Monday, October 27, 2008

Case 7 - The Misdirected Gentleman

Henry McWilliams had been born in London. Dressed in his short grey pants, white shirt, and school tie, he rode the London underground every day to his exclusive school. One day, when he was nine, he saw a man rubbing up against a woman on the Underground.

Henry was small when he was nine, and even in the crowded subway car he has an excellent eye-level view. The woman (she was an adult, though Henry had no idea how old) was a bit overweight and dressed in a tight-fitting mini-skirt. She was facing away from the man, who allowed the weight of the crowd surging through the doors top press him up against her. The man tugged at his crtoch, and then, as the train began to move, rubbed himself against her.

"I never saw her face, but I could tell she didn't like it," said Henry. "She tried to push him away, she tried to move, but there was no place for either of them to go. Then the train stopped and he ran out the door."

Henry the adult, age 24, had now referred himself for treatment. He had moved with his parents to the United States when he was 15. Since his graduation from high school, he had worked as a messenger for a large legal firm. Many days he spent on the subway in his official capacity. He guessed that he had rubbed against 200 women in five years. He was seeking help at the insistance of one of the partners in his law firm, who the week before had happened to ride the same train and watched him in action.

When Henry was in need, he would go into the men's room and put on a condom so as not to stain his trousers. Then he would roam up and down the outskirts of a crowd on a subway platform until he found a woman who interested him. This would be someone who was youngish but not young ("They're less likely to scream."), and well-rounded enough to stretch tight the material of her skirt or slacks. He especially liked it if the material was leather. He would board after she did, and if she did not turn around, would rub his erection up and down against her buttocks as the train began to roll.

"I'm very sensitive, so it doesn't take much pressure." Sometimes the woman didn't even seem to realize what was going on, or maybe she didn't want to admit it, even to herself. He usually climaxed within a minute. Then he would bolt out the door at the next stop. In the event that he was interrupted, he would hang out around the platform until he spotted another woman in another crowd.

"It helps if I imagine that we're married or engaged," he explained. "I'll pretend that she's wearing my ring, and I've come home for a quickie."

Saturday, October 25, 2008

Case 6 - Melvin B.

Melvin B. a sixty-two-year-old black male, was referred for therapy by his physician. He had been diagnoses as having gastric ulcers

Monday, October 13, 2008

Case 5 - The Case of the Quiet Zombie

An eleven-year-old girl asked her mother to take her to a psychiatrist because she feared she might be "going crazy." Several times during the last two months she has awakened confused about where she is until she realizes she is on the living room couch or in her little sister's bed, even though she went to bed in her own room. When she recently woke up in her older brother's bedroom, she became very concerned and felt quite guilty about it.

Her younger sister says that she has seen the patient walking during the night, looking like a "zombie," that she didn't answer when she called her, and that the patient has done that several times, but usually goes back to her bed.

The patient fears she may have "amnesia" because she has no memory of anything happening during the night.

There is no history of seizures or of similar episodes during the day. An electroencephalogram and physical examination prove normal. The patient's mental status is unremarkable except for some anxiety about her symptoms and the usual early adolescent concerns. School and family functioning are excellent.

Thursday, October 9, 2008

Child Case - Baby Susan

Susan was admitted to the hospital at age 6 months by an aunt for evaluation of failure to gain weight. She had been born into an impoverished family after an unplanned, uncomplicated pregnancy. During the first four months of life, she gained weight steadily. Regurgitation was noted during the fifth month, and increased in severity to the point where she was regurgitating at every feeding.

After each feeding, Susan would engage in one of two behaviors:

1) She would open her mouth, elevate her tongue, and rapidly thrust it backward and forward, after which milk would appear at the back of her mouth and slowly trickle out; or

2) She would vigorously suck her thumb and place fingers in her mouth, following which milk would slowly flow out of the corner of her mouth.

In the past two months, Susan had been cared for by a number of people, including her aunt and paternal grandmother. Her parents were making a marginal marital adjustment. Nevertheless, Susan often smiled and was responsive to all of her caregivers.

Case 4 - Wally Graham

"The news is good," announced Wally Graham's clinician. "Your x-rays and the other tests show nothing wrong - no cancer, no ulcer, not even gastritis."

Wally Graham did not look pleased. "I don't understand it."

"I mean I don't understand why I'm still having the pain and why I'm throwing up nearly every morning." He slowly began to put on his shirt.

The clinician leafed through his chart. "I checked with your previous HMO. They said you'd had the same set of tests done there six months ago. And the year before that."

"Yes, I told you all about that, last time I was here. I haven't held anything back." Wally had begun to sound angry. "This has been going on for four or five years now. I don't like being this way, you know."

