Task:1
Review the 3 case studies provided (one for each DSM-V section covered in the module). Determine the correct DSM-V diagnosis including any applicable specifiers. Provide a brief rationale for your specific diagnosis .
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Paulina Davis, a 32-year-old single African American woman with epilepsy first diagnosed during adolescence and no known psychiatric history, was admitted to an academic medical center after her family found her convulsing in her bedroom. Before she was taken to the emergency room (ER), emergency medical services had administered several doses of lorazepam, with no change in her presentation. On her arrival in the ER, a loading dose of fosphenytoin was given that successfully stopped the convulsive activity. Laboratory studies of samples obtained in the ER revealed therapeutic levels of her usual antiepileptics and no evidence of any infection or metabolic disturbance. Urine toxicology screens were negative for use of illicit substances. Ms. Davis was subsequently admitted to the neurology service for further monitoring.
During her admission, a routine electroencephalogram (EEG) was ordered. Shortly after the study began, Ms. Davis began convulsing; this prompted administration of intravenous lorazepam. When the EEG was reviewed, no epileptiform activity was identified. Ms. Davis was subsequently placed on video-EEG (vEEG) monitoring while her antiepileptics were tapered and discontinued. In the course of her monitoring, Ms. Davis had several episodes of convulsive motor activity; none were associated with epileptiform activity on the EEG. Psychiatric consultation was requested.
On interview, Ms. Davis denied prior psychiatric evaluations, diagnoses, or treatments. She denied having depressed mood or any disturbance of sleep, energy, concentration, or appetite. She reported no thoughts of harming herself or others. She endorsed no signs or symptoms consistent with mania or psychosis. There was no family history of psychiatric illness or substance abuse. Her examination revealed a well-groomed woman, sitting on her hospital bed with EEG leads in place. She was pleasant and easily engaged and made good eye contact. Cognitive testing revealed no deficits.
Ms. Davis noted that she had recently moved to the state to start graduate school; she was excited to start her studies and “finally get my career on track.” She denied any recent specific psychosocial stressors other than her move and stated, “My life is finally where I want it to be.” She was future oriented and concerned about the impact that her seizures might have on her long-term health and was worried that a protracted hospitalization might cause her to miss the first day of classes (only a week away from the time of the interview). Moreover, she was quite concerned about the costs of her hospitalization because her health insurance coverage did not begin until the school semester commenced and the payment for extended benefits coverage from her previous employer would have a significant impact on her budget.
When the findings of the vEEG study were discussed with Ms. Davis, she quickly became quite irritable, asking, “So, everyone thinks I’m just making this up?” She was not calmed by her treaters’ attempts to clarify that they did not believe her to be faking her symptoms or by their reassurance that her symptoms might be helped by psychotherapy. Ms. Davis pulled her EEG leads from her scalp, dressed herself, and left the hospital against medical advice.
Feeding and Eating Disorders Case Study:
Uma, an 11-year-old girl in a gifted and talented school, was referred to an eating disorder specialist by a child psychiatrist who was concerned that Uma had drifted below the 10th percentile for weight. The psychiatrist had been treating Uma for perfectionistic traits that caused her significant anxiety. Their sessions focused on anxiety, not on eating behavior.
Uma’s eating difficulties started at age 9, when she began refusing to eat and reporting a fear that she would vomit. At that time, her parents sought treatment from a pediatrician, who continued to evaluate her yearly, explaining that it was normal for children to go through phases. At age 9, Uma was above the 25th percentile for both height and weight (52 inches, 58 pounds), but by age 11, she had essentially stopped growing and had dropped to the 5th percentile on her growth curves (52.5 inches, 55 pounds).
