second, she felt she could not be tied down by a job that was interfering with her medical appointments.
Illness Anxiety Disorder
Ed is a 28-year-old single Caucasian heterosexual man who works as a high school teacher. He often has unprovoked, violent outbursts of aggressive and assaultive behavior, during which he throws whatever objects he can get his hands on and yells profanities. He soon calms down, though, and feels intense regret for whatever damage he has caused, explaining that he didn't know what came over him. In the most recent episode, Ed threw a coffee pot at another teacher in the faculty lounge, inflicting serious injury. After the ambu- lance took the injured man to the hospital, Ed's principal called the police. Ed was taken into custody and imme- diately suspended from his job.
Intermittent Explosive Disorder
Ellen is a married, Caucasian, heterosexual 69-year-old woman. Her husband took her to her family physician after becoming increasingly concerned by Ellen's fail- ing memory and strange behavior, such as her not being able to remember the names of basic household items like spoon and dishwasher. Her day-to-day for- getfulness had become so problematic that she would repeatedly forget to feed or walk the dog. As the weeks went by, Ellen seemed to get worse. She would leave food burning on the stove and water overflowing the bathtub. However, she had no family history of relatives diagnosed with early-onset Alzheimer's dis- ease. Ellen's physician sought consultation from a neuropsychologist, who determined that Ellen showed significant impairments in memory, learning, and lan- guage. In addition, a complete medical examination identified no other possible causes for her cognitive symptoms, and she did not meet the criteria for major depressive disorder.
Major Neurocognitive Disorder Due to Alzheimer's Disease
Paula believes that she is the best thing since sliced bread. She believes that she is the smartest student in her class and feels that the professor should recognize her greatness and give her an automatic A just for showing up. She has a secret fear of rejection and loss, so when she received a C in her course, she was completely devastated and complained to the dean about her grade, and trumped up allegations against her professor.
Narcissistic Disorder
Chad is a single 26-year-old Caucasian male who identi- fies as gay. For the past few years, he has been desper- ately trying to find success as an actor. However, he has had only minor acting jobs and has been forced to sup- port himself by working as a waiter. Despite his lack of success, he brags to others about all the roles he rejects because they aren't good enough for him. Trying to break into acting, he has been selfishly exploitative of any person he sees as a possible connection. He intensely resents acquaintances who have obtained act- ing roles and devalues their achievements by commenting that they are just lucky. Yet if anyone tries to give him constructive criticism, Chad reacts with out- rage, refusing to talk to the person for weeks. Because of what he regards as his terrific looks, he thinks he deserves special treatment from everyone. At the restaurant, he has recurrent arguments with his supervi- sor because he insists he is a "professional" who should not have to demean himself by clearing dirty dishes from the tables. He annoys others because he always seeks compliments on his clothes, hair, intelligence, and wit. He is so caught up in himself that he barely notices other people and is grossly insensitive to their needs and problems.
Narcissistic Personality Disorder
Sam presents with anhedonia (failure to enjoy or find pleasure in anything) and dysphoria bordering on depression. He complains of inability to tolerate people's stupidity and selfishness in a variety of settings. He admits that as a result of his "intellectual superiority" he is not well placed to interact with others or even to understand them and what they are going through. He is a recluse and fears that he is being mocked and ridiculed behind his back as a misfit and a freak. Throughout the first session, he frequently compares himself to a machine, a computer, or a member of an alien and advanced race, and talks about himself in the third person singular. Life, bemoans Sam, has dealt him a bad hand. He is consistently and repeatedly victimized by his clients, for instance. They take credit for his ideas and leverage them to promote themselves, but then fail to re-hire him as a consultant. He seems to attract hostility and animosity incommensurate with his good and generous deeds. He even describes being stalked by two or three vicious women whom he had spurned, he claims, not without pride in his own implied irresistibility. Yes, he is abrasive and contemptuous of others at times but only in the interests of "tough love." He is never obnoxious or gratuitously offensive.
