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You see Jill (age 24) in the emergency room of a hospital where her parents have brought her for
evaluation. They are worried because she is giving away all of her possessions and says she is planning to
move to Seattle so she can "save the world." Her parents say that she has hardly been sleeping at all,
but she seems very energetic. They say she has appeared to be "in a frenzy" lately. When you interview
Jill you notice that she speaks very rapidly. It is hard to get her to be quiet long enough for you to ask
questions. She seems agitated, and has difficulty sitting still.

Bipolar disorder. Jill's plans to move to Seattle so she can "save the world" suggest that she is having
grandiose delusions, which is a possible symptom of mania. Feeling energetic despite getting very little
sleep is also a symptom of mania. The fact that her parents describe her as "in a frenzy" is also
suggestive of a manic episode. Rapid speech is also a characteristic of a manic episode. People
experiencing bouts of mania are also frequently described as agitated, and they may have difficulty
sitting still.

2. Morris has been referred to you for psychotherapy following a suicide attempt. When you interview
him he is very teary. He speaks slowly and looks down at the ground as he speaks. He reports difficulty
in falling asleep and staying asleep for the past month. Morris states that he hasn't had much of an
appetite and has lost 15 pounds. He reports that things he used to like just don't seem enjoyable
anymore, and he thinks that life is not worth living. Morris doesn't expect things to improve in the
future, which is why he tried to kill himself.

Major depressive disorder. Suicidal thoughts (ideation) and attempts are common in people with major
depressive disorder. Teariness is another symptom of major depression. Slow speech and looking down
at the ground (downcast looks) are also characteristics of major depression. Many people with
depression report a change in appetite with gain or loss of weight. Loss of pleasure in activities that used
to be enjoyable and general feelings of hopelessness are further signs of depression. Note that Morris
reports difficulty falling asleep and staying asleep for the past month; this is another symptom of
depression. The latter also suggests that Morris has been depressed for at least the past month. The
MINIMUM duration of symptoms required to diagnose major depression is 2 weeks. Morris' symptoms
clearly exceed the minimum requirements to receive this diagnosis.

3. Lenore has been feeling very sad since her husband died 12 days ago. She has eaten very little, and
has difficulty sleeping. She is weepy most of the time. Lenore is preoccupied with thoughts of her dead
husband and does not want to do much other than thinking about him. She has declined all invitations
by friends and spends most of her time alone.

"Normal" bereavement (not a psychological disorder; therefore not a mood disorder). As we have
discussed many times, before we make a diagnosis of mental disorder, it is important to decide whether
the person's problems exceed what would "normally" be expected under the circumstances. The
symptoms described here (eating very little, difficulty sleeping, crying, preoccupation with thoughts of
the dead person, and wanting to be alone) are probably fairly normal reactions to loss of a loved one.
Note also, that Lenore's husband only died 12 days ago. We might also consider a diagnosis of
Additional info: adjustment disorder with depressed mood if we thought that Lenore's problems
exceeded the "normal" response to bereavement.

Based on the symptoms presented in Lenores case and the four key criteria for determining whether
behavior is abnormal, would you say that Lenore has a psychological disorder? Why or why not?

No, it does not appear that Lenore has a disorder. Although 12 weeks is a considerable time period to
mourn a persons death, it is not atypical considering the person was her husband. Mourning is not
irrational behavior. Her behavior is slightly maladaptive since she does not want to do anything else but
think of him, but it does not seem to be extreme enough to be a mental disorder. She is distressed
about her husbands death, not her behavior towards it.

If you answered yes, what disorder (if any) should be considered? Explain why you chose this disorder.

Although I find it unlikely that Lenore has a mental disorder, it is possible that she has a major
depressive disorder. She matches some symptoms of major depressive disorder by displaying irregular
sleeping and eating patterns as well as losing interest in her family and social life.

4. Elise is a 35-year-old architect. She comes to you in great distress, feeling that she is unable to work,
and generally unable to function. She says that she feels tired all the time, to the point of feeling
completely exhausted. She says that she cries easily, and almost every day. She is having difficulty
sleeping, and has lost 20 pounds in the last 2 months without trying. She says that things have been
"real bad" for the last 2 months; she doesn't enjoy doing anything and thinks frequently of suicide.
However, she also says that she has never been a very happy person. She says that things rarely go right
for her, and she has given up on expecting good things to happen for her.

