Case 1 DSM-5™ Clinical Cases

by Michael Gitlin, M.D. STUDENT NOTES

Adapted

Nancy Ingram, a 33-year old stock analyst and

married mother of two children, was brought to the
emergency room (ER) after 10 days of what her
husband described as “another cycle of dark days.”
His wife was tearful, then explosive, and she had
almost no sleep.

Ms. Ingram’s husband said he had decided to bring

her to the ER after he discovered that she had
recently created a blog entitled Nancy Ingram’s
Best Stock Picks. Such an activity not only was out
of character but, given her job as a stock analyst for
a large investment bank, was strictly against
company policy.

Mr. Ingram said his wife was working on the stock

picks around the clock, forgoing her own meals as
well as her responsibilities at work and with her
children. Ms. Ingram argued with her husband at
this time and said, her blog “would make them
rich.”

The patient had first been diagnosed with

depression in college, after the death of her father
from suicide. On examination, the patient was
pacing angrily in the exam room. Her eyes
appeared glazed and unfocused. She responded to
the examiner’s entrance by sitting down and
explaining that this was all a miscommunication,
that she was fine and needed to get home
immediately to tend to her business. She was
speaking so rapidly, it was difficult for the examiner
to interrupt.

She denied hallucinations, but admitted with a

smile, to a unique ability to predict the stock
market. She refused to be cognitively tested and
she said, “I will not be a trained seal, a guinea pig, or
a barking dog, thank you very much, and may I
leave now?”
Case 2 DSM-5™ Clinical Cases
by Richard J. Loewenstein, M.D. STUDENT NOTES
Adapted COMORBIDITY – there are 3 potential diagnoses
that co-occur or present simultaneously.
Irene Upton was a 29-year-old special education
teacher who sought a psychiatric consultation
because “I’m tired of always being sad and alone.”
…She had been hospitalized twice for suicidal
ideation and severe self-cutting that required
stiches.

She told the therapist that her sister reported

“weird sexual touching” by their father when Ms.
Upton was 13. There had never been a police
investigation, but her father apologized to the
patient and her sister as part of a church
intervention…. Ms. Upton casually dismissed the
possibility that she had ever been abused. She
denied any negative feelings toward her father and
said, “He took care of the problem. I have no reason
to be mad at him.”

Ms. Upton reported little memory for her life

between about ages 7 and 13 years. Her siblings
would joke about her inability to recall family
holidays, school events, and vacation trips. She
explained this by saying, “Maybe nothing important
happened and that’s why I don’t remember.”

Ms. Upton described being “socially withdrawn”

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
distinguished teacher of autistic children.

She denied use of alcohol or drugs, and described

intense nausea and stomach pain at even the smell
of alcohol.

She described herself as “numb” and said thoughts

of suicide were “always around.” She denied
flashbacks or intrusive memories, but reported
recurrent nightmares of being chased by a
“dangerous man” from whom she could not escape.
She reported an intense startle reaction and
avoidance of dating men. She did not have
instances of time loss or unexplained possessions
or inexplicable skills, habits and/or knowledge.
Case 3 DSM-5™ Clinical Cases
by Jason P. Caplan, M.D.
Theodore A. Stern, M.D. STUDENT NOTES
Adapted

Paulina Davis a 32-year-old single African

American woman with epilepsy first diagnosed
during adolescence. She was admitted to a medical
center after her family found her convulsing in her
bedroom.

During her hospital admission, a routine

electroencephalogram (EEG) was ordered. Shortly
after the study began, Ms. Davis began convulsing.
When the EEG was reviewed, no epileptiform
activity was identified. Ms. Davis was subsequently
placed on video-EEG (vEEG) monitoring. In the
course of her monitoring, Ms. Davis had several
episodes of convulsive motor activity; none were
associated with epileptiform activity on the EEG.
Psychiatric consultation was requested.

On interview, Ms. Davis noted that she had recently

moved to the state to start graduate school; she was
excited to start her studies and “finally get my
career on track.” She denied any recent specific
psychosocial stressors other than her move and
stated, “My life is finally where I want it to be.” She
was worried about missing the first day of classes
(only a week away from the time of the interview).
She was also worried about the costs of her
hospitalization because her health insurance
coverage did not being until the school semester
commenced.

