Flashcards in Cases Deck (37):
A 22-year-old graduate student presents to University Counseling Services for anxiety. She worries often about her schoolwork, her future, her family, and relationship issues. She feels tense, has difficulty concentrating, has frequent headaches, and has been sleeping poorly. She has felt this way most of the day, most days of the week over the past year. She thought this was normal considering the amount of stress in her life, but is now concerned that she is getting “too edgy” with her friends and is inadvertently pushing them away.
Generalized anxiety disorder
A 20-year-old man presents to the emergency room via ambulance with shortness of breath, sudden onset of chest pain, and anxiety starting about 15 minutes ago. He says, “Help me! I’m going to die!” Examination reveals an elevated pulse rate and blood pressure, diaphoresis and facial flushing. EKG shows sinus tachycardia. You administer 1 milligram of lorazepam intramuscularly. Vital signs stabilize and he is asymptomatic within 15 minutes. He then tells you that he has been having these spells several times a month, and they happen without warning.
Panic Attack (possibly panic disorder)
You are considering referring a 35-year-old man with an anxiety problem to a psychiatrist after the patient failed a trial of Prozac 20 mg per day. His symptoms strike you as peculiar: whenever he is driving and hits a pothole or a branch, he worries that he ran someone over. He knows this makes no sense, and he has never been in an accident with bodily injury before, but he feels overwhelming anxiety unless he circles around the block, sometimes two or three times, to verify that nobody was injured.
You are working in an outpatient primary care clinic. A 31-year- old woman presents with “depression” since a motor vehicle accident six months ago. She was the driver and survived, but her eight-year-old son, who was unbuckled, was seriously injured. She has not driven since the accident and finds no enjoyment in her activities. She thinks about the crash several times a day and has nightmares at least twice a week about losing her son. She thinks that her “nerves are shot” because she is easily startled. She has started to drink two to four glasses of wine after dinner.
A 34-year-old woman had been involved in a car accident that did not necessitate hospitalization. Following the accident she experienced episodic headaches, dizziness, neck pain, and upper back pain. Over the past five years, her condition worsens and she is evaluated by two neurologists, a "neuro- opthalmologist", a physiatrist, an endocrinologist, and a psychiatric pain specialist. Once she was diagnosed with epilepsy based on minor EEG abnormalities. She required an admission to the ICU for a severe allergic reaction to an anti- epileptic medication. Her symptoms and functional limitations did not resolve when her personal injury case was settled.
Somatic Symptom disorder = you have symptoms that are extremely bothersome, disproportionate to how they feel about it.
A 25-year-old man is brought into the emergency room by police after he knocked on the window of the police cruiser and threatened to kill himself. He looks ill and distressed. He tells you that he had been feeling depressed for the last two weeks. He has had poor energy, difficulty concentrating, poor appetite, “no sleep,” and thoughts to “end it all.” He confides that he plans to overdose on heroin. On review of symptoms he has runny nose, cough, stomach cramping, diarrhea, and cold intolerance. His blood pressure is 165/100 and pulse is 104. He has multiple tattoos and “goose-pimples” on his skin. He has a coarse tremor visible on his tongue and in his arms when they are outstretched. As you conclude your evaluation, he asks, “Hey, are you going to give me something?”
-alcohol is another worry, major depression is possible but active use of substances is not a good time to diagnose that.
Course tremor shows he is in acute alcohol withdrawal, if you don't notice that he can seize and die. The main motivation is to get treatment for substance use disorder. It is important to look past the malingering
A 28 yo married woman, who works as a second year resident is high achieving and can be quite self critical. In the last month, the patient has felt increasingly fatigued with difficulty concentrating. On the floors she is noted to be quite irritable at times. She has come to feel guilty that she can't perform at work up to her standards. She is waking up by 4:30am every day and doesn't have much interest in eating. She has lost ten pounds. At home, her husband describes her as having little interest in their relationship and sex. Finally, she has begun to wonder if life is worth living and has had thoughts of how she might end her life.
