Psychopathology Midterm I

Brief psychotic disorder

1 day-1 month sudden onset of one or more of the following psychotic symptoms, at least one being (1), (2) or (3) 1. delusions 2. hallucinations 3. disorganized speech 4. disorganized or catatonic behavior Specify if: - with marked stressor(s) - without marked stressor(s) - with postpartum onset - with catatonia

Schizophreniform disorder

1-6 months presence of two (or more) positive psychotic symptoms, each present for a significant portion of time during a 1-month period - at least one symptom must be delusions, hallucinations or disorganized speech *provisional: if within 6 months and patient is still ill Specify if: - with good prognostic features (at least 2 of: (1) onset of psychotic sxs within 4 weeks of first noticeable change in behavior/functioning, (2) confusion, (3) good premorbid functioning, (4) absence of flat affect) - without good prognostic features - with catatonia Differential Dx: brief psychotic disorder (duration is less than 1 month)

Psychotic symptoms

1. Delusions: fixed beliefs that are not amenable to change in light of conflicting evidence - cannot be explained by cultural upbringing - variety of themes (persecutory, referential, somatic, religious, grandiose, erotomanic) 2. Hallucination: perception-like experiences that occur without an external stimulus - must occur in context of clear sensorium (fully awake/aware) - can occur in any sensory modality (commonly auditory) 3. Disorganized thinking (speech): impair effective communication - can include derailment, loose association, tangentiality or incoherence 4. Grossly disorganized/abnormal motor behavior: ranges from childlike "silliness" to unpredictable agitation, leads to difficulties in performing daily activities 5. Negative symptoms: ranges from reduced range of expression to amount/fluency of speech to loss of will to do things

CASE STUDY: "I'd rather have her with me, if that's all right." Lucy Gould was responding to the clinician's suggestion that her mother wait outside the office. "By now, I don't have any secrets from her." Since age 18, Lucy hadn't gone anywhere without her mother. In fact, in those 6 years she'd hardly been anywhere at all. "There's no way I could go out by myself—it's like entering a war zone. If someone's not with me, I can barely stand to go to doctor appointments and stuff like that. But I still feel awfully nervous." The nervousness Lucy complained of hadn't included actual panic attacks; she never felt that she couldn't breathe or was about to die. Rather, she experienced an intense motor agitation that had caused her to flee from shopping malls, supermarkets, and movie theaters. Nor could she ride on public transportation; buses and trains both terrified her. She had the feeling, vague but always present, that something awful would happen there. Perhaps she would become so anxious that she would pass out or wet herself, and no one would be able to help her. She hadn't been alone in public since the week before her high school commencement. She had only been able to go up onto the platform to receive her diploma because she was with her best friend, who would know what to do if she needed help. Lucy had always been a timid, rather sensitive girl. The first week of kindergarten, she had cried each time her mother left her by herself at school. But her father had insisted that she "toughen up," and within a few weeks she had nearly forgotten her terror. She'd subsequently maintained a nearly perfect attendance record at school. Then, shortly after her 17th birthday, her father died of leukemia. Her terror of being away from home had begun within a few weeks of his funeral. To make ends meet, her mother had sold their house, and they had moved into a condominium across the street from the high school. "It's the only way I got through my last year," Lucy explained. For several years, Lucy had kept house while her mother assembled circuit boards at an electronics firm outside town. Lucy was perfectly comfortable in that role, even though her mother was away for hours at a time. Her physical health had been good; she had never used drugs or alcohol; and she had never had depression, suicidal ideas, delusions, or hallucinations. But a year ago Lucy had developed insulin-dependent diabetes, which required frequent trips to the doctor. She had tried to take the bus by herself, but after several failures— once, in the middle of traffic, she had forced the rear door open and sprinted for home—she had given up. Now her mother was applying for disability assistance so that she could remain at home to provide the aid and attendance Lucy required.

Agoraphobia rationale: - avoidance of a variety of situations/places - worry that help may not be available - required a companion

CASE STUDY: Elisabeth Jacks ran a catering service with her second husband, Donald, who was the main informant. At age 38, Elisabeth already had two grown children, so Donald could understand why this pregnancy might have upset her. Even so, she had seemed unnaturally sad. From about her fourth month, she spent much of each day in bed, not arising until afternoon, when she began to feel a little less tired. Her appetite, voracious during her first trimester, fell off, so that by the time of delivery she was several pounds lighter than usual for a full-term pregnancy. She had to give up keeping the household and business accounts, because she couldn't focus her attention long enough to add a column of figures. Still, the only time Donald became really alarmed was one evening at the beginning of Elisabeth's ninth month, when she told him that she had been thinking for days that she wouldn't survive childbirth and he would have to rear the baby without her. "You'll both be better off without me, anyway," she had said. After their son was born, Elisabeth's mood brightened almost at once. The crying spells and the hours of rumination disappeared; briefly, she seemed almost her normal self. Late one Friday night, however, when the baby was 3 weeks old, Donald returned from catering a banquet to find Elisabeth wearing only bra and panties and icing a cake. Two other just-iced cakes were lined up on the counter, and the kitchen was littered with dirty pots and pans. "She said she'd made one for each of us, and she wanted to party," Donald told the clinician. "I started to change the baby—he was howling in his basket—but she wanted to drag me off to the bedroom. She said 'Please, sweetie, it's been a long time.' I mean, even if I hadn't been dead tired, who could concentrate with the baby crying like that?" All the next day, Elisabeth was out with girlfriends, leaving Donald home with the baby. On Sunday she spent nearly $300 for Christmas presents at an April garage sale. She seemed to have boundless energy, sleeping only 2 or 3 hours a night before arising, rested and ready to go. On Monday she decided to open a bakery; by telephone, she tried to charge over $1,600 worth of kitchen supplies to their Visa card. She'd have done the same the next day, but she talked so fast that the person she called couldn't understand her. In frustration, she slammed the phone down. Elisabeth's behavior became so erratic that for the next two evenings Donald stayed off work to care for the baby, but his presence only seemed to provoke her sexual demands. Then there was the marijuana. Before Elisabeth became pregnant, she would have an occasional toke (she called it her "herbs"). During the past week, not all the smells in the house had been fresh-baked cake, so Donald thought she might be at it again. Yesterday Elisabeth had shaken him awake at 5 a.m. and announced, "I am becoming God." That was when he had made the appointment to bring her for an evaluation. Elisabeth herself could hardly sit still during the interview. In a burst of speech, she described her renewed energy and plans for the bakery. She volunteered that she had never felt better in her life. In rapid succession she then described her mood (ecstatic), how it made her feel when she put on her best silk dress (sexy), where she had purchased the dress, how old she had been when she bought it, and to whom she was married at the time.

Bipolar I disorder, currently manic, severe with mood-congruent psychotic features, with peripartum onset rationale: - high mood - other symptoms: reduced need for sleep, talkativeness, flight of ideas, poor judgement - considerable distress, for family

CASE STUDY: "I'm a writer," said Iris McMaster. It was her first visit to the interviewer's office, and she wanted to smoke. She fiddled with a cigarette but didn't seem to know what to do with it. "It's what I do for a living. I should be home doing it now—it's my life. Maybe I'm the finest creative writer since Dostoevsky. But my friend Charlene said I should come in, so I've taken time away from working on my play and my comic novel, and here I am." She finally put the cigarette back into the pack. "Why did Charlene think you should come?" "She thinks I'm high. Of course I'm high. I'm always high when I'm in my creative phase. Only she thinks I'm too nervous." Iris was slender and of average height; she wore a bright pink spring outfit. She looked longingly at her pack of cigarettes. "God, I need one of those." Her speech could always be interrupted, but it was salted with bon mots, neat turns of phrase, and original similes. But Iris was also able to give a coherent history. At 45, she was married to an engineer and had a daughter who was nearly 18. And she really was a writer, who over the last several years had sold (mainly to women's magazines) articles about a variety of subjects. For 3 or 4 months Iris had been in one of her high phases, cranking out an enormous volume of essays on wide-ranging topics. Her "wired" feeling was uncomfortable in a way, but it hadn't troubled her because she felt so productive. Whenever she was creating, she didn't need much sleep. A 2-hour nap would leave her rested and ready for another 10 hours at her computer. At those times, her husband would fix his own meals and kid her about having "a one-track mind." Iris never ate much during her high phases, so she lost weight. But she didn't get herself into trouble: no sexual indiscretions, no excessive spending ("I'm always too busy to shop"). And she volunteered that she had never "seen visions, heard voices, or had funny ideas about people following me around." She had never spent time "in the funny farm." As Iris paused to gather her thoughts, her fingers clutched the cigarette package. She shook her head almost imperceptibly. Without uttering another word, she grabbed her purse, arose from the chair, and swooped out the door. It was the last the interviewer saw of her for a year and a half. In November of the following year, a person announcing herself as Iris McMaster dropped into that same office chair. She seemed like an impostor. She'd gained 30 or 40 pounds, which she had stuffed into polyester slacks and a bulky knit sweater. "As I was saying," were the first words she uttered. Just for a second, the corners of her mouth twitched up. But for the rest of the hour she soberly talked about her latest problem: writer's block. About a year ago, she had finished her play and was well into her comic novel when the muse deserted her. For months now, she had been arising around lunchtime and spending long afternoons staring at her computer. "Sometimes I don't even turn it on!" she said. She couldn't focus her thinking to create anything that seemed worth clicking on "save." Most nights she tumbled into bed at 9. She felt tired and heavy, as though her legs were made of bricks. "It's cheesecake, actually," was how Iris described her weight gain. "I have it delivered. For months I haven't been interested enough to cook for myself." She hadn't been suicidal, but the only time she felt much better was when Charlene took her out to lunch. Then she ate and made conversation pretty much as she used to. "I've done that quite a lot recently, as anyone can see." Once she returned home, the depression flooded back. Finally, Iris apologized for walking out a year and a half earlier. "I didn't think I was the least bit sick," she said, "and all I really wanted to do was get back to my computer and get your character on paper!"

Bipolar II disorder, depressed, moderate, with atypical features rationale: hypomanic episode - elevated mood - 4/3 symptoms: high self-esteem, decreased need for sleep, talkativeness, increased goal-directed activity depressive episode - sxs: feeling depressed, weight gain, hypersomnia, fatigue, poor concentration - otherwise, would qualify as Unspecified bipolar disorder

CASE STUDY: Rosalind Noonan came to her university's student health service because of a stutter. This was remarkable because she was 18 and she had only been stuttering for 2 days. It had begun on Tuesday afternoon during her women's issues seminar. The class had been discussing sexual harassment, which gradually led to a consideration of sexual molestation. To foster discussion, the graduate student leading the seminar asked each participant to comment. When Rosalind's turn came, she stuttered so badly that she gave up trying to talk at all. "I still ca-ca-ca-can't understand it," she told the interviewer. "It's the first time I've ever had this pr-pr-pro-pro—difficulty." Rosalind was a first-year student who had decided to major in psychology, she said, "to help me learn more about myself." What she already knew included the following. Rosalind had no information about her biological parents. She had been adopted when she was only a week old by a high school physics teacher and his wife, who had no other children. Her father was a rigid and perfectionistic man who dominated both Rosalind and her mother. As a young child, Rosalind was overly active; during her early school years she'd had difficulty focusing her attention. She would probably have qualified for a diagnosis of attention-deficit/hyperactivity disorder, but the only evaluation she had ever had was from their family physician, who thought it was "just a phase" that she would soon outgrow. Despite that lack of diagnostic rigor, when she was 12 she did begin to grow out of it. By the time she entered high school, she was doing nearly straight-A work. Although she had had many friends in high school and had dated extensively, she'd never had a serious boyfriend. Her physical health had been excellent, and her only visits to doctors had been for immunizations. Her mood was almost always bright and cheerful; she had no history of delusions or hallucinations, and she had never used drugs or alcohol. "I g-g-grew up healthy and happy," she protested. "That's why I d-d-d-don't understand this!" "Hardly anyone reaches adulthood without having some problems." The interviewer paused for a response, but received none, and so continued: "For example, when you were a child, did anyone ever approach you for sex?" Rosalind's gaze seemed to lose focus as tears trickled from her eyes. Haltingly at first, then in a rush, the following story emerged. When she was 9 or 10, her parents had become friendly with a married couple, both English teachers at her father's school. When she was 14, the woman had suddenly died; subsequently, the man was invited for dinner on a number of occasions. One evening he consumed too much wine and was put to bed on their living room sofa. Rosalind awakened to find him lying on top of her in her bed, his hand covering her mouth. She was never certain whether he actually entered her, but her struggles apparently caused him to ejaculate. After that, he left her room. He never again returned to their home. The following day she confided her story to her mother, who at first assured Rosalind that she must have been dreaming. When confronted with the evidence of the stained sheets, her mother urged her to say nothing about the matter to her father. It was the last time the subject had ever been discussed in their house. "I'm not sure what we thought Daddy would do if he found out," Rosalind commented, with notable fluency, "but we were both afraid of him. I felt I'd done something to be punished for, and I suppose Mom must have worried he'd attack the other teacher."

