Cases From DSM-IV-TR® Casebook and Its Treatment Companion

DOI: 10.1176/appi.books.9781585622665.30967/ ^& U1 _" |; J0 E
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The Radiologist
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A 38-year-old radiologist is evaluated after returning from a 10-day stay at a famous out-of-state diagnostic center to which he had been referred by a local gastroenterologist after "he reached the end of the line" with the radiologist. The patient reports that he underwent extensive physical and laboratory examinations, X-ray examinations of the entire gastrointestinal tract, esophagoscopy, gastroscopy, and colonoscopy at the center. Although he was told that the results of the examinations were negative for significant physical disease, he appears resentful and disappointed rather than relieved at the findings. He was seen briefly for a "routine" evaluation by a psychiatrist at the diagnostic center, but had difficulty relating to the psychiatrist on more than a superficial level.
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8 p" |- u! E  }On further inquiry concerning the patient's physical symptoms, he describes occasional twinges of mild abdominal pain, sensations of "fullness,""bowel rumblings," and a "firm abdominal mass" that he can sometimes feel in his left lower quadrant. Over the last few months he has gradually become more aware of these sensations and convinced that they may be the result of a carcinoma of the colon. He tests his stool for occult blood weekly and spends 15–20 minutes every 2–3 days carefully palpating his abdomen as he lies in bed at home. He has secretly performed several X-ray studies on himself in his own office after hours.
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; y+ G! H, F; v* a, AAlthough he is successful in his work, has an excellent attendance record, and is active in community life, the patient spends much of his leisure time at home alone in bed. His wife, an instructor at a local school of nursing, is angry and bitter about this behavior, which she describes as "robbing us of what we've worked so hard and postponed so much for." Although she and the patient share many values and genuinely love each other, his behavior causes a real strain on their marriage.
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5 K0 Y+ p. W+ E) b# |$ CWhen the patient was 13, a heart murmur was detected on a school physical exam. Because a younger brother had died in early childhood of congenital heart disease, the patient was removed from gym class until the murmur could be evaluated. The evaluation proved the murmur to be benign, but the patient began to worry that the evaluation might have "missed something" and considered the occasional sensations of "skipping a beat" as evidence that this was so. He kept his fears to himself; they subsided over the next 2 years, but never entirely left him.* p/ ?/ b' q7 n$ w' Z  i

; P4 e4 V( N& ^; {, e( e1 P4 D& tAs a second-year medical student he was relieved to share some of his health concerns with his classmates, who also worried about having the diseases they were learning about in pathology. He realized, however, that he was much more preoccupied with and worried about his health than they were. Since graduating from medical school, he has repeatedly experienced a series of concerns, each following the same pattern: noticing a symptom, becoming increasingly preoccupied with what it might mean, and having a negative physical evaluation. At times he returns to an "old" concern, but is too embarrassed to pursue it with physicians he knows, as when he discovered a "suspicious" nevus only 1 week after he had persuaded a dermatologist to biopsy one that proved to be entirely benign.
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$ ]4 D& i# k3 e  [" UThe patient tells his story with a sincere, discouraged tone, brightened only by a note of genuine pleasure and enthusiasm as he provides a detailed account of the discovery of a genuine, but clinically insignificant, urethral anomaly as the result of an intravenous pyelogram he had ordered himself. Near the end of the interview, he explains that his coming in for evaluation now is largely at his own insistence, precipitated by an encounter with his 9-year-old son. The boy had accidentally walked in while he was palpating his own abdomen for "masses" and asked, "What do you think it is this time, Dad?" As he describes his shame and anger (mostly at himself) about this incident, his eyes fill with tears./ ~8 M$ Y+ c6 U, A. n2 Z
, {. n6 D# U2 |: r* g' l3 O" b! y+ WDSM-IV-TR Casebook Diagnosis of "The Radiologist"0 V: V- Q: g5 T  [3 k2 @2 E! |4 R" p( ^

  r3 k3 J2 H/ CIt is apparent that this doctor's symptoms are not caused by any general medical disorder. Preoccupation with physical symptoms can be seen in disorders such as Schizophrenia, Major Depressive Disorder, or Anxiety Disorders, but there is no evidence for any of these disorders in this case. This suggests, therefore, a Somatoform Disorder—a mental disorder with physical symptoms suggesting a general medical disorder, but for which there is positive evidence, or a strong presumption, that the symptoms are linked to psychological factors.+ k5 ~; j3 U* c! {; g  X" ?

; u/ ~- R! |' l8 ?; }A variety of physical symptoms not adequately explained by general medical conditions is seen in Somatization Disorder. In this case the symptoms are few, whereas in Somatization Disorder typically there are a large number of different symptoms that appear in many different organ systems. Furthermore, in Somatization Disorder the preoccupation is generally with the symptoms themselves. In this case the disturbance is preoccupation with the fear of having a serious disease resulting from an unrealistic interpretation of physical signs or sensations. The persistence of this irrational fear for more than 6 months, despite medical reassurance, indicates Hypochondriasis (see DSM-IV-TR).


DOI: 10.1176/appi.books.9781585622665.30981/ ~$ `; t2 [3 c3 @
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Rx Florida
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* Y) z4 K3 v' K" A1 lIn the winter of 1982, John Redland, a 42-year-old physician, married with two children, applied to a special depression treatment program of the National Institute of Mental Health (NIMH). He stated that over the last few weeks, he felt he was again slipping into a depression.$ N$ v  a3 E6 t# J" C: ~
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John says his first depression occurred at age 21 after he had moved to the Washington, D.C., metropolitan area from Florida, where he had lived until that time. Depressions recurred the next four winters, while he was in college and early in medical school. During the last of these episodes, John was hospitalized and was told that, because of his recurrent depressions, he was unlikely ever to succeed in becoming a physician, which had been his lifelong goal. He remained depressed and in the hospital for the next year, during which time he was treated with psychotherapy alone. His depression remitted in the spring and he remained free of depressions for several years, during which he completed medical school and his internship. However, the winter depressions had returned each year for the 9 years before he applied to the NIMH treatment program.( ~* o; F8 Q% [# T# U' S6 }# T
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John now realizes that all of his depressive episodes seem to follow the same pattern. They start around the first of December (plus or minus 3 weeks) and begin to lift by April. In most years the onset of depression is gradual, but sometimes it occurs more precipitously, apparently in response to some environmental stress. When depressed, John is lethargic, apathetic, irritable, and pessimistic. His mood is worse in the morning. He cannot sleep through the night. He craves carbohydrates (bread, cake, cookies) and gains weight. He has noticed that his winter clothes are often two sizes larger than his summer ones. He recalls feeling much better during a winter vacation in Bermuda, the mood improvement occurring a few days after he arrived there. However, he relapsed a few days after returning home. He also recalls one particularly difficult winter when he worked in Syracuse, New York. These associations between latitude, the weather, and his mood make him wonder whether the climate might actually be influencing his mood changes.
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5 p; I$ L1 Q( M. ]John has been treated for several years with psychotherapy and a tricyclic antidepressant, both of which he has found to be "quite helpful."
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1 d" s" p; X& x# H2 Y/ {DSM-IV-TR Casebook Diagnosis of "Rx Florida"" Z4 v" x" }6 U: S/ u. E2 {8 h
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There can be little doubt that John has a Major Depressive Disorder, Recurrent (see DSM-IV-TR). He has had numerous episodes of persistent depressed mood, disturbed sleep, increased appetite and weight gain, decreased energy, and loss of interest in usual activities. As he is once again "slipping into a depression," we note the current severity as Mild, although in the past his depressions have been severe.
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) H& z  R/ M4 lWhat is unusual about John's depressions is that they apparently all began in the winter and remitted in the spring. Recurrent mood disorders that regularly begin and end during a particular period of the year have been called Seasonal Affective Disorders. John's case illustrates the most common pattern, in which depression begins in fall or winter and ends in spring. Less common patterns involve recurrent depressions or Manic Episodes that begin in the summer and remit in the fall or winter. In DSM-IV-TR, the concept of Seasonal Affective Disorder is expressed with the specification With Seasonal Pattern (see DSM-IV-TR). The seasonal pattern should have been present, as in this case, during at least each of the past 2 years, with no nonseasonal episodes during the same period. Seasonal episodes should substantially outnumber nonseasonal episodes over the patient's lifetime.
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+ c7 V# g" n6 c6 y+ |John's weight gain and craving for carbohydrates are typical of patients with Seasonal Affective Disorder. In other ways John's case is atypical; most patients with Seasonal Affective Disorder are women, and most complain of increased sleeping (hypersomnia) rather than of disturbed sleep (insomnia).
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, F; b( J" f% K; {  F: rWhen John entered the NIMH treatment program, he was maintained on an antidepressant and entered a light treatment research protocol involving exposure for 3 hours, twice a day, morning and evening, to 2,500 lux of full-spectrum light. The light treatments involved his sitting 3 feet in front of a standard 2-foot by 4-foot metal light fixture containing six 40-watt Powertwist Vitalite™ tubes and glancing at the light for a few seconds every 1 or 2 minutes. After 1 week of treatment, he became much less depressed, and his Hamilton Rating Scale for Depression (Hamilton 1960) score fell from 21 to 8.
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After the formal light treatment study was over, John's antidepressant was increased. He was maintained on light treatment during the day and in the evening hours and remained free of depression on the combination of light and medication. John has used lights each winter since then and remains on the antidepressant during the winter months. He has been virtually free of depression and is not currently in psychotherapy.
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4 u& K# }- E0 c: X. p2 I& hLike many patients with Seasonal Affective Disorder, during the summer John is able to reduce the dose of antidepressant medication and discontinue the light treatment; however, in the winter he is unable to stop the light treatment for more than a few days without experiencing a return of his depressive symptoms.


DOI: 10.1176/appi.books.9781585622665.30999
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9 R+ y6 a6 U* ]4 ZSam Schaefer
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A psychiatrist was asked by the court to evaluate a 21-year-old man arrested in a robbery because his lawyer raised the issue of his competence to stand trial. During the course of a 2-hour evaluation, the patient acknowledged frequent encounters with the law since he was age 11 and incarceration in various institutions for criminal offenses, but was reluctant to provide details about them.* p, G& j0 H0 w9 e2 T
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During the interview the man appeared calm and in control, sat slouched in the chair, and had good eye contact. His affect showed a good range. His thought processes were logical, sequential, and spontaneous even when he was describing many difficulties with his thinking. He seemed guarded in his answers, particularly to questions about his psychological symptoms. He gave the impression of thoughtfully considering his answers before responding and seemed to be pretending a reluctance to talk about symptoms suggesting psychosis when, in fact, he apparently enjoyed elaborating the details of presumably psychotic experiences.' {  o. R3 B; x

6 p7 I! ]5 E" [0 W" _* c$ d3 ]1 i( SHe claimed to have precognition on occasion, knowing, for instance, what is going to be served for lunch in the jail; that people hear his thoughts, as if broadcast on the radio; and that he does not like narcotics because Jean Dixon doesn't like narcotics either, and she is in control of his thoughts. He stated that he has seen a vision of General Lee in his cell and that his current incarceration is a mission in which he is attempting to be an undercover agent for the police, although none of the local police realize this. He said that Sam Schaefer is his "case name." He felt that the Communists were taking over and were locking up those who would defend the country. Despite the overtly psychotic nature of these thoughts as described, the patient did not seem to be really engaged in the ideas; he seemed to be simply reciting a list of what appeared crazy rather than recounting actual experiences and beliefs.. f0 E6 a  a/ p& D( X

3 C; v1 t5 w- c, \3 i1 N. aHe was asked about the processes and procedures of a trial and stated that there was a jury, which he thought consisted of 8–10 friends. He also thought there was a judge present, who asked for money and made decisions about the procedure. He described the prosecuting attorney as someone who pointed out all your faults and tried to make the jury think that you were bad, and the defense attorney as someone who tried to point out your good points. He saw no particular reason why he could not cooperate with his attorney. When asked the date, he said that it was June 28, either 1970 or 1985. He then saw the inconsistency in the dates he gave for the year and said that this therefore must be 1978, as he was 20 and was born in 1958. When asked where he was, he said it was a Communist control center in Austin, Texas. He reported that he graduated from high school in 1976. When asked to do serial 7 subtractions from 100, his responses were 88, 76. Asked to do additions, he responded: 4 + 6 = 10, 4 + 3 = 7, 4 + 8 = 14. Asked to recall Presidents, he mentioned Ford and said that Agnew was President before him.
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; y8 e/ P$ S+ I& K+ JWhen asked the color of the red rug in the room, he said it was orange; his blue and white striped shirt he said was white on white. When presented with some questions from an aphasia screening test, he copied a square faithfully except for rounding the corners; a cross was copied as a capital "I." When shown a picture of a clock, he said he did not know what it was, but it looked familiar. A dinner fork was identified as a "pitchfork."
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When asked whether he thought he was competent to stand trial, he replied, "Yes," and said he did not think there was anything wrong with him mentally. When told that the examiner agreed with his assessment, he thought for several seconds and then, somewhat angered, protested that he probably couldn't cooperate with his attorney because he couldn't remember things very well, and therefore was incompetent to stand trial.9 u, v5 N$ i0 D5 w6 r
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DSM-IV-TR Casebook Diagnosis of "Sam Schaefer"0 ?" y# M0 d  u2 S! S, n5 X

