PSY71 - Case Histories

PSY71 - Case Histories - oer—233 : aeee 15 39 TLIFTS...

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Unformatted text preview: oer—233 : aeee 15 39 TLIFTS PavCHoLnov DEPT 61'? N 5273131 l iii-ii Dill M willy" «Tit ti ll Hill. 3 ill and nightmares, startle reactions, and physiological responses to trigger stii-nuli becomes less terrifying ii" the patient understands beforehand that these are e‘xpectable reactions and likely to he shortdlived. Once Posttraumatic Stress Disorder is established, there is a considerable risk of it becoming chronic, particularly if secondary gains [such as continuing to stay out oF worlt and receive disability payments] enter the picture. Q'l‘ten there is an interaction between the condition and the secondary gain {e .g‘., the workplace evokes terror, and the symptoms enable the patient to continue to avoid being exposed to the workplace that would. trigger the Posttraurnatic Stress Disorder symptoms). Treatment should combine continued psycho- education, exploring eognitions, behavioral exposure, and, very often, medi- cation. It is Very important to foster the expectation that the individual will recover. Summary An ounce of prevention is worth a pound of cure. A diagnosis of Acute Stress Disorder made shortly after symptoms develop can be helpful if psycho- education is provided to help individuals know what kinds of symptoms to expect so that they will understand that these reactions are not unusual and that they shouldn’t try to avoid them. Psychoeducation, desensitization, and normalization Can help these individuals regain a sense of control over their lives. Antidepressants as well as cognitivewbehavior therapy have been found to be effective in treating Posttraumatic Stress DiSorder. It is also important to Website for both Panic Disorder and Major Depressive Disorder because these frequently co-occur with Posttraumatic Stress Disorder. Alcohol and/ or Other Substance Abuse may also develop when Posttraumatic Stress Disorder is untreated. Generalized Anxiety Disorder a Case Study: A Worrier on the Verge of a NEIVOUS Breakdown3 Mr. Y, a 30—year~old married real Estate investment company owner, goes to a local outpatient psychiatric clinic saying that he “is on the verge of a nerd vous breakdown.” He reports that he has always hoen a "worricr” but not to 3.Thanks to Mary Sederstrom, M.D., of the Psychiatry Department of Dulce Uni- versity Medical Center For supplying this case. UCT‘EE-EEIEIE. 15:4[21 l TR {EASE STl..ll?ill-£.S . responses to trigger :ands beforehand that .ived. . there is a considerable ins (such as continuing nor the picture. Often scondary gain (e.g., the a patient to continue to gger the Posttraurnatic line continued psycho" and, very often, medi- that the individual will iagnosis of Acute Stress i be helpful if psycho- : kinds of symptoms to one are not unusual and on, desensitization, and 156 of control over their herapy have been found rder. It is 3150 important essive Disorder because ress Disorder. Alcohol ien Posttraumatic Stress. rder — 3 lervous Breakdown ornpany owner, goes to s on the verge of a net-I n a “worrier” but not to v Department of Duke TLIFTS PSYCHOLOGY DEPT 6176273181 the extent that his lift-t was ail-footed in any noticeable- way. However, over the past year he has heeu experiencing a "tweaked" feeling of inner agile-- tion and “stays keyed up” most of the time. Mr. "(T has i-‘rut'niently corn- }:ilained of stomach upsets and Clliii'i'l‘lt‘tt over the past 6 months as well as a decreased ability to concentrate at work. His wife, an attractive and well- educated woman in her iniri~2lls, accompanies her husband to the clinic and says that he tosses and turns in bed until about 2 or 3 AM. and frequently gets up to urinate. She goes on to cot-uplain that her husband has gotten very irritable in the past 6—33 months and frequently yells at people, even at their 5-year-old daughter. The oldest and only male in a family of four children, Mr. Y is from an affluent anti wellvcducated family steeped in tradition. His father, grand- father, and several other men in the family attended the same northeastern ivy League university. Mr. Y felt compelled to continue this tradition, but he was apprehensive that his academic skills were not refined enough, although he was in the 90th percentile of his graduating class. Once he Was accepted to this prestigious university, he began to feel the pressure to perform exceedingly well. Despite experiencing tremendous anxiety and tension around exam time, Mr. Y graduated from the university with dis- tinction. While in college, Mr. Y began dating his wife and recalls that he would worry for days about whether he had picked the right restaurant for the date, whether he had selected the right flowers, or whether his ear, which had recently undergone a minor repair, would break down on the date. He notes that although he worried a lot about something or other not working right, he never had difficulty asking women out on dates or having them accept. He describes himself as driven and generally on the extro— vetted side. Three years before the current evaluation, Mr. Y‘s parents separated and his real estate investment company came close to bankruptcy. Although he has been successful at gradually rebuilding the company over the ensuing years and "getting his feet back on the ground,” he has been unable to sup- press his nervousness and tension. At night, he lays awake staring at the ceil- ing and worrying about routine work issues, what the future holds for him, and how he would support himself and his family if his company went bankrupt. it makes him sick to his stomach to think about losing his busi— ness and not having health insurance to covar the allergy shots his daughter needs. Mr. Y went to see an internist and a gastroenterologist, but his exams were normal and his symptoms Were thought to be "anxiety related." He calms himself down oceasionally with a beer or two but denies any alco- .‘ hill-related problems. He tried cocaine a couple of times in his early 205 but did not like the feeling and denies using any other street drugs. He feels sad but denies feelings of worthlessness or suicidal thoughts. F283 DCT-EE-EE’IBE 15:42! TUFTS PSYCHDLCIGY DEPT . 