Major Depressive Disorder (melancholy)
SIG E CAPS
35 yo single man went to his EAP after he became very upset at his
annual performance review. He gives the history of his first depression
at age 13 when his dad became hospitalized. Since then he has felt
depressed on and off throughout his life and has never felt as if he met
his potential at work. Despite these feelings he seldom had trouble
sleeping or eating, felt he could concentrate at work, did enjoy his time
outdoors, and although he sometimes wondered if life was worth living,
he had never had active suicidal thoughts. Finally, he stated that
although his symptoms have waxed and waned over his lifetime, the last
time he felt well was three years ago. He has no history of
hypomanic/manic symptoms or substance abuse.
depressed on and off throughout his
-he seldom has trouble sleeping or eating, he sometimes thought if life is worth living, no active suicidal thoughts, the last time he felt well was 3 years ago, has no history of hypomanic/manic symptoms or substance abuse
Persistent Depressive Disorder
40 yo man stated that he hasn’t been well for 6 months. He
has felt guilty and has been either very withdrawn or irritable.
He feels down/w low energy, has trouble sleeping, has lost
interest in his very stressful job and admitted he has been
using cocaine very regularly. He is not suicidal. He clarified he
had been stressed at work for about a year, but only
experienced the above symptoms 6 mos ago (3 mos after
starting cocaine use). The symptoms are present every day.
He has no previous psychiatric history.
Stressed at work about a year, above sympoms 6montsh ago, 3 months after starting cocaine use. No previous psych history.
He has depression and meets substance use
Substance/Medication use Depressive Disorder
A 79 yo man was diagnosed with Parkinson’s disease
six years ago. He had done well until 3 months ago,
when he began declining invites, feeling
withdrawn/less interested and noticing more trouble
with concentration/memory, had a 15 pound wt loss
and trouble staying asleep. He didn’t really feel sad
or more worried but knew he wasn’t’ himself. He
had no thoughts of suicide. His Parkinson symptoms
were worsening. He had no history of substance use
Depressive Disorder due to another medical condition,
and you have to treat both
43 yo woman complained of recurrent, episodic depressions.
She currently feels guilty, has no energy at home or work, with overeating/wt gain/excessive sleep. She has tearful episodes and has thought more of death but doesn’t have suicidal thoughts. She has had at least 5 such episodes since college. Her husband said that at times she can have periods of being unusually happy/ excited/productive, need little sleep and be hypersexual. At those times, she was able to function at home and work, but she was clearly a different person. Each of these “happy” episodes lasted 6 or 7 days. She has no history of substances.
her symptoms were hypomanic. She went to work, got her stuff done but it was still off.
An 18-year-old male with no prior PPH1
presents with new-onset paranoia. He
demonstrates a pervasive distrust and
suspiciousness about others and is described
as “eccentric” by his few friends; He is
emotionally detached from social
relationships but is without any perceptual
disturbances and does not abuse drugs or
Schizotypal Personality Disorder
A patient presents with a chief complaint of
depressed mood. During the interview, he/she
demonstrates an incapacity to appreciate
anyone else’s point of view other than their
own. You determine that its this egocentrism
that is the etiology of their depression.
Narcissistic Personality Disorder
DBT differences from CBT
Like CBT, DBT sessions focus on problem-solving and skill-building. One notable difference, however, is DBT almost always requires several weekly sessions. Typically, one group session each week is devoted to learning behavioral skills in a classroom format, and at least one weekly individual therapy session is dedicated to problem-solving and helping the client implement the skills learned in the skills training group. Another notable difference is that DBT includes and encourages the use of phone-coaching, which involves contacting the therapist between sessions for help in using skills. The main reason for the increased frequency of sessions and phone encounters is to help combat severe emotional distress and impulsivity, which can be hard to combat in once-weekly therapy.
DBT Skills training is broken up into four modules:
Core Mindfulness Skills
Ms. A recalls troubled family life including various forms of abuse. Married and divorced in the 1970 ’s. First felt seriously depressed in her 20’s. • Has tried many antidepressants. Has chosen generally to stay away from therapy.
• Married again in 1990’s but disastrous relationship and moved back in with her mother. There she contemplated suicide during uncontrolled period of crying and was hospitalized. During that time she found out that her husband had suddenly died. • Is bothered by impaired recent memory that is exacerbated by stress. • However, she appears happy while saying she is depressed.
Treatment Resistent Depression.
Presents to the clinic accompanied by his mom who is
concerned about his future. He has been discouraged
about not being able to do as well in school as he
thought he should. Mom notes his IQ is 65 and he is
in a special class for handicapped youth. She thinks
he should be able to attend a community college and
get a degree in nursing, an area of his interest. He
gets anxious when test taking and reportedly does
well in school. He has friends with whom he studies,
plays sports, hangs out at the mall, etc.
