Clinical cases

Case 1
Gregory Baker was a 20-year-old African-American man who was brought to the emergency room
(ER) by the campus police of the university from which he had been suspended several months
earlier. The police had been called by a professor who reported that Mr. Baker had walked into his
classroom shouting, “I am the Joker, and I am looking for Batman.” When Mr. Baker refused to
leave the class, the professor contacted security.
Although Mr. Baker had much academic success as a teenager, his behavior had become
increasingly odd during the past year. He quit seeing his friends and spent most of his time lying
in bed staring at the ceiling. He lived with several family members but rarely spoke to any of them.
He had been suspended from college because of lack of attendance. His sister said that she had
recurrently seen him mumbling quietly to himself and noted that he would sometimes, at night,
stand on the roof of their home and wave his arms as if he were “conducting a symphony.” He
denied having any intention of jumping from the roof or having any thoughts of self-harm, but
claimed that he felt liberated and in tune with the music when he was on the roof. Although his
father and sister had tried to encourage him to see someone at the university‘s student health office,
Mr. Baker had never seen a psychiatrist and had no prior hospitalizations.
During the prior several months, Mr. Baker had become increasingly preoccupied with a female
friend, Anne, who lived down the street. While he insisted to his family that they were engaged,
Anne told Mr. Baker‘s sister that they had hardly ever spoken and certainly were not dating. Mr.
Baker‘s sister also reported that he had written many letters to Anne but never mailed them; instead,
they just accumulated on his desk.
His family said that they had never known him to use illicit substances or alcohol, and his
toxicology screen was negative. When asked about drug use, Mr. Baker appeared angry and did
not answer.
On examination in the ER, Mr. Baker was a well-groomed young man who was generally
uncooperative. He appeared constricted, guarded, inattentive, and preoccupied. He became
enraged when the ER staff brought him dinner. He loudly insisted that all of the hospital‘s food
was poisoned and that he would only drink a specific type of bottled water. He was noted to have
paranoid, grandiose, and romantic delusions. He appeared to be internally preoccupied, although
he denied hallucinations. Mr. Baker reported feeling “bad” but denied depression and had no
disturbance in his sleep or appetite. He was oriented and spoke articulately but refused formal
cognitive testing. His insight and judgment were deemed to be poor.
Mr. Baker‘s grandmother had died in a state psychiatric hospital, where she had lived for 30 years.
Her diagnosis was unknown. Mr. Baker‘s mother was reportedly “crazy.” She had abandoned the
family when Mr. Baker was young, and he was raised by his father and paternal grandmother.
Ultimately, Mr. Baker agreed to sign himself into the psychiatric unit, stating, “I don‘t mind staying
here. Anne will probably be there, so I can spend my time with her.”

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Case 2
Aidan Jones, a 30-year-old graduate student in English, visited a psychiatrist to discuss his
difficulty staying asleep. The trouble began 4 months earlier, when he started to wake up at 3:00
every morning, no matter when he went to bed, and then was unable to fall back to sleep. As a
result, he felt “out of it” during the day. This led him to feel increasingly worried about how he
was going to finish his doctoral dissertation when he was unable to concentrate owing to
exhaustion. At first he did not recall waking up with anything in particular on his mind. As the
trouble persisted, he found himself dreading the upcoming day and wondering how he would teach
his classes or focus on his writing if he was getting only a few hours of sleep. Some mornings he
lay awake in the dark next to his fiancée, who was sleeping soundly. On other mornings he would
cut his losses, rise from bed, and go very early to his office on campus.
After a month of interrupted sleep, Mr. Jones visited a physician‘s assistant at the university‘s
student health services, where he customarily got his medical care. (He suffered from asthma, for
which he occasionally took inhaled β2-adrenergic receptor agonists, and a year earlier he had had
mononucleosis.) The physician‘s assistant prescribed a sedative-hypnotic, which did not help.
“Falling asleep was never the problem,” Mr. Jones explained. Meanwhile, he heeded some of the
advice he read online. Although he felt reliant on coffee during the day, he never drank it after 2:00
P.M. An avid tennis player, he restricted his court time to the early morning. He did have a glass
or two of wine every night at dinner with his fiancée, however. “By dinnertime I start to worry
about whether I‘ll be able to sleep,” he said, “and, to be honest, the wine helps.”
The patient, a slender and fit-appearing young man looking very much the part of the young
academic in a tweed jacket and tortoise-rimmed glasses, was pleasant and open in his storytelling.
Mr. Jones did not appear tired but told the evaluating psychiatrist, “I made a point to see you in
the morning, before I hit the wall.” He did not look sad or on edge and was not sure if he had ever
felt depressed. But he was certain of the nagging, low-level anxiety that was currently oppressing
him. “This sleep problem has taken over,” he explained. “I‘m stressed about my work, and my
fiancée and I have been arguing. But it‘s all because I‘m so tired.”
Although this was his first visit to a psychiatrist, Mr. Jones spoke of a fulfilling 3-year
psychodynamic psychotherapy with a social worker while in college. “I was just looking to
understand myself better,” he explained, adding with a chuckle that as the son of a child
psychiatrist, he was accustomed to people assuming he was “crazy.” He recalled always being an
“easy sleeper” prior to his recent difficulties; as a child he was the first to fall asleep at slumber
parties, and as an adult he inspired the envy of his fiancée for the ease with which he could doze
off on an airplane.