Narcissistic Personality Disorder
John is a 56-year-old man who presents to you for treatment. His symptoms started slowly; he tells you that he was always described as an anxious person and remembers being worried about a lot of things throughout his life. For instance, he reported he was very afraid he'd contract HIV by touching doorknobs, even though he tells you he knew this was "irrational." He tells you that about 10 years ago, following a few life stressors, his anxiety and intrusive thoughts worsened significantly. He tells you he began washing his hands excessively. He reports he developed an intense fear that someone would break into the house and it would be his fault because he left something unlocked. He states that this fear led him to repeatedly check doors and windows before sleep in a specific order, which was a source of contention with his wife. He says that his fear of making a mistake also leads him to be slow to turn in work for his job, checking many times to make sure there are no mistakes, for which he gets reprimanded on occasion. John reports that his symptoms are getting worse, which is why he has sought treatment. For example, currently he washes his hands until he finishes the whole soap bar, and his hands are cracked because they are so dry. He says he continues to check the doors and windows of his house numerous times throughout the day, not just at night, and has on occasion driven home from work to be sure everything truly was locked. If he notices even a speck of dust on the floor, he states he has the urge to clean the whole house and he often complies with that urge. John expresses significant distress over these symptoms, as they are taking up more of his time and robbing him of his confidence, as he is increasingly distracted at work and in his family life.
Obsessive Compulsive Disorder
Cesar is a 16-year-old Mexican American male high school student. He was referred for treatment by one of his teachers, who became disturbed by Cesar's irratio- nal concern about the danger posed by an electrical outlet at the front of the classroom. Cesar pleaded daily with the teacher to have the outlet disconnected to pre- vent someone from accidentally getting electrocuted while walking by it. The teacher told Cesar his concerns were unfounded, but he remained so distressed that he felt driven, when entering and leaving the classroom, to shine a flashlight into the outlet to make sure a loose wire was not exposed. During class time, he could think of nothing else but the outlet.
Obsessive-Compulsive Disorder
Trevor is a married 42-year-old Latino heterosexual male. For as long as he can remember, Trevor has been preoccupied with neatness and order. As a child, he kept his room meticulously clean. Friends and relatives chided him for excessive organization. For example, he insisted on arranging the toys in his toy closet according to color and category. In college, his rigid housekeeping regimen both amazed and annoyed his roommates. He was tyrannical in his insistence on keeping the room orderly and free of clutter. Trevor has continued this pat- tern into his adult life. Employed as a file clerk, he prides himself on never having missed a day of work, regard- less of health problems and family crises. However, his boss will not offer Trevor a promotion because she feels he is overly attentive to details of the filing process, thus slowing the work of the office as he checks and rechecks everything he does. Trevor enhances his sense of self-importance in the office by looking for opportunities to take control. For example, when his co-workers are planning a party, he tends to slow matters because of his concerns about every detail of the event, such as the time it will start, how much food to order, and decora- tions. More often than not, his co-workers try to avoid letting him get involved because they object to his rigidity in such trivial matters.
Obsessive-Compulsive Personality Disorder
Magda is distressed when I reschedule our appointment. "But we always meet on Wednesdays!" - she pleads, ignoring my detailed explanations and my apologies. She is evidently anxious and her voice trembles. In small, precise movements she rearranges the objects on my desk, stacking stray papers and replacing pens and pencils in their designated canisters. Anxiety breeds frustration and is followed by rage. The outburst lasts but a second and Magda reasserts control over her emotions by counting aloud (only odd numbers). "So, when and where are we going to meet?" - she finally blurts out.
Obsessive-compulsive personality disorder
Jimmy is a 38-year-old single biracial heterosexual male. He is homeless and has been addicted to heroin for the past 10 years. He began to use the drug at the sugges- tion of a friend who told him it would help relieve the pressure Jimmy was feeling from his unhappy marriage and financial problems. In a short period of time, he became dependent on the drug and got involved in a theft ring to support his habit. Ultimately, he lost his home and moved to a shelter, where workers assigned Jimmy to a methadone treatment program.
Opioid Use Disorder
Dave is a 41-year-old male who was referred by his primary care physician after presenting to the ER with difficulty breathing. Dave's physician was unable to find a medical explanation for his symptoms, which left Dave feeling confused, stressed, and angry. Over the last 6 months, Dave has had several instances where he felt an intense fear that would reach a peak within a few minutes. During these instances, he would also experience sweating, heart palpitations, chest pain and discomfort, and shortness of breath. At times, Dave worried that might die. As a result, Dave has persistent worry about having another attack. In addition, he has begun to avoid unfamiliar places and people where it may be difficult to get help in the event of another panic attack. The panic and associated avoidance are significantly impacting Dave's life as he has been turning down social invitations, making excuses to stay at home whenever possible, and relying on his wife to drive their children to their various activities. Although she was understanding at first, Dave's wife has grown frustrated with what she perceives as his irrational fear of panic attacks.
