Case Studies #2
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 based
on the DSM checklists in the book.
I.
Hilde is a 42-year-old homemaker who sought help from her family
physician for a combination of complaints, including headaches, mild
depression & marital difficulties. He referred her to a private
psychiatrist. In the initial interview, Hilde appeared to be motivated,
although at times she rambled so much that he had to bring her back to
the subject at hand. As he listened to her, it became apparent that she
had not really reflected in any depth on the issues that she discussed &
was only pumping out information much as a computer would. She
delighted in giving extensive historical descriptions of her past, again
without much insight (or even interest) as to how these had any causal
role in her present distress. When confronted with any irrelevancies in
her stories, she first adopted a cute & charming manner, & if this proved
ineffective in persuading her psychiatrist to change topics, she became ill
tempered & irritated.
When she described her present difficulties, she was always inclined to
ascribe the responsibility to some person or situation other than herself.
She stated that her husband was indifferent to her & added that she
suspected he had been seduced by one of the secretaries in his office.
This situation, along with a “lot of stress in my life”, was given as the
reason for the headaches & depression. When pressed for more details,
she found it hard to describe interactions with her husband in any
meaningful way.
An interview with her husband revealed that he “had simply become tired
of dealing with her.” He admitted that his original attraction to Hilde was
for her social status, her “liveliness” & her physical attractiveness. Over
the years, it became clear that her liveliness was not the exuberance &
love of life of an integrated personality, but simply a chronic flamboyance
& an intensity that was often misplaced. Her physical attractiveness was
naturally declining, & she was spending inordinate amounts of her time &
money attempting to keep it up. Her husband admitted that, when he had
married her, he had been reserved & inhibited. He viewed Hilde as his
ticket to a new life. Now that he had established himself on his own, &
had both matured & loosened up emotionally, he had simply grown tired
of her childish & superficial manner. As he put it, “I still care for her & I
don’t want to hurt her, but I’m just not interested in putting up with all of
this stuff too much longer.
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Hilde’s childhood history revealed that her beauty was prized, & the
response it received from friends in her parents’ social circle also
provided her with more than simple attention. Her mother delighted in
having her stay up & greet guests at her parties, something she never
consistently allowed Hilde’s sisters to do. Also Hilde soon discovered that
is she misbehaved, a charmingly presented “I’m sorry” to her father
usually avoided punishment. As Hilde moved into adolescence, she
developed a wide circle of friends, but she never attained much depth in
any one relationship. Her beauty, social grace & her high status in the
community made it easy for her to flit about like a princess among her
courts. Males came to her as bees come to a flower. She had a reputation
for being loose sexually, but it is clear this was based on hopes & rumor
rather than actual behavior. As Hilde put it, “They like the promise; you
don’t really have to pay off.” Hilde remembers her junior high & high
school years as “the happiest time of my life”, an assessment that is
probably accurate.
II.
Mr. Simpson is a 44-year old, single, unemployed, white male brought to
the emergency room by the police for striking an elderly woman in his
apartment building. His chief complaint is, “That damn bitch. She & the
rest of them deserved more than that for that they put me through”.
He has been continuously “ill” since the age of 22. During his first year of
law school, he gradually became more and more convinced that his
classmates were making fun of him. He noticed that they would snort and
sneeze whenever he entered the classroom. When a girl he was dating
broke off the relationship, he believed she had been “replaced” by a look
alike. He called the police to solve the “kidnapping”. His academic
performance in school dramatically declined, & he was asked to leave and
seek psychiatric care.
He got a job as an investment counselor at a bank, which he held for 7
months. However, he was getting an increasing number of distracting
“signals” from coworkers, & he became more and more suspicious &
withdrawn. It was at this time that he first reported hearing voices. He
was eventually fired, & soon after was hospitalized for the first time, at
age 24. He has not worked since then.
He has been hospitalized 12 times, his longest stay being 8 months.
During the hospitalizations he has received antipsychotics. Although
outpatient antipsychotics have been prescribed, he usually stops taking
them shortly after being discharged. Aside from twice-yearly lunches
with his uncle & his contacts with mental health workers, he is totally
isolated socially. He lives on his own & is able to keep his affairs in order.
