DSM-5 Case Studies
Read the case studies in this packet and use the “DSM-5 Student Abridged Version” to make your diagnoses. The names of the disorders are highlighted in yellow. The “Diagnostic Criteria” are all you are required to pay attention to. However, the narrative information about the disorder (“Diagnostic Features,” “Prevalence,” “Development and Course,” “Risk and Prognostic Factors,” “Culture- and Gender-related Diagnostic Issues,” “Differential Diagnosis,” “Comorbidity,” etc.) may help you narrow down a diagnosis and/or understand a disorder a little better. A glossary is included at the end of the document.
Once you have made your diagnosis, type the name of the disorder next to the title of the case study. Then copy and paste the criteria from the “DSM-5 Student Abridged Version” and insert them after each corresponding example in the case study. Whatever you insert into the case study should be in another color so it stands out.
See the next page for a sample of what I’m looking for.
Jessica – Major Depressive Disorder
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. A7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
For the past few weeks Jessica has felt unusually fatigued A6. Fatigue or loss of energy nearly every day and found it increasingly difficult to concentrate at work. A8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) Her coworkers have noticed that she is often irritable and withdrawn, which is quite different from her typically upbeat and friendly disposition. A1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful) 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. B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
At home, Jessica’s husband has noticed changes as well. She’s had difficulties falling asleep at night, and her insomnia has been keeping him awake as she tosses and turns for an hour or two after they go to bed. A4. Insomnia or hypersomnia nearly every day; A5. Psychomotor agitation or retardation nearly every day; (observable by others, not merely subjective feelings of restlessness or being slowed down) 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”. A1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful)
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. A9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide 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. B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
A physical exam performed by her primary care doctor one week prior was normal. All laboratory testing was normal, including complete blood count, electrolytes, blood urea nitrogen, creatinine, calcium, glucose, thyroid function tests, folate, and vitamin B12. She denied any illicit drug use and reported an occasional glass of wine with dinner. C. The episode is not attributable to the physiological effects of a substance or to another medical condition.
Mr. Upton
Mr. Upton, a 37 -year-old man, presents with his wife to a mental health clinician for evaluation in the context of having difficulties at work. He says that he believes that he is "fine" but that his boss-and his wife, he adds reluctantly-may have a problem with his "neatness." Mr. Upton has missed opportunities for promotion at work because he has trouble completing tasks, even though he is "the most conscientious worker there." His wife reports that he is a "control freak" He is puzzled by his boss's attitude toward him. Mr. Upton states, "I'm a real perfectionist. You would think a supervisor would like that!" Mr. Upton is inflexible about matters of morality and ethics. He points out his opinion to coworkers routinely because they are often, he says, so "woolly headed" about the basics of "right and wrong." Interviewing the couple reveals that Mr. Upton is very devoted to work activities to the exclusion of leisure activities and family. He is very critical of his wife's inability to maintain his standard of neatness. He will come home from work and redo household cleaning tasks that his wife completed earlier the same day. He scrutinizes their financial budget and has tried to restrict his wife's spending. He says that he wants to make sure they keep some money for "future emergencies." He reports that he has "always been a stickler for the rules, even as a kid." As a young child he recalls having fits if someone else sat in his assigned seat at the dinner table. He was socially unpopular in high school because he would report schoolmates for "tardiness." His overinvestment in rules has caused conflict in many social spheres from a very young age.
Ms. Gordon
Ms. Gordon is a 39-year-old woman brought to the emergency department by police for allegedly harassing a popular music star. She appeared well dressed, was tastefully made up, and was outwardly friendly. She had a college education, was single, and had no substance abuse history. She appropriately answered all questions from the nurses and doctor. When she was asked about the harassment complaints involving the musician, however, she became upset and explained that she was supposed to marry him. In addition, for the past 2 years Ms. Gordon has been writing the celebrity love letters and trying to call him; tonight she tried to approach him at the hotel where he was staying before a concert. When asked further questions about this "relationship," she explained in elaborate detail how they met online and how they were supposed to get married this night. Her mental status examination was unremarkable, save for the fixed false belief that she was supposed to marry this celebrity. She remained calm as long as no one challenged this false belief. She was eventually given a low dose of an antipsychotic to keep her calm and help her sleep. Her sister arrived later and provided more details. According to her sister, the family at first believed that Ms. Gordon was seeing this man but quickly realized it was not true. Her sister confirmed that aside from her preoccupation with the celebrity, Ms. Gordon had normal mood, sleep, energy, and activity levels. She lived alone and had stable employment in an advertising agency. The sister had not observed any symptoms of mania, depression, or hallucinations.