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Case 3
Andrew Quinn, a 60-year-old businessman, returned to see his longtime psychiatrist 2 weeks after
the death of his 24-year-old son. The young man, who had struggled with major depression and
substance abuse, had been found surrounded by several emptied pill bottles and an incoherent
suicide note.
Mr. Quinn had been very close to his troubled son, and he immediately felt crushed, like his life
had lost its meaning. In the ensuing 2 weeks, he had constant images of his son and was “obsessed”
with how he might have prevented the substance abuse and suicide. He worried that he had been
a bad father and that he had spent too much time on his own career and too little time with his son.
He felt constantly sad, withdrew from his usual social life, and was unable to concentrate on his
work. Although he had never previously drunk more than a few glasses of wine per week, he
increased his alcohol intake to half a bottle of wine each night. At that time, his psychiatrist told
him that he was struggling with grief and that such a reaction was normal. They agreed to meet for
support and to assess the ongoing clinical situation.
Mr. Quinn returned to see his psychiatrist weekly. By the sixth week after the suicide, his
symptoms had worsened. Instead of thinking about what he might have done differently, he became
preoccupied that he should have been the one to die, not his young son. He continued to have
trouble falling asleep, but he also tended to awake at 4:30 A.M. and just stare at the ceiling, feeling
overwhelmed with fatigue, sadness, and feelings of worthlessness. These symptoms improved
during the day, but he also felt a persistent and uncharacteristic loss of self-confidence, sexual
interest, and enthusiasm. He asked his psychiatrist whether he still had normal grief or had a major
depression.
Mr. Quinn had a history of two prior major depressive episodes that improved with psychotherapy
and antidepressant medication, but no significant depressive episodes since his 30s. He denied a
history of alcohol or substance abuse. Both of his parents had been “depressive” but without
treatment. No one in the family had previously committed suicide.

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Case 4
Trevor Lewis, a 32-year-old single man living with his parents, was brought to his psychiatric
consultation by his mother. She noted that since adolescence he had been concerned with germs,
which led to long-standing hand-washing and showering rituals. During the prior 6 months, his
symptoms had markedly worsened. He had become preoccupied with being infected by HIV and
spent the day cleaning not only his body but all of his clothing and linen. He had begun to insist
that the family also wash their clothing and linen regularly, and this had led to the current
consultation.
Mr. Lewis had in the past received a selective serotonin reuptake inhibitor and cognitive-
behavioral therapy for his symptoms. These had had some positive effect, and he had been able to
complete high school successfully. Nevertheless, his symptoms had prevented him from
completing college or working outside the home; he had long felt that home was relatively germ-
free in comparison to the outside world. However, over the past 6 months he had increasingly
indicated that home, too, was contaminated, including with HIV.
At the time of presentation, Mr. Lewis had no other obsessive-compulsive and related disorder
symptoms such as sexual, religious, or other obsessions; appearance or acquisition preoccupations;
or body-focused repetitive behaviors. However, in the past he had also experienced obsessions
concerning harm to self and others, together with related checking compulsions (e.g., checking
that the stove was switched off). He had a childhood history of motor tics. During high school, he
found that marijuana reduced his anxiety. Referencing his social isolation, he denied having had
access to marijuana or any other psychoactive substance for at least a decade.
On mental status examination, Mr. Lewis appeared disheveled and unkempt. He was completely
convinced that HIV had contaminated his home and that his washing and cleaning were necessary
to stay uninfected. When challenged with the information that HIV was spread only by bodily
fluids, he answered that HIV might have come into the home via the sweat or saliva of visitors. In
any event, the virus might well be surviving on clothes or linen, and could enter his body via his
mouth, eyes, or other orifices. He added that his parents had tried to convince him that he was
excessively worried, but not only did he not believe them but his worries kept returning even when
he tried to think of something else. There was no evidence of hallucinations or of formal thought
disorder. He denied an intention to harm or kill himself or others. He was cognitively intact.