6176273181 13.1214 I, i 100 1011501411" 7-101 1:19:1st 007‘s 0:11 s0 .DSM-IVJI'R Diugsmsis Axis 1: 300.02 Gemrsssed Axixiety .13001-0m 1 Axis II: V71 .09 N0 diagnosis Axis III: None f Axis IV: Marital stress, problems On the job -,, Axis V: GA}: t 65 . ‘ DSM-IV-TR dia-gflostic criteria for . ‘ I.” 7 IHBOQ-flZIGefleralizéd AnXiety‘ Disorder “ Ekc‘iéssisis WQrfyleii-ipreheiisiiié expeiiiaiion), Datusiiiig mam: “01210310112051; 6 mbriihs, ‘iibp'utl‘s number-I01: sirents or atti‘iriti'es (50"‘1153 cirkor'schcsbl filérformsnéce) : ‘ ' ' * ' ‘ ‘ ‘ .Idiffifiiill: 1:0 Cdntrql‘the West-11y; I' hesiixiety In twnsrry aré‘associated with-three [mfinorélgflt‘hé ibilciwi u “10's six mfifliifigz‘ (with st .iéist'ssms 0013mm: ‘pré‘ssnt'fo'rmofs fie-1'15. I hsri'not'fafthe‘psistfi mdnt'h's] Misti-g: th‘yuoné'itgm‘is [EQuirEd 0111111-” 1 1' :"‘ " 1‘ r I‘ ‘ 1' . ."' ‘ - ‘ -‘ ‘I ‘ és'tlssssssissiséiiiis#5961170???50135120 5-3 21 {be r [y‘vfatigued '9 "if sgr‘tyssssssssssgj'sr'isms 85011130111111] - 4:} 0 02" (difficiiiiy f 0i saying-1511:0123; 017 {asses-.505. fr amass- ‘tlié-I-szfiisigty011121sz‘misLfiloillééfififie'd00130500111700Df‘afi‘AxisI V ‘ispitiéiyfleg "fhé-‘sriq'éiety 01f 'is‘ndi: abd'iijt havirigs Pfihifi (as in: ssié‘jmsdrd‘ ,’ hams smfilsr'rssj‘ jdfin‘public' (as is ‘sbjgi‘al'lPhubiaJ, being ‘ it” d in-i‘Qbséssi0ej€Q010p11kivéiDis0id§r1fbéihg from ‘ 111m:(as-m,sssssssssiixnmeiyDismiss],gsipmgwsgm' s ~ _ sis-mamas);dissing“multipiegphyssssl"complaintqas m," .,offiatiifitibfi D.i501*d§17),‘; ‘orfli‘lhlavihg'fla $E.fi§fi$.giiin'055 [115.111 Hypnéhfifidi’i- (331$) 1:11.10 Weiryfdo Extiiisiiiéiy'dfiring Postirmfl " ~ Qr‘pii Syniptd‘a-msxc'isuscefiiliiiicslly‘ Signifit'shi‘dis- i' H iltréss'fp'rf‘iippsifitiént"irijsdciiai;f'gccfipatidiisi, onlbihér iinpoi‘tfiifflisress of ‘I: .,-:- 11:92 is dueltdi'thélsiiregtj‘physiiriogiés].Effects 0f 11 51113-1: .3 s z ., Tidifiswfabussssis'edisafisrilsré'géhsfalfi‘iéditalcofidisisn. ' ‘h'ypéstsyrsiaissfl misuse; not."sagas-textlhsively;durisgsgmms ' 'Psybhagic Discidégar‘s Péévssive“pgbiaellopménial Disofder. J DCT-EE-EIZIEIE 15:41 TLIFTS PSYCHOLOGY DEPT 61715273181 P E15 ml- ‘ M “if-Til. CASE S'l'llifii'iiii Assistir ill-llsmile!!!“1-2? L1, 5 1 Guidelines for Differential Diagnosis offienernliaed Anxiety Disorder Since Generalized Anxiety Disorder was introduced in DSM-iil, it has been one of the least successful diagnoses in the manual. With each iteration. of the system, the criteria set for this disorder has undergone additional changes in an effort to increase its redability, clarify its boundaries, reduce heterogeneity, and help to predict treatment response. There has been much controversy concerning whether the emphasis in the criteria. should be on cognitive symptoms [such as excessive worry) 01‘ on the somatic symptoms of anxiety (such as muscle tension or fatigue). The definition of the disorder given in DSM-IV (and DSM—IV—TR) is yet another attempt to balance these two aspects of the disorder. Those who believe that somatic symptoms are the most important aspect of Generalized Anxiety Disorder feel that the DSM—IV definition places too much emphasis on excessive worry, whereas those who are strongly oriented toward cognitive therapy think that the con— cept of excessive worry is integral to the definition. It is of interest that both the somatic and cognitive aspects were included under Freud's definition of anxiety neurosis. Mr. Y has been Worrying excessively about many everyday issues (eg, keeping his company going and keeping his health insurance to cover his daughter’s allergy shots] and has also been experiencing somatic symptoms such as a feeling of inner agitation and being "keyed up” as well as stomach upsets and diarrhea. Another concern in developing the DSM-IV criteria was to reduce the overlap with Panic Disorder. A number of symptoms that were more charac- teristic of Panic Disorder were deleted from the DSM-III—R Generalized ‘Anxiety Disorder criteria set to arrive at the DSM—IV' definition. The most important features for the differential diagnosis of the two disorders are the I ‘ different characteristic sympmms and the very different time course. Panic ‘I Disorder is characterized by a crescrindo effect, with attacks beginning and ‘ ending quickly, whereas Generalized Anxiety Disorder is more a way of life, I' with the anxiety a pervasive presence in the individual’s everyday existence. For example, Mr. Y has tended to be a worrier all his life, agonizing in college 1: over the right restaurant or flowers to choose fora date and over how well he Would do in his studies, despite his good performance. If criteria are met for both disorders, however, both can be diagnosed. Another important differential involves the aches, pains, and worries of ev— E‘Wdaylife that nearly everyone experiences at one time or another. The E critea “On fer Generalized Anxiety Disorder, requiring that "the anxiety, Worry, or thSi‘lal Symptoms cause clinically significant distress or impairment in social, fecupational, or other important areas of functioning, " is included precisely to . TLIFTS PSYCHOLOGY DEPT 617627318 ‘ 1 REE: 188 DSll/lle-JTR {EASE S’l‘liflllls A; help make this distinction. in addition, the criteria require excessive anxiety g 5.3 and worry that are present more days than not for at least 6 moot hs as well as the ' H presence of at least three somatic symptoms [in adults}. ill-teas retpiirements l (:1 are included to help ensure that Generalised Anxiety Disorder is not over- ‘ U diagnosed in individuals with everyday worries and problems; however, this is E ultimately still. a matter of clinical judgment that may be influenced. by the eval- uator’s cultural background and onto tendencies toward worry. Although Mr. Y has been a “Worrier” all his life, his worry and Somatic symptoms appear to have interfered significantly with his functioning only during the past year. He has been worrying almost censtantly about everyday affairs; has frequently had trouble sleeping; has been extremely irritable and yelled at people, including his daughter; has had difficulty concentrating at Work; and has experienced somatic symptoms that were severe enough for him to seek evaluation by an internist and a gastroenterologist, who could find no physical cause for his problems. Therefore, a diagnosis of Generalized Annie ety Disorder would seem appropriate for Mr. Y at the time of this evaluation, although his symptoms would not have warranted such a diagnosis when he Was younger. Note that anxiety frequently occurs as an associated feature in many other mental disorders and is also a side effect of certain medications and sub- stances. Generalited Anxiety Disorder would not be diagnosed when the amt- iety is part of another mental disorder or is due to the direct physiological I effects of a substance or a general medical condition (see CrltEria D and F). -“-_'-(-§:*;.o‘. ix; .