When the findings of the vEEG study were

discussed with Ms. Davis, she quickly became quite
irritable asking, “So, everyone thinks I’m just
making this up?” The psychiatrist/clinician tried to
ease Ms. Davis’ concerns by telling her that about
10% of people with epilepsy also experience non-
epileptic seizures (NES). NES can be caused by
subconscious thoughts, emotions or 'stress', not
abnormal electrical activity in the brain.
Professionals do not believe that the seizures are
purposely or fictitiously produced. The clinician
told Ms. Davis she would not be exposed to
unnecessary medication or studies, and that
treatment, in the form of psychotherapy was
available.
Case 4 DSM-5™ Clinical Cases
by James L. Levenson, M.D. STUDENT NOTES
Adapted

Norma Balaban is a 37-year-old married woman

who was referred to a psychiatrist by her primary
care physician. Other than obesity and undergoing
gastric bypass surgery 6 years earlier, Ms. Balaban
had been generally healthy.

As she entered the consulting room, Ms. Balaban

handed the psychiatrist a three-page summary of
her physical concerns that have been occurring
over the past year. Nocturnal leg spasms and
daytime aches were her initial concerns. She then
developed sleep difficulties that led to “brain fog”
and head heaviness. She had intermittent cold
sensations in her extremities, face, ears, eyes, and
nasal passages. She also had neck stiffness with
accompanying upper back spasms.

Ms. Balaban’s primary care physician had evaluated

the initial symptoms and then referred her to
specialists. A rheumatologist (arthritis and
autoimmune diseases) diagnosed mechanical back
pain without evidence of inflammatory arthritis.
Several neurologists examined her and diagnosed
possible migraines. A review of tests done at the
two local medical centers indicated that she had
received the following essentially normal tests: two
electroencephalograms (EEG), … three brain and
three spinal magnetic resonance images (MRI), …
and serial laboratory exams. Ms. Balaban shared
with the psychiatrist that she was very frustrated
that despite having seen several specialists, she had
received no clear diagnosis and she was still very
concerned about her symptoms.

Ms. Balaban found it difficult to concentrate and

complete her work and was spending a lot of time
on the Internet researching her symptoms. She also
felt bad about not spending enough time with her
children or husband.
Case 5 DSM-5™ Clinical Cases MULTIPLE CASES
by Susan Samuels, M.D. STUDENT NOTES
Adapted

Thomas an 8-year-old boy with a mild to moderate

intellectual disability was brought into the
emergency room (ER) by his parents after his
abdominal pain of the past several weeks had
worsened over the prior 24 hours.

The teachers at in his special education classroom

and parents agreed that Thomas often looked
distressed, rocking, crying, and clutching his
stomach. A pediatrician had diagnosed chronic
constipation and recommended over-the-counter
laxative, which did not help.

An abdominal X-ray revealed multiple small

metallic particles throughout the gastrointestinal
tract. The family’s bathroom was in the process of
being renovated because its paint was old and
peeling. Thomas’ blood lead level was 4 times the
normal amount. Endoscopy successfully extricated
three antique toy soldiers from Thomas’ stomach.

Case 6 DSM-5™ Clinical Cases

by Susan L. McElroy, M.D.
Adapted

Yasmine Isherwood a 55-year-old married woman

had been in psychiatric treatment for 6 months for
an episode of major depression.

She began to complain of weight gain, so the

psychiatrist clarified her eating history. Her BMI
was 23.3, which is considered normal. Ms.
Isherwood had recurrent, distressing episodes of
uncontrollable eating of large amounts of food. She
reported that the episodes occurred two or three
times per week. She ate rapidly and alone, until
uncomfortably full. She did report that in her late
20s, she had become a competitive runner. At that
time, she had often run 10-kilometer races and
averaged about 36 miles a week. She reached her
lowest weight ever of 113. She felt “vital and in
control.” A foot injury eventually forced her to shift
to swimming, biking, and the elliptical machine,
although she only does this for 30 minutes a day
regardless of her eating habits.
Case 7 DSM-5™ Clinical Cases MULTIPLE CASES
Jennifer J. Thomas, Ph.D. STUDENT NOTES
Anne E. Becker, M.D., Ph.D.
Adapted

Valerie Gaspard a 20-year-old single black woman

who had recently immigrated to the United States
from West Africa with her family to do missionary
work. She visited the hospital due to frequent
headaches, poor concentration, and chronic fatigue.