' Q1 m1 Q! I0 }1 |) Y! P7 D+ c$ n( mThis gentleman is in trouble, and apparently he has concluded that his best chance of avoiding prosecution is to prove that he is crazy and therefore not competent to stand trial. He goes about trying to prove this by claiming to have a variety of unrelated bizarre beliefs and by giving responses to questions that would suggest severe cognitive impairment. However, he presents the responses in a manner that is inconsistent with the disorganization of psychological functioning that would be expected if the symptoms were genuine. Furthermore, some of his responses to the questions testing cognitive functioning, although clearly wrong, indicate that he knows the correct response (e.g., rounding the corners of a square indicates appreciation that a square has four sides). If there is any doubt about his motivation, it is eliminated when he becomes angry with the examiner for agreeing that he is sane and competent to stand trial.5 r( N2 T5 u3 y9 M0 \- M+ Z
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There is little question that in this case the "psychotic" symptoms are under voluntary control. The differential diagnosis is therefore between a Factitious Disorder and Malingering. Because the goal this fellow hopes to achieve is obviously motivated by external incentives (avoiding prosecution) and there is no evidence of an intrapsychic need to maintain the sick role, what is involved is an act of malingering, which in DSM-IV-TR is given a V code as a Condition That May Be a Focus of Clinical Attention.
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- B6 z, }% T/ [* ~# XThis clinical picture has some of the features of what has been referred to as Ganser's syndrome—the giving of "approximate" answers to questions, commonly associated with other symptoms such as amnesia, disorientation, perceptual disturbances, fugue, and conversion symptoms. The full picture of Ganser's syndrome is classified in DSM-IV-TR as a Dissociative Disorder Not Otherwise Specified. Because there is no evidence of dissociative symptoms in this case, a diagnosis of a Dissociative Disorder is not made.
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From the history there is a strong suggestion of Antisocial Personality Disorder—a diagnosis that needs to be ruled out, but that will be of no help to this man in avoiding prosecution. Even if there were sufficient evidence to warrant a diagnosis of Antisocial Personality Disorder, it would still be appropriate to note Malingering on Axis I. Lying is a common symptom of Antisocial Personality Disorder; but when it is elaborated to create the impression of a mental disorder, then it should be identified in its own right as the V code Malingering (see DSM-IV-TR).


DOI: 10.1176/appi.books.9781585622665.31015
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Close to the Bone, with treatment discussion ; N1 i0 _5 ^( l$ c

) P7 r( t$ m" WA 23-year-old woman from Arkansas wrote a letter to the head of a New York research group after seeing a television program in which he described his work with patients with unusual eating patterns. In the letter, which requested that she be accepted into his program, the woman described her problems as follows:' K2 w5 S) n: T2 h- T; ]3 b. a

3 K* c2 @- @4 d6 E* lSeveral years ago, in college, I started using laxatives to lose weight. I started with a few and increased the number as they became ineffective. After 2 years I was taking 250–300 Ex-Lax pills at one time with a glass of water, 20 per gulp. I would lose as much as 20 pounds in a 24-hour period, mostly water and some food, [and would be] dehydrated so that I couldn't stand, and could barely talk. I ended up in the university infirmary several times with diagnoses of food poisoning, severe gastrointestinal flu, etc., with bland diets and medications. I was released within a day or two. A small duodenal ulcer appeared and disappeared on X rays in 1975.; j0 m# D/ w9 ?! Z- u3 b% n6 X
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I would not eat for days, then would eat something, and, overcome by guilt at eating, and hunger, would eat, eat, eat. A girl on my dorm floor told me that she occasionally forced herself to vomit so that she wouldn't gain weight. I did this every once in a while and discovered that I could consume large amounts of food, vomit, and still lose weight. This was spring of 1975. I lost nearly 50 pounds over a few months, to 90 pounds. My hair started coming out in handfuls, and my teeth were loose.: P+ D0 {, k! S! o6 m! k# B* @9 `
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I never felt lovelier or more confident about my appearance: physically liberated, streamlined, close-to-the-bone. I was flat everywhere except my stomach when I binged, when I would be full-blown and distended. When I bent over, each rib and back vertebra was outlined. After vomiting, my stomach was once more flat, empty. The more I lost, the more I was afraid of getting fat. I was afraid to drink water for days at a time because it would add pounds on the scale and make me miserable. Yet I drank (or drink; perhaps I should be writing this all in the present tense) easily a half-gallon of milk and other liquids at once when bingeing. I didn't need the laxatives as much to get rid of food, and eventually stopped using them altogether (although I am still chronically constipated, I become nauseous whenever I see them in the drugstore).- B+ G, S) q: N; v1 J9 n6 P

( w% r$ e/ F  B/ r" f+ M: DI exercised for hours each day to tone my figure from the weight fluctuations, and joined the university track team. I wore track shoes all the time and ran to classes and around town, stick-legs pumping. I went to track practice daily after being sick, until I was forced to quit; a single lap would make me dizzy, with cramps in my stomach and legs.
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( `* [! \& H+ h( y: w% rAt some point during my last semester before dropping out I came across an article on anorexia nervosa. It frightened me; my own personal obsession with food and body weight was shared by other people. I had not menstruated in 2 years. So, I forced myself to eat and digest healthy food. Hated it. I studied nutrition and gradually forced myself to accept a new attitude toward food—vitalizing—something needed for life. I gained weight, fighting panic. In a rigid, controlled way I have maintained myself nutritionally ever since: 105–115 pounds at 5'6". I know what I need to survive and I eat it—a balanced diet with the fewest possible calories, mostly vegetables, fruits, fish, fowl, whole grain products, and so on. In 5 years I have not eaten anything like pizza, pastas or pork, sweets, or anything fattening, fried or rich without being very sick. Once I allowed myself an ice cream cone. But I am usually sick if I deviate as much as one bite.  q3 L- l1 O1 ]5 j2 I

& j" n* Y5 o# X8 `7 x0 k, Z. t  ~% gIt was difficult for me to face people at school, and I dropped courses each semester, collecting incompletes but finishing well in the few classes I stayed with. The absurdity of my reclusiveness was evident even to me during my last semester when I signed up for correspondence courses, while living only two blocks from the correspondence university building on campus. I felt I would only be able to face people when I lost "just a few more pounds."
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Fat. I cannot stand it. This feeling is stronger and more desperate than any horror at what I am doing to myself. If I gain a few pounds I hate to leave the house and let people see me. Yet I am sad to see how I have pushed aside the friends, activities, and state of energized health that once rounded my life.' |4 k" v  W5 A
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For all of this hiding, it will surprise you to know that I am by profession a model. Last year when I was more in control of my eating-vomiting I enjoyed working in front of a camera, and I was doing well. Lately I've been sick too much and feel out-of-shape and physically unself-confident for the discipline involved. I keep myself supported during this time with part-time secretarial work, and whatever unsolicited photo bookings my past clients give me. For the most part I do the secretarial work. And I can't seem to stop being sick all of the time.- ]& u+ {/ y& U- s$ o

" e. T* F5 }; u+ a  C% }The more I threw up when I was in college, the longer it took, and the harder it became. I needed to use different instruments to induce vomiting. Now I double two electrical cords and shove them several feet down into my throat. This is preceded by 6–10 doses of ipecac [an emetic]. My knees are calloused from the time spent kneeling sick. The eating-vomiting process takes usually 2–3 hours, sometimes as long as 8. I dread the gagging and pain and sometimes my throat is very sore and I procrastinate using the ipecac and cords. I sit on the floor, biting my nails, and pulling the skin off around my nails with tweezers. Usually I wear rubber gloves to prevent this somewhat.
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0 F. f% J3 j6 n& }* wAfter emptying my stomach completely I wash thoroughly. In a little while I will hydrate myself with a bottle of diet pop, and take a handful of Lasix [furosemide; a diuretic] 40 mg (which I have numerous prescriptions for). Sometimes I am faint, very cold. I splash cool water on my face, smooth my hair, but my hands are shaking some. I will take aspirin if my hands hurt sharply, . . . so I can sleep later. My lips, fingers are bluish and cold. I see in the mirror that blood vessels are broken. There are red spots over my eyes. They always fade in a day or two. There is a certain relief when it is over, that the food is gone, and I am not horribly fat from it. And I cry often . . . for some rest, some calm. It is foolish for me to cry for someone, someone to help me; when it is only me who is hiding and hurting myself.
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. X% }  }9 n5 j! n8 G7 }Now there is a funny new split in my behavior, this honesty about my illness. Hopefully it will bring me more help than humiliation. Sometimes I feel an hypocrisy in my actions, and in the frightened, well-ordered attempts to seek out help. All the while I am still sick, night after night after night. And often days as well.
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' m! d+ N2 Y$ LTwo sets of logic seem to be operating against each other, each determined, each half-canceling the effects of the other. It is the part of me which forced me to eat that I'm talking about . . . which cools my throat with water after hours of heaving, which takes potassium supplements to counteract diuretics, and aspirin for torn hands. It is this part of me, which walks into a psychiatrist's office twice weekly and sees the liability of hurting myself seriously, which makes constant small efforts to repair the tearing-down.
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It almost sounds as if I am being brutalized by some unrelenting force. Ridiculous to feel this way, or to stand and cry, because the hands that cool my throat and try to make small repairs only just punched lengths of cord into my stomach. No demons, only me.( `0 [, h9 u; e8 z9 L3 G
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For your consideration, I am
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3 ]: B6 X& U0 K4 a! N4 vGratefully yours,
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& X" W, [/ @% E& \' F7 NNancy Lee Duval
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Ms. Duval was admitted to the research ward for study. Additional history revealed that her eating problems began gradually during her adolescence and had been severe for the past 3–4 years. At age 14, she weighed 128 pounds, and she had reached her adult height of 5'6". She felt "terribly fat" and began to diet without great success. At age 17, she weighed 165 pounds. Ms. Duval began to diet more seriously for fear that she would be ridiculed and went down to 130 pounds over the next year. She recalled feeling very depressed, overwhelmed, and insignificant. She began to avoid difficult classes so that she would never get less than straight As and lied about her school and grade performance for fear of being humiliated. She had great social anxiety in interacting with boys, which culminated in her transferring to a girls' school for the last year of high school.
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When Ms. Duval left for college, her difficulties increased. She had trouble deciding how to organize her time—whether to study, date, or see friends. She became more desperate to lose weight and began to use laxatives, as she describes in her letter. At age 20, in Ms. Duval's sophomore year of college, she reached her lowest weight of 88 pounds (70% of ideal body weight) and stopped menstruating.0 z0 R/ Q, E6 D2 Z9 A  N

2 y6 a( W6 D9 i" p6 DAs Ms. Duval describes in her letter, she recognized that there was a problem and eventually forced herself to gain weight. Nonetheless, the overeating and vomiting she had begun the previous year worsened. Because she was preoccupied with her weight and her eating, her school performance suffered, and she dropped out of school midway through college at age 21.
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Ms. Duval is the second of four children and the only girl. She comes from an upper-middle-class professional family. From the patient's description, it sounds as though the father has a history of alcoholism. There are clear indications of difficulties between the mother and the father and between the boys and the parents, but no other family member has ever had psychiatric treatment.2 E7 G2 u. i7 @, v- ]
# g: K& c1 Y; a. p+ O8 RDSM-IV-TR Casebook Diagnosis of "Close to the Bone"6 D# E5 r, ?! ?) l

