DSM-5 Case Studies

Read the case studies in this packet and use the “DSM-5 Student
Abridged Version” to make your diagnoses. The names of the disorders
are highlighted in yellow. The “Diagnostic Criteria” are all you are
required to pay attention to. However, the narrative information about
the disorder (“Diagnostic Features,” “Prevalence,” “Development and
Course,” “Risk and Prognostic Factors,” “Culture- and Gender-related
Diagnostic Issues,” “Differential Diagnosis,” “Comorbidity,” etc.) may
help you narrow down a diagnosis and/or understand a disorder a little
better. A glossary is included at the end of the document.

Once you have made your diagnosis, type the name of the disorder next
to the title of the case study. Then copy and paste the criteria from the
“DSM-5 Student Abridged Version” and insert them after each
corresponding example in the case study. Whatever you insert into the
case study should be in another color so it stands out.

See the next page for a sample of what I’m looking for.
JESSICA – Major Depressive Disorder

Jessica is a 28 year-old married female. She has a very demanding, high stress job as a second
year medical resident in a large hospital. Jessica has always been a high achiever. She graduated
with top honors in both college and medical school. She has very high standards for herself and
can be very self-critical when she fails to meet them. Lately, she has struggled with significant
feelings of worthlessness and shame due to her inability to perform as well as she always has in
the past. A7. Feelings of worthlessness or excessive or inappropriate guilt (which may be
delusional) nearly every day (not merely self-reproach or guilt about being sick)

For the past few weeks Jessica has felt unusually fatigued A6. Fatigue or loss of energy nearly
every day and found it increasingly difficult to concentrate at work. A8. Diminished ability to
think or concentrate, or indecisiveness, nearly every day (either by subjective account or as
observed by others) Her coworkers have noticed that she is often irritable and withdrawn,
which is quite different from her typically upbeat and friendly disposition. A1. Depressed mood
most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad,
empty, hopeless) or observation made by others (e.g., appears tearful) She has called in sick
on several occasions, which is completely unlike her. On those days, she stays in bed all day,
watching TV or sleeping. B. The symptoms cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning.

At home, Jessica’s husband has noticed changes as well. She’s had difficulties falling asleep at
night, and her insomnia has been keeping him awake as she tosses and turns for an hour or two
after they go to bed. A4. Insomnia or hypersomnia nearly every day; A5. Psychomotor
agitation or retardation nearly every day; (observable by others, not merely subjective
feelings of restlessness or being slowed down) He’s overheard her having frequent tearful
phone conversations with her closest friend, which have him worried. When he tries to get her to
open up about what’s bothering her, she pushes him away with an abrupt “everything’s fine”.
A1. Depressed mood most of the day, nearly every day, as indicated by either subjective
report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears
tearful)

Although she hasn’t ever considered suicide, Jessica has found herself increasingly dissatisfied
with her life. She’s been having frequent thoughts of wishing she was dead. A9. Recurrent
thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific
plan, or a suicide attempt or a specific plan for committing suicide She gets frustrated with
herself because she feels like she has every reason to be happy, yet can’t seem to shake the sense
of doom and gloom that has been clouding each day as of late. B. The symptoms cause
clinically significant distress or impairment in social, occupational, or other important
areas of functioning.

A physical exam performed by her primary care doctor one week prior was normal. All
laboratory testing was normal, including complete blood count, electrolytes, blood urea nitrogen,
creatinine, calcium, glucose, thyroid function tests, folate, and vitamin B12. She denied any
illicit drug use and reported an occasional glass of wine with dinner. C. The episode is not
attributable to the physiological effects of a substance or to another medical condition.
DEAR DOCTOR

Myrna Field, a 55-year-old woman, was a cashier in a hospital coffee shop 3 years ago when she
suddenly developed the belief that a physician who dropped in regularly was intensely in love
with her. She fell passionately in love with him, but said nothing to him and became increasingly
distressed each time she saw him. Casual remarks that he made were interpreted as cues to his
feelings, and she believed he gave her significant glances and made suggestive movements,
though he never declared his feelings openly. She was sure this was because he was married.

After more than 2 two years of this, she became so agitated that she had to give up her job; she
remained at home, thinking about the physician incessantly. Eventually she went to her family
doctor, who found her so upset he referred her to a male psychiatrist. She was too embarrassed to
confide in him, and it was only when she was transferred to a female psychiatrist that she poured
forth her story.

Myrna was an illegitimate child whose stepfather was excessively strict. She was a slow learner
and was always in trouble at home and at school. She grew up anxious and afraid, and during her
adult life consulted many doctors because of hypochondriacal concerns. She was always insecure
in company.

Myrna married, but the marriage was asexual, and there were no children. Although her husband
appeared long-suffering, she perceived him as overly critical and demanding. Throughout their
married life she had periodically abused alcohol and, during the past 3 years, had been drinking
more heavily and steadily to try to cope with her distress. She could not confide in her husband
about her "love" affair.

When she was interviewed, Myrna was very distressed and talked under great pressure. Her
intelligence was limited and many of her ideas appeared simple; but the only clear abnormality
was the unshakable belief that her physician "lover" was passionately devoted to her. She could
not be persuaded otherwise.
EASILY TRIGGERED

Eric Reynolds was a 56-year-old married Vietnam War veteran who referred himself to the
Veterans Affairs outpatient mental health clinic for the chief complaint of having "a short fuse"
and being "easily triggered."

Mr. Reynolds's symptoms began more than three decades earlier, soon after he left the combat
zone in Vietnam, where he served as a field radio operator. He had never sought help for his
symptoms, apparently because of his strong need to be independent. An early retirement led to
greater recognition of symptoms and a stronger desire to seek help.

Mr. Reynolds's symptoms included uncontrollable rage when unexpectedly startled; recurrent
intrusive thoughts and memories of death-related experiences; weekly vivid nightmares of
combat operations that led to nighttime fright and insomnia; isolation, vigilance, and anxiety;
loss of interest in hobbies that involve people; and excessive distractibility.