She was only 78 pounds and her height was 5 feet 1

inch, resulting in a body mass index (BMI) of 14.7.
This is severely underweight. Ms. Gaspard had
missed her last menstrual period. When Ms.
Gaspard recalled her meals the day before she was
consuming only 600 calories. Ms. Gaspard provided
multiple reasons for her poor intake. The first was
lack of appetite: “My brain doesn’t even signal that
I’m hungry,” she said, “I have no desire to eat
throughout the whole day. Secondly, she said, “I
just feel so uncomfortable after eating.”

She walked approximately 3-4 hours per day. She

denied that her activity was motivated by a desire
to burn calories. She did not have a car and disliked
waiting for the bus. Ms. Gaspard said, “I know I
need to gain weight. I’m too skinny. She said her
family had been “nagging” for a year about it.

Case 8 DSM-5™ Clinical Cases

James E. Mitchell, M.D.
Adapted

Wanda Hoffman was a 24-year-old white woman

who presented with a chief complaint: “I have
problems throwing up.” These problems began in
early adolescence, when she began dieting despite a
normal BMI. At age 18, she went away to college
and began to overeat in the context of new
academic and social demands. A 10-pound weight
gain led her to routinely skip breakfast. She often
skipped lunch as well, but then famished, would
overeat in the late afternoon and evening. She felt
out of control. Worried her habits would lead to
weight gain; she saw self-induced vomiting as a way
of controlling her fears. She appeared well
nourished: Her BMI was normal at 23.
Case 9 DSM-5™ Clinical Cases
Arshya Vahabzadeh, M.D. STUDENT NOTES
Eugene Beresin, M.D.
Christopher McDougle, M.D.
Adapted

Brandon was a 12-year-old boy brought in by his

mother for psychiatric evaluation for temper
tantrums.

Even Brandon’s teachers noted that he often cried

and rarely spoke in class. They said he was
academically capable but that he had little ability to
make friends. In recent months, multiple teachers
heard him screaming at other boys, generally in the
hallway, but sometimes in the middle of class. The
teachers assumed he was responding to a
provocation.

When interviewed alone, Brandon responded with

nonspontaneous mumbles when asked questions
about school, classmates, and his family. When the
examiner asked if he was interested in toy cars,
however, Brandon lit up. He pulled several cars,
trucks, and airplanes from his backpack and, while
not making good eye contact, did talk at length
about vehicles, using their apparently accurate
names (e.g., front-end loader, B-52, Jaguar).

When asked again about school, Brandon pulled out

his cell phone and showed a strong of test
messages: “dumbo!!!!, mr stutter, LoSeR, freak!,
EVERYBODY HATES YOU.” Brandon added that
other boys would whisper “bad words” to him in
class and then scream in his ears in the hall. “And I
hate loud noises.”

According to his mother, he had always been “very

shy” and had never had a best friend. He struggled
with jokes and typical childhood banter because “he
takes things so literally.”

On examination, Brandon stumbled over his words,

paused excessively, and sometimes rapidly
repeated words or parts of words. Brandon said he
felt okay but added he was scared of school.
Case 10 DSM-5™ Clinical Cases MULTIPLE CASES
Robert Haskell, M.D. STUDENT NOTES
John T. Walkup, M.D.
Adapted

Ethan, a 9-year-old boy, was referred to a

psychiatric clinic by his teacher who noticed his
attention was flagging. The teacher told Ethan’s
parents that although Ethan had been among the
best students in his class in the fall, his grades had
slipped during the spring semester. He tended to
get fidgety and distracted when the academic work
became more challenging.

Ethan’s mother agreed: She had noticed that he

often seemed to be shrugging his shoulders,
grimacing, and blinking, which she took to be a sign
of anxiety. These movements worsened when he
was tired or frustrated, and they diminished in
frequency during calm, focused activities like
clarinet practice.