- u._.;._a-—u:— 2‘ i t Treatment Planning for Generalized Anxiety Disorder The treatment of Generalized Anxiety Disorder is an area that has received relatively little study. Because there may be heterogeneous presentations of this disorder, different treatments may be effective for different types of presentations. The results of the studies that have been done are not particw larly Satisfying or clear-cut enough to suggest any firm recommendations. A variety of medications have been tried without resounding success. Many individuals do seem to benefit from [and want to take) anxiolytic or antide- ‘ pressant medications. A cognitiVE-hehavioral approach that focuses on the target symptom of worry and the avoidance that results from this worry is often helpful. A combir nation of medication and cognitive therapy may be particularly helpful. Indi- viduals with this disorder also sometimes do well with psychodynamic treatments that try to uncover the underlying unconscious dangers that are con- cealed under the EVeryday worries with which the individual is preoccupied. UCT‘EE—EEBE 15: 42 TR CASE STUDIES {hire eXCessive anxiety 6 months as well as the. These requiremrents Disorder is not oVer— blerns; however, this is influenced by the eval- d worry. * his worry and somatic I h his functioning only stantly about everyday :xtremely irritable and .culty concentrating at rere severe enough for ologist, who could find is of Generalized Anxi— time of this evaluation, :h a diagnosis when he :iated feature in many 11 medications and sub iagnoaed when the anx— . he direct physiological :e criteria I) and F]. l 1 area that has receive an done are not particu .‘n rocommendations.lA sanding success. Mari :e) anxiolytic or antide the target symptom? . often helpful. A comb}: articularly helpful. Indi l with psychodyna ous dangers that are cofi ' dividual is preoccupied TUFTS PSYCHDLDEY DEPT Anxiety Disorders Summary El?62?3181 P - 3?-.- 189 Generalized Anxiety Disorder was one of the least reliable diagnoses in DEM—Ill and DSM-IIi—R. It is not yet clear whether the changes made in the DSMJV definition or“ the disorder will improve its reliability. Partly as a re— sult of the lack of diagnostic clarity, very little systematic research has been done on the treatment for Generalized Anxiety Disorder. TLIFTS PSYCHEILEIEY DEPT 6176273181 F' [38 ass I insoles/Ira. (sass S'l"‘iiifiii tall factual overlap in which individuals who really had only one Eating Blane-"tier nevertheless received two diagnoses. The diagnostic: algorithm was revised in I DSM—IV so that the diagnosis is either Anorexia Nervosa, Binge-Eistth Purging Type, if the patient is markedly underweight, or Bulimia Nervosa, ii" the patient is normal weight or overweight. The following two cases will ill'us-u trate this distinction. Anorexia NerVosa «a Case Study. The Very Thin Ballet Student1 Ms. R is a very thin 1 Bwyearuold single ballet student who comes in at the in- sistence of her parents for a consultation concerning her eating behavior. The patient and her family report that Ms. R has had a lifelong interest in ballet. She began to attend classes at age 5, was recognized by her teachers as having impressive talent by age 8, and, since age 14, has been a member I of a national ballet company. The patient has had clear diffiCulties with cat- ing since age 15 when, for reasons that she is unable to explain, she began to induce vomiting after what she felt was overeating. The vomiting was pre- l ceded by many years of persistent dieting begun with the encouragement of l her ballet teacher. Over the past 3 years, Ms. R’s binges have occurred once E a day in the evening and have been routinely followed by self—induced vorn- i iting. The hinges consist of dozens of rice cakes or, more rarely, a half gallon of ice cream. Ms. R consumes this food late at night, after her parents have ‘ gone to bed. For some time, Ms. R’s parents have been suspicious that their daughter has a problem with her eating, but she consistently denied diffi- culties until about a month before this consultation. Ms. R reached her full height of 5'8" at age 15. Her highest weight was 120 pounds at age 16, which she describes as being “fat.” For the past 3 years, her weight has been reasonably stable at between 100 and 104 pounds. She exercises regularly as part of her profession, and she denies the l use of laxatives, diuretics, or diet pills as methods of weight control. Except when she is binge eating, she avoids the consumption of highefat Foods and l sweets. Since age 15, she has been a strict vegetarian and consumes no meat 1 or eggs and little cheese. For the past 3 or 4 years, Ms. R has been uncom- fortable eating in front of other people and goes to great lengths to avoid such situations. This places great limitations on her social life. Ms. R had two spontaneous menstrual periods at age 15 when her weight was about I l .m— 1.Thanks to B. Timothy Walsh, M.D., of the New York State Psychiatric Institute for supplying these cases. ‘b‘b'b’b'b H UCT-EE—EE’IEE 15:43 TLIFTS PSYCHOLOGY DEPT 6176273181 FUZEI WTR EASE 51111131133 Eating Disorders 241. nly one Eating Disorder 1.. 120 pounds, but she has not menstruated since. algorithm was revised in ; . After completing high school, Ms. R became a full-time member of the Nervosa, Binge-Eating/ " , ballet company. Ballet classes arid rehearsals occupy her Jr‘or about 4 hours a r or Bulimia Nervosa, if ,, clay, and she Spends most ofthe rest of her time reading. She finds historical novels particularly interesting. Ms. R’s parents describe her as being a serious and able student, al— though they are concerned about her social isolation. She has few close girl~ friends and has never dated or had any sexual experiences. During the interview, the patient is embarrassed and somewhat guarded in describing her eating behavior and chooses her words carefully. She re« ports some concern about her inability to control her overeating but thinks she has no particular problems otherwise. Her demeanor is serious and hu- wing two cases will illus_ . 