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Case 11 Wanda was a 15-year-old girl whose mother brought her…
Case 11
Wanda was a 15-year-old girl whose mother brought her for a psychiatric evaluation to help her with long-standing shyness.
Although Wanda was initially reluctant to say much about herself, she said she felt constantly tense. She was generally unable to speak in any situation outside of her home or school classes. She refused to leave her house alone for fear of being forced to interact with someone. She was especially anxious around other teenagers, but she also became “too nervous” to speak to adult neighbors she had known for years. She said it felt impossible to walk into a restaurant and order from “a stranger at the counter” for fear of being humiliated.
Wanda also felt she was constantly on her guard, needing to avoid the possibility of getting attacked. She was the most confident when she was alone in her room. From seventh grade to ninth grade, Wanda’s peers turned on her. The bullying was daily and included intense name-calling (for example – “stupid,” “ugly,” and “crazy”) and physical threats. One girl (the ringleader) had been Wanda’s good friend in elementary school, but hit her and gave her a black eye. Wanda did not fight back. She refused to tell her parents what happened but cried herself to sleep at night.
Wanda transferred to a specialty arts high school for ninth grade. Even though the bullying ended, she could not make friends. Wanda felt even more unable to venture into new places. She felt increasingly self-conscious that she could not do as much on her own.
Wanda was even scared to read a book herself in a local, public park. She had nightmares about the bullies in her old school. She spent whole weekends “trapped” in her home.
COMORBIDITY – 3 potential diagnoses co-occur or are present simultaneously.
Case 6
Ike Belarus was a 32-year-old man referred for a mental health evaluation by the human resources department at a construction site. Although he presented as a very motivated and skilled worker at the interview with two carpentry certificates, in the first two weeks of employment, he had frequent arguments, was absenteeism, and made many dangerous mistakes. When confronted by supervisors, he was dismissive of the problem and said if someone got hurt, “it’s because of their stupidity.”
When the head of human resources met with him to discuss termination, Mr. Bean said he would sue on the grounds of the American Disability Act: He demanded an evaluation for attention-deficit/ hyperactivity disorder (ADHD) and bipolar.
During the mental health evaluation, Mr. Bean focused on unfairness at the company and how he was “a hell of a better carpenter than anyone there could ever be.” He had been married twice and had two children. Mr. Bean refused to pay child support, which is why he said both ex-wives “lied to judges and got restraining orders saying I’d hit them.” He was not interested in seeing his children. He said they were “little liars” like their mothers.
During high school, he said he “must have been smart” because he was able to make Cs in school despite only showing up half the time. He spent time in juvenile hall at age 14 for stealing “kid stuff, like tennis shoes and wallets that were practically empty.” He left school at age 15 after being “framed for stealing a car.” He pointed this out to show how he had overcome injustice. Mr. Bean concluded the interview by demanding a note from the examiner that said he had “bipolar” and “ADHD.”
Phone calls revealed that Mr. Bean had been expelled from two carpentry training programs and that both of his certificates had been falsified. He got fired from his job at one local construction company after a fistfight with his supervisor.
Case 4
Brad was a 12-year-old boy brought in by his mother for psychiatric evaluation for temper tantrums.
Even Brad’s teachers noted that he often cried and rarely spoke in class. They said he was academically capable but that he had little ability to make friends. In recent months, multiple teachers heard him screaming at other boys, generally in the hallway, but sometimes in the middle of class. The teachers assumed he was responding to a provocation.
When interviewed alone, Brad responded with nonspontaneous mumbles when asked questions about school, classmates, and his family. When the examiner asked if he was interested in toy cars, however, Brad lit up. He pulled several cars, trucks, and airplanes from his backpack and, while not making good eye contact, did talk at length about vehicles, using their proper names (e.g., front-end loader, B-52, Jaguar).
When asked again about the school, Brad pulled out his cell phone and showed strong test messages: “dumbo!!!!, mr stutter, LoSeR, freak!, EVERYBODY HATES YOU.” Brad added that other boys would whisper “bad words” to him in class and then scream in his ears in the hall. “And I hate loud noises.”
According to his mother, he had always been “very shy” and had never had a best friend. He struggled with jokes and typical childhood banter because “he takes things so literally.”
On examination, Brad stumbled over his words, paused excessively, and sometimes rapidly repeated words or parts of words. Brad said he felt okay but added he was scared of school.
COMORBIDITY – 2 potential diagnoses co-occur or present simultaneously
Questions for Case 11,6and4
What is your Diagnosis?
What led you to that diagnosis?
