Final Exam Case Studies

For each case, you will address the following?

1. Primary Diagnosis:Which disorder are you most likely to diagnose the person in your case with? Be sure to support the answer with a couple of statements on what you think the main symptoms are meeting the diagnostics criteria. Do NOT list every symptom or quote the case, I really am asking for a diagnosis and short support...For example, you might submit your answer as: Primary Diagnosis Schizophrenia because she reportsactive hallucinations (i.e. hearing voices talking all the time) as well as a strong delusion (i.e. believes she is Marilyn Monroe). Give enough detail to show you understand some of the key symptoms.
2. Differential Diagnosis:What other one disorder do you think you might need to consider based on the symptoms. For example: Possibly a depressive disorder as she says she always has mood swings, feeling so normal one moment and then so sad another.
3. What else do you need to know?Rarely do these case studies give you all the information you might need to make a proper diagnosis. Here I would like for you to show me some of the thoughts you have about what else you might need to feel you have the whole story and can make a proper diagnosis.For example: I think it would be important to know when she first started hearing voices, and if she ever heard voices before this current episode. Also, getting more information about her prior hospitalizationcan help.These should be unique to each case.
4. What evidenced based treatment would you suggest?Why?For this question refer to the textbook and BE SPECIFIC as to what the best evidence-supported treatment would be for the diagnosis you identified.Give 2 per diagnosis. Be sure you explain the treatment, don't just list.

For your answers, just type the name of the case, then answers as follows:

Ken:

1. Primary Diagnosis:
2. Differential Diagnosis:
3. What else do you need to know?
4. What treatment would you suggest?

Case #1: Ken

The patient is a 37-year-old Asian male who has been married for 6 years. At Ken's first meeting, he was dressed in a blue suit with a yellow tie, exclaiming it was his "power tie, bro!" He made decent eye contact but seemed nervous. His voice shook, and at times he rambled on, without stopping, or seemingly taking a breath. His wife said he was acting excitedly the past 7 days and added that he showed inappropriate affect at times, laughing and smiling when it was not appropriate. Ken carried a pager (before cell phones we used pagersJ ) with him at all times, which he initially refused to turn off, stating, "What happens if something goes down at the hotel, knowing all the things I can do? They call me Superman at the hotel. I am Clark Kent!"

Ken remembers having periods of "moodiness" that typically last a couple weeks, starting back when he began graduate school. He assumed this extreme sadness was normal and attributed it the academic transitions in his life. His wife explained, "The periods of sadness were obvious, which could last for weeks at a time. There were times where Ken could not get out of bed. He did not have the energy engage in conversations with me or anyone else and he rarely ate. At times he talked about wanting to just leave it all behind." These moods eventually lifted, and then Ken would go back to being "normal". Sometimes after the lows, Ken was stable, and at times feeling euphoric for about a week at a time. This is when Ken felt high, on top of the world with no worries. Sometimes during these euphoric periods, Ken would spend a lot of money but didn't really care because "it felt good; I felt good." While Jackie was talking about one incident where Ken spent $5,000, Ken interjected with, "Sometimes I cut myself with a knife, which really concerns Jackie. But I just laugh it off. What's weird is the pain doesn't hurt it all because nothing could bother me. I am Superman! The last 2 days I've had a lot of energy and I wanted to tackle some home renovations so last night while Jackie was sleeping, I cleared out the basement and starting painting. I didn't really want to sleep, and I felt wired."

Case Study #2: Crystal

Crystal Smith, a 33-year-old African American homemaker, came to an outpatient clinic seeking "someone to talk to" about feelings of despair that had intensified over the previous 8-10 months. She was particularly upset about marital conflict and an uncharacteristic irritability with her mother-in-law.