1 lsmdem “1011355: 131113 She C1035 not seem depressed. There is no evidence of a formal thought disorder. rho cornea in at the in- g her eating behavior.- . I :1 a lifelong interest in DSMJV-TR Diagnosis prized by her teachers 4, has been a member .r difficulties with eat- ‘Axis I: 307.1 Anorexia Nervosa, Binge-Eating/Purging Type ' Axis 11: 301.82 Avoidant Personality Disorder 3 explain. she began to Axis 111: 626.0 Amenorrhea ['hevomiting was pre- . . ' Axis 1V: None the encouragement of - ‘- "Axis V: GAF = 65 ea have oceurred once lby self-induced vom- ‘ are rarely, a half gallon after her parents have :n suspicious that their isistently denied diffi- ier highest weight was ' rig "fat." For the past ' Between 100 and 104 ‘ ion, and she denies the weight Control. Except a of‘high-Fat Foods and j and consumes no meat 115. R has been uncom— great lengths to avoid ‘ social life. Ms. R had .1 her weight was about : State Psychiatric In 't DCT~23—EIZ’IIZ’IE~ 15:44 TLIFTS PSYCHDLDEY DEPT k. .. 6176273181 p.121 24-2 ass/raves. case armies _ .,m——-‘-.._._.... ----——--_ i-——-——.. --——-1 r- ‘—-—-—----.. n------—-u-- --———- uv---_1- .——-----‘- --‘-———------ r-----———-...___.,_ .- a, . anarchicaria-rarer, 1 ' w 1 3207-1 Messier?Nearesaf‘lagntiaaadljj‘g 93.1“. ' I I - w y g- . g . , ~ ; . r . .; . -. ~ '5 ‘ engagementassessaaransnewsman-tagspangs ;'_ V “has'nor‘ireéghla'rlyjengdgfdl“‘bfnsstfltllfla iiififi‘dilfisVliEhai’liir,liaise”? - ‘ Bulimia Nervosa a- Case Study: A Young Woman Who Can't Stop Eating Ms. T is a 28-year-old single insurance policy analyst who presents for con- sultation regarding her eating problems. She is the third of four children of a welluto~do Midwestern attorney and his wife, who was a homemaker while Ms. T was growing up. No one in the family has had a problem with being overweight, but a premium has always been placed on being strong, fit, and “in shape." As a child, Ms. T was a good student and an athlete and developed an interest in figure skating. As a young teenager, she placed well in local competitions and gradually devoted more time and energy to training. . At age 15, as she entered her sophomore year of high school, Ms. T transferred to an‘ all-girls boarding school in the East because her parents felt this would increase her chances of being admitted to an Ivy League col- lege. She made several Friends, did well in her courses, and generally coped well with the demands of the new school. She continued to pursue her in- terest in figure skating and began training with a new coach. Although for the most part supportive and encouraging. the coach did comment on one occasion that Ms. T might do better competitively if she lost a few pounds. At this time, Ms. T's weight was 128 pounds, normal for her age and height of 5'7", and her diet was not unusual. Stung by her coach's remark, Ms. T embarked on a vigorous program of exercise and dieting. In addition to her daily skating practices, she went to an aerobics class 6 days a week. She also eliminated desserts and red meat from her diet. Because of the time- consuming nature of these activities, she grew distant from the new friends she had made at school. EICT-EB-EEIBE: 15:45 TLIFTS PSYCHOLOGY DEPT 6176273181 P.11 Eating Disorders 243 are case sruoiss During the first year at boarding school, lVls. T’s weight dropped from 128 to 100 pounds, and her menstrual periods, “which had been regular since age 13, ceased. When she returned home for summer vacation, Ms. T's parents were very concerned by her obvious weight loss and insisted that she see her pediatrician who, in turn, referred her to a psychiatrist. it is not clear what diagnosis was made and, after a few visits, Ms. T refused to con- tinue treatment. During that summer, however, her eating habits began to change. Although Ms. tried to maintain the dieting program she had be« i H gun at school, she found herself struggling to control her appetite and, on several occasions, ate a box of cookies and a pint of ice cream late at night after the rest of the family had gone to bed. When she returned to school, Ms. T continued to intermittently overeat and eventually developed a pat- tern of dieting during the week and overeating on weekends. Although she continued to skate competitively, she was unable to maintain the vigorous exercise program she had initiated during her first year at boarding school. Her weight gradually rose through the rest of high school to 125 pounds, and her menses resumed after 9 months of amenorrhea. After she graduated from high school, Ms. T entered a competitive Ivy League college where she majored in history and was a good, but not out- standing, student. Her weight continued to rise, reaching a high of 150 pounds in the fall of her freshman year. When she was home for Christmas that year, she found herself unable to stop eating the holiday cookies and snacks in the house. Greatly distressed at the prospect of gaining more weight, she decided she would induce vomiting after overeating. She did so and thus began a pattern of overeating and then inducing vomiting several times a week that has persisted for the past 10 years. On nights when she knows her roommate will be out, Ms. T typically buys a pint of ice cream and a box of checolate chip cookies on the way home from work. After ar- riving home, she consumes the cookies and ice cream and any other leftover desserts in the refrigerator over the course of an hour while she watches TV She then induces vomiting. Ms. T is very ashamed of this "disgusting habit" and has resolved to stop on numerous occasions; however, she has been un— able to do so for more than 2 weeks at any given time. When she is not over— eating, Ms. T attempts to diet rigorously. She continues to avoid red meat and desserts and her weight is reasonably stable at 145 pounds. She views her appearance as "gross." Ms. T has been reasonably successful professionally. Since graduating from college, she has been employed by a large insurance firm and is pro- greasing well in the middle—management ranks. She shares an apartment with a woman whom she views as her best friend but whom She has not told about her eating problem. Ms. T reports that her social life has been irn- PP-ired by her concern about her eating and her weight. She is self-conscious about both and is reluctant to go to dinner with male friends because she fears that her strict dieting will seem incongruous in light of "how big I am." .