The only child of two professional parents who had divorced 5 years earlier, Uma lived with her mother on weekdays and with her nearby father on weekends. Her medical history was significant for her premature birth at 34 weeks’ gestation. She was slow to achieve her initial milestones but by age 2 was developmentally normal. Yearly physical examinations had been unremarkable with the exception of the recent decline of her growth trajectory. Uma had always been petite, but her height and weight had never fallen below the 25th percentile for stature and weight for age on the growth chart. Uma was a talented student who was well liked by her teachers. She had never had more than a few friends, but recently she had stopped socializing entirely and had been coming directly home after school, reporting that her stomach felt calmer when she was in her own home.
For the prior 2 years, Uma had eaten only very small amounts of food over very long durations of time. Her parents had tried to pique her interest by experimenting with foods from different cultures and of different colors and textures. None of this seemed effective in improving her appetite. They also tried to let her pick restaurants to try, but Uma had gradually refused to eat outside of either parent’s home. Both parents reported a similar mealtime pattern: Uma would agree to sit at the table but then spent her time rearranging food on her plate, cutting food items into small pieces, and crying if urged to eat another bite.
When asked more about her fear of vomiting, Uma remembered one incident, at age 4, when she ate soup and her stomach became upset and then she subsequently vomited. More recently, Uma had developed fear of eating in public and ate no food during the school day. She denied any concerns about her appearance and only became aware of her low weight after her most recent visit to the pediatrician. When educated about the dangers of low body weight, Uma became tearful and expressed a clear desire to gain weight.
Disruptive, Impulse-Control, and Conduct Disorders Case Study:
Lucas Sandahl, a 32-year-old landscape architect, presented to a psychiatrist for help with anger. He came to the office with his wife, the mother of their two young children. The couple agreed that Mr. Sandahl had become “almost impossible to live with.” Mr. Sandahl’s wife reported that although she had always considered her husband “high-strung,” the outbursts were increasing in both frequency and intensity, and she worried that he would become violent with her.
Their most recent argument began when Mr. Sandahl came home after a “hard day at work” to find that dinner was not ready. When he entered the kitchen and saw his wife sitting at the table reading the newspaper, he “exploded” and launched into a tirade about how “bad” a wife she was. When his wife tried to explain her own long day, Mr. Sandahl cursed at her and broke glassware and a kitchen chair. Terrified, Mr. Sandahl’s wife ran out of the kitchen, gathered up the toddlers, and left for her mother’s house a few miles away. The next day, she told her husband that he would need to get help immediately or prepare for a divorce.
Mr. Sandahl said his “blowups” began in childhood but did not become “problematic” for him until age 13. At about that time, he started having frequent fights with classmates that would occasionally result in trips to the principal’s office. In between the altercations, he was active socially and a solid student.
Mr. Sandahl estimated that he had had approximately four verbal outbursts a week in recent years, generally in response to frustration, unexpected demands, or perceived insults. In addition to these heated verbal tussles, Mr. Sandahl described acts of violence about every 2 months; for example, he threw a computer monitor across the room when it started “acting up,” he kicked a hole in a wall when one of his children would not quit crying, and he destroyed his mobile phone during an argument with his mother. He denied physical fights since his adolescence, although he had nearly come to blows with a neighbor as well as an assortment of strangers and employees. The idea that he might physically hurt someone scared Mr. Sandahl “to the core.”
These outbursts blighted his relationships with colleagues and romantic partners and led to his decision to start his own landscaping company at age 25. The business had done well, despite his demanding style and “hair-trigger” temper that led to high employee turnover.
Mr. Sandahl described the episodes as short-lived, reaching a peak within seconds and rarely lasting more than a few minutes. Between episodes, he described himself as feeling “fine.” He had experienced brief periods of depressed mood and increased anxiety, but these had not impaired him significantly and tended to resolve on their own within a week. Mr. Sandahl drank socially, but neither he nor his wife linked the outbursts to the alcohol. He had a history of experimentation with various drugs of abuse, but not in recent years.
Mr. Sandahl reported at least two other immediate family members with significant “anger issues.” His father was emotionally abusive and perfectionistic, expecting “great things” from his only son. Mr. Sandahl’s older sister also had problems with her temper; he attributed her three divorces to her emotionally abusive behavior.
