Case Studies #1
Instructions: For each of the 5 cases below, first state a specific diagnosis.
Then state at least 3 symptoms from the case that support this diagnosis.
I.
A 27-year-old married electrician complains of dizziness, sweating palms,
heart palpitations, and ringing of the ears of more than 18 months' duration.
He has also experienced dry mouth and throat, periods of extreme muscle
tension, and a constant "edgy" and watchful feeling that has often interfered
with his ability to concentrate. These feelings have been present most of the
time over the previous 2 years; they have not been limited to discrete periods.
He constantly worries about the health of his parents. His father, in fact, had a
myocardial infarction 2 years previously but is now feeling well. He also
worries about whether he is "a good father," whether his wife will ever leave
him (there is no indication that she is dissatisfied with the marriage), and
whether co-workers on the job like him. Although he recognizes that his
worries are often unfounded, he cannot stop worrying.
II.
A 19-year old music student has been ill for about a year. Without any
tangible cause, while studying music, he became depressed, felt ill at ease and
lonely, made all sorts of plans, which he always gave up. During a visit to
Munich, he felt as if people in the street had something to say to him, and as if
he were talked about everywhere. He heard an offensive remark at an inn at
the next table, which he answered rudely. He heard that students asked for
him at the door, and he left Munich quickly with every precautionary measure,
because he thought himself accompanied and followed on the way. Since then
he overheard people in the street who threatened to shoot him, and to set fire
to his house, and on that account he had no light in his room. In the streets
voices pointed out the way he ought to go so as to avoid being shot. Behind
doors, windows, hedges, pursuers seemed everywhere to lurk. He also heard
long conversations of not very flattering purport as to his person. In
consequence of this, he withdrew altogether from society, but yet behaved in
such an ordinary way that his relatives, whom he visited, did not notice his
delusions. At last the many mocking calls, which he heard at every turn,
provoked the thought of shooting himself.
After about 6 months he felt freer, "comfortable, enterprising, and cheerful,"
began to talk a lot, compose, criticized everything, concocted great schemes,
and was insubordinate to his teacher. The voices still continued, and he
recognized in them the whisperings of master spirits. Hallucinations of sight
now became very marked. The patient saw Beethoven's image radiant with
joy at his genius; saw Goethe, whom he had abused, in a threatening attitude;
masked men and ideal female forms floated through his room. He saw
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lightning and glorious brilliancy of colors, which he interpreted partly as the
flowing out of his great genius, partly as attestations of applause from the
dead.
III.
A 27-year old, upper-middle class woman has referred herself for therapy
after her behaviors began to intrude on her ability to carry out her work,
which was a source of meaning and satisfaction for her. She had always
been a top student and recognized at her job. She was absorbed with her
job and had very few friends. She complained of vague anxieties about
dating, marriage, having a family and other related issues. Around the
same time, she began experiencing symptoms that focused on cleanliness.
Her concern with cleanliness gradually evolved into a thorough cleansing
ritual, which usually was precipitated by touching her genitals or anal
area. In her ritual, she would remove all of her clothing in a sequence. She
would lie out each piece of clothing on specific areas of her bed and
examine each one for any indications of “contamination”. She would then
thoroughly scrub her body, starting at her feet and working meticulously
up to the top of her head, using specific washcloths for certain body areas.
Any articles of clothing that appeared to have been contaminated were
thrown into the laundry. Clean clothing was put in the vacant spots on her
bed. She would then dress herself in the opposite order from which she
took the clothes off. If she deviated from this order, she would wonder if
she had missed any contamination and began the sequence again. It was
not uncommon that she did this 4-5 times in a row. As time passed, she
developed other rituals in response to thoughts, usually related to using
the toilet, sexual issues or encountering “contamination in public places”.
As her rituals widened, her ability to function decreased more and more
due to the time and energy she spent engaging in them. She was aware of
the absurdities of her behaviors but felt compelled to engage in them.
IV.
A 23-year old MBA student complains that she has been frustrated and
dissatisfied with her life for years. She has always done well academically,
but lately she has had little interest in doing her schoolwork and lacks
confidence that she can do well. She describes herself, as someone with
“big plans” but won’t ultimately “cut it”. She also fears that she will never
be satisfied with life even if she is successful. She frequently feels
irritable, despondent and helpless. She said, “It’s as if my entire life has
been laid out for me. I don’t feel like I have any choice about what I do.
Worst of all, I think it may all be a complete waste”. Lately her persistent
negative cognitions have interfered with her schoolwork and her duties
as a teaching assistant. She is easily distracted and often puts work off
until weeks after it is due. She says that sometimes she puts it off because
she worries that her advisor will see it as substandard (this has never
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actually happened); other times she just doesn’t do it because she doesn’t
care anymore.
V.
A 31-year old nurse has received on and off in-patient psychiatric care
over the past 5 years. Approximately 2 weeks after her most recent
readmission, she became very confused about her surroundings and
complained, “Everything had changed”. When staff tried to her calm her,
she became verbally abusive, shouting obscenities and swinging her fists.
She gave the present date as 8 months prior and believed she was at a
hospital over a thousand miles away. The date and hospital description
corresponded to a hospital she had been admitted to. She appeared not to
remember much of the months that followed this stay. Amnesiac episodes
were frequent for her. She is a quiet, demur and conscientious person, but
her behavior often changes during these amnesiac episodes. According to
reports made by her family and friends, and previous therapists, her
behavior during these “black outs” was often hostile, angry and selfdestructive. She did not remember these episodes, yet she would often
find physical evidence, such as new cuts and bruises after a blackout. She
often woke up to find herself in bed with a man she did not know.
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