What further info is needed
the basis for his low tested IQ, extent to which he socializes with peers, actual levels of achievement and functioning
Betty, age 12-years is referred for school
difficulties and recent fears of going to school
over the past few months. She has always been
shy and when stressed complains of stomach
and head aches. There is a maternal family
history of anxiety disorders.
Separation Anxiety Disorder
-there is a genetic predisposition,
Gary is a 15 yr old, he spent a night at juvy because of verbal threats to his teacher. These have been problems since the first grade however this is the first time the police have been called. Since the age of 6 he has had temper tantrums and destroying hand held electronics. Once he punched a whole in the wall. Since 12 not a month gone back has he had a serious tantrum.
Intermittent Explosive disorder
-started around age of 6
Tina is 5 yr old, assistance with behavior at home. Recently caught her lying more, cheating more, fighting more with sister and at school, Tina has a few friends at school but will threaten them if they don't cooperate. Tina started with age 3 when she had difficulty following instructions, and she is figity, and she won't do her homework.
ODD and ADHD look similar, figity, seems to have both diagnoses.
11 yr old boy is brought because of continued fighting and bullying. He got out of line too often. Recently found stolen goods and minor proerty damamge and lied when asked about it. Reginald would sneak back after midnight. he was recently suspended at school. He jumped people and pushed people off bikes. He repeated first and second grade. He looked unhappy and upset. 2nd oldest in a single parent home and widely unsupervised. He hits or bites her. He complained sister was mean to him
There is an increase in the problematic behaviors, he is setting up blockage trying to get money from kids, caught stealing, there is a definite dimension greater in these issues.
A 19 yo man was reported missing from his dorm for 2 days. He was eventually located with his friend 200 miles from campus. After being found, the patient was interviewed. He stated that he was studying in his room and remembered suddenly seeing a shadowy male figure in his room and the room began spinning. All the objects in the room looked distorted and unreal. He didn’t remember who he was or anything about his travels during that 2 days before he was found. He has no history of seizure or substance use disorder, head trauma or other medical conditions. He said that prior to this event he was struggling with extreme worry and stress ; he is about to lose his scholarship to school and doesn’t know what will happen to him. After being in therapy for a time, he revealed that he had been repeatedly sexually abused as a child by an older brother.
He had a fugue,
20 yo female college student, referred for
“being out of it”. For about 3 mos her mind
had often felt blank and she felt increasingly
detached from her body, like a robot. Many
times, not sure if she were alive or dead.
These experiences left her feeling very anxious
for hours. Grades and socialization declined. She had broken up a serious relationship
months earlier. During stressful periods as a
child she remembers times of feeling as if
things around her were misshapen and not
real. She has no history of mood or psychotic
d/o, substances. Physical and labs were wnl.
Should think of trauma,
A 40 yo woman with 10 previous psychiatric admissions for cutting herself and suicide attempts was admitted to the unit. The patient's history includes being raised until 4 by alcoholic parents and then after age 4 being raised in foster homes with numerous episodes of sexual abuse. Adolescence was marked by episodes of running away, poor school performance and prostitution. The patient stabilized after age 20 for time but continued to struggle with a failed marriage and work difficulties. During this stay she began to talk about hearing "voices" of crying children, internal conversations, memory lapses and loss of time. She was eventually able to identify 5 alters: a sad 5 yo child, an angry 15 yo girl, a 20 yo female prostitute, a sadistic 40 yo male and a protective 50 yo female.
You are called to the ED to evaluate an 81 year old, right-handed woman with a past history of hypertension presenting with sudden onset “confusion” over night. Her family describe her as “very active” at baseline; living alone and frequently involved with social activities with friends. Last evening, her daughter was talking to her on the phone and noticed that she sounded strange. Her sentences did not make sense and she sounded sleepy. Her daughter advised her to go to bed, but when she still acted strange the next day, she brought her to the ED.
Vitals: Stable except for HR of 105 bpm
81 year old woman who appears her stated age. She is dressed appropriately but slightly unkempt. She is somnolent but arouses to verbal stimulation and responds with one to two word answers to questions. She immediately closes her eyes when not engaged in conversation. She says the year is “1995” and does not answer when asked about the month or day. She knows she is in a hospital but can not say which one or where. She is able to identify her daughter and her birthdate. Language output is minimal but she seems to understand simple commands like “stick out your tongue”. She did not follow more complex commands. She could not describe how she got to the hospital or the name of the current president. She can not recall 3 simple words after 5 minutes and her ability to draw a clock is impaired.
Remainder of exam is non-focal.