Panic Disorder
Frieda is a single 31-year-old heterosexual Latina female. She is a former delivery driver who sought treatment because of recurrent panic attacks that have led her to become fearful of driving. She has become so frightened of the prospect of having an attack on the job that she has asked for medical leave. Although initially she would leave the house when accompanied by her mother, she now is unable to go out under any circum- stances, and her family is concerned that she will become a total recluse.
Panic Disorder and Agoraphobia
Anita is a single 34-year-old African American female who identifies as gay. She is a computer programmer who constantly worries that other people will exploit her knowledge. She regards as "top secret" the new data- base management program she is writing and even fears that, when she leaves the office at night, someone will sneak into her desk and steal her notes. Her distrust of others pervades all her interpersonal dealings, with suspicions that she is being cheated tainting even rou- tine transactions in banks and stores. Anita likes to think of herself as rational and able to make objective deci- sions; she regards her inability to trust other people as a natural reaction to a world filled with what she calls "opportunistic and insincere corporate ladder climbers."
Paranoid Personality Disorder
Dale's first enquiry is whether I am in any way associated either with the government or with his former employer. He doesn't seem reassured by my negative response. He eyes me skeptically and insists that I inform him if things change and I do become entangled with his persecutors. Why do I treat him pro bono? He suspects some ulterior motives behind my altruism and inexplicable generosity. I explain to him that I donate 25 hours a month to the community. "It's good for your image, gives you access to local bigwigs, I bet." - he retorts, accusingly. He refuses to allow me to tape record our conversation.
Paranoid Personality Disorder
Kirk is a 38-year-old married heterosexual Caucasian male. Shortly following his marriage, Kirk began devel- oping an inappropriately close relationship with Amy, his 8-year-old stepdaughter. It seemed to start out inno- cently, when he took extra time to give her bubble baths and back rubs. But after only 2 months of their living in the same house, Kirk's behavior went outside the boundary of common parental physical affection. After his wife left for work early each morning, Kirk invited Amy into his bed on the pretext that she could watch cartoons on the television in his bedroom. Kirk would begin stroking Amy's hair and gradually proceed to more sexually explicit behavior, encouraging her to touch his genitals, saying that it would be "good" for her to learn about what "daddies" are like. Confused and frightened, Amy did as she was told. Kirk reinforced compliance to his demands by threatening that, if Amy told anyone about their secret, he would deny every- thing and severely beat her. This behavior continued for more than 2 years, until one day Kirk's wife returned home unexpectedly and caught him engaging in this behavior.
Pedophilic Disorder
Kimiko is a single 34-year-old heterosexual Japanese American female. She currently works as a community college instructor, and for the past 3 years has had per- sistent feelings of depressed mood, inferiority, and pes- simism. She realizes that, since her graduation from college, she has never felt really happy and that, in recent years, she has struggled with thoughts of worthlessness and sad mood. Her appetite is low, and she struggles with insomnia. During waking hours, she lacks energy and finds it difficult to do her work. She often finds herself staring out the window of her office, consumed by thoughts of how inadequate she is. She fails to fulfill many of her responsibilities and has received consistently poor teacher evaluations for the past 3 years. Getting along with her colleagues has become increasingly difficult. Consequently, she spends most of her free time alone in her office.
Persistent Depressive Disorder (Dysthymia)
Josh is a 27 year-old male who recently moved back in with his parents after his fiancée was killed by a drunk driver 3 months ago. His fiancée, a beautiful young woman he'd been dating for the past 4 years, was walking across a busy intersection to meet him for lunch one day. He still vividly remembers the horrific scene as the drunk driver ran the red light, plowing down his fiancée right before his eyes. He raced to her side, embracing her crumpled, bloody body as she died in his arms in the middle of the crosswalk. No matter how hard he tries to forget, he frequently finds himself reliving the entire incident as if it was happening all over. Since the accident, Josh has been plagued with nightmares about the accident almost every night. He had to quit his job because his office was located in the building right next to the little café where he was meeting his fiancée for lunch the day she died. The few times he attempted to return to work were unbearable for him. He has since avoided that entire area of town. Normally an outgoing, fun-loving guy, Josh has become increasingly withdrawn, "jumpy", and irritable since his fiancé's death. He's stopped working out, playing his guitar, or playing basketball with his friends - all activities he once really enjoyed. His parents worry about how detached and emotionally flat he's become.
