Mood and Anxiety Disorders 3/8/11 Case 1.

. A 36 year-old woman is at her primary care doctors office for a routine scheduled checkup. When asked how she is feeling, she tells the doctor that she has been down in the dumps for the past 3-4 weeks. She says that her husband has been very stressed at work lately. He stays late at the office, brings work home with him, and is irritable and isolative when not actually working. She notices that she is more tired and needs to sleep more than usual, and is more likely to find herself snacking on sweets between meals. She no longer looks forward to seeing her husband when he comes home at night. 1. What questions would you have to ask this patient to determine whether or not she has a diagnosable mood disorder? What disorders would you be considering as you further evaluate her? Case 2. A 48 year-old man has been gloomy and irritable since his divorce 6 months ago. He was hurt and angry when his wife decided to leave him, but has refused to talk about it with anyone, saying Thats just life, I guess. He no long cares to socialize with his few friends, but spends hours every night playing computer solitaire. He falls asleep readily, but wakes up very early every morning. He refuses friends offers to introduce him to women, saying, Who would want me? - Ill only get hurt. His appetite is off and he has lost 10lbs since the divorce. He has lost interest in golf, which had been a major source of enjoyment for him. He has no plans to commit suicide, but cannot see how he can go on living indefinitely feeling as he does. He has never felt this bad before, but he remembers that his father behaved very similarly for a year after he retired. 1. What is the most likely diagnosis? 2. What biological, environmental, and behavioral risk factors does this man have for developing depressive illness? 3. If left untreated, what other symptoms might develop as his illness became more severe? Case 3. A 23 year-old woman is brought to the emergency room by her sister after having taken an overdose of sleeping medication. She tells the doctor that she had been drinking when her boyfriend called to tell her he was thinking of breaking up with her. She became furious, slammed the phone down, and impulsively took an entire packet of over-the-counter sleeping medication. Her sister, who was in the next room, heard the noise and came in to see what was happening. The patient had had two prior emergency room visits for overdoses within the past 4 months, both under circumstances similar to the present. 1. What risk factors does this patient demonstrate for suicide attempt and completion?

2. What factors would be important in assessing whether it is safe for the patient to return home vs. be hospitalized for treatment? Case 4. An 18 year old college freshman is living away from home for the first time. He had been going to bed no earlier than 2AM to study or socialize, but has lately been going to bed at 4 and getting up at 6AM, energetic and ready for the day. He tells friends that he is working on equations for a unified field theory that will explain all of physics. He has recently joined the college newspaper, the political union, and a fraternity, and believes he will be running all 3 organizations by the end of the academic year. When his roommate expresses doubts about this, he tells him he is obviously of inferior intelligence and must have been admitted to the college by mistake. The young man has never behaved this way before, but had been diagnosed as having Attention Deficit Disorder in elementary school. A maternal uncle had required hospitalization several times, but the family never talks about the details. 1. 2. 3. 4. What is the most likely diagnosis? What other symptoms typically accompany the illness. What biological and environmental factors may have triggered this episode? What would you predict about the course of the disorder over time, treated and untreated?

Case 5. A 45 year-old single woman complains to her doctor that she is having a lot of trouble with nervousness. She describes herself as a socially shy person who has always had a tendency to over-worry, but lately has been having trouble forcing herself to take public transportation to work. She is very self-conscious on the bus, and has a recurrent thought that she appears vulnerable, which might induce a male passenger to follow her and snatch her purse when she gets off. She recognizes that this is unlikely, but cant get the thought out of her mind, and sometimes feels herself getting panicky and short of breath while thinking about it. The woman was, in fact the victim of a purse snatching two weeks before her anxiety began to worsen. 1. Which anxiety disorders might possibly be causing this womans difficulties? 2. What questions would you ask to determine the correct diagnosis?