Although all of these symptoms were very distressing, Mr. Reynolds was most worried about his
uncontrollable aggression. Examples of his "hair-trigger temper" included confrontations with
drivers who cut him off, curses directed at strangers who stood too close in checkout lines, and
shifts into "attack mode" when coworkers inadvertently surprised him. Most recently, as he was
drifting off to sleep on his physician's examination table a nurse touched his foot and he leapt up,
cursing and threatening. His involuntary reaction scared the nurse as well as the patient.

Mr. Reynolds said that no words, thoughts, or images intervened between the unexpected
stimulation and his aggression. These moments reminded him of a time in the military when he
was on guard at the front gate and, while he was dozing, an incoming mortar round stunned him
into action. Although he kept a handgun in the console of his car for self-protection, Mr.
Reynolds had no intention of harming others. He was always remorseful after a threatening
incident and had long been worried that he might inadvertently hurt someone.

Mr. Reynolds was raised in a loving family that struggled financially as Midwestern farmers. At
age 20, Mr. Reynolds was drafted into the U.S. Army and deployed to Vietnam. He described
himself as having been upbeat and happy prior to his army induction. He said he enjoyed basic
training and his first few weeks in Vietnam, until one of his comrades got killed. At that point,
all he cared about was getting his best friend and himself home alive, even if it meant killing
others. His personality changed, he said, from that of a happy-go-lucky farm boy to a terrified,
overprotective soldier.

Upon returning to civilian life, he managed to get a college degree and a graduate business
degree, but he chose to work as a self-employed plumber because of his need to stay isolated in
his work. He had no legal history. He had married to his wife for 25 years and was the father of
two college-age students. In his retirement, he looked forward to woodworking, reading, and
getting some "peace and quiet."
Mr. Reynolds had tried marijuana during his early adulthood and used excessive alcohol
intermittently; however, he had not consumed excessive alcohol or used marijuana during the
past decade.

On examination, Mr. Reynolds was a well-groomed African American man who appeared
anxious and somewhat guarded. He was coherent and articulate. His speech was at a normal rate,
but the pace accelerated when he discussed disturbing content. He denied depression but was
anxious. His affect was somewhat constricted but appropriate to content. His thought process
was coherent and linear. He denied all suicidal and homicidal ideation. He had no psychotic
symptoms, delusions, or hallucinations. He had very good insight. He was well oriented and
seemed to have above average intelligence.
TEMPER TANTRUMS
Brandon was a 12-year-old boy brought in by his mother for psychiatric evaluation for temper
tantrums that seemed to be contributing to declining school performance. The mother became
emotional as she reported that things had always been difficult but had become worse after
Brandon entered middle school.

Brandon's sixth-grade teachers reported that he was academically capable but that he had little
ability to make friends. He seemed to mistrust the intentions of classmates who tried to be nice to
him, and then trusted others who laughingly feigned interest in the toy cars and trucks that he
brought to school. The teachers noted that he often cried and rarely spoke in class. In recent
months, multiple teachers had heard him screaming at other boys, generally in the hallway but
sometimes in the middle of class. The teachers had not identified a cause but generally had not
disciplined Brandon because they assumed he was responding to provocation.

When interviewed alone, Brandon responded with nonspontaneous mumbles when asked
questions about school classmates, and his family. When the examiner asked if he was interested
in toy cars, however, Brandon lit up. He pulled several cars, trucks, and airplanes from his
backpack and, while not making good eye contact, did talk at length about vehicles, using their
apparently accurate names (e.g., front-end loader, B-52, Jaguar). When asked again about school,
Brandon pulled out his cell phone and showed a string of text messages: "dumbo!!!!, mr stutter,
LoSeR, freak!, EVERYBODY HATES YOU." While the examiner read the long string of texts
that Brandon had saved but apparently not previously revealed, Brandon added that other boys
would whisper "bad words" to him in class and then scream in his ears in the hall. "And I hate
loud noises." He said he had considered running away, but then had decided that maybe he
should just run away to his own bedroom.

Developmentally, Brandon spoke his first word at age 11 months and began to use short
sentences by age 3. He had always been very focused on trucks, cars, and trains. According to
his mother, he had always been "very shy" and had never had a best friend. He struggled with
jokes and typical childhood banter because "he takes things so literally." Brandon's mother had
long seen this behavior as "a little odd" but added that it was not much different from that of
Brandon's father, a successful attorney, who had similarly focused interests. Both of them were
"sticklers for routine” who "lacked a sense of humor."

On examination, Brandon was shy and generally nonspontaneous. He made below-average eye
contact. His speech was coherent and goal directed. At times, Brandon stumbled over his words,
paused excessively, and sometimes rapidly repeated words or parts of words. Brandon said he
felt okay but added he was scared of school. He appeared sad, brightening only when discussing
his toy cars. He denied suicidality and homicidality. He denied psychotic symptoms. He was
cognitively intact.
OBSESSIONS

Now 37, Darcy reckoned that she had begun having obsessions around age nine, soon after her
beloved grandma had died. Already grieving the loss of the person she was closest to in life,
Darcy experienced further alienation – and resultant anxiety — when her father relocated the
family from the small town in Vermont where they lived to Chicago. Adjusting to big-city life
wasn’t easy for someone as anxious as Darcy, and she soon found that she was obsessing. She
had fears of being hit by a speeding car if she stepped off the curb. She feared that the new
friends she made in Chicago would be kidnapped by bad people. And she was terrified that, if
she didn’t do an elaborate prayer routine at night, all manner of terrible things would befall her
family.

The prayer routine, relatively simple at first, grew to gigantic proportions, containing many rules
and restrictions. Darcy believed that she had to repeat each family member’s full name 15 times,
say a sentence that asked for each person to be kept safe, promise God that she would improve
herself, clap her hands 20 times for each person, kneel down and get up 5 times, and then put her
hands into a prayer position while bowing. She “had” to do this routine at least 10 times each
night, and if she made a mistake anywhere along the way, she had to start totally over again from
the beginning, or else something bad would happen to her parents or little brother. Once she went
flying to her mother’s side in the kitchen, tears streaming down her face, because she couldn’t
get her “prayers” right. Darcy was certain that she was a huge disappointment to God and
everybody.
ON STAGE

Harry is a 33-year-old man who lives in Seattle with his wife. He has been employed as a
salesperson for an insurance company since graduating from college. He came to a private
psychiatrist, recommended by a friend, complaining of "anxiety at work."