On examination, Mr. Sandahl was casually dressed, cooperative, and coherent. He was worried about his behavior and contrite toward his wife. He denied depression, psychosis, and confusion. He denied any thoughts of hurting himself or others. He was cognitively intact.
His insight and judgment were good during the course of the interview.
Task 2
Review the 3 case studies provided (one for each DSM-V section covered in the module). Determine the correct DSM-V diagnosis including any applicable specifiers. Provide a brief rationale for your specific diagnosis .
Sexual Dysfunctions Case Study:
Gerhard Palmer, a 55-year-old married accountant, presented to a psychiatrist for a second opinion in the context of recurrent major depression. He had not responded to two 3-month antidepressant trials, one with fluoxetine and another with sertraline, both at high dosages. He had not been taking medications for about a month following the last failed trial.
The evaluation revealed a severely depressed man with profound psychomotor retardation, poor concentration, early insomnia, mildly diminished libido, and anhedonia. Mr. Palmer denied substance abuse, drank minimally, and did not smoke. He had started taking propranolol for hypertension about 6 months previously. His physical examination was unremarkable. Basic laboratory tests were within normal limits. His blood pressure was 135/85.
Treatment with clomipramine was initiated, and the dose was quickly titrated to 250 mg/day. Buspirone 30 mg/day was added. After 5 weeks of treatment, Mr. Palmer reported feeling much improved. He was sleeping and eating well, was participating in enjoyable activities with increasing enthusiasm, and, for the first time in many months, felt a return of his sexual interest.
After not having had sexual intercourse in months, Mr. Palmer tried unsuccessfully to have sex several times. He was distressed to find that for the first time in his life, he was unable to maintain an erection during intercourse and was unable to ejaculate, even during masturbation. These problems persisted for a month. He recalled having had slightly delayed ejaculation while taking fluoxetine. He did not recall sexual problems during a prior trial of bupropion.
Paraphilic Disorders Case Study:
Terry Najarian, a 65-year-old salesman for a large corporation, presented for a psychiatric evaluation after his wife threatened to leave him. Although he said he was embarrassed to discuss his issues with a stranger, he described his sexual interest in women’s undergarments in a quite matter-of-fact manner. This interest had surfaced several years earlier and had not been a problem until he was caught masturbating by his wife 6 weeks prior to the evaluation. Upon seeing him dressed in panties and a bra, she initially “went nuts,” thinking he was having an affair. After he clarified that he was not seeing anyone else, she “shut him out” and hardly spoke to him. When they argued, she called him a “pervert” and made it clear that she was considering divorce unless he “got help.”
Mr. Najarian’s habit began in the setting of his wife’s severe arthritis and likely depression, both of which significantly reduced her overall activity level and specifically her interest in sex. His “fetish” was the bright spot during his frequent and otherwise dreary business trips. He also masturbated at home but generally waited until his wife was out of the house. His specific pattern was to masturbate about twice weekly, using bras and panties that he had collected over several years. He said that intercourse with his wife had faded to “every month or two” but was mutually satisfying.
The patient had been married for over 30 years, and the couple had two grown children. Mr. Najarian had planned to retire comfortably later that year, but not if the two choices were either to “split the assets or to sit around the house and be called a pervert all day.” He became visibly anxious when discussing his marital difficulties. He described some recent difficulty falling asleep and “worried constantly” about his marriage but denied other psychiatric problems. He had made a show of throwing away a half dozen pieces of underwear, which had seemed to reassure his wife, but he had saved his “favorites” and “could always buy more.” He said he was of mixed mind. He did not want to end his marriage, but he saw nothing harmful in his new mode of masturbating. “I’m not unfaithful or doing anything bad,” he said. “It just excites me, and my wife certainly doesn’t want to be having sex a few times a week.”