Conversion disorder, with speech symptom (stuttering), acute episode, with psychological stressor (concerns about molestation) - rationale: not IAD as client focused on the symptom, rather than fear of having some serious disease

CASE STUDY: "I'm a yo-yo!" Without her feathers and sequins, Honey Bare looked anything but provocative. She had begun life as Melissa Schwartz, but she loved using her stage name. The stage in question was Hoofer's, one of the bump-and-grind joints that thrived near the waterfront. The billboard proclaimed that it was "Only a Heartthrob Away" from the Navy recruiting station. Since she'd dropped out of college 4 years earlier, Honey had been a front-liner in the four-girl show at Hoofer's. Every afternoon on her way to work she passed right by the mental health clinic, but this was her first visit inside. "In our current gig, I play the Statue of Liberty. I receive the tired, the poor, and the huddled masses. Then I take off my robes." "Is that a problem?" the interviewer wanted to know. Most of the time, it wasn't. Honey liked her little corner of show biz. When the fleet was in, she played to thunderous applause. "In fact, I enjoy just about everything I do. I don't drink much, and I never do drugs, but I go to parties. I sing in our church choir, go to movies—I enjoy art films quite a bit." When she felt well, she slept little, talked a lot, started a hundred projects, and even finished some of them. "I'm really a happy person—when I'm feeling up." But every couple of months, there'd be a week or two when Honey didn't enjoy much of anything. She'd paste a smile on her face and go to work, but when the curtain rang down, the smile came off with her makeup. She was never suicidal, and her sleep and appetite didn't suffer; her energy and concentration were normal. But it was as if all the fizz had gone out of her ginger ale. She could see no obvious cause for her mood swings, which had been going on for years. She could count on the fingers of both hands the number of weeks she had been "just normal." Lately, Honey had acquired a boyfriend—a chief petty officer who wanted to marry her. He said he loved her because she was so vivacious and enthusiastic, but he had only seen her when she was bubbly. Always before, when she was depressed, he had been out to sea. Now he had written that he was being transferred to shore duty, and she feared it would be the end of their relationship. As she said it, two large tears trickled through the mascara and down her cheeks. Four months and several visits later, Honey was back, wearing a smile. The lithium carbonate, she reported, seemed to be working well. The peaks and valleys of her moods had smoothed out to rolling hills. She was still playing the Statue of Liberty down at Hoofer's. "My sailor's been back for nearly 3 months," she said, "and he's still carrying the torch for me."

Cyclothymic disorder rationale: - no vegetative symptoms (not a major depressive episode) - "up" moods were not abnormal, but part of her normal functioning

CASE STUDY: Molly McConegal, a tiny sparrow of a woman, sat perched on the front of her waiting room chair. On her lap she tightly clutched a scuffed black handbag; her gray hair was caught up in a fierce little bun at the back of her head. Through spectacles as thick as highball glasses, she darted myopic, suspicious glances about the room. She had already spent 45 minutes with the consultant behind closed doors. Now she was waiting while her husband, Michael, had a turn. Michael confirmed much of what Molly had already said. The couple had been married for over 40 years, had two children, and had lived in the same neighborhood (the same house, in fact) nearly all of their married life. Both were retired from the telephone company, and they shared an interest in gardening. "That was where it all started, in the garden," said Michael. "It was last summer, when I was out trimming the rose bushes in the front yard. Molly said she caught me looking at the house across the street. The widow woman who lives there is younger than we are, maybe 50. We nod and say 'Hi,' but in 10 years, I've never even been inside her front door. But Molly said I was taking too long on those rose bushes, that I was waiting for our neighbor—her name is Mrs. Jessup—to come out of the house. Of course, I denied it, but she insisted. Kept talking about it for days." In the following months, Molly pursued the idea of Michael's supposed extramarital relationship. At first she only suggested that he had been trying to lure Mrs. Jessup out for a meeting. Within a few weeks, she "knew" that they had been together. Soon this had become a sex orgy. Molly had talked of little else and had begun to incorporate many commonplace observations into her suspicions. A button undone on Michael's shirt meant that he had just returned from a visit with "the woman." The adjustment of the living room Venetian blinds tipped her off that he had been trying to semaphore messages the night before. A private detective Molly hired for surveillance only stopped by to chat with Michael, submitted a bill for $500, and resigned. Molly continued to do the cooking and washing for herself, but Michael now had to take care of his own meals and laundry. She slept normally, ate well, and—when she wasn't with him—seemed to be in good spirits. Michael, on the other hand, was becoming a nervous wreck. Molly listened in on his telephone calls and steamed open his mail. Once she told him that she would file for divorce, but she "didn't want the children to find out." Twice he had awakened at night to find her wrapped tightly in her bathrobe and standing beside his bed, glowering down at him. "Waiting for me to make my move," he said. Last week she had strewn the hallway outside his room with thumbtacks, so that he would cry out and awaken her when he sneaked away for his late-night sexual rendezvous. Michael smiled and said sadly, "You know, I haven't had sex with anybody for nearly 15 years. Since I had my prostate operation, I just haven't had the ability."

Delusional disorder, jealous type

CASE STUDY: Miriam Phillips was 23 when she was hospitalized. She had spent nearly all her life in the Ozarks, where she sometimes attended class in a three-room school. Although she was bright enough, she had little interest in her studies and often volunteered to stay home to care for her mother, who was unwell. She dropped out of 12th grade to stay home full-time. It was lonely living in the hills. Miriam's father, a long-distance trucker, was away most of the time. She had never learned to drive, and there were no close neighbors. Their television set received mostly snow; there was little in the way of mail; and there were no visitors at all. So she was surprised late on a Monday afternoon when two men paid a call. After identifying themselves as FBI agents, they asked if she was the Miriam Phillips who 3 weeks earlier had written a letter to the president. When she asked how they had known, they showed her a faxed copy of her own letter: Dear Mr. President, what do you plan to do about the Cubans? They have been working on mother. Their up to no good. Ive seen the police, but they say Cubans are your job, and I guess their right. You have to do your job or Ill have a dirty job to do. Miriam Phillips. When Miriam finally figured out that the FBI agents thought she had threatened the president, she relaxed. She hadn't meant that at all. She had meant that if no one else took action, she'd have to crawl under the house to get the gravity machines. "Gravity machines?" The two agents looked at each other. She explained. They had been installed under the house by Cuban agents of Fidel Castro after the Bay of Pigs invasion in the 1960s. The machines pulled your body fluids down toward your feet. They hadn't affected her yet, but they had bothered her mother for years. Miriam had seen the hideous swelling in her mother's ankles. Some days it extended almost to her knees. The two agents listened to her politely, then left. As they passed through town on their way to the airport, they called at the local community mental health clinic. Within a few days, a mental health worker came to interview Miriam, who agreed to enter the hospital voluntarily for a "checkup." On admission, Miriam appeared remarkably intact. She had a full range of appropriate affect and normal cognitive abilities and orientation. Her reasoning ability seemed good, aside from the story about the gravity machines. As far back as her teens, her mother had told her how the machines came to be installed in the crawlspace under their house. Mother had been a nurse, and Miriam had always accepted her word in medical matters. By some unspoken agreement, the two had never discussed the matter with Miriam's father. After Miriam had been on the ward for 3 days, her clinician asked whether she thought any other explanation for her mother's edema was possible. Miriam considered. She had never felt the gravity effects herself. She had believed that her mother told her the truth, but she now supposed that even Mother could have been mistaken. Though Miriam was given no medication, after a week she stopped talking about gravity machines and asked to be discharged. At the end of their shift that afternoon, two young attendants gave her a lift home. As they walked her to the front door, it was opened by a short woman, quite stout, with salt-and-pepper hair. Her lower legs were neatly wrapped in elastic bandages. Through the partly opened door she darted a glance at the two men. "Hmmm!" she said. "You look like Cubans."

Delusional disorder, persecutory type, with bizarre content

CASE STUDY: Jason Bird carried no health care card—he claimed he had lost his billfold to a mugger a few hours before he came to the emergency room of a Midwestern hospital late one Saturday night, complaining of crushing substernal chest pain. Although his electrocardiogram (EKG) was markedly abnormal, it did not show the changes typical of an acute myocardial infarction. The cardiologist on call, noting his ashen pallor and obvious distress, ordered him admitted to the cardiac ICU, then waited for the cardiac enzyme results. The following day, Jason's EKG was unchanged, and the serum enzymes showed no evidence of heart muscle damage. His chest pain continued. He complained loudly that he was being ignored. The cardiologist urgently requested a mental health consultation. At age 47, Jason was a slightly built man with a bright, shifting gaze and a 4-day growth of beard. He spoke with a nasal Boston accent. His right shoulder bore the tattoo of a boot and the legend "Born To Kick Ass." Throughout the interview he frequently complained of chest pain, but he breathed and talked normally, and he showed no evident anxiety about his medical condition. He said he had grown up in Quincy, Massachusetts, the son of a physician. After high school he had attended college for several years, but found he was "too creative" to stick with a profession or a conventional job. Instead, he had turned to inventing medical devices, and numbered among his successes a positive-pressure respirator that bore his name. Although he had made several fortunes, he had lost nearly everything to his penchant for playing the stock market. He had been visiting in the area, relaxing, when the chest pain struck. "And you've never had it before?" asked the interviewer, looking through the chart. Jason denied that he'd had any previous heart trouble. "Not even a twinge. I've always been blessed with good health." "Ever been hospitalized?" "Nope. Well, not since a tonsillectomy when I was a kid." Further questioning was similarly unproductive. As the interviewer left, Jason was demanding extra meal service. Playing a hunch, the interviewer began telephoning emergency room physicians in the Boston area to ask about a patient with Jason's name or peculiar tattoo. The third try struck pay dirt. "Jason Bird? I wondered when we'd hear from him again. He's been in and out of half the facilities in the state. His funny-looking EKG—probably an old MI—looks pretty bad, so he always gets admitted, but there's never any evidence that anything acute is going on. I don't think he's addicted. A couple of years ago, he was admitted for a genuine pneumonia and got through a week without pain medication and with no withdrawal symptoms. He'll stay in the ICU a couple of days and rag on the staff. Then he'll split. He seems to enjoy needling medical people." "He told me that he was the son of a physician and that he was a wealthy inventor." The voice on the other end of the line chuckled. "The old respirator story. I checked into that one when he was admitted here for the third time. That was a different Bird altogether. I don't know that Jason's ever invented anything in his life—other than his medical history. As for his father, I think he was a chiropractor." Returning to the ward to add a note to the chart, the interviewer discovered that Jason had discharged himself against advice and departed, leaving behind a letter of complaint to the hospital administrator.