Harry describes himself as having been outgoing and popular throughout his adolescence and
young adulthood, with no serious problems until his third year of college. He then began to
become extremely tense and nervous when studying for tests and writing papers. His heart would
pound; his hands would sweat and tremble. Consequently, he often did not write the required
papers or, when he did, would submit them after the date due. He could not understand why he
was so nervous about doing papers and taking exams when he had always done well in these
tasks in the past. As a result of his failure to submit certain papers and his late submission of
others, his college grades were seriously affected.

Soon after graduation, Harry was employed as a salesperson for an insurance firm. His initial
training (attending lectures, completing reading assignments) proceeded smoothly. However, as
soon as he began to take on clients, his anxiety returned. He became extremely nervous when
anticipating phone calls from clients. When his business phone rang, he would begin to tremble
and sometimes would not even answer it. Eventually, he avoided becoming anxious by not
scheduling appointments and by not contacting clients whom he was expected to see.

When asked what it was about these situations that made him nervous, he said that he was
concerned about what the client would think of him: "The client might sense that I am nervous
and might ask me questions that I don't know the answers to, and I will feel foolish." As a result,
he would repeatedly rewrite and reword sales scripts for telephone conversations because he was
"so concerned about saying the right thing. I guess I'm just very concerned about being judged."

Although never unemployed, Harry estimates that he has been functioning at only 20% of his
work capacity, which his employer tolerates because a salesman is paid only on a commission
basis. For the last several years, Harry has had to borrow large sums of money to make ends
meet.

Although financial constraints have been a burden, Harry and his wife entertain guests at their
home regularly and enjoy socializing with friends at picnics, parties, and formal affairs. Harry
lamented, "It's just when I'm expected to do something. Then it's like I'm on stage, all alone, with
everyone watching me."
THE SAILOR

Psychiatric consultation is requested by an emergency room physician for an 18-year-old male

who has been brought into the hospital by the police. The youth appears exhausted and shows
evidence of prolonged exposure to the sun. He identifies the current date incorrectly, giving it as
September 27 instead of October 1. It is difficult to get him to focus on specific questions, but
with encouragement he supplies a number of facts. He recalls sailing with friends, apparently
about September 25, on a weekend cruise, off the Florida coast, when bad weather was
encountered. He is unable to recall any subsequent events and does not know what became of his
companions. He has to be reminded several times that he is in a hospital, as he expresses
uncertainty as to his whereabouts. Each time he is told, he seems surprised.

There is no evidence of head injury or dehydration. Electrolytes and cranial nerve examination
are unremarkable. Because of the patient's apparent exhaustion, he is permitted to sleep for 6
hours. Upon awakening, he is much more attentive, but is still unable to recall events after
September 25, including how he came to the hospital. There is no longer any doubt in his mind
that he is in the hospital, however, and he is able to recall the contents of the previous interview
and the fact that he had fallen asleep. He is able to remember that he is a student at a southern
college, maintains a B average, has a small group of close friends, and has a good relationship
with his family. He denies any previous psychiatric history and says he has never abused drugs
or alcohol.

Because of the patient's apparently sound physical condition, a sodium amytal interview is
performed. During this interview he relates that neither he nor his companions were particularly
experienced sailors capable of coping with the ferocity of the storm they encountered. Although
he had taken the precaution of securing himself to the boat with a life jacket and tie line, his
companions had failed to do this and had been washed overboard in the heavy seas. He
completely lost control of the boat and felt he was saved only by virtue of good luck and his
lifeline. He had been able to consume a small supply of food that was stowed away in the cabin
over a 3-day period. He never saw either of his sailing companions again. He was picked up on
October 1 by a Coast Guard cutter and brought to shore, and subsequently the police had
brought him to the hospital.
RELATIONSHIP CONTROL

Ogen Judd and his boyfriend, Peter Kleinman, presented for couples therapy to address
escalating conflict around the issue of moving in together. Mr. Kleinman described a several
month-long apartment search that was made "agonizing" by Mr. Judd's rigid work schedule and
his "endless" list of apartment demands. They were unable to come to a decision, and eventually
they decided to just share Mr. Judd's apartment. As Mr. Kleinman concluded, "Ogden won."

Mr. Judd refused to hire movers for his boyfriend's belongings, insisting on personally packing
and taking an inventory of every item in his boyfriend's place. What should have taken 2 days
took 1 week. Once the items were transported to Mr. Judd's apartment, Mr. Kleinman began to
complain about Mr. Judd's "crazy rules" about where items could be placed on the bookshelf,
which direction the hangers in the closet faced, and whether their clothes could be intermingled.
Moreover, Mr. Kleinman complained that there was hardly any space for his possessions because
Mr. Judd never threw anything away. "I'm terrified of losing something important," added Mr.
Judd.

Over the ensuing weeks, arguments broke out nightly as they unpacked boxes and settled in.
Making matters worse, Mr. Judd would often come home after 9:00 or 10:00 P.M., because he
had a personal rule to always have a blank "to-do" list by the end of the day. Mr. Kleinman
would often wake early in the morning to find Mr. Judd grimly organizing shelves or closets or
sorting books alphabetically by author. Throughout this process, Mr. Judd appeared to be
working hard at everything while enjoying himself less and getting less done. Mr. Kleinman
found himself feeling increasingly detached from his boyfriend the longer they lived together.

Mr. Judd denied symptoms of depression and free-floating anxiety. He said that he had never
experimented with cigarettes or alcohol, adding, "I wouldn't want to feel like I was out of
control." He denied a family history of mental illness. He was raised in a two-parent household
and was an above average high school and college student. He was an only child and first shared
a room as a college freshman. He described that experience as being difficult due to "conflicting
styles-he was a mess and I knew that things should be kept neat." He had moved mid-year into a
single dorm room and had not lived with anyone until Mr. Kleinman moved in. Mr. Judd was
well liked by his boss, earning recognition as "employee of the month" three times in 2 years.
Feedback from colleagues and subordinates was less enthusiastic, indicating that he was overly
rigid, perfectionistic, and critical.