Post Traumatic Stress Disorder
Steve is a single 35-year-old biracial heterosexual male. For the past 10 years, he has suffered from flashbacks in which he relives the horrors of his 9-month-long deploy- ment as a marine in Afghanistan. These flashbacks occur unexpectedly in the middle of the day, and Steve is thrown back into the emotional reality of his war experiences. These flashbacks, and the nightmares from which he often suffers, have become a constant source of torment. Steve has found that alcohol provides the only escape from these visions and from the distress he feels. Often, he ruminates about how he should have done more to prevent the deaths of his fellow soldiers, and he feels that his friends should have survived rather than he.
Post Traumatic Stress Disorder
Victor is a 27-year-old man who comes to you for help at the urging of his fiancée. He was an infantryman with a local Marine Reserve unit who was honorably discharged in 2014 after serving two tours of duty in Iraq. His fiancé has told him he has "not been the same" since his second tour of duty and it is impacting their relationship. Although he offers few details, upon questioning he reports that he has significant difficulty sleeping, that he "sleeps with one eye open" and, on the occasions when he falls into a deeper sleep, he has nightmares. He endorses experiencing several traumatic events during his second tour, but is unwilling to provide specific details - he tells you he has never spoken with anyone about them and he is not sure he ever will. He spends much of his time alone because he feels irritable and doesn't want to snap at people. He reports to you that he finds it difficult to perform his duties as a security guard because it is boring and gives him too much time to think. At the same time, he is easily startled by noise and motion and spends excessive time searching for threats that are never confirmed both when on duty and at home. He describes having intrusive memories about his traumatic experiences on a daily basis but he declines to share any details. He also avoids seeing friends from his Reserve unit because seeing them reminds him of experiences that he does not want to remember.
Post Traumatic Stress Disorder
Danny is a 32-year-old Army veteran who comes to you reporting that he has been having unusual experiences, such as hearing the pigeons that live around his building talk to him. Additionally, he has been increasingly concerned that he is being monitored by government agencies. In response, he has begun to avoid technology that he believes can be used to track him, such as cellular phones or laptops. He reports that he first began to hear things that those around him appeared not to notice and to become concerned about being watched by the government about a year ago. As a result, he has been unable to maintain a job during this time and reports that he is arguing more with his girlfriend. When he presents in your office, you notice that he does not demonstrate much emotion and that his facial expressions and tone of voice do not change much throughout your interview.
Psychotic Disorder
Mark, a single 48 year old man, prefers to work the third shift as a word processor for a law firm. His co-workers see him as unwaveringly serious and cold. He does not participate in any social functions, and rarely speaks to any of them. He gives short answers to questions and is unlikely to participate in water cooler sessions.
Schizoid Disorder
Demetrios is a single 45-year-old heterosexual Greek American male. He works as a night security guard at a bank and likes his job because he can enter the private world of his thoughts without interruptions from other people. Even though his long years of service make him eligible for a daytime security position, Dmitri has repeat- edly turned down these opportunities because daytime work would require him to deal with bank employees and customers. Dmitri has resided for more than 20 years in a small room at a boarding house. He has no television or radio, and he has resisted any attempts by other house residents to include him in social activities. He has made it clear he is not interested in small talk and prefers to be left alone. Neighbors, co-workers, and even his family members (whom he also avoids) per- ceive him as a peculiar person who seems strikingly cold and detached. When his brother died, Dmitri decided not to attend the funeral because he did not want to be bothered by all the carrying on and sympa- thetic wishes of relatives and others.
