C6432 Cases for Weekly Diagnosis Exercise Diagnosis of Cases Online Postings – 6 sets of 5 cases for posting worth 5 points each for a total of 30 points. Beginning the second week of class you are to make a 6 online contacts with your classmates in which you give an Axis 1 initial tentative diagnosis (with the page # of DSM-IV-TR where it is located) on the five case studies provided you for that specific week. You must first identify relevant symptoms, which lead you to your initial tentative diagnosis. You must also list what diagnoses you will need to rule out as you continue to work with this client. You must also provide a tentative treatment plan utilizing empirically based treatments, which would include if referring to a psychiatrist for medication. I will post an idealized response table a few hours after all students have met the deadline for posting their responses. Then it is my hope we will stimulate discussion about these five cases amongst the class to help clarify the diagnostic thinking and process involved in such cases. The Table on which you fill in your response and email back in your email posting is below: Week # : Case Study Diagnostic Exercise Table of Responses Case # – Name of Case: Relevant Symptoms: DSM-IV-TR Axis I Diagnosis with Page #: Diagnostic Rule Outs: Tentative Treatment Plan: Case # - Name of Case Relevant Symptoms: DSM-IV-TR Axis I Diagnosis with Page #: Diagnostic Rule Outs: Tentative Treatment Plan: Case # - Name of Case Relevant Symptoms: DSM-IV-TR Axis I Diagnosis with Page #: Diagnostic Rule Outs: Tentative Treatment Plan: Case # - Name of Case Relevant Symptoms: DSM-IV-TR Axis I Diagnosis with Page #: Diagnostic Rule Outs: Tentative Treatment Plan: Case # - Name of Case Relevant Symptoms: DSM-IV-TR Axis I Diagnosis with Page #: Diagnostic Rule Outs: Tentative Treatment Plan: Set 1 1. Tommy 2. George 3. Antonio 4. Angelica 5. Robin Set 2 6. Suzette 7. Richele 8. Rosie 9. Gloria 10. Juan Set 3 11. Arthur 12. Joel 13. Fantasia 14. Harriet 15. Joseph Set 4 16. Luis 17. David 18. Jaime 19. Arnold 20. Emanuel Set 5 21. Connie 22. Mrs. Brown 23. Gladys 24. Kristina 25. Gerald Set 6 26. Josh 27.Ronald 28.Samantha 29. Robert 30. Mary Beth Set 1: Cases 1-5 CASE 1 - Tommy Tommy has been referred to you by a school psychologist. Information concerning Tommy can be requested from his file. Neurological exam revealed impaired balance and fine motor control. Tommy was born in the breech position. At age three he had 20 stitches in his chin after a fall. Physical stature is more like an 11-year-old than an 8-year-old. The 90% confidence band for the WISC-R is 120-130. Developmental milestones were generally advanced. Currently he is barely maintaining passing grades--appears to have more potential. He was able to read at age four while in Montessori school. His 2nd grade teacher says he's always in a fog--unable to listen. He does not finish classroom assignments unless teacher prods him. He spends much of his time drawing pictures in class. He has wandered away from home without supervision. He is not well liked by classmates -- tends to boss them. He has occasional arguments at home about his cluttered room. He knows he is smarter than his grades indicate. He has good eye-contact when talking with adults. He is generally warm and cuddly with parents. Parents report that he is disobedient occasionally. He tends to be unpopular with peers -- picked last for games. Often he will just blurt out comments in class without thinking. He gets frustrated when requested to finish an assignment. He seems to hear every small sound in the classroom. He generally is easy going. He doesn't get into many fights. His physical size makes him stand out among his peers. His wandering has decreased since parents built high fence around house. His Mom reports that he has always been trouble. She reported him to be an irritable infant with poor eating habits. His parents say they have tried everything over past six years. CASE 2 - George (T) Hello, Mr. and Mrs. Bramble. I hear that you are concerned about your son. (Mom) Yes, George is just about three and a half now and he just doesn't seem to be doing well. (Dad) Well, we're very worried because he's not really talking yet. He just seems to be in a world of his own and doesn't pay attention to us. He never says hi to me when I get home from work and he has no interest in playing with his younger brother. (T) I see. Is there anything else about his language that seems unusual to you? (M) George has this habit of just repeating things that we say. Our other boy (Jeb) doesn't do these things. George didn't seem so different until we saw how well Jeb learned to talk. (T) From the way you describe George's behavior it sounds like it must be frustrating trying to be good parents. (D) Boy! You hit the nail right on the head. Sometimes we feel like we are talking to a blank wall. It's funny but George seems so cold and aloof. We're scared. What do you think is the problem? What can we do? (T) Well, before we proceed it will be necessary to first get some more information about George. After this is done we'll have a better idea about what is happening with George. Background George (a first born child) had a difficult birth with anoxia. Audiometric evaluation indicates normal hearing bilaterally. George is at the 55th %ile for height and 45th %ile for weight. Neurological examination was unremarkable. Passed non-language 3-year-old tasks on Stanford-Binet but failed all verbal tasks. Receptive and expressive language estimated to be at 18 months. Babbles and repeats words and phases inappropriately. Indicates he is thirsty by asking...'Do you want a drink?' Often sits watching bright lights and spinning objects. Flaps his hands and stands on tiptoes when listening to music. He screams uncontrollably when routine is disrupted. He spends his day placing kitchen utensils on the floor. He seems stiff and tight when his parents try to hug him. George does not play with his brother Jeb. Violent tantrums occur when left with a babysitter. George is reported to stiffen when hugged as an infant. Parents say he did not play 'baby games' when a few months old. George has bitten his parents when they tried to retrieve kitchen utensils. He does not maintain eye contact when spoken to. George mimics the intonation in others' speech. He seems cold..distant..aloof. George rarely cries or shows any signs of fear reaction. He usually responds in a ritualistic and rigid manner. George’s parents seem to be supportive and concerned. George’s younger brother Jeb (age 2) already is speaking in sentences. Mother has not returned to work because she needs to take care of George. George's grandparents show favoritism for Jeb. Parents were first concerned when George was four months old. Language and social delays have been chronic. George’s behavior is tolerable if parents do not change his routine. His parents feel that George is falling further behind all the time. CASE 3 - Antonio Background Information (T) Antonio, I think you know why we are meeting today. (C) Well, she had it coming to her just like all those bitches. (T) Since you came to this School two years ago, we have talked many times about how your feelings towards women are just getting you into trouble. (C) So what! Who gives a damn about women anyway? If they knew what a hunk I was, they would run to me -- Besides she had it coming anyway. She's been teasing me ever since I got here. (T) I need to know if you have any other weapons before you can return to your room. (C) Look, don't bug me or you'll get the same treatment. (Antonio pushes the counselor away and runs to his room). Antonio is of average height and weight. Antonio has had numerous stitches to close knife wounds. Repeated alcohol and drug use is known to occur. Antonio has been seen by no fewer that five counselors since age six. WISC-R test scores: Verbal IQ = 85, Performance IQ = 110. Memory and reasoning are within normal limits. Consistently engages in denial of his problems. Obsessed with thoughts of sexuality. Antonio is tactilely defensive. He reacts violently if touched. He reports sleeping seven hours each night. He lifts weights regularly so as to 'protect himself.' He speaks in a soft voice purposely avoiding any eye contact. He was placed in this residential school by the state because he was incorrigible. His school records indicate he has been suspended 10 times for fighting. He reports that he hates his parents and curses at teachers. Antonio was just caught forcing a female staff member to undress at knife point. He physically hurt family pets when seven. In the past he has 'Stonewalled it' to protect members of his gang from trouble. He is extremely distrustful of adults. He almost daily fights with school staff. He finds it difficult to accept help from the school staff. He continues to deny the car thefts that precipitated entry in school. He is typically described by the staff as having a 'Chip on his shoulder'. Explosively strikes out at others. School psychologist considered SED placement for Antonio in fourth grade. Antonio’s older brother is serving a prison term for armed robbery. He faces expulsion from school for attempted rape of a staff member. He has not been visited by his mother during the past two years. Antonio