The Diagnosis:

• List social factors: Age, Socio-economic status (SES), job, family, etc. about the client
• State the client's current level on Maslow's Pyramid of Needs with supporting reasons
• List contributing biological factors (Genetics, Stress, current health, etc.) with supporting example
• Name the disorder and list (bullet point) each diagnostic symptom to meet the specified criteria with an example from the case study as support.

A. Mary is a 35-year old social worker who was referred to a psychiatrist for treatment of chronic pain in her right forearm and hand. She had a complex medical history that included asthma, migraine headaches, diabetes, and obesity. She was found to be highly hypnotizable, and quickly learned to control her pain with self-hypnosis. Mary was quite competent in her work, but had a rather non-existent personal life. She had been married briefly and divorced 10 years earlier and had little interest in remarrying. She spent most of her free time volunteering in a hospice. As a thorough psychiatric evaluation continued, she reported the strange observation that on many occasions, when she returned home from work the gas tank of the car was nearly full, yet when she got into the car to go to work the next day, it was half empty. She began to keep track of the odometer, and discovered that on many nights 50 to 100 miles would be put on the car overnight, although she had no memory of driving it anywhere. Further questioning revealed that she had gaps in her memory for large parts of her childhood. After several months of hypnotic treatment for pain control, an explanation for the lost time emerged. During hypnosis, the physician again asked about the lost time. Suddenly a different voice responded, "It's about time you knew about me." The (alter) personality with a slightly different name, Marian, now spoke and described the drives that she took at night, which were retreats to the nearby hills and seashore to "work out problems." As the psychiatrist got to know Marian over time, it was apparent that she was as abrupt and hostile as Marian was compliant and concerned about others. Marian considered Mary to be rather pathetic and far too interested in pleasing others, and she said that "worrying about anyone but yourself is a waste of time." In the course of therapy, some six other personalities emerged, roughly organized along the lines of a dependent/aggressive continuum. Considerable tension and disagreement emerged among these personalities, each of which was rather two-dimensional. Competition for control of time "out" was frequent, and Marian would provoke situations that frightened the others, including one who identified herself as a 6-year old child. The memories that emerged with these dissociated personalities included recollections of physical and sexual abuse at the hands of her father and others, and considerable guilt about not having protected other children in the family from such abuse. Mary recalled her mother as being infrequently abusive, but quite dependent, and forcing Mary to cook and clean from a very early age. After about 4 years of psychotherapy, Mary gradually integrated portions of these personality states. Two similar personalities merged, although she remained partially dissociated. The personality states were aware of one another, and continued to "fight" with each other periodically.

B. When Ernest's desperate wife finally got him to agree to a comprehensive inpatient evaluation, he was 37, was unemployed, and had been essentially nonfunctional for several years. After a week during which he was partying all night and shopping all day, his wife said that she would leave him if he did not check into a psychiatric hospital. The admitting psychiatrist found him to be a fast-talking, jovial, seductive man with no evidence of delusions or hallucinations. Ernest's troubles began 7 years before when he was working as an insurance adjuster and had a few months of mild, intermittent, depressive symptoms, anxiety, fatigue, insomnia, and loss of appetite. At the time, he attributed these symptoms to stress at work, and within a few months was back to his usual self. A few years later an asymptomatic thyroid mass was noted during a routine physical exam. One month after removal of the mass, Ernest noted dramatic mood changes. Twenty-five days of remarkable energy, hyperactivity, and euphoria were followed by 5 days of depression during which he slept a lot and felt that he could hardly move. This pattern of alternating periods of elation and depression, apparently with few "normal" days, repeated itself continuously over the following years. During his energetic periods, Ernest was optimistic and self-confident, but short tempered and easily irritated. His judgment at work was erratic. He spent large sums of money on unnecessary and, for him, uncharacteristic purchases, such as a high-priced stereo system and several Doberman pinschers. He also had several impulsive sexual flings. During his depressive periods, he often stayed in bed all day because of fatigue, lack of motivation, and depressed mood. He felt guilty about the irresponsibility and excesses of the previous several weeks. He stopped eating, bathing, and shaving. After several days of this withdrawal, Ernest would rise from bed one morning feeling better and, within 2 days, be back at work, often working feverishly, though ineffectively, to catch up on work he had let slide during his depressed periods. Although both he and his wife denied any drug use, other than drinking binges during his hyperactive periods, Ernest had been dismissed from his job 5 years previously because his supervisor was convinced that his over activity must be due to drug use. His wife had supported him since then. When he finally agreed to a psychiatric evaluation 2 years ago, Ernest was minimally cooperative and noncompliant with several medications that were prescribed, including antidepressants. His mood swings had continued with few interruptions set up to the current hospitalization.