Schizoid Personality Disorder
Mark sits where instructed, erect but listless. When I ask him how he feels about attending therapy, he shrugs and mumbles "OK, I guess". He rarely twitches or flexes his muscles or in any way deviates from the posture he has assumed early on. He reacts with invariable, almost robotic equanimity to the most intrusive queries on my part. He shows no feelings when we discuss his uneventful childhood, his parents ("of course I love them"), and sad and happy moments he recollects at my request. Mark veers between being bored with our encounter and being annoyed by it. How would he describe his relationships with other people? He has none that he can think of. In whom does he confide? He eyes me quizzically: "confide?" Who are his friends? Does he have a girlfriend? No. He shares pressing problems with his mother and sister, he finally remembers. When was the last time he spoke to them? More than two years ago, he thinks.
Schizoid Personality Disorder
Joshua is a single 43-year-old biracial heterosexual male. Most days, he stands near the steps of a local bank on a busy street corner, wearing a Red Sox base- ball cap, a yellow T-shirt, worn-out hiking shorts, and orange sneakers. Rain or shine, day in and day out, Joshua maintains his post at the bank. Sometimes he converses with imaginary people. Sometimes he explodes in shrieks of laughter. Without provocation, he sobs miserably. Police and social workers keep tak- ing him to shelters for the homeless, but Joshua man- ages to get back on the street before he can receive treatment. He has repeatedly insisted that these peo- ple have no right to keep bothering him.
Schizophrenia
Esther is a single 36-year-old heterosexual Caucasian female. She lives with her mother, and for the past 10 years she has worked as a clerical assistant in an insurance company and no longer shows the delusions, disorganized speech, and lack of emotional expression that originally led to her two prior hospitalizations within a 2-year period. At the moment, she is able to hold her job and maintain a relationship with her mother and a few friends.
Schizophrenia, Multiple Episodes, Currently in Full Remission
When Deion, a married African American male, devel- oped a psychological disorder, he was 26 years old and worked for a convenience store chain. Although family and friends always regarded Deion as unusual, he had not experienced psychotic symptoms. This all changed as he grew more and more disturbed over the course of several months. His mother thought that he was just "stressed out" because of his financial problems, but Deion did not seem concerned about such matters. He gradually developed paranoid delusions and became preoccupied with reading the Bible, though he did not actively practice any religion. What brought his distur- bance to the attention of his supervisors was the fact that he had submitted an order to the district office for 6,000 loaves of bread. He had scribbled at the bottom of the order form, "Jesus will multiply the loaves." When his supervisors questioned this inappropriate order, Deion became enraged and insisted that they were plot- ting to prevent him from fighting world hunger. Paranoid themes and bizarre behaviors also surfaced in Deion's interactions with his wife and children. Following 2 months of increasingly disturbed behavior, Deion's boss urged him to see a psychiatrist. With rest and relatively low doses of antipsychotic medication, Deion returned to normal functioning after a few weeks
Schizophreniform Disorder
Cary believes that she is a clairvoyant and can "see" things that others cannot. Although she is an American born Caucasian, she speaks with a heavy West Indian accent. She also believes that she has the mental power to "change" things around her. These beliefs have isolated her from other people, who perceive her to be weird.
Schizotypal Disorder
El-Or's real name is George. He changed it as a result of an epiphany he experienced at the tender age of 9 when he encountered an alien spaceship in his back yard and "in all probability" was abducted by its crew. Can't he remember for sure? It's all kind of fuzzy, but ever since then he has had numerous out of body experiences and has developed psychic capabilities such as clairvoyance and remote viewing. "I can see that you don't believe a word of it." - he declaims bitterly - "You probably can't wait to tell the other therapists here about me and have a good laugh at my expense." I remind him that therapy sessions are strictly confidential but he nods his head sagely: "Yeah, sure, whatever you say, Doc."