Factitious disorder imposed on self

CASE STUDY: For most of his adult life, Bert had been "a worry-wart." At age 35, he still had dreams that he was flunking all of his college electrical engineering courses. But recently he had felt that he was walking a tightrope. For the past year he had been the administrative assistant to the chief executive officer of a Fortune 500 company, where he had previously worked in product engineering. "I took the job because it seemed a great way to move up the corporate ladder," he said, "but almost every day I have the feeling my foot's about to slip off the rung." Each of the company's six ambitious vice-presidents saw Bert as a personal pipeline to the CEO. His boss was a hard-driving workaholic who constantly sparked ideas and wanted them implemented yesterday. Several times he had told Bert that he was pleased with his performance. In fact, Bert was doing the best job of any administrative assistant he had ever had, but that didn't seem to reassure Bert. "I've felt uptight just about every day since I started this job. My chief expects action and results. He has zero patience for thinking about how it should all fit together. Our vice-presidents all want to have their own way. Several of them hint pretty broadly that if I don't help them, they'll put in a bad word with the boss. I'm always looking over my shoulder." Bert had trouble concentrating at work; at night he was exhausted but had trouble getting to sleep. Once he did, he slept fitfully. He had become chronically irritable at home, yelling at his children for no reason. He had never had a panic attack, and he didn't think he was depressed. In fact, he still took a great deal of pleasure in the two activities he enjoyed most: Sunday afternoon football on TV and Saturday night lovemaking with his wife. But recently, she had offered to take the kids to her mother's for a few weeks, to relieve some of the pressure. This only resurrected some of his old concerns that he wasn't good enough for her—that she might find someone else and leave him. Bert was slightly overweight and balding, and he looked apprehensive. He was carefully dressed and fidgeted a bit; his speech was clear, coherent, relevant, and spontaneous. He denied having obsessions, compulsions, phobias, delusions, or hallucinations. On the MMSE, he scored a perfect 30. He said that his main problem—his only problem—was his nagging uneasiness. Valium made him drowsy. He had tried meditating, but it only allowed him to concentrate more effectively on his problems. For a few weeks he had tried having a cocktail before dinner; that had both relaxed him and prompted worries about alcoholism. Once or twice he even went with his brother-in-law to an Alcoholics Anonymous meeting. "Now I've decided to try dreading one day at a time.

Generalized anxiety disorder

CASE STUDY: Though well educated (Columbia University) and a talented pianist, Langley Collyer probably never held gainful employment. He and his older brother, Homer, lived in the Harlem house left them by their parents, an obstetrician and his wife who were first cousins. Trained as a lawyer, Homer worked for a time, but his vision deteriorated and he suffered from arthritis. So, as they grew older, the brothers lived on their inherited money. They didn't require much: They had no gas, electricity, or telephone service. Even the water was eventually turned off. For decades, they essentially camped out indoors. Langley would walk miles to the store for supplies that he'd bring home in a wagon, pulled along by a string. On these journeys, he also collected much of the debris that ultimately invaded their living space. Though he wore clothes long out of fashion, Langley was not completely asocial. As reported from accounts of those who knew him, he was pleasant, at times grateful for company. He even admitted that he was too reclusive. In 1947, at age 61, Langley died, crushed under the weight of the booby trap he'd designed and installed over a period of years to prevent criminals from stealing the brothers' possessions. Finding the doorways stuffed with 10-foot-high walls of bailed newspaper and other debris, police had to chop their way in. It took them over 2 weeks to find Langley's body, which lay just 10 feet from where Homer had subsequently also died—of starvation. After the bodies had been removed, the house was cleared of its holdings. Workers found dressmaker's dummies, sheets of Braille, a doll carriage, bicycles, a photograph of Mickey Rooney, old advertisements, firearms and ammunition, parts for old radios, chunks of concrete, and shoelaces. The brothers had stored some of their body waste in jars. There was a two-headed baby preserved in formaldehyde (probably an artifact from their father's medical practice), a canoe, a dismantled Model T automobile, two pipe organs, thousands of empty tin cans, and 14 pianos. There were also tons of newspapers, saved so that Homer could catch up on the news, once he regained his sight. In all, the house eventually yielded 180 tons of junk, with everything covered in decades of dust.

Hoarding disorder, with excessive acquisition

CASE STUDY: "Wow! That chart must be 2 inches thick." Julian Fenster was being checked in for his third emergency room visit in the past month. "That's just Volume 3," the nurse told him. At age 24, Julian lived with his mother and a teenage sister. Years ago, he'd started attending a college several hundred miles away. After only a semester, he'd moved back home. "I didn't want to be that far from my doctors," he remarked. "When you're trying to prevent heart disease, you can't be too careful." With a practiced hand, he adjusted the blood pressure cuff around his upper arm. When Julian was a young teenager, his dad had died. "His death was self-inflicted," Julian pointed out. "He'd had rheumatic fever as a child, which gave him an enlarged heart. And the only thing he ever exercised was his right to eat anything fried, including Twinkies. And he smoked—he was a proud two-pack-a-day man. Look where that got him." None of these health risks applied to Julian, who was nothing if not careful about what he put into his body. He had spent hours searching the Internet for information on diet, and he'd attended a lecture by Dean Ornish. "I've followed a plant-based diet ever since," Julian said. "I'm especially keen on tofu. And broccoli." Julian had never complained much of symptoms—just the odd palpitation, maybe "hot flushes" on an especially humid day. "I don't feel bad," he explained. "I just feel scared." This time, he'd heard a report on NPR about young people with heart disease. It had startled him so much he'd dropped the dish he had been putting into the cupboard. Without even cleaning up the mess, he caught the next bus to the ER. Julian agreed that he needed a different approach to his health care needs, and thought he might be willing to give cognitive-behavioral therapy a try. "But first," he asked, "could you check my blood pressure just once more?"

Illness anxiety disorder, care-seeking type rationale: disproportionate concern for a concern he'd been assured he did not have

CASE STUDY: Seated in the clinician's waiting room, Shorty Rheinbold should have been relaxed. The lighting was soft, the music soothing; the sofa on which he was sitting was comfortably upholstered. Angel fish swam lazily in their sparkling glass tank. But Shorty felt anything but calm. Perhaps it was the receptionist—he wondered whether she was competent to handle an emergency with his sort of problem. She looked something like a badger, holed up behind her computer. For several minutes he had been feeling worse with every heartbeat. His heart was the key. When Shorty first sat down, he hadn't even noticed it, quietly ticking away, just doing its job inside his chest. But then, without any warning, it had begun to demand his attention. At first it had only skipped a beat or two, but after a minute, it had begun a ferocious assault on the inside of his chest wall. Every beat had become a painful, bruising thump that caused him to clutch at his chest. He tried to keep his hands under his jacket so as not to attract too much attention. The pounding heart and chest pain could mean only one thing—after 2 months of attacks every few days, Shorty was beginning to get the message. Then, right on schedule, the shortness of breath began. It seemed to arise from his left chest area, where his heart was doing all the damage. It clawed its way up through his lungs and into his throat, gripping him around the neck so he could breathe only in the briefest of gulps. He was dying! Of course, the cardiologist Shorty consulted the week before had assured him that his heart was as sound as a brass bell, but this time he knew it was about to fail. He couldn't fathom why he hadn't died before; he had feared it with every attack. Now it seemed impossible that he would survive this one. Did he even want to? That thought made him suddenly want to retch. Shorty leaned forward so he could grip both his chest and his abdomen as unobtrusively as possible. He could hardly hold anything at all: The familiar tingling and numbness had started up in his fingers, and he could sense the shaking of his hands as they tried to contain the various miseries that had taken over his body. He glanced across the room to see whether Miss Badger had noticed. No help was coming from that quarter; she was still pounding away at her keyboard. Perhaps all the patients behaved this way. Perhaps—suddenly, there was an observer. Shorty was watching himself! Some part of him had floated free and seemed to hang suspended, halfway up the wall. From this vantage point, he could look down and view with pity and scorn the quivering flesh that was, or had been, Shorty Rheinbold. Now the Spirit Shorty saw that Shorty's face had become fiery red. Hot air had filled his head, which seemed to expand with every gasp. He floated farther up the wall and the ceiling melted away; he soared out into the brilliant sunshine. He squeezed his eyes shut but could not keep out the blinding light. Shorty opened his eyes to discover that he was lying on his back on the waiting room floor. Two people were bending over him. One was the receptionist. He didn't recognize the other, but he guessed it must be the mental health clinician who was supposed to interview him. "I feel like you saved my life," he said. "Not really," the clinician replied. "You're just fine. Does this happen often?" "Every 2 or 3 days now." Shorty cautiously sat up. After a moment or two, he allowed them to help him to his feet and into the inner office. Just when his problem had begun wasn't quite clear at first. Shorty was 24 and had spent 4 years in the Coast Guard. Since his discharge, he'd knocked around a bit, and then moved in with his folks while he worked in construction. Six months ago, he'd gotten a job as cashier in a filling station. That was just fine, sitting in a glassed-in booth all day making change, running credit cards through the electronic scanner, and selling chewing gum. The wages weren't exciting, but he didn't have to pay rent. Even with eating out almost every evening, Shorty still had enough at the end of the week to take his girl out on Saturday nights. Neither one of them drank or used drugs, so even that didn't set him too far back. The problem had begun the day after Shorty had been working for a couple of months, when the boss told him to go out on the wrecker with Bruce, one of the mechanics. They had stopped along the eastbound Interstate to pick up an old Buick Skylark with a blown head gasket. For some reason, they had trouble getting it into the sling. Shorty was on the traffic side of the truck, trying to manipulate the hoist in response to Bruce's shouted directions. Suddenly, a caravan of tractor-trailer trucks roared past. The noise and the blast of wind caught Shorty off guard. He spun around into the side of the wrecker, fell, and rolled to a stop, inches from huge tires rolling by. Shorty's color and heart rate had returned to normal. The remainder of his story was easy enough to tell. He continued to go out on the wrecker, even though he felt scared, near panic every time he did so. He'd only go when Bruce was along, and he carefully avoided the traffic side of the vehicles. But that wasn't the worst of the problem—he could always quit and get another job. Lately, Shorty had been having these attacks at other times, when he was least expecting them. Now nothing seemed to trigger the attacks; they just happened, though not when he was at home or in his glass cage at work. When he was shopping last week, he'd had to abandon the cart full of groceries he was buying for his mother. Now he didn't even want to go to the movies with his girl. For the last few weeks he had suggested that they spend Saturday night at her place watching TV instead. She hadn't complained yet, but he knew it was only a matter of time. "I have just about enough strength to tough it out through the work day," Shorty said. "But I've got to get a handle on this thing. I'm too young to spend the rest of my life like a hermit in a cave."