He maintains that his apartment is the center of a large communication
system that involves three major TV networks, his neighbors &
apparently hundreds of actors in his neighborhood. There are secret
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cameras in his apartment that carefully monitor all his activities. When he
is watching TV many of his minor actions (like using the bathroom) are
soon commented on by the TV announcer. Whenever he goes outside the
“actors” have been warned to keep him under surveillance. His neighbors
operate 2 different “machines”; one is responsible for all of his voices,
except for the “joker”. A machine generates the other voices he hears
several times a day. He believes the neighbor he attacked controls this
one. Another machine he calls the “dream” machine because it puts erotic
dreams into his head.
He recently traveled miles to buy some “unaltered” shoes. But he found
out that they too had “nails” put into them to annoy him.
He realizes that millions of dollars are involved in keeping him under
surveillance and believes it’s to discover his “superior intelligence”.
III.
Hank was charged with the murder of 10 women. On one occasion after
killing one of his victims he went to dinner with his wife to celebrate his
birthday. Hank began to burglarize with an older brother at 7, and at 12 was
put on probation. A year later he was sent to the California Youth Authority
for committing "lewd and lascivious acts" with a 6-year-old girl. As a
teenager he faced charges of armed robbery and auto theft. A habitual truant,
he was suspended from high school at 17. Hank married seven times. He beat
each of his wives. Most of the marriages lasted no more than a few months.
When he was 23, Hank went on a crime spree that eventually covered five
states. Stealing license plates and cars, holding up bars and drugstores, he
eluded capture until caught and convicted for the armed robbery of a motel.
When his daughter finally informed authorities of 6 years of abuse, felony
charges were filed against him for incest, among other things. Hank responded
by changing his name. Using the stolen driver's license of a state police
officer, he obtained a new birth certificate and Social Security number, and he
and his wife moved to another town. He was also a heavy drinker. His wife
once cautioned him as he drank and drove that the combination was illegal. "F
the law," he answered. His mother filled his childhood with physical and
emotional abuse. His father was incarcerated and later executed for his
crimes.
IV.
Jill is a 25-year old flight attendant single woman who works as a flight
attendant. After getting home from flight late at night, Jill went out to a local
store and bought a half-gallon of chocolate ice cream, a 1-pound box of
cookies, a medium-sized pizza, a loaf of French bread, and a quart of milk.
When she got home, she put the pizza in the oven & waited impatiently for it
to cook. When the pizza was just edible, she brought it out & ate everything
she bought as quickly as possible, stuffing large mouthfuls. When she
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finished, she ran to the bathroom, kneelt at the toilet, thrust her hand down her
throat & vomited everything she had just eaten. The next day she consulted an
internist for help concerning her recent periods of weakness & dizziness. After
performing a routine exam, he asked her about eating habits. She was
extremely embarrassed & guilty about describing these to him, but she wanted
to get well. She confessed to a long-standing pattern of uncontrollably
consuming extremely large quantities of food & then vomiting. This pattern
began years ago but it had become more frequent & severe since she began
working as a flight attendant. When he asked her to describe her eating pattern
in more detail, she awkwardly described the previous night. This was a fairly
typical amount of food, which she typically consumed in 20 minutes. She
almost always induced vomiting right after eating by usually sticking her hand
down her throat. She also admitted to bouts of depression.
V.
As a result of a severe flu attack at age 39, Dr. S experienced an irregular
heartbeat. His personal doctor and colleague, Dr. F, told him that his habit of
smoking cigars had caused it & advised him to stop smoking. When Dr. S
tried to quit, he became depressed & occasionally suffered an even worse
pulse rate. After several attempts to quit, he returned to smoking about 20
cigars a day. He developed cancer of the jaw at age 67. Despite 33 operations
& the removal of his entire jaw because of various cancerous & precancerous
conditions, Dr. S continued to smoke. At age 73, he developed angina pectoris
(chest pains from heart disease), which was relieved whenever he stopped
smoking. Yet, although he continued to try to stop smoking, he could not. He
died from cancer at age 83, after many years of severe suffering from
operations, cancer & heart disease.
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