came to this state sponsored school at age 14 and he Is now 16. He was caught joy riding in a stolen car when 13. He destroyed toys and broke some lights while in kindergarten. His violent outbursts have increased during past three months. CASE 4 - Angelica Angelica your client tells you: Well, I guess that I am just not adjusting to school here as much as I thought I would. My parents were probably right. They said that I should stay closer to home.” You ask: “What makes you say that Angelica?” She says: “Probably because I've gotten myself into such a mess!” You say: “You mean all that stuff with your boyfriend.” She says: “Yeah, I guess so.” You say: “What's this 'I guess so.' Is there something else?” Angelica says: “No. (pause) I know he's not going to college and probably I'll never marry him but he's got money as he works. I like that part of him. He's stable and we do lots of neat things together. We have lots of fun.” You say: “I hear some hesitation in your voice. What's that all about?” Angelica answers: “I don't know. I guess when he hit me I just felt like I deserved it. You know he was so sorry afterwards. But that seems to be how I often feel. You know...sorry afterwards.” You then say: “You know, I can't help but notice that you have something else on your mind. Can you tell me?” She says: “ I guess I should...” You find out the following information: She sees a doctor often for acne troubles. She has chronic asthma. She appears healthy. At times she complains of feeling weak. She is bright and loves to talk. She graduated from high school with a 3.95 GPA. She displays no bizarre thoughts besides an active imagination. Sometimes she forgets parties or events with friends. She will often not look at you when you confront her. She will often eat junk food at night when she is upset. Sometimes after eating what she considers is too much she will vomit. When she eats in binges she avoids letting others know. Her parents are not happy with her being so far from home. She wants to move out of boyfriend's home but never seems to do so. He sometimes hits her. She does not like herself after she eats too much. She does not have enough money so has to work two jobs. She allows others to control her. She is very critical of herself and others. She doesn't like to confront people. She alternates between acting on impulse and being passive. She swings mildly from being slightly depressed to being ok. She seems happiest when home with her parents and family. She can't seem to pass a fast food place without stopping. Her family lives 2000 miles away. Current living situation with boyfriend is unacceptable to her. She has few new friends at the university. She has no time for outside interest. She began overeating when in high school (5 years ago). She began purging when she entered college. She has lived with her boyfriend for 4 months. She has attended college for 6 months. CASE 5 – Robin Robin and her friend Bart have arrived in your office. Robin is in her early 20's and appears quite normal. When you ask her to step into your office she makes the request that Bart comes with her. When you ask if Bart has anything to do with her needing to come to see you, Robin says 'no'. This gets you curious so you decide to ask Robin to come in alone for at least a few minutes. You find out that.... Robin was involved in family counseling when around 7 years old when her mother and father divorced. Robin has frequent asthma attacks for which she sees a doctor. Robin has a slight limp from when a cow fell on her. Robin is currently training to be a clown in the circus. She has had to forgo her training due to her problem. Robin seems to allow fearful thoughts into consciousness rather easily. Robin reports no bizarre thoughts. Robin at times can suddenly lose control of her thoughts and become fearful. When Robin entered your office she started trembling. Robin asked that you leave the door open when she went into your office. Robin avoids any public place unless accompanied by a friend. Robin will start to breath rapidly and sometimes will faint when in a crowd. Public places make Robin panic. Robin wants to feel loved by her parents. They both seldom talk to her. Robin wants to be a circus clown but nobody takes this seriously. Robin likes to make others laugh and is good at it. Robin prefers being with one or two people than at a party. Robin is able to talk quite freely about her feelings to you. Robin reports some feelings of depression lately. Robin often will suddenly get up and check the doors and windows to make sure that they are not locked. There is no indication of suicidal thoughts. Robin comes from a large family of 14 brothers and sisters. Robin was raised in a farming town until the age of 7 when she moved to a big city. Robin loves Bart a lot. They are to be married soon. These symptoms started appearing when Robin was around 18 years old. Robin has not wanted to leave her house for about 6 months now. Bart and Robin started living together 8 months ago. Set 2: Cases 6-10 CASE 6 - Suzette Your agency has recently hired a new counselor who worked previously at a hospital across the country. During a staff consultation session you find out that four years ago she saw a client (Suzette) at her hospital that you have just started with last week. She saw this client (Suzette) for stress due to terminal cancer and you are seeing her on the advice of a physician concerning bleeding ulcers. You have decided to ask the new counselor questions about your client. Her answers are as follow. To my knowledge she underwent 3 operations to remove intestinal cancers while at the hospital. She was 31 years old when I last saw her. They were unable to trace the cancer. She left the hospital against the doctor's advice. She also reported violent headaches related to a possible brain tumor. She was very alert and knew quite a bit about her problems. She was not paranoid and did not have any psychotic symptoms. She was great at debating current political event. Few patients matched her on computer games. She liked being in the hospital but seemed to really want to be cured. Often she would talk quickly and get excited about her illness. She did not have a job as she was in the hospital so often. She did not like to take showers. She was afraid of being alone- preferred company. Nurses were always on her case for being so dirty. She was unable to work and had no family support. She refused to be treated by female doctors. She was slightly abrasive. She seemed to have few friends. She was demanding of attention. She had a way of getting you to do what she wanted. She was sometimes excitable. She was demanding and slightly impulsive. She didn't seem to care about herself. If she doesn't get her way....watch out! She revealed that she was raped by her physician when 15 years old. She was a pre-med major in college but was not accepted at medical school. Her mother and father have decided to not see her anymore. I think her rejection from all medical schools really affected her. She started reporting physical problems around the age of 21. Her symptoms varied in length of duration. She disappeared when a doctor had no other solutions to try. I have a feeling she will be here for as long as she can. CASE 7 - Richele An 18 year old female high-school student who will not speak and is not eating is referred to you by a nearby hospital. She is disheveled and has very little movement. Her mother is concerned because her daughter will not respond to her. (Mother) I just don't understand what is happening. She was to enter college next year and we had so many plans. You know, she was going to be a Doctor.... (You) (Interrupting) Can you tell... (Mother) (Interrupting) She was thinking about becoming a Psychiatrist, but you must understand that we hadn't made a final decision yet. My, what a bright girl she is, but lately... What is wrong! Please tell me! You find out that: She has no drug use history. She was admitted to hospital 3 days ago as she had not eaten for 10 days. Her grandmother was committed to a mental hospital for most of her life. Her mother was admitted once to a hospital for what she called a 'breakdown'. An 'A' student until 1 year ago. Now failing. Behavioral descriptions: Spoke of spirits and the devil talking to her when last talked. Often she is incoherent with marked loosening of associations and illogical thinking. Currently she seems to have no interest to talk. She does not move but allows others to move her. She stares into space most of the time. She had never been active in sports. She has stopped cleaning herself entirely. Her mother often blames her for her husband leaving. There is little money in the family. She was raised to be afraid of men. Currently she does not relate at all to others. One year ago she was seemingly normal (a little on the shy side). She has never made any close friendships. She seems to have no affect--a flat affect. Junior high teacher reports unwillingness to attend school dances. Did not participate in extracurricular activities in high school. Even when young she seemed to swallow her feelings She seemed to be a normal child until a little over 1 year ago. Family history of mental hospital commitments. Father abandoned the family when she was nine years old. Mother does not work and has little money. Over 1 year from first signs of change in her. 6 months of more severe changes such as refusing to go to school. 