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Case Study 3: “Joe” Joe, a 24-year-old mechanic, had been referred for psychotherapy by his physician, whom he has consulted because of difficulty falling asleep. He was quite visibly distressed during the entire intial interview, gulping before he spoke and continually fidgeting in his chair. He repeatedly requested water to slake a seemingly unquenchable thirst… He described his physical concerns at first … (and) reported that he nearly always felt tense. He seemed to worry about everything. He was apprehensive of disasters that could befall him as he interacted with other people and worked, and he described worrying much of the time about his ability to form a relationship, his finances, and other issues. He reported a long history of difficulties relating to others, which had led to his being fired from several jobs. As he put it, “I really like people and try to get along with them, but it seems like I fly off the handle too easily. Little things upset me too much. I just can’t cope unless everything is going exactly right.” Joe reported that he had always felt more nervous than other people but that his anxiety had become much worse after a romantic breakup one year ago. Reference: Kring, A. M., et al. (2010, p. 125) 1. What do you observe about the case or the person in the vignette that is diagnostically significant (i.e., symptoms, mental status elements)? (5 correct responses for full credit; 10 points total) 2. What general diagnostic category would fit this person’s behavior & why? (4 points) 3. Name at least two possible diagnoses for the person in the vignette. (2 points) 4. Name one diagnosis or diagnostic category you would “rule out” and why. (4 points) 5. Which diagnosis best fits the information provided in the case or video clip and why? (Use the DSM-5 diagnostic classification system) (5 points) Example of how this should be answered using the DSM-5 Sample Case Study The patient has almost to be carried into the room, as he walks in a straddling fashion on the outside of his feet. On coming in, he throws off his slippers, sings a hymn loudly, and then cries twice (in English), “My father, my real father!” He is 18 years old, and a high school student, tall, and rather strongly built, but with a pale complexion, on which there is very often a transient flush. The patient sits with his eyes shut, and pays no attention to his surroundings. He does not look up even when he is spoken to, but he answers, beginning in a low voice, and gradually screaming louder and louder. When asked where he is, he says, “You want to know that too; I tell you who is being measured and is measured and shall be measured. I know all that, and could tell you, but I do not want to.” When asked his name, he screams, “What is your name? What does he shut? He shuts his eyes. What does he hear? He does not understand; he understands not. How? Who? Where? When? What does he mean? When I tell him to look, he does not look properly. You there, just look! What is it? What is the matter? Attend; he attends not. I say, What is it, then? Why do you give me no answer? Are you getting impudent again? How can you be so impudent? I’m coming! I’ll show you! You don’t turn whore for me. You mustn’t be smart either; you’re an impudent, lousy fellow, an impudent, lousy fellow as stupid as a hog. Such an impudent, shameless, miserable, lousy fellow I’ve never met with. Is he beginning again? You understand nothing at all – nothing at all; nothing at all does he understand. If you follow me now, he won’t follow, will not follow. Are you getting still more impudent? Are you getting impudent still more? How they attend, they do atend,” and so on. At the end he scolds in quite inarticulate sounds. The patient understands perfectly, and has introduced many phrases he has heard before into his speech, without once looking up. He speaks in an affected way, now babbling like a child, no lisping and stammering, sings suddenly in the middle of what he is saying, and grimaces. He carries out orders in an extraordinary fashion, gives his hand with the fist clenched, goes to the blackboard when he is asked, but, instead of writing his name, suddenly knocks down a lamp, and throws the chalk among the audience. He makes all kinds of senseless movements, pushes the table away, crosses his arms, and turns round on his axis, chair and all, or sits balancing, with his legs crossed and his hands on his head… When he is to go away, he will not get up, has to be pushed, and calls out loudly, “Good-morning, gentlemen; it has not pleased me.” The patient himself was always quiet and very industrious, but of moderate mental endowment. Seven months ago, during the holidays, he suddenly began to learn in a quite senseless way, and then became confused, thought he was laughed at for being dirty, and washed himself all day long, was afraid his effects would be taken, broke the windows, seemed to hear voices, attacked his mother without any cause, became wet and dirty in his habits, and would not speak a word. In the hospital he was almost dumb, was cataleptic, gave his hand stiffly and jerkily, and almost entirely refused to eat. His expression was