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Case 5
Eric Reynolds was a 56-year-old married Vietnam War veteran who referred himself to the
Veterans Affairs outpatient mental health clinic for a chief complaint of having “a short fuse” and
being “easily triggered.” Mr. Reynolds‘s symptoms began more than three decades earlier, soon
after he left the combat zone in Vietnam, where he served as a field radio operator. He had never
sought help for his symptoms, apparently because of his strong need to be independent. An early
retirement led to greater recognition of symptoms and a stronger desire to seek help.
Mr. Reynolds‘s symptoms included uncontrollable rage when unexpectedly startled; recurrent
intrusive thoughts and memories of death-related experiences; weekly vivid nightmares of combat
operations that led to nighttime fright and insomnia; isolation, vigilance, and anxiety; loss of
interest in hobbies that involve people; and excessive distractibility.
Although all of these symptoms were very distressing, Mr. Reynolds was most worried about his
uncontrollable aggression. Examples of his “hair-trigger temper” included confrontations with
drivers who cut him off, curses directed at strangers who stood too close in checkout lines, and
shifts into “attack mode” when coworkers inadvertently surprised him. Most recently, as he was
drifting off to sleep on his physician‘s examination table a nurse touched his foot and he leapt up,
cursing and threatening. His involuntary reaction scared the nurse as well as the patient.
Mr. Reynolds was raised in a loving family that struggled financially as midwestern farmers. At
age 20, Mr. Reynolds was drafted into the U.S. Army and deployed to Vietnam. He said he enjoyed
basic training and his first few weeks in Vietnam, until one of his comrades got killed. At that point,
all he cared about was getting his best friend and himself home alive, even if it meant killing others.
His personality changed, he said, from that of a happy-go-lucky farm boy to a terrified,
overprotective soldier.
Mr. Reynolds had tried marijuana during his early adulthood and used excessive alcohol
intermittently; however, he had not consumed excessive alcohol or used marijuana during the past
decade.
On examination, Mr. Reynolds was a well-groomed African American man who appeared anxious
and somewhat guarded. He was coherent and articulate. His speech was at a normal rate, but the
pace accelerated when he discussed disturbing content. He denied depression but was anxious. His
affect was somewhat constricted but appropriate to content. His thought process was coherent and
linear. He denied all suicidal and homicidal ideation. He had no psychotic symptoms, delusions,
or hallucinations. He had very good insight. He was well oriented and seemed to have above
average intelligence.

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Case 6
Valerie Gaspard was a 20-year-old single black woman who had recently immigrated to the United
States from West Africa with her family to do missionary work. She presented to her primary care
physician complaining of frequent headaches and chronic fatigue. Her physical examination was
unremarkable except that her weight was only 78 pounds and her height was 5 feet 1 inch, resulting
in a body mass index (BMI) of 14.7 kg/m2, and she had missed her last menstrual period. Unable
to find a medical explanation for Ms. Gaspard‘s symptoms, and feeling concerned about her
extremely low weight, the physician referred Ms. Gaspard to the hospital eating disorders program.
Upon presentation for psychiatric evaluation, Ms. Gaspard was cooperative and pleasant. She
expressed concern about her low weight and denied fear of weight gain or body image disturbance:
“I know I need to gain weight. I‘m too skinny,” she said. Ms. Gaspard reported that she had
weighed 97 pounds prior to moving to the United States and said she felt “embarrassed” when her
family members and even strangers told her she had grown too thin. Notably, everyone else in her
U.S.-dwelling extended family was either of normal weight or overweight.
Despite her apparent motivation to correct her malnutrition, Ms. Gaspard‘s dietary recall revealed
that she was consuming only 600 calories per day. The day before the evaluation, for example, she
had eaten only a small bowl of macaroni pasta, a plate of steamed broccoli, and a cup of black
beans. Her fluid intake was also quite limited, typically consisting of only two or three glasses of
water daily.
Ms. Gaspard provided multiple reasons for her poor intake. The first was lack of appetite: “My
brain doesn‘t even signal that I‘m hungry,” she said. “I have no desire to eat throughout the whole
day.” The second was postprandial bloating and nausea: “I just feel so uncomfortable after eating.”
The third was the limited choice of foods permitted by her religion, which advocates a vegetarian
diet. “My body is not really my own. It is a temple of God,” she explained. The fourth reason was
that her preferred sources of vegetarian protein (e.g., tofu, processed meat substitutes) were not
affordable within her meager budget. Ms. Gaspard had not completed high school and made very
little money working at a secretarial job at her church.
Ms. Gaspard denied any other symptoms of disordered eating, including binge eating, purging, or
other behaviors intended to promote weight loss. However, with regard to exercise, she reported
that she walked for approximately 3–4 hours per day. She denied that her activity was motivated
by a desire to burn calories. Instead, Ms. Gaspard stated that because she did not have a car and
disliked waiting for the bus, she traveled on foot to all work and leisure activities.
Ms. Gaspard reported no other notable psychiatric symptoms apart from her inadequate food intake
and excessive physical activity. She appeared euthymic and did not report any symptoms of
depression. She denied using alcohol or illicit drugs. She noted that her concentration was poor
but expressed hope that an herbal supplement she had just begun taking would improve her
memory. When queried about past treatment history, she reported that she had briefly seen a
dietitian about a year earlier when her family began “nagging” her about her low weight, but she
had not viewed the meetings as helpful.

