Mrs. CP

Mrs. CP is a 64-year-old widowed Filipino woman who came to see a psychiatrist at an outpatient mental health clinic. She had been in treatment intermittently since 1998 for depression and anxiety. Her symptoms included anxious mood, insomnia, hypervigilant behavior, tearfulness, poor concentration, and feelings of palpitations. She reported that over the past year she had been more forgetful and distractible, forgetting where she had placed her keys, pocket cash, and other items. She would forget to get off the bus at a familiar stop and could not remember to purchase needed items at the grocery store. Of greater concern, she had left the stove on several times and had limited recollection of this. Mrs. CP's behavior included unusual incidents such as leaving rotting bananas in the closet and going back into the shower fully clothed after she had just bathed and dressed herself. Because of these behaviors, her younger son and a close friend moved in with her to assist and monitor her behavior.

The first sign of some unusual behavior began one year prior to Mrs. CP's current treatment when she described episodes of "sleepwalking" during the day. She reported walking for blocks past a location and past an appointment time, and did not realize that she had done so until something distracted her, such as her cell phone ringing or a taxi honking a horn. She felt that she lost brief periods of time. Mrs. CP also spoke of symptoms occurring at night, such as talking in her sleep, and her waking up to find that all of the windows had been opened, or that the television or air conditioner had been turned on without her awareness. The patient's son had witnessed the patient flailing about at night and talking in her sleep.

However, the patient's overall functional performance of her activities of daily living and instrumental activities of daily living were not consistent with someone who had a dementing process or an amotivational or inattentional process. She shopped for her food, cooked, paid her bills, and followed up with her medical appointments. On psychological testing, she did not show poor executive planning, aphasia, personality change, or other signs of early dementia. The patient was very uncomfortable about the increasing dependence on others, and felt helpless and concerned that there would not be an explanation forthcoming about her diagnosis.

Mrs. CP had consulted three neurologists from different hospitals in the past and had been told by one that her problem was "anxiety," by another that it was "stress and depression," and by a third that she had early-onset Alzheimer's disease. The patient's medical history was significant for hypertension, chronic vertigo, osteoarthritis, osteopenia, and gastroesophageal reflux disease. Medications included hydrochlorothiazide 25 mg daily, meclizine 12.5 mg twice daily, and esomeprazole 40 mg daily. She was diagnosed with seizures as a child but had not taken any anticonvulsant medication for many years. Mrs. CP underwent a noncontrast head computed tomography (CT) scan in April 2006, which revealed bilateral frontal volume loss. A subsequent magnetic resonance imaging (MRI) scan of the brain done in September of that year did not reveal such an abnormality. Due to the uncertain history of seizures, she underwent a three-day electroencephalogram (EEG) study with overnight monitoring, which did not reveal any abnormalities. Laboratory work-up was unremarkable.

Mrs. CP was born in the Philippines and had had a turbulent childhood and a severe eating disorder early on. She recalled weighing 80 pounds at one point and thinking that she was overweight. She binged and purged, and used diet pills. She was emotionally labile, "became hysterical" at times, had episodes of getting very upset, and other episodes of staring off into space for minutes, frozen, while eating. She also displayed obsessive thoughts about germs and cleanliness. Mrs. CP had many washing rituals due to fears that she would die if she was not clean enough. As a teenager, Mrs. CP had a "nervous breakdown" due to depression, and her father consulted with a psychiatrist. At that time, she was abusing her mother's diet pills, engaging in purging and excessive coffee drinking, not sleeping for long periods, and then sleeping for days at a time. While she was in her 20s, she made three attempts to end her life, once by overdosing on 50 pills of 10-mg chlordiazepoxide; another time, she overdosed on over-the-counter sleeping pills; and, in a third attempt on her life, she ingested a powder used for her skin. She described feeling driven by the stress of being in an "inescapable, abusive marriage." Her husband was often drunk, physically abusive, tortured the childrensometimes with an axand used them for "target practice."

Mrs. CP appeared to want help with her problems but was easily overwhelmed and presented with a diagnostic challenge. The psychiatrist was concerned about how to proceed.

Vignette Rubric

1. Symptoms that are identified in the vignette
2. Diagnoses considering and why (not just those in the disorders currently being discussed)
3. Diagnoses that are ruled out and why
4. Final diagnoses (including any others not part of the disorders being discussed)

Andie

The Andie is an 18-year-old female from Germany. She has been living in the U.S. for the last three years. Her mother died four years ago (cause of death unknown). Andie witnessed mother's death. Andie 's mother was never very involved in her life. She was raised by her grandmother. She has no prior history of mental illness or any other medical problems.

The Andie appeared under nourished at the time of the interview. Andie fainted during the clinical interview when her hand was placed in cold water. Otherwise, she exhibited good physical strength for her size. Andie had a pleasant disposition, is responsive, and seems oriented to time and place.

Andie was brought in by her father and grandmother. Father and grandmother complained that Andie steals and lies, frequently. For example, father reported that she will take money from his pocket and then deny that she had done so. Father stated that Andie stole a pocketknife from her teacher. Andie claimed that she did not steal it, but rather found it. Father and grandmother claimed that Andie steals money to buy candy from the store. Andie will often assert that it was another little girl who actually bought the candy.

