Cases Flashcards
(37 cards)
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.
OCD
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.
PTSD
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?”
Opiate withdrawal
- malingering suicidality
- 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
problems.
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.
Bipolar 2
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 alcohol.
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
Interpersonal Effectiveness
Distress Tolerance
Emotion Regulation
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.
Intellectual disability
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.
Conduct Disorder
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,
dissociative amnesia
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,
depersonalization/derealization disorder
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.
DID
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.