Schizophrenic Disorders and Somatoform Disorders 3/16/11 Case 1. A fifty year-old woman was diagnosed as having schizophrenia at the age of 23. She lives at home with her parents, manages her daily routine independently, and participates in a daytime program that includes 3 hours a day in paid work shelving merchandise in a department store. She does not socialize either at work or at home. She believes that the FBI takes a special interest in her and sends agents to spy on her wherever she goes. She believes these agents put audible messages into her head with electronic devices, warning her that, any misdeeds will be punished . She expresses herself clearly, but shows little emotion when speaking. She does not laugh at jokes, and appears not to understand what is funny. 1. What positive and negative symptoms of schizophrenia does this woman display? 2. What types of schizophrenic symptoms does she not display? 3. What types of schizophrenic symptoms are the most severe, in terms of interfering with life function? Why? Case 2. A 27 year-old man began to change from his normal behavior when he was 16, withdrawing from his friends and becoming preoccupied with the occult and science fiction. He began to make long rambling speeches to his family on this topic, which have gradually become more and more difficult to follow. He is unable to answer most questions directly, speaking on tangential matters instead. He lives in a group home where he has to be urged to shower at least weekly. His hair is long and his clothes do not match. He sometimes begins to laugh for no apparent reason. He has an identical twin brother who is married and works, but has two paternal uncles who were diagnosed with schizophrenia. Case 3. A fifty-year old computer programmer lives alone and has never married. He works the night shift on a software maintenance job where his interactions with other people are minimal. He firmly believes that he has been kidnapped by aliens and taken for extensive spaceship rides during which his mind has been electronically probed to help the aliens understand the human race. These trips have been conducted under timewarp conditions so he has never had to miss any work. Even when going through his routine on earth, he is able to hear the voices of the aliens coming out of his wristwatch. He learned early on that others do not believe him about these things, and so he never talks about them, except with his one friend, a person who reports having had similar experiences. Both his parents had been treated for depression, but nobody in his family has had symptoms similar to his. Case 4. A 38 year- old woman lives in an assisted living facility that serves many chronically mentally ill people. When not attending meals, she spends most of her time sitting in a chair, staring into space, and sometimes smiling for no apparent reason. She

does not voice any unrealistic ideas and does not appear to be preoccupied with internal stimuli. She rarely speaks spontaneously unless she needs something, and answers questions in very few words, often in vague terms, or by saying I dont know. She came to the attention of the mental health system because she was found living in doorways regardless of the weather, malnourished and inadequately clothed. She could not be induced to use the shelter system, saying only, Id prefer not to. Her parents were both functional people, but her father had been described as an odd man who kept to himself. When she was 8 years old, she had a bicycle accident in which she briefly lost consciousness, after which she seemed to return to her usual behavior and functioning. Cases 2-4 describe very different people, all of whom would qualify for the diagnosis of schizophrenia. 1. Considering the heterogeneity, do you think that the diagnostic category of schizophrenia is valid? 2. What are the unifying concepts and features that might justify giving these three people the same diagnoses? 3. What features distinguish manic patients with psychotic features from people with schizophrenia? 4. Why might monozygous twins be discordant for schizophrenia? Case 5. A 45 year- old woman has had a life that revolves around doctors for the past 20 years. Her most persistent complaint has been abdominal pain, for which she has been extensively evaluated, including 2 exploratory surgeries, none of which disclosed the cause. She has also been evaluated for periods of nausea and vomiting, and substernal burning. These have responded only transiently to treatment. In addition to abdominal pain, she has sought treatment for recurrent migraine headache, burning in her feet, and low back pain. Before the onset of menopause, she would often go for several months without having her period. During periods of frequent headache, she would describe weakness in both hands, but not to an extent that interfered with her function. She has switched doctors many times when they would not prescribe treatments or agree to further evaluations. No clear diagnosis has been found for any of the above symptoms. The patient lives on medical disability payments. 1. The above describes a patient with Somatization Disorder. Explain why she does not meet criteria for Conversion Disorder, Hypochondriasis, Factitious Disorder, or Malingering. 2. What is meant by the terms primary gain and secondary gain? 3. How do these terms apply to the disorders named in Question 1?