Case of delirium. The exact etiology is not clear from the case but common causes might include a UTI or constipation.
Delirium, ataxia, eye-movement abnormalities
No muscle weakness, it would be really hard to get a stroke without that.
-just give them thiamine, its too hard to test delirious people
Delirium, ataxia, pupillary dilation, tachycardia, decreased
sweating, slurred speech, picking behavior
Anticholinergic delirium - picking behavior (chicken)
Delirium, bradykinesia, rigidity, polyminimyoclonus, negative myoclonus
Negative myoclonus is a decrease in muscle tone leading to a jerk - asterixis. Too much ammonia
Hepatic failure - encephalopathy
Delirium, (mostly postural and action) tremor, autonomic
instability, agitation, diarrhea, intense hallucinations
A 77 year old woman comes to consult with you after a fall. She describes an episode of standing up quickly from a chair and then “passing out”. After further discussion, you discover that for the past year her memory has been steadily declining for names, appointments and recent conversations. In addition, her family has noticed that she has been walking more slowly and having difficulty with fine motor movements like buttoning buttons. She has also been complaining of seeing “small animals” in her room at night. She knows they are not real, but they bother her nonetheless.
Vitals: Blood Pressure 110/70 laying down, 90/55 standing.
Neurological Exam: CN’s intact. She has mild rigidity is all extremities; proximal more than distal, and slow RAM’s. She has a slow and shuffling gait with stooped posture.
Mental Status Exam: She recall 5/5 words immediately but only 2/5 after five minutes. She can recall 4/5 with cues. Her language function is intact but she has some difficulty with digit span and can not copy a cube. Her fund of knowledge is intact. There are no hallucinations or delusions currently and her mood is euthymic.
Lewy Body Dementia
cognitive problems came on with Parkinsonism and hallucinations > LWB
Mrs. A is a 55 year old woman who is coming to you for evaluation of personality changes and odd behaviors. Her grown daughters described her as having been a happy, loving mother/homemaker and upstanding citizen prior to the onset of her illness. One day, she saw a young man (who did not appear disabled) park his sports car in a handicapped spot. She became angry at his presumed flouting of the parking regulations and proceeded to scratch his vehicle with her keys and attempted to scratch his face as well. She also has been eating more and has had significant weight gain causing her to increase in dress sizes. When her daughters took her shopping for new outfits, she insisted that she was her previous size, despite all evidence to the contrary, and would refuse to try on or buy larger sizes. Her daughters surreptitiously purchased new clothes for her in the correct size and removed the labels, so that the patient had items that fit.
General physical and neurological exam: Normal except some mild facial bradykinesia (i.e. hypomimia) when performing other activities.
Mental Status Evaluation: Disinhibited manifested by reaching out an grabbing the doctor’s tie and commenting on the pattern during the interview. Also breaking into “Shave and a Haircut” during testing of RAM’s, followed by giggling. Thought process was often tangential. Mood and affect were normal and no evidence of delusions or hallucinations. Memory was 5/5 for immediate registration and 3/5 with delayed recall that improved to 5/5 with cues. Tests of attention, such as digit span and serial letter identification, were impaired. She was not able to complete a Trails B task. Visuospatial reasoning, fund of knowledge, and language were intact.
Frontotemporal Dementia – Pick’s disease
she suffers from disinhibition, asognosia, executive dysfunction.
Infers frontal lobe - knife edge atrophy.
Pick bodies. Their primary problems are behavioral. Others their first problem wasn't memory or behavior, it was expressive language
Primary progressive aphasia
It is more common than AD in the 45-65 age group
Pick bodies, atrocystici plaques, cytoplasmic inclusions, and ballon neurons
Memory loss, “patchy” focal neurological findings, high blood pressure, high cholesterol, and diabetes.
Memory loss, wide-based gait with short stride length and step height, and urinary incontinence.
Memory loss, poor attention and executive function, chorea, ataxia, dystonia, depression.
Significant memory loss over a few months, startle myoclonus, disinhibition and personality change.
1. stroke, vascular dementia
2. normal pressure hydrocephalus
4.Creutzfeld Jacob disease
Jan is a 12-year-old adolescent girl who presents for evaluation at her family doctor’s office
for problems functioning in school and easy crying. Her teacher is concerned that she is depressed and may need therapy. Jan had been doing well in school until a little over a year ago, when her grades began to drop and she was unable to keep up with the other kids. Her younger brother, age 11, described as a “whiz,” gets things done very quickly. He has been taking a stimulant medication after being diagnosed at age 6 with ADHD, hyperactive-impulsive classification. Jan takes longer to do things, but is very successful in beating her brother at video games. She never seems to have what she needs to complete her schoolwork, however, and often finds herself daydreaming about becoming rich and famous. She particularly struggles with math and has difficulty socializing with her peers at home or at school.