On examination, Mr. Judd was a thin man with eyeglasses and gelled hair, sitting on a couch
next to his boyfriend. He was meticulously dressed. He was cooperative with the interview and
sat quietly while his boyfriend spoke, interrupting on a few occasions to contradict. His speech
was normal in rate and tone. His affect was irritable. There was no evidence of depression. He
denied specific phobias and did not think he had ever experienced a panic attack. At the end of
the consultation, Mr. Judd remarked, "I know I'm difficult, but I really do want to change.”
EPISODIC DEPRESSIONS

Pamela was a 43-year-old married librarian who presented to an outpatient mental health clinic
with a long history of episodic depressions. Most recently, she described depressed
mood during the month since she began a new job. She said she was preoccupied with concerns
that her new boss and colleagues thought her work was inadequate and slow and that she was
unfriendly. She had no energy and enthusiasm at home, either, and instead of playing with her
children or talking to her husband, she tended to watch television for hours, overeat, and sleep
excessively. This had led to a 6-pound weight gain in just 3 weeks, which made her feel even
worse about herself. She had begun to cry several times a week, which she reported as the sign
that she "knew the depression had returned." She had also begun to think often of death but had
never attempted suicide.

Ms. Kramer said her memory about her history of depression was a little fuzzy, so she brought in
her husband, who had known her since college. They agreed that she had first become depressed
in her teens and that she had experienced at least five discrete periods of depression as an adult.
These episodes generally included depressed mood, amotivation, hypersomnia, deep feelings of
guilt, decreased libido, and mild to moderate suicidal ideation without plan. Her depressions
were also punctuated by periods of "too much" energy, irritability, pressured speech, and flight
of ideas. These episodes of excess energy could last hours, days, or a couple of weeks. The
depressed mood would not lift during these periods, but she would "at least be able to do a few
things."

When specifically asked, Ms. Kramer's husband described distinctive times when Ms. Kramer
seemed unusually excited, happy, and self-confident, and like a "different person." She would
talk fast, seem energized and optimistic, do the daily chores very efficiently, and start (and often
finish) new projects. She would need little sleep and still be enthusiastic the next day. Ms.
Kramer recalled these periods but said they felt "normal." In response to a question about
hypersexuality, Ms. Kramer smiled for the only time during the interview, saying that although
her husband seemed to be including her good periods as part of her illness, he had not been
complaining when she had her longest such episode (about 6 days) when they first started dating
in college. Since then, she reported that these episodes were "fairly 1 frequent" and lasted 2 or 3
days.

Because of her periodic low mood and thoughts of death, she had seen various psychiatrists since
her mid-teenage years. Psychotherapy tended to work "okay" until she had another depressive
episode, when she would be unable to attend sessions and would then just quit. Three
antidepressant trials of adequate dosage and duration (6 months to 3 years) "were each associated
with short-term relief of depression, followed by relapse. Both alone and in the presence of her
husband, Ms. Kramer denied a history of alcohol and substance abuse. A maternal aunt and
maternal grandfather had been recurrently hospitalized for mania, although Ms. Kramer was
quick to point out that she was “not at all like them."

On examination, Ms. Kramer was a well-groomed, overweight woman who often averted her
eyes and tended to speak very softly. No abnormal motor movements were noted, but her
movements were constrained, and she did not use hand gestures. Her mood was depressed. Her
affect was sad and constricted. Her thought processes were fluid, though possibly slowed. Her
thought content was notable for depressive content, including passive suicidal ideation without
evidence of paranoia, hallucinations, or delusions. Her insight and judgment were intact.
COMPULSIONS

Alan, a 10-year-old boy, is brought for a consultation by his mother because of "severe
compulsions." The mother reports that the child at various times has to run and clear his throat,
touch the doorknob twice before entering any door, tilt his head from side to side, rapidly blink
his eyes, and suddenly touch the ground with his hands by flexing his whole body. These
"compulsions" began 2 years ago. The first was the eye blinking, and then the others followed,
with a waxing and waning course. The movements occur more frequently when he is anxious or
under stress. The last symptom to appear was the repetitive touching of the doorknobs. The
consultation was scheduled after the child began to make the middle finger sign while saying
"fuck."

When examined, Alan reported that most of the time he did not know in advance when the
movements were going to occur except for the touching of doorknobs. Upon questioning, he said
that before he felt he had to touch a doorknob, he got the thought of doing it and tried to push it
out of his head, but he couldn't because it kept coming back until he touched the doorknob
several times; then he felt better. When asked what would happen if someone did not let him
touch the doorknob, he said he would just get mad; once his father had tried to stop him and Alan
had had a temper tantrum. Alan explained that the touching of the doorknobs didn't really bother
him—what did was all the "other stuff" that he couldn't control."

During the interview the child grunted, cleared his throat, turned his head, and rapidly blinked
his eyes several times. At times he tried to make it appear as if he had voluntarily been trying to
perform these movements.

Personal history and physical and neurological examination were totally unremarkable except for
the abnormal movements and sounds. The mother reported that her youngest uncle had had
similar symptoms when he was an adolescent, but she could not elaborate any further. She stated
that she and her husband had always been "very compulsive," by which she meant only that they
were quite well organized and stuck to routines.
PANIC

Maria Greco was a 23-year-old single woman who was referred for psychiatric evaluation by her
cardiologist. In the prior 2 months, she had presented to the emergency room four times for acute
complaints of palpitations, shortness of breath, sweats, trembling, and the fear that she was about
to die. Each of these events had a rapid onset. The symptoms peaked within minutes, leaving her
scared, exhausted, and fully convinced that she had just experienced a heart attack. Medical
evaluations done right after these episodes yielded normal physical exam findings, vital signs,
lab results, toxicology screens, and electrocardiograms.