Panic Disorder, Agoraphobia rationale: - experience of unexpected panic attacks - altered his activity due to worry/concern - ruled out medical conditions/substance-induced anxiety - fear of situations that involved being away from home - avoidance of situations or need to be accompanied by Bruce/girlfriend

CASE STUDY: For Noah Sanders, life had never seemed much fun. He was 18 when he first noticed that most of the time he "just felt down." Although he was bright and studied hard, throughout college he was often distracted by thoughts that he didn't measure up to his classmates. He landed a job with a leading electronics firm, but turned down several promotions because he felt that he could not cope with added responsibility. It took dogged determination and long hours of work to compensate for this "inherent second-rateness." The effort left him chronically tired. Even his marriage and the birth of his two daughters only relieved his gloom for a few weeks at a time, at best. His self-confidence was so low that, by common consent, his wife always made most of their family's decisions. "It's the way I've always been. I am a professional pessimist," Noah told his family doctor one day when he was in his early 30s. The doctor replied that he had a depressive personality. For many years, that description seemed to fit. Then, when Noah was in his early 40s, his younger daughter left home for college; after this, he began to feel increasingly that life had passed him by. Over a period of several months, his depression deepened. He had worsened to the point that he now felt he had never really been depressed before. Even visits from his daughters, which had always cheered him up, failed to improve his outlook. Usually a sound sleeper, Noah began awakening at about 4 a.m. and ruminating over his mistakes. His appetite fell off, and he lost weight. When for the third time in a week his wife found him weeping in their bedroom, he confessed that he had felt so guilty about his failures that he thought they'd all be better off without him. She decided that he needed treatment. Noah was started on an antidepressant medication. Within 2 weeks, his mood had brightened and he was sleeping soundly; at 1 month, he had "never felt better" in his life. Whereas he had once avoided oral presentations at work, he began to look forward to them as "a chance to show what I could do." His chronic fatigue faded, and he began jogging to use up some of his excess energy. In his spare time, he started his own small business to develop and promote some of his engineering innovations. Noah remained on his medication thereafter. On the two or three occasions when he and his therapist tried to reduce it, he found himself relapsing into his old, depressive frame of mind. He continued to operate his small business as a sideline

Persistent mood disorder, severe, early onset, with intermittent major depressive episode, with current episode, with melancholic features

CASE STUDY: "Look, I don't need you to tell me what's wrong. I know what's wrong. I just need you to fix it." One ankle crossed over the other, Amy Jernigan slouched in the consultation chair and gazed steadily at her clinician. "I brought a list of my symptoms, just so there won't be any confusion." She unfolded a half-sheet of embossed stationery. "It always starts out 4 or 5 days before my period," she recited. "I begin by feeling uptight, like I'm waiting to take an exam I haven't studied for. Then, after a day or two, depression sets in and I just want to cry." She looked up and smiled. "You won't catch me doing that now—I'm always just fine after my period starts." Still in her early 20s, Amy had graduated from a college near her home in the Deep South. Now, while waiting for her novel to sell, she did research for a political blogger. With another glance at the paper, she continued. "But before, I'm depressed, cranky, lazy as a hound dog in August, and I don't really give a shit about anything." Amy's mother, an antifeminist who'd campaigned against the Equal Rights Amendment, had refused to validate Amy's premenstrual symptoms, though she might have had them herself. Amy's problems had begun in her early teens, almost from the time of her first period. "I'd be so pissed off, I'd drive away all my friends. Fortunately, I'm pretty outgoing, so they didn't—don't—stay lost for long. But reliably every month, my breasts get so sensitive they could read Braille. Then I know I'd better put a lock on my tongue, or the next week I'll be buying beers for everyone I know." Amy tucked her list into her back pocket and sat up straight. "I hate being the feminist with PMS—I feel like a walking cliché."

Premenstrual dysphoric disorder (provisional)

CASE STUDY: Velma Dean's lips curled upwards, but the smile didn't touch her eyes. "I'm really sorry about this," she told her therapist, "but I guess—well, I don't know what." She reached into the large shopping bag she had carried into the office and pulled out a 6-inch kitchen knife. First she grasped it in her hand, with her thumb along the blade. Then she tried clutching it in her fist. The therapist reached for the alarm button under the desk top, ruefully aware of yet another change of course in this patient's multifaceted history. A month before her 18th birthday, Velma Dean had joined the Army. Her father, a colonel of artillery, had wanted a son, but Velma was his only child. Over the feeble protests of her mother, Velma's upbringing had been strict and semi-military. After working 3 years in the motor pool, Velma herself had just been promoted to sergeant when she became ill. Her illness started with 2 days in the infirmary for what seemed like bronchitis, but as the penicillin took effect and her fever resolved, the voices began. At first they seemed to be located toward the back of her head. Within a few days they had moved to her bedside water glass. As nearly as she could tell, their pitch depended on the contents of her glass: If the glass was nearly empty, the voices were female; if it was full to the top, they spoke in a rich baritone. They were always quiet and mannerly. Often they gave her advice on how to behave, but at times she said they "nearly drove me crazy" by constantly commenting on what she was doing. A psychiatrist diagnosed Velma's condition as schizophrenia and prescribed neuroleptics. The voices improved, but never quite disappeared. She concealed the fact that she had "figured out" that her illness had been caused by her first sergeant, who for months had tried unsuccessfully to get her into bed. She also hid the fact that for several weeks she had been drinking nearly a pint of Southern Comfort each evening. The Army retired her as medically unfit, 100% disabled. When she was well enough to travel, her father drove her the 600 miles back home. For her treatment, Velma enrolled at her local Department of Veterans Affairs (VA) outpatient clinic. There, her new therapist verified (1) the continuing presence (now for nearly 8 months) of her barely audible hallucinations, and (2) her increasingly profound symptoms of depression. These included low self-esteem and hopelessness (much worse in the morning than in the evening); loss of appetite; a 10-pound weight loss over the past 8 weeks; insomnia that caused her to awaken early most mornings; and the guilty conviction that she had disappointed her father by "deserting" the Army before her hitch was up. She denied thoughts of injuring herself or other people. Velma's VA clinician initially deferred making a diagnosis, noting that she had been ill too long for schizophreniform disorder and that her mood symptoms seemed to argue against schizophrenia. Physical exam and laboratory testing ruled out general medical conditions. Although Alcoholics Anonymous helped her stop drinking, her depressive and psychotic symptoms continued. Because Velma's depressive symptoms might be secondary to a partly treated psychosis, her neuroleptic dose was increased. This completely eliminated the hallucinations and delusions, but the depressive symptoms continued virtually unabated. The antidepressant imipramine at 200 mg/day only produced side effects; after 4 weeks, lithium was added. Once a therapeutic blood level was reached, her depressive symptoms melted completely away. For 6 months she remained in a good mood and free of psychosis, though she never obtained a job or did very much with her time. Now it seemed that Velma might actually be suffering from a major depressive disorder with psychotic features. At this point, her clinician became uneasy that the neuroleptic could produce side effects such as tardive dyskinesia. With Velma's consent, the neuroleptic was gradually reduced by about 20% per week. After 3 weeks, she began once again to hear voices commanding her to run away from home. During this time her mood remained good; with the exception of some difficulty getting to sleep at night, she developed none of the vegetative symptoms she had formerly had with depression. Her full former dose of neuroleptic medication was rapidly restored. After several months of renewed stability, Velma and her therapist decided to try again. This time they began cautiously to reduce the imipramine, by 25 mg each week. Each week they met to evaluate her mood and check for symptoms of psychosis. By December she had been free of the antidepressant for 2 months, and had remained symptom-free (except for her habitual bland, smiling affect). Now her therapist took a deep breath and decreased her lithium by one tablet per day. The following week Velma returned to the office, hallucinating and wondering whether to hold a kitchen knife in her hand or in her fist.

Schizoaffective disorder, depressive type rationale: - psychosis began first and lasted at least 2 weeks before mood symptoms commenced - mood symptoms occurred with and without psychotic symptoms, lasting more than half of duration of total illness

CASE STUDY: "She's nowhere near as bad as Ivan." Mr. Oblamov was talking about his two grown children. At 30 years of age, Ivan had such severe disorganized schizophrenia (as it was then known) that, despite neuroleptics and a trial of electroconvulsive therapy, he could not put 10 words together so they made sense. Now Natasha, 3 years younger than her brother, had been brought to the clinic with similar complaints. Natasha was an artist. She specialized in oil-on-canvas copies of the photographs she took of the countryside near her home. Although she had had a one-woman exhibition in a local art gallery 2 years earlier, she had never yet earned a dollar from her artwork. She had a room in her father's apartment, where the two lived on his retirement income. Her brother lived on a back ward of the state mental hospital. "I suppose it's been going on for quite a while now," said Mr. Oblamov. "I should have done something earlier, but I didn't want to believe it was happening to her, too." The signs had first appeared about 10 months ago, when Natasha stopped attending class at the art institute and gave up her two or three drawing pupils. Mostly she stayed in her room, even at mealtimes; she spent much of her time sketching. Her father finally brought Natasha for evaluation because she kept opening the door. Perhaps 6 weeks earlier she had begun emerging from her room several times each evening, standing uncertainly in the hallway for several moments, then opening the front door. After peering up and down the hallway, she would retreat to her own room. In the past week, she had reenacted this ritual a dozen times each evening. Once or twice, her father thought he heard her mutter something about "Jason." When he asked her who Jason was, she only looked blank and turned away. Natasha was a slender woman with a round face and watery blue eyes that never seemed to focus. Although she volunteered almost nothing, she answered every question clearly and logically, if briefly. She was fully oriented and had no suicidal ideas or other problems with impulse control. Her affect was as flat as one of her canvases. She would describe her most frightening experiences with no more emotion than she would making a bed. Jason was an instructor at the art institute. Some months earlier, one afternoon when her father was out, he had come to the apartment to help her with "some special stroking techniques," as she put it (referring to her brush). Although they had ended up naked together on the kitchen floor, she had spent most of that time explaining why she felt she should put her clothes back on. He left unrequited, and she never returned to the art institute. Not long afterward, Natasha "realized" that Jason was hanging about, trying to see her again. She would sense his presence just outside her door, but each time she opened it, he had vanished. This puzzled her, but she couldn't say that she felt depressed, angry, or anxious. Within a few weeks she started to hear a voice quite a bit like Jason's, which seemed to be speaking to her from the photographic enlarger she had set up in the tiny second bathroom. "It usually just said the 'C word,' " she explained in response to a question. "The 'C word'?" "You know, the place on a woman's body where you do the 'F word.' " Unblinking and calm, Natasha sat with her hands folded in her lap. Several times in the past several weeks, Jason had slipped through her window at night and climbed into her bed while she slept. She had awakened to feel the pressure of his body on hers; it was especially intense in her groin area. By the time she had fully awakened, he would be gone. The previous week when she went in to use the bathroom, the head of an eel—or perhaps it was a large snake—emerged from the toilet bowl and lunged at her. She lowered the lid on the animal's neck and it disappeared. Since then, she had only used the toilet in the hall bathroom.

Schizophrenia, first episode, acute rationale: - symptoms: visual hallucination, nonbizarre delusions about Jason, negative symptom of flat affect -active symptoms evident for a few months, prodromal symptom of staying in room present for about 10 months

CASE STUDY: At age 24, Nadine Mortimer still lived at home. The only reason for her evaluation, she told the clinician, was that her mother and stepfather had just signed on to join the Peace Corps; she, Nadine, would be left behind. "I just know I won't be able to stand it." She sobbed into her Kleenex. Being alone had frightened Nadine from the time she was very small. She thought she could trace it back to her father's death: He was a mechanic who drove a racing car for fun until the weekend he encountered a wall at the far turn of their hometown track. Her mother's response was strangely stoic. "I think I took on the job of grieving for both of us," Nadine commented. Within the year, her mother had remarried. Her first day of first grade, Nadine had been so fearful that her mother had stayed in the classroom. "I was afraid something terrible would happen to her too, and I wanted to be there, for safety." After several weeks, Natalie had been able to tolerate being left, but the following year, she threw up when Labor Day rolled around. After a few miserable weeks in second grade, she was withdrawn and home-schooled. In 10th grade, she was reading and doing math at 12th-grade level. "But my socialization skills were near nil. I'd never even been to a sleepover at another girl's house," she said. So her parents bribed her with a cell phone and a promise that she could call any time. By the time Nadine was in junior college—hardly farther away than her high school—she'd negotiated for a smart phone with a GPS device; now she could track her mother's whereabouts to within a few feet. With that, she said, she could "roam comfortably, stores and whatnot, as long as I could check Mom's location whenever I wished." Once, when her battery died, she had suffered a panic attack. Nonetheless, she still didn't graduate from junior college, and after a semester she returned home to be with her mother. "I know it seems weird," she told the interviewer, "but I always imagine that someday she won't come home to me. Just like Daddy."