James
James, a 14-year-old Hispanic male, is seen for an outpatient evaluation at a pediatric clinic in the southeastern United States. He has consistently been very anxious when interacting with others. His parents encourage him to "hang out" with kids in their neighborhood, but he cannot make himself do this. Every social circumstance feels overwhelming to him, even if his parents are with him. During the evaluation, he does not have any problems with speaking. He wants to participate in high school activities and to go out with friends, but he has not pursued any of these activities for fear that he will make a fool of himself and become embarrassed. He says that he thinks he will not be seen as "macho" -he wants to be "machismo"-but thinks he will be teased for being "nervous" instead. He says he cannot be "in public." He mainly stays at home, surfs the Internet, and does his homework. He aspires to go to a professional school of some sort, but recently he has begun to worry about whether he can even finish high school because of his nervousness. He denies any physical symptoms, and his recent medical workup was normal. He does not use alcohol or other substances and does not take substances I medications that may cause anxiety. He denies having homicidal and/ or suicidal ideation, intent, and/ or plans.
Ms. Sawyer
Ms. Sawyer is a 34-year-old married mother of two children, ages 3 and 5 years. She presents with complaints of significantly increased irritability that began after the birth of her second child. She reports that before her first pregnancy, she noticed feeling more sensitive and frustrated a few days before her period. Once menses began, however, she was quickly "back to her old self." The symptoms did not interfere with her schoolwork or relationships, but she began to notice a pattern over time. Ms. Sawyer's pregnancies were uneventful; both children are healthy and she enjoys being a mother. She de-scribes a stable marriage, ample child care, and support from friends and family. She is confused about what she calls her "Jekyll and Hyde" personality. Currently, every month she experiences intense mood swings" that last about 10 days before her menses. She has difficulty sleeping and feels exhausted during the day. She has trouble concentrating and feels more disorganized than usual. Ms. Sawyer reports being most upset about the effect that her “monthly personality change" has on her family and her weight. She becomes extremely irritable and often feels u out of control and overwhelmed." She finds she yells at her children over minor things. She craves carbohydrates and gains 1-2 pounds per month. She is finally relieved of her symptoms 2-3 days after her menstrual flow begins. un is as if a toxin leaves my body and then I'm back to my old self again for about 20 days."
Jon
A 17-year-old boy named Jon has been referred by his parents to the clinic for "having trouble getting along with people." Jon is a bright teenager who excels at academics, particularly in his stated interests of math and history, and when prompted he can ex-pound at length on dates and events of colonial American history. He describes himself as being "socially awkward" and reports increasing feelings of isolation. Jon has a supportive family and has one or two friends at school who share his interest in computers and video games. He watches public programming on television but never watches sitcoms because he does not understand "why people find them funny." Jon has never had a girlfriend and rarely socializes with peers after school or on weekends, although he admits that he would like to do so. He is not able to recollect details from his child-hood clearly but states that he always felt different from other kids and never had "best friends" growing up. He states that his parents never told him that he was behind developmentally and otherwise reports no notable psychiatric or medical history. During the interview, Jon presents as fairly robotic, with a flattened tone and stilted, adult-like language, which almost sounds like he is quoting text. When spoken to, Jon appears uncomfortable, avoiding eye contact and instead appearing to stare intently at the interviewer's mouth. Upon review of depressive symptoms, Jon states that "maybe" he feels down at times, and he goes on to express that people who commit suicide are "stupid" because there is always a logical reason to stay alive.