"No, of course not," said the clinician. "I didn't mean that. I meant that for years you've had stomach pains, nausea, vomiting, and diarrhea, and for years you've been afraid you have cancer. You've had at least four workups by excellent clinicians; they've all reassured you that nothing is wrong. Only you don't feel reassured. Last week you were even gastroscoped by our gastroenterologist. That's the most definitive test you can get. There weren't even enough findings to diagnose an upset stomach! I'm not saying you don't have pain, but I think your problem is somewhere besides your stomach. I'd like to check out some other possibilities, to see if we can get to the bottom of this."

"I hope so." Wally Graham was less angry, but he still sounded unconvinced. Fully dressed now in his tie and sports jacket, he looked somehow smaller than he had before. He was a 42-year-old, unmarried accountant who worked for a branch of one of the large national firms that advertised on TV. He liked his job (except during tax season, which nobody liked). but several days a month he had to stay in bed with abdominal pains. His supervisor was becoming restive.

Of course, Wally had been worried, maybe even a little depressed. He had felt this way occasionally throughout his ordeal of the past several years, but his concentration had been good and his interest in work and leisure activities had been high. Any problems with sleep or appetite had been due to the abdominal distress, which only lasted for a few days each time. He had never had suicidal ideas.

Wally had never tried street drugs; for years he avoided alcohol in any form. Except for his abdominal distress, his health was good. He denied everything on an impressively long list of symptoms that included headache, dizziness, chest pain, painful urination, and musculoskeletal and neurological complaints. Over the years he had quite a lot of anxiety about having cancer, but he never experienced a full-blown panic attack. He had never heard voices or seen visions, nor did he believe that people were plotting or talking about him behind his back.

The first few times a clinician told Wally that he did not have cancer, he felt relieved, but after a few days, the symptoms would start again and he would worry. "What if the lab had switched somebody else's tests with his?" "Suppose the radiologist had misread the film." "Or perhaps, I didn't have cancer then, but I've developed it since the last tests were made. How's anyone going to reassure me about that?"

*Note, You are looking for an Axis I diagnosis. Also, how is this case different from that of Jason Bird in Case 3?

Wednesday, October 1, 2008

Case 3 - Jason Bird

Jason Bird was a 47 year old man who was admitted to a cardiac intensive care unit despite having no health care card-- he claimed he had lost his billfold to a mugger a few hours earlier. He came to the emergency room of a Midwestern hospital late on Saturday night, complaining of crushing sub-sternal chest pain. Although his electrocardiogram (EKG) was markedly abnormal, it did not show the changes typical of an acute myocardial infarction (MI). The cardiologist on call, noting his ashen pallor and obvious distress, ordered him admitted and then waited for the cardiac enzyme results.

The following day, Jason's EKG was unchanged and the serum enzymes showed no evidence of heart muscle damage. His chest pain continued. He complained loudly that he was being ignored. The cardiologist urgently requested a mental health consultation. Jason was a slightly built man with a bright, shifting gaze an a four day growth of beard. He spoke with a nasal Boston accent. His right shoulder bore the tattoo of a boot and the legend "Born to Kick Ass". Throughout the interview he frequently complained of chest pain, but had no difficulty breathing or talking, and he showed no signs of anxiety about his medical condition.

He said he had grown up in Quincy, Massachusetts, the son of a physician. After high school, he attended college for several years, but found he was "too creative" for a profession or conventional job. Instead, he had turned to inventing medical devices, and numbered among his successes a positive-pressure respirator that bore his name. Although he had made several fortunes, he had lost nearly everything to his penchant for playing the stock market. He had been visiting in the area, relaxing, when the chest pain struck.

"And you've never had it before?" asked the interviewer, looking through the chart.
Jason denied that he'd had any previous heart trouble.
"Not even a twinge. I've always been blessed with good health."
"Ever been hospitalized?"
"Nope. Well, not since a tonsillectomy when I was a kid."
Further questioning was similarly unproductive. As the interviewer left, Jason was demanding an extra meal service. Playing a hunch, the interviewer began telephoning emergency room physicians in the Boston area to ask about a patient with Jason's name or peculiar tattoo. The third try struck pay dirt.

"Jason Bird? I wondered when we'd hear from him again. Hes been in and out of half the facilities in the state. His funny looking EKG-- probably an old MI looks pretty bad, so he always gets admitted, but there's never any evidence that anything acute is going on. I don't think that he's addicted. A couple of years ago he was admitted with genuine pneumonia and got through a week without pain medication and with no withdrawal symptoms. He'll stay in the ICU a couple of days and rag on the staff. Then he'll split. He seems to enjoy needling medical people."

"He told me that he was the son of a physician and that he was a wealthy inventor."

The physician at the other end of the line chuckled. "The old respirator story. I checked into that one when he was admitted here for the third time. That was a different Bird altogether. I don't know that Jason's ever invented anything in his life. As for his father, I think he was a chiropractor." Returning to the ward to add a note to the chart, the interviewer discovered that Jason had discharged himself against medical advice and departed, leaving behind a complaining letter to the hospital administrator.