1 month of hearing voices. 1 week of not eating or moving. CASE 8 - Rosie Rosie is an elderly woman and is presently sitting across from you. She is dressed nicely and is patiently waiting for you to speak. She has only told you that her husband wanted her to come in to see you. Her medical doctor has run a complete laboratory exam and found nothing of importance. A CAT scan reveals that the brain is atrophied. Rosie’s mother had Alzheimer's disease. Rosie is 73 years old. Rosie is absent-minded. She has had no bizarre thoughts. Rosie rationalizes away her forgetfulness. Rosie’s judgment seems impaired as she has thrown away valuables. Rosie interprets proverbs concretely. She has no focal neurological signs. Rosie is friendly but less social lately. Rosie often asks you to repeat questions. She often leaves water running and the stove on all day. Her husband Charlie and Rosie fight about her forgetfulness. No physical harm is done. Rosie’s son has been trying to get her committed to a care home. Charlie has begun to give up on her. Charlie can not afford to send Rosie to a nice nursing home. She does not have the sparkle she used to have. She is shyer now. She sometimes forgets who people are which causes embarrassing situations. She is slightly subdued lately. She sometimes says the strangest things to strangers. Occasionally she will become irate but she is not depressed. Usually she is subdued. She recently was found shopping at 2 am for bananas. She does not seem to laugh much lately. Her husband is partially disabled with a bad back. Rosie and Charlie have lived in the same comfortable suburban home for 20 years. Their children all live out of town. Charlie noticed a slight absent-mindedness about 4 years ago. She has progressively become more absent-minded over last 4 years. Her judgment has been impaired for the last year. She has forgotten names of family members for the last 6 months. CASE 9 - Gloria Gloria, your client across from you is in her mid 40's and is very neatly dressed. You notice that Gloria is on the thin side and shakes slightly. You ask her: What can I do for you?”. Gloria says: “Well, my minister thought I might speak to you. Actually he recommended someone else but he was too busy. So I called you as you seem to have more time free. Do you believe in Jesus? You respond: “Is it important to you that I am a Christian counselor?” Gloria says: “No. It depends on your beliefs. Our church says that if you drink it is because of the devil. Do you believe in the devil?” Gloria has been involved in three major accidents in the last 5 years. Gloria managed to recover in good health from each one. Her doctor advised her that continued use of alcohol would ruin her health. Gloria saw a psychologist for several years when Gloria divorced her first husband. Gloria has reported some mild hallucinations during the last several days. Gloria seems of normal intelligence and had no trouble following your conversation. Gloria rambles on and on at times. Gloria has fits of tremors in her hands and eyelids. Gloria vomited in your waiting room but you have not found this out yet. Gloria complains of a bad headache. She says her sleep is very fitful. Her current religious leader has insisted that Gloria fast to get rid of her urges for alcohol. Her husband will not attend church services with her. Gloria can't reconcile her drinking with her religious beliefs. Gloria is a follower of others. Gloria will usually never say “no” even to herself. Gloria is big with denial. Sometimes Gloria is slightly depressed. Gloria is not usually irritable but lately has been. Gloria is a heavy drinker of alcoholic beverages. Her friend all drink rather heavily. Her parents were alcoholics. Her present symptoms have been present off and on for 4 days. Gloria told her minister that Gloria stopped drinking 4 days ago but Gloria started again and did not stop until yesterday. Gloria reports that she has been drinking alcohol for her 'whole life.' CASE 10 - Juan You have been volunteering some of your time at a local rehabilitation clinic for disabled persons. The man across from you today is Juan. He looks tired and begins by talking about how his boss really gets on his nerves. You encourage him but soon the discussion turns to other issues and seems to dwindle. Juan seems to lose interest in being at the clinic and says that he probably needs to go home now. After he leaves you find yourself wondering if you have missed something as nothing seemed to be accomplished by Juan's visit. Is Juan someone who often falls through the cracks of counseling? Juan is 27 years old and lost his leg in an automobile accident 8 years ago. Juan's leg was amputated above the knee. His operation was fairly straightforward with no complications. Juan saw a psychologist for two years after the accident. Currently Juan smokes marijuana but takes no other drugs. Juan's boss at the firm he works for indicates that Juan makes too many mistakes and he might fire him. Juan's attention sometimes wanders while you speak to him. Juan reports occasional thoughts of death. Juan has no bizarre thoughts. Juan is socially withdrawn and does not talk much. Sometimes Juan will develop tears for apparently little reason. Juan reports a difficulty in sleeping enough. Juan also reports that he is always tired. Juan's career as an athlete ended with the auto accident. Juan still lives with his parents although he would like to move out. Juan has allowed himself to become overweight. Juan would like to meet a woman who would marry him but he is afraid to even try to find someone. Juan is friendly but shy. Juan will usually look for something negative about himself in what other people say. If someone praises Juan he feels that they pity him. Juan is often down or 'blue'. Juan seems to have lost interest in much of what he does. Juan is not at all impulsive. Juan lost his leg in an auto accident when 18 years old. Juan's parents did not have adequate insurance coverage and are still paying off the hospital bills. Juan has frequent arguments with his parents. Juan has been 'low' for about 4 years. Occasionally Juan feels normal for a few weeks at a time. Set 3: Cases 11-15 CASE 11 - Arthur This client is male, in his 40's, and a lawyer. He appears rushed and he tells you several times that his rushed schedule means that he must leave exactly at 15 till 3 or else he will not even consider continuing this session. He insists that you give your promise to this before you begin. But, before you begin, he arranges the furniture in your office so that he can see the wall clock easily, he sits down carefully and then says, 'There are only 42 minutes left. Why haven't you started? He often complains of eye strain and has seen an ophthalmologist about this but to no avail. He must often seek out chiropractors as he engages in very active sports after periods of no exercise. Background: He has high blood pressure. He has a problem with constipation and hemorrhoids. Must have every detail perfect. Excelled in school--studied all day and night. Indecisive when he takes on more than he can handle as he usually does. Has no history of bizarre thoughts. Does not recall dreams. He is the hardest driving member of a hard driving law firm. Treats his children like mechanical dolls. He is sexually disinterested and has trouble relaxing. He is scrupulous in manners and dress. He is also dry and humorless. His wife wants a divorce unless he spends more time at home. Co-workers are grumbling over his excessive criticisms. He is furious at himself that he cannot keep up with his work. He is demanding that his body stay young even though he mistreats it. Cold and distant and demanding. He has gone through 3 secretaries/year for 15 years. Sees work as more important than family and friends. Expects others to react instantly to his orders. He has little emotional attachment to people. He is cold. He can be quickly upset over tiny errors by his co-workers. Ferocious competitor in sports and poor loser. He can change his emotions rather quickly. Both parents are hard driving business persons. His children were colicky when babies and still cry and complain a lot at home. His wife married him when they were both law students. She is sad to not have a career. He is overextended in investments but refuses to admit any mistakes. He has been an overachiever his whole life. Marriage problems began when his wife was pregnant with their first child six years ago. Work problems became serious about 10 years ago when became full partner. Star of soccer team at age six when won championship for kindergartners. CASE 12 - Joel The client Joel is a 27 year old male, currently working as an engineer. He is an only child from an Orthodox Jewish environment. He moved out of his parents’ home two years ago. Somewhat nervous while speaking, his eyes remain fixed on the floor for most of the session. We enter this session after 20 minutes have passed..... (T) So, you find that for the first time you might have the opportunity to have sex with a female and this is making you very nervous. (Cl) Yes, and, in addition, since we are not married, I am not sure that I