CLINICAL CASE SCENARIOS (SET 4)

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

Jerry Atkins was a 33-year-old single Caucasian woman who had recently graduated from college with a
degree in landscaping. With the encouragement of her outpatient therapist, Jerry had decided to admit
herself to the hospital for her ongoing, and lately increasing, problems with eating. Specifically, Jerry
said that her eating was “out of control.” She reported extended periods when she restricted her food
intake drastically, fueled by her negative body image (i.e., dissatisfaction with her weight and physical
appearance) and her poor self-esteem. Jerry restricted her food intake because she felt that she
weighed too much, a conclusion that was very distressing to Jerry, who gauged her value as a person by
her perceptions of her physical appearance and weight. Her efforts at reducing the amount of food she
ate were often rewarded by marked reductions in weight. In fact, as the result of her most recent period
of fasting, Jerry had lost 60 pounds.

However, as had always happened in the past, this period of restriction was followed by a period of
binge eating and purging. During a binge, Jerry ate large amounts of food (often sweets, such as cake,
cookies, and ice cream, or starches such as mashed potatoes) in a short period of time. She reported
that she was totally out of control during these binges and felt as if she could not stop eating or control
the amount of food she was ingesting. After the binge, Jerry would experience tremendous distress over
the prospect of gaining weight. Consequently, after every binge, Jerry purged the food by sticking her
finger down her throat to make herself vomit. Nevertheless, because of her binge eating and changes in
her metabolism resulting from her frequent vomiting, Jerry had gained back a lot of weight that she had
lost during her period of food restriction. When she admitted herself to the hospital, Jerry weighed 180
pounds.

CASE 2

Patty Bensusan was a 19-year-old single Caucasian female who had just moved away from home to
enter her freshman year of college. During her senior year of high school, Patty had been admitted to an
inpatient psychiatric hospital for 1 month because of extreme weight loss resulting from her severely
restricted food intake and intense fear of gaining weight. At the time Patty was admitted to the inpatient
unit, she was 5 4 tall and weighed 92 pounds. Her body mass index (BMI kilograms divided by meters
squared) was 15.8, which indicated that she weighed only 69% of her ideal body weight. She attempted
to avoid eating altogether, would not eat with her family, and ate only when her relentless attempts at
restriction were overcome by hunger. Every time Patty ate, she experienced a sense of failure and
humiliation.

She began running multiple miles per day in addition to her swim practices at school, and would often
run at night on a treadmill while her family slept. Her food restriction and excessive drive for weight loss
began to have many serious consequences. Patty’s academic performance declined because she was not
able to concentrate in school, feeling fatigued and obsessed with thoughts of food and eating. She
became increasingly depressed and socially withdrawn; she worried continually about social interactions
at school. Although she was captain of her varsity swim team, she was asked by her coach to stop
swimming in practices and swim meets after her weight loss became pronounced. Her coach’s request
followed an incident when Patty was unable to finish a race in an important swim meet because of the
fatigue caused by her weight loss. Patty’s health was markedly compromised by her weight loss and
excessive exercise. She stopped menstruating for several months (amenorrhea). She became prone to
illness and infection, and frequently contracted minor but debilitating viruses and bacterial infections. At
the request of her parents and school, Patty underwent a comprehensive medical examination. The
results of this exam indicated that Patty had developed signs of cardiac problems (low pulse rate) and
had lost a substantial amount of bone density due to her weight loss.

CASE 3

Steve is a 43 year old man who had been discharged from the Navy and is now working as a chef and
going to school for a master’s degree in art. Steve reported that he drank 1 pint of vodka per day.
Beginning in the mid to late morning he kept the bottle of vodka by his side throughout the day, until he
finished it off by early evening. Almost every night, Steve drank a six-pack of beer “so that I can sleep.”
In addition to this excessive intake of alcohol, previous attempts to stop or cut back his drinking, Steve
reported experiencing sweating, trembling, insomnia, anxiety, nausea, and restlessness. In some past
instances, Steve had resumed his drinking to eliminate these unpleasant withdrawal symptoms.

Steve reported that he began drinking when he was 18 years old when he started his career in the
military. For 17 years (between the ages of 18 and 35), Steve served as a chief steward on a ship in the
U.S. Navy. To begin his military training in California, Steve was separated from his high school
sweetheart, whom he was dating at the time and married 5 years later (and divorced at age 26). Steve
stated that his drinking resulted mainly from his feeling alone and homesick during this year on the West
Coast. However, Steve recalled that his drinking was not abusive during this time: He drank primarily on
weekends and during rest and recreation periods with his buddies.

However, Steve’s drinking increased substantially when he was 19 after the mysterious death of his
mother. Steve reported that his father had an extensive history of being physically abusive to him and
his mother. After Steve learned of his mother’s death, he began to drink more heavily and more
frequently. He recalled that during this time he found alcohol to be “consoling” and useful in controlling
his feelings of rage and sadness. In addition, Steve reported discovering that alcohol reduced the
frequency of his nightmares and thus made him sleep better.