Separation anxiety disorder

panic attack

abrupt surges of intense fear that reaches a peak within minutes, accompanied by a variety of physical and other symptoms (at least 4 of 13 physical/cognitive sxs)

Selective Mutism

characterized by a consistent failure to speak in social situations in which there is an expectation to speak, except when alone/with close intimates (for at least 1 month) - significant consequences in academic and social functioning

Major depressive disorder

depressed mood or loss of interest/pleasure that lasts at least 2 weeks and represents a change from previous functioning (at least 5 of following sxs are present): 1. depressed mood 2. markedly diminished interest/pleasure 3. significant weight loss/gain 4. insomnia/hypersomnia 5. psychomotor agitation 6. fatigue or loss of energy 7. feelings of worthlessness or excessive/inappropriate guilt 8. inability to concentrate 9. recurrent thoughts of death/suicide Specify: - single or recurrent episode (interval of at least 2 months in which criteria is not met), - current severity, - if with psychotic features, - remission status - any additional specifiers

Manic episode

distinct period of abnormally and persistently elevated, expansive or irritable mood and an increase in activity or energy for at least 1 week At least 3 symptoms present (4 if mood is only irritable): 1. inflated self-esteem or grandiosity 2. decreased need for sleep 3. talkativeness/pressured speech 4. flight of ideas 5. distractibility 6. increase in goal-directed activity 7. excessive involvement in activity with high potential for painful consequences - marked impairment, often resulting in hospitalization

Bipolar II disorder

lifetime experience of at least 1 major depressive episode and 1 hypomanic episode (NO manic episodes) Specify current or most recent episode, severity and any other relevant specifiers

Psychological factors affecting other medical conditions

medical symptoms or condition is present - psychological/behavioral factors adversely affect the condition Specify current severity: mild (increases risk), moderate (worsens condition), severe (causes hospital visit) or extreme (severe, life-threatening risk)

obsessions vs. compulsions

obsessions: recurrent, persistent thoughts, urges or images that are experiences as intrusive or unwanted compulsions: repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession

Conversion disorder

one or more symptoms of altered voluntary motor or sensory function with no recognized neurological/medical cause Specify - symptom type: with weakness or paralysis, abnormal movement, swallowing symptoms, speech symptoms, attacks or seizures, anesthesia or sensory loss, special sensory symptom, mixed symptoms - Acute episode: less than 6 months - Persistent: longer than 6 months - With psychological stressor (specify) - Without psychological stressor

Generalized Anxiety Disorder

persistent and excessive anxiety and worry about various domains that the individual has difficulty controlling (occurring most days for at least 6 months) - experiences physical/somatic symptoms

Grief

predominant feelings of emptiness or loss that typically decreases in intensity over time and occurs in waves - self-esteem is generally preserved - thoughts of death are generally focused on the deceased

Excoriation

recurrent picking of one's skin resulting in skin lesions, and repeated attempts to decrease/stop picking

Trichotillomania

recurrent pulling out of one's hair resulting in hair loss, and repeated attempts to decrease/stop hair pulling

signs vs. symptoms

signs: objective findings observed by clinician symptoms: subjective experience reported by client

Depressive disorders (categories)

1. Disruptive mood dysregulation disorder 2. Major depressive disorder 3. Persistent depressive disorder 4. Premenstrual dysphoric disorder

Obsessive-compulsive and related disorders (categories)

1. Obsessive-compulsive disorder 2. body dysmorphic disorder 3. hoarding disorder 4. trichotillomania (hair-pulling) 5. excoriation (skin-picking)

DSM changes

1. Regrouping/renaming of chapters: clustering based on shared sxs and adjacency conceptualized on an internalizing/externalizing framework 2. Reflects a developmental schemata 3. Replaced multi-axial for a nonaxial system: stresses integrative look 4. Harmonization of ICD-11 and DSM codes 5. Greater emphasis on age, gender and cultural considerations and assessment

spectrum of schizophrenia (categories)

1. Schizotypal personality disorder 2. Delusional disorder 3. Catatonia 4. Brief psychotic disorder 5. Schizophreniform disorder 6. Schizophrenia 7. Schizoaffective disorder

Somatic symptom and related disorders (categories)

1. Somatic symptom disorder 2. Illness anxiety disorder 3. Conversion disorder 4. Psychological factors affecting other medical conditions 5. Factitious disorder

CASE STUDY: By the time she was 21, Winona Fisk had already had two lengthy mental health hospitalizations, one each for mania and depression. Then she remained well for a year on maintenance lithium, which in the spring of her junior year in college she abruptly discontinued because she "felt so well." When two of her brothers brought her to the hospital 10 days later, she had been suspended for repeatedly disrupting classes with her boisterous behavior. On the ward, Winona's behavior was mostly a picture of manic excitement. She spoke nonstop and was constantly on the move, often rummaging through other patients' purses and lockers. But many of the thoughts flooding her mind were so sad that for 8 or 10 days she often spontaneously wept for several minutes at a time. She said she felt depressed and guilty—not for her behavior in class, but for being such a burden to her family. During these brief episodes, she claimed to hear the heart of her father beating from his grave, and she would express the wish to join him in death. She ate little and lost 15 pounds; she often awakened weeping at night and was unable to get back to sleep. Nearly a month's treatment with lithium, carbamazepine, and neuroleptics was largely futile. Her mood disorder eventually yielded to six sessions of bilateral ECT.

Bipolar I disorder, current episode manic, severe with mood-congruent psychotic features, with mixed features rationale: - feeling "too good", poor judgement, talkativeness, increased psychomotor activity - hospitalization - "microdepressions" - felt depressed, feelings of inappropriate guilt, ruminations of death

CASE STUDY: Cecil Crane was only 24 when he was referred. "He came in here last week asking for a rhinoplasty," said the plastic surgeon on the telephone, "but his nose looks perfect to me. I told him that, but he insisted there was something wrong with it. I've seen this kind of patient before—if I operate, they're never satisfied. It's a lawsuit waiting to happen." When Cecil appeared a few days later, he had the most beautiful nose the clinician had ever seen, apart from one or two Greek statues. "What seems to be wrong with it?" "I was afraid you'd ask that," said Cecil. "Everybody says that." "But you don't believe it?" "Well, they look at me funny. Even at work—I sell suits at Macy's—I sometimes feel that the customers notice. I think it's this bump here." Viewed from a certain angle, the area Cecil pointed out bore the barest suggestion of a convexity. He complained that it had cost him his girlfriend, who always said it looked fine to her. Weary of Cecil's trying to look at his profile in every mirror he passed and banging on about plastic surgery all the time, she'd finally sought greener pastures. Cecil felt unhappy, though not depressed. He admitted that he was making a mess of his life, but he had nevertheless maintained his interests in reading and going to the movies. He thought his sex interest was good, though he'd had no chance to test it since the departure of his girlfriend. His appetite was good, and his weight was about average for his height. His flow of thought was unremarkable; its content, aside from his concern for his nose, seemed quite ordinary. He even admitted that it was possible that his nose was less ugly than he feared, though he thought that unlikely. Cecil couldn't say exactly when his worry about his nose began. It may have been about the time he started shaving. He recalled frequently gazing at a silhouette of his profile that had been cut from black paper during a seashore vacation with his family. Although numerous relatives and friends had remarked that it was a good likeness, something about the nose had bothered him. One day he had taken it down from the wall and, with a pair of scissors, he'd tried to put it to rights. Within moments the nose lay in snippets on the kitchen table, and Cecil was grounded for a month. "I sure hope the plastic surgeon is a better artist than I am," he commented.

Body dysmorphic disorder, with fair insight

CASE STUDY: This was Melanie Grayson's first pregnancy, and she had been quite apprehensive about it. She had gained 30 pounds, and her blood pressure had been slightly too high. But she had needed only a spinal block for anesthesia, and her husband was in the room with her when she delivered a healthy baby girl. That night she slept fitfully; she was irritable the next day. But she breastfed her baby and seemed to listen attentively when the nurse practitioner came to instruct her on bathing and other postpartum care. The next morning, while Melanie was having breakfast, her husband came to take her and the baby home. When she ordered him to turn off the radio, he looked around the room and said he didn't hear one. "You know very well what radio," she yelled, and threw a tea bag at him. The mental health consultant noted that Melanie was alert, fully oriented, and cognitively intact. She was irritable but not depressed. She kept insisting that she heard a radio playing: "I think it's hidden in my pillow." She unzipped the pillowcase and felt around inside. "It's some sort of a news report. They're talking about what's happening in the hospital. I think I just heard my name mentioned." Melanie's flow of speech was coherent and relevant. Apart from throwing the tea bag and looking for the radio, her behavior was unremarkable. She denied hallucinations involving any of the other senses. She insisted that the voices she heard could not be imaginary, and she didn't think someone was trying to play a trick on her. She had never used drugs or alcohol, and her obstetrician vouched for her excellent general health. After much discussion, she agreed to remain in the hospital a day or two longer to try to get to the bottom of the mystery.

Brief psychotic disorder, with postpartum onset (provisional)

CASE STUDY: The evidence was stark: Brittany Fitch's face was replete with pits and scars. A few of her lesions were still inflamed, and one on her forehead had scabbed over. She'd covered her fingernails with tape. When she was 11, Brittany had developed acne, which her mother would "relieve" by squeezing the pustules and blackheads. Brittany endured long minutes standing with her head wedged into a corner, her mother's muscular fingers digging away "as if for gold," Brittany would recall years later. Released at last, she'd run to the bathroom and dab cool water on her smarting, spotted face. She'd hated her mother. Now in college, Brittany had taken over the squeezing and picking job, though she knew it only led to more damaged skin. Several times a week she'd attack herself, usually just a few minutes at a time, but longer if she was alone in the bathroom. She felt drawn to mirrors to inspect, to criticize her face; those inspections, inevitably, ushered in further bouts of destruction. Because she felt ashamed of the damage she'd wreaked, she avoided dating. It had been 6 months since she'd attended a play or a concert, even by herself. "I hope you can help me," she said with a wry smile. "More than anything, I want to stop being my mother."