should. (T) Why don't you tell me more about your values then? (Cl) Well, my mother believes that one should not have sex until married. I guess I sort of agree with her but...... (T) It seems as though you have more to say to me about your mother. (Cl) I do. But it is not easy to tell anyone. After all, she is my mother. She was very overprotective of me and did not let me date during my adolescence. I'm ashamed to mention this, but occasionally she would not dress in the house and I would see her naked. This became very exciting for me. (T) I realize that this is hard to talk about, but it does seem important. (Cl) Yes, I never felt right about it. I also never masturbated as this seemed so dirty. My only ejaculations came at night after seeing my mother naked which also made me feel terrible......I guess.....I guess I should also tell you that - He has no problems with achieving erections although has never engaged in intercourse. Between 13 and 18 he only had orgasms with nocturnal emissions. Joel takes no drugs. Joel appears healthy and has no physical complaints. He seems clear and bright and successful now that he is on his own. He has a slight stutter when nervous. He often daydreams, sometimes at the expense of work. His memory for childhood events seems obscure. He exhibits himself to women and follows with orgasms and ejaculation. He becomes very nervous as he becomes friendlier with women. He speaks little and softly. After exposing himself he quickly leaves the scene feeling ashamed. He would like to have normal relationships with females. He would like to stop exhibiting himself to women. Joel would like to have sex with his girlfriend but is very afraid. He must drive 2 hours round trip to work. He is submissive to women but accepts this. He is very polite and tends to internalize criticism. He adores children and acts friendly to them. He avoids older people. He has never had an angry outburst or marked shift in attitude. He tries to resist the desire to expose himself but he can't. When young he was afraid that he would have an erection in his mother’s presence. He often is depressed after having exposed himself. Sexuality was strongly condemned by both parents as dirty. Father was authoritarian and mother domineering and intrusive. Mother bathed him until 10 years of age. Family was rich when young but now is not. When stressed has exposed himself to women. He started at age 18. He did not date women until 25 years old. He goes through spells when he controls himself. CASE 13 - Fantasia Background Information: Dear Counselor, This letter is being written because I am concerned about a student in my class, Fantasia. I have enclosed the release of information form signed by her father. Fantasia has been in my English class since September and she has yet to speak. Once, I asked her to stay after class and tried to ask her why she did not speak up in class. She just kept her head down and wouldn't say a word. When I asked her to please try and share her ideas in class she just nodded her head and then ran out of the room. Will you please contact her father and see Fantasia? Sincerely, Mrs. Barbara Jean Walters Teacher Information: Fantasia is 16 years old. Developmental milestones were normal. Received compound fracture of left arm at age 10. History of cardiovascular disease on mothers' side of family. Completes all written assignments and maintains a 'B' average. Received speech therapy in second grade for minor lisp. Diary written for English class is coherent and well organized. Able to care for the needs of her six younger siblings. Has not spoken out in class for more than a year. Teacher reports that Fantasia does not talk during class breaks. Younger sibling indicates that Fantasia talks at home. Fantasia is slim but no recent weight change has been noted. Diary reports indicate she is tired of caring for her siblings. Responded in interview with monosyllabic answers. Fantasia apparently does not see her silence as being a problem. Her father rarely responds to school inquiries. Fantasia will not talk to any of her teachers. Fantasia does give verbal directions to her siblings. Assumes major household responsibilities for siblings. Has two close friends at school with whom she does talk. Mood is even but with little affect. Younger sister reports the siblings 'Love each other very much.' Reports feelings overwhelmed by things since her mother's death. Seems accepting of other people. Father works late and this forces household chores on her. Mother died of cardiovascular problems about one year ago. Refuses to complete speech assignment in English class. School behavior was normal until one year ago. Severity has been consistent during the past year. Fourth-grade teacher reports that Fantasia was a 'little angel.' CASE 14 - Harriet Harriet your client is sitting across from you and is about 25 years old. Harriet has medium length straight hair that she has covering part of her face. Harriet is fairly short. Harriet is wearing new jeans and a simple blouse. You notice that Harriet pulls her legs up into the chair so that she can wrap her arms around them and sort of hides behind them. Harriet stares at you and states... ”NOW what!”... You respond: “Well. How did the week go? Did you do the homework?” She replies: “Of course not. It was stupid.” You say (trying to not be angry): “You didn't think so last week. How would you change it?” Harriet says: “You know best. (She pauses) Oh...I'll do it. I actually did do some of it.” You respond: “Great. So how did it go?” She says: “Well...you were right. I didn't mind talking to her. So now she keeps after me to talk more. How do you turn her off?” You respond: “Do you want to?” Harriet says: “YES...no.” Harriet appears to be in excellent health. She has gotten very drunk before exams on several occasions. She is not taking any medication. Harriet has had to be treated for Sexually Transmitted Diseases at the health center, as when she gets drunk she will sleep with degenerates. Harriet is a graduate student in History. Lately Harriet has complaints of not being able to study as she spends all her time preparing lessons for her teaching assignments. Harriet complains of memory losses at times Harriet refuses to look at you in the eyes. Harriet says that you'll see too much if she allowed that. Harriet reports that she has no friends. Her way of sitting or walking is to make herself as unnoticeable as possible. Harriet has a habit of leaving any group conversation by sneaking away as unnoticed as possible. Her father has never liked her. Harriet feels that others always see her as weak and unattractive yet she is often desperate for their friendship. Harriet hates teaching History yet that is what she will have to do if she graduates. Harriet loves to write poetry but there is no money in that field. Harriet will never start a conversation. She will often be spiteful of another to make the person go away even though Harriet really might like the person. Harriet will allow others to get only so close before she abandons them. In reality Harriet is terribly needful of their friendships. If one pushes her Harriet will flee. Harriet seems to be holding in a lot of anger. She is often depressed. When events seem to be breaking through her tightly controlled world Harriet will lash out to escape. She continually hints at suicide and a desire to end it all. Her father seems to prefer her brother to her. Her mother will on a few occasions side with her when alone but will always side with her father in his presence. Harriet was often ridiculed in grade school, as she was very bad at outside games. Harriet has managed to choose a major where little to no contact with others was possible. She has felt this way for as long as she can remember. Lately Harriet has felt worse as she is coming to a difficult decision about career choices. At 4 her father repeatedly said to her that Harriet should never have been born. CASE 15 - Joseph Joseph was very hesitant in talking to the psychologist about his problems. Joseph is a Middle School English teacher Joseph’s school principal where referred him. His principal noticed that Joseph was complaining about his heart problems and seemed out of sorts lately. Although this psychologist is familiar with the DSM-IV-TR, the psychologist is also hesitant to make a diagnosis. Joseph is 55 years old. He recently has been having some heart problems, although nothing serious yet. He has been very dissatisfied with his sexual relations with his wife for many years now. Joseph has had some problems with impotency. Joseph finds himself daydreaming often at work and at home. He is of normal intelligence. His daydreams are of sexual encounters with little girls. He constantly belittles himself. He is sweating and stumbles for his words while relating his problem to you. His sexual functioning is normal. He is neat in appearance and very polite. He says that he has never actually carried out his sexual fantasies with children. He does not want to die without leaving his family in a more secure position. The little children in his fantasies remind him of his own children. His wife seems to be turning into what he calls an “old woman” before he is ready to become an “old man”. Joseph’s teaching is suffering and his principal has