8 ~/ b: M7 x/ [6 FMs. Duval has Anorexia Nervosa (see DSM-IV-TR), a disorder that was first described 300 years ago and was given its current name in 1868. Although theories about the cause of the disorder have come and gone, the essential features have remained unchanged. Ms. Duval poignantly describes these features.
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& X& }0 b' J7 O) Z, H, @& N; _She had an intense and irrational fear of becoming obese, even when she was emaciated. Her body image was disturbed in that she perceived herself as fat when her weight was average and "never lovelier" when, to others, she must have appeared grotesquely thin. She lost about 30% of her body weight by relentless dieting and exercising, self-induced vomiting, and use of cathartics and diuretics. She had not menstruated for the past 3 years.
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7 X- `4 s. |$ v4 V5 ]& aShe also has recurrent episodes of binge eating—rapid, uncontrolled consumption of high-calorie foods. These binges are followed by vomiting and remorse. Because of this pattern of recurrent binge eating and purging, the diagnosis of Anorexia Nervosa is qualified as the Binge-Eating/Purging Type.
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# \6 w) x( x6 R$ m% z! y+ B' fFollow-Up' \3 ?7 k- |. O7 o9 X9 C' |6 S. b5 P

" h; r. x. Q0 n( s& QMs. Duval remained in the research ward for several weeks, during which time she participated in research studies and, under the structure of the hospital setting, was able to give up her abuse of laxatives and diuretics. After her return home, she continued in treatment with a psychiatrist in psychoanalytically oriented psychotherapy two times a week, which she had begun 6 months previously. That therapy continued for approximately another 6 months, at which point her family refused to support it. The patient also felt that, although she had gained some insight into her difficulties, she had been unable to change her behavior.
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3 c) m* D% t# s7 R' ~6 {Two years after leaving the hospital, she wrote that she was "doing much better." She had reenrolled in college and was completing her course work satisfactorily. She had seen a nutritionist and believed that form of treatment was useful for her in learning what a normal diet was and how to maintain a normal weight. She was also receiving counseling from the school guidance counselors, but she did not directly relate that to her eating difficulties. Her weight was normal, and she was menstruating regularly. She continued to have intermittent difficulty with binge eating and vomiting, but the frequency and severity of these problems were much reduced. She no longer abused diuretics or laxatives.1 b+ X# I. ^8 M: w$ X) o. q' d
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Discussion of "Close to the Bone" by Katherine A. Halmi, M.D.*$ \" Q% \/ T' a  f
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Effective treatment of a patient with an Eating Disorder must begin with an organized and intelligent assessment of the Eating Disorder. After reading the dramatic, media-appealing letter of the patient, it was necessary for the treatment staff to obtain additional pertinent history, such as a height and weight history, in order to establish a feasible target—maintenance weight for the patient. At age 14, Ms. Duval achieved her adult height of 5'6" and weighed 128 pounds. A normal weight range at this height can be from 118 to 148 pounds, which corresponds with a body mass index (kilograms divided by height in square meters) from 19 through 24. Dieting is the most common stress factor that induces binge eating. This patient certainly engaged in overeating, if not binge eating, after periods of food restriction to reach a weight of 165 pounds at age 17. At that time, she was definitely overweight, with a body mass index of about 26.7. In setting a target weight, it is also helpful to know at what weight a patient's menses begins. Because this patient had been overweight, it is more reasonable to set a target weight in the middle to the upper end of a normal range, as it requires less stress to maintain a weight closer to a lifetime high weight.
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The next category to assess is Eating Disorder symptoms. By the time she left for college, Ms. Duval had lost 35 pounds, and her dieting behavior was out of control. At college, she began her laxative abuse, which was followed by vomiting, and reached her lowest weight of 88 pounds while becoming amenorrheic. It is somewhat surprising that she survived the periods of losing 20 pounds over 24 hours with her excessive Ex-Lax pill abuse without requiring an emergency room visit for cardiac arrhythmias. As the weight loss progressed, so did the fear of becoming fat and the increased time spent exercising. Fear of the consequences of having Anorexia Nervosa forced the patient to maintain a weight between 105 and 115 pounds, which is below the lowest acceptable weight for someone at a height of 5'6".& q/ O6 b( y# z( a- {
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Usually, the longer the patient has been self-inducing vomiting, the easier it is to do so, but this apparently was not the case with Ms. Duval. The use of ipecac can be very dangerous because it may cause irreversible cardiac muscle damage, resulting in heart failure. The combination of ipecac use, diuretic abuse, and vomiting can lower the serum potassium level dangerously and create an environment for cardiac arrhythmias and sudden death. This patient's history calls for immediate, appropriate medical tests. Blood chemistry testing reveals the serum potassium level, which, if below 2.5 mEq/L, calls for hospitalization. With the strong history of potassium depletion behaviors, an electrocardiogram is an absolute necessity. Liver enzymes may be elevated, which is associated with malnutrition, and increased serum amylase levels are related to severity of self-induced vomiting. A complete blood count is necessary because a low white blood cell count is related to emaciation and malnutrition. Patients who binge and purge have a high association (30%–40%) of alcohol and substance abuse, which needs to be explored and verified with a urine toxicology screen (Halmi 2003).
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A general psychiatric screen for common comorbid disorders, such as Major Depressive Disorder, and Anxiety Disorders (especially Obsessive-Compulsive Disorder, Social Phobia, and Posttraumatic Stress Disorder) is necessary to plan an effective treatment program. Special inquiry should be made into impulsive or self-injurious behaviors, which occur with the binge-eating/purging type of Anorexia Nervosa. Inquiries should also be made concerning suicidal preoccupation and past suicide attempts. An assessment of current level of functioning may provide further evidence for whether hospitalization is justified. The family history of such patients often reveals alcoholism, Mood Disorders, and Anxiety Disorders. It is not unusual for these families to be most chaotic in their interactions.
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( p1 ~9 r. U* ?% T' }6 g+ }! QTreatment—Phase 1
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+ q) ^3 I" I4 u" C- i4 g; f, t: iMs. Duval's out-of-control, life-threatening Eating Disorder behaviors required hospitalization in a specialized Eating Disorder treatment setting (Halmi 2003).
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; A# I/ t9 s" c& s1 N3 i# [One of the most aggravating problems in treating patients with severe bulimic behaviors and laxative abuse is the failure of third-party payers to acknowledge the need for these patients to be hospitalized. In most cases, the patient's electrolytes must be severely deranged or the patient must have a markedly abnormal electrocardiogram for the managed care company to approve of hospitalization. For Ms. Duval, the only way she was able to get proper treatment was to be admitted to a state-financed research unit where treatment was free so long as she fit into a research protocol. Patients with severe binge eating and laxative abuse are unable to reduce or stop the behavior without inpatient therapy. Thus, patients continue on and on in outpatient therapy, and, subsequently, their behavior becomes more and more reinforced.
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( p! M$ n/ E; }! _+ ETreatment during this hospitalization will include 1) 24-hour surveillance for response-prevention of bingeing and purging; 2) individual cognitive-behavioral psychotherapy sessions; 3) multiple group therapy sessions for body image and eating behavior issues, self-esteem and self-efficacy, and assertiveness problems and specific female issues; 4) family counseling; and 5) appropriate medical treatment.
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# ^! V7 Q( z* o5 I" wIt is essential to stop the binge-purge behavior in order to treat the medical abnormalities (e.g., electrolyte imbalances and dehydration), as well as to reestablish normal eating behavior. The opportunity to binge is removed, and access to food is restricted to meal times and supervised snacks. A nutritionist should calculate the number of calories required for the patient to maintain her weight, and every few days the total calorie intake should be increased in order for the patient to gain weight if she is underweight. It is feasible for Ms. Duval to gain a minimum of 2–3 pounds per week. In the hospital, patients are observed during meals and for several hours after meals. Access to the bathroom is restricted or supervised to prevent surreptitious vomiting. The urge to binge may be extinguished with relaxation techniques or having the patient engage in a favorite activity.: x% k- {# x* N4 m6 m

1 F2 i' a* u( W+ nTo ensure adequate intake of all nutrients, including amino acids, minerals, vitamins, and fatty acids, and to allow a precise determination of daily caloric intake, the patient is given a liquid formula in six equal feedings throughout the day. When the patient is within 85% of her target weight range, food can be added, and if the patient continues to gain, she can be placed entirely on food provided on trays so that an accurate intake and output can be calculated. The patient should be weighed each morning after urinating, and generally it is beneficial to tell the patient her weight. Gradually, the preselected food trays should be removed—first breakfast, then lunch, and then dinner—so, eventually, she may have the experience of choosing her own foods before she is discharged from the hospital.
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There are very few randomized, controlled trials for the treatment of Anorexia Nervosa to provide evidence-based treatment recommendations. There is evidence that selective serotonin reuptake inhibitors (SSRIs) are effective in reducing binge-purge behavior and perhaps are effective in preventing weight relapse in patients with Anorexia Nervosa (Fluoxetine Bulimia Nervosa Collaborative Study Group 1992; Kaye et al. 2000). For this reason, I would place Ms. Duval on an SSRI such as fluoxetine (Prozac) when she is within 85% of her target weight. SSRIs are not very helpful when a patient is below 80% of his or her target weight.
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) u6 \, z* m  hIn a controlled inpatient environment, behavior therapy was found effective for inducing weight gain (Vitousek 2002). Behavior therapy includes contingency contracting, in which the patient and the therapist agree on rewards (e.g., visiting privileges, increased physical activity, and social activity) that the patient will receive when weight gain is achieved. Behavior therapy is used primarily to restore weight, which is necessary for two reasons. First, the state of emaciation causes irritability, depression, preoccupation with food, and sleep disturbance. Second, cognitive impairment is a common by-product of emaciation. It is exceedingly difficult to achieve behavioral change with psychotherapy in a patient who is experiencing the psychological and emotional effects of emaciation (Halmi 2003).3 o% x+ E" @% K* p, I. k; ?6 R
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As Ms. Duval lost more weight, she became more perfectionistic and depressed. She also had increased social anxiety in interacting with boys and eventually became isolated from most of her peers. She had a rigid and extreme thinking style, especially on matters of weight and body image. She also had distorted thoughts about issues of self-esteem and self-adequacy and had a self-concept with pervasive feelings of ineffectiveness. These cognitive distortions are best dealt with in individual cognitive therapy. Cognitive therapy techniques for treating anorexia were first developed by Garner and Bemis (1985), and more recent refinement of these techniques is well described by Kleifield et al. (1996). Controlled clinical trials have shown cognitive-behavioral therapy (CBT) to be more effective than drug treatment or other forms of psychotherapy. In individual therapy sessions, Ms. Duval should be taught cognitive restructuring and problem-solving techniques. Cognitive restructuring is a method in which patients are taught to identify automatic thoughts and challenge their core beliefs. Patients become aware of specific negative thoughts, present arguments and evidence to support the validity of these thoughts, and then present arguments and evidence that cast doubt on the validity of the thoughts. Finally, patients form a reasoned conclusion based on the evidence. Problem solving is a method whereby patients learn to reason through dealing with difficult food-related and/or interpersonal situations and is especially relevant to events likely to trigger anorectic or bulimic behaviors. When patients learn to use these techniques effectively, they reduce their vulnerability to relying on anorectic behaviors as a means of coping.
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For example, a cognitive restructuring exercise with Ms. Duval would be to have her state her distorted cognition that if she gains a few pounds, everyone will notice. She would list the evidence to support this idea and then the evidence against it. With the guidance of her therapist, she would realize that most people would be unaware that she had gained weight, and most people would find her equally, if not more, attractive. Ms. Duval would then reach the final logical conclusion that a drastic behavior such as refusing to go out of the house is ridiculous.7 j5 z5 t$ A- o" v/ |' I
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An example of problem solving would be to have Ms. Duval state her problem of binge eating. She would then think of different methods to use to stop binge eating. One possibility is that she could eat at regular 3- to 4-hour intervals to prevent extreme hunger. Another possibility is that she could engage in a series of alternative behaviors to binge eating. Ms. Duval would then decide on a strategy to use for the following week and practice it. At her next therapy session, she would discuss the effectiveness and/or problems with her chosen strategy., ?' ^& t: y$ q; V0 V