Ms. Smith said she had begun to wake before dawn, feeling down and tearful. She had difficulty getting out of bed and completing her usual household activities. At times, she felt guilty for not being her "usual self." At other times, she became easily irritated with her husband and impatient with her mother-in-law for minor transgressions. She relied on her mother-in-law for assistance with her children, but recently her mother-in-law appeared to be less available. Ms. Smith worries that she has become a burden to her mother-in-law. Her related guilt, in combination with her insomnia and fatigue, have made it very difficult for Ms. Smith to get her children to school on time. In the past few months, she had lost 13 pounds without dieting. She denied current suicidal ideation, saying she "would never do something like that," but acknowledged having thought that she "should just give up" and that she "would be better off dead." She decided to make an appointment after she attended her good friend's wedding and found she did not enjoy any of it.

Ms. Smith lived with her husband of 13 years and two school-age children. Her husband's parents lived next door. She said her marriage was good, although her husband suggested she "go see someone" so that she would not be "pacing and yelling at everyone all the time." While historically sociable, she now rarely talked to her own mother and sisters, much less her friends. Previously a regular churchgoer, she had quit attending because she felt her faith was "weak." Her pastor had always been supportive, but she had not contacted him with her problems because "he wouldn't want to hear about these kinds of issues."

Case Study #3: Victor

Victor is a 27-year-old man who comes to you for help at the urging of his fiance. He was an infantryman with a local Marine Reserve unit who was honorably discharged in 2014 after serving two tours of duty in Iraq. His fianc has told him he has "not been the same" since his second tour of duty and it is impacting their relationship. Although he offers few details, upon questioning he reports that he has significant difficulty sleeping, that he "sleeps with one eye open" and, on the occasions when he falls into a deeper sleep, he has nightmares. He endorses experiencing several traumatic events during his second tour but is unwilling to provide specific details - he tells you he has never spoken with anyone about them and he is not sure he ever will. He spends much of his time alone because he feels irritable and doesn't want to snap at people. He reports to you that he finds it difficult to perform his duties as a security guard because it is boring and gives him too much time to think. At the same time, he is easily startled by noise and motion and spends excessive time searching for threats that are never confirmed both when on duty and at home. He describes having intrusive memories about his traumatic experiences on a daily basis but he declines to share any details. He also avoids seeing friends from his Reserve unit because seeing them reminds him of experiences that he does not want to remember.

Case #4: Peggy

Peggy Isaac was a 41-year-old administrative assistant who was referred for an outpatient evaluation by her primary care physician with a chief complaint of "I'm always on edge." Ms. Isaac had lived with her longtime boyfriend until 8 months earlier, at which time he had abruptly ended the relationship to date a younger woman. Soon thereafter, Ms. Isaac began to agonize about routine tasks and the possibility of making mistakes at work. She felt uncharacteristically tense and fatigued. She had difficulty focusing. She also started to worry excessively about money and, to economize, she moved into a cheaper apartment in a less desirable neighborhood. She repeatedly sought reassurance from her office mates and her mother. No one seemed able to help, and she worried about being "too much of a burden."

During the 1 month prior to the evaluation, Ms. Isaac began to avoid going out at night, fearing that something bad would happen and she would be unable to summon help. More recently, she avoided going out in the daytime as well. She also felt "exposed and vulnerable" walking to the grocery store three blocks away, so she avoided shopping. After describing that she had figured out how to get her food delivered, she added, "It's ridiculous. I honestly feel something terrible is going to happen in one of the aisles and no one will help me, so I won't even go in." When in her apartment, she can often relax and enjoy a good book or movie.

Ms. Isaac said she had "always been a little nervous." Through much of kindergarten, she had cried inconsolably when her mother tried to drop her off. She reported seeing a counselor at age 10, during her parents' divorce, because "my mother thought I was too clingy." She added that she had never liked being alone, having had boyfriends constantly (occasionally overlapping) since age 16. She explained, "I hated being single, and I was always pretty, so I was never single for very long." Nevertheless, until the recent breakup, she said she had always thought of herself as "fine." She had been successful at work, jogged daily, maintained a solid network of friends, and had "no real complaints."