noticed. He is warm and friendly to almost everyone. He has a tendency to overlook others faults and internalize them. He does not like to talk about “secret” or emotional topics. He is awkward at parties. He seems to be slightly depressed. He has never hit anyone or caused harm to his recollection. He says that he has never acted out his sexual fantasies. Joseph had a summer job several years ago where his fellow workers exposed him to pornographic movies. He finds that he enjoys these fantasies more than sex with his wife. His wife is cold and distant. He lives in a small town. He has been having these fantasies for about two years. He has been having problems with his wife for about ten years with more problems occurring after learning of his heart condition. He learned of his heart condition about two years ago. Set 4: Cases 16-20 CASE 16 - Luis (T) Hello Luis. I have read what our receptionist wrote down when you called which basically says that you are 20 years old and a junior in college. Your grades are excellent; yet, you report having difficulties studying because of prevailing repetitive thoughts that you are unable to dispel. Do you have anything you would like to add to this? (C) Well I am having great difficulties as I seem to need to rehash the days events for hours every night. I go over and over every event to see if I have done everything ok. I have a terrible fear that I will ruin something if I have made a mistake. The only thing that keeps my grades ok is that I always sit in the third row and fifth seat in every class. (T) You always sit in the third row and fifth seat in every class? (C) Yes! I also avoid certain buildings on campus. If I do not I know I'll get bad grades. (T) You believe your grades are the results of your avoiding buildings? (C) I guess so. It sounds a little silly but I find the same thing with friends. I mean, if I take several hours to dress and fix myself up in the morning, then my friends stay with me. I don't like having to do these things but I see no other choices. I have a difficult time keeping these activities from my friends. Do you think I am ok, I mean, what do you think I should do? (T) Luis, I get the feeling that you often ask for approval from others of what you do. (C) You are right. I just want to do things perfectly. I'm very anxious about this all the time. (T) Yes, I noticed that you are wringing your hands constantly. I sense you are fearful about something. How long have you felt like this? (C) I've felt this way for 3 or 4 years now and it seems to be getting worse. I never seem to get away from these thoughts. (T) Luis, how about your friends? You mentioned them earlier. (C) I still have a lot of friends. It does take a lot of time though as I take so long getting ready to see them. (T) And your parents? (C) They are ok. I wish they were not so demanding. I see them about twice a month now. (T) Luis, have you had any medical or physical problems in the last few years? (J) No, except for an accident several years ago where I ruptured my spleen. Luis had a complete physical after his accident with no significant findings. Luis has used marijuana about once a week for the last several years. Luis's family has a history of heart disease. Luis often complains of mild headaches and colds. Luis is not led on by voices or visions of how to act. Luis's memory and attention to detail is extraordinary. Luis's SAT scores were 2 deviations above normal Luis often can't finish exams due to interfering thoughts Although Luis is nervous he demonstrates no 'tics'. Luis ritualistically arranges his books and pens before studying. If Luis's seat is taken he will become angry and aggressive. Luis is physically awkward. Luis is ashamed and bothered by the superstitions that govern his behavior. Luis is unable to shorten his two-hour grooming period. Luis's mother and father expect him to be an honor student. Luis has many parking tickets which he needs to pay to continue in college. Luis is very dependent on his parents and always seeks their approval. Luis is overly concerned with his outward appearance and impression on others. Luis can be quick to anger when interrupted from one of his routines. Luis can be the life of a party by acting awkward and dumb. Luis is angry at himself for his inability to control his thoughts. Luis's energy seems appropriate, although possibly a little high. Luis can become so nervous that he runs from a situation. At times Luis is mildly depressed. Luis comes from an upper-middle class family. Luis is an only son. Religion has been a very important factor for Luis's parents. Luis went to a private elementary school away from home for several years. Luis has for 5 months spent 2-3 hours thinking about relations with friends. The parking tickets problem has occurred for the last 3 semesters. Problems with self-esteem have existed for Luis since childhood. CASE 17 - Jaime Jaime is 30 years old and has come to you upon the recommendation of her boss. She appears upset and has arrived 15 minutes late for the appointment. She has a long explanation about forgetting her keys because of some copying her boss wanted her to do. She seems of good health with no medical problems. She saw a school psychologist when young for being a terror in the classroom. She is a computer programmer and seems quite bright. People tell her that she needs to stop procrastinating. She seems to be slightly forgetful. She is always missing appointments and deadlines at work. When you repeatedly asked about some information she seemed to be very stubborn about telling you. Even though capable to perform some simple programming she sometimes will take a very long time to finish a job. She resents being told what to do. She would like to be promoted but never is. Her friends get frustrated with her, which leads to arguments. Her boyfriend recently left her. She tends to believe that her problems are caused by other people's negative opinions of her. She will make many promises to her friends. They have come to ignore them. She will withdraw and get sullen if she can't get her way. She is slightly depressed and would like to figure out what is wrong with her. There are no impulse problems. When confronted with complaints she gets quite defensive. She has had problems of following orders in school. She is living alone. She has plenty of money. Her problems seem to go back to grade school. She is only coming in because she is afraid her boss is angry with her. CASE 18 - David Background Information David has been admitted to a hospital after he was discovered semiconscious with tape and a shoelace wrapped around his neck. Information available at the time of admission indicates that the previous day he was admitted to a juvenile detention center. He was involved with some friends who stole a car and drove it to Los Angeles. When asked why he did this, he responded that, 'It seemed like fun at the time and it was my birthday.' (He is now 15). When admitted to the juvenile detention center, he vowed that he would kill himself. Your task is to determine the nature of David's problem so that a remedial program can be planned. He experienced temporary respiratory impairment from the suicide attempt. He has periodically used drugs (LSD, glues, and marijuana) since age 13. He has received family therapy while in a group home at age 14. He has had numerous broken bones, lacerations, etc. during childhood. Until the age of 13 David maintained a 'B' average in school. In the interview David was well oriented to time/person/place. For the past three years David has often acted on impulse. He won the school spelling Bee in grade six. David reported having difficulty sleeping during the past two weeks. Already of slender build David has eaten very little recently. In the interview David spoke in a subdued voice. David reports feeling unworthy of any special care or attention. David reports he feels as if he has let his parents down again. He has some buddies but 'They just lead me into trouble.' Parents report that they are unable to control his behavior. David passively accepts his parents' guidance (when he's not on drugs). He has little regard for others' property when taking drugs. David is not involved in any school clubs or activities. David is daily in trouble at school for not paying attention. David says that he is a failure in life. This suicide attempt failed but he says the next one will not. David has shown no interest in recreational activities. David says that he is so mixed up that he just can't think. He ran away from home after a fight with his parents at 13. He hit the principal and was expelled from school at 14. David spent six months in a group home and his behavior improved. Recently he started drugs again and broke and entered 10 homes. Social and emotional development was normal until age 13. David started drugs again 6 months ago and has been despondent for 3 weeks. David has had periods of good functioning in the past three years. His previous psychological reports indicate only mild depression. CASE 19 - Arnold You are working at a clinic that is located next to a university. It is finals time and many students are dropping in. His roommate who leaves to take a final has just brought in Arnold. The first thing that Arnold does is tell you to “GO