Childhood Disorders and Eating Disorders 4/12/11 Case 1. The parents of a 15 year-old boy are distressed that he has been getting into trouble in school since elementary school. He is a bright child, but he has always been disruptive in the classroom unable to stay in his seat for long periods, teasing his classmates, and blurting out funny comments. He has trouble completing his homework, and complains that his teachers assign much more reading than he has time to do. His parents complain that he does not seem to listen to anything they tell him. They have learned to buy him the cheapest version of anything he needs because he loses so many of his possessions. While he can be very charming, he is moody and tends to fly into rages when his parents try to set expectations or limits. At other times he is despondent, saying, I guess Im just a dumb screw-up. 1. The above vignette presents disruptive features common to Bipolar Disorder, Attention Deficit Disorder, Oppositional Defiant Disorder, and Conduct Disorder. What is the most likely diagnosis, and how do you distinguish it from the other disorders? 2. How might core symptoms of inattention, distractibility, and impulsivity produce secondary effects on self-image, self-esteem, mood, social relations and career trajectory? 3. Medical school Deans Offices sometimes get requests from students for extra time on exams because they have recently been diagnosed with ADD. Do you think it is possible to get into medical school despite undiagnosed ADD? Why or why not?

Case 2. A 9 year old girl who had previously experienced no special difficulties begins frequently to tell her mother that she does not feel well enough to go to school, complaining of stomach ache, dizziness, or fatigue in the morning. Her teacher reports that she has recently seemed to become shyer, keeping to herself at recess and lunch times. She has stopped giggling with the other girls at school, and at home, seems to have lost interest in her favorite toys and TV shows. 1. Discuss the differential diagnosis of this condition. 2. What are the relative roles of medication and other types of treatment in childhood vs. adult depressive illness? Case 3. The parents of a 7 year-old boy seek consultation because he continues to show little interest in other children. Instead, his time at home is spent almost exclusively in playing one or two video games or throwing a ball against his garage wall over and over. He has also shown remarkable aptitude for chess, where he is able to plan out complex decision trees dozens of moves in advance. He is inflexible and often flies into a rage if

his routine is disrupted or he is prevented from engaging in his repetitive activities. His parents were hoping that he would make friends when he started school, but this has not happened. He is able to keep up with the schoolwork, but seems uncomfortable around other children and they tend to view him as weird. 1. What is the differential diagnosis of this condition? 2. What deficits does this boy share with children who have bipolar disorder and schizophrenia? What are the major differences? Case 4. A 24 year-old woman has become progressively more preoccupied with her weight since she was in college. She is 5 4 and now weighs 82 pounds, down from a weight of 110 when she graduated from high school. Oddly, the less she weighs, the more convinced she is that she is on the verge of losing control and becoming seriously obese; gaining even one pound confirms this fear. Her breakfast consists of coffee and a low-fat yogurt, and lunch is a salad with no dressing. At home in the evening, however, she often binges on high carbohydrate foods such as cold cereal or pasta, after which she induces vomiting to undo the effects of eating. On some days, when she decides she may have eaten too much, she uses laxatives to purge the food from her digestive tract. She has not menstruated in the past year and goes to bed early because of fatigue. 1. What is the most likely diagnosis? 2. What underlying genetically transmitted traits increase the risk of developing eating disorders? 3. What interpersonal and cultural factors affect the risk of eating disorders? 4. What are typical medical complications of anorexia and bulimia?