Schizotypal Personality Disorder
Mike is a 20 year-old who reports to you that he feels depressed and is experiencing a significant amount of stress about school, noting that he'll "probably flunk out." He spends much of his day in his dorm room playing video games and has a hard time identifying what, if anything, is enjoyable in a typical day. He rarely attends class and has avoided reaching out to his professors to try to salvage his grades this semester. Mike has always been a self-described shy person and has had a very small and cohesive group of friends from elementary through high school. Notably, his level of stress significantly amplified when he began college. You learn that when meeting new people, he has a hard time concentrating on the interaction because he is busy worrying about what they will think of him - he assumes they will find him "dumb," "boring," or a "loser." When he loses his concentration, he stutters, is at a loss for words, and starts to sweat, which only serves to make him feel more uneasy. After the interaction, he replays the conversation over and over again, focusing on the "stupid" things he said. Similarly, he has a long-standing history of being uncomfortable with authority figures and has had a hard time raising his hand in class and approaching teachers. Since starting college, he has been isolating more, turning down invitations from his roommate to go eat or hang out, ignoring his cell phone when it rings, and habitually skipping class. His concerns about how others view him are what drive him to engage in these avoidance behaviors. After conducting your assessment, you give the patient feedback that you believe he has social anxiety disorder, which should be the primary treatment target. You explain that you see his fear of negative evaluation, and his thoughts and behaviors surrounding social situations, as driving his increasing sense of hopelessness, isolation, and worthlessness.
Social Anxiety Disorder
Theo is a single 19-year-old Caucasian bisexual male. He is a sophomore in college and reports that he is terrified at the prospect of speaking in class. His anxiety is so intense that he enrolls only in very large lecture classes,where he sits in the back of the room, slouching in his chair to make himself as invisible as possible. On occa- sion, one of his professors randomly calls on students to answer certain questions. When this occurs, Theo begins to sweat and tremble. Sometimes he rushes from the classroom and frantically runs back to his dormitory for a few hours and tries to calm himself down.
Social Anxiety Disorder
Helen, a 34-year-old married Caucasian bisexual woman, is seeking treatment because her physician said there was nothing more he could do for her. When asked about her physical problems, Helen recited a litany of complaints, including frequent episodes when she could not remember what had happened to her and other times when her vision was so blurred that she could not read the words on a printed page. Helen enjoys cooking and doing things around the house, but she becomes easily fatigued and short of breath for no apparent reason. She often is unable to eat the elabo- rate meals she prepares, because she becomes nause- ated and is prone to vomit any food with even a touch of spice. According to Helen's husband, she has lost all interest in sexual intimacy, and they have intercourse only about once every few months, usually at his insis- tence. Helen complains of painful cramps during her menstrual periods and at other times says she feels that her "insides are on fire." Because of additional pain in her back, legs, and chest, Helen wants to stay in bed for much of the day. She lives in a large, old Victorian house, from which she ventures only infrequently "because I need to be able to lie down when my legs ache."
Somatic Symptom Disorder
Audra is a 15-year-old Caucasian female. For most of her childhood and adolescence, she lived a fairly isolated existence with no close friends. Although she never dis- cussed her unhappiness with anyone, she often felt depressed and hopeless. As a young child, Audra lay in bed on many nights secretly tugging at her hair. Over time, this behavior increased to the point at which she plucked the hair, strand by strand, from her scalp. Typically, she pulled out a hair, examined it, bit it, and either threw it away or swallowed it. Because her hair was thick and curly, her hair loss was not initially evident, and Audra kept her hair carefully combed to conceal the bald spots. One of her teachers noticed that she was pulling her hair in class, however, and in looking more closely, she saw the bald patches on Audra's head. She referred Audra to the school psychologist, who called Audra's mother and recommended professional help.
Trichotillomania
Brendan is a married 40-year-old Caucasian hetero- sexual male. He had no prior history of mental health concerns until 2 weeks ago when he survived a wildfire that destroyed his apartment and many buildings in his neighborhood. Since the fire Brendan has been tor- mented by graphic images of waking to see his room filled with smoke. Although he was treated and released within several hours from the emergency room, he described himself as feeling in a daze, emotionally unre- sponsive to the concerns of his friends and family, and seemingly numb. He continued to experience these symptoms for several weeks, after which they gradually subsided.
Acute Stress Disorder
Mala is a 55-year-old married heterosexual Israeli Amer- ican woman. She has been a stay-at-home parent since the birth of her and her husband's first child. Every afternoon, Mala makes herself the first in a series of daiquiris. On many evenings, she passes out on the couch by the time her husband arrives home from work. Mala lost her driver's license a year ago after being arrested three times on charges of driving while intoxicated. Although her family has urged her to obtain treatment for her disorder, she denies that she has a problem because she can "control" her drinking. The mother of three grown children, Mala began to drink around age 45, when her youngest child left for college. Before that, she kept her- self extremely busy through her children's extracurricular activities. When she found herself alone every afternoon, she took solace in having an early cocktail. Over a period of several years, the daily cocktail developed into a series of five or six strong mixed drinks. Mala's oldest daughter has lately begun to insist that something be done for her mother. She does not want to see Mala develop the fatal alcohol-related illness that caused the premature death of her grandmother.