Excoriation disorder

CASE STUDY: Police reports are usually pretty dry; they don't often moisten the eye. The Frankel case proved the exception to that rule. When Rose Frankel was only 2 years old, she began to experience intestinal and other symptoms that would fill the next 6 years of her life. It started with spells of vomiting that seemed intractable to treatment. In all, she was carried back and forth to the pediatrician's office, and frequently to the hospital, some 200 times. Each visit led to new tests, new attempts at treatment that led nowhere. She had undergone nearly two dozen operative procedures, and swallowed numerous medications for diarrhea, infections, seizures, and spells of vomiting, when finally nurses on the pediatric intensive care unit noticed that Rose would appear to be on the mend until her mother, Claudia, arrived and would take her to a private room. They'd hear Rose crying, and her health would take another turn for the worse—sometimes, just when she was thought ready for discharge. In all, Rose suffered nearly a dozen serious infections; one of them, a life-threatening sepsis, involved multiple organisms. Through it all, Claudia worked closely with their family doctor. They would speak in person or on the phone several times a day, and Dr. Bhend often spoke of Claudia as his "good right arm" in trying to get to the bottom of the calamity that was engulfing their patient. During the 4 years of her medical ordeal, the only time that Rose remained healthy longer than a month was when Claudia left town to nurse her own mother, during what proved to be that old lady's final illness. For the last few weeks of her kindergarten year, Rose bloomed. But she sickened again, shortly after Grandma died and Claudia returned home. Several on the hospital nursing staff were beyond suspicious. Once, they'd found a bottle of Ipecac discarded in the room Rose had occupied. On another occasion, a monitoring device that three staff members had checked within the hour had been found turned off. As they told the investigating officers, most staff members had concluded that Claudia was directly responsible for her daughter's illness, so they hid a camera in the private room Claudia always used during Rose's many admissions. When he found out, Dr. Bhend, concerned about the loss of trust, warned Claudia of the "impending sting." That afternoon, she checked Rose out of the hospital, and they were lost to follow-up. The staff revealed the full details to the police, who opened a file but were never able to pull together solid information.

Factitious disorder imposed on another (provisional)

CASE STUDY: "I just know it was a terrible mistake to come here." For the third time, Aileen Parmeter got out of her chair and walked to the window. A wiry 5 feet 2 inches, this former Marine master sergeant (she had supervised a steno pool) weighed a scant 100 pounds. Through the slats of the Venetian blinds, she peered longingly at freedom in the parking lot below. "I just don't know whatever made me come." "You came because I asked you to," her clinician explained. "Your nephew called and said you were getting depressed again. It's just like last time." "No, I don't think so. I was just upset," she explained patiently. "I had a little cold for a few days and couldn't play my tennis. I'll be fine if I just get back to my little apartment." "Have you been hearing voices or seeing things this time?" "Well, of course not." She seemed rather offended. "You might as well ask if I've been drinking." After her last hospitalization, Aileen had been well for about 10 months. Although she had taken her medicine for only a few weeks, she had remained active until 3 weeks ago. Then she stopped seeing her friends and wouldn't play tennis because she "just didn't enjoy it." She worried constantly about her health and had been unable to sleep. Although she didn't complain of decreased appetite, she had lost about 10 pounds. "Well, who wouldn't have trouble? I've just been too tired to get my regular exercise." She tried to smile, but it came off crooked and forced. "Miss Parmeter, what about the suicidal thoughts?" "I don't know what you mean." "I mean, each time you've been here—last year, and 2 years before that—you were admitted because you tried to kill yourself." "I'm going to be fine now. Just let me go home." But her therapist, whose memory was long, had ordered Aileen held for her own protection in a private room where she could be observed one-on-one. Sleepless still at 3 a.m., Aileen got up, smiled wanly at the attendant, and went in to use the bathroom. Looping a strip she had torn from her sweatsuit over the top of the door, she tried to hang herself. As the silence lengthened, the attendant called out softly, then tapped on the door, then opened it and sounded the alarm. The code team responded with no time to spare. The following morning, the therapist was back at her bedside. "Why did you try to do that, Miss Parmeter?" "I didn't try to do anything. I must have been confused." She gingerly touched the purple bruises that ringed her neck. "This sure hurts. I know I'd feel better if you'd just let me go home." Aileen remained hospitalized for 10 days. Once her sore neck would allow, she began to take her antidepressant medication again. Soon she was sleeping and eating normally, and she made a perfect score on the MMSE. She was released to go home to her apartment and her tennis, still uncertain why everyone had made such a fuss about her.

Major depressive disorder, recurrent, severe rationale: - loss of interest in usual activities for longer than 2 weeks - symptoms: fatigue, insomnia, weight loss, suicidal behavior - impaired to the point of hospitalization

CASE STUDY: Brian Murphy had inherited a small business from his father and built it into a large one. When he sold out a few years later, he invested most of his money; with the rest, he bought a small almond farm in northern California. With his tractor, he handled most of the farm chores himself. Most years the farm earned a few hundred dollars, but as Brian was fond of pointing out, it really didn't make much difference. If he never made a dime, he felt he got "full value from keeping busy and fit." When Brian was 55, his mood, which had always been normal, slid into depression. Farm chores seemed increasingly to be a burden; his tractor sat idle in its shed. As his mood blackened, Brian's body functioning seemed to deteriorate. Although he was constantly fatigued, often falling into bed by 9 p.m., he would invariably awaken at 2 or 3 a.m. Then obsessive worrying kept him awake until sunrise. Mornings were worst for him. The prospect of "another damn day to get through" seemed overwhelming. In the evenings he usually felt somewhat better, though he'd sit around working out sums on a magazine cover to see how much money they'd have if he "couldn't work the farm" and they had to live on their savings. His appetite deserted him. Although he never weighed himself, he had to buckle his belt two notches smaller than he had several months before. "Brian just seemed to lose interest," his wife, Rachel, reported the day he was admitted to the hospital. "He doesn't enjoy anything any more. He spends all his time sitting around and worrying about being in debt. We owe a few hundred dollars on our credit card, but we pay it off every month!" During the previous week or two, Brian had begun to ruminate about his health. "At first it was his blood pressure," Rachel said. "He'd ask me to take it several times a day. I still work part-time as a nurse. Several times he thought he was having a stroke. Then yesterday he became convinced that his heart was going to stop. He'd get up, feel his pulse, pace around the room, lie down, put his feet above his head, do everything he could to 'keep it going.' That's when I decided to bring him here." "We'll have to sell the farm." That was the first thing Brian said to the mental health clinician when they met. Brian was casually dressed and rather rumpled. He had prominent worry lines on his forehead, and he kept feeling for his pulse. Several times during the interview, he seemed unable to sit still; he would get up from the bed where he was sitting and pace over to the window. His speech was slow but coherent. He talked mostly about his feelings of being poverty-stricken and his fears that the farm would have to go on the block. He denied having hallucinations, but admitted to feeling tired and "all washed up— not good for anything any more." He was fully oriented, had a full fund of information, and scored a perfect 30 on the MMSE. He admitted that he was depressed, but he denied having thoughts about death. Somewhat reluctantly, he agreed that he might need treatment. Rachel pointed out that with his generous disability policy, his investments, and his pension from his former company, they had more money coming in than when he was healthy. "But still we have to sell the farm," Brian replied.

Major depressive disorder, single episode, severe with mood-congruent psychotic features, with melancholic features, with moderate anxious distress rationale: - longer than 2 weeks duration - 6/5 symptoms: low mood, loss of interest, fatigue, sleeplessness, low self-esteem, loss of appetite, agitation - impaired to the point of hospitalization

Mood disorder specifiers

Major depressive episode only: - with melancholic features ("classic sxs": wake early, lose appetite/weight, feel guilty, slowed down) - with atypical features - with anxious distress - with mixed features - with mood-congruent or mood-incongruent psychotic features - with catatonia - with peripartum onset - with seasonal pattern (recurrent episodes only) Course of recurring episodes: - with rapid cycling: patient has had at least 4 mood episodes within 1 year - with seasonal pattern

CASE STUDY: Pausing for a moment, Leighton Prescott leaned forward to straighten a stack of journals on the interviewer's desk. The chapped skin on the backs of his hands was the color of dusty bricks. Apparently satisfied, he resumed his narrative. "I would get this feeling that there could be semen on my hands and that it might be transferred to a woman and get her pregnant, even if I only shook hands with her. So I started washing extra carefully each time I masturbated." Leighton was a 23-year-old graduate student in plant physiology. Though he was enormously bright and dedicated to science, his grades had slipped badly over the past few months. He attributed this to the handwashing rituals. Whenever he had the thought that he might have contaminated his hands with semen, he felt compelled to scrub them vigorously. A year earlier, this had only meant 3 or 4 minutes with a bar of soap and water as hot as he could stand it. Soon he required a nail brush; still later he was brushing his hands and wrists as well. Now an elaborate ritual had evolved. First he scraped under his nails with a blade; then he used the brush on them. He then lathered surgical soap up to his elbows and scrubbed with a different brush for 15 minutes per arm. Then he would have to start over with his nails, because semen he had scrubbed off his arms might have lodged under them. If he had the thought that he had not performed one of the steps exactly right, he would have to start all over again. In recent weeks this had become the norm. "I know it seems crazy," he said with a glance at his hands. "I'm a biologist. That part of me knows that spermatozoa can't live longer than a few minutes on the skin. But if I don't wash, the pressure just builds up and up, until I have to wash—washing is the only thing that relieves the anxiety." Leighton didn't think he was depressed, though he was appropriately concerned about his symptoms. His sleep and appetite had been normal; he had never felt guilty or suicidal. "Just stupid, especially when my girl stopped seeing me. I used the bathroom in a restaurant where I took her to eat. After 45 minutes, she had to send the manager in for me." He laughed without much humor. "She said she might see me again, if I'd clean up my act."

Obsessive-compulsive disorder, with good insight

CASE STUDY: When he was young, Lyonel Childs had always been somewhat isolated, even from his two brothers and his sister. During the first few grades in school, he seemed almost suspicious if other children talked to him. He seldom seemed to feel at ease, even with those he had known since kindergarten. He never smiled or showed much emotion, so that by the time he was 10, even his siblings thought he was peculiar. Adults said he was "nervous." For a few months during his early teens, he was interested in magic and the occult; he read extensively about witchcraft and casting spells. Later he decided he would like to become a minister. He spent long hours in his room learning Bible passages by heart. Lyonel had never been much interested in sex, but at age 24, still attending college, he was attracted to a girl in his poetry class. Mary had blonde hair and dark blue eyes, and he noticed that his heart skipped a beat when he first saw her. She always said "Hello" and smiled when they met. He didn't want to betray too great an interest, so he waited until an evening several weeks later to ask her to a New Year's Eve party. She refused him, politely but firmly. As Lyonel mentioned to an interviewer months later, he thought that this seemed strange. During the day Mary was friendly and open with him, but when he ran into her at night, she was reserved. He knew there was a message in this that eluded him, and it made him feel shy and indecisive. He also noticed that his thoughts had speeded up so that he couldn't sort them out. "I noticed that my mental energy had lessened," he told the interviewer, "so I went to see the doctor. I told him I had gas forming on my intestines, and I thought it was giving me erections. And my muscles seemed all flabby. He asked me if I used drugs or was feeling depressed. I told him neither one. He gave me a prescription for some tranquilizers, but I just threw it away." Lyonel's skin was pasty white and he was abnormally thin, even for someone so slightly built. Casually dressed, he sat quietly without fidgeting during that interview. His speech was entirely ordinary; one thought flowed logically into the next, and there were no made-up words. By summer, he had become convinced that Mary was thinking about him. He decided that something must be keeping them apart. Whenever he had this feeling, his thoughts seemed to become so loud that he felt sure other people must be able to hear. He neglected to look for a summer job that year and moved back into his parents' house, where he kept to his room, brooding. He wrote long letters to Mary, most of which he destroyed. In the fall, Lyonel realized that his relatives were trying to help him. Although they would wink an eye or tap a finger to let him know when she was near, it did no good. She continued to elude him, sometimes only by minutes. At times there was a ringing in his right ear, which caused him to wonder whether he was becoming deaf. His suspicion seemed confirmed by what he privately called "a clear sign." One day while driving he noticed, as if for the first time, the control button for his rear window defroster. It was labeled "rear def," which to him meant "right-ear deafness." When winter deepened and the holidays approached, Lyonel knew that he would have to take action. He drove off to Mary's house to have it out with her. As he crossed town, people he passed nodded and winked at him to signal that they understood and approved. A woman's voice, speaking clearly from just behind him in the back seat, said, "Turn right!" and "Atta boy!"

