Fun with Abnormal Psych: Case Analysis and Clinical Impression

CASE A
An 80-year-old man has a history of myocardial infarction and had coronary artery bypass graft surgery 8 years ago.
He plays tennis three times a week, takes care of his grandchildren 2 afternoons each week, generally enjoys life,
and manages all of his activities of daily living independently; however, he complains of excessively early morning
awakening. He goes to sleep at 9:00 P.M. and sleeps well, with nocturia once nightly, but wakes at 3:30 A.M.
although he would like to rise at 5:00 A.M. He does not endorse daytime sleepiness as a problem. His physical
examination, mental status, and cognitive function are normal. What is the most likely the diagnosis?
Clinical Impression: __.__ (F__._) ___________________________

Justification: (Minimum of 3 sentences for justification)

There is no specific disorder that the old man has been suffering with. Clearly, with his age and status it is
possible that this short length of sleep is due to his age since our quality of sleep deteriorates as we age. Most of the
older people tend to sleep shorter because of external and internal factors. Perhaps in the old man state it is because
of his history with myocardial infarction and coronary artery bypass graft surgery, thus he also has been suffering
with nocturia which is a condition of waking up in the night to urinate which are quite common with older people.
CASE B
A 50-year-old emergency department nurse complains of sleepiness at work interfering with her ability to function.
She recently switched from the 7 A.M.– 4 P.M. day shift to the 11 P.M.–8 A.M. night shift in order to have her
afternoons free. Even with this schedule change, she finds it difficult to sleep in the mornings at home, has little
energy for recreational activities or household chores in the afternoon, and feels exhausted by the middle of her
overnight shift. What is the most likely the diagnosis?
Clinical Impression: 307.45 (G47.26) Circadian Rhythm Sleep-Wake Disorders, Work Shift Type

Justification: (Minimum of 3 sentences for justification)

The nurse is currently suffering from Circadian Rhythm Sleep-Wake Disorder work shift type. Usually people
who works in the hospital especially assigned in emergency department must work irregular hours due to patients
who come in any other hour. Thoroughly it affected her daily activities because the abrupt change of sleeping pattern
had affected the produce of melatonin which the scientist believed that it contributes to the setting of our biological
clock. Hence, as she claimed she felt sleepiness at work interfering with her ability to function is one the result in
having unfixed sleeping pattern. Thus, it is more prevalent in individuals older than 50 years and typically worsens
with the passage of time if the disruptive work hours persist.
CASE C
A 14-year-old girl frequently wakes in the morning with clear recollection of very frightening dreams. Once she
awakens, she is normally alert and oriented, but the dreams are a persistent source of distress. Her mother reports
that the girl sometimes murmurs or groans but does not talk or move during the period before waking. Her history is
otherwise notable for having been homeless and living with her mother in a series of temporary shelter
accommodations for 1 year when she was 10 years old. What is the most likely diagnosis?
Clinical Impression: 307.47(F51.5) Nightmare Disorder

Justification: (Minimum of 3 sentences for justification)

The child is clearly suffering from a Nightmare Disorder. Features such as having a memory or well-
remembered dreams and alertness and oriented upon awakening is clearly a sign of a nightmare disorder.
Nightmares most likely appear in children exposed to acute or chronic psychosocial stressors such as in the child’s
case experiencing being homeless and living in a temporary shelter for a while. Hence, one of the functional
consequences of nightmares is distress which is the child also has experienced having these persistent types of
dreams.
CASE D
A 51-year-old man presents with symptoms of chronic fatigue and excessive worrying about current life stressors. He
has a strong family history of depression and a past history of a major depressive episode, with some improvement
while maintained on antidepressants. On weekday nights, it takes him several hours to fall asleep, and he then has
difficulty getting up to go to work in the morning, experiencing sleepiness for the first few hours of awake time. On
weekends, he awakens later in the morning and feels less fatigue and sleepiness. What is the most likely the
diagnosis?
Clinical Impression: 307.45 (G47.21) Circadian Rhythm Sleep-Wake Disorders, Delayed Sleep Phase Type

Justification: (Minimum of 3 sentences for justification)

The man has been suffering from a Circadian Rhythm Sleep-Wake Disorder, Delayed Sleep Phase Type
because he has been experiencing excessive sleepiness prior to awakening time and difficulty of getting up. Hence,
this type is also strongly associated with depression in which the man has history with. Thus, delay in the timing of
the major sleep period since it takes him several hours for him to fall asleep. On the other side the guy is also
experiencing some major depressive episode symptoms such as excessive worrying and insomnia. Also, based on
my observation the guy is hyposensitive to morning light since if he woke up in morning to work he experience more
of sleepiness but in the weekend if he awakes later in the morning he feels less fatigue and sleepiness.