The patient reported a total of five such attacks in the prior 3 months, with the panic occurring at
work, at home, and while driving a car. She had developed a persistent fear of having other
attacks, which led her to take many days off work and to avoid exercise, driving, and coffee. Her
sleep quality declined, as did her mood. She avoided social relationships. She did not accept the
reassurance offered to her by friends and physicians, believing that the medical workups were
negative because they were performed after the resolution of the symptoms. She continued to
suspect that something was wrong with her heart and that without an accurate diagnosis, she was
going to die. When she had a panic attack while asleep in the middle of the night, she finally
agreed to see a psychiatrist.

Ms. Greco denied a history of previous psychiatric disorders except for a history of anxiety
during childhood that had been diagnosed as a "school phobia."

The patient's mother had committed suicide by overdose 4 years earlier in the context of a
recurrent major depression. At the time of the evaluation, the patient was living with her father
and two younger siblings. The patient had graduated from high school was working as a
telephone operator, and was not dating anyone. Her family and social histories were otherwise
noncontributory.

On examination, the patient was an anxious-appearing, cooperative, coherent young woman. She
denied depression but did appear worried and was preoccupied ·with ideas of having heart
disease. She denied psychotic symptoms, confusion, and all suicidality. Her cognition was intact,
insight was limited, and judgment was fair.
UNFAIRNESS
Ike Crocker was a 32-year-old man referred for a mental health evaluation by the human
resources department at a construction site. Although he presented as a very motivated and
skilled worker at the interview with two carpentry certificates, in the first two weeks of
employment, he has had frequent arguments, absenteeism, and made many dangerous mistakes.
When confronted by supervisors, he was dismissive of the problem and said if someone got hurt,
“it’s because of their own stupidity.”

When the head of human resources met with him to discuss termination, Mr. Crocker said he
would sue on the grounds of the American Disability Act: He demanded a psychiatriatric
evaluation for attention-deficit/hyperactivity disorder (ADHD) and bipolar.

During the mental health evaluation, Mr. Crocker focused on unfairness at the company and how
he was “a hell of a better carpenter than anyone there could ever be.” He had been married twice
and had two children. Mr. Crocker refused to pay child support, which is why he said both ex-
wives “lied to judges and got restraining orders saying I’d hit them.” He was not interested in
seeing his children. He said they were “little liars” like their mothers.

During high school, he said he “must have been smart” because he was able to make Cs in
school despite only showing up half the time. He spent time in juvenile hall at age 14 for
stealing “kid stuff, like tennis shoes and wallets that were practically empty.” He left school at
age 15 after being “framed for stealing a car.” He pointed this out to show how he had overcome
injustice. Mr. Crocker concluded the interview by demanding a note from the examiner that said
he had “bipolar” and “ADHD.”

Phone calls revealed that Mr. Crocker had been expelled from two carpentry training programs
and that both of his certificates had been falsified. He got fired from his job at one local
construction company after a fistfight with his supervisor.
INCREASINGLY ODD

Gregory Baker was a 20-yearold African American man who was brought to the emergency
room (ER) by the campus police of the university from which he had been suspended several
months earlier. The police had been called by a professor who reported that Mr. Baker had
walked into his classroom shouting, "I am the Joker, and I am looking for Batman." When Mr.
Baker refused to leave the class, the professor contacted security.

Although Mr. Baker had much academic success as a teenager, his behavior had become
increasingly odd during the past year. He quit seeing his friends and spent most of his time lying
in bed staring at the ceiling. He lived with several family members but rarely spoke to any of
them. He had been suspended from college because of lack of attendance. His sister said that she
had recurrently seen him mumbling quietly to himself and noted that he would sometimes, at
night, stand on the roof of their home and wave his arms as if he were "conducting a symphony."
He denied having any intention of jumping from the roof or having any thoughts of self-harm,
but claimed that he felt liberated and in tune with the music when he was on the roof. Although
his father and sister had tried to encourage him to see someone at the university's student health
office, Mr. Baker had never seen a psychiatrist and had no prior hospitalizations.

During the prior several months, Mr. Baker had become increasingly preoccupied with a female
friend, Anne, who lived down the street. While he insisted to his family that they were engaged,
Anne told Mr. Baker's sister that they had hardly ever spoken and certainly were not dating. Mr.
Baker's sister also reported that he had written many letters to Anne but never mailed them;
instead, they just accumulated on his desk. His family said that they had never known him to use
illicit substances or alcohol, and his toxicology screen was negative. When asked about drug use,
Mr. Baker appeared angry and did not answer.

On examination in the ER, Mr. Baker was a well-groomed young man who was generally
uncooperative. He appeared constricted, guarded, inattentive, and preoccupied. He became
enraged when the ER staff brought him dinner. He loudly insisted that all of the hospital's food
was poisoned and that he would only drink a specific type of bottled water. He was noted to have
paranoid, grandiose, and romantic delusions. He appeared to be internally preoccupied, although
he denied hallucinations. Mr. Baker reported feeling "bad" but denied depression and had no
disturbance in his sleep or appetite. He was oriented and spoke articulately but refused formal
cognitive testing. His insight and judgment were deemed to be poor.

Mr. Baker's grandmother had died in a state psychiatric hospital, where she had lived for 30
years. Her diagnosis was unknown. Mr. Baker's mother was reportedly "crazy." She had
abandoned the family when Mr. Baker was young, and he was raised by his father and paternal
grandmother. Ultimately, Mr. Baker agreed to sign himself into the psychiatric unit, stating, "I
don't mind staying here. Anne will probably be there, so I can spend my time with her."
FRAGILE AND ANGRY

Juanita Delgado, a single, unemployed Hispanic woman, sought therapy at age 33 for treatment
of depressed mood, chronic suicidal thoughts, social isolation, and poor personal hygiene.
She had spent the prior 6 months isolated in her apartment, lying in bed, eating junk food,
watching television, and doing more online shopping than she could afford. Multiple treatments
had yielded little effect.