Schizophrenia, first episode, currently in acute episode rationale: - two symptoms: delusions and hallucinations

CASE STUDY: As his sister told it, Bob Naples was always quiet when he was a kid, but not what you'd call peculiar or strange. Nothing like this had ever happened in their family before. Bob sat in a tiny consulting room down the hall. His lips moved soundlessly, and one bare leg dangled across the arm of his chair. His sole article of clothing was a red-and-white-striped pajama top. An attendant tried to drape a green sheet across his lap, but he giggled and flung it to the floor. It was hard for his sister, Sharon, to say when Bob first began to change. He was never very sociable, she said; "You might even call him a loner." He hardly ever laughed and always seemed rather distant, almost cold; he never appeared to enjoy anything he did very much. In the 5 years since he'd finished high school, he had lived at their house while he worked in her husband's machine shop, but he never really lived with them. He had never had a girlfriend—or a boyfriend, for that matter, though he sometimes used to talk with a couple of high school classmates if they dropped around. About a year and a half ago, Bob had completely stopped going out and wouldn't even return phone calls. When Sharon asked him why, he said he had better things to do. But all he did when he wasn't working was stay in his room. Sharon's husband had told her that at work, Bob stayed at his lathe during breaks and talked even less than before. "Sometimes Dave would hear Bob giggling to himself. When he'd ask what was funny, Bob would kind of shrug and just turn away, back to his work." For over a year, things didn't change much. Then, about 2 months earlier, Bob had started staying up at night. The family would hear him thumping around in his room, banging drawers, occasionally throwing things. Sometimes it sounded like he was talking to someone, but his bedroom was on the second floor and he had no phone. He stopped going in to work. "Of course, Dave'd never fire him," Sharon continued. "But he was sleepy from being up all night, and he kept nodding off at the lathe. Sometimes he'd just leave it spinning and wander over to stare out the window. Dave was relieved when he stopped coming in." In the last several weeks, all Bob would say was "Gilgamesh." Once Sharon asked him what it meant and he answered, "It's no red shoe on the backspace." This astonished her so much that she wrote it down. After that, she gave up trying to ask him for explanations. Sharon could only speculate how Bob came to be in the hospital. When she'd come home from the grocery store a few hours earlier, he was gone. Then the phone rang and it was the police, saying that they were taking him in. A security guard down at the mall had taken him into custody. He was babbling something about Gilgamesh and wearing nothing but a pajama top. Sharon blotted the corner of her eye with the cuff of her sleeve. "They aren't even his pajamas—they belong to my daughter."

Schizophrenia, first episode, currently in acute episode (provisional) rationale: - symptoms: disorganized speech and behavior

CASE STUDY: When she was 20 and had been married only a few months, Ramona Kelt was hospitalized for the first time with what was then described as "hebephrenic schizophrenia." According to records, her mood had been silly and inappropriate, her speech disjointed and hard to follow. She had been taken for evaluation after putting coffee grounds and orange peels on her head. She told the staff about television cameras in her closet that spied upon her whenever she had sex. Since then, she had had several additional episodes, widely scattered across 25 years. Whenever she fell ill, her symptoms were the same. Each time she recovered enough to return home to her husband. Every morning Ramona's husband had to prepare a list spelling out her day's activities, even including meal planning and cooking. Without it, he might arrive home to find that she had accomplished nothing that day. The couple had no children and few friends. Ramona's most recent evaluation was prompted by a change in medical care plans. Her new clinician noted that she was still taking neuroleptics; each morning her husband carefully counted them out onto her plate and watched her swallow them. During the interview, she winked and smiled when it did not seem appropriate. She said it had been several years since television cameras bothered her, but she wondered whether her closet "might be haunted."

Schizophrenia, multiple episodes, currently in partial remission rationale: - symptoms: disorganized behavior, delusion about television cameras - one serious ongoing negative symptom, avolition - though with only one symptom, client appeared partly recovered from last episode

CASE STUDY: When he was 3, Arnold Wilson's family had entered a witness protection program. At least that's what he told the mental health intake interviewer. Arnold was slim, of medium height, and clean-shaven. He wore a name tag identifying him as a medical student. His eye contact was direct and steady, and he sat quietly as he described his experiences. "It was on account of my dad," he explained. "When we lived back East, he used to be in the Mob." Arnold's father, the principal informant, later remarked, "OK, I'm an investment banker. You might think that's bad enough, but it isn't the Mob. Well, anyway, it's not that mob." Arnold's ideas had come to him as a revelation 2 months earlier. He was at his desk, studying for a physiology test, when he heard a voice just behind him. "I jumped up, thinking I must have left my door open, but there was no one in the room but me. I checked the radio and my iPod, but everything was turned off. Then I heard it again." The voice was one he recognized. "But I can't tell you whose. She told me not to." The woman's voice spoke very clearly to him and seemed to move around a lot. "Sometimes she seemed like she was just behind me. Other times, she stood outside whatever room I was in." He agrees that she spoke in complete sentences. "Sometimes full paragraphs. What a gabby person!" he remarked with a laugh. At first, the voice told him he "needed to cover my tracks, whatever that meant." When he tried to ignore it, she became "really angry, told me to believe her, or . . . " Arnold didn't finish the sentence. The voice pointed out that his last name, before he was 3, was Italian. "You know, she was really beginning to make sense." "The name change part's true," his father explained. "When I married his mother, Arnold was part of the deal. His biological father had died of cancer of the kidney. We both thought it would be best if I adopted him." That was 20 years ago. Arnold had had difficulty in middle school. His attention wandered, and so did he. As a result, he spent a lot of time in the principal's office. Although several teachers despaired of him, in high school he'd hit his stride. There he'd made excellent grades, gotten into a good college, and then been accepted at a better medical school. That autumn, just before starting his freshman year, his physical exam (and a panel of blood tests) had been completely normal. He said his roommate would testify that he hadn't used any drugs or alcohol. "It was pretty confusing, at first—the voice, I mean. I wondered if I was losing my mind. But then we talked it over, she and I. Now it seems pretty clear." When Arnold talked about the voice, he became quite animated, using appropriate hand gestures and vocal inflections. Throughout, he gave full attention to the interviewer, except once when he turned his head, as though listening to something. Or someone.

Schizophreniform disorder (provisional), with good prognostic features rationale: too long for Brief psychotic disorder, too brief for Schizophrenia - evidence of good prognosis: (1) illness began abruptly, (2) premorbid functioning was good, (3) affect was intact during evaluation

CASE STUDY: "It starts right here, and then it spreads like wildfire. I mean, like real fire!" Valerie Tubbs pointed to the right side of her neck, which she kept carefully concealed with a blue silk scarf. "It" had been happening for almost 10 years, any time she was with people; it was worse if she was with a lot of people. Then she felt that everybody noticed. Although she had never tried, Valerie didn't think that her reaction was something she could control. She just blushed whenever she thought people were watching her. It had started during a high school speech class, when she had to give a talk. She had become confused about the difference between a polyp and a medusa, and one of the boys had commented on the red spot that had appeared on her neck. She had quickly flushed all over and had to sit down, to the general amusement of the class. "He said it looked like a bull's-eye," she said. Since then, Valerie had tried to avoid the potential embarrassment of saying anything to more than a handful of people. She had given up her dream of becoming a fashion buyer for a department store, because she couldn't tolerate the scrutiny the job would entail. Instead, for the last 5 years she had worked dressing mannequins for the same store. Valerie said that it seemed "stupid" to be so afraid. It wasn't just that she turned red; she turned beet-red. "I can feel prickly little fingers of heat crawling out across my neck and up my cheek. My face feels like it's on fire, and my skin is being scraped with a rusty razor." Whenever she blushed, she didn't feel exactly panicky. It was a sense of anxiety and restlessness that made her wish her body belonged to someone else. Even the thought of meeting new people caused her to feel irritable and keyed up.

Social anxiety disorder

CASE STUDY: When Cynthia Fowler told her story, she cried. At age 35, she was talking with the most recent in her series of health care professionals. Her history was a complicated one; it began in her mid-teens with arthritis that seemed to move from one joint to another. She had been told that these were "growing pains," but the symptoms had continued to come and go over the intervening 20 years. Although she was subsequently diagnosed as having various types of arthritis, laboratory tests never substantiated any of them. A long succession of treatments had proven fruitless. In her mid-20s, Cynthia was evaluated for left flank pain, but again nothing was found. Later, abdominal pain and vomiting spells were worked up with gastroscopy and barium X-rays. Each of these studies was normal. A histamine antagonist was added to her growing list of medications, which by now included various anti-inflammatory agents, as well as prescription and over-the-counter analgesics. Cynthia had thought at one time that many of her symptoms were aggravated by her premenstrual syndrome, which she had recognized in herself after reading about it in a women's magazine. She had invariably been irritable with cramps before her period, which used to be so heavy that she would sometimes stay in bed for several days. When she was 26, therefore, she'd had a total hysterectomy. Six months later, persistent vomiting led to endoscopy; other than adhesions, no abnormalities were found. Alternating diarrhea and constipation then caused her to experiment with a series of preparations to regulate her bowel movements. When she was questioned about sex, Cynthia shifted uncomfortably in her chair. She didn't care much for it and had never experienced a climax. Her lack of interest was no problem to her, though each of her three husbands had complained a lot. When she was a young teenager, something sexual might have happened to her, she finally admitted, but that was a part of her life she really couldn't recall. "It's as if someone cut a whole year out of my diary," she explained. When she was 2 and her brother was 6 months old, Cynthia's father had deserted the family. Her mother subsequently worked as a waitress and lived with a succession of men, some of whom she married. When Cynthia was 12, her mother escaped from one of Cynthia's stepfathers; she then placed the two children in foster care. One way or another, each of Cynthia's former clinicians had disappointed her. "None of the others knew how to help me. But I just know you'll find out what's wrong. Everyone says you're the best in town." Through her tears, she managed a confident smile.

Somatic symptom disorder

CASE STUDY: Ruby Bissell placed a hand on each chair arm and shifted uncomfortably. She had been talking for nearly half an hour, and the dull, constant ache had worsened. Pushing up with both hands, she hoisted herself to her feet. She winced as she pressed a fist into the small of her back; the furrows on her face added a decade to her 45 years. Although Ruby had had this problem for nearly 6 years, she wasn't sure exactly when it began. It could have started when she helped to move a patient from the operating table to a gurney. But the first orthopedist she ever consulted explained that her pulled ligament was mild, so she continued to work as an operating room nurse for nearly a year. Her back hurt whether she was sitting or standing, so she'd had to resign from her job; she couldn't maintain any physical position longer than a few minutes at a time. "They let me do supervisory work for a while," she said, "but I had to quit that, too. My only choices were sitting or standing, and I have to spend part of each hour flat on my back." From her solidly blue-collar parents, Ruby had inherited a work ethic. She'd supported herself from the age of 17, so her forced retirement had been a blow. But she couldn't say she felt depressed about it. In fact, she had never been very introspective about her feelings and couldn't really explain how she felt about many things. She did deny ever having hallucinations or delusions; aside from her back pain, her physical health had been good. Although she occasionally awakened at night with back pain, she had no real insomnia; appetite and weight had been normal. When the interviewer asked whether she had ever had death wishes or suicidal ideas, she was a little offended and strongly denied them. A variety of treatments had made little difference in Ruby's condition. Pain medication provided almost no relief at all, and she had quit them all before she could get hooked. Physical therapy made her hurt all the more, and an electrical stimulation unit seemed to burn her skin. A neurosurgeon had found no anatomical pathology and explained to Ruby that a laminectomy and spinal fusion were unlikely to improve matters. Her own husband's experience had caused her to distrust any surgical intervention. He had been injured in a trucking accident a year before her own difficulty began; his subsequent laminectomy had left him not only disabled for work, but impotent. With no children to support, the two lived in reasonable comfort on their combined disability incomes. "Mostly we just stay at home," Ruby remarked. "We care a lot for each other. Our relationship is the one part of my life that's really good." The interviewer asked whether they were still able to have any sort of a sex life. Ruby admitted that they did not. "We used to be very active, and I enjoyed it a lot. After his accident, and he couldn't perform, Gregory felt terribly guilty that he couldn't satisfy me. Now my back pain would keep me from having sex, regardless. It's almost a relief that he doesn't have to bear all the responsibility."

