Reference no: EM133264772

Case Study: A Young Woman With a Confusing Presentation

Ms. D is a 26-year-old woman whose family brings her to the emergency room in an acutely psychotic state. Ms. D is the youngest of six siblings. She was born prematurely, weighing 4 pounds, but had no other prenatal complications. Her subsequent developmental. Her subsequent developmental history was normal: She did well in school, made friends, and went to work in a bank after graduating from high school. She then married (4 years before her first admission) and had two children. Ms. D has not worked outside the home since the birth of her children. There is a family history of psychotic illness in a maternal aunt and of drug abuse in two siblings.

A week before the present evaluation, Ms. D came to the psychiatric emergency clinic complaining of dizziness and trouble sleeping. She said she was also experiencing intermittent depression and felt that she was a failure as a wife and a mother. An appointment at the mental health center was scheduled, but before the appointment could take place, Ms. D's family brought her into the emergency room for this evaluation, which results in Ms. D being admitted to the psychiatric unit for the second time.

Four months before the present evaluation, Ms. D separated from her husband and returned home to live with her mother and two siblings. Shortly after she began living with her mother, one of her brothers was sent to jail and her boyfriend wrecked her new car.  About a month after Ms. D began living with her mother, her family noticed a deterioration in her functioning that culminated in her being found in a confused state in a train station. On that day she was brought to the hospital, where she was observed to be agitated and hallucinating, with marked thought disorder. She complained of voices making both encouraging and derogatory statements about her and of command hallucinations to kill herself and her husband. Ms. D was hospitalized and treated with antipsychotic medication. She was discharged after 3 days, returned to live with her mother, and began outpatient treatment at the local mental health center.

When Ms. D is admitted for this second time, she reports that she has had been having anxiety, insomnia, delusions, and auditory hallucinations for the past 3 weeks. It turns out that she has actually been experiencing hallucinations and delusions for the past 3 months, but her fear of readmission to the hospital prevented her from reporting these to her outpatient therapist. She describes paranoid delusions about her mother wanting to hurt her. She states that she believes that the television is controlling her mind and that others can read her thoughts. She is experiencing auditory control hallucinations and says that they have occurred frequently ever since her first admission.

Ms. D is also displaying prominent manic symptoms, which her mother reports began only 3 weeks before this admission. Ms. D's mother says that at that time her daughter began to go on frequent shopping sprees, suddenly seemed as if she was driven by a motor, was not sleeping, and was and arousing her sexually. She hardly slept for the 2 nights before she was admitted, and her family reports that she had been dancing, singing loudly, and reciting the Bible at the dinner table.

During this second admission, Ms. D is initially hostile and agitated, stating repeatedly that she believes the staff is trying to hurt her through a mirror in her room. She is hyperactive, and excited; displays a flight of ideas; and talks nonstop. She continues to experience somatic hallucinations. She shows hypersexual behavior toward other patients and experiences grandiose delusions that she can heal them with her thoughts.

Ms. D is treated with fluphenazine in does up to 60 doses up to 60 mg/day. Despite 2 weeks of treatment with fluphenazine, her symptoms continue to worsen and a trial of lithium is initiated. Within 3 weeks after MS. D achieves a therapeutic blood level of lithium, her mental status returns to normal. She is discharged on fluphenazine 15 mg at night and lithium carbonate 300 mg tid.

Her outpatient therapist helps her set simple goals for helping with small household and child-care tasks. Ms. D and her mother continue to be seen regularly in family treatment. These sessions focus on education about Ms. D's illness, recognition of early signs of relapse reduction of tension at home, and setting of realistic goals for Ms. D during the recovery process. Over the next 6 months, Ms. D's fluphenazine does is reduce and finally discontinued, and she regains her premorbid level of functioning and is maintained on lithium.

Use this SAMPLE FORMAT

Diagnosis I: F43.10 Post Traumatic Stress Disorder with Dissociative Symptoms (Depersonalization)

Differential Diagnoses: 

F32.1 Major Depressive Disorder

Other Conditions That May Be a Focus of Clinical Attention:

Z56.9 Other Problems Related to Employment

Medical Conditions: Second-degree and third-degree burns covering one-third of the body

Mr. R's primary diagnosis appears to be Post Traumatic Stress Disorder, as he meets all eight (A-H) diagnostic criteria:

A1: R directly experienced a life-threatening event and received a serious injury as a result when he almost burned to death in a fire.

B2: R is experiencing recurrent nightmares related to the traumatic event. 

C2: R was reluctant to return to the fire station and after a bad experience, does not think he can ever return or perform his duties as a firefighter. 

D2: R has experienced negative cognitions and mood: he has persistent and exaggerated negative beliefs about himself because he blames himself for being burned, and he is ashamed to face his coworkers. 

D6: He has been withdrawing from people. 

D7: R is afraid to leave his house by himself, helpless, and wonders if life is worth living

E2: R is engaging in chain-smoking and drinking himself to sleep and to calm his nerves.

E4: He exhibited an exaggerated startle response when he heard the fire alarm at the fire station.

E6: R is experiencing sleeplessness. 

F: The duration for the disturbances of criteria B-E has been approximately 5 weeks (37-40 days).

H: These disturbances are not attributable to any other substance or medical condition. 

Dissociative symptoms (depersonalization): R reports frequently feeling "dizzy, numb, and detached," and does not feel like himself anymore.

Differential Diagnosis: Several of R's symptoms could be considered symptomatic of Major Depressive Disorder, however, he only meets four criteria (five are required to be able to diagnose MDD): 

A1: Depressed mood; feeling sad and hopeless

A4: Insomnia nearly every day

A5: Psychomotor agitation (pacing in his house, exaggerated startle response to fire alarm)

A7: Feelings of worthlessness and excessive or inappropriate guilt: horrified at his physical appearance, blaming himself for getting burned.

R has expressed some suicidal ideation, in that he has "begun to wonder if life is worth living," however it is unknown if this is recurrent. If it does become recurrent, that would be the fifth diagnostic criteria over two weeks, which is the requirement for Major Depressive Disorder, however, this diagnosis would not account for PTSD criteria B and C symptoms (nightmares and avoidance behaviors), therefore this diagnosis was not chosen. 

Other conditions that may be the focus of clinical attention - Other problems related to employment: R is questioning whether he can ever return to his firehouse or ever respond to another fire again. Obviously, this could cause significant vocational issues that will need to be considered in his treatment. R may require vocational counseling to help him find another job within the fire department, or outside of the fire service altogether.