Ms. Delgado was the middle of three children in an upper-middle-class immigrant family in
which the father reportedly valued professional achievement over all else. She felt isolated
throughout her school years and experienced recurrent periods of depressed mood. Within her
family, she was known for angry outbursts. She had done well academically in high school but
dropped out of college because of frustrations with a roommate and a professor. She attempted a
series of internships and entry-level jobs with the expectation that she would return to college,
but she kept quitting because "bosses are idiots. They come across as great and they all turn out
to be twisted." These "traumas" always left her feeling terrible about herself (“I can't even
succeed as a clerk?") and angry at her bosses ("I could run the place and probably will"). She had
dated men when she was younger but never let them get close physically because she become too
anxious when any intimacy began to develop.

Ms. Delgado's history included cutting herself superficially on a number of occasions, along with
persistent thoughts that she would be better off dead. She said that she was generally "down and
depressed" but that she had had dozens of 1- to 2-day "manias" in which she was energized and
edgy and pulled all-nighters. She tended to "crash" the next day and sleep for 12 hours.

She had been in psychiatric treatment since age 17 and had been psychiatrically hospitalized
three times after overdoses. Treatments had consisted primarily of medication: mood stabilizers,
low dose neuroleptics, and antidepressants that had been prescribed in various combinations in
the context of supportive psychotherapy.

During the interview, she was a casually groomed and somewhat unkempt woman who was
cooperative, coherent, and goal directed. She was generally dysphoric with a constricted affect
but did smile appropriately several times. · She described shame at her poor performance but
also believed she was "on Earth to do something great." She described her father as a spectacular
success, but he was also a "Machiavellian loser who was always trying to manipulate people."
She described quitting jobs , because people were disrespectful. For example, she said that when
she worked as a clerk at a department store, people would often be rude or unappreciative ("and I
was there only in preparation to become a buyer; it was ridiculous"). Toward the end of the
initial session, she became angry with the interviewer after he glanced at the clock ("Are you
bored already?"). She said she knew people in the neighborhood, but most of them had "become
frauds or losers." There were a few people from school who were "Facebook friends” doing
amazing things all over the world. Although she had not seen them in years, she intended to
"meet up with them if they ever come back to town."
FALSE RUMORS 

Bob, age 21, comes to the psychiatrist's office, accompanied by his parents, on the advice of his
college counselor. He begins the interview by announcing that he has no problems. His parents
are always overly concerned about him, and it is only to get them "off my back" that he has
agreed to the evaluation. "I am dependent on them financially, but not emotionally."

The psychiatrist is able to obtain the following story from Bob and his parents. Bob had
apparently spread malicious and false rumors about several of the teachers who had given him
poor grades, implying that they were having homosexual affairs with students. This, as well as
increasingly erratic attendance at his classes over the past term, following the loss of a girlfriend,
prompted the school counselor to suggest to Bob and his parents that help was urgently needed.
Bob claimed that his academic problems were exaggerated, his success in theatrical productions
was being overlooked, and he was in full control of the situation. He did not deny that he spread
the false rumors, but he showed no remorse or apprehension about possible repercussions for
himself.

Bob is a tall, stylishly dressed young man with a dramatic wave in his hair. His manner is distant,
but charming, and he obviously enjoys talking about a variety of intellectual subjects or current
affairs. However, he assumes a condescending, cynical, and bemused manner toward the
psychiatrist and the evaluation process. He conveys a sense of superiority and control over the
evaluation.

Accounts of Bob's development are complicated by his bland dismissal of its importance and by
the conflicting accounts about it by his parents. His mother was an extremely anxious,
immaculately dressed, outspoken woman. She described Bob as having been a beautiful, joyful
baby, who was gifted and brilliant. She recalled that after a miscarriage, when Bob was age 1,
she and her husband had become even more devoted to his care, giving him "the love for two."
The father was a rugged-looking, soft-spoken, successful man. He recalled a period in Bob's
early life when they had been very close, and he had even confided in Bob about very personal
matters and expressed deep feelings. He also noted that Bob had become progressively more
resentful with the births of his two siblings. The father laughingly commented that Bob "would
have liked to have been the only child." He recalled a series of conflicts between Bob and
authority figures over rules and noted that Bob had expressed disdain for his peers at school and
for his siblings. 

In his early school years, Bob seemed to play and interact less with other children than most
others do. In fifth grade, after a change in teachers, he became arrogant and withdrawn and
refused to participate in class. Nevertheless, he maintained excellent grades. In high school he
had been involved in an episode similar to the one that led to the current evaluation. At that time
he had spread false rumors about a classmate whom he was competing against for a role in the
school play.

In general, it became clear that Bob had never been "one of the boys." He liked dramatics and
movies, but had never shown an interest in athletics. He always appeared to be a loner, though he
did not complain of loneliness. When asked, he professed to take pride in "being different" from
his peers. He also distanced himself from his parents and often responded with silence to their
overtures for more communication. His parents felt that behind his guarded demeanor was a sad,
alienated, lonely young man. Though he was well known to classmates, the relationships he had
with them were generally under circumstances in which he was looked up to for his intellectual
or dramatic talents.

Bob conceded that others viewed him as cold or insensitive. He readily acknowledged these
qualities, and that he had no close friends, but he dismissed this as unimportant. This represented
strength to him. He went on to note that when others complained about these qualities in him, it
was largely because of their own weakness. In his view, they envied him and longed to have him
care about them. He believed they sought to gain by having an association with him.

Bob had occasional dates, but no steady girlfriends. Although the exact history remains unclear,
he acknowledged that the girl whose loss seemed to have led to his escalating school problems
had been someone whom he cared about. She was the first person with whom he had had a
sexual relationship. The relationship had apparently dissolved after she had expressed an
increasing desire to spend more time with her girlfriends and to go to school social events.
THUNDERSTORMS 

Sheila, a 28-year-old housewife, sought psychiatric treatment for a fear of storms that had
become progressively more disturbing to her. Although she had been frightened of storms since
she was a child, the fear seemed to abate somewhat during adolescence, but had been increasing
in severity over the past few years. This gradual exacerbation of her anxiety, plus the fear that
she might pass it on to her children, led her to seek treatment.

