CLINICAL CASE SCENARIOS (SET 3)

INSTRUCTIONS: For each of the presented clinical cases, answer the following:

1. How would you diagnose the patient? Provide the name and numerical code of all your
diagnoses and justify your decision by citing the specific diagnostic criteria he/she meets for
each diagnosis. (Use DSM 5)
2. How do you differentiate his/her diagnosis from that of other possible conditions?
3. What could be the possible sources or cause of the patient’s condition?

Note: Answers should be encoded and printed.

CASE 1

Jessica is a 28 year-old married female. She has a very demanding, high stress job as a second year
medical resident in a large hospital. Jessica has always been a high achiever. She graduated with top
honors in both college and medical school. She has very high standards for herself and can be very self-
critical when she fails to meet them. Lately, she has struggled with significant feelings of worthlessness
and shame due to her inability to perform as well as she always has in the past.

For the past few weeks Jessica has felt unusually fatigued and found it increasingly difficult to
concentrate at work. Her coworkers have noticed that she is often irritable and withdrawn, which is
quite different from her typically upbeat and friendly disposition. She has called in sick on several
occasions, which is completely unlike her. On those days she stays in bed all day, watching TV or
sleeping.

At home, Jessica’s husband has noticed changes as well. She’s shown little interest in sex and has had
difficulties falling asleep at night. Her insomnia has been keeping him awake as she tosses and turns for
an hour or two after they go to bed. He’s overheard her having frequent tearful phone conversations
with her closest friend, which have him worried. When he tries to get her to open up about what’s
bothering her, she pushes him away with an abrupt “everything’s fine”.

Although she hasn’t ever considered suicide, Jessica has found herself increasingly dissatisfied with her
life. She’s been having frequent thoughts of wishing she was dead. She gets frustrated with herself
because she feels like she has every reason to be happy, yet can’t seem to shake the sense of doom and
gloom that has been clouding each day as of late.

CASE 2

George was 35 years old, married, and the father of two young children. He worked at a small junior
college where he taught physical education and coached both the men’s and women’s track teams. Until
his breakdown, the teams had been having an outstanding season. They were undefeated in dual
competition and heavy favorites to win the conference championship. The campus was following their
accomplishments closely because it had been many years since one of the school teams had won a
championship. In fact, track was the only sport in which the school had a winning record that season.
This was not the first time that George had experienced psychological problems. His first serious episode
had occurred during his junior year in college. It did not seem to be triggered by any particular incident;
in fact, things had been going well. George was playing defensive back on the university football team.
He was in good academic standing and fairly popular with the other students.

Nevertheless, during the spring semester, George found that he was losing interest in everything. It was
not surprising that he did not look forward to classes or studying. He had never been an outstanding
student. But he noticed that he no longer enjoyed going out with his friends. They said he seemed
depressed all the time. George said he just did not care anymore. He began avoiding his girlfriend, and
when they were together, he found fault with almost everything she did. Most of his time was spent in
his apartment in front of the television. It did not seem to matter what program he watched because his
concentration was seriously impaired. He kept the TV on as a kind of distraction, not as entertainment.

When he did not show up for spring football practice, the coach called him to his office for a long talk.
George told his coach that he did not have the energy to play football. In fact, he did not feel he could
make it through the easiest set of drills. He did not care about the team or about his future in sports.
Recognizing that George’s problem was more than a simple lack of motivation, the coach persuaded him
to visit a friend of his—a psychiatrist at the student health clinic.

George began taking antidepressant medication and attending individual counseling sessions. Within
several weeks, he was back to his normal level of functioning, and treatment was discontinued. George
had also experienced periods of unusual ambition and energy. As a student, he had frequently spent
several days cramming for exams at the end of a semester. Many of his friends took amphetamines to
stay awake, but George seemed able to summon endless, internal reserves of energy. In retrospect,
these periods seemed to be hypomanic episodes (i.e., periods of increased energy that are not
sufficiently severe to qualify as full-blown mania). At the time, these episodes went relatively unnoticed.
George’s temporary tendency toward excess verbosity, his lack of need for sleep, and his ambitious
goals did not seem pathological. In fact, his energetic intervals were productive, and his behavioral
excesses were probably adaptive in the competitive university environment.

