Reference no: EM133256770

1. What symptoms is the patient currently exhibiting and what diagnostic symptom clusters do these belong to?

2. What is the most accurate DSM V diagnosis for these symptoms? What led you to rule out other possible diagnoses?

3. What information (if any) is still needed to strengthen the diagnosis? How will you obtain this information?

4. What factors may have contributed to the onset/etiology of the disorder?

5. What current factors might be maintaining the disorder?

FACTs:

Susan is a 25-year-old female presenting at the emergency room because of recent changes in behaviour that have caused concern for her family.

According to her partner, Susan has had recent changes in her behaviour. She recently dropped out of her university program and stays out for multiple nights in a row before coming home. In the days leading up to her disappearing, she appears to be irritable, requires very little sleep (2-3 hours per night), and often speaks about new business ideas. Once she is home, it is reported that she spends multiple days in bed. She often does not eat meals or complete self-care (i.e., brushing teeth, showering) unless her family or partner helps her to do so. It takes approximately 3 weeks for Susan to return to some level of functioning. This cycle has begun repeating every other month.

When asked what Susan is doing for the days she is not home, she reports that she cannot remember the details, but reports alcohol and drug use. She denies any irritability, changes in mood or behaviour. When prompted about her previous mental health experiences, she acknowledges periods of difficulty in the past when she was in high school, but states that now is not like that. Susan reports heavy cocaine use and consumes alcohol 4-6 times per week. She often forgets what happened on a night of partying and can wake up in random locations not remembering how she got there.

Susan was previously enrolled in a Bachelor of Science specializing in Life Sciences. When discussing her future career goals, she shared that she hopes to go to medical school. She described feeling hopeless as she has failed over half of her courses and was asked to leave the program. Susan explained that partying takes her mind off disappointment she feels with herself. She shared that she does not feel like she has much potential to successfully engage in any career.

Susan is the youngest of six children who grew up in a middle-class urban home. She attended public school and was mostly a C and B student. In the past, Susan had periods where she has been moody and irritable throughout adolescence. She previously had outbursts that would escalate to the point where she would destroy household items. Susan also has had multiple periods of time where she experienced very low mood, loss of interest in activities, weight loss, challenges with sleep, and concentration difficulties. As a result, her academics suffered, and she was held back from starting high school. She successfully graduated high school two years later than planned.

Susan's previous treatment history includes visits to her family doctor at the beginning of high school. She was prescribed 20 mg of Escitalopram. Following this prescription, she was reported to have improved mood which at times seemed to be expansive. She continued to take this medication throughout high school and her early 20s. She stopped taking the medication about 3 years ago and she is no longer taking any prescribed medications.

On examination, Susan was distracted, casually but appropriately dressed, young woman appearing her stated age, who made poor eye contact. Her speech was normal with regards to rhythm and rate. She had no psychomotor slowing or agitation.