Ms. Smythe
Ms. Smythe is a 42-year-old recent immigrant to the United States. She cites political and economic reasons for leaving her parents and extended family. Unable to find work in her professional field, she supports herself by working as a maid in a hotel. Generally friendly, she has made some acquaintances at work and.at church. She misses her old life, especially her family, but hopes to bring her parents to the United States. In church, she enrolled in a vocational program that helps members find higher-paying work. While Ms. Smythe was in the program, the minister noticed that she was becoming increasingly disheveled and distracted. When asked about this, she became tearful and upset. She said everything was going so well until a man began to follow her home from work. At first she thought nothing of it, but now she was sure that he was from the secret police from her native country. Somehow he had been able to put listening devices in her apartment and had slipped a micro-tracking device in her food, which she can taste when she eats. When asked why anyone would go to such lengths to follow her, she whispered that she was the rightful heir to the throne and the man needed to stop her from taking power. The minister suggested she speak to someone at the community clinic and arranged for an appointment with a psychiatrist. On interview, the psychiatrist noted that Ms. Smythe seemed preoccupied and repeatedly looked out the window. When the psychiatrist asked what she was looking at, she stated nonchalantly that city buses with a certain advertisement were sending her codes from loyalists in her homeland. The psychiatrist noted that she spoke slowly and calmly and did not appear agitated. Ms. Smythe reported sleeping well and going to work as scheduled. Of note, she has no history of substance use and had been diagnosed 5 years earlier with hyperthyroidism, which is under good control.
Ms. Hernandez
Ms. Hernandez is a 26-year-old single white woman who presents to the emergency department after consuming 20 tablets of her antidepressant medication. She says she took the pills suddenly after an intense fight and "breakup for the last time" with her boyfriend. Ms. Hernandez called her boyfriend immediately after taking the pills, and he came with her to the emergency department. Ms. Hernandez reports that she and her boyfriend have had an "on-and-off" relationship-she says she always feels that she "needs" him but they have "lots of fights" and cannot "hold it together" for more than a couple of weeks at a time. Most of her family relationships are strained, but she says her sister is her "best friend" now that they "are on speaking terms with each other again." Ms. Hernandez says that she took the overdose because she "can't stand to be alone." She volunteers that she "sees lots of other guys" and has a pattern of risky sexual behaviors when she and her boyfriend are having problems. She engages in binge drinking ("only when I am really mad") many times each month. Ms. Hernandez reports that she has had "anger issues" and "is always suicidal" since her teenage years. She has been in therapy many times, with many different therapists because she cannot find one that "understands” her. "At first they seem to 'get me'-understand what I am going through-but then, they always pull back at some point."
Ms. Hansen
Ms. Hansen is a 35-year-old single woman who works as a university librarian. She presents to her first psychotherapy visit for help with intrusive thoughts focused on a form of contamination fear that she has struggled with since her early 20s. Back then, for no apparent reason, Ms. Hansen began worrying that the water supply in the house she shared with her three college roommates became contaminated by the sewer system. As a result, she started having trouble drinking the water at her house and started avoiding using the bathroom for fear she might worsen the problem and contaminate her housemates' potable water. Since then, this concern has forced Ms. Hansen to relocate numerous times, but each move would only give her a brief respite before her fears recurred, typically a few months after each move, causing significant anxiety and prompting yet another relocation. Over the years, Ms. Hansen has sought reassurance through numerous expensive consultations and inspections with plumbers, architects, and general contractors, as well as several laboratory tests meant to test water quality. None of these measures, however, provided sustained relief. Ms. Hansen currently spends 3 hours per day worrying about cross-contamination between the clean water and waste systems in her house, or seeking reassurance that the two have not become somehow linked. She blames her preoccupation with this problem on her limited social life and absence of romantic relationships. Except for moderate depression that typically follows each move, Ms. Hansen has not suffered from other psychiatric symptoms, including tics. She has been physically healthy all her life. She drinks alcohol rarely and has never used other substances. When asked by her new therapist to describe the problem that caused her to seek help, Ms. Hansen gives this preface to her answer: "I know this is crazy and makes absolutely no sense, but I can’t help worrying about it.”