There had been two subsequent episodes of depression with symptoms that were similar to those of the
first episode. The most recent incident had occurred 8 months prior to his current hospitalization. It was
September, 2 weeks after the start of the fall semester. George had been worried about his job and the
team all summer. Who would replace his star sprinter who had transferred to the state university?
Would his high jumper get hurt during the football season? Could they improve on last year’s winning
record? Over the past month, these concerns had become constant and consuming. George was having
trouble getting to sleep; he was also waking up in the middle of the night for no apparent reason. He felt
tired all the time. His wife and children noticed that he was always brooding and seemed preoccupied.
Then came the bad news. First, the athletic department told him that he would not get an increase in
travel funds, which he had expected. Then he learned that one of his assistant coaches was taking a
leave of absence to finish working on her degree. Neither of these events would have a drastic effect on
the upcoming season, but George took them to be disasters. His mood changed from one of tension and
anxiety to severe depression.

Over several days, George became more and more lethargic until he was almost completely
unresponsive. His speech was slow and, when he did say more than a word or two, he spoke in a dull
monotone. Refusing to get out of bed, he alternated between long hours of sleep and staring vacuously
at the ceiling. He called the athletic director and quit his job, pointing to minor incidents as evidence of
his own incompetence.

CASE 3

Elise is a 35-year-old architect. She comes to you in great distress, feeling that she is unable to work, and
generally unable to function. She says that she feels tired all the time, to the point of feeling completely
exhausted. She says that she cries easily, and almost every day. She is having difficulty sleeping, and has
lost 20 pounds in the last 2 months without trying. She says that things have been "real bad" for the last
2 months; she doesn't enjoy doing anything and thinks frequently of suicide. However, she also says that
she has never been a very happy person. She says that things rarely go right for her, and she has given
up on expecting good things to happen for her.

CASE 4

Susie is a 20-year-old sophomore at a small Midwestern college. For the past five days she has gone
without any sleep whatsoever and she has spent this time in a heightened state of activity which she
herself describes as “out of control.” For the most part, her behavior is characterized by strange and
grandiose ideas that often take on a mystical or sexual tone. For example, she recently proclaimed to a
group of friends that she did not menstruate because she was a “of a third sex, a gender above the
human sexes.” When her friends questioned her on this, she explained that she is a “superwoman” who
can avoid human sexuality and still give birth. That is, she is a woman who does not require sex to fulfil
her place on earth.

Some of Susie’s bizarre thinking centers on the political, such as believing that she had somehow
switched souls with the senior senator from her state. From what she believed were his thoughts and
memories, she developed six theories of government that would allow her to single-handedly save the
world from nuclear destruction. She went around campus, explaining these theories to friends and even
to her professors and began to campaign for an elected position in the U.S. government (even though
no elections were scheduled at the time). She feels that her recent experiences with switching souls
with the senator would make her particularly well suited for a high position in government; perhaps
even the presidency.

Susie often worries that she will forget some of her thoughts and has begun writing notes to herself
everywhere; in her notebooks, on her computer---even on the walls of her dormitory. Susie’s family and
friends, who have always known her to be extremely tidy and organized, have been shocked to find her
room in total disarray with frantic and incoherent messages written all over the walls and furniture.
These messages reflect her disorganized, grandiose thinking about spiritual and sexual themes.

Susie has experienced two previous episodes of wild and bizarre behavior similar to what she is
experiencing now; both alternated with periods of intense depression. When she was in the depressed
state, she could not bring herself to attend classes or any campus activities; she suffered from insomnia,
poor appetite, and difficulty concentrating. At the lowest points of the depressive side of her disorder,
Susie contemplated suicide.