CLINICAL CASE SCENARIOS (SET 2)

INSTRUCTIONS: For each of the presented clinical cases, answer the following:

1. How would you diagnose the patient? Provide the name and numerical code of all your
diagnoses and justify your decision by citing the specific diagnostic criteria he/she meets for
each diagnosis. (Use DSM 5)
2. How do you differentiate his/her diagnosis from that of other possible conditions?
3. What could be the possible sources or cause of the patient’s condition?

Note: Answers should be encoded and printed.

CASE 1

"Kathy" is a 32 year old female who has had 17 prior admissions to acute care psychiatric facilities for
suicide attempts and self-mutilation. She reported hearing voices and losing periods of time for which
she could not account.

According to her account, Kathy's childhood was characterized by two alcoholic parents who exhibited
violence toward each other and Kathy. They divorced when Kathy was 5 and Kathy lived with her
mother and a series of "stepfathers" who physically and sexually abused her. Kathy's mother confirmed
much of this abuse in sessions with Kathy's therapist. Kathy was first hospitalized at age 13 following a
Tylenol overdose. Shortly thereafter she refused to go to school and lived on the streets where she
traded sex for food and shelter. Kathy was picked up by the juvenile authorities and spent the next 4
years in a residential program as a ward of the state.

Kathy's behavior improved with the structure; she completed high school and got a secretarial job. She
married at age 20, but soon after began to have problems. Kathy's husband reported that she was
extremely moody and would often become hysterical during sex. Kathy began having "flashbacks" of
sexual abuse and became extremely depressed. She was hospitalized repeatedly during the next 10
years receiving diagnoses of schizo-affective disorder, bipolar mood disorder and borderline personality
disorder.

Kathy had seen her current therapist for six months at the time of admission. A clinical interview
conducted by this therapist revealed that Kathy often heard "mean voices in her head" and "children
crying." Kathy reported that she cut on her arms and abdomen to "relieve the internal pressure and stop
the bad feelings." Kathy said she frequently lost periods of time and would find herself in strange places
not remembering how she got there. Upon request, the therapist was able to talk to an alter
personality, Julie, who said that she helped Kathy during times of stress.

CASE 2

The patient is a 28-year old male final year medical student from the South-Eastern region of Nigeria in
sub-Saharan Africa. He was declared missing for 10 days prior to presentation because his whereabouts
was unknown. He was later seen in a city in South-Western Nigeria, a distance of about 634km from
South-Eastern Nigeria where he lived and schooled. Ten days before presentation, while studying in his
room alone at night, the patient suddenly saw a full human skeleton reading at the same table with him,
sitting at the opposite side. At the same time, the patient claimed he felt unease and quite
uncomfortable. He saw the whole room turning with everything inside becoming unstable and unreal.
After this he had overwhelming fears and did not know when he left the room. Two days later, he
discovered he was with his younger sibling in South-Western Nigeria. The patient had no knowledge of
how he made the journey that takes approximately 8 hours by road. He equally could not remember
where he slept the night he left his room, how he raised money for the journey or the buses and routes
he took. The patient denied all memory of events for the 2 days from when he left his room at the
university to the time he suddenly realized he was at his brother’s house, 634km away. The brother,
however, reported that the patient appeared unkempt, looked exhausted but was fully conscious and
alert on arrival at his house without any assistance.

Prior to this episode, the patient had been under severe economic and academic pressures. The younger
brother who paid the patient’s bills had threatened to withdraw his sponsorship because of the patient’s
prolonged stay in school beyond the stipulated duration of training occasioned by his repeats of
examinations and classes. The patient had been worried that he might also fail in his final qualifying
examinations scheduled to be held in 3 months. He subsequently became involved in several religious
activities to obviate his perception of impending doom.

CASE 3

Robert, a 10 year old boy, Grade 5 student, presented complaints of stiffness in body and inability to flex
knee joints. History revealed occasional complaints of body pain for the last 2 months which was
relieved by body massage. One week back the boy complained of body pain and vomited after having
breakfast. He was not sent to school.

He slept for about 2 hours and woke with stiffness of body and inability to flex upper and lower limbs.
He was admitted in a hospital, where he regained mobility of the upper limbs but was not able to bend
his knees and walked with a stiff gait. His mother noticed that when the child was asleep his limbs were
not rigid and would be flexed. The following morning he was able to walk and run. When discharge was
planned there was a relapse. He was then referred to the Department of Clinical Psychology, SRU.

There was no significant past history of psychiatric or neurological disturbances. Developmental history
was reported to be unremarkable. Family relationships were reported to be cordial. Problems in the
school were reported. A gradual decline in performance was reported. He feels discriminated and
victimised by his class teacher and expressed strong resentment for not getting required attention and
reinforcement from his class teacher.

CASE 4

Greg, a 28-year-old student, was referred by his primary care doctor for psychological assessment and
treatment because of Greg’s unrelenting fear that his recent episodes of tachycardia, dizziness, and
chest pain meant that he was suffering from a serious heart condition. A comprehensive medical
evaluation, including a complete cardiac work-up, revealed no evidence of a medical condition that
might account for his complaints. Despite these results, Greg was intent on determining the exact
nature and cause of his symptoms, believing that a serious undetected medical illness was present.
He required that his fiancée, Jody, stay with him at all times in case he needed to be transported to the
hospital. Because of his fear that physical exertion would strain his ‘‘delicate’’ heart, Greg abstained
from many athletic activities he previously enjoyed, including jogging, biking, and playing basketball. He
used a portable heart-rate monitor for checking his heart rate and blood pressure to determine whether
immediate medical attention was needed. He reported spending hours searching the Internet for
information about cardiovascular and other medical diseases that might account for his symptoms.

Greg had been told by various physicians that the ‘‘symptoms’’ he feared were ‘‘not serious’’ and that
he ‘‘had nothing to worry about.’’ Greg was not satisfied with these doctors because they were not
interested in trying to determine what was causing his symptoms. He believed he was not being taken
seriously enough and that his doctors thought his problems were ‘‘all in his head.’’ When it was initially
suggested to Greg that he seek consultation with a psychologist, Greg became angry and felt cast off. He
strongly believed that his symptoms were ‘‘real,’’ not imaginary.