Clinical Vignette:

Emily Vicks, born April 1st 1989. Emily is a married 34 year old African American female college student, presented for evaluation by her Primary care doctor for issues dealing with mood instability. Emily has a slight hearing impairment, but able to drive on her own without assistance. Her symptoms of chronic mood instability had persisted and worsened since she returned from a 22- month military tour in Iraq and Afghanistan. During Deployment Emily attempted self harm,and was placed on a 72 hour hold in a psychiatric hospital. Emily was able to speak with a psychiatrists and also psychologist while in the hospital. Emily was flagged as attempting self harm and went to outpatient treatment for 2 months. Emily talks to the therapist and describes that this whole process is a joke, with the psychiatrist, psychologist and even the therapist as no one can fully understand what she experienced and also what she saw.

Emily worked in air traffic control while on deployment and although she was not directly involved in a combat zone, she lost many of her friends that were in the military in the combat zone areas. This was Emily's first psychiatric evaluation. Emily does not like to talk about her time in the military but her husband insists that she does. Emily reports of her mood being down, has nightmares, sleepwalks, night terrors, wakes up sweating, out of breath, and confused. Most of the time she doesn't enjoy being around husband or enjoying time with her three young children (2, 4, 6).

Emily reports moments of being restless, hopeless, and always reports of being hypervigillant while in public as she has to always look at her surroundings. Emily avoids driving, especially when she has to go over bridges as she would rather stick with the area she is most comfortable with. Emily's sleep is interuptted often which she has distubring dreams of hearing bombs go off and screams, on top of loud noises.

Emily's husband has convinced her to go back to college to find a better outlook on life in which she will be able to find a career that she loves that also brings her flexibility with raising her children.

Emily reports moments of poor concentration since returning back from service. Marijuana and cocaine initially helped Emily deal with her symptoms, but her ability to turn in assignments, study and be present for school has declined due to her cocaine and marijuana use. Emily has fleeting thoughts of suicidality while using cocaine and marijuana. Her appeite has been good, no history of panic attacks, obsessive compulsions or psychosis.

Emily proudly talks about her psychiatric hospitilization and hold she was placed on and also discuss how she doesn't believe in outpatient treatment. There are family history of also psychiatric hospitilization in which her father tried to attempt suicide and also abused alcohol. Mother was diagnosed with bordeline personality disorder while she was 27.

Emily, first started using cocaine and marijuana when she was 15. Emily had a high tolerance for this in which she would use drugs 2x a week. Emily use of drugs escalated more while in the military in which it almost became out of control for her. After being released from the military Emily would use drugs 2-3x per day for at least 3 days per week and sometimes even more.

During the moments of heavy use Emily would black out, would have tremors and speech would be affected. Emily identified cocaine as her identified drug of choice and just needed the marijuana to supress her mood. Emily noted that she used cocaine to snort and also decided one day decided to experiment with crack cocaine. Emily's Husband did not know of her cocaine or marijuana use.

Emily lost at least four jobs since being out of the military because of her cocaine and marijuana use. Emily also uses nicotine as well to calm her nerves and mood in which she smokes 5-8 cigarettes per day. Her efforts to quit smoking are failing because of her cravings and withdrawal symptoms.