‘t Stop Eating rho presents for con- ‘d of four children of a was a homemaker i had a problem with iced on being strong, at and an athlete and iager, she placed well time and energy to f high school, Ms. T because her parents to an Ivy League (201- I . and generally coped led to pursue her in- coach. Although for did comment on one he lost a few pounds. ; or her age and height )ach's remark, Ms. T : 1g. In addition to her :lays a week. She also ecause of the time- ‘ I from the new friends ‘ DCT-EE-EBBE 15:46 TUFTS PSYCHOLOGY DEPT 61762?3181 an , awn [ll 5 1W ‘ H i i’jsflgams i fififlsl” lifi7.fii Hufirnhiisesvusa,ianing‘f “‘ ‘ BUY-Hi Anorexia Hers/rise Write“ l-iisinw , Axis ll: Vii DE} No diagnosis Axlfi lil: None Axis TV: Nhr‘i‘i' Axis V1 GAP {55 t DSMJV-TR ding iostie criteria for 307.51 Bulimia Nervosa IIIIIn-IIIIliIInuIIIIIIflnnnInuHun-unnnnunum-i-n-Iul-Il l A. Recurrent episodes of binge eating. An episode of binge eating is charan teriaed by both ofthe Following: ‘ ' [1) eating, in a discrete period of time [e.g., within any 2-hour period), ' an amount of food that isclefinitely larger than most people would ‘ i eat during a similar period of time and under similar circumstances {2) " alsense of lack of control over eating‘during the episode (e.g., a feel- ingthat one cannot stop eating or control what or how much one is ‘ . eating)...‘, - - _ I i B, ‘ Reeurrentinappmpriate compensatory behavior in order to prevent weight gain, such as self-induced femitingjniisuse of laxatives; diuretics, enemas, ‘ or- other meglications; fasting,- or excessive-exercise. ‘ ‘ ‘ C, The binge eating and inappropriate compensatory behaviors both occur, "onlavera'ge, atfle‘ast twice a Weelr. for Brnonths. ‘ . j 1 'D. ‘LSelfievalu'ation is unduly influenced lay body shape and weight. E -‘ The disturbance-does not occur exclusively during episodes of Anorexia I ' Nereos'a.‘ {337 = " ‘ ' ‘ ' ' ‘ .I‘Spacifltyperr.‘ a ‘1‘ f. e e ‘ , e e M PurgingType: adoring the current episocie ofBuliinia Nervosa',tl1e person has T gregmilatly‘lengaged in self-induCed vomiting or the misuse of laxatives, eli— u '- qualities-1a: enemas , l ‘ ' a. ‘ ‘ I I ' I ' ' ‘ ' ' ‘Nonpurging Type: during‘the Current episode of Bulimia Nerrosa, the person " sinuses other inappropriate. compensatory behaviors, stick as'fasting or ex- , cessive'exereise, but has not regularly engaged in self—induced vomiting or t I the misiise of laxatiVes, diuretics, or enemas ‘ ,._. .,__ A..._..M-.—_.u--—m———-- a..__ u—__..-.—._..-__..- .,—. Guidelines for Differential Diagnosis ofEating Disorders The cases of Ms. R and Ms. T illustrate how to distinguish between the diag- noses of Anorexia Herman and Bulimia Nervosa. Ms. R, the ballet dancer, re- P. 12 ‘~“4m*mm.h i, E. 3? Hfi."-w3"]!"r‘("; (“J '7'G‘Hcrorr' 37 211 <‘ U'Z'll'tifbnejf-s "1:3 (DELU- 5 Elf'fir'FHU-IT' EICT-EB—EEIBE: 15:46 TLIFTS PSYCHOLOGY DEPT 6176273181 P.13 V-"l"R CASE STUDIES Eating Disorders 3245 selves a diagnosis of Anorexia l‘lervosa, Binge-Eating/l7’urging Type, because her body weight of 100—104 pounds is less than 85% of that expected for someone who is 5'8", and she has been amenorrheic for the past 3 years (since. age 16). Ms. R is intensely afraid of becoming fat and has a very seri- ously distorted view of her own body size, describing herself as “fat” even though she weighs only 100 pounds and everyone around her finds her ema— ciated. The subtype “Binge-Eating/Purging Type” is applicable here because Ms. R hinges on rice cakes or ice cream each evening and then vomits. Ms. T has a history of Anorexia Nervosa, but her current diagnosis would be Bulimia Nervosa because her weight is now not below that which would be expected for her height of 5'7" and she has regular menstrual periods. She reg- ularly binge eats and then vomits in a pattern that has continued over the past 10 years. She also has a distorted sense of her own body, considering herself to be “gross” at 145 pounds. The subtype “Purging Type” is applied because of Ms. T’s regular self-induced vomiting. It is important to note that the diagnoses of Anorexia Nervosa and Bulimia Nervosa are not fixed for a lifetime and often alternate as a result of weight gains and losses. Ms. R’s diagnosis of Anorexia Nervosa would change to Bulimia Nervosa if she were to gain enough weight to be within the normal range or her periods Were to resume. On the other hand, Ms. T’s symptoms would have been diagnosed as Anorexia Nervosa when she was younger be- - ‘ cause her weight was very low and she was amenorrheic, even though she also if engaged in binge—eating and purging behavior. Iv-Ier diagnosis changed to I ‘ Bulimia Nervosa when her weight increased to a normal level and her periods resumed. Although this convention is certainly less than elegant and there may be patients who fall .in a borderline area at certain times, it does avoid the problem of describing a single set of symptoms with two separate diagnoses. : it probably would have been better to handle these disorders in the diag« 'nostic system by including a single Eating Disorder with different subtypes depending on a patient’s current weight and menstrual status and on the pres ence of binge‘ea‘ting and purging behaviors. ‘ Nonetheless, the separate categories of Anorexia Nervosa and Bulimia iNervosa have been maintained in DSM-IV (and in DSM-IV—TR) in part because of their different treatment implications and in part because the -'DSM-lV Task Force was very conservative in making changes. Moreover, In hereare many individuals with Anorexia Nervosa who never binge or purge Who would receive the diagnosis Anorexia NerVosa, Restricting Type} and many individuals with Bulimia Nervnsa whose weight has never been below nrmal. Dry) ‘ In diagnosing Anorexia Nervosa, it is important to distinguish abnormally inguish between the dis 0 b I .W Indy Weight from "normal" thinness, particularly in people who Work in is. R, the ballet danceni DCT-EE—EEBE 15:48 TUFTS PSYCHOLOGY DEPT 61769?3181 246: DEM-Willi CASE S'Tllfliil professions that require low body weight. Although Ms. R is a dancer and is quired to maintain a fairly low weightli'or this profession, her weight loss has gone far beyond what is