# m" a! |# r. v4 \. B* t8 PMs. Duval would also benefit from repeated exercises of cost-benefit analyses. These are especially useful at a time when the patient is tempted to engage in harmful Eating Disorder behaviors. In a cost-benefit analysis, Ms. Duval would list the costs of one of her behaviors, such as vomiting, on one side of a pa-per and the benefits on the other. The costs of vomiting would include the medical problems of dental injury and weakness from a low potassium level. Social costs would include isolation from friends. The benefits would include the escape from or avoidance of interpersonal problems or issues of maturity, such as independence.
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Finally, Ms. Duval would benefit from some joint counseling sessions with her parents, both because there is evidence of multiple problems in their family relationships and she is highly dependent on her parents, who are financing her treatment.
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Throughout hospitalization and before discharge, Ms. Duval should have counseling sessions with a nutritionist who can give her alternative food plans and help her understand what she should be eating to maintain her weight within a normal range. It is a common myth among educated laypeople and many uninformed therapists that discovering the "cause" will cure the patient with Anorexia Nervosa and will allow the patient to stop her bingeing and purging behavior. How can one, in reality, ever know what the true cause of the illness is and whether a single factor determines the illness? The patient, through psychodynamic psychotherapy, may become aware of certain relationships between events of the past and the development of her eating behavior, but that, in and of itself, does not provide evidence for a "cause" nor does this insight lead to behavior change, as Ms. Duval has found.
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+ B9 E% r. |4 `% c: nTreatment—Phase 2
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9 X# k- v. S6 P* VAfter discharge from the inpatient setting, CBT should be continued. It is notable that 2 years after Ms. Duval left the research program in the hospital, she was still occasionally binge eating and vomiting, although less frequently. Outpatient cognitive-behavioral psychotherapy is effective in treating binge-purge behavior and would most likely be beneficial and effective for Ms. Duval (Fairburn et al. 1995). She noted that, although she gained some insight into her difficulties with post-hospitalization psychoanalytically oriented psychotherapy, she was unable to change her behavior. The techniques patients learn in cognitive therapy can also be applied to solving problems in interpersonal relationships and other stressful situations.+ r3 D1 [5 w  S6 x8 R
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Because the relapse rate is high in both Anorexia Nervosa and Bulimia Nervosa (about 40%), it would most likely be a good idea to have three or four "booster" sessions in the course of 1 year to review the CBT techniques and strategies that were effective for Ms. Duval so that she can maintain weight and cease bingeing and purging behavior (Mitchell et al. 2001).
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*Dr. Halmi is Professor of Psychiatry at Cornell University Medical College and Director of the Eating Disorder Program. For the past 20 years, Dr. Halmi's research has primarily focused on eating behavior and Anorexia Nervosa and Bulimia Nervosa disorders. She has investigated the disorders with a broad perspective, including neuroendocrine studies, cognitive behavioral and pharmacological treatment studies, metabolic studies, investigations of comorbid psychopathology, studies of core Eating Disorder psychopathology, and longitudinal follow-up studies. She is well known internationally because of her published research.: S" ~% m0 X; f* l: ^& M1 Y# I
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9 t2 ^' e6 c6 N" r! a" NFairburn CG, Norman PA, Welch SL, et al: A prospective study of outcome in bulimia nervosa and the long-term effects of three psychological treatments. Arch Gen Psychiatry 52:304–312, 1995  [PubMed]
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Fluoxetine Bulimia Nervosa Collaborative Study Group: Fluoxetine in the treatment of bulimia nervosa: a multicenter placebo-controlled double-blind trial. Arch Gen Psychiatry 49:139–147, 1992 / K: m% R3 M( q- u1 J: G
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Garner DM, Bemis KM: A cognitive-behavioral approach to anorexia nervosa, in Handbook of Psychotherapy for Anorexia Nervosa and Bulimia. Edited by Garner DM, Garfinkel PE. New York, Guilford Press, 1985, pp 107–146
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Halmi KA: Eating disorders: anorexia nervosa, bulimia nervosa and obesity, in Textbook of Clinical Psychiatry. Edited by Hales RE, Yudolfsky SC. Washington, DC, American Psychiatric Publishing, 2003, pp 1001–1021
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3 w" k% k/ L/ |! pKaye WH, Nagata T, Weltzin TE, et al: Double-blind placebo-controlled administration of fluoxetine in restricting and purging-type anorexia nervosa. Biol Psychiatry 49:644–652, 2000
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Kleifield EI, Wagner S, Halmi KA: Cognitive-behavioral treatment of anorexia nervosa. Psychiatr Clin North Am 19:715–734, 1996  [PubMed] # f- h$ r9 D: j; I+ D$ h! H8 d! u
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Mitchell JE, Peterson CB, Myers T, et al: Combining pharmacotherapy and psychotherapy in the treatment of patients with eating disorders. Psychiatr Clin North Am 24:315–323, 2001  [PubMed]
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% Q, Y  N; R/ L7 sVitousek KB: Cognitive-behavioral therapy for anorexia nervosa, in Eating Disorders and Obesity. Edited by Fairburn CG, Brownell KD. New York, Guilford Press, 2002, pp 308–313


DOI: 10.1176/appi.books.9781585622665.31078
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9 |3 s8 W" B" R8 bUnder Surveillance, with treatment discussion 8 ^# v! u, B6 {5 ]
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Mr. Simpson is a single, unemployed, 44-year-old white man brought to the emergency room by the police for striking an elderly woman in his apartment building. His chief complaint is, "That damn bitch. She and the rest of them deserved more than that for what they put me through."
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The patient has been continuously ill since age 22. During his first year of law school, he gradually became more and more convinced that his classmates were mak-ing fun of him. He noticed that they would snort and sneeze whenever he entered the classroom. When a girl he was dating broke off the relationship with him, he believed that she had been "replaced" by a look-alike. He called the police and asked for their help to solve the "kidnapping." His academic performance in school declined dramatically, and he was asked to leave and seek psychiatric care.
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' z% [: D+ I$ n; j  [Mr. Simpson got a job as an investment counselor at a bank, which he held for 7 months. However, he was receiving an increasing number of distracting "signals" from co-workers, and he became more and more suspicious and withdrawn. It was at this time that he first reported hearing voices. He was eventually fired and soon thereafter was hospitalized for the first time, at age 24. He has not worked since.9 k! ?4 u  m1 l6 t# J

7 g4 E: e/ S% rMr. Simpson has been hospitalized 12 times, the longest stay being 8 months. However, in the last 5 years he has been hospitalized only once, for 3 weeks. During the hospitalizations he has received various antipsychotic drugs. Although outpatient medication has been prescribed, he usually stops taking it shortly after leaving the hospital. Aside from twice-yearly lunch meetings with his uncle and his contacts with mental health workers, he is totally isolated socially. He lives on his own and manages his own financial affairs, including a modest inheritance. He reads the Wall Street Journal daily. He cooks and cleans for himself.# b1 P5 E, u) |2 Z$ E# w6 [7 p

0 k- {: c) ?. K! l# ^Mr. Simpson maintains that his apartment is the center of a large communication system that involves all the major television networks, his neighbors, and apparently hundreds of "actors" in his neighborhood. There are secret cameras in his apartment that carefully monitor all his activities. When he is watching television, many of his minor actions (e.g., going to the bathroom) are soon directly commented on by the announcer. Whenever he goes outside, the "actors" have all been warned to keep him under surveillance. Everyone on the street watches him. His neighbors operate two different "machines"; one is responsible for all of his voices, except the "joker." He is not certain who controls this voice, which "visits" him only occasionally and is very funny. The other voices, which he hears many times each day, are generated by this machine, which he sometimes thinks is directly run by the neighbor whom he attacked. For example, when he is going over his investments, these "harassing" voices constantly tell him which stocks to buy. The other machine he calls "the dream machine." This machine puts erotic dreams into his head, usually of "black women."' H) E- X' }/ w
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Mr. Simpson described other unusual experiences. For example, he recently went to a shoe store 30 miles from his house in the hope of buying some shoes that wouldn't be "altered." However, he soon found out that, like the rest of the shoes he buys, special nails had been put into the bottom of the shoes to annoy him. He was amazed that his decision concerning which shoe store to go to must have been known to his "harassers" before he himself knew it, so that they had time to get the altered shoes made up especially for him. He realizes that great effort and "millions of dollars" are involved in keeping him under surveillance. He sometimes thinks this is all part of a large experiment to discover the secret of his "superior intelligence."  H% D) T9 z+ l2 W4 U2 a
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At the interview, Mr. Simpson is well groomed, and his speech is coherent and goal-directed. His affect is, at most, only mildly blunted. He was initially very angry at being brought in by the police. After several weeks of treatment with an antipsychotic drug that failed to control his psychotic symptoms, he was transferred to a long-stay facility with a plan to arrange a structured living situation for him./ S+ o$ Y2 f1 p; W
& O: \  _, @  U) `. |9 ], vDSM-IV-TR Casebook Diagnosis of "Under Surveillance"7 P2 r2 }* q- M& z3 {! S: @

; T! O0 C1 v. t+ t8 S* BMr. Simpson's long illness apparently began with delusions of reference (his classmates mak-ing fun of him by snorting and sneezing when he entered the classroom). Over the years, his delusions have become increasingly complex and bizarre (his neighbors are actually actors, his thoughts are monitored, a machine puts erotic dreams in his head). In addition, he has prominent hallucinations of different voices that harass him.* R$ N& e8 P  _  D

' O% R( L6 w4 ^; j/ e  F3 gBizarre delusions and prominent hallucinations are the characteristic psychotic symptoms of Schizophrenia (see DSM-IV-TR). The diagnosis is confirmed by the marked disturbance in his work and social functioning and the absence of a sustained mood disturbance or a general medical condition or use of a substance that can account for the disturbance.
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  {1 t& [) q% v4 _' k0 _, x- ~1 g1 EAll of Mr. Simpson's delusions and hallucinations seem to involve the single theme of a conspiracy to harass him. This preoccupation with a delusion, in the absence of disorganized speech, flat or inappropriate affect, or catatonic or grossly disorganized behavior, indicates the Paranoid Type (see DSM-IV-TR), further specified as Continuous, as he has not been free of psychotic symptoms for many years.
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Discussion of "Under Surveillance" by Thomas H. McGlashan, M.D.*
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The common feature of paranoid patients is an overriding, watchful, suspicious interpretation of experience. These patients demand special consideration by virtue of being, without doubt, the most difficult patients to treat psychotherapeutically. They invariably enter treatment under coercion and bristling with hostility. Convinced that people always misunderstand them, they trust no one.# E5 E& Y* U& {' M$ Z8 E) E0 |9 ?

$ e) m6 I# ?- n+ E1 S4 E$ xMr. Simpson represents the paranoid patient par excellence and, as such, is one of the most challenging persons any psychiatrist will ever treat. The patient's clinical history, symptoms, and severe functional deficits leave little doubt as to the diagnosis of Schizophrenia, Chronic Paranoid subtype, and there are no reasonable differential diagnostic entities to consider. The patient's symptoms are continuous, and his deficits in reality testing are particularly severe. He is totally disabled functionally with regard to work and social interactions. After 20 years of active psychosis and 12 hospitalizations, he presents any treater with a daunting challenge—any treater, that is, who is willing to try.. c" s  R+ Q2 N: R6 Z: T

2 d1 G6 {, y  `5 w' G" r$ ]2 H' JMr. Simpson's overall prognostic potential is slim if the goal is symptomatic and functional recovery. His expected future course is likely to be an extension of his course over the last 20 years. Mr. Simpson assaulting an elderly female neighbor might signal further deterioration. If deterioration continues, his prospects for living outside of a long-stay asylum or jail will diminish drastically. On the other hand, the past 5 years have seen only one hospitalization, suggesting that his disorder could be mellowing.. P/ l: d& y: F. j& b: s, Z

4 n  l0 n* ]  ATwo additional elements bode ominously with respect to prognosis. The first is that his psychotic world of delusions and hallucinations literally fills his apartment and his life. His disorder is not just persecutory, it is also interesting, exciting, and, at times, amusing and gratifying. In short, his investment in psychosis is substantial compared to his investment in "real" life and people. The second ominous prognostic element is his obviously negative attitude toward any and all efforts at treatment—an attitude that has translated into noncompliant behavior with virtually every therapeutic encounter., g& C. }" R( Z7 v% {4 B

# n5 i( X- T* _; A; |On the other hand, two positive prognostic elements stand out. One is his degree of organization. His affect is intact. He has few negative symptoms (e.g., lack of motivation, poverty of speech), and most of the time he displays little disorganization, all of which is consistent with the paranoid subtype. Most strikingly, he is self-sufficient and takes care of himself. He is almost certainly unable to work, but his modest inheritance keeps him off of disability and provides an illusion of instrumental self-sufficiency. The other positive prognostic development, paradoxically, is that he has broken the law and gotten himself into treatment as a consequence. He probably denies responsibility for the precipitating assault, but, nevertheless, his behavior has added a real problem to his delusional ones, and it could be the key to "locking" him into an adequate trial of treatment for the first time in his life. Mr. Simpson may not see his delusions and hallucinations as a problem, but no matter how intensely paranoid he may be about the police, unlike his other persecutors, they are real.+ @$ p$ k. ^3 w9 n0 l0 [
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Two bodies of information would be especially desirable to have in evaluating his case. The first are records of his prior treatments, supplemented with whatever observations the patient is willing to share about his career as a "patient." The history indicates that a recent several-week trial of an antipsychotic drug failed to control his psychotic symptoms. Information regarding his compliance with this medication is crucial because it determines the direction of pharmacotherapeutic treatment planning. If he did not take the medicine, the issue is familiar (i.e., willful noncompliance). If he did take it, then the issue is biological resistance and suggests considering different neuroleptics, including atypical antipsychotics (such as Zyprexa [olanzapine], Risperdal [risperidone], Seroquel [quetiapine], Geodon [ziprasidone], and Abilify [aripiprazole]) and clozapine. The second area requiring clarification is Mr. Simpson's legal status. Is he remanded by court to the long-stay institution? Who does he have to answer to, if anyone? Of pivotal importance is whether the treating psychiatrist has any leverage in this matrix. Unless the patient is required by the court to be a patient, Mr. Simpson will exercise his civil right to deny intervention. For patients like Mr. Simpson, treatment often depends on a loss of civil rights.! w7 t) p- H5 h