TO HELL”. No background information is available at the time of the interview. Arnold has talked almost constantly since arriving. What Arnold is saying is interesting and intelligent; yet, hard to follow. Arnold's thoughts seem to be speeded up. Arnold seems slightly paranoid and is constantly on the lookout. You notice that Arnold's pupils are dilated. Arnold also seems speeded up and when you take his pulse it is very rapid. His hands are wet with perspiration. Arnold is belligerent and has impaired social judgment. Arnold's roommate mentioned something about pressure of test before leaving. Arnold says something about spending the whole night studying for his test. Arnold looks tired but says that he needs to go study. Arnold keeps saying that his parents expect only an A grade. At the moment Arnold is belligerent. He insists that you understand that he is correct. He wants those around him to understand his intelligence. Arnold seems to have no control over impulses at the moment. Arnold seems to feel great. Arnold has a test today. Arnold mentions that he must get an 'A' on this test to pass the course. Arnold states that he is an 'A' student. Apparently Arnold has felt this way for only a few hours. Arnold refuses to give you any other information on whether he has felt this way before. Arnold has now been in your office for 25 minutes. CASE 20 - Emanuel In an initial session with parents: father announces: Something is wrong with my son Emanuel.” Mother says she has come for help now because she just can't take it anymore. You ask: What has he done that concerns you both? Mother responds: “Well he’s pestering me and…” The parents go on to relate the following information about Emanuel: Mother smoked during pregnancy but Emanuel weighed 7 lbs. at birth. Emanuel has numerous headaches and stomach aches on school days. Pediatrician can find no physical cause for Emanuel's ailments. Teacher reports that he does average to above average work. Emanuel passively accepts directions from teacher. Teacher reports he is not a happy child. Lingers at school gate when mom drops him off for school. Classmates tease him for being a 'mommy's' boy. He can't seem to concentrate on his school work. School reports that Emanuel has been this way since Kindergarten. Emanuel says: 'I'm always scared that mommy will leave me with the babysitter.' Mother reports that Emanuel's afraid his mother will die. Refuses to sleep in his bed at night - sleeps with parents. 'Emanuel started sleeping in our bed at age two and he's now seven.' Stands at door when mother goes to bathroom or dresses. Mother reports that “Emanuel follows me around the house ALL the time.” His parents say Emanuel cannot stand being alone. He hangs on his mother's coattails whenever he can. Shows no sign of distress when father leaves home. Emanuel has uncontrollable tantrums when his mom leaves him alone. His mother worries about him being kidnapped. Parents are concerned because they feel like they're in prison. Younger sibling seems to be very independent. He never seems to act spontaneously - he's always cautious. During an initial session with Emanuel only: Had to leave door open (mom outside) during clinical interview. Set 5: Cases 21-25 CASE 21 - Connie (Counselor) Hi Connie, my name is John. I understand that you have undergone some difficult times recently. I would like to help, but in order to do so I will need to know some more about you. Possibly a good place to begin is by telling me something about what has happened recently that lead you to come see me. (E) Mr. Smith... (Counselor) No...No...Please, call me John. (E) Ok...John. I guess my friends have convinced me that I have changed lately. They have noticed that I drift off in day-dreams and I...I even forget where I am or why I'm in a store.. (She sobs slightly- regains control, and then seems slightly numb) (Counselor) Connie, this seems to have you very upset. Is there any reason or event that has happened recently that is making you so upset? (E) Well, it probably is tied into the arrest of ...of HIM! (Counselor) Who is 'HIM'? (E) The man who killed Jason. Oh I know you do not know all this. I probably should tell you about....Jason. Jason and I were to get married this summer, but now...(sobs).. One night about eight months ago we were walking home late when this man stopped us and demanded all our money. We gave him everything and then turned and started to run. Jason waited a few seconds so that I could get a head start, but after a few steps I noticed that Jason wasn't following. When I turned around the man had gone, but Jason was lying on the ground....with a knife in his back...dead.... (at this point Connie has a blank stare on her face) (Counselor) Connie...Connie...what happened to you just now as you were telling me about Jason? (E) Just now...I don't know. I must have blanked out again. (Counselor) Connie, does this blanking out happen often? (E) Sometimes. I just can't seem to concentrate at work or anywhere I often seem to be startled out of drifting in my mind. (Counselor) I realize that this was a very upsetting experience. Do you have any other problems that seem to be connected with it? (E) I can't sleep at night lately. I have bad nightmares....and I just can't help but think that it was my fault that Jason is.. DEAD! Since that man's arrest I've had a horrible time. Connie is 27 years old. Connie often used diet pills until late adolescence. Connie's father has duodenal ulcers. Connie had a lump in her breast biopsied last month which was not malignant. Connie's friends describe her as preoccupied. Connie has a BA in Psychology. Connie's GPA in college was 2.35 although 3.2 in Psychology. Connie has a hard time remembering people's names. Connie is slow and lethargic lately. Connie will respond explosively on occasion without much reason. Connie has recently begun to stay up late and watch TV till 3 or 4 AM. Connie will often call in late to work as she prefers to stay in bed. Connie is re-experiencing the murder in her dreams. Connie is frustrated because her career seems to be uneventful lately. Connie feels that her parents are unhappy with her. Connie is afraid of the night. Connie has recently become quite reclusive. Connie states that she feels other people don't like her now. Connie prefers a deep intimate friendship to shallow acquaintances. Connie is usually very cooperative. Connie reports feeling numb or a very dull affect lately. Connie did not seem to care about her life situation. Connie seems a little explosive on occasion followed by apathy. Relevant events in the history: Recent arrest of man accused of Jason's murder. It is winter and Connie must go to work and return at night. Connie's father was robbed when alone 9 years ago. He was unharmed. Connie has severe financial difficulties following Jason's death. Most problems started after the murderer was arrested 4 weeks ago. Problems have not decreased but instead are getting worse. Parents rejected her when she moved in with Jason and still do. Financial situation only recently became bad due to drain on savings. CASE 22 – Mrs. Brown Dear Counselor, It has been a long time since I've seen you. I hope all is fine with your program at Florida. I'm writing as I have a client (Mrs. Brown) who is moving to Tampa and I would like for you to begin seeing her or find a competent therapist for her. She is 72 years old and recently widowed. She has an active social life and volunteers at local hospitals and other agencies. She is moving because her current boyfriend (Tom) wants to work in Tampa. Tom is 24 years old and they are engaged. Mrs. Brown's children are very concerned about their mother and have convinced her to begin therapy. She only saw me for 2 visits and was not too happy about seeing a therapist as she doesn't believe that one can help. She has not had previous therapy. She is very talkative and will often speak very rapidly. She has, of course, mentioned that she believes that her children are trying to get her declared insane so they can get to her money. Her children say that this talkative and almost hostile manner is quite different from her previous way of relating to others. She often approaches strangers to let them know how happy she is. This is in sharp contrast to the conventional way that she was raised. It seems that these mannerisms started shortly after her husband's death about 1 year ago and reached a climax about 3 months ago. Her behavior has not changed but has stayed about the same. I hope that this short description will help you get off to a better start than I did. Sincerely Yours, Your Worried Colleague Background Mrs. Brown has had a complete check-up with no serious complications present when a tumor was removed 6 months ago. She has no drug history and does not report any now. Her vision is such that she cannot legally drive even with glasses. She can still swim well and is in fairly good shape for her age. She seems to be clear headed; reports no bizarre thoughts or visions. Her thoughts seem to race from one subject to another on occasions. It is relatively easy to distract her. She would not take any test for mental abilities. She sleeps only 3 to 4 hours per night. She spends many evenings dancing at bars with her fiancé. She is easily irritated if interrupted