There are two case studies available to you in the Course Material section. Please access these and begin your work for this week. Please remember:
a. The case studies are from the readings for this week concerning substance abuse and anxiety disorders. (Don’t try to take on the other hundreds of disorders in DSM. We’re breaking it down!)
b. The case studies do not involve personality disorders. These are more intractable and serious disorders even though the material may make them look relevant. We’ll consider these categories by themselves.
c. Each case study involves only one primary diagnosis. As I mentioned elsewhere, in real life a person can have more than one disorder. For our purposes I have chosen case studies that involve only one disorder each.
d. Be sure to justify your diagnosis. Please note which DSM symptoms are evident in the case study that lead to your conclusions.
e. Add qualifiers such as severity, duration of symptoms, etc. as is appropriate. Also information concerning psychosocial stressors (what the client is going through now such as job loss, family disruptions, etc) and any relevant medical information such as medications or physician indicated medical diagnoses.
For each one you will need to give a complete diagnosis and your rationale for this diagnosis. Both case studies are related to this week’s readings regarding Substance Abuse and Anxiety Disorders, so don’t look at other categories, especially NOT personality disorders. Also, while clients in real life may indeed have more than one diagnosis, for our purposes, there is only one–so don’t try to list every possible diagnosis. You will need to narrow your choice by identifying the diagnosis that most closely matches the DSM criteria. Furthermore the complexity personality disorders is something we will consider in depth before you attempt to utilize this information. Be sure to include as much detail in your diagnosis as possible remembering that while we no longer use the multiaxial system, some of that information such as severity, etc. still needs to be included in the diagnosis.

A Man on the Verge of a “Nervous Breakdown”

            Mr. Y, a 30-year-old married real estate investment company owner, goes to a local outpatient psychiatric clinic saying that he “is on the verge of a nervous breakdown.”  He reports that he has always been a worrier but not to the extent that his life was affected in any noticeable way.  However, over the past year he has been experiencing “tweaked” feelings of inner agitation and “stays keyed up” most of the time.  Mr. Y has frequently complained of stomach upsets and diarrhea over the past 6 months as well as a decreased ability to concentrate at work.  His wife, an attractive and well-educated woman in her mid 20’s, accompanies her husband to the clinic and says that he tosses and turn in bed until about 2 or 3 am and frequently gets up to urinate.  She goes on to complain that her husband has gotten very irritable in the past 6—8 months and frequently yells at people, even at their 5-year-old daughter.

The oldest and only male in a family of four children, Mr. Y is from an affluent and well-educated family steeped in tradition.  His father, grandfather, and several other men in the family attended the same northeastern Ivy League university.  Mr. Y felt compelled to continue this tradition, but he was apprehensive that his academic skills were not refined enough, although he was in the 90th percentile of his graduating class.  Once he was accepted to this prestigious university, he began to feel the pressure to perform exceedingly well.  Despite experiencing tremendous anxiety and tension around exam time, Mr. Y graduated from the university with distinction.  While in college, Mr. Y began dating his wife and recalls that he would worry for days about whether he had picked the right restaurant for the date, whether he had selected the right flowers, or whether his car, which had recently undergone a minor repair, would break down on the date.  He notes that although he worried a lot about something or other not working right, he never had difficulty asking women out on dates or having them accept.  He describes himself as driven and generally on the extroverted side.

Three years before the current evaluation, Mr. Y’s parents separated and his real estate investment company came close to bankruptcy.  Although he has been successful at gradually rebuilding the company over the ensuing years and “getting his feet back on the ground,” he has been unable to suppress his nervousness and tension.  At night, he lies awake staring at the ceiling and worrying about routine work issues, what the future holds for him, and how he would support himself and his family if his company went bankrupt.  It makes him sick to his stomach to think about losing his business and not having health insurance to cover the allergy shots his daughter needs.  Mr. Y went to see an internist and a gastroenterologist, but his exams were normal and his symptoms were thought to be “anxiety related.”  He calms himself down occasionally with a beer or two but denies any alcohol-related problems.  He tried cocaine a couple of times in his early 20’s but did not like the feeling and denies using any other street drugs. He feels sad but denies feelings of worthlessness or suicidal thoughts.

Case Study:  Nancy

 Nancy is a 43-year-old single woman who did not drink much in her early adult life and had no strong family history of drinking. Nancy’s drinking slowly escalated in her 20s. As a hostess in a restaurant, she was surrounded by alcohol, and she began drinking more frequently, making excuses about why she should drink. Nancy also described her drinking as a way to “numb the pain” and sadness she had long felt over the early death of her younger sister and later the untimely death of her older sister. This depression pervaded Nancy’s daily life, and consequently she often drank alone and used alcohol to help her sleep at night.

Soon Nancy was drinking almost a quart of vodka daily, she no longer was working, and her drinking was sabotaging her marriage. Her husband filed a restraining order, which she violated. Ultimately, she was arrested three times for this and other alcohol-related violations. Nancy’s use of alcohol had become so profound that she drank to avoid the shaking she experienced when she wasn’t drinking. About three years ago, Nancy’s primary care doctor prescribed an antidepressant for Nancy, which she used inconsistently. She also briefly tried Alcoholics Anonymous but admitted she was not ready to stop drinking. Her husband later divorced her, and her children distanced themselves from her.

Nancy entered rehabilitation over two years ago, but still she was not ready to quit drinking. She had been given acamprosate after this first detoxification, but she took the medication only once in a while and did not follow through with outpatient counseling or 12-Step therapy. She resumed drinking heavily, and a short time later tried to stop drinking on her own. Her abrupt abstinence resulted in a seizure that left her unconscious for five days. After her recovery, she resumed drinking again, went to rehabilitation for a second time, and made little progress.

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