$ ?/ H/ ^4 q& z& {. y2 C, ~9 MThe treating psychiatrist's first meeting with Mr. Simpson will be crucial if the effort is to have any chance of success. The doctor should be ready to face someone who is lined up against any encounter. A conservative and supportive approach, especially in the early phases of treatment, is necessary if there is to be some chance of developing a working alliance. Because such patients often enter treatment feeling coerced and exhibiting great mistrust and hostility, they are best greeted by the therapist with a removed but matter-of-fact attitude. A high degree of professionalism and reliability, and no evident desire to be liked by the patient, will enhance the possibility of success in establishing some trust. The reality of the patient's delusions should neither be accepted nor argued, and observations should be offered as hypotheses. Attempts to modify or diminish paranoid defenses should be made only after a reasonable working alliance has been established and should be undertaken without ambitious expectations on the part of the therapist.
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  }, a+ z8 n( xThe doctor should explicitly address his or her understanding that Mr. Simpson is being seen under coercion—that he is here because of the police. The doctor should also make explicit his or her role in this situation and inform the patient who it was that recruited him or her to intervene, for what purpose, to what end, and with what contingencies (i.e., what Mr. Simpson has to do in order to resecure his freedom and autonomy). The doctor should be nonjudgmental with respect to the patient's guilt or innocence, or whether Mr. Simpson's behavior was justifiable or not, given his delusional conviction about his neighbor's persecution. The doctor should state that he or she is willing to explore all these issues with Mr. Simpson, with the goal being how Mr. Simpson can react so as to not have any further trouble with the police.- O5 i3 P3 a& `' p4 C( t: F$ [5 X1 G

. V0 t( h, T+ L+ h. zThe doctor should be truthful and unambiguously state who he or she is, what he or she believes is going on with Mr. Simpson at this time, and what he or she can and cannot do with or for Mr. Simpson. He or she should acknowledge up front being a psychiatrist brought in by the court because Mr. Simpson assaulted his neighbor and add that Mr. Simpson's act was judged by the court to have occurred because Mr. Simpson was psychotic and delusional. The doctor may share the diagnosis given by the court (i.e., Schizophrenia) and offer to elaborate on what that means at some future time if Mr. Simpson is at all interested.
! y) K: D/ ?$ C. W9 M: K8 A+ \3 B+ r* r9 J& L- {0 S+ F0 ?
The doctor should also say that he or she assumes mental illness is involved because he or she was called into the case as a psychiatrist but that he or she is willing to listen to Mr. Simpson's side of the story, again with the aim not of assigning blame or determining whether the events were real but to help Mr. Simpson avoid trouble with the police and to secure greater personal freedom. The doctor then outlines what the process involves—regular meetings to get to know each other and to explore the events that led to Mr. Simpson's trouble.
. a: T9 R, B( u8 l" R# [1 Z2 s
# s) F! ^9 I5 r/ r) `5 w1 yThe doctor should also be clear in the first encounter about the "rules" of this "process" (the word treatment should be avoided). The rules include a clear delineation of the limits of confidentiality in the doctor-client relationship such as limits relating to responsibilities the doctor has for reporting back to court and especially limits relating to dangerousness. Regarding the latter, the doctor should be explicit with Mr. Simpson that he or she will warn any potential victims of the patient's wrath and that he or she will inform the courts and police of any plans Mr. Simpson has to hurt himself or anyone else. If it seems appropriate, the doctor may predict that Mr. Simpson may become suspicious of him or her (or more suspicious than he already is), much like he is suspicious of just about everyone else, but that this in no way suggests they cannot work together, especially if Mr. Simpson can talk about his misgivings.
6 h8 u; _/ {& j, L3 N8 {* [5 p. H6 Q1 L
At this point, the doctor says something such as, "That's who I am and what I see myself doing here. What did you expect? I think I can be useful to you. What do you think?" Hopefully, Mr. Simpson will engage and elaborate. If he does, the doctor can elaborate further on what to expect in the sessions and, over time, include more active treatment modalities such as medication and cognitive-behavioral techniques. Before these are introduced, however, time and effort must first be invested in establishing a relationship.
3 l3 F2 }& A/ ~% g- v) B6 y
& U+ O6 d) ^  n7 Q1 P0 O. G! OBecause of suspiciousness, disorganization, indifference, or ambivalence about human attachments, establishing a relationship with a patient with Schizophrenia can be challenging. Analytic strategies of passive neutrality and anonymity can easily be misinterpreted as disinterest or dislike and are generally discouraged. Consistency, straightforwardness, and an active effort to establish rapport are advocated. Within bounds, a reasonable degree of self-disclosure on the therapist's part can help to counter distortions by allowing the patient to become comfortable with the therapist as a person. A relationship should be sought on the patient's terms. If the patient initially wants the therapist only to meet some immediate need (e.g., to secure discharge from a hospital or intervene with the patient's family), this is taken as the starting point and viewed positively as a sign that the therapist is seen as potentially useful. At times, engaging in activity (walking or playing a game), finding a neutral topic of common interest (sports, music), or placidly accepting periods of silence will further promote establishing a relationship. Creativity and patience are the only rules.
" X( w0 j1 R" d0 V2 n$ G$ S' C' G3 ^/ a/ d
The process of engagement is often hard, unrewarding, and sometimes scary. The latter, especially, should never be ignored. The aggressive patient requires great care and some experience for one-to-one interactions to be safe. The maintenance of mutual respect, firmness, and an undistorted awareness of one's own anxiety are all strongly recommended. Limit setting, ranging from verbal remonstrance to meeting in the presence of readily available help, to the use of restraints, to timely termination of a volatile session, can be instituted as the situation dictates. Very frequently, the open and candid admission by the therapist to a highly threatening patient that he or she is frightened will defuse the patient's need to be defensively attacking. In all of these situations, it is important that the therapist acknowledge his or her own difficulties in becoming comfortable with the patient. Should these difficulties prove insurmountable, the therapist should seek supervision or consider a change of therapist. It is highly unrealistic to expect oneself to be both comfortable and effective with all patients.
5 m* H# x+ H) R4 N$ l: ^4 M; V0 K- Z( _% ?$ b2 H, e, e& R# S
What could be talked about? The events surrounding Mr. Simpson's assault on his neighbor will need to be elaborated eventually, but initially, the doctor might fruitfully focus on what Mr. Simpson has done right over the last 5 years rather than focus on what he did wrong. The doctor should observe out loud that Mr. Simpson avoided hospitalization and trouble with the law (with one exception) for the past 5 years and that it might be useful to explore how he has managed to do that., W0 K, @  C* G3 d( G9 f

' U8 C0 p0 q/ p) V  ~If Mr. Simpson takes up the offer, an opening into his life and experiences may be created. The doctor remains nonjudgmental and focuses on how the patient successfully coped with his delusional and hallucinatory "experiences" in his everyday life for the last 5 years. These experiences are not labeled as psychotic but are dealt with as real enough to Mr. Simpson that he probably struggled many times to keep from doing what he ultimately did to his neighbor. The doctor focuses on the times Mr. Simpson was successful in that struggle (i.e., when he remained in behavioral control) and what he did to achieve that control. The process highlights the patient's rational capacities and strengths; it provides models for successful coping in the future, and it does so without getting into contentious debates about the "reality" of the patient's experiences.
/ w3 ]: p% S6 ?
8 v5 w$ A9 S& Q3 H1 K9 W% p4 H( HOnly after a certain degree of familiarity and comfort has been established can the patient's psychotic symptoms be approached in any systematic and technical fashion. Cognitive-behavioral strategies become relevant at this point. The patient's rational cognitive capacity is called on to challenge and scrutinize his delusional realities. As outlined by Dickerson (2000), cognitive-behavioral therapy (CBT) approaches include belief modification, focusing/reattribution, and normalizing the psychotic experience, among other strategies.6 |/ p. W( H4 p" K" \$ G

- V% a: l, }, n1 X! eIn belief modification, evidence for delusional belief is challenged in reverse order to the importance of the delusion to the patient and the strength with which it is held. In Mr. Simpson's case, this might be applied to the sequence about his shoes being altered. He reported being quite surprised by this turn of events, suggesting that he might be willing to entertain alternative hypotheses about what was happening. Focusing/reattribution targets auditory hallucinations such as the voices that Mr. Simpson hears at times. The phenomenology of the voices is explored in detail: who is talking, how frequently, how loud, etc. The patient is asked to keep a daily diary of the voices' frequency and content. The patient and therapist examine the beliefs the patient has elaborated around the voices, their source, and their aim. By elaborating and embedding the patient's hallucinations in the matrix of everyday life, including the patient's concomitant thoughts and feelings, the therapist attempts to help the patient reattribute the voices to him- or herself. Asking Mr. Simpson to elaborate the details surrounding the moments when the "joker" talks, for example, may link the experience to other aspects of the patient's mental state and thereby suggest an internal rather than an external origin of the voice.0 S% f5 k# ^( g) {- u; I

9 K3 l. c/ c" @9 jIn normalizing the patient's psychotic experience, the therapist tries to put the patient's thinking in the frame of antecedent stressful events to "explain" the patient's symptoms in a stress-diathesis context. This helps to make the psychotic experience appear less bizarre and "crazy" to the patient. With Mr. Simpson, it might be useful to focus on the event bringing him into treatment—his assault of the elderly neighbor who operated one of the "voice machines." Despite countless days and nights filled with harassing voices and plots, he lost control only this once. Something different was probably happening around this event, and careful detailing of the experience might reconstruct the link between symptoms, assault, stress, and personal history. Highlighting the emergence of stress and personal history in the elaborated story can possibly help Mr. Simpson "normalize" the experience and take some personal responsibility for it.+ d8 A* I; ~# x, r; Y7 X
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CBT strategies, such as that described above, could be tried with Mr. Simpson's extensive paranoid delusions and auditory hallucinations should he ever be sufficiently motivated and develop a relationship with the doctor that is strong and trusting enough to manage the effort. If he proved he was able to negotiate such a sequence of exercises, sufficient rationality and alliance may be present to introduce other treatment modalities for consideration, particularly medication. It is highly unlikely that Mr. Simpson would ever reach this level. Nevertheless, should he reach the level of CBT exercises, his treatment could be regarded as highly successful, even if he remained delusional, unemployed, and socially isolated. He would have a realistic chance of achieving what is most precious to him—his freedom to resume a paranoid lifestyle to which he has become accustomed and adapted but to resume it with a greater capacity for containing it safely.2 r& {; _5 ^* D$ ~# [- u
; S8 v+ F& e* H' e
*Dr. McGlashan is Professor of Psychiatry at the Yale University Department of Psychiatry. Schizophrenia has been a major focus of Dr. McGlashan's career, starting in residency at Massachusetts Mental Health Center with Elvin Semrad. He is a biological psychiatrist and psychoanalyst who has interdigitated research and treatment of psychiatric disorders, especially schizophrenia, since his training. This has included work on a first-episode schizophrenia unit at the National Institutes of Health with Will Carpenter and 15 years at Chestnut Lodge Hospital treating and tracking schizophrenic patients with many colleagues, notably Christopher Keats, with whom he wrote a book (McGlashan TH, Keats CJ: Schizophrenia: Treatment Process, and Outcome. Washington, DC, American Psychiatric Press, 1-9-8-9), and Wayne Fenton, with whom he has written many pa-pers on the course and therapy of schizophrenia. At Yale, he has articulated the reduced synaptic connectivity hypothesis of schizophrenia with Ralph Hoffman and initiated early identification and intervention research in schizophrenia both at home and abroad.$ R2 v5 e3 b6 Q: Z1 N( ^  Y/ ?