yet interrupts others often. Her daily routine has changed drastically over the last year. She is afraid that there is not enough time for her to do everything. Her fiancé is also seeing other women. She does not want to be counseled. Her children seem to be constantly badgering her. She is abusive and demanding. She wants others to visit her often and on her demand. She wants others to join in on her bizarre ideas and trips. She often attempts to be seductive. There has been no indication of remorse or sadness over her husband's death. Her mood is very euphoric and fast paced. She insists that she is very happy. On an impulse she will give money away or become angry over a price being asked for something she desires. She has never been on her own or 'free' (Mother or Husband were the boss). Her life style until 1 year ago was very sheltered. She has lots of money and this is well known in the community. Her children were raised in foreign schools and are not close to her. The length of symptoms is about 6 to 9 months. There have been no remissions. Her lack of sleep seems to be slowing her down during the last 2 weeks. CASE 23 - Gladys NAME: Gladys Sanders. CHRONOLOGICAL AGE: 14 EXAMINER: Joseph McDonald, Ph.D. REASON FOR REFERRAL: Gladys was referred for this evaluation by school personnel who are concerned about her behavior at school. An interview was conducted with Gladys and her parents. In addition, school personnel were asked for detailed information. A complete battery of psychological tests was administered. BEHAVIORAL OBSERVATIONS: Gladys presented as a child of average height and weight but was dressed untidily. Her hair had obviously not been combed for some time and her long fingernails were painted four different colors (red, brown, green, and blue. During the session she initially gave the impression of being quite lethargic, having much difficulty answering questions. She actively avoided eye contact, laughing inappropriately, yet occasionally gave very sophisticated answers. These mature responses, however, were invariably spoiled as she lost the ability to attend to the task at hand. ADDITIONAL DATA COLLECTED BY COUNSELOR: Mother related numerous bizarre stories of her own past in interview. Parents say other doctors have said Gladys has a mental disorder. Despite unkempt appearance medical examine is normal. Neurological examination is normal. The 90% confidence band for the WISC iv is 69-74. Developmental milestones were delayed. Speech began at age four. All academic skill areas are measured at the 1st percentile. Gladys reports hearing the voice of an alien but knows others cannot hear it. Her speech tends to be inappropriately loud. Children’s Apperception Test stories contained numerous immature sexual allusions. Gladys disrupts family with inability to sleep through the night. When asked about others' feelings she says... “I don't want to be in their bodies.” Gladys is failing her special education classes. Despite her appearance she sees herself as sexually desirable. Teacher reports she loses control if given too much work. Gladys has a tendency to violence when unsure of herself. Her 12-year-old brother avoids her and says 'She's weird.' Gladys bites- hits- kicks- family members when frustrated. Father says he feels like he's in a loony bin half the time. Gladys is noted to withdraw from her mom's physical contact. Her teacher reports that Gladys always seems to be in her own world. Gladys does not seem to express normal feelings in everyday situations. Gladys has suddenly jumped up in class claiming she heard voices. Gladys reports feeling good about herself… “I'm a super genius!” Her family had multiple moves while her father was in the military. The parents report marital discord related to Gladys's care is increasing. She is disoriented in class as she reads what isn't in her books. Mom reports that 'Oh…Gladys has always been that way.' Dad reports that Gladys has always seemed a bit different. She has not cared for her personal needs well during the past 6 months. CASE 24 - Kristina (T) Kristina, tell me about when things were hardest for you. When was that? (CL) It was around Christmas time last year. (T) How old were you then? (CL) 13. (T) What bothered you the most when things were at their worst? (CL) Well, all the things I did were really STUPID and didn't make sense; but, I felt like I had to do them anyway -- it was a scary feeling. (T) What things were you doing? (CL) Well it's like this. When I was 13 there were 13 doors in my house. All 13 doors needed to be shut as it was probably only 13 degrees outside. Now 13 is a really important number as I was 13 that Christmas. (Kristina gets up to make sure the door is closed. She first takes a Kleenex and cleans the handle, then says) I don't know why, but the number 13 seems very important to me. General physical examination was normal. Weight is 10 lbs. below average for height and age. Treated for severely dry hands last winter. Family has no history of medical problems. Reports feeling compelled to act out her thoughts. There is no indication of visual hallucinations. Is superstitious about numbers and certain words. Has maintained a B+ average in schools. Washes hands in morning with alcohol (causes excessively dry hands). Shakes clothing for 30 minutes to eliminate all germs. Placed Kleenex on office seat at start of counseling session. Says 'soap and water' whenever she hears a 'germ' word. Must get up at 5 AM each morning to get to school on time. Feels extreme shame about badly cracked hands. Reports that she feels out of control - 'I can't stop these ideas.' Dating and social contacts have decreased since condition started. Has several good friends - forgets problems when with them. Reports that she feels her parents care about her. Feels she would let her mother down if she wasn't always clean. Kristina feels that her behavior is very stupid - 'I'm dumb.' Intense tension builds when Kristina tries to resist her thoughts. She was 'down' when things were worst but feels better now. Can't stop thinking of the number 13 and its' multiples. Kristina's mother is reported to demand an orderly and neat house. Fears seeing grandmother - 'I might give her a disease.' 'These thoughts came into my mind just about my 13th birthday.' 'I've been bothered by this problem almost constantly.' 'Things have been a bit better lately.' CASE 25 - Gerald You have been seeing a man named Gerald in his 40's whose chief complaint is that his children are driving him crazy. Your supervisor needs a DSM IV-TR category as she is making a report to the governing board of your clinic tomorrow. Good luck! Gerald saw a psychologist after divorcing his first wife. He also saw a psychologist after his oldest son died while on a mission for the Army. He seems to be in fine health. In the past he has had high blood pressure. He is bright and has reentered college to pursue a Ph.D. There are no indications of bizarre thoughts. He recently took the GRE and received high scores. He seems to not believe that others understand him and repeats himself often. His voice has a nagging quality to it. He does not look into people's eyes when talking. He mentions often that his current wife isn't interested in sex. His children constantly fight and get into trouble at high school. His current wife either gives up or explodes at the 5 children. He has a hard time studying when his children need so much time. Gerald’s children often take sides based on which parent they believe can give them what they want. He likes others to always agree with him. He seldom laughs but is mostly serious. When he gets angry he plays the martyr role. Gerald controls his anger and seldom explodes. He prides himself on being the logical one in arguments. He does not appear depressed - although he is worried. After his first wife left he has not been as open to emotions. He takes blame for his son's death as he says his son entered the army to escape from Gerald. He has children from both marriages at home. The problems at home have built up for 3 to 4 years. His son died 5 years ago and his first wife left 18 years ago. All of his 5 children are now teenagers. Set 6: Cases 26-30 CASE 26 - Josh Josh has come to talk to you about his marriage. He has been married several years but with numerous fights and separations. He is considering divorce. (you) Josh, what do you want to tell me today? (Josh) I guess I'd like to find out what is wrong with me... (Josh starts to weep slightly) I just can't live without her...now I don't mean that I'm going to do myself in or anything. It's just that I feel so empty when she leaves, which she does after a big argument. (you) Is she gone now? (Josh) No. But it'll happen again. (you) How does it start? (Josh) Oh, for example, we'll be both very busy and the house will get messy. I don't like it being messy, but as soon as I ask for help to clean up she'll yell at me to stop being such a xxx xxxxx sexist pig. It'll get worse from there. Josh is 33 years old and 6 feet 10 inches tall. Josh was over conscious of his height while growing up. From the age of ten he has been bothered by height problem. Josh is quite slim weighing 180 pounds. Josh has occasional asthma attacks. Josh has had several operations on his knees. Josh has a MA in Engineering. He