required for her dancing and is accompanied by bra-- tures that are characteristic of an Eating Disorder (e.g., excessive fear or" Weight gain, a distorted body image, amenorrhea, and binge eating and plug ing). It is also important to rule out other causes of weight loss (e.g., general medical conditions such as cancer, the effects oiT other mental disorders such as Major Depressive Disorder, or the effects of poverty or poor nutrition} from weight loss that is due to Anorexia Nervosa. In diagnosing Bulimia Nervosa, it is important to distinguish a regular pats tern of binge eating from behavior that involves generalized overeating (often called “grazing"] and from overeating that occurs in a specific context on a special occasion (e.g., a party or holiday celebration). To make this distinction, it is helpful to determine what types offood Were eaten (hinges most often ind volve sweet, highacalorie foods], how much was eaten (to qualify‘for a binge, the amount eaten must be what would be considered excessive for most indi- viduals in that situation], the circumstances in which the binge eating took place, and how often the binge eating occurred. Ms. T’s binge eating usually involved cookies and ice cream, she hinged when she was alone and um observed, and she had been doing this regularly (several times a week] For 10 years. She consumed a quantity of food that is clearly excessive in those cir— cumstances to most individuals. To make the diagnosis of Bulimia Nervosa, the individual must also use “inappropriate compensatory behaviors to prevent weight gain." These be- haviors most often involve self—induced vomiting or laxative abuse [in which case, the subtype “Purging Type" is used) or less often may involve fasting or excessive exorciSe (in which case, the subtype “Nonpurging Type” is used]. Ms. T regularly induces vomiting after her hinges in a pattern that began when she was .a teenager. The vomiting that occurs in Bulimia Nervosa is self- indueed and is doue for the purpose of avoiding weight gain the to the binge eating. This must be distinguished from vomiting that is caused by a general medical condition or by the use of substanCes. Overeating and weight gain may also occur in Major Depressive Disorder With AtypiCai Features. However, the type of overeating that is associated with depression is not associated with inappropriate compensatory mecha' nisms or a distorted view of one’s body weight or size. Binge eating may occur as part of the impulsiVe behavior that is character» istic of Borderline Personality Disorder and is usually not accompanied by in- appropriate compensatory mechanisms to avoid weight gain. However, Borderline Personality Disorder and Bulimia Nervosa are often comorhid, and, when criteria for both are met, both should he diagnOSEd. P.1d lT‘fl-‘J CLH I‘T‘t") DCT-EE—EEIBE: 15:48 TLIFTS PSYCHEILEIEY DEPT 6176273181 P.15 not case Srtioies Eating Disorders 247 Two other disorders that may siznnetimes be confused with Eating Dison ders and may also be contorbid with them are Obsessive—Compulsive Disorder and Body Dysrnorphic Disorder: Individuals with OboessiveeCompulsive ' Disorder may have obsessions or compulsions related to food, but they are not driven by an intense fear of weight gain. Their obsessions and compulsions also include concepts that are unrelated to food or eating [e.g., contamination, hurting someone, or damaging something). Like individuals with Eating Dis- orders, those with. Body Dysmorphic Disorder have a distorted image of their bodies, but this is not related to an intense fear of gaining weight and is not associated with low body weight. if the body image problem is characteristic of Anorexia Nervosa, no separate diagnosis of Body Dysrnorphic Disorder is necessary. in some cases, however, both diagnoses may be present, for example, an individual who meets criteria for Anorexia Nervosa who also has a pathological preoccupation with the idea that her nose is ugly and mis~ shapen. . Individuals who binge eat without using compensatory mechanisms to ' avoid weight gain may warrant a diagnosis of Eating Disorder Not Otherwise Specified if their behavior invoIVes impairment or distress. Binge-eating dis~ order is a proposed diagnosis to describe this situation. As might be expected, these individuals tend to be overweight. Binge-eating disorder is listed as an example of Eating Disorder Not Otherwise Specified with research criteria included in the appendix for "Criteria Sets and Axes Provided for Further 9' Study. ” ls. Ris a dancer and is re- sion, her weight loss has lis accompanied by fea- [e.g., eXcessivc fear of d binge eating and purg- veight loss [e.g., general er mental disorders such verty or poor nutrition] distinguish a regular pat- I ' 3 ralized overeating (often " ' n a specific context on a To make this distinction, :en (hinges most often in- gn (to qualify for a hinge, I d excessive for most indi- ' ich the binge eating took 3 5. T's binge eating usually ‘. 1 she was alone and un- n? H E. r-e E m tn 3} m it L...» E” H ,._. D rly exceSsive in those cir- “Treatment Planning for Eating Disorders apattern thatbeganwhe Both Anorexia Nervosa and Bulimia Nervosa can involve serious medical ‘ complications, particularly Anorexia Nervosa. Complications associated with fight gain due to t H Ammrexia Nervosa include constipation, abdominal pain, cold intolerance, that is caused by a gent: 'ethargy, excess energy, significant hypotension, hypothermia, dry skin, and ‘ bradycardia. Some individuals develop lanugo, a fine downy body hair on Aajor Depressive Disofdl their trunks; peripheral edema; skin yellowing; hypertrophy of the salivary flaming that is associati’. glands; and (rarely) petechiae. In addition, individuals with Anorexia Ner- YDsa sometimes exhibit laboratory abnormalities and several general medical . nOrmochromic normocytie anemia, impaired renal function, ,ardiovascular problems, dental problems, and osteoporosis. The long-term mortality of individuals with severe presentations of Anorexia Nervosa who E, admitted to university hospitals is more than 10%. Death most comr manly results from starvation, multiple organ failure, electrolyte imbalance, lCide_ :3 p. .... L". O :1 “3 - size. . :behavior that is char ' Lily not accompanied lily-1‘ .d weight gain. Hows“. rvosa are often comm be diagnosed. EC DCT-EE-EBIZIE: 15:49 TLIFTS PSYCHOLOGY DEPT 6176273181 F' 16 1243 i135 M.» W" CA3 F .7. 