Using the DSM 5 TR how would you diagnose the following patient? Sally, 23, is brought in by her parents, who are both in their 60s. Sally is the youngest of five siblings, all of whom are at least 10 years older than she, and married. The four eldest siblings were raised on the family farm. When Sally was about 10, her parents sold the farm and moved to the small city where they now live. Two of her siblings live in the same area. Two have left the area to pursue work opportunities.

Sally seems irritated. She asks, "Will you explain to my parents that I don't need to be here? I want to get home and work on my book." The family explains that Sally has been writing a novel. Sally believes that once she publishes her work, she will be acclaimed for setting the new direction in American literature.

Sally works as a ticket agent for an airline. She has continued to live at home in order to save money to attend a graduate school program. Sally's parents are concerned. They report they hear her typing in her room for hours at a time, even during the wee hours of the night. Her mother is concerned because she can't be getting much sleep. Alternately she becomes frustrated about writer's block, so much so that she has broken things. This is not like her. They also worry because she recently bought a new car that they do not believe she can afford. They feel this is an unusual step for her. She states that their concerns do not take into account the large advance she will get once she shows her novel to a publishing agent. Sally's parents are not sure if they are overreacting or not. Her mother says, "At least she's not like Ted was." Ted is an older brother who attempted suicide several years ago and is being treated with antidepressant medication.

It is difficult to get Sally to talk about much other than her writing. She eventually agrees to discuss other topics "If that's the only way I'm going to get out of your office this morning." She states she has good relationships with all family members, especially her young nephews and nieces. However, she does not have time for family right now. She also reports she is now irritated with her parents for selling the farm 10 years ago: "That would have been the perfect environment in which to have some peace so that I could focus on writing."

Sally denies that she has any other problems worth talking about.