Junior

Executive\((P((P.155),
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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.4 z5 C1 x l m$ H'
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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 23 times weekly for
2.5 years overlapping graduate school.
Although 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.8 b$ E
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Just 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
155 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.% N. l#
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.

Toxic Neighborhood
Robert Cortland is a 38-year-old man who presents to a community mental health
center for follow-up outpatient treatment after his third psychiatric hospitalization in
3 years. Despite holding degrees in pharmacy and dentistry, he has been unable to
work for the past 3.5 years, receives disability insurance, and lives with his mother.
He was prescribed lithium and Trilafon (perphenazine) on hospital discharge and
complains of feeling tired, feeling angry at having been hospitalized, and having
difficulty feeling any emotions ("Try-a-laughing on Tril-a-fon"). He claims not to feel
depressed, irritable, or euphoric; denies changes in appetite or libido; and says he is
sleeping about 9 hours a night. He denies hallucinations and problems with
concentration, although he has difficulty responding clearly to many questions. He
wants to move out of his mother's house because he is suspicious of the neighbors
but feels guilty about abandoning his mother.
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Dr. Cortland reluctantly recounts his psychiatric history. Fortunately, hospital records
have also been forwarded to the evaluating psychiatrist. He initially presented for
treatment 3 years ago. At that time, the police brought him to the psychiatric
emergency service after neighbors reported that he was outside screaming at them
through their windows to "turn the radiation off!" Police found him shirtless in 30F
weather and wearing a "samurai headband." Dr. Cortland was admitted and treated
with Haldol (haloperidol) and Cogentin (benztropine). He is embarrassed about
describing any other symptoms leading up to this first hospitalization but
remembers being unable to sleep for days because he felt like his mind was
"buzzing," his eyes were "bulging," and his bedroom was overheated. About 1
month before this episode, he decided that he no longer wanted to practice
dentistry because it did not allow him to be creative enough with his hands, so he
began painting "impressionistic" art on discarded window glass.9
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Dr. Cortland never returned to work after this first hospitalization, despite working
briefly with an occupational therapist. Although he was referred to a psychiatrist for
follow-up treatment, he missed "at least half" of his appointments and took Haldol
only sporadically for 3 months before discontinuing it because it made him feel
"dead." He spent most of his time over the next year painting in his basement and
occasionally grocery shopping for his mother but otherwise was reclusive. He

remained suspicious of his neighbors and glared at them in chance encounters. He

described feeling down and discouraged during this time, unsure of what to do with
his life, and afraid to interact with people because they might recognize that he was
"crazy." Dr. Cortland was admitted for his second psychiatric hospitalization
approximately 1 year ago, after his mother called 911 because he again believed
his neighbors were beaming microwaves at his bedroom from their satellite dish to
keep him awake. In the hospital discharge summary, he was described as extremely
agitated, threatening, and irritable, with pressured speech on admission. He was
also suspected of hearing voices because of his extreme distractibility, although he
denied it. In addition, he was reported to have had a fixed, persecutory delusion
about his neighbors in the year before admission. He was discharged on Depakote
(divalproex), Zyprexa (olanzapine), and Ativan (lorazepam).
Dr. Cortland was again "too proud" to follow up with outpatient treatment and
discontinued his medication when his prescriptions ran out 1 month after discharge.
He felt well for approximately 3 months but then resumed being reclusive, slept for
more than 16 hours a day, stopped shaving, and bathed infrequently and only at his
mother's insistence. He was admitted for the third time 2 months ago after
appearing at the psychiatric emergency service because he "couldn't take it
anymore." He had been driving aimlessly for hours on the interstate, often at high
speeds, hoping he would be stopped and shot by police. He was agitated and
irritable, believed that the Holy Spirit was sending messages through his painting,
and believed that his neighbors were still aiming microwaves at his brain. He
reported that he "could hear them scheming through the walls." He refused to
resume Depakote and Zyprexa but gradually improved on lithium and Trilafon. Dr.
Cortland appeared physically healthy on examination in the hospital, and there were
no significant laboratory abnormalities, including normal thyroid function tests and
brain magnetic resonance imaging.
Dr. Cortland is an only child and had always been somewhat of a "loner" growing up.
He received a Registered Pharmacist degree in a 5-year college program, worked for
several years as a pharmacist, and then successfully applied for admission to dental
school. He operated a solo dentistry practice for 12 years. He lived at home with his
mother all his life, feeling obligated to take care of her (although she is in good
health) when his father died 15 years ago. He had several protracted periods of
feeling down during college and dental school, usually because of rejection by
women he was dating. He could not provide any more elaborate history of
depressive symptoms. Dr. Cortland's father was "a strange man" but never received
psychiatric care. His paternal uncle had "nervous breakdowns," and a paternal first
cousin spent years in a state psychiatric facility.