She is most frightened of lightning, but is uncertain about the reason for this. She is only vaguely
aware of a fear of being struck by lightning and recognizes that this is an unlikely occurrence.
When asked to elaborate on her fears, she imagines that lightning could strike a tree in her yard
and the tree might fall and block her driveway, thus trapping her at home. This frightens her, but
she is quite aware that her fear is irrational. She also recognizes the irrational nature of her fear
of thunder. She begins to feel anxiety long before a storm arrives. A weather report predicting a
storm later in the week can cause her anxiety to increase to the point where she worries for days
before the storm. Although she does not express a fear of rain, her anxiety increases even when
the sky becomes overcast because of the increased likelihood of a storm.

During a storm, she does several things to reduce her anxiety. Because being with another person
reduces her fear, she often tries to make plans to visit friends or relatives or go to a store when a
storm is threatening. Sometimes, when her husband is away on business, she stays overnight
with a close relative if a storm is forecast. During a storm she covers her eyes or moves to a part
of the house far from windows where she cannot see lightning should it occur.)

Sheila has three young children. She describes her marriage as a happy one and states that her
husband has been supportive of her when she is frightened and has encouraged her to seek
psychiatric treatment. She is in good physical health, and at the time she entered treatment there
were no unusually stressful situations in her life or other emotional difficulties. Her parents
separated shortly after she began treatment. Although she found this distressing, she felt her
personal supports were adequate and that this occurrence did not necessitate psychiatric
attention.  

She describes her personal history as generally unremarkable in terms of any obvious emotional
problems, except for her fear of storms. She feels that she may have "learned" this fear from her
grandmother, who also was frightened of storms. She denies panic attacks, or any other unusual
or incapacitating fears.
MISERY 

An orthopedic surgeon in Seattle requested a psychiatric consultation on Peggy Sandler, a single

28-year-old graduate student who was recovering from a recent spinal fusion, because he thought
she was not complying with physical therapy.

The psychiatrist noted that Ms. Sandler was an attractive young woman with a below-the-knee
amputation of her left leg. She was oddly ingratiating and cheerful and didn't seem to be
appropriately troubled by her deteriorating medical condition. She reported that 5 years
previously she had been thrown to the ground by a boyfriend, injuring her back. Over the next 2
years she had multiple surgical procedures on her back. Finally, a fusion left her pain free until 6
months ago, when she was diagnosed with spinal degenerative changes and was referred for
physical therapy.

Amazed that she didn't volunteer any information about her amputation, the psychiatrist asked
how it happened and learned that shortly after the original surgery to her back, she had been in a
motorcycle accident, sustaining burns to her left ankle. This became a chronic injury and
ultimately lead to amputation of her leg a year and a half ago. She reported this calmly and
denied any distress over the disfigurement or disability. She also calmly reported that fluctuating
swelling of her stump and recurrent ulcers had interfered with her being successfully fitted with a
prosthesis. Thus, she had remained in a wheelchair. She had also been hospitalized several times
many years earlier for colitis and kidney stones.

The psychiatrist called the surgeon who had performed her amputation. He reported that the
original burn had quickly progressed to a chronic injury, with chronic pain and swelling of the
left leg. When the leg proved unresponsive to medical management, the patient received a series
of skin grafts, all of which failed because of infection and edema. She was instructed to keep her
leg elevated, but did not comply, and her leg continued to deteriorate. She saw many doctors and
was followed in a pain clinic but continued to experience pain, massive edema, and recurrent
infections. Ms. Sandler repeatedly urged her surgeon to amputate her leg, claiming that it was
painful and of no use to her. Ultimately he complied.

The surgeon who performed the amputation also reported that Ms. Sandler had recently had
several admissions for left-sided weakness and numbness. Physical findings were inconsistent,
the workup was negative, and she was discharged with a diagnosis of conversion disorder. It was
shortly thereafter that her back pain recurred. The surgeon also commented that various
physicians involved in the management of her leg injury had raised the possibility that her
symptoms might be self-induced.

Ms. Sandler is an only child, born to a middle-class family. By her own account, after graduating
from college, she moved from job to job for a number of years, generally leaving because of
medical problems and repeated hospitalizations. At the time of admission, she was a part-time
graduate student being supported by social security. No one had accompanied her to the hospital,
and she had no visitors during her hospitalization. She asked that her doctors not contact her
family.
Ms. Sandler was transferred to an inpatient rehabilitation unit, where she quickly developed a
string of largely unexplained medical problems, including a urinary tract infection,
gastroenteritis with diarrhea and fever, painful swelling of the right hand and wrist, a rash on her
back and torso, and atypical mental status changes, including difficulty doing rudimentary
calculations and inconsistent memory deficits. Meanwhile, she repeatedly refused to comply
with safety procedures on the unit, leaving her wheelchair unlocked and her bed rail down,
despite constant reminders by the staff. Over time she generated a good deal of anger and
frustration among most staff members, although a few found her a particularly sad and pathetic
case.

After her previous surgeon had been contacted, the staff became suspicious about the role that
she might be playing in the development of her symptoms. Ms. Sandler's room was searched and
furosemide (a diuretic), cathartics, and an exercise band that could serve as a tourniquet were
found. These were believed possibly to explain many of her symptoms as well as the
unexplained metabolic abnormalities that had been noted in her chart. Careful review of her chart
revealed that her urinary tract infection had been diagnosed on the basis of positive cultures in
the absence of cells in the urine, most consistent with a fecal contaminant. It remained unclear if
or how she might have factitiously elevated her temperature, even while observed, or how she
might have induced the bitelike lesions on her back and torso.
CHRONIC LYME DISEASE

Oscar Capek, a 43 -year-old man, was brought by his wife to an emergency room (ER) for what
he described as a relapse of his chronic Lyme disease. He explained that he had been fatigued
for a month and bedridden for a week. Saying he was too tired and confused to give much
information, he asked the ER team to call his psychiatrist.

