Case Study of Jamal

Read the Case Study of Jamal then respond to the following questions or issues:

1. What are the diagnostic possibilities presented by Jamal's case? (Be sure to detail at least three possible differential diagnoses.)

2. What in Jamal's case history presents these possibilities?

3. Provide a series of questions you could ask to evaluate the differential diagnoses you listed in Question 1, above, and pair them with potential responses that would move you toward or away from the diagnosis in question.

4. What further information, evaluation, and referrals would you want in order to clarify Jamal's diagnostic status?

5. Describe the neuropsychological changes related to Jamal's diagnosis and suggest a basic program for assessing and remediating these issues.

Case Study:

Jamal is a 66-year old immigrant from Iraq. He was a successful high-ranking military officer who helped the United States after the first Gulf War, and who had to leave Iraq because of this role and the fact that there were some in Iraq who considered him to be a traitor. He is accompanied to the interview by his wife of forty-years, Farrah, and an adult son, Ali, who is a local high school teacher who moved to the United States while in college. Jamal used to be a happy man, his wife says, but this has been changing for a year or two. He speaks good English and is financially secure because of a pension and family monies. He is not happy to be in your office and has only come because his son has pressed the issue, saying simply, "Dad's forgetting things and he's completely bollixed up their checking account." Jamal complains vigorously that there is nothing wrong with him that an obedient wife could not cure. He is simply mad because of all the things his wife has been doing to bother him lately, like moving things he's put down and hiding things from him. The problems seen from Jamal's and his family's perspectives started about two years earlier.

As you ask about his history, you notice that Jamal continually looks to Farrah for cues to even the simplest questions. She quickly nods, frowns, moves a hand, or provides subtle cues that Jamal uses to answer your questions. You take a break, during which you rearrange the chairs so that Jamal cannot easily see Farrah, and in an aside to her and Ali you ask them to not provide any further cues to Jamal as you want Jamal to answer the questions by himself. When Jamal has to turn all the way around in his chair to see his wife, and she then will not provide him cues, he gets angry and shouts, "You see. She's not a good wife. She used to be, but she's not any mule! Why won't you help me!?" he demands of her. You ask if he meant to say, "mule," to which he says, "I did not say that." His wife and son indicate that he frequently uses the wrong words lately, or that he can not find the word at all. He has also taken to wandering around the house in the middle of the night, something he never did previously. They found him half a block away in his pajamas two nights earlier.

You calm Jamal down, then explain that you have asked his wife and son to not provide any answers and that you want the answers to come from him (Jamal). He bristles, says, "You think I can not talk!? I will show you!" You ask him to remember three words for a period of ten minutes. He tells you to remember them yourself because "I do not have time for such childishness." You tell him the words anyway and he angrily repeats them immediately back to you. "See! I am not a child, you know." You ask him to do what he must to remember then for ten minutes, and he nods, "okay." When you ask him his wife's maiden name, he says "Arrafat," to which his wife shakes her head. That is not her maiden name. You ask the date, time of day, and what the name of the place the interview is taking place. Jamal laughs and shakes his head then gets the date wrong by two months, the time by three hours, and he calls your office, "that place." You ask him to repeat the three words you gave him only four minutes earlier, and he says, "What words? You did not tell me any words." You ask him what to do if he is the first person to notice fire in crowded a movie theatre and he says, "Scream fire at the top of my voice and run like mad so I do not get trampled."

Jamal does not drink alcohol, and never has. He had a small stroke when he was fifty-two, and another when he was sixty, but he recovered from each of them after brief periods of some mild language difficulties and mild weakness on the right side of his body. You learn, too, that he was in an automobile accident when he was 63, and that he lost consciousness for about 36-hours. As with his mild strokes he came back from that with only a little residual confusion after only three or four months. "That is why I can not remember everything," he says as if grabbing on to this to explain his family's concerns. "It is not bad, though. I get by okay." You also learn that Jamal has been hospitalized four times throughout adulthood for major depression, and on the last occasion (seven years earlier); he required electro-convulsive therapy (ECT) to break the depressive cycle. His depressions were often marked by agitated and irritable behaviors, insomnia, and a decline in concentration skills.