Double Depression" (major Depression superimposed on dysthymic disorder). Elise's current

symptoms (overall difficulty functioning, feeling tired all the time, crying easily and frequently, difficulty
sleeping, significant weight loss without trying, suicidal thoughts. and duration of symptoms of 2
months) are indicative of Major Depressive Disorder (also see comments on example 2, above). As we
learn more about Elise, however, we learn that she also has long-standing symptoms of dysthymic
disorder: She says that she has never been a very happy person, that she feels like things never go right
for her, and she has a hopeless outlook on life (also see comments on Case 4, above).

Additional info: She says that things have been real bad for the last 2 months; she doesnt enjoy doing
anything and thinks frequently of suicide. However, she also says that she has never been a very happy
person. She says that things rarely go right for her, and she has given up on expecting good things to
happen for her.

Based on the symptoms presented in Elises case and the four key criteria for determining
whether behavior is abnormal, would you say that Elise has a psychological disorder? Why or
why not?

Elise is exhibiting atypical behavior by crying every day, feeling tired all the time, and losing 20 pounds in
two months. Other behaviors she is displaying that appear to be atypical are her feelings of restlessness
and irritability. Elise is acting irrationally by calling her husband or children very often and constantly
worrying about them. Her behavior is maladaptive in the way that she cannot work or function
regularly. Her husband and children are likely very distressed by her behavior which is a good indicator
that she is unwell. It is likely that Elise has a psychological disorder.

If you answered yes, what disorder(s) (if any) should be considered? Explain why you chose this

Elise seems to be suffering a comorbid mental disorder. She seems to have a major depressive disorder
and a generalized anxiety disorder. Extreme weight loss and lack of sleep are major symptoms of MDD
and so is feeling tired and weak. Elise exhibits both of these symptoms along with extremely sad
thoughts such as thinking that she does not enjoy anything and thoughts of suicide. These symptoms
indicate her major depressive disorder. Excessive worrying and feelings of restlessness and irritability
are not symptoms of MDD and indicate that she is simultaneously suffering from generalized anxiety
disorder. This is supported by her distressing moods.

5. Amy, age 38, is a worrier. She is restless, irritable and has difficulty concentrating. She worries that
she worries so much and isnt always sure what it is that she is worried about. She cant let her husband
or children leave the house without making them call her regularly to reassure her that they are okay.
Her husband is growing weary of her fretting. Her children cant understand what all the fuss is about.
Their impatience with her only makes her worry more. Amy has generalized anxiety disorder.

Generalized Anxiety Disorder: Amy has Generalized Anxiety Disorder. With this disorder, there are six
main symptoms: (1) restlessness or feeling keyed up or on edge (2) being easily fatigued (3) difficulty
concentrating or mind going blank (4) irritability (5) muscle tension (6) sleep disturbance (difficulty
falling or staying asleep, or restless unsatisfying sleep) . Amy has at least three of the above. She is
always restless, she has difficulty concentrating, and she is very irritable. With Generalized Anxiety
Disorder, the patient finds it difficult to control their worries, and, at times, the patient worries about
how much they are worrying. This shows the extent to which this disorder causes problems with the
patient. This disorder does not only cause problems for the patient, it also causes problems to the
people that are around the patient. It can be very stressful and frustrating to always have to deal with
the worry-er.

Additional - Amy is diagnosed with Generalized Anxiety Disorder. According to DSM-IV-TR, Amy finds it
difficult to control the worry. The intensity, duration, or frequency of the anxiety and worry is far out of
proportion to the actual likelihood or impact of the feared event. The person finds it difficult to keep
worrisome thoughts from interfering with attention to tasks at hand and has difficulty stopping the
worry. Adults with Generalized Anxiety Disorder often worry about everyday, routine life circumstances
such as possible job responsibilities, finances, the health of family members, misfortune to their
children, or minor matters.

6.Hannah, age 55, was in a major car accident 20 years ago during a cross-country trip. Ever since, she
has been unable to drive on major highways. Although she does drive, she goes to great lengths to travel
only on back roads and scenic routes. She is able to go where she wants to go but it often takes much
longer to get there than it should. Hannah has developed a phobia about highway driving.

phobias: Phobias are attempts to compartmentalize fear into a few situations that can be avoided. by
attaching all the panicky feelings onto a few situations, the person can avoid those situations and go on
with life. Unfortunately, phobias can take on a life of their own and take over more and more of a
person's life. A fear of dogs can, for example, be fairly easy to manage just don't go near dogs. But a fear
of flying may limit social and business opportunities.

