Irene Upton was a 29-year-old special education teacher who sought a psychiatric education teacher who sought a psychiatric consultation because â€œIâ€™m tired of always being sad and alone.â€
The patient reported chronic, severe depression that had not responded to multiple trials of antidepressants and mood stabilizer augmentation. She reported greater benefit from psychotherapies based on cognitive behavioral therapy and dialectical behavior therapy. Electroconvulsive therapy had been suggested, but she refused. She was hospitalized twice for suicidal ideation and sever self-cutting that required stitches.
Ms. Upton reported that previous therapists focused on the likelihood of trauma, but she casually dismissed the possibility that she had ever been abused. It was her younger sister how reported â€œweird sexual touchingâ€ by their father when Ms. Upton was 13. They had never been a police investigation, but her father apologized to the patient and her sister as part of a resultant church intervention and an inpatient treatment for alcoholism and â€œsex addiction.â€ She denied any feelings about these events and said, â€œHe took care of the problem. I have no reason to be mad at him.â€
Ms. Upton reported little memory for her life between about ages 7 and 13 years. Her siblings would joke with her about her inability to recall family holidays, school events, and vacation trips. She explained her amnesia by saying, â€œMaybe nothing important happened, and thatâ€™s why I donâ€™t remember.â€
She reported a â€œgoodâ€ relationship with both parents. Her father remained â€œcontrollingâ€ toward her mother and still had â€œanger issues,â€ but had been abstinent from alcohol for 16 years. On closer questioning, Ms. Upton reported that her self-injurious and suicidal behavior primarily occurred after visits to see her family or when her parents surprised her by visiting.
Ms. Upton described being â€œsocially withdrawnâ€ until high school, at which point she became academically successful and a member of numerous teams and clubs. She did well in college. She excelled at her job and was regarded as a gifted teacher of children with autism. She described several friendships of many years. She reported difficulty with intimacy with men, experiencing intense fear and disgust at any attempted sexual advances. Whenever she did get at all involved with a man, she felt intense shame and a sense of her own â€œbadness,â€ although she felt worthless at other times as well. She tended to sleep poorly and often felt tired.
She denied use of alcohol or drugs and described intense nausea and stomach pain at even the smell of alcohol.
On mental status examination, the patient was well groomed and cooperative. Her responses were coherent, and goal directed, but often devoid of emotional content. She appeared herself as â€œnumb.â€ She denied hallucinations, confusion, and a current intention to kill herself. Thoughts of suicide were, however, â€œalways around.â€
More specific questions led Ms. Upton to deny that she had ongoing amnesia for daily life, particularly denying ever being told of behavior she could not recall, unexplained possessions, subjective time loss, fugue episodes, or inexplicable fluctuations in skills, habits, an/or knowledge. She denies a sense of subjective self-division, hallucinations, inner voices, or passive influence symptoms. She denied flashbacks or intrusive memories but reported recurrent nightmares or being chased by â€œa dangerous manâ€ from whom she could not escape. She reported difficulty concentrating, although she was â€œhyper focusedâ€ at work. She reported an intense startle reaction. She repeated counting and singing in her mind, repeated checking to ensure that doors were locked, and compulsive arranging to â€œprevent harm from befalling me.â€
- What are the most likely diagnoses for this patient?
- What subjective and objective information leads you to these diagnoses?
- What is in your differential diagnoses?
- Is there anything else you would like to know in order to solidify your choice of diagnoses?
Peggy Isaac was a 41-year-old administrative assistant who was referred for an outpatient evaluation by her PCP with the chief complaint of â€œIâ€™m always on edge.â€ She lived alone and never married or had children. She has no past psychiatric history of inpatient or outpatient treatment.
Ms. Isaac lived with her longtime boyfriend until 8 months earlier, at which time he abruptly ended the relationship to date a younger woman. Soon thereafter, Ms. Isaac began to agonize about routine tasks and the possibility of making mistakes at work. She felt uncharacteristically tense and fatigued. She had difficulty focusing. She also started to worry excessively about money and, to economize, she moved into a less expensive apartment in a less desirable neighborhood. She repeatedly sought reassurance from her office mates and her mother. No one seemed able to help, and she worried about being â€œtoo much of a burden.â€
During the 3 months prior to the evaluation, Ms. Isaac began to avoid going out at night, fearing that something bad would happen and she would be unable to summon help. More recently, she avoided going out in the daytime as well. She also felt â€œexpose and vulnerableâ€ walking to the grocery store three blocks away, so she avoided shopping. After describing that she figured out how to get her food delivered, she added, â€œItâ€™s ridiculous. I honestly feel something terrible is going to happen in one of the aisles and no one will help me, so I wonâ€™t even go in.â€ When in her apartment, she could often relax and enjoy a good book or movie.
Ms. Isaac said she had â€œalways been a little nervous.â€ Through much of kindergarten, she cried inconsolably when her mother tried to drop her off. She reported seeing a counselor at age 10, during her parentsâ€™ divorce, because â€œmy mother thought I was too clingy.â€ She added that she never liked being alone, having had boyfriends constantly (occasionally overlapping) since age 16. She explained, â€œI hated being single, and I was always pretty, so I was never single for very long.â€ Nevertheless, until the recent breakup, she said she had always thought of herself as â€œfine.â€ She had been successful at work, jogged daily, maintained a solid network of friends, and had â€œno real complaints.â€
On initial interview, Ms. Isaac said she had been sad for a few weeks after her boyfriend left, but denied ever having felt worthless, guilty, hopeless, anhedonic, or suicidal. She said her weight was unchanged and her sleep was fine. She denies psychomotor changes. She did describe significant anxiety, with a Beck Anxiety Inventory score of 28, indicating severe anxiety.
- What is the most likely diagnosis for this patient?
- What subjective and objective information leads you to this diagnosis?
- What is in your differential diagnoses?
- Is there anything else you would like to know in order to solidify your choice of diagnosis?