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: X4 c6 c& r1 K- h7 v, i) F. WDickerson FB: Cognitive behavioral psychotherapy for schizophrenia: a review of recent empirical studies. Schizophr Res 43:71–90, 2000  [PubMed]
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0 P$ W! F$ X# PSuggested Reading7 [% C  X: Z! r' B

9 W! R& o6 ]9 D% }1 I# ?Dingman CW, McGlashan TH: Psychotherapy, in A Clinical Guide for the Treatment of Schizophrenia. Edited by Bellack AS. New York, Plenum, 1-9-8-9, pp 263–282
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Fenton WS, McGlashan TH: Individual psychotherapy, in Kaplan and Sadock's Comprehensive Textbook of Psychiatry, 7th ed. Edited by Sadock BJ, Sadock VA. Philadelphia, PA, Lippincott Williams & Wilkins, 2000, pp 1217–1231# l; E# |' y8 _, W2 G: J

- C# A& H8 f" S" r# jMcGlashan TH: Intensive individual psychotherapy of schizophrenia: a review of techniques. Arch Gen Psychiatry 40:909–920, 1983


DOI: 10.1176/appi.books.9781585622665.311215 r1 _( e3 U7 n

* X+ I2 ~/ W1 ~Dear Doctor
9 \3 H0 X' F: p3 H( n
" g% C/ j& k6 }: X- [9 `Myrna Field, a 55-year-old woman, was a cashier in a hospital coffee shop 3 years ago when she suddenly developed the belief that a physician who dropped in regularly was intensely in love with her. She fell passionately in love with him, but said nothing to him and became increasingly distressed each time she saw him. Casual remarks that he made were interpreted as cues to his feelings, and she believed he gave her significant glances and made suggestive movements, though he never declared his feelings openly. She was sure this was because he was married.' u: @8 B: a6 o/ ^+ V" Q
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After more than 2 two years of this, she became so agitated that she had to give up her job; she remained at home, thinking about the physician incessantly. She had frequent, intense abdominal sensations, which greatly frightened her. (These turned out to be sexual feelings, which she did not recognize as she had never been orgasmic before.) Eventually she went to her family doctor, who found her so upset he referred her to a male psychiatrist. She was too embarrassed to confide in him, and it was only when she was transferred to a female psychiatrist that she poured forth her story.
2 H8 ^, U* S. @
  \5 }0 G8 A: ^" o$ B! \. G- }Myrna was an illegitimate child whose stepfather was excessively strict. She was a slow learner and was always in trouble at home and at school. She grew up anxious and afraid, and during her adult life consulted many doctors because of hypochondriacal concerns. She was always insecure in company.  X# u1 V, r" H9 y% j, U% s$ C' w

0 ^8 l% Q9 v/ F5 _Myrna married, but the marriage was asexual, and there were no children. Although her husband appeared long-suffering, she perceived him as overly critical and demanding. Throughout their married life she had periodically abused alcohol and, during the past 3 years, had been drinking more heavily and steadily to try to cope with her distress. She could not confide in her husband about her "love" affair.8 J9 q* K1 ~. w/ Y

2 Z' X& a; e" F0 g- ]When she was interviewed, Myrna was very distressed and talked under great pressure. Her intelligence was limited and many of her ideas appeared simple; but the only clear abnormality was the unshakable belief that her physician "lover" was passionately devoted to her. She could not be persuaded otherwise.1 C/ z) V$ X0 r, g
1 o3 `5 r! d- V( k! G$ hDSM-IV-TR Casebook Diagnosis of "Dear Doctor"" G6 N- |. K' |

$ g# S! w: [+ c5 ?- k8 PMyrna's only symptom is a delusion that she is loved by a doctor whom she barely knows. Although her belief seems false, it is certainly possible that a doctor could fall in love with her; thus, it is a nonbizarre delusion. This kind of delusion, in the absence of prominent hallucinations, bizarre behavior, a mood syndrome, or a general medical condition or use of a substance that could account for it, indicates a diagnosis of Delusional Disorder (see DSM-IV-TR). The content of the delusion, that the person is loved by someone (usually of higher status), makes it the Erotomanic Type.6 a, c; N% z: h4 S0 Z" l

) ^2 ~: o9 {9 v$ n# V: NBecause we think that Alcohol Abuse (see DSM-IV-TR) is very likely, we would note it as a provisional diagnosis.; R3 M: M- R5 F) r7 ~
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5 [8 C/ p4 ~% \4 n- |) s1 I5 u; v  nMyrna readily accepted medication, and an antipsychotic drug was prescribed. Over a period of 3–4 weeks she became much calmer, the delusion became less insistent, and she reduced her alcohol consumption considerably. She developed an episode of depression, which responded to a tricyclic antidepressant that was temporarily added to her antipsychotic medication.7 |- N+ _5 G( d" w/ l( W

+ z# h1 E; R/ Y) l2 |# {Three years later, Myrna remains well and rarely drinks. She and her husband appear content with their marriage, which remains platonic. She occasionally thinks of the physician with some nostalgia and still believes he loves her, but is no longer distressed about this. She continues to take her antipsychotic medication.


DOI: 10.1176/appi.books.9781585622665.31138; s( T0 [5 ^2 `( F3 K& A3 U
6 G, ^6 [+ ]) B/ o* @
Mr. Macho* . c8 J: s1 |, Y

2 o, h2 c0 ?1 A0 r, J; c1 uHank Allen was charged with the murder of 10 women. His wife, Jody, who eventually testified against him, had worked as his partner, luring victims to their deaths.
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Wanting to further her husband's fantasy of finding the "perfect lover," Jody had accompanied him to shopping centers or county fairs and talked young girls into climbing into their customized van. Once inside, the victims were confronted by her husband, who held a handgun and bound them with adhesive tape. Most were teenagers, though two of the final victims were adults; the youngest was 13. The oldest victim, age 34, was a bartender who closed up late one night, went out to her car, then rolled down her window to talk to the couple, who had been inside drinking and who now approached her. The Allens kidnapped her and drove her back to their own residence. While Jody sat inside watching an old movie on television, Hank assaulted his victim in the back of the van, scripting her to play the role of his teenage daughter. When he was through, Jody rejoined him and drove away in the early morning hours, the radio blaring to drown out the sounds of her husband in the back of the van, strangling his victim to death. That evening they celebrated Hank's birthday at a restaurant.
9 D+ ~) e* S6 O3 H4 [& R* z2 l# `) r! ?0 v
Most of Hank's victims were petite blonds like Jody and Hank's own daughter. All were sexually abused, then shot or strangled to death; several were buried in shallow graves. One, a pregnant 21-year-old hitchhiker (Jody was also pregnant at the time), was raped, strangled, and buried alive in sand.
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Hank rated the sexual performance of each of his victims and always made sure that Jody knew she was never number one. Jody tried to redeem herself in the eyes of her difficult husband by submitting to his every demand. Even when she finally separated from him, she was unable to say no. They had been apart for several months when Hank called her, asking that they get together one more time. She agreed, and that day they claimed their ninth and tenth victims.
9 X; O, j5 B) [% u! _% b4 b
+ X3 j$ j" r5 ?Hank's violence was a legacy from his father. When he was born, his 19-year-old father was serving a prison sentence for auto theft and passing bad checks. A later conviction earned him a term for second-degree robbery, but he escaped. In an ensuing saga of recapture, escape, recapture, and escape, he killed a police officer and a prison guard, blinding the latter by tossing acid into his face before beating him to death. A short time before he was executed, his father wrote: "When I killed this cop, it made me feel good inside. I can't get over how good it did make me feel, for the sensation was something that made me feel elated to the point of happiness. . . . "0 F* r3 _2 i: o* O9 o
9 g- X" W& }; T; Q# E% O
Often told that he was going to be just like his father when he grew up, Hank was 16 when he learned that his father had been captured and executed in a gas chamber after his mother betrayed his hiding place. Hank later confessed to the police: "Sometimes I [think] about blowing her head off. . . . Sometimes I wanta put a shotgun in her mouth and blow the back of her head off. . . . "
' S3 ~. q3 X, p; o  E6 w" H0 U! ^0 A5 G+ K0 m5 c0 H
In a forensic psychiatric evaluation, Hank revealed that his mother was the object of his most intense sexual fantasy:
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$ R0 o/ A9 t' m5 V- ` I was gonna string her up by her feet, strip her, hang her up by her feet, spin her, take a razor blade, make little cuts, just little ones, watch the blood run out, just drip off her head. Hang her up in the closet, put airplane glue on her, light her up. Tattoo "bitch" on her forehead. . . .
  ?6 R  L* _& O, c) J  o- b  
" `+ j5 b; O# [' w$ w6 l- ]; w  qHank's mother had beaten and mocked her son, a bed wetter until age 13, calling him "pissy pants" in front of guests. One of her husbands punished him mercilessly, forcing him to drink urine and burning a cigar coal into his wrist. When his mother tried to intervene, his stepfather smashed her head into a plaster wall. From that point on, she joined in the active abuse of her children. As far back as he could remember, Hank had nightmares of being smothered by nylon stocking material and being strapped to a chair in a gas chamber as green gas floated into the room.7 f5 g  ^0 j, }6 y. c) a$ f
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Hank began to burglarize with an older brother at 7, and at 12 was put on probation. A year later he was sent to the California Youth Authority for committing "lewd and lascivious acts" with a 6-year-old girl. As a teenager he faced charges of armed robbery and auto theft. A habitual truant, he was suspended from high school at 17 with F's in five academic subjects and F's in five categories of "citizenship." That same year he married for the first time.' H/ S8 P" z# |- t
9 i, ?5 d. v5 U+ A" Q& n( A
Often knocked unconscious in fights, he was comatose twice, briefly at 16 and for over a week at 20. A computed tomography brain scan revealed "abnormally enlarged sulci and slightly enlarged ventricles." A neuropsychological battery showed "damage to the right frontal lobe."
7 `: e& v' A1 A& e5 d  J) S$ _3 {5 U6 c5 @4 E4 L7 h5 ~: }
Hank married seven times. He beat each of his wives, sometimes badly. Most of the marriages lasted no more than a few months. One wife described him as "dominant" and said "he's got to be in control." Another, who had had clumps of hair yanked from her head, called him "a Jekyll and Hyde." Yet another said he was "vicious." When she told him she wanted out, he took revenge by beating her parents. His first marriage ended when he beat his wife with a hammer. When she left him, she replaced his mother in his central fantasy. They had married 5 days after the birth of a baby daughter and a custody battle ensued. In spite of his lengthy record of assaults, thefts, and parole violations, Hank won.0 l- B( s2 y; B, j& s
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When he was 23, Hank went on a crime spree that eventually covered five states. Stealing license plates and cars, holding up bars and drugstores, he eluded capture until caught and convicted for the armed robbery of a motel. Sent to prison for 5 years to life, he molested his 6-year-old daughter for the first time during a conjugal visit.8 V* S# d. m0 w3 M
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Upon release, Hank went to live with his mother, who had not visited him during his 3 years in prison. While there, he got involved with a woman whom he impregnated and whom he once kicked out of bed, literally, when she refused him anal intercourse. He chose not to marry her, she later recalled, as "he didn't want the responsibility." Thirteen days after she gave birth, he married another woman, his fifth wife. He was 28.9 ]* K# _9 E# o% C7 L; `% W1 z8 }
6 N: v4 ?( u0 g% c/ l' {
Hank and his fifth wife separated when he was released from parole. He took up residence with his 13-year-old daughter, whom he soon impregnated. She had an abortion. His daughter had, by this time, replaced his first wife in his favorite fantasy, and he often raped her in the back of the van to which he and Jody would later lure victims. He had first raped her when she was in the fourth grade and, for the next 6 years, assaulted her at least once a week. When a friend of hers arrived for a 2-week visit, he also raped her.: j9 |7 E, a( ^# ^5 g5 Y! N3 D
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He was 30, and his divorce from his fifth wife had not been finalized when he moved in with Jody. By the time they met, Hank had been arrested on 23 separate occasions. The following summer Hank was fired from his job as a driver. He had been fired often, and it was an event that usually left him sexually impotent. An employer at the time termed him "inadequate." A week earlier he had celebrated his birthday by sodomizing his 14-year-old daughter. When his daughter finally informed authorities of the 6 years of abuse, felony charges were filed against Hank for in-cest, unlawful sexual acts, sodomy, and oral copulation. Hank responded by changing his name. Using the stolen driver's license of a state police officer, he obtained a new birth certificate and Social Security number, and he and Jody moved to another town.
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Shortly before his final arrest, Hank, a gun enthusiast, owned a semiautomatic assault rifle, an automatic pistol, two revolvers, and a derringer. He was working as a bartender. A co-worker described him as a ladies' man and said that women called him at work at all hours. After hanging up, he would rate them. Several women referred to him as "Mr. Macho." He was also a heavy drinker. Jody once cautioned him as he drank and drove that the combination was illegal. "Fuck the law," he answered. For his crimes, he eventually received multiple death sentences.
) t, v0 z9 N6 u8 L1 H; M) d   
. z3 p$ o8 `7 S) ^: @1 c6 uDSM-IV-TR Casebook Diagnosis of "Mr. Macho"
9 Z1 y; n, q% O% {3 Y% c
" v; @9 s% S0 _, @Hank Allen's terrible behavior has been punished by the criminal justice system, and many readers may wonder about the appropriateness of trying to assess his behavior from the perspective of psychiatric diagnosis. This case provides vivid examples of extremely antisocial behavior that is symptomatic of several mental disorders.
9 P8 E  S, X+ X. t. u8 g; z2 y* i# l0 {  p7 A0 q& I# Y
Perhaps the most frightening aspect of this man's behavior is that the link between sexual arousal and sadistic behavior is so extreme that it involves killing his victims. Such behavior is a symptom of Sexual Sadism (see DSM-IV-TR), a paraphilia in which the person is sexually excited by the psychological or physical suffering of a victim.
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Hank's sadism is not only in the service of sexual excitement. He also demonstrates a lifelong pattern of cruel, demeaning, and aggressive behavior. He has been physically cruel in order to establish dominance in relationships, he humiliates and demeans other people, he gets other people to do what he wants by intimidating them, and he is fascinated by violence and weapons. This personality pattern was described in the DSM-III-R appendix diagnosis of Sadistic Personality Disorder. Unfortunately (at least from our perspective), this category was entirely removed from DSM-IV.2 Y* c/ _% }' D: h8 O! C) c
5 K5 ?/ @/ Z9 b0 F" n/ }  a, r
Finally, Hank demonstrates a lifelong pattern of irresponsible and antisocial behavior, beginning with stealing and truancy as a child and, as an adult, engaging in robbery, assault, and murder. This pattern indicates Antisocial Personality Disorder (see DSM-IV-TR).
1 H* h0 p) f8 _( ~% @& _0 H0 Q: k' K& G) V! V
It is hard to know how to interpret the abnormal findings on the brain scan and on the neuropsychological and neuropsychiatric tests. We are not sure whether they were merely the result of his frequent head trauma or whether they reflected an underlying brain abnormality that itself was a factor in the development of his pathological behavior.5 V. E. D* v2 F8 {5 u: i* V