Case 11 DSM-5™ Clinical Cases

Brian Palen, M.D.
Vishesh K. Kapur, M.D., M.P.H.
Adapted

Cesar Lopez, a 57-year-old Hispanic man

complained of worsening fatigue, daytime
sleepiness, and generally “not feeling good.” He
lacked the energy to do his usual activities. On
physical examination, he was 5 feet 10 inches tall,
weighed 235 pounds, and had a BMI of 34. His neck
circumference was 20 inches.

His wife had to sleep in the guest bedroom because

he snored very loudly. She said he often woke with
choking sound. Mr. Lopez said, “All the men in
family are snorers. I’ve snored ever since I was a
child.”

A sleep study (polysomnography) showed the

following sleep stages throughout the night:
o Time in Non-REM 1 (N1 sleep): 20%
o Time in Non-REM 2 (N2 sleep): 60%
o Time in Non-REM 3 (N3 sleep): 10%
o Time in REM sleep: 10%
REM is typically 15-20% for adults
Case 12 DSM-5™ Clinical Cases
Ming T. Tsuang, M.D., Ph.D., D.Sc.
William S. Stone, Ph.D.
Adapted STUDENT NOTES

Gregory Baker was a 20-year-old African

American man who was brought to the emergency
room (ER) by campus police of his university. He
refused to leave a classroom after randomly
walking into a lecture hall and shouting to the
audience.

His sister said that he had quit seeing his friends

and spent most of his time lying in bed staring at
the ceiling. She also explained that she repeatedly
saw him mumbling quietly to himself and noted
that he would sometimes, at night, stand on the roof
of their home and wave his arms as if he were
“conducting a symphony.” Mr. Baker defended
himself by saying that he felt liberated and in tune
with the music when he was on the roof.

During the prior several months, Mr. Baker had

become increasingly preoccupied with a female
friend, Anne, who lived down the street. While he
insisted to his family that they were engaged, Anne
told Mr. Baker’s sister that they had hardly ever
spoken and certainly were not dating.

On examination in the ER, Mr. Baker became

enraged when the staff brought him dinner. He
loudly insisted that all of the hospital’s food was
poisoned and that he would only drink a specific
type of bottled water.

Ultimately, Mr. Baker agreed to sign himself into the

psychiatric unit, stating, “I don’t mind staying here.
Anne will probably be there, so I can spend my time
with her.”
Case 13 DSM-5™ Clinical Cases
Charles L. Scott, M.D. STUDENT NOTES
Adapted

Ike Crocker was a 32-year-old man referred for a

mental health evaluation by the human resources
department at a construction site. Although he
presented as a very motivated and skilled worker at
the interview with two carpentry certificates, in the
first two weeks of employment, he has had frequent
arguments, absenteeism, and made many
dangerous mistakes. When confronted by
supervisors, he was dismissive of the problem and
said if someone got hurt, “it’s because of their own
stupidity.”

When the head of human resources met with him to

discuss termination, Mr. Crocker said he would sue
on the grounds of the American Disability Act: He
demanded a psychiatriatric evaluation for
attention-deficit/hyperactivity disorder (ADHD)
and bipolar.

During the mental health evaluation, Mr. Crocker

focused on unfairness at the company and how he
was “a hell of a better carpenter than anyone there
could ever be.” He had been married twice and had
two children. Mr. Crocker refused to pay child
support, which is why he said both ex-wives “lied to
judges and got restraining orders saying I’d hit
them.” He was not interested in seeing his children.
He said they were “little liars” like their mothers.

During high school, he said he “must have been

smart” because he was able to make Cs in school
despite only showing up half the time. He spent
time in juvenile hall at age 14 for stealing “kid stuff,
like tennis shoes and wallets that were practically
empty.” He left school at age 15 after being “framed
for stealing a car.” He pointed this out to show how
he had overcome injustice. Mr. Crocker concluded
the interview by demanding a note from the
examiner that said he had “bipolar” and “ADHD.”

Phone calls revealed that Mr. Crocker had been

expelled from two carpentry training programs and
that both of his certificates had been falsified. He
got fired from his job at one local construction
company after a fistfight with his supervisor.
Case 15 DSM-5™ Clinical Cases
Frank Yeomans, M.D., Ph..D. MULTIPLE CASES
Otto Kernberg, M.D. STUDENT NOTES
Adapted

Juanita Delago was a 35-year-old single,

unemployed Hispanic woman who sought therapy
at age 33 for chronic suicidal thoughts.