CASE 4

Ms. I. is a 37-year-old career woman who “has it all.” She was referred by her primary care
physician, following her yearly routine physical examination due to complaints of difficulty sleeping. She
has struggled with mild sleeplessness throughout her life, but it seems to have worsened after launching
her career, marriage, and family. She had considerable difficulty sleeping during graduate school, and
she attributed her inability to sleep to her need for more time to accomplish school tasks and study. She
indicates that she lies in bed at night thinking about the tasks she has to perform during the next day.
She typically works on her laptop prior to trying to fall asleep, and her phone stays on during the night,
charging on the table next to her bed. She has tried medication and counting to help her to sleep, but
she has not been satisfied with the results. She occasionally uses alcohol to promote sleepiness, but
indicates that she might just be one of those people who do not sleep much. Ms. I. reports feeling
sleepy during the day, and she compensates for her sleepiness with caffeinated beverages
approximately four to six times per day.

CASE 5
Mr. O. is a 62-year-old factory worker who was referred to counseling on the insistence of his wife. His
symptoms have been present for a number of years, but they have become increasingly more severe in
the last nine months. Additionally, he has become more forgetful, sleepy, and grumpy, thus impairing
his ability to manage the line at work, and he has received complaints from coworkers on his shift. His
wife complains of his excessive snoring, as he awakens her frequently. She is also concerned that this
will exacerbate other health issues. This has impacted their level of marital satisfaction, as he has low
energy, low sex drive, and his wife regularly asks him to sleep on the couch. Mr. O. is moderately
overweight, smokes one pack of cigarettes each day, and drinks a moderate amount of beer. He has not
been evaluated by a sleep specialist, and he is reluctant to have a sleep evaluation.

CASE 6
Mr. N.M. is a 43-year-old male who presented for therapy because his partner insisted he seek
treatment. Mr. N.M. experiences terrible dreams four to five times each week. The typical theme of his
distressing dreams involves falling. Many times he tries to stop himself or another person from falling,
but is not successful. He is often awakened by the dreams, and he can usually recall the dreams in great
detail. When asked if he has ever witnessed or experienced a traumatic fall, his response is “I can’t
remember.” Mr. N.M. has suffered with nightmares since his early childhood. It is helpful when his
partner is kind and soothing; however, she is often visibly shaken when awakened by his reaction to the
nightmares. His partner reports that after nights when he has nightmares, he seems tired and grumpy
during the next day. He has no known history of substance abuse, and he is not taking a large amount of
medication. He does not have children. When asked about his early recollections, he indicated that he
does not remember much before middle school. Mr. N.M. did not meet the diagnostic criteria for PTSD.

CASE 7
Sarah is a 13-year-old self-identified female, although she was assigned the gender of male at birth. She
was referred to the clinical psychologist after a teacher noticed some self-injurious behavior. Sarah also
told her teacher there were a few students at the school who had been calling her names and bullying
her on Facebook. Sarah’s parents noticed their child (born male) by about age three was insistent she
was a girl. Sarah played with stereotypical female toys, and most of her peers in the daycare were girls
rather than boys. Sarah does not have a disorder of sex, and therefore no biological/medical treatment
is needed at this time.

Sarah reported a memory as early as age four when she bit a child in preschool when the child insisted
Sarah was a boy. Sarah stated she felt angry, sad, and confused as to why her peer kept insisting she was
a boy. A second memory was around age eight when she and her father went to the grocery store. She
stated she remembers the adult in the check-out line talking in a quiet voice, saying Sarah’s father was
“disgusting for letting his son wear a dress.” Sarah reported her father became angry and made a
comment to the person in line, telling them to “mind their own business.” Sarah said at that time she
felt bad that what she was wearing made it hard on her father, and that she was embarrassed about her
identity.

CASE 8

Bill was a 42-year-old successful investigative journalist who seemingly disappeared for four days before
being found in an alley outside of a “crack” house in Denver, Colorado. Bill had used cocaine off and on
since his early 20s, but more recently intensified his use to several times a day. Once he was introduced
to crack cocaine, nothing else mattered. In the four days of his final use, Bill had withdrawn over
$4,000 from his bank accounts.

From an early age Bill remembers feeling supported by his siblings and, to a lesser degree, his parents.
Bill never had to work very hard for anything, in that most everything came naturally. He attributes this
in part to his brothers’ willingness to teach and help him. He took advantage of this, as he did very well
in school, and specifically athletically. His dream of being a professional athlete ended when he was in
college. He remembers this being the single most devastating thing to ever happen to him. It was about
this time that Bill began to use cocaine. Through the years Bill used cocaine as his primary support
system to deal with frustration, loss, and difficulty in general. After a difficult divorce his cocaine use was
out of control until a friendly colleague (older brother figure) helped him stop. This was three years
before his current binge.