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Case 7
Yasmine Isherwood, a 55-year-old married woman, had been in psychiatric treatment for 6 months
for an episode of major depression. She had responded well to a combination of psychotherapy
and medications (fluoxetine and bupropion), but she began to complain of weight gain. She was
at her “highest weight ever,” which was 140 pounds (her height was 5 feet 5 inches, so her BMI
was 23.3).
The psychiatrist embarked on a clarification of Ms. Isherwood‘s eating history, which was marked
by recurrent, distressing episodes of uncontrollable eating of large amounts of food. The overeating
was not new but seemed to have worsened while she was taking antidepressants. She reported that
the episodes occurred two or three times per week, usually between the time she arrived home
from work and the time her husband did so. These “eating jags” were notable for a sense that she
was out of control. She ate rapidly and alone, until uncomfortably full. She would then feel
depressed, tired, and disgusted with herself. She usually binged on healthy food but also had “sugar
binges” where she ate primarily sweets, especially ice cream and candy. She denied current or past
self-induced vomiting, fasting, or misuse of laxatives, diuretics, or weight-loss agents. She
reported exercising for an hour almost every day but denied being “addicted” to it. She did report
that in her late 20s, she had become a competitive runner. At that time, she had often run 10-
kilometer races and averaged about 35 miles per week, despite a lingering foot injury that
eventually forced her to shift to swimming, biking, and the elliptical machine.
Ms. Isherwood stated that she had binged on food “for as long as I can remember.” She was
“chunky” as a child but stayed at a normal weight throughout high school (120–125 pounds)
because she was so active. She denied a history of anorexia nervosa. At age 28, she reached her
lowest adult weight of 113 pounds. At that point, she felt “vital, healthy, and in control.”
In her mid-30s, she had a major depressive episode that lasted 2 years. She had a severely
depressed mood, did not talk, “closed down,” stayed in bed, was very fatigued, slept more than
usual, and was unable to function. This was one of the few times in her life that the binge eating
stopped and she lost weight. She denied a history of hypomanic or manic episodes. Although she
lived with frequent sadness, she denied other serious depressive episodes until the past year. She
denied a history of suicidal ideation, suicide attempts, and any significant use of alcohol, tobacco,
or illicit substances.
The evaluation revealed a well-nourished, well-developed female who was coherent and
cooperative. Her speech was fluent and not pressured. She had a mildly depressed mood but had a
reactive affect with appropriate smiles. She denied guilt, suicidality, and hopelessness. She said
her energy was normal except for post-binge fatigue. She denied psychosis and confusion. Her
cognition was normal. Her medical history was unremarkable, and physical examination and basic
laboratory test results provided by her internist were within normal limits.