generally indifferent, though sometimes cheerful, and visits from his relations made no impression at all on him. The patient understood quite well what was taking place around him, but as a rule he did not obey orders; indeed, he sometimes did the exact opposite of what was wanted. Thus, he shut his eyes when his pupils were mentioned, covered his face with his handkerchief if you wished to see it, and drew his hand back when he ought to have stretched it out. He was often dirty, and also smeared feces about, and rolled them into little balls – a sign diagnostic of great emotional dullness. After refusing food for a long time, he suddently asked for Swiss cheese and then for chocolate, and devoured them both greedily. From this we can plainly see the senseless and impulsive nature of his refusal of food. Once he laid his outstretched leg on the next bed, and remained in that position when the bed was moved away. In the seventh month of the illness the patient began to be excited, after having sung occassionally during the period of dumbness. In the middle of the night he threw away his bedding, rocked rhythmically up and down on the bedstead, and screamed incessantly, “Now, I want to know where my brother is.” Since then he has been in a continual state of excitement, is destructive and abusive, and talks in a confused way. He briefly informed his relations, from whom he takes the eatbles they bring when they come to see him, without talking to them much, that he was going to travel by Gibraltar to the Cameroons and by Constantinople to Bucharest. 1. What do you observe about the case or the person in the vignette that is diagnostically significant (i.e., symptoms, mental status elements)? (10 points total) Answers necessary for full credit (at least 4 of these): – disorganized speech (nonsensical speech, or similar description – acceptable) – disorganized OR tangential thought (nonsensical thoughts, or similar description – acceptable) – hallucinations (auditory hallucinations, hears voices – acceptable) – delusions OR bizarre delusions OR referential delusions – grossly disorganized or abnormal motor behavior (catatonia) Other possible answers: – poor grooming (indicates level of functioning as markedly below prior functioning) – blunted affect – disheveled (indicates level of functioning as markedly below prior functioning) – agitated movement – bizarre movement 2. In what general diagnostic category would you place this person’s behavior & why? (4 points) Schizophrenia Spectrum and Other Psychotic Disorders (must have at least one of following reasons for full credit – can give partial credit if reason “why” not included or incorrect) – presence of delusions and/or hallucinations – disorganized or abnormal behavior (catatonia acceptable) – disorganized thinking (nonsensical thoughts, or similar description – acceptable) – disorganized speech (nonsensical speech, or similar description – acceptable) 3. Name at least two possible diagnoses you considered for this person. (2 points; 2.5 points for each correct response) For credit, must have TWO of the following: Schizophrenia Schizoaffective Disorder Schizophreniform Disorder Psychosis due to a Medical Condition Catatonia Associated with Another Mental Disorder Catatonic Disorder due to Another Medical Condition Unspecified Catatonia 4. Name one diagnosis or diagnostic category you ruled out and why. (4 points) Acceptable answers for credit: – Substance/Medication-induced Psychotic Disorder: no substance use indicated – Mental disorders due to a GMC: (why) no medical condition indicated – Delirium: sxs are continuous, delirium consists of fluctuations in symptoms and additional disturbancs in memory, disorientation, etc. – Dementia: there are other sxs in addition to memory impairment – Schizoaffective disorder: no indication that major depressive or manic episodes have occurred concurrently with symptoms of schizophrenia – Depressive disorder with psychotic features: no indication that major depressive or manic episodes have occurred concurrently with symptoms of psychosis – Bipolar disorder with psychotic features: no major depressive or manic episodes have occurred concurrently with symptoms of psychosis 5. Which diagnosis best fits the information provided in this case or video clip and why? (Use the DSM-5 diagnostic classification system) (5 points) Required for credit: Schizophrenia, With Catatonia, Continuous* *this and other course specifiers (e.g., first episode, currently in acute episode/full remission/partial remission) are only used after a 1-year duration and if they are not in contradiction to the diagnostic course criteria *partial credit may be awarded for incorrect diagnosis, depending on how relevant to the case; if diagnosis and reason why given, you will receive no less than 1 point for this question Answer for “why” may include: **if don’t include reason why but give correct diagnosis, may receive partial credit) Prominent features are disorganized speech, disorganized behavior, negativism, and catatonic behavior; delusions and hallucinations are also present but are not most prominent, or other adequate reasons for the individual in the vignette meeting the diagnostic criteria