seems bright. No mention of bizarre thoughts or hallucinations. Memory seems intact. Josh moves slowly and slightly awkwardly. Josh describes his sex life as ok. He says his wife is cold though. Josh functions normally at his job and with friends. Amount of sensitivity and caring in marriage is low. Josh feels a need for more sex in his marriage. Josh does not like it when he begs for his wife to return after a separation. Josh is easy going and sensitive. Josh shows his emotions of sadness easily. Josh is slightly dependent on others for his self-esteem. No impulse problems. Josh is slow but not depressed. Josh cries easily when sad. History of fights in marriage and before marriage. Both are engineers and met in college. Married due to common interest. Two years of marriage and four of courtship. CASE 27 - Ronald Ronald is a student at a college and he has come to you complaining that he is no good. Unfortunately, he seems resistant to explain. Ronald has recently hurt his knee in a tennis accident. Ronald has never been in therapy before. He is tall and in great health. Ronald is an average student. Recently his grades have dropped some. There seem to be no bizarre thoughts. He is very rational while talking to you. You notice that Ronald got quite tense at one point in the session. At the point of tension you were talking about tennis. Ronald seems very polite and is clean and neat. Ronald wants to go into medicine like his father and mother did. Ronald wants to be a top tennis player also. Ronald wants to be rich and famous. Ronald seems like a con-artist or that he's not telling you something. Ronald is very polite and reflective. Ronald looks into your eyes but doesn't seem sincere. Ronald is calm and slightly introverted. Ronald reports a slight degree of being down due to his grades. At the end of the day when you left to play tennis yourself you noticed that your tennis balls were missing. When Ronald was anxious during the session you sensed some form of guilt. Ronald comes from an affluent family. Ronald has a demanding coach who tells him he can make it to the top. Until lately Ronald was always the center of attention. Ronald says that he has wanted to see someone for about one year now. He indicated that he has had this problem on and off for many years. Ronald did not give you much to go on until after the session and the day was over. CASE 28 - Samantha Background Information: Samantha is a 13-year-old who has been referred to you because she is not doing well in school. Her father indicates that he just received the mid-semester grades and Samantha got F's in every class except Physical Education. He reports that she has never done well in school, but this year has been hard on the entire family. She is beginning to talk back to her teachers and has been very uncooperative at home. All attempts made by her parents to encourage her to do her homework have met with failure. Her father says that he is very concerned that Samantha may not earn enough credits to graduate. Samantha's father says she takes two hours to finish simple homework assignments. I Samantha had a difficult birth and a birth weight below 2500 grams. She has had a history of upper respiratory infections during preschool. She had tubes inserted to control chronic Otitis Media at age four. The school Audiological screening indicated normal hearing thresholds. Samantha reports repeating first grade because her teacher was mean. t is reported that she walked at 12 months and talked at 18 months. She repeated the first grade and received special tutorial help during grades 2 and 3. Her performance has deteriorated since enrolling in junior high school. You arrange an appointment to see Samantha in order to learn more about the difficulties she is having at school. Test and School Observation Results: WISC-R test results: Verbal IQ = 94, Performance IQ = 115. Teacher reports Samantha is slow and doesn't complete her reading. Wide Range Achievement Scores: Reading = 78, Math = 92, Spelling = 82. Samantha was very cooperative during the clinical evaluation. She became agitated when requested to complete a reading task. Speech and conversational skills were appropriate. During an achievement test repeatedly said, 'I'm a massive failure'. Teacher reports that she frequently acts out in group settings. Teacher reports she has to give Samantha a lot of individual attention. Samantha says that the other kids in class boss her around. Samantha reports that her teachers expect too much of her. Her relationship with her parents is warm and supportive. Samantha has several good friends who try to help her in class. Samantha likes sports and team events, especially soccer. Samantha does occasionally get frustrated and tears up her papers. She has hit classmates but always feels guilty afterwards. Teacher reports Samantha shows interest in films and lectures. Samantha cries rarely. Her chronic school difficulties have exacerbated in junior high school. There is mild tension at home regarding Samantha's comments of hating school. She recently was sent to the school principal for hitting a boy who teased her. Both parents are college graduates and have lots of hopes for her. CASE 29 - Robert Robert has been brought to your campus office by the police after being reported to be hanging around the University Commons. He is 24 years old and neatly dressed. He is a Junior at the University. His first question perplexes you as he asks if you are Italian. No indications from Robert of any medical problems. Robert says that he has taken no drugs. Robert seems to be in fine physical condition. Issues: Robert seems to believe the Mafia is out to kill him. Robert speaks rapidly and sometimes leaves out important connecting phrases. Robert is intelligent and believes he thinks faster than others which confuses them. Robert reports that since childhood he’s been affected by his father's domineering attitude. Robert appears to have a slight superiority complex. Robert reports no bizarre thoughts. Robert is nervous and looks suspiciously at everyone. Robert did not sleep well for the last 2 nights. Robert wants the door to your office to remain open. Several times Robert gets up and carefully looks out your window. A woman had reported that Robert raped her while he says she was willing. Robert does not get along with his father although he would like to. Robert has few long-term friends. Robert is afraid his college career is ruined by the rape charge. Robert is afraid of emotional discussions with others. Robert sees most things in absolutes. Robert now sees all strange men as potential Mafia men. He has sent legal letters about rape charges to various officials on impulse. He refuses to show emotions over rape charge and his involvement. Robert is very motivated to clear up whatever is wrong with him. Robert thought that his date went well with the woman that charged him with rape. He even went back to her house the next day. Robert believed that men in the parking lot outside the girl's house were there to beat him up. After a long drive home (10 hours) he discovered that he had left his house keys behind. Newspaper article mentioned his alleged rape. One week since the episode he has felt the girl's father (Italian) put him on hit list. CASE 30 - Mary Beth One of your new clients, Mary Beth, is attending graduate school and told you that she believes that she will flunk out. You are concerned and decide to ask some questions to help her. You ask: ”What's happening to you anyway. You missed class again.” Mary Beth says: “Do you really care!” You respond: “Yes I do. Mary Beth then says: “I'm sorry...Yeah, I just couldn't get out of bed again.” You say: “Based on what you told me last week, are you and your mother arguing again?” Mary Beth starts crying and says: “I...I guess I need to tell someone...My mother died from her cancer last summer. I just haven't been myself since...I just can't think clearly anymore.” Mary Beth is 25 years old and of very good health. She plays handball regularly. You know nothing of her medical records. She seems to be of sound mind. No bizarre thoughts. Her grades are suffering as she does not finish assignments. She is usually a good debater in school. Mary Beth is not getting up on time to attend her morning lectures. When she talks about finishing graduate school she often gets nervous. Sometimes she will leave tasks unfinished which are mainly school tasks. She has not played handball much this year. Since her mother's death she has to support herself. Her mother was the one who really did not want her to go away to school. She is afraid of losing your support in the counseling sessions now that she has told you. She is very friendly and warm. She does not talk about her family to even close friends. She is very concerned least she offends another person. Her emotions about her mother seem intense. She blames herself some. She does not do things on an impulse. She seems happy and normal most of the time. Her mother died from cancer 5 months ago. Attending school in another state meant seeing her mother only on vacations. She has no family members living close to her. School problems started several weeks after mother's death. School problems have lasted about 4 months. She went on school probation 2 weeks ago.