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Case 8
Nancy Ingram, a 33-year-old stock analyst and married mother of two children, was brought to the
emergency room (ER) after 10 days of what her husband described as “another cycle of depression,”
marked by a hair-trigger temper, tearfulness, and almost no sleep. He noted that these “dark periods”
had gone on as long as he had known her but that she had experienced at least a half dozen of these
episodes in the prior year. He said they typically improved within a few weeks of restarting her
fluoxetine. He added that he wondered whether alcohol and clonazepam worsened her symptoms,
because she routinely ramped up their use when the dark periods began.
Ms. Ingram‘s husband said he had decided to bring her to the ER after he discovered that she had
recently created a blog entitled Ms. Ingram‘s Best Stock Picks. Such an activity not only was out
of character but, given her job as a stock analyst for a large investment bank, was strictly against
company policy. He said that she had been working on these stock picks around the clock, forgoing
her own meals as well as her responsibilities at work and with her children. She countered that she
was fine and that her blog would “make them as rich as Croesus.”
The patient had first been diagnosed with depression in college, after the death of her father from
suicide. He had been a wildly erratic, alcohol-abusing businessman whom the patient loved very
much. Her paternal grandmother had several “nervous breakdowns,” but her diagnosis and
treatment history were unknown. Since college, her mood had generally been “down,” interspersed
with recurrent bouts of enhanced dysphoria, insomnia, and uncharacteristically rapid speech and
hyperalertness. She had tried psychotherapy sporadically and taken a series of antidepressant
medications, but her husband noted that the baseline depression persisted and that the dark periods
were increasing in frequency.
Her outpatient psychiatrist noted that Ms. Ingram appeared to have dysthymia and a recurrent
major depression. He also said that he had never seen her during her periods of edginess and
insomnia—she always refused to see him until the “really down” periods improved—and that she
had refused him access to her husband or to any other source of collateral information. On
examination, the patient was pacing angrily in the exam room. She was dressed in jeans and a shirt
that was carelessly unbuttoned. Her eyes appeared glazed and unfocused. She responded to the
examiner‘s entrance by sitting down and explaining that this was all a miscommunication, that she
was fine and needed to get home immediately to tend to her business. Her speech was rapid,
pressured, and very difficult to interrupt. She admitted to not sleeping but denied that it was a
problem. She denied hallucinations but admitted, with a smile, to a unique ability to predict the
stock market. She refused cognitive testing, saying she would decline the opportunity to be a
“trained seal, a guinea pig, Mr. Ed, and a barking dog, thank you very much, and may I leave now?”
Her insight into her situation appeared poor, and her judgment was deemed to be impaired.

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Case 9
Ike Crocker was a 32-year-old man referred for a mental health evaluation by the human resources
department of a large construction business that had been his employer for 2 weeks. At his initial
job interview, Mr. Crocker presented as very motivated and provided two carpentry school
certifications that indicated a high level of skill and training. Since his employment began, his
supervisors had noted frequent arguments, absenteeism, poor workmanship, and multiple errors
that might have been dangerous. When confronted, he was reportedly dismissive, indicating that
the problem was “cheap wood” and “bad management” and added that if someone got hurt, “it‘s
because of their own stupidity.”
When the head of human resources met with him to discuss termination, Mr. Crocker quickly
pointed out that he had both attention-deficit/hyperactivity disorder (ADHD) and bipolar disorder.
He said that if not granted an accommodation under the Americans with Disabilities Act, he would
sue. He demanded a psychiatric evaluation.
During the mental health evaluation, Mr. Crocker focused on unfairness at the company and on
how he was “a hell of a better carpenter than anyone there could ever be.” He claimed that his two
marriages had ended because of jealousy. He said that his wives were “always thinking I was with
other women,” which is why “they both lied to judges and got restraining orders saying I‘d hit
them.” As “payback for the jail time,” he refused to pay child support for his two children. He had
no interest in seeing either of his two boys because they were “little liars” like their mothers.
Mr. Crocker said he “must have been smart” because he had been able to make Cs in school despite
showing up only half the time. He spent time in juvenile hall at age 14 for stealing “kid stuff, like
tennis shoes and wallets that were practically empty.” He left school at age 15 after being “framed
for stealing a car” by his principal. Mr. Crocker pointed out these historical facts as evidence that
he was able to overcome injustice and adversity.
In regard to substance use, Mr. Crocker said he smoked marijuana as a teenager and started
drinking alcohol on a “regular basis” after he first got married at age 22. He denied that use of
either substance was a problem.
On mental status examination, Mr. Crocker was a casually dressed white man who made
reasonable eye contact and was without abnormal movements. His speech was coherent, goal-
directed, and of normal rate. There was no evidence of any thought disorder or hallucinations. He
was preoccupied with blaming others, but these comments appeared to represent overvalued ideas
rather than delusions. He was cognitively intact. His insight into his situation was poor.
The head of human resources did a background check during the course of the psychiatric
evaluation. Phone calls revealed that Mr. Crocker had been expelled from two carpentry training
programs and that both his graduation certificates had been falsified. He had been fired from his
job at one local construction company after a fistfight with his supervisor and from another job
after abruptly leaving a job site. A quick review of their records indicated that he had provided
them with the same false documentation.