Additional: After Hannah's major accident she avoids driving on major highways Collaboration Hannah's
symptoms I have come to the conclusion that Hannah is suffering from chronic posttraumatic stress
disorder or PSTD. PSTD can occur in people who have experienced or witnessed a natural disaster, or a
serious accident. and their response to the accident consists of intense fear, helplessness, flashbacks or

7. Bert is 40 years old and works on an assembly line in a brush factory. He is terribly afraid of being
contaminated by germs. He avoids shaking hands with others. He wont eat in the cafeteria. He
has trouble leaving the bathroom because he isnt sure he has washed his hands well enough.

obsessive compulsive disorder: Bert has a bad case of obsessive compulsive disorder. He repeatedly
washes his hands in an attempt to "wash off all the germs." He is constantly paranoid about getting
dirty. He is trying to prevent a bad situation from happening. More recently, effective psychologic and
pharmacologic treatment methods have been recognized. Medications that inhibit serotonin reuptake
have been found to be effective in the treatment of obsessive-compulsive disorder. In general, therapy
for obsessive-compulsive disorder must be based on several factors. It is important to remember that, in
most cases, symptoms will be reduced but not eliminated.

8. A 28-year-old woman was walking through her local shopping mall when she began to feel intensely
anxious. The anxiety was accompanied by sensations of choking, smothering, and a sudden sense that
the people and stores around her were unreal. She began to fear that she was going crazy and the more
she worried about this the more anxious she became. A guard, seeing that she was in distress, brought
her to the mall office where she was able to lie down. A few minutes later the symptoms began to
subside. She went home after leaving the mall but she did not tell her husband what happened. A week
later she had a similar attack while she was walking down the street. She was able to reach her house
where she lay down until the attack ended. In the following three weeks she had two or more
attacks. Between attacks she was constantly worried about having another attack. The patient was
finally forced to tell her husband about the problem because she was so fearful of not being able to get
help if an attack occurred that she would not leave her house alone or travel on public transportation.

Panic Disorder with Agoraphobia: The patient suffers from recurrent and unexpected panic attacks,
whose symptoms include sensations of choking, shortness of breath, and derealization. She also suffers
from agoraphobia, where the patient fears being outside her home alone and several modes of public
transportation. Her persistent concern about having additional attacks has led to a significant change in
behavior. Moreover, these panic attacks are not the result of substance abuse or a mental disorder.
Because of all of these symptoms, the patient can be diagnosed with Panic Disorder with Agoraphobia.

9. A 36-year-old man and his young son were driving through an intersection when another car ran
through a red traffic light and struck them. The two were trapped in the car until a fire department
rescue team freed them. The patient was bruised but not seriously hurt. His son had a broken leg. The
first few days after the accident the patient was preoccupied with arranging care for his son and getting
the car repaired. A few days later he began having recurrent distressing thoughts and images of the
accident. These symptoms lasted for several weeks. The memory of his sons screams after the car was
struck seemed particularly vivid. The patient became irritable, had difficulty concentrating, and avoided
talking about the accident. He went out of his way to avoid driving down the street where the accident
occurred. As time went on he could no longer remember whether the traffic light was red or
green when he approached it.

Acute Stress Disorder: The man reported that these symptoms lasted for several weeks, and acute
stress disorder is only known to last for 4 weeks. Also, another major symptom of acute stress disorder
is recurrent images of the traumatic event. The man exhibits this symptom with the reoccurring images
of his son screaming after the car was hit. Dissociative trauma, another symptom of acute stress
disorder, is the inability to remember an important aspect of the trauma. The man cannot remember
whether the light was green or red when he entered the intersection, showing that he has yet another
symptom of acute stress disorder. The man also stated that he goes out of his way just to avoid the
intersection where the accident occurred. Marked avoidance of stimuli that would arouse remembrance
of the traumatic event is another major symptom of acute stress disorder. The many symptoms shown
by the 36-year-old man are all symptoms of Acute Stress Disorder.

10. Jack graduated from high school and got a job working in a video store. After working for about 6
months Jack began to hear voices that told him he was no good. He also began to believe that his boss
was planting small video cameras in the returned tapes to catch him making mistakes. Jack became
increasingly agitated at work, particularly during busy times, and began "talking strangely" to customers.
For example, one customer asked for a tape to be reserved and Jack indicated that that tape may not be
available because it had "surveillance photos of him that were being reviewed by the CIA". After about a
year Jack quit his job one night, yelling at his boss that he couldn't take the constant abuse of being
watched by all the TV screens in the store and even in his own home.

Schizophrenia: Some symptoms include hallucination, social withdrawal, depersonalization (internal

anxiety and a feeling of being unreal), loss of appetite , loss of hygiene, the sense of being controlled by
outside forces. There will rarely be an outward appearance of being ill its mostly internal. Schizophrenia
can occur at any age but it usually first develops between adolescence and young adulthood. In children
the symptoms are more severe.