Her parents have been told that she tests in the bright range on intelligence measures, but she
does not excel at anything. The family plays tennis regularly at the local country club. Jan has had lessons and, while she has the technical skills, she does not seem able to compete very effectively or to associate with other kids. Mom describes similar problems when she was a child and pre-teen, but ultimately she was able to go on to become a nurse. Dad, a businessman with an Ivy League education, is an exceptionally articulate, accomplished man.
Tony is a 4-year-old boy who has frequent temper tantrums during which he destroys his toys
and those of his older sister and cannot be soothed or settled. His parents note that he was a perfectly normal, happy boy until he reached the age of 16 months when, according to them, “all hell broke loose,” and he started running around the house without paying attention to objects or people. He prefers to play by himself, but does not seem to understand how to play with most toys, except simple infant toys. He rarely looks others in the eye and doesn’t respond when his parents call him. He shrieks whenever his parents or sister leave him alone, yet he does not want to be hugged or to accept affection. He is unable to tell them what the matter is and often does not appear to understand what they are explaining to, or requesting of, him.
His parents at one point were concerned that he might be deaf because he did not seem to hear
them. However, Tony is extremely sensitive to certain sounds such as the vacuum cleaner. His language is delayed as well; he speaks primarily in single words and simple phrases. His parents are concerned that he might have difficulty when he starts school and ask about getting him tested for ADHD. They are also concerned because he seems to panic whenever they go someplace new or they change his routine of bathing or napping and wonder whether he is actually worse behaviorally than he was at age 3. In eliciting the history, you learn that Tony never really responded to his name, would often repeat the same words over and over sometimes without a connection to the situation. He is able however to build marvelous towers and to take apart anything he gets his hands on. While he is in your office, he flicks his fingers in front of his face several times in a row and flaps his hands when excited. You notice that he has several bruises on his arms.
Jim, a 13-year-old boy, presents to the pediatrician with a three-month history of being
agitated, increased activity, distractibility, worsening school grades and of getting into fights on his way to and from school. Jim relates feeling very bad about his recent behavior; he also reports some difficulty sleeping. His teacher has requested that he be tested for ADHD. His mother is very concerned about him; she states that his older 15-year-old brother has been hanging out with a gang and she fears that Jim will start to do the same. The brother may be doing drugs and that is also a concern she has about Jim. His mother reports Jim has always been a B student until this school year. He has not had any prior school suspensions or indications of misbehavior at school. Jim reports he feels that he is not smart enough to go to the next grade.
On mental status examination, Jim appears thin for his age and he is somewhat fidgety; there is
no psychomotor agitation. He is irritable and mildly anxious, but relates appropriately to the examiner. His thought content includes wishing that everyone in the world could have good health and be happy, that his father would stop drinking and that he would do better in school. Jim denies hallucinations or delusions, but feels that he should be punished because of his angry thoughts toward his parents, particularly his father. He would not choose himself as a friend and would take his older brother to the moon if he could select someone to go with him. He admits sometimes wishing that he were dead, but has not thought about a way of doing it and is similarly indecisive about several other issues. He is oriented X3, able to spell “World” forward and in reverse, name sports figures of his favorite sport, but made 2 errors on serial 7s down to 56. He is unable to generalize similarities.
Angela, age 11 years, 8th grade girl lives with both parents
Has been angry over the past 15 months
almost all of the time. Verbal, explosive rages occur frequently.
Often over little things. No physical
aggression. She sometimes appears very happy and
describes such feelings. Mom has history of severe anxiety; dad
has had depressive episodes.
Disruptive Mood Disregulation Disorder
-onset before age of 10
-angry almost all the time
Severe recurrent verbal (rages) &/or behavioral(physical aggression) temper outbursts
Excessively and developmentally disproportionate
>12 months, sometimes feels happy.
47 yr old caucasian male presents with chief complaint of depressed mood and difficulty concentrating. His recent history is indicatve of impulsive acts including texting inappropriate messages to another woman. He also endorses loss of interest, impaired concentration, a diminished appetite and difficulty falling asleep. The likely diagnosis is
Major depressive disorder