% F' g/ O( H% s0 GOne could discuss at some length the childhood experiences that undoubtedly were a factor in the evolution of Hank's psychopathology and criminal behavior. As is often the case in people who physically victimize others, he was himself psychologically and physically abused as a child.
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# W% R% N& R3 m5 q# cFollow-Up( x5 M( ~8 K0 n  s7 X* x

1 l  `$ l. p2 I; E) e1 ]Mr. Macho decided to represent himself in several of the murder trials. He was sentenced to death in more than one state. Five years after his arrest, he now awaits execution.
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( d0 S, I0 O8 ]  |# u*From Dietz PE, Harry B, Hazelwood RR: "Detective Magazines: Pornography for the Sexual Sadist?" Journal of Forensic Sciences 31:197–211, 1986.


DOI: 10.1176/appi.books.9781585622665.311724 O* O  s$ m: {; D: |
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Junior Executive, with treatment discussion : O$ E( v* ^: c0 N* h& W
- m. m) L+ y  a" ]
Joan Demarest is a 38-year-old junior executive with a master's degree in business administration who, for the last year and a half, has worked on a marketing team in a large pharmaceutical firm. She is referred by a colleague for "supportive" treatment. She complains of being tired, uninterested in life, and "depressed" about everything: her job, her husband, and her prospects for the future.
. J8 v  s8 v- ^1 n9 D2 H" Z1 n. u! o/ }* @6 e$ f% {4 H
She has had two previous extensive courses of psychotherapy for persistent feelings of depressed mood, inferiority, and pessimism, which she claims to have had since she was 16 or 17. These symptoms have waxed and waned. During her senior college year, she describes a 3-month period when, in addition to her chronic symptoms, she was not sleeping, was not eating, and probably had sufficient symptoms to meet the criteria for a Major Depressive Episode. She saw a therapist twice weekly for 3 years while in college and a psychoanalyst 2–3 times weekly for 2.5 years overlapping graduate school.
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1 {; U3 p/ B. d0 u- S0 wAlthough she did reasonably well in college, she often ruminated about students who were "genuinely intelligent." She rarely dated during college and graduate school and would never go after a guy she thought was "special," always feeling inferior and intimidated. Whenever she met such a man, she acted stiff and aloof or walked away as quickly as possible, only to berate herself afterward and then fantasize about him for months. She claimed that her previous therapies had helped her to better understand herself but had little, if any, effect on her depressive symptoms.
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# R1 g" S9 |& s. O6 m3 O1 sJust after graduation, she married her husband, whom she had dated for a year. She thought of him as reasonably desirable, although not "special," and married him primarily because she felt she "needed a husband" for companionship. Shortly after their wedding, the couple started to bicker. She rarely complains directly to him but disapproves of his clothes, his job, and his parents; he, in turn, accuses her of being rejecting and moody. Her social life with her husband involves several other couples. The man in these couples is usually a friend of her husband's. She is sure that the women find her uninteresting and unimpressive and that the people who seem to like her are probably as boring as she is. She now wonders whether her marriage was a mistake and sometimes thinks that she would leave her husband were she not afraid to be alone. They have had no children, in part because she felt inadequate to be a mother.9 ~. `/ o! B, |5 B2 z! B
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Recently, she has also been having difficulties at work. She is assigned the most menial tasks and is never given an assignment of importance or responsibility. She has trouble concentrating, and rarely demonstrates assertiveness or initiative to her supervisors. She views her boss as self-centered, unconcerned, and unfair, but nevertheless admires his success. She thinks that she will never go far in her profession because she does not have the right "connections," and neither does her husband., d( m' o0 e: \+ P; g
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DSM-IV-TR Casebook Diagnosis of "Junior Executive"3 Q3 `' d1 b$ @: i% n$ I6 N8 R
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Ms. Demarest has had a chronically depressed mood since adolescence. Because her depression is currently not severe enough to meet the criteria for a Major Depressive Episode, and the mood disturbance and associated symptoms have persisted for more than 2 years, the diagnosis is most likely either Dysthymic Disorder or Major Depressive Disorder in Partial Remission. Because her depression did not begin with a Major Depressive Episode and there is no evidence of either specific etiological factors such as a general medical condition or chronic substance use, or of a Manic or Hypomanic episode in her lifetime, the diagnosis is Dysthymic Disorder (see DSM-IV-TR).' R5 v" U. k( k; _
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Discussion of "Junior Executive" by John C. Markowitz, M.D.*
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The diagnosis of Dysthymic Disorder is frequently missed (Markowitz et al. 1992). Clinicians may focus on recent depressive symptoms and diagnose Major Depressive Disorder, but in fact the symptoms more likely represent a worsening of Dysthymic Disorder. About a third of all depressions are chronic: These can be categorized as either Dysthymic Disorder; Major Depression, chronic (in which the individual chronically has the full depressive syndrome); or recurrent Major Depressive Disorder without full interepisode recovery. The course of chronic depressions has been shown to be worse than that of episodic Major Depressive Disorder. As in Ms. Demarest's case, Dysthymic Disorder typically leads sooner or later to a Major Depressive Episode. Such cases are referred to as double depression (Keller and Shapiro 1982)—that is, Major Depressive Disorder superimposed on Dysthymic Disorder. It is unlikely that this actually represents two separate disorders but, rather, the addition of a couple of acute symptoms to persistent dysthymia. Patients with Dysthymic Disorder often present for treatment when their depressive symptoms become severe enough to warrant a diagnosis of Major Depressive Disorder, although such was not the story in Ms. Demarest's case.) Z" x8 e2 C+ t- r9 C7 X

8 Q8 A2 G6 x7 r" d5 gA second diagnostic confusion is whether the patient has a Depressive Personality Disorder or a chronic mood disorder: Are the symptoms a trait or a (chronic) state? Patients tend to experience a chronic simmering depression as their personality. Such confusion is understandable considering that, as far back as they can recall, they may have always felt that way. Historically, such patients were believed to have a personality disorder and typically received long-term psychotherapy, whereas pharmacological treatment was not considered. Since 1980, the Diagnostic and Statistical Manual of Mental Disorders has classified chronic milder depressive symptoms as a Mood Disorder (Dysthymic Disorder) rather than a personality disorder, a nosological change that has encouraged the often successful use of pharmacotherapy.8 A/ L- L) E7 X- G* K
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Ms. Demarest is unusual in that she is married. Because of their interpersonal difficulties, most patients with Dysthymic Disorder either have never married or have separated or divorced. Like Ms. Demarest, patients with dysthymia believe that they are boring and inadequate and feel uncomfortable in social situations. Emotional intimacy would require them to expose their self-perceived inner deficits. Interpersonal difficulties are indeed a hallmark of chronic depression. The patient's cognitive and emotional sense of inadequacy—feeling guilty, helpless, hopeless, worthless, like a fraud—is often more prominent than are neurovegetative depressive symptoms, such as problems with sleep and appetite. (That is, the DSM-IV Appendix B alternative symptom criteria for Dysthymic Disorder, which are based on research findings, are more germane than the standard criteria.) Dysthymic individuals tend to function better at work—where a job description provides role definition—than in the less structured social domain.1 p8 C& L6 c2 f3 v4 m3 n4 T
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Ms. Demarest is 38 and seeks treatment for the third time. This is consistent with the findings of studies of chronically depressed outpatients who typically are in their 30s, have had unsuccessful treatment with psychotherapy, and yet rarely have had an adequate trial of antidepressant medication. These patients present with infectious discouragement, and often demoralize their therapists as well. It is important that the clinician not share the patient's discouragement, because effective treatments exist.  ?5 J- J8 d; c5 H$ N& o6 M1 N

# R9 A4 n2 E: p% v+ ^Antidepressant pharmacotherapy is the best proven treatment and should be considered the first-line intervention. All classes of antidepressant medications tested to date have worked about equally well, but selective serotonin reuptake inhibitors are most commonly used. The specific choice of medication depends on several factors, including response to previous medications, the match of the medication's effects with prominent symptoms (e.g., a sedating drug for a patient with insomnia), the medication's common side effects (e.g., increased activation, sexual dysfunction, weight gain), and interactions with other medications. With this patient, as with most patients, I would probably start with a selective serotonin reuptake inhibitor, first carefully informing her of its likely benefits, side effects, and course of action.
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Medication may relieve decades-long symptoms in a matter of a few weeks (Kocsis et al. 1988) and improve social and vocational functioning as well (Markowitz 1994). To some patients, the sudden discovery of normal mood (euthymia) can feel like a personality change. Treatment should proceed as it would for Major Depressive Disorder: adequate doses of medication for an adequate acute duration—at least 8 weeks. Response rates are slightly lower (closer to 50%) than for Major Depressive Disorder (60%–70%) but are still substantial. If patients do not respond to a therapeutic dosage after 6–8 weeks, augmentation with or switching to another medication may well work. Because dysthymic patients are easily discouraged, therapists should take pains to ensure that patients do not blame themselves for treatment nonresponse and persevere with another treatment trial that might work. Once patients respond to medication, they tend to need years of maintenance pharmacotherapy to protect against relapse.
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Psychotherapy has been less well studied but is likely helpful (Markowitz 1998), perhaps optimally in conjunction with medication (Keller et al. 2000), both to relieve symptoms and to help develop needed interpersonal skills. Time-limited psychotherapies such as cognitive-behavioral therapy (CBT), interpersonal psychotherapy (IPT), and the cognitive-behavioral analysis system of psychotherapy (CBASP) were designed to treat mood disorders. Given the risk of relapse, a successful acute course of such psychotherapies would need to be followed by continuation and maintenance psychotherapy. This approach is analogous to ongoing pharmacotherapy for this chronic disorder.
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  q4 P: N. X/ O6 Z  Z" ^( O- MCBT is a diagnosis-targeted treatment based on the observation that depressed patients have characteristically distorted thoughts (e.g., "I'm a loser,""People don't find me interesting,""My life situation is overwhelming,""Nothing will ever get any better"), which seem to arise "automatically." Ideas such as "My work is slipshod" both are painful and inhibit normal functioning. CBT therapists encourage patients to examine and test these mood-congruent thoughts rather than simply believing them. Homework includes mutually agreed-on behavioral tasks—going out for a walk, for example, rather than sitting at home—and writing down and assessing the automatic thoughts. In research studies of CBT, the therapy is time limited (12–20 sessions). CBT has been better tested for acute Major Depressive Disorder than for chronic Mood Disorders.& F* W' ?/ m8 e2 l/ C: Y, K4 V