Personality Disorders and Cognitive Disorders 4/20/11 Case 1. A 45 year old man works in a bookstore, where he is haunted by the conviction that his supervisor is looking for excuses to fire him. When a coworker asks him a workrelated question with the supervisor present, he suspects that the coworker is trying to set him up by deliberately asking things he will not know. He broods about this, and secretly vows to do as little as possible to help the coworker. If his wife or a friend offers to help him with a task, he wonders what they expect from him in return. He frequently lashes out at his wife for what he sees as her attempts to put me down. On these occasions she tearfully denies any intention to do so. The mans mother sometimes tries to console her daughter-in-law, saying Dont take it personally, hes just always been that way. 1. What makes the above an Axis II rather than an Axis I disorder? 2. What makes the above a personality disorder rather than simply a personality type? 3. What is the major ego mechanism of defense operating in this man? What is being defended against, and how does the defense work? Case 2. A 32 year-old woman seeks psychiatric treatment for my depression and mood swings. Much of the time she feels empty, but has had periods of buoyant mood and optimism when she has been associated with special people. Such special people have included boyfriends, a favorite psychology professor in college, and the pastor of her church. She has become intensely involved with them, finding ways to spend as much time with them as possible, looking to them for support and direction. Inevitably, however, she ends these relationships in disappointment, coming to the conclusion that these people are shallow and dont really care as much as she thought they did. Once, when told by her pastor that he had to spend more time with other members of the congregation, she told him she would probably kill herself. She did not follow through with this threat, but went through a period of several months when she was sexually promiscuous and snorted cocaine. 1. What is the most likely diagnosis? 2. Patients with Borderline Personality Disorder and Narcissistic Personality Disorder both attempt to deal with underlying low self-esteem. Compare and contrast the manner is which they try to compensate for this deficit. 3. Why do many physicians dread dealing with patients who have Borderline Personality Disorder? How does the concept of counter-transference apply to this situation? What might be the difficulties they would present in a medical practice, and how might such difficulties differ in different types of practice (e.g. primary care vs. ENT)? How might the physician deal with these difficulties?

Case 3. A 40 year-old man in a middle management position has become frustrated about his career progression. He has been passed over for promotion because he has not learned to delegate tasks adequately. He defends himself saying, The only way to make sure things get done right is to do them myself. In the service of this, he spends long hours at work, beyond what is required of him, including coming into the office on weekends. Those under him complain that he is inflexible and unable to deviate from a by the book approach. His wife complains that he is unemotional and not affectionately demonstrative, to which he replies by explaining at length his theories on indirect expression of love in marriages. 1. 2. 3. 4. What is the most likely diagnosis? What does this condition have in common with other Cluster C disorders? Compare and contrast Cluster C disorders with those in Clusters A and B. Some aspects of this disorder might actually be advantageous to medical students and physicians. What aspects might fit well with the demands of medical practice and which would be a handicap? 5. To what extent might the disordered aspect of this personality type be assessed differently within a group of accountants vs. actors? Case 4. An 84 year- old woman is admitted to a medical service because she has become lethargic and unable to take care of her daily hygiene needs. She has been living with her daughter and family, with whom she takes meals. During the past year she has more frequently forgotten to enter checks into her checkbook, so her daughter has taken over balancing her bank account. Otherwise, she has functioned independently. On admission to the hospital, she remains lethargic, but responds to verbal communication. She believes she is on vacation at a hotel, and identifies the medical student as the bellhop. She is unable to remember any of 3 facts after 5 minutes. Over the course of the first day in hospital, she goes through periods of agitated anxiety, in which she is afraid the doctors are plotting to kill her. These alternate with drowsy periods in which she must be stimulated by tactile means in order to respond. She has no previous psychiatric history. 1. What is the most likely diagnosis? 2. How does this presentation differ from that of primary psychiatric disorders? 3. What are the major risk factors for delirium in the elderly? Case 5. A 79 year-old man who has been living with his 73 year old wife begins to complain that she is stealing things from him, and that is the reason that he cannot find many items in his possession. He has gotten lost while driving in his own neighborhood in recent months, and reacts angrily to his wife when she tries to keep him from driving by himself. His son notes that he asks the same questions over and over in their telephone conversations. The man has been an avid bird watcher for years, but now when asked to identify a bird, is likely to say That must be a new one in this area, Ill have to look it up.

1. Is this more likely to describe a case of Alzheimer Disease or Picks Disease? Why? 2. Why is this person paranoid? 3. What is meant by the term executive functioning? How does it manifest in dementia? 4. How might this patient present if he lives for another 2 years? 5. What might be some typical effects on his wife if the two of them continue to live at home together?