Alcohol Use Disorder
Ani was referred to therapy by the court, as part of a rehabilitation program. He is serving time in prison, having been convicted of grand fraud. The scam perpetrated by him involved hundreds of retired men and women in a dozen states over a period of three years. All his victims lost their life savings and suffered grievous and life-threatening stress symptoms. He seems rather peeved at having to attend the sessions but tries to hide his displeasure by claiming to be eager to "heal, reform himself and get reintegrated into normative society". When I ask him how does he feel about the fact that three of his victims died of heart attacks as a direct result of his misdeeds, he barely suppresses an urge to laugh out loud and then denies any responsibility: his "clients" were adults who knew what they were doing and had the deal he was working on gone well, they would all have become "filthy rich." He then goes on the attack: aren't psychiatrists supposed to be impartial? He complains that I sound exactly like the "vicious and self-promoting low-brow" prosecutor at his trial.
Antisocial Personality Disorder
Tommy is a single 38-year-old Caucasian heterosexual male. He grew up in a chaotic home atmosphere, his mother having lived with a series of violent men who were heavily involved in drug dealing and prostitution. At age 18, Tommy was jailed for brutally mugging and stabbing an older woman. This was the first in a long series of arrests for offenses ranging from drug traffick- ing to car thefts to counterfeiting. At one point, between jail terms, he met a woman at a bar and married her the next day. Two weeks later, he beat her when she com- plained about his incessant drinking and involvement with shady characters. Tommy left her when she became pregnant, and he refused to pay child support. From his vantage point now as a drug trafficker and leader of a child prostitution ring, Tommy shows no regret for what he has done, claiming that life has "sure given me a bum steer."
Antisocial Personality Disorder
Jeong is a 6-year-old Chinese American male currently receiving treatment at a residential school for children with intellectual disabilities. As an infant, Jeong did not respond well to his parents' efforts to play with and hold him. His mother noticed that his whole body seemed to stiffen when she picked him up from his crib. No matter how much she tried, she could not entice Jeong to smile. When she tried to play games by tickling his toes or touching his nose, he averted his eyes and looked out the window. Not until Jeong was 18 months old did his mother first realize that his behavior reflected more than just a quiet temperament—that he was, in fact,developing abnormally. Jeong never did develop an attachment to people; instead, he clung to a small piece of wood he carried with him everywhere. His mother often found him rocking his body in a corner, clinging to his piece of wood. Jeong's language, though, finally indi- cated serious disturbance. At an age when most children start to put together short sentences, Jeong was still babbling incoherently. His babbling did not sound like that of a normal infant. He said the same syllable over and over again—usually the last syllable of something that had just been said to him—in a high-pitched, mono- tone voice. Perhaps the most bizarre feature of Jeong's speech was that he did not direct it to the listener. Jeong seemed to be communicating in a world of his own.
Autism Spectrum Disorder
"I would like to be normal" - says Gladys and blushes purple. In which sense is she abnormal? She prefers reading books and watching movies with her elderly mother to going out with her colleagues to the occasional office party. Maybe she doesn't feel close to them? How long has she been working with these people? Eight years in the same firm and "not one raise in salary" - she blurts out, evidently hurt. Her boss bullies her publicly and the searing shame of it all prevents her from socializing with peers, suppliers, and clients. Does she have a boyfriend? I must be mocking her. Who would date an ugly duckling, plain secretary like her? I disagree wholeheartedly and in details with her self-assessment. I think that she is very intelligent. She half rises from her seat then thinks better of it: "Please, doctor, there no need to lie to me just in order to make me feel better. I know my good sides and they don't amount to much. If we disagree on this crucial point, perhaps I should start looking for another therapist."
Avoidant Personality Disorder
Danielle appears to be very shy. She desires to be around people and have friends, but is afraid of being criticized. Although she would like to be involved in a relationship, she rarely pursues one because of her uncertainties.
