Case 18.

9
Lack of Self-Confidence

Nate Irvin was a 31-years-old white man who sought outpatient psychiatric services for
“lack of self-confidence”. He reported lifelong troubles with assertiveness and was specifically
upset by having been “stuck” for 2 years at his current “dead-end” job as an administrative
assistant. He wished someone would tell him where to go next so that he would not have to
face the “burden” of decision. At work, he found it easy to follow his boss’s directions but had
difficulty making even minor independent decisions. The situation was “depressing”, he said,
but nothing new.
Mr. Irvin also reported dissatisfaction with his relationships with women. He described
a series of several-month-long relationships over the prior 10 years that ended despite his doing
“everything I cloud”. His most recent relationship had benn with an opera singer. He reported
having gone to several operas and taken singing classes to impress her, even though he did not
particularly enjoy music. That relationship had recently ended for unclear reasons. He said his
mood and self-confidence were tied to his dating. Being single made him feel desperate, but
desperation made it even harder to get a girlfriend. He said he felt trapped by that spiral. Since
the latest breakup, he had been quite sad, with frequent crying spells. It was this depression
that had prompted him to seek treatment. He denied all other symptoms of depression,
including problems with sleep, appetite, energy, suicidality and ability to enjoy things.
Mr. Irvin initially denied taking any medications, but he eventually revealed that 1 year
earlier his primary care physician had begun to prescribe alprazolam 0,5 mg/day for “anxiety”.
His dose had escalated and at the time of the evaluation, Mr. Irvin was taking 5 mg/day and
getting prescriptions from three different physicians. Cutting back led to anxiety and “the
shakes”.
Mr. Irvin denied any prior personal or family psychiatric history, including outpatient
psychiatric appointments.
After hearing this history, the psychiatrist was concerned about Mr. Irvin’s escalating
alprazolam use and his chronis difficulties with independence. She thought the most accurate
diagnosis was benzodiazepine use disorder comorbid with a personality disorder. However,
she was concerned about the negative unintended effects that these diagnoses might have on
the patient, including his employment and insurance coverage, as well as how he would be
dealt with by future clinicians. She typed into the electronic medical record a diagnosis of
“adjustment disorder with depressed mood”. Two weeks later, Mr. Irvin’s insurance company
asked her his diagnosis and she gave the same diagnosis.

Diagnoses
- Dependent personality disorder
- Benzodiazepine use disorder

Discussion
Mr. Irvin has and excessive need for someone to take care of him and make decisions
for him. He has difficulty making decisions independently and wishes that others would make
them for him. He lacks the confidence to initiate projects or do things on his own, he generally
feelsuncomfortable being alone and he is reluctant to disagree on even minor matters. He goes
to almost desperate lengths to seek and maintain relationships and to obtain support and
nurturing from others.
Mr. Irvin, therefore, meets at least six of the eight DSM-5 criteria (only five are
required) for dependent personality disorder. To meet the criteria for the diagnosis, these
patterns must also fit the general criteria for the diagnosis, these patterns must also fit the
general criteria for a personality disorder (i.e., the symptoms must differ from cultural
expectations and be enduring, inflexible, pervasive and associated with distress and/or
impairment in functioning). Mr. Irvin’s symptoms meet this standard. Furthermore, his
symptoms are persistent and debilitating and lie outside the normal expectations for a healthy
adult man of his age.
Many psychiatric diagnoses can intensify dependent personality traits or be comorbid
with dependent personality disorder. In this patient, it is especially important to consider a
mood disorder, because he presents with “depression” that has recently worsened. Some
patients with mood disorders can present with symptoms that mimic personality disorders, so
if this patient is in the midst of a major depressive episode, his dependent symptoms may be
confined to that episode. Mr. Irvin, however, denies other symptoms of depression and does
not meet criteria for any of the depressive disorders.
Notably, Mr. Irvin is using alprazolam. He has been taking the medication in increasing
amounts over a longer period of time that was intented. To obtain an adequate supply, he gets
prescriptions from three different physicians. He has developed tolerance (resulting in dose
escalation) and withdrawal (as demonstrated by anxiety and shakes). Assuming that futher
exploration would confirm clinically significant impairment or distress, Mr. Irvin meets criteria
for a benzodiazepine use disorder. Given his history of use and his tendency not to be entirely
transparent, it would be especially important to tactfully explore the possibility that he is using
other substances, including alcohol, tobacco, illicit drugs and prescription drugs such as
opioids.
The psychiatrist in this case faces a conflict common in clinical practice.
Documentation of patients’ diagnoses in clinical charts and their release to third parties can
sometimes have downstream effects on patients’ insurance coverage or disability status and
can lead to stigmatization, both within and outside the health care system. Given this reality,
psychiatrists can be tempted to record only the least severe of several diagnoses, or sometimes
to report inaccurate but presumably less pejorative disorders. In this case, the psychiatrist does
both. Although the patient has depressed mood, he does not meet creteria for the adjustment
disorder that is recorded by his psychiatrist. He does, however, appear to meet criteria for both
dependent personality disorder and benzodiazepine use disorder, but neither of these more
serious and potentially more stigmatizing diagnoses is included in the chart or disclosed to the
insurer.
When diagnoses are inaccurately recorded in medical charts, ostensibly for the purpose
of protecting patients, this may end up causing harm instead. Subsequent clinicians who review
the records may lack critical information regarding patients’ presentation and treatment. For
example, if Mr. Irvin were to urgently call for a prescription of benzodiazepines, a covering
psychiatrist might have no way of knowing from the patient’s chart about either the pattern of
benzodiazepine abuse or the physiological dependence. As a physician who intends to “do no
harm”, Mr. Irvin’s psychiatrist has tried to shield him from stigma but has instead exposed him
to medical risk.
The psysician has other responsibilities beyond those to the patient. When the psysician
and the patient agree to accept payment from an insurer, the physician may be obligated to
provide to insurers and governmental agencies a reansonable amount of honest clinical
information. Lack of disclosure is tantamount to fraud and can be prosecuted. In addition,
althought being part of the medical profession afford many privileges, it also involves
responsibilities. Diagnostic deceit may seem like an innocuous effort to protect the patient, but
the dishonesty negatively affect the reputation of the entire profession, a reputation that is
integral to the ability to render treatment to future patients.