Grandma's Child (P 401)

Tanya, age 4, was seen for assessment in a child psychiatry clinic at the request of
her grandparents. Tanya was the only child of parents who were longtime heroin
users. Several months ago, not having seen Tanya or her parents for several years,
the grandparents were called by the child protection agency in another state and
informed that Tanya's parents had been arrested and she had been placed in foster
care.
Soon thereafter, when Tanya came to live with them, the grandparents noticed that
she did not have the verbal skills of a normal 4-year-old child, and she had marked
problems with social interaction. She often seemed oblivious to ordinary invitations
to hug or play with her grandparents and other relatives. She also exhibited a
rapidly alternating mixture of responses in which sometimes she seemed to want to
get very close to people and at other times would push them away. The
grandparents later learned that, since she was an infant, Tanya had often been left
with various friends of her parents, many of whom were themselves heavy drug
users,
and
they
were
often
only
minimally
attentive
to
her.
On examination Tanya was found to have mild language delays and marked
problems in social interaction. She tended to avoid interaction, or, when it could not
be avoided, become very anxious and disorganized. After several months of
consistent care in her grandparents' home, her use of language became much more
appropriate for a 4-year-old child, but she still had some difficulties in social
interaction.
Sniper (P 405)
Leah, age 7, was referred by her teacher for evaluation because of her tearfulness,
irritability, and difficulty concentrating in class. Two and a half months earlier Leah
had been among a group of children pinned down by sniper fire on her school
playground. Over a period of 15 minutes, the sniper killed one child and injured
several others. After the gunfire ceased, no one moved until the police stormed the
sniper's apartment and found that he had killed himself. Leah did not personally
know the child who was killed or the sniper. J&
Before the shooting, according to her teacher, Leah was shy but vivacious, wellbehaved, and a good student. Within a few days after the incident, there was a
noticeable change in her behavior. She withdrew from her friends. She began to
bicker with other children when they spoke to her. She seemed uninterested in her
schoolwork and had to be prodded to persist in required tasks. The teacher noticed
that Leah jumped whenever there was static noise in the public address system and
when the class shouted answers to flashcards. u# f* n7 Q2 @# K
Leah's parents were relieved when the school made the referral, because they were
uncertain about how to help her. Leah had been uncharacteristically quiet when her
parents asked her about the sniping incident. At home she had become moody,
irritable, argumentative, fearful, and clinging. She was apprehensive about new
situations and fearful of being alone and insisted that someone accompany her to

the bathroom. Leah regularly asked to sleep with her parents. She slept restlessly
and occasionally cried out in her sleep. She always appeared to be tired,
complained of minor physical problems, and seemed more susceptible to minor
infections. Her parents were especially worried after Leah nearly walked in front of a
moving car without being aware of it. Although she seemed less interested in many
of her usual games, her parents noticed that she frequently engaged her siblings in
nurse games, in which she was often bandaged.
When asked about the incident in the interview, Leah said that she had tried
desperately to hide behind a trash can when she heard the repeated gunfire. She
had been terrified of being killed and was "shaking all over," her heart pounding and
her head hurting. She vividly told of watching an older child fall to the ground,
bleeding and motionless. She ran to safety when there was a pause in the shooting.
Leah described a recurring image of the injured girl lying bleeding on the
playground. She said that thoughts of the incident sometimes disrupted her
attention, though she would try to think about something else. Lately, she could not
always remember what was being said in class. She no longer played in the area
where the shooting had occurred. During recess or after school, she avoided
crossing the playground on her way home from school each day and avoided the
sniper's house and street. She was particularly afraid at school on Fridays, the day
the shooting had occurred. Although her mother and father comforted her, she did
not know how to tell them what she was feeling. Leah continued to be afraid that
someone would shoot at her again. She had nightmares about the shooting and
dreams in which she or a family member was being shot at or pursued. She ran
away from any "popping noises" at home or in the neighborhood. Although she said
that she had less desire to play, when asked about new games, she reported
frequently playing a game in which a nurse helped an injured person. She began to
watch television news about violence and recounted news stories that
demonstrated that the world was full of danger.
Compulsion (P 409)
Alan, a 10-year-old boy, is brought for a consultation by his mother because of
"severe
compulsions." The mother reports that the child at various times has to run and
clear
his
throat,
touch the doorknob twice before entering any door, tilt his head from side to side,
rapidly
blink
his
eyes, and suddenly touch the ground with his hands by flexing his whole body.
These
"compulsions"
began 2 years ago. The first was the eye blinking, and then the others followed,
with
a
waxing
and
waning course. The movements occur more frequently when he is anxious or under
stress.
The
last

symptom to appear was the repetitive touching of the doorknobs. The consultation
was
scheduled
after the child began to make the middle finger sign while saying "fuck."
When examined, Alan reported that most of the time he did not know in advance
when
the
movements were going to occur except for the touching of doorknobs. Upon
questioning,
he
said
that before he felt he had to touch a doorknob, he got the thought of doing it and
tried
to
push
it
out
of his head, but he couldn't because it kept coming back until he touched the
doorknob
several
times;
then he felt better. When asked what would happen if someone did not let him
touch
the
doorknob,
he said he would just get mad; once his father had tried to stop him and Alan had
had
a
temper
tantrum. Alan explained that the touching of the doorknobs didn't really bother him
what
did
was
all the "other stuff" that he couldn't control.
During the interview the child grunted, cleared his throat, turned his head, and
rapidly
blinked
his
eyes several times. At times he tried to make it appear as if he had voluntarily been
trying
to
perform
these movements.
Personal history and physical and neurological examination were totally
unremarkable
except
for
the
abnormal movements and sounds. The mother reported that her youngest uncle
had
had
similar
symptoms when he was an adolescent, but she could not elaborate any further. She
stated
that
she
and her husband had always been "very compulsive," by which she meant only that
they
were
quite
well organized and stuck to routines.