Somatic symptom disorder, with predominant pain rationale: complaints of severe pain for several years that markedly affected her life and ability to work

CASE STUDY: A slightly built woman of nearly 70, Esther Dugoni was healthy and fit, though in the last year or two she had developed a tremor characteristic of early Parkinson's disease. For the several years since she had retired from her job teaching horticulture in junior college, she had concentrated on her own garden. At the flower show the year before, her rhododendrons had won first prize. But 10 days earlier, her mother had died in Detroit, over halfway across the country. She and her sister had been appointed co-executors. The estate was large, and she would have to make several trips to probate the will and dispose of the house. That meant flying, and this was why she had sought help from the mental health clinic. "I can't fly!" she had told the clinician. "I haven't flown anywhere for 20 years." Esther had been reared during the Depression; as a child, she had never had the opportunity to fly. With five children of her own to care for on her husband's schoolteacher pay, she hadn't traveled much as an adult, either. She had made a few short hops years ago, when two of her children were getting married in different cities. On one of those trips, her plane had circled the field for nearly an hour, trying to land in Omaha between thunderstorms. The ride was wretchedly bumpy; the plane was full; and many of the passengers were airsick, including the men seated on either side of her. There was no one to help—the flight attendants had to remain strapped in their seats. She had kept her eyes closed and breathed through her handkerchief to try to filter out the odors that filled the cabin. They finally landed safely, but it was the last time Esther had ever been up in an airplane. "I don't even like to go to the airport to meet someone," she reported. "Even that makes me feel short of breath and kind of sick to my stomach. Then I get sort of a dull pain in my chest and I start to shake—I feel that I'm about to die, or something else awful will happen. It all seems so silly." Esther really had no alternatives to flying. She couldn't stay in Detroit until all of the business had been taken care of; it would take months. The train didn't connect, and the bus was impossible.

Specific phobia, situational (fear of flying) rationale: - anxiety sxs cued by air travel - avoidance of travel

CASE STUDY: "I don't know why I do it, I just do it." Rosalind Brewer had been referred to the mental health clinic by her dermatologist. "I get to feeling sort of uptight, and if I just pop one little strand loose, somehow it relieves the tension." She selected a single strand of her long blonde hair, twined it neatly twice around her forefinger, and tweaked it out. She gazed at it a moment before dropping it onto the freshly vacuumed carpet. Rosalind had been pulling out her hair for nearly half her 30 years. She thought it had started during her sophomore or junior year in high school, when she was studying for final exams. Perhaps the tingling sensation on her scalp had helped her stay awake; she didn't know. "Now it's a habit. I've always only pulled the hairs from the very top of my head." The top of Rosalind's head bore a round, almost bald spot about the size of a silver dollar. Only a few broken hairs and a sparse growth of new hair sprouted there. It looked like a tiny tonsure. "It used to make my mom really angry. She said I'd end up looking like Dad. She'd order me to stop, but you know kids. I used to think I had her by the short hairs." She laughed a little. "Now that I want to stop, I can't." Rosalind had sucked her thumb until the age of 8, but otherwise her childhood hadn't been remarkable. Her physical health was good; she had no other compulsive behaviors or obsessive thinking. She denied using drugs or alcohol. Although she had no significant symptoms of depression, she admitted that her hair pulling was a serious problem for her. She could wear a hairpiece to hide her bald spot, but the knowledge that it was there had kept her from forming any close relationships with men. "It's bad enough looking like a monk," Rosalind said. "But this thing has got me living like one, too."

Trichotillomania

Persistent depressive disorder

chronic depressed mood for at least 2 years in adults or 1 year in children - relatively mild (no thoughts of death/suicide, no excessive feelings of guilt) - individual is never without symptoms for longer than 2 months Specify if: - early or late onset (before or after 21 years of age) - with pure dysthymic syndrome - with persistent major depressive episode - with intermittent major depressive episodes, with/without current episode - current severity - any additional specifiers

Disruptive mood dysregulation disorder

chronic, severe persistent irritability manifested in (1) frequent temper outbursts and (2) chronic, persistently irritable or angry mood between outbursts - that is developmentally inappropriate - and occurs across at least 2 contexts - onset is before 10 years of age

Bipolar I disorder

classic manic-depressive disorder, at least one lifetime manic episode required (may be preceded or followed by hypomanic or major depressive episodes)

DSM-5

classification system used to communicate about certain clusters of behaviors and to organize our thinking about what the patient presents and what we observe - provides a 'common' professional language - systematizes categorization of disorders - normalizes personal situations as not being unique/inexplicable - integrates mental and physical health care

case formulation

concise summary of social, psychological and biological factors that may have contributed to developing a given mental disorder - involves careful clinical history *important in developing a comprehensive treatment plan

Factitious disorder imposed on self/another

falsification of physical or psychological symptoms, or induction of injury or disease, associated with identified deception - deceptive behavior is evident even in absence of obvious external rewards (wants to occupy the "sick role") Specify: - Single episode - Recurrent episodes

Cyclothymic disorder

for the majority of at least 2 years in adults or 1 year in children, experience of both hypomanic and depressive symptoms without ever fulfilling criteria for mood episode - individual is never symptom free for more than 2 motnsh

Premenstrual dysphoric disorder

in the majority of menstrual cycles of preceding year, at least 5 symptoms occur repeatedly a few days before the start of menses At least 1 mood symptom from: 1. marked affective lability (mood swings, tearfulness, sensitivity to rejection) 2. marked irritability/anger 3. marked depressed mood, hopelessness or self-deprecating thoughts 4. marked anxiety/tension At least 1 behavioral symptom from: 1. decreased interest in usual activities 2. difficulty concentrating 3. lethargy, lack of energy 4. marked change in appetite 5. insomnia/hypersomnia 6. feeling overwhelmed/out of control 7. physical sxs - breast tenderness, muscle/joint pain, bloating, weight gain *Provisional if symptoms have not been confirmed for at least two symptomatic cycles

Panic Disorder

individual experiences recurrent unexpected panic attacks and for at least 1 month is (1) persistently concerned with having more panic attacks and (2) the implications of having these panic attacks, and (3) changes behavior in maladaptive ways

Agoraphobia

individual is fearful of situations in which escape might be difficult or help may not be readily available in the event of developing anxiety symptoms (at least 6 months, usually alone or away from home) Differential Dx: Specific phobia, situational type or Separation anxiety - what is the cognitive ideation?

Social Anxiety Disorder

individual is fearful or anxious about or avoidant of social interactions and situations that involve the possibility of being scrutinized (for at least 6 months) - specify if "Performance-based" - typically includes speaking, eating/drinking or writing in public, use of public restroom (males), or being the center of attention

Separation Anxiety Disorder

individual is fearful or anxious about separation from attachment figures (at least 4 weeks in children, 6 months in adults) - persistently fearful of harm coming to attachment figures - nightmares or symptoms of physical distress can occur differential dx: GAD, agoraphobia

Specific Phobia

individuals are fearful or anxious about or avoidant of a specific object or situation, or endured with much anxiety (lasting at least 6 months) - fear, anxiety or avoidance is almost immediately induced by phobic stimulus to a degree that is persistent and out of proportion to the actual risk imposed - specify: Animal type, Natural environment type, Blood-Injection-Injury type, Situational, Other most commonly: flying, heights, animals, injections, blood Differential Dx: situational - Agoraphobia

Schizophrenia

lasts at least 6 months and includes at least 1 month of active-phase symptoms presence of two (or more) psychotic symptoms, at least one being delusions, hallucinations or disorganized speech - marked impairment in functioning Specify if lasting at least 1 year: {First episode}{Multiple episodes}, + currently in {acute episode}{partial remission}{full remission}

Hypomanic episode

less severe/disruptive version of manic episode: change in mood and increase in activity level lasting 4 days or more - quality of mood tends to be euphoric (without driven quality of mania) - clearly different from patient's usual non-depressed mood, though without marked impairment (NO psychosis or hospitalization)

Hoarding disorder

persistent difficulty discarding or parting with possessions, regardless of their actual value, as a result of (1) a strong perceived need to save items and (2) distress associated with discarding them, resulting in accumulation that congests, clutters or compromises living areas Specify if: with excessive acquisition & degree of insight

Illness anxiety disorder

preoccupation with having or acquiring a serious illness when somatic symptoms are not present, or if they are, only mild in intensity - high level of anxiety about health and excessive health-related behaviors - preoccupation present for at least 6 months Specify whether: - Care-seeking type - Care-avoidant type

Body dysmorphic disorder

preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or only slight to others, along with mental acts/repetitive behaviors in response to appearance concerns specify if: with muscle dysmorphia & degree of insight

OCD

presence of obsessions, compulsions, or both that are time consuming - if obsessions, individual attempts to ignore, suppress or neutralize them (ie. by performing compulsion) - if compulsion, behavior/action is aimed at preventing or reducing anxiety/distress, thought not connected in a realistic way/clearly excessive specify if: - with good or fair insight - with poor insight - with absent insight/delusional beliefs common symptom dimensions: cleaning, symmetry, forbiddin or taboo thoughts and harm

Delusional disorder

presence of one or more delusions with a duration of 1 month or longer (if present, other psychotic sxs are not prominent/related to delusions and mood symptoms are relatively brief) Specify: - type of delusion - with bizarre context if lasting at least 1 year: {First episode}{Multiple episodes}, + currently in {acute episode}{partial remission}{full remission}

Somatic symptom disorder

presence of one or more somatic symptoms that are distressing or significantly disruptive, and persistent (lasting at least 6 months) + excessive thought, feeling or behavior related to symptoms (thoughts about seriousness of sxs, persistently high anxiety, and/or excessive time/energy expended on concern) Specify if: - with predominant pain - persistent (severe symptoms, long duration of more than 6 months) - severity (mild: 1 sxs of criterion B, moderate: 2+ sxs, severe: 2+ sxs and multiple somatic complaints) Differential Dx: panic disorder

Muscle dysmorphia

specific type of Body dysmorphic disorder that is characterized by the belief that one's body build is too small or insufficiently muscular

malingering

the intentional production of false or grossly exaggerated physical or psychological symptoms motivated by external incentives suspect according to: 1. medicolegal context of presentation 2. marked discrepancy between individual's claimed stress and objective findings 3. lack of cooperation during eval and compliance with treatment regimen 4. antisocial personality disorder

Schizoaffective disorder

uninterrupted period of illness for at least 1 month during which there is a major mood episode (depressive or manic) concurrent with active-phase symptoms of Schizophrenia - delusions or hallucinations occur for at least 2 weeks in the absence of the mood episode - symptoms of mood episode are present for majority of the total duration of illness Specify: - Bipolar type (if during manic episode) - Depressive type (must show depressed mood, not just anhedonia) - with catatonia if lasting at least 1 year: {First episode}{Multiple episodes}, + currently in {acute episode}{partial remission}{full remission}