Andie often behaves like a child much younger than 18. Father reported that Andie came to him stating that she wanted to be loved and be his baby like the other little girl. Andie went on to say "I'm a good girl now, ain't I? I don't steal anymore, do I?" Father said she had a peculiar look on her face during this time. Father claimed that the Andie will change behaviors frequently. For example, Andie once ran away and claimed that she was whipped excessively at home. However, on other occasions, as stated above, Andie will seek out father's love and affection.

Although father claimed that she is not whipped excessively, he does admit to whipping her when she returned home after she ran away. I am not convinced that the Andie is not physically abused. Family did not seem to be very fond of Andie. For example, Andie 's grandmother called her "a terrible little liar."

Andie is frequently interested in things that one would associate with a young child, not an 18-year-old. For example, she reported stealing money from teacher in order to buy candy, ice cream, and rollerskates. Andie appeared more gullible than one would expect for an 18-year-old. For example, Andie stole items and called people "wicked" names when told to by a boy (15) who lives on her street.

During the interview the Andie talked about her interaction with the aforementioned boy and another girl (11). Andie described how the boy tried to get the other girl to go into the bushes with him. Andie said that she did not know what this meant, and that the other girl would not tell her. Andie said that the boy will say bad names to her and try to get her to steal, but that he is nice to the other girl. Later in the interview, however, Andie talked about how the boy tries to get her to go out into the bushes with her (after having said that he never tried to get her to do that). Andie also stated that the boy had knocked down the other girl and tried to take her clothes off (after having said that he was nice to her). Andie went on to say that the other girl told her lots of bad names that that boy taught her (after having stated that the girl does not say bad words).

From the interview provided, it appears as though the Andie switches from herself to "the other girl," about whom she was talking. The other girl then appears to be talking about the "Andie." I believe this is why the girl contradicts herself, as described above. Furthermore, I believe this is why the Andie (18) buys candy, ice cream, and rollerskates (interests more characteristic of an 11-year-old) with the money she steals. This may also explain why she claims not to remember stealing certain items.

Vignette Rubric

1. Symptoms that are identified in the vignette
2. Diagnoses considering and why (not just those in the disorders currently being discussed)
3. Diagnoses that are ruled out and why
4. Final diagnoses (including any others not part of the disorders being discussed)

Julie

Julie was a 29 year old, female who was being seen for therapy. In the middle of December, Julie was observed not wearing appropriate clothing for the weather (jean overalls, short sleeve shirt, and flip flops). It was clear that Julie had bathed in quite some time, evidence by her odor and greasing looking hair. Her clothes appeared similar, likely with her having worn the same clothing for many days. Julie came into session wide eyed and staring at various spaces of the therapy room. At times it appeared so though she was unaware of the therapist. She indicated that she was currently working for the CIA on a top secret project and was telepathically working on nine different computer screens, monitoring "activity." She was either unable or unwilling to answer many questions directed towards her. It was determined that Julie had not taken her medicine for some time and was in need of inpatient treatment. She was placed in a separate room while the clinician called the ambulance. Julie sat in a chair in the corner of the room, staring at one spot, not blinking and not speaking for approximately 10 minutes straight before ambulance arrived. She went willingly with paramedics as she thought they were in support of her work and also worked for the government, like her. Julie, who has a history of alcohol and methamphetamine use, was tested for substances, which came back negative. Upon further evaluation, Julie stated that she has never used substances before but that people falsified drug tests or put them in her food without her knowledge. A timeline of her substance use was impossible to get at intake.

Vignette Rubric

1. Symptoms that are identified in the vignette
2. Diagnoses considering and why (not just those in the disorders currently being discussed)
3. Diagnoses that are ruled out and why
4. Final diagnoses (including any others not part of the disorders being discussed)

Jesse

Jesse is a 22 year old male who has a long history of medical concerns. He was diagnosed with cancer during childhood, which he was treated and was currently in remission. However, as a result of the treatment, he began to experience seizures, which led to a brain surgery to fix. While his seizures decreased in severity and frequency, he still required medication and would experience seizures periodically. At this point, he is functioning normally, like any other 10 year old boys. He does well in school, has many friends, plays sports, functioning well. Still leaving with his parents, one morning, approximately six months before the current evaluation, Jesse began acting strangely. He was pacing and severely agitated. He appeared to be speaking/referring to things that others could not see. He could not articulate what he was feeling or seeing. This went on for approximately five days, until one morning, he was stupor, devoid of verbal responses, grimacing, and would not respond to instructions or external stimuli. This is how he has been behaved for approximately six months. Medical professionals appear to have ruled out medical/neurological causes of the behaviors and symptoms. In the current evaluation, his parents attended the appointment, which was for diagnostic clarification. Initially, Jesse would look at the evaluator when asked direct questions but would quickly look towards parents to answer whatever question was posed. Shortly after the start of the evaluation, Jesse fell asleep. Fort-five minutes later, evaluators woke up Jesse, at which time posturing, grimacing, rigid movements on his left side began with consistency. Only an interview was conducted as he would have been unable to complete any psychological testing.

Vignette Rubric

1. Symptoms that are identified in the vignette
2. Diagnoses considering and why (not just those in the disorders currently being discussed)
3. Diagnoses that are ruled out and why
4. Final diagnoses (including any others not part of the disorders being discussed)