3111131135 Complications associated with Bulimia Neryosa include significant loss of dental enamel due to recurrent vorniting; increased number of dental. cavi- ties; enlargement of the salivary glands; and, rarely, potentially fatal problems, including esophageal tears, gastric rupture, and cardiac arrhythmias, Fortunately, both of these conditions can usually be treated successt'ully if intervention is timely. The treatment usually consists of some combination or" cognitive—behavior therapy and medication. Summary Although Anorexia Nervosa and Bulimia Nervosa are listed as separate diag— noses in DSMaIV-TR, they are often different aspects of a single Eating Dis~ order. Individuals with Eating Disorders are often remarkably embarrassed about their pattern of binge eating and purging, so the clinician should ask specifically about eating patterns, particularly in any relatively young woman who presents with depressive symptoms. DCT-EB-EEBE 15:49 TR CASE STUflililS :order [e.g., someone ssional drug dealer or . antisocial acts, other ~ Disorders or Schizo- used to describe indi- eloping or isolated an» they can be noted by . the DSM—lV—TR sec- :al Attention. ” e a pattern of behavior nosis of Conduct Dis— escent or young adult rs that are not severe liSorder, a diagnosis of e DSM-IV—TR defini- 1nnot be given to any- ~opriateness of a diag- iship of the behaviors " ‘l is in many ways an ex- , le with a proclivity for. tugs; however, people “ :ome involved in such rug use and peer pres— ‘ ole of drugs and peer". resence- does not‘pred :ity Disorder requires. ‘ sent and had its onset ' ither Personality Dis- V .. to G H Q... 41 ._.l H- :5 'U a: "1 E r: F‘— is: 1'! sorders. r Disorder appears to et killed or kill the gs .d become less ant part of the clinics ion. Individuals With TLIFTS PSYCHOLOGY DEPT 6176273181 P.1'?‘ Personality disorders 2'95 this Personality Disorder often also have episodes of depression that may re quire treatment and suicide rislt prevention, especially given the high suicide rate associated with the disorder. One major problem is where and how treatment should be provided. in- dividuals with Antisocial Personality Disorder are usually noncon‘ipliant with. outpatient intervention. PriSOn rehabilitation programs have not been very ef- fective , and these individuals become wolves among sheep when hospitalized in psychiatric facilities, as Seen in the way Mr. V behaved during his psychiat- ric hospitalizations. Ifthis discussion of the treatment ofAntisocial Personal- ity Disorder sounds pessimistic, it is meant to. Borderline Personality Disorder a Case Study: A Woman With an Unstable Life Ms. E is a 25~year~old woman brought to the emergency room by her boy— friend, who has become progressively more alarmed at her complaints, de- mands, and erratic behavior. Her chief complaint to the staff is “I keep thinking about wanting to kill myself. ” Ms. E is a competent secretary, has her own apartment, and is self—supporting. She is also attending university classes in the evening because she wants to advance her education and does not “want to stay a secretary all my life." The current crisis began when her boyfriend, Mr. M, refused to cons sider her demands for marriage after a 2—year exclusive relationship. Ms. E began to call him at work demanding more and more time, finally threaten— ing to kill herself if he didn't spend every evening with her. Mr. M reported that her demands, phone calls, and escalating threats were becoming intol- erable and were making him want to break off the relationship entirely. On the evening Mr. M brought Ms. E to the emergency room, he had told her that he had to go on a business trip and would be away for several days. Ms. E insisted that he was doing this just to get away from her. She became severely agitated and began to talk wildly about killing herself. In the eme r- gency room, Ms. E angrily belittles her boyfriend in front of the staff and accuses him of using anti then rejecting her. After physically separating the arguing couple, the staff is able to obtain a history of the progressive devel- opment of Ms. E’s symptoms. In response to the stress of the past several months, Ms. E has devel- oped fluctuating depressive moods, a tendency to oversleep [especially sleeping in the evenings and on weekends), and a tendency to binge eat that has reSulted in a 20wpound weight gain. Ms. E says she is constantly anxious and has been having increasing difficulty concentrating on her studies. She has continued to work throughout this stressful period, seeking support DCT-EE-EE’IE’IE 15:58 TLIFTS PSYCHDLDEY DEPT 6176273181 P.1B i' l ‘ 1" {my-:11 tl'HJf-H,‘ ‘i'l her A?!“ lil‘fi.‘ i - . FL, . .'.3. '. a. ti iz-i‘ltgliift'i'nne or Mr iilwui Lilial..‘ilH‘tiri.l|11i:'vt.ifil L‘s/l5. ‘: imjlinjle 5:'n"i_)ltjii‘1jgei,l l'ilfliLiJJ-ifil " ‘Iijiijini ltilllnja, .T‘ i" lativl's‘vi-‘i'ii‘l and :: r'hi-Str‘e i'tr. mart " ll-"il'iii'rii'ia vv hen she is atoms ‘li£"‘H~" lic‘i‘s‘ell'. l'll'it.‘ says that or. several l_it_t_'.'iéi'l\'n'1.’i she has to“ her tingle; wail: .n,.‘. i :- ,,- , ‘ i\,..-3_.,. ,, .I, .,...,1.j.‘ 4.. ., -,t.'.t‘_. , , 1.. “(ages and use! hits wait. 1.1inh gaunt: mi l. [in as ii man; a ensuing”, some; i ‘ - . .. J , - i , _ ., , L i I ‘l't‘t‘lC-i lot and umittractive as weli as completely i.‘Li"iiLi\.«‘iil.;ic‘ and ‘wm‘tnacsa. Al. j . that at these shrub-t 5' and dead inside and feeling little pair: Ms. such moments, she calls Mr. M on the phone a mi threatens to t'ornrnit sni- t'itle tu'lless he comes and keeps her company. Mr. M reports that. she has also begun to lose control oi“ her temper. For example, shortly before he brought her to the sitter-geiicy room, she attacked him with her lists in the midst of an argument. ‘ Ms. E was the youngest oi: Four children and one of two girls. Her par-- ents separated and divorced when she was 3 years old because other father's alcoholism and physical abuse of his Wife and children. A family secret was that Ms. E was sexually abused when she was 10 years old by a brother 5 years her senior. In adolescence, Ms. E associated with a rebellious group and became involved in drug abuse and early sexuality to fit in. Ms. E said that her mother attributed Ms. E's teenage rebellion to a need to "find a father" and that she thought that Ms. E had gotten “her