0 [8 p# ^3 h# \9 C* E! J, _' xIPT, also time-limited (12–16 acute sessions) and diagnosis-focused, addresses the relationship between a patient's mood and his or her life situation. It is based on the observation that depressive episodes tend to occur not in a vacuum but in the context of a difficult life situation: the death of a significant other, a problematic relationship, or some other life change. Working on interpersonal functioning and solving the life crisis also relieves mood. For Ms. Demarest, IPT might focus on her marital dispute or her work role, particularly on her inability to express her needs to her husband and at work. The model of IPT was developed to treat acute depression and requires some adaptation for patients with chronic mood syndromes (Markowitz 1998). IPT has demonstrated efficacy in the treatment of acute Major Depressive Disorder; ongoing research is assessing its benefits for chronic Mood Disorders (Browne et al. 2002; Markowitz 2003).& @2 A& w/ w& p. W" E* H/ r
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CBASP (McCullough 2000), which combines aspects of CBT, IPT, and psychodynamic psychotherapy, was compared to pharmacotherapy in one large trial for patients with chronic Major Depressive Disorder. (Chronic Major Depressive Disorder is related but not identical to Dysthymic Disorder.) CBASP is a highly structured treatment that focuses on how chronically depressed patients handle or mishandle interpersonal situations. CBASP worked as well as medication, and the combination of medication plus CBASP worked better than either treatment alone (Keller et al. 2000). The combination of time-limited psychotherapy and antidepressant medication may be the optimal treatment for many chronically depressed patients./ r0 W3 }6 z3 h; w8 r! V

$ |' V& H7 N& b, X0 w3 c0 R4 zPsychoanalytically oriented therapy or psychodynamic psychotherapy, although in widespread clinical use, has not been systematically tested as a treatment for dysthymic patients. Its focus on the past may be less helpful than one of the previously discussed therapies, which help patients to solve current problems (Markowitz 1994).: c3 @, o. H' [) [& |* B) x: Q. b; l

: v1 x+ s: H6 [" o0 |9 uIn treating Ms. Demarest, I would present her with her diagnosis of Dysthymic Disorder and explain the range of treatment options. Inasmuch as she has never had an antidepressant medication trial despite years of having the disorder, I would recommend that she seriously consider one, explaining the strong research evidence for the efficacy of pharmacological treatment. She might respond rapidly to this medication and possibly need no additional treatment. On the other hand, it is unlikely that pharmacological treatment—even if largely successful in treating her mood symptoms—would solve her problems with her husband. For that reason, I would also suggest she consider focal, time-limited psychotherapy.
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) [, T$ W+ o! [& s$ uIf Ms. Demarest refused medication after an extended discussion of its advantages and disadvantages, I would suggest treatment with IPT, CBT, or CBASP. Marital therapy might be another option. If, at the end of that time-limited treatment, the patient had not improved, she and I might by then have built enough of a treatment alliance to negotiate a pharmacotherapy trial. Regardless of which intervention ultimately worked, Ms. Demarest would likely need ongoing treatment in order to maintain euthymia and to have the opportunity to develop new social skills.
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As with treatment-resistant depression, an important aspect of treating chronic mood syndromes is that the therapist remain hopeful and optimistic. If one intervention does not work, the therapist should ensure that the patient does not give up or blame him- or herself. Hopelessness is a symptom of depression and particularly of chronic depression, but the prognosis is never hopeless.; L7 M% n6 n- U- Y

: `! \0 f0 I5 L" r; C*Dr. Markowitz is Associate Professor of Psychiatry at Weill Medical College of Cornell University and Research Psychiatrist at the New York State Psychiatric Institute in New York City. Dr. Markowitz was trained in interpersonal psychotherapy (IPT) by the late Gerald L. Klerman, M.D., who, with Dr. Myrna Weissman, developed IPT in the 1970s. Dr. Markowitz is the author of Interpersonal Psychotherapy for Dysthymic Disorder (Markowitz 1998) and coauthored Comprehensive Guide to Interpersonal Psychotherapy (Basic Books, 2000) with Drs. Weissman and Klerman.
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3 e' q! b9 F" t. tBrowne G, Steiner M, Roberts J, et al: Sertaline and/or interpersonal psychotherapy for patients with dysthymic disorder in primary care: 6-month comparison with longitudinal 2-year follow-up of effectiveness and costs. J Affect Disord 68:317–330, 2002  [PubMed]
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, c, z+ Q5 Q. R& f$ V8 FKeller MB, Shapiro RW: "Double depression": superimposition of acute depressive episodes on chronic depressive disorders. Am J Psychiatry 139:438–442, 1982  [PubMed] 4 J9 `$ Y# z% u, Q

# q; B* `* d1 |3 I$ ^7 I8 T( NKeller MB, McCullough JP, Klein DN, et al: The acute treatment of chronic major depression: a comparison of nefazodone, cognitive behavioral analysis system of psychotherapy, and their combination. N Engl J Med 342:1462–1470, 2000  [PubMed] 7 q5 U$ ?: @1 o& h* M! W

2 I  G3 U' z- c% G3 x' X4 }( MKocsis J, Frances AJ, Voss C, et al: Imipramine and social-vocational adjustment in chronic depression. Am J Psychiatry 145:997–999, 1988  [PubMed] - Z4 r3 A4 g  [6 m; x" p# p
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Markowitz JC: Psychotherapy of the post-dysthymic patient. J Psychother Pract Res 2:157–163, 1993
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Markowitz JC: Psychotherapy of dysthymia. Am J Psychiatry 151:1114–1121, 1994  [PubMed] $ i  E) [/ m5 q4 r, `
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Markowitz JC: Interpersonal Psychotherapy for Dysthymic Disorder. Washington, DC, American Psychiatric Press, 1998
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Markowitz JC: Interpersonal psychotherapy for chronic depression. J Clin Psychol 59:847–858, 2003  [PubMed]
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( o$ n5 x) L, K6 x" c& x, AMarkowitz JC, Moran ME, Kocsis JH, et al: Prevalence and comorbidity of dysthymic disorder among psychiatric outpatients. J Affect Disord 24:63–71, 1992  [PubMed]
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McCullough JP: Treatment for Chronic Depression: Cognitive Behavioral Analysis System of Psychotherapy. New York, Guilford, 2000


DOI: 10.1176/appi.books.9781585622665.31203
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! _* ^' q* ?! |* ANo Fluids " P& v2 V' b8 L4 z0 C8 \
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Ann, a 32-year-old medical secretary in Dublin, Ireland, is referred to a clinic for treatment of depression. She confides that the reason she is depressed is that for the last 5 months, she has been afraid that she will urinate in public. She has never actually done this; and in the safety of her own home, she considers the idea that it will actually happen to her to be nonsensical.
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When Ann is away from home, the fear dominates her thinking, and she takes precautions to prevent its happening. She always wears sanitary napkins, never travels far from home, limits her intake of fluids, has stopped drinking alcohol, and has had her desk at work relocated near a toilet. For the 2 weeks before the consultation, she was unable to go to work because the fear had become so intense./ [7 _6 M1 _# E, q0 |% G

7 U  Y' F- D# T$ MAnn vaguely recalls that her deceased father also had a fear of urinating in public. Before leaving for work each day, he urinated several times and avoided taking any fluids. Her younger sister has been successfully treated for a cleansing ritual.
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" n) w# o, Z* M2 {* M5 NAnn had psychiatric treatment 10 years ago when she began to fear that she had contracted syphilis, even though there was no clinical or laboratory evidence of infection. Up until 5 months ago, she had never feared that she would urinate in public. In addition to these specific fears, she has always been an anxious, insecure person, considered by her family to be overly cautious and perfectionistic. For the past year she has been upset about her boyfriend's impending return to his home country, after completing his medical studies in Ireland. She was divorced 5 years previously and is now living with her 7-year-old-son and mother. Her mother disapproves of her boyfriend, and Ann has felt increasing pressure to end the relationship. She believes that the onset of her current difficulties coincided with the stress of her relationship with her mother and the threat of her boyfriend's departure from the country.
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When interviewed, Ann is visibly anxious. She remarks that she has been feeling despondent about her problems. She has trouble sleeping and has no energy during the day. Although her appetite is poor, she has not lost any weight.
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5 `/ x. Z  p3 l0 X+ w, k# XDSM-IV-TR Casebook Diagnosis of "No Fluids") ~6 H( _* S, R6 \& T

! e+ ~3 q7 V: q7 B9 W$ ^Ann has markedly restricted her usual activities because of a fear that she will involuntarily urinate in public. The fear of being in situations from which escape might be difficult in the event of developing an embarrassing or incapacitating symptom is called Agoraphobia. Usually Agoraphobia is a complication of Panic Disorder, in which the person avoids certain situations that he or she associates with having had a panic attack. Much more rarely, there is no history of Panic Disorder, and the fear is of developing some specific symptom such as loss of bladder control (as in Ann's case), vomiting, or cardiac distress. In such cases the diagnosis is Agoraphobia Without History of Panic Disorder (see DSM-IV-TR).( A% J" G" k: `3 v

3 l, t$ F0 N+ o. f& ?. FA reader may wonder why Ann's condition is not diagnosed as Social Phobia: a persistent fear of a situation in which she is exposed to possible scrutiny by others and fears that she may do something (e.g., urinate) that will be humiliating or embarrassing. In Social Phobia, the person is attempting to accomplish a voluntary activity (e.g., speaking, eating, writing, urinating) and fears that the normal activity will be impaired by signs of anxiety (e.g., be unable to speak, choke while eating, tremble while writing, be unable to urinate). In contrast, in Agoraphobia Without History of Panic Disorder, the person is afraid of suddenly developing a symptom that is unrelated to the activity that he or she is trying to accomplish (e.g., cardiac distress while shopping, involuntary urination when away from home, dizziness while crossing the street).
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Ann is also depressed and has several symptoms of the depressive syndrome, including poor appetite, insomnia, and decreased energy. We suspect a Major Depressive Episode, but because there is inadequate information to determine whether the full criteria are met, we note Depressive Disorder Not Otherwise Specified (see DSM-IV-TR)." z) m4 }3 e1 B- c# k1 z, w" B
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Ann was treated with an antidepressant. Her fear that she might urinate in public lessened after 10 days of treatment, and a behavioral program was then instituted to correct her repertoire of avoidance behaviors. Before her boyfriend left the country, Ann and her son moved away from her mother, and she was able to lead a more independent life. Her medication was phased out after 2 months, and the fear that she would urinate in public did not return. The psychiatrist attributed her initial improvement to the medication, and her continued improvement to the behavioral program and the changes that she made in her life circumstances, particularly moving away from her mother.


DOI: 10.1176/appi.books.9781585622665.31220
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9 ^( z6 Q5 I# Q, f' V# |$ |. GJoe College 7 U  ^9 j" |0 N/ k( E  a* |

" l. e$ B8 P4 u5 }/ oA 19-year-old college freshman spends an afternoon drinking beer in a bar with fraternity brothers. After 8 or 10 glasses, he becomes argumentative with one of his larger companions and suggests that they step outside and fight. Normally a quiet, unaggressive person, he now speaks in a loud voice and challenges the larger man to fight with him, apparently for no good reason. When the fight does not develop, he becomes morose and spends long periods looking into his beer glass. He seems about to cry. After more beers, he begins telling long, indiscreet stories about former girlfriends. His attention drifts when others talk. He tips over a beer glass, which he finds humorous, laughing loudly until the bartender gives him a warning look. He starts to get up and say something to the bartender, but trips and falls to the floor. His friends help him to the car. Back at the fraternity house, he falls into a deep sleep, waking with a headache and a bad taste in his mouth. He is again the quiet, shy person his friends know him to be.2 `  t6 R3 J& c
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DSM-IV-TR Casebook Diagnosis of "Joe College"+ t' D4 j- K+ ^2 ~2 _
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Although intoxication in the physiologic sense occurs in social drinking, maladaptive behavior is required for the mental disorder diagnosis of a Substance-Induced Intoxication. In this case there is evidence of disinhibition of aggressive impulses (picking a fight), impaired judgment (telling indiscreet stories), mood lability (argumentative, then crying and morose), and physiologic signs of intoxication (incoordination and unsteady gait). This is therefore Alcohol Intoxication (see DSM-IV-TR), as obviously alcohol is the offending substance.
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# D1 y9 C! C% a! |0 ZWe are not told if this kind of behavior occurs repeatedly. If it did, the diagnosis of Alcohol Abuse, or even Alcohol Dependence, should be considered.