She had done well academically I high school but

dropped out of college. She kept quitting entry-
level jobs because she said the “bosses were idiots.”
This also left her feeling terrible about herself (“I
can’t even succeed as a clerk?”) She said in the
department store, people would often be rude: “it
was ridiculous.”

She had a history of cutting herself superficially

along with persistent thoughts that she’d be better
off dead. Toward the end of the first session, she
became angry at the interviewer after he glanced at
the clock. She asked, “Are you bored already?” She
had few friends and felt most people in the
neighborhood had become “frauds or losers.”

Case 16 DSM-5™ Clinical Cases

Katharine A. Phillips
Adapted

Vincent Mancini, a 26-year-old single white man,

was brought for an evaluation by his parents. They
were distressed that since age 13, Mr. Mancini had
been excessively preoccupied with his “scarred”
skin, “thinning” hair, “asymmetrical” ears, and
“wimpy” muscular build. His parents thought he
looked normal, but he thought he looked “ugly” and
“hideous.” He believed others made fun of him
because of his appearance.

Mr. Mancini spent 5-6 hours a day looking in

mirrors and other reflective surfaces checking the
areas he disliked. He would pull on his ears to
“even them up.” He used a razor blade to pick his
skin and “clear it up.” He lifted weights daily and
wore multiple t-shirts to look bigger. He almost
always wore a cap in the gym to cover his hair. He
had received dermatological treatment for his skin
concerns but felt it had not helped. He felt life was
not worth living “if I look like a freak.”
Case 17 DSM-5™ Clinical Cases
Richard A. Friedman, M.D.
Adapted MULTIPLE CASES
STUDENT NOTES
Andrew Quinn a 60-year-old businessman,
returned to see his longtime psychiatrist 2 weeks
after the death of his 24-year old son. The young
man was tragically killed in a car accident.

Mr. Quinn was very close to his son and he

immediately felt crushed, like life had lost its
meaning. In the ensuing 2 weeks, he felt constantly
sad, withdrew from his usual social life, and was
unable to concentrate on his work. His psychiatrist
told him he was struggling with grief and that such
a reaction was normal. Mr. Quinn was to return for
ongoing assessment.

By the sixth week, of visiting the psychiatrist, his

symptoms had worsened. He started to become
preoccupied that he should have been the one to
die, not his son. He had trouble falling asleep, but
he also tended to wake up at 4:30 A.M. and just
stare at the ceiling, feeling overwhelmed with
fatigue and sadness.

Case 18 DSM-5™ Clinical Cases

Katharina Meyerbröker, Ph.D.
Adapted

Olaf Hendricks a 51-year-old businessman,

complained of his inability to travel by plane. His
only daughter had just delivered a baby, and
although he desperately wanted to meet his first
granddaughter, he felt unable to fly across the
Atlantic Ocean to where his daughter lived.

Mr. Hendrick’s colleagues saw him as a forceful and

successful businessman who could “easily” deliver
speeches in front of hundreds of people. When
specifically asked, he reported that as a child, he
had been “petrified’ that he might get attacked by a
wild animal. This fear had led him to refuse to go
on family camping trips or even on long hikes in the
country. As an adult he did not have these fears
because he lived in a large city and took vacations
by train to other large urban areas.
Case 19 DSM-5™ Clinical Cases
Elizabeth L. Auchincloss, M.D. MULTIPLE CASES
Adapted STUDENT NOTES

Karmen Fuentes was a 50-year-old married

Hispanic woman who threatened her psychiatrist
that she would overdose on Advil. She was urged to
go to the emergency room where she explained that
her back was “killing” her.

When asked about her suicidal comments, she said

they were “no big deal.” She said she just wanted to
worry her husband to “teach him a lesson” because
“he has no compassion for me.” Ever since she had
a bad fall at work, she said her husband was not
supportive. I feel “abandoned.” When asked if she
would hurt herself with pills, Ms. Fuentes exclaimed
with a smile, “Oh wow, I didn’t realize it’s so serious
to make threats. I shouldn’t do that again.”