The psychiatrist reported that he had treated Mr. Capek for more than two decades. He first saw
Mr. Capek for what appeared to be a panic attack. It resolved quickly, but Mr. Capek continued
to see him for help coping with his chronic illness. Initially a graduate student pursuing a
master's degree in accounting, Mr. Capek dropped out of school over worries that the demands of
his studies would exacerbate his disease. Since then, his wife, a registered nurse, had been his
primary support. He supplemented their income with small accounting jobs but limited these lest
the stress affect his health.

Mr. Capek usually felt physically and emotionally well. He deemed that his occasional fatigue,
anxiety, and concentration difficulties were "controllable" and did not require treatment. He was
typically averse to psychotropic medications and took a homeopathic approach to his disease,
including exercise and proper nutrition. When medication was required, he used small doses
(e.g., one quarter of a 0.5-mg lorazepam pill). His psychiatric sessions were commonly devoted
to concerns about his underlying disease; he would often bring in articles on chronic Lyme
disease for discussion and was active in a local Lyme disease support group.

Mr. Capek's symptoms would occasionally worsen. This occurred less than yearly, and these
"exacerbations" usually related to some obvious stress. The worst was 1 year earlier when his
wife briefly left him following his revelation of an affair. Mr. Capek expressed shame about his
behavior toward his wife both the affair and his inability to support her. He subsequently cut off
contact with the other woman and attempted to expand his accounting work. The psychiatrist
speculated that similar stress was behind his current symptoms.

The psychiatrist communicated regularly with Mr. Capek's internist. All testing for Lyme disease
thus far had been negative. When the internist explained this, Mr. Capek became defensive and
produced literature on the inaccuracy of Lyme disease testing. Eventually, the internist and
psychiatrist had agreed on a conservative treatment approach with a neutral stance regarding the
disease's validity.

On examination, Mr. Capek was a healthy, well-developed adult male. He was anxious and
spoke quietly with his eyes closed. He frequently lost his train of thought, but with
encouragement and patience, he could give a detailed history that was consistent with the
psychiatrist' s account. Physical examination was unremarkable. Lyme disease testing was
deferred given his past negative tests. A standard laboratory screen was normal with the
exception of a slightly low hemoglobin value. On hearing about the low hemoglobin, Mr. Capek
became alarmed, dismissed reassurances, and insisted this be investigated further.
EDGY ELECTRICIAN

A 27-year-old married electrician complains of dizziness, sweating palms, heart palpitations, and
ringing of the ears of more than 18 months' duration. He has also experienced dry mouth and
throat, periods of extreme muscle tension, and a constant "edgy" and watchful feeling that has
often interfered with his ability to concentrate. These feelings have been present most of the time
over the previous 2 years; they have not been limited to discrete periods. Although these
symptoms sometimes make him feel "discouraged," he denies feeling depressed and continues to
enjoy activities with his family.

Because of these symptoms, the patient had seen a family practitioner, a neurologist, a
neurosurgeon, a chiropractor, and an ear-nose-throat specialist. He had been placed on a
hypoglycemic diet, received physiotherapy for a pinched nerve, and been told he might have "an
inner ear problem.

He also has many worries. He constantly worries about the health of his parents. His father, in
fact, had a myocardial infarction 2 years previously but is now feeling well. He also worries
about whether he is "a good father," whether his wife will ever leave him (there is no indication
that she is dissatisfied with the marriage), and whether co-workers on the job like him. Although
he recognizes that his worries are often unfounded, he cannot stop worrying.

For the past 2 years, the patient has had few social contacts because of his nervous symptoms.
Although he has sometimes had to leave work when the symptoms became intolerable, he
continues to work for the same company he joined for his apprenticeship after high school
graduation. He tends to hide his symptoms from his wife and children, to whom he wants to
appear "perfect," and reports few problems with them as a result of his nervousness.
A CHILD IS CRYING

Fifteen-year-old Cindy was brought to a mental health clinic by her father after he received a call
from the counselor at school, who was concerned that Cindy was depressed and possibly
suicidal. Her father had also been concerned about her because she had seemed sad and
withdrawn for the past month.

The household consists of Cindy, her father, her mother, and two younger siblings. According to
Cindy, she has been depressed ever since she had a fight with her mother 2 years ago. During the
fight her mother threw a pot of hot water and burned Cindy on the shoulder. She was taken to a
medical emergency room and treated for the burn. Since then, she stays out of her mother's way.

Cindy's mother has a long history of mental problems, with multiple hospitalizations and long-
term outpatient treatment. She is reported by the father to be chronically "psychotic" and to have
marked mood swings. There have been many conflicts in the marriage over the years, and the
couple is now in the process of getting a divorce and selling their home. For the past 2 years,
since the incident with the boiling water, Cindy's mother has occupied the third floor of their
house and has had little contact with the family.

Before the incident with her mother, Cindy was very socially involved, taking dancing and music
lessons and participating in both church and school activities. She was a straight-A student.

Cindy says that her mood has been much worse in the past 6 months. She feels depressed almost
every day, all day long. She worries about her mother and feels that the fight was probably her
fault. She has lost interest in school and social activities and has not really paid attention to her
schoolwork for the past 6 months. Her grades have dropped from A's to B's and C's. She is tired
all the time and takes a nap when she comes home from school. At night she has trouble falling
asleep and in the morning often has trouble getting up.

In the past 3 weeks, Cindy has become anxious and has had two experiences in which she felt
"spacey and unreal." She often hears the voice of a young child crying for help; but when she
looks to see if there is someone outside the door, there is never anyone there. At times, recently,
especially when she feels guilty about the fight with her mother, she is convinced she doesn't
deserve to live and has considered killing herself. Three weeks ago, while she was washing
dishes, she thought about cutting her wrists with a knife; but the thought of how upset her father
would be kept her from doing anything.

The psychiatrist who evaluated Cindy recommended an elective admission to the hospital.
However, both she and her father felt that she would be able to follow through with outpatient
treatment. She was given the telephone number of the emergency room and the following day
called to say that the voices were getting worse, and she was afraid she might hurt herself. She
was directed to go immediately to the emergency room and was subsequently admitted to the
hospital.