Avoidant Personality Disorder
Eduard is a single 53-year-old African American male who identifies as gay. He works as delivery person for a large equipment corporation. Eduard's co-workers describe him as a loner because he does not spend time in casual conversation and avoids going out to lunch with others. Little do they know that every day he struggles with the desire to interact with them but is too intimidated to follow through. Recently, Eduard turned down a promotion to a manager's job because he real- ized it would require a considerable amount of day-to- day contact with others. What bothered him most about the prospect was that he might make mistakes others would notice. Eduard has hardly dated, and every time he feels interested in a man, he becomes paralyzed with anxiety over the prospect of talking to him, much less asking him for a date. When co-workers talk to him, he blushes and nervously tries to end the conversation as soon as possible.
Avoidant Personality Disorder
Gary is a 19-year-old who withdrew from college after experiencing a manic episode during which he was brought to the attention of the Campus Police ("I took the responsibility to pull multiple fire alarms in my dorm to ensure that they worked, given the life or death nature of fires"). He had changed his major from engineering to philosophy and increasingly had reduced his sleep, spending long hours engaging his friends in conversations about the nature of reality. He had been convinced about the importance of his ideas, stating frequently that he was more learned and advanced than all his professors. He told others that he was on the verge of revolutionizing his new field, and he grew increasingly irritable and intolerant of any who disagreed with him. He also increased a number of high-risk behaviors - drinking and engaging in sexual relations in a way that was unlike his previous history. At the present time, he has returned home and his been placed on a mood stabilizer (after a period of time on an antipsychotic), and his psychiatrist is requesting adjunctive psychotherapy for his bipolar disorder. The patient's parents are somewhat shocked by the diagnosis, but they acknowledge that Gary had early problems with anxiety during pre-adolescence, followed by some periods of withdrawal and depression during his adolescence. His parents are eager to be involved in treatment, if appropriate.
Bipolar Disorder
Sarah is a 42-year-old married woman who has a long history of both depressive and hypomanic episodes. Across the years she has had a variety of diagnoses. A review of symptoms indicates that she indeed have multiple episodes of depression beginning in her late teens, but that clear hypomanic episodes later emerged. Her elevated interpersonal conflict, hyper-sexuality and alcohol use during her hypomanic episodes led to the provisional borderline diagnosis, but in the context of her full history, ______ appears the best diagnosis. Sarah notes that she is not currently in a relationship and that she feels alienated from her family. She has been taking mood stabilizers for the last year, but continues to have low level symptoms of depression. In the past, she has gone off her medication multiple times, but at present she says she is "tired of being in trouble all the time" and wants to try individual psychotherapy.
Bipolar Disorder
Richard is a 62-year-old single man who says that his substance dependence and his bipolar disorder both emerged in his late teens. He says that he started to drink to "feel better" when his episodes of depression made it hard for him to interact with his peers. He also states that alcohol and cocaine are a natural part of his manic episodes. He also notes that coming off the cocaine and binge drinking contribute to low mood, but he has not responded well to referrals to AA and past inpatient stays have led to only temporary abstinence. Yet, Richard is now trying to forge a closer relationship to his adult children, and he says he is especially motivated to get a better handle on both his bipolar disorder and his substance use. He has been more compliant with his mood stabilizing and antidepressant medication, and his psychiatrist would like his dual diagnoses addressed with psychotherapy.
Bipolar Disorder and Substance Use Disorder
Isabel is a single 38-year-old bisexual Hispanic Ameri- can female. She works as a software engineer at a large tech company, where she has worked for about 10 years. For the past week, she has shown signs of uncharacter- istically outlandish behavior, beginning with thoughts of quitting her job so that she could develop her own soft- ware company out of her apartment. Isabel went without sleep for 3 days, spending most of her time at her com- puter developing a business model for the company. Within a few days, she took out nearly $1 million in loans, although she had few resources to finance even one of them. She visited several banks and other investors, each time making a scene with anyone who expressed skepticism about her plan. While at a bank, she became so upset when she was denied a loan that she angrily pushed over the banker's desk, and screamed at the top of her lungs that the bank was keeping her from her multimillion-dollar profit. The police were called, and Iso- bel was brought to an emergency room, from which she was transferred for intensive evaluation and treatment at a nearby psychiatric hospital.
Bipolar I Disorder