She went on to say how “nice and sweet” it was that

so many doctors and social workers wanted to hear
her story. She called many of them by their first
names. She was also somewhat flirtatious with her
male resident interviewer, who had mentioned that
she was the “best-dressed woman in the ER.”

Case 20 DSM-5™ Clinical Cases

Robert Michels, M.D.
Adapted

Larry Goranov was a 57-year-old single

unemployed white man who was in weekly
psychotherapy. He found it “humiliating” that he
was forced to see trainees who rotated off his case
every year or two. He frequently found that the
psychiatry residents were not especially educated,
cultured, or sophisticated and felt they knew less
about psychotherapy than he did. He preferred to
work with female therapists, because men were
“too competitive and envious.”

He enjoyed fine restaurants and “five-star hotels,”

but he added that he could no longer afford them.
He wore clothing that appeared to be by a hip-hop
designer generally favored by men in their 20s.
Case 21 DSM-5™ Clinical Cases
Barbara L. Milrod, M.D. STUDENT NOTES
Adapted COMORBIDITY – there are 3 potential diagnoses
that co-occur or present simultaneously.
Nadine was a 15-year-old girl whose mother
brought her for a psychiatric evaluation to help her
with long standing shyness.

Although Nadine was initially reluctant to say much

about herself, she said she felt constantly tense.
She was generally unable to speak in any situation
outside of her home or school classes. She reused
to leave her house alone for fear of being forced to
interact with someone. She was especially anxious
around other teenagers, but she also became “too
nervous” to speak to adult neighbors she had
known for years. She said it felt impossible to walk
into a restaurant and order from “a stranger at the
counter” for fear of being humiliated.

Nadine also felt she constantly on her guard,

needing to avoid the possibility of getting attacked.
She was the most confident when she was alone in
her room. From seventh grade to ninth grade,
Nadine’s peers turned on her. The bullying was
daily and included intense name-calling (for
example - “stupid,” “ugly,” “crazy”) and physical
threats. One girl (the ringleader) had been Nadine’s
good friend in elementary school, but hit her and
gave her a black eye. Nadine did not fight back. She
refused to tell her parents what happened, but cried
herself to sleep at night.

Nadine transferred to a specialty arts high school

for ninth grade. Even though the bullying ended,
she could not make friends. Nadine felt even more
unable to venture into new places. She felt
increasingly self-conscious that she could not do as
much on her own.

Nadine was even scared to read a book by herself in

a local, public park. She had nightmares about the
bullies in her old school. She spent whole
weekends “trapped” in her home.
Case 22 DSM-5™ Clinical Cases
Ryan E. Lawrence, M.D.
Deborah L. Cabaniss, M.D. MULTIPLE CASES
Adapted STUDENT NOTES

Peggy Isaac was a 36-year-old administrative

assistant who was referred to outpatient evaluation
by her primary care physician. Ms. Isaac had lived
with her longtime boyfriend until 8 months earlier,
at which time he had abruptly ended the
relationship. Before the break-up, she always had a
boyfriend: She was alone for the first time and
hated it.

Ms. Isaac began to agonize about the possibility of

making mistakes at work. She felt
uncharacteristically tense and fatigued. She
worried about money, and to economize, she
moved into a cheaper apartment in a less desirable
neighborhood. She repeatedly sought reassurance
from her mother and office-mates, but soon she
worried about being “too much of a burden.”

She even started to get her food delivered, so she

could avoid going to the store: She felt “exposed
and vulnerable,” like something bad would happen.

Case 23 DSM-5™ Clinical Cases

Mayumi Okuda, M.D.
Helen Blair Simpson, M.D., Ph.D.
Adapted

Samuel King , a 52-year-old janitor smelled of

strong disinfectant on examination. He said that he
was worried about contracting diseases like HIV, so
he washed his hands incessantly with bleach. On
average, he washed his hands up to 30 times a day.
He also avoided touching practically anything
outside of his home, but if he felt contaminated, he
would wash.

Mr. King also had intrusive images of hitting

someone and fears that he might offend or disturb
the neighbors. He often apologized for fear he
might have sounded rude. When he showered, he
made sure that the water in the tub only reached a
certain level for fear he could flood his neighbors.
He recognized that his fears and urges were “kinda
crazy,” but he felt they were out of his control.