sexual urges confused with wanting to be loved and cared for." By age 16, Ms. E had already embarked on the pattern of chaotic unstable involvements with men that continues to ; characterize her adult life. Her Jfirst drug overdose occurred at age 17 in response to a perceived rejection by her boyfriend. A series of intense relationships followed this incident, each of which Followed a similar pattern: Ms. B would become progressively more clinging until she gradually alienated her partners. Each rejection was marked by a period of anger and self-abuse, Followed quickly by a new and identical relationship. Ms. E’s current boyfriend is only the latest in a long series of disappointing partners. DSM-IVTR Diagnosis Axis I: 296.32 Major Depressive Disorder, Moderate, ReCurrent, With Atypical Features, Without Full Interepisode Recovery, Without Preexisting Dysthymie Disorder Axis 11: 301.83 Borderline Personality Disorder Axis III: None Axis IV: Breakup of relationship with boyfriend Axis V: GAF = 35 (current); 80 (highest level in past year) DCT-EB-EEBE TR CASE STUDEES :o-Worlcers produces is they are with her. r1 she is alone. These l and a desire to hurt aer thighs with razor .m a distance, numb .t at these times she ale and worthless. At stens to commit sui— reports that she has e, shortly before he with her lists in the if two girls. Her par- ecause of her father's A family secret was a old by a brother 5 a group and became MS. E. said that her o “find a father" and Jrges confused with id already embarked Ien that continues to noose to a perceived nships followed this Is. E would become d her partners. Each se, Followed quickly .oyfriend is only the I' ‘I oderate, Recurrent??- ut Full lnterepisode Dysthymic Disorde- 15:58 TUFTS PSYCHOLOGY DEPT Ei?6273181 P.19 Personality ilitisorders 997 it ' I ‘ I DSiM--IV4TR‘diagnostie criteria‘for ' i ' ‘ 301-”.83 Borderline Personality Disorder ' - A'perirasive pattern of instability of interpersonal relationships, self-image, and ‘ affects, and marked impulsivity beginning'hy early adulthooda'nd preSent me i Ivariety of contents, as indicated by fiyeifor merelof'the following: , , i m" flank GNOME amiri mu m imagiii‘id'Iahsfidonment- "Note: no i ll hot iridude ‘SuiCidal "3ilieiimutiletinsibelievi'ereavei-ed it! ite'a . ‘ .rionS,”‘. " ~ - . ‘I I, I ‘i i‘ “apartment unstable ‘a'aa‘inisase: relationshipsshared. i . iteriz‘ed by alternating hetwe on estimates of idealjieation' an'dilde'ya-l‘ua. 5 " 1‘s .‘ Ciiisriefii "r. urrent‘suioidal Behave gestirr' 'li‘iihi‘iibi ‘ .. H I I affeetiveinstability due toa martedrea I I spits II I I .Iii‘id' fihliiiiiiélifi mfirsltbe I ,I_a'-f¢W d1" 3 Ith'ro'nio. sat-panes" aliases;assess.mi suit (centralisasess . dilaplaysof temper, “‘ " I , H I "s ind-[stressfrela I I I I I I H symptomsi' . '1'. {Guidelines for Differential Diagnosis of Borderline Personality Disorder Although Mood Disorders and Borderline Personality Disorder can often oi:- ur together (as was the case for Ms. E), they may also be confused with each "W161". The diagnosis of Borderline Personality Disorder is frequently used .ifiappropriately and pejorativer for individuals who are temporarily irritable, lidemanding, manipulative, and self~destructive during a Major Depressive Elle .30de- Such behavior does not warrant a diagnosis oi Borderline Personality "Disorder unless the features have an early onset, a pervasive impact, and a ore or less Chronic course. In some cases, the patient’s “borderline symp- “ms” disappear as the mood symptoms remit, whereas, in others, both diag- DCT-EE-EE’IEE 15:51 TLIFTS PSYCHOLOGY DEPT 6176273181 P.2lZi 29s; DSM-W-“i‘R case. an nails noses are warranted. An individual 's response to ‘treatl‘nent may be helpltil in, melting the distinction. The same kinds of issues apply-to individuals with Substance-“Rein i'ei‘l Problems who may behave in unstable and impulsive ways when intoxicated with substances but who may behave very differently when off SHl)Stifll1t‘Ti'.‘_§_ The clinician is faced with the same chicken and egg problem we discussed for Antisocial Personality Disorder: Because Borderline Personality Disorder is often characterized by self—destructive Substance Use, it can be very difficult to establish whether the destructive personality features led to the Substance Use or whether the Substance Use produced the impairment in personality. Borderline Personality Disorder tends to be cornorbid with many Axis i conditions, including Mood Disorders, Substance-Related Disorders, Eating Disorders (especially Bulimia Nervosa), Posttraumatic Stress Disorder, and Attention —Deficit/Hypera ctivity Disorder, each of which must be considered in the differential diagnosis. Because completed suicide occurs in 5%—l 0% of individuals with Borderline Personality Disorder, it is especially important to identify and treat comorbid Mood Disorders when they are present. Border- ‘ line Personality Disorder is also often comorbid with other Personality Dis~ orders. Treatment Planning for Borderline Personality Disorder In treating an individual with Borderline Personality Disorder, the clinician must first focus on the target symptoms of depression and Substance Use. After these have been evaluated and treated, several promising treatments that have been developed Specifically for Borderline PersOnality Disorder can be used. These include cognitive—behavior therapy (dialectical behavior therapy], which focuses on particular problems such as interpersonal rejection I sensitivity, selfsdestructive and aggressive behavior, depersonalization, and a tendency to see the world without shades of gray. Long-term psycho- dynamic therapy, with an emphasis on increasing insight and providing a corrective emotional experience, is also often very helpful. Whatever the treatment chosen, it is important to avoid creating conditions in which re- gression can take place or that reinforce suicide attempts. Hospitalization can often do as much harm as good and should be avoided or kept brief whenever possible Time is on our side in treating Borderline Personality Disorder. A number of studies indicate that the longsterm prognosis is surprisingly good because patients seem to mellow out with age. ...
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PSY71 - Case Histories - oer—233 : aeee 15 39 TLIFTS...

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