Mr. Najarian denied any difficulties related to sexual functioning, adding that he could maintain erections and achieve orgasm without women’s undergarments. He recalled being aroused when he touched women’s underwear as a teenager and had masturbated repeatedly to that experience. That fantasy had disappeared when he became sexually active with his wife. He denied any personal or family history of mental illness.
Personality Disorder Case Study:
Larry Goranov was a 57-year-old single unemployed white man who was asking for a review of his treatment at the psychiatric clinic. He had been in weekly psychotherapy for 7 years with a diagnosis of dysthymic disorder. He complained that the treatment had been of little help and he wanted to make sure that the doctors were on the right track.
Mr. Goranov reported a long-standing history of low-grade depressed mood and decreased energy. He had to “drag” himself out of bed every morning and rarely looked forward to anything. He had lost his last job 3 years earlier, had broken up with a girlfriend slightly later, and doubted that he would ever work or date again. He was embarrassed that he still lived with his mother, who was in her 80s. He denied any immediate intention or plan to kill himself, but if he did not improve by the time his mother died, he did not see what he would have to live for. He denied disturbances in sleep, appetite, or concentration.
Clinic records indicated that Mr. Goranov had been adherent to adequate trials of fluoxetine, escitalopram, sertraline, duloxetine, venlafaxine, and bupropion, as well as augmentation with quetiapine, aripiprazole, lithium, and levothyroxine. He had some improvement in his mood while taking escitalopram but did not have remission of symptoms. He also had a course of cognitive-behavioral therapy early in his treatment; he had been dismissive of the therapist and treatment, did not do his assigned homework, and appeared to make no effort to use the therapy between sessions. He had never tried psychodynamic psychotherapy.
Mr. Goranov expressed frustration at his lack of improvement, the nature of his treatment, and his specific therapy. He found it “humiliating” that he was forced to see trainees who rotated off his case every year or two. He frequently found that the psychiatry residents were not especially educated, cultured, or sophisticated, and felt they knew less about psychotherapy than he did. He much preferred to work with female therapists, because men were “too competitive and envious.”
Mr. Goranov previously worked as an insurance broker. He explained, “It’s ridiculous. I was the best broker they had ever seen, but they won’t rehire me. I think the problem is that the profession is filled with big egos, and I can’t keep my mouth shut about it.” After being “blackballed” by insurance agencies, Mr. Goranov did not work for 5 years, until he was hired by an automobile dealer. He said that although it was beneath him to sell cars, he was successful, and “in no time, I was running the place.” He quit within a few months after an argument with the owner. Despite encouragement from several therapists, Mr. Goranov had not applied for a job or pursued employment rehabilitation or volunteer work; he strongly viewed these options as beneath him.
Mr. Goranov has “given up on women.” He had many partners as a younger man, but he generally found them to be unappreciative and “only in it for the free meals.” The psychiatric resident notes indicated that he responded to demonstrations of interest with suspicion. This tendency held true in regard to both women who had tried to befriend him and residents who had taken an interest in his care. Mr. Goranov described himself as someone who had a lot of love to give, but said that the world was full of manipulators. He said he had a few buddies, but his mother was the only one he truly cared about. He enjoyed fine restaurants and “five-star hotels,” but he added that he could no longer afford them. He exercised daily and was concerned about maintaining his body. Most of his time was spent at home watching television or reading novels and biographies.
On examination, the patient was neatly groomed, had slicked-back hair, and wore clothing that appeared to be by a hip-hop designer generally favored by men in their 20s. He was coherent, goal directed, and generally cooperative. He said he was sad and angry. His affect was constricted and dismissive. He denied an intention to kill himself but felt hopeless and thought of death fairly often. He was cognitively intact.
Task 4
PowerPoint presentation of Medical Treatments for Post Stress Traumatic disorder (PTSD Medical Option treatment) The purpose of this activity is for students to explore more deeply a subspecialty area of interest and share that learning experience with peers. Prepare a narrated slide presentation which is no more than 20 slides, excluding the title and reference slide