Case-1

A 23-year-old woman is admitted to the inpatient psychiatric unit after slashing both wrists when
her therapist left for a week’s vacation. The cuts were superficial and did not require stitches.
The patient says that she is angry with her psychiatrist for “abandoning her.” She claims that she
is often depressed, although the depressions last “only a couple of hours.” When she was first
admitted to the hospital, she told the admitting psychiatrist that she heard a voice telling her that
“she will never amount to anything,” but she subsequently denies having heard the voice. This is
the patient’s fourth hospital admission, and all of them have been precipitated by someone in her
life leaving, even temporarily. After 3 days in the unit, the patient’s psychiatry resident gets into
an argument with the nursing staff. He says that the patient has been behaving very well,
responding to his therapy, and is deserving of a pass. The nurses claim that the patient has not
been following unit rules, sleeping through her group meetings, and ignoring the limits set. Both
parties go to the unit director complaining about the other. What is the most likely diagnosis?
1. What defense mechanism is being employed by the patient?
2. What should the hospital staff do next?

Case-2
A 47-year-old man is referred to a psychiatrist at his employee assistance program because of
continuing conflicts on the job. This is the third time the patient has been referred to a
psychiatrist under such circumstances. He lost two previous jobs because of conflicts with
coworkers. The patient states that people do not like him and would like to see him fail. He cites
as an example one instance in which one of his colleagues was late in sending him some material
he needed, resulting in the patient being unable to complete his assignment in a timely fashion.
Although the colleague apologized for the mistake, the patient says that he knows that this man
is “out to get me fired.” He has since broken off all contact with this coworker and refuses to
speak with him directly, preferring to use only written communication. On a mental status
examination, the patient appears somewhat angry and suspicious. He glares intently at the
interviewer and sits with his back to the wall. He repeatedly requests a clarification of questions,
often asking, “What will this material be used for? I bet you are going to use it against me so that
I will be fired.” When the interviewer’s pager goes off, the patient accuses him of trying to
shorten the time allotted to him by arranging to have the pager interrupt them. The patient’s
mood is described as “fine,” but his affect is tense and he appears suspicious and ill at ease. The

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patient’s thought processes and thought content are both within normal limits.
1. What is the most likely diagnosis?
2. What is the best strategy in approaching this patient?

Case-3
A 21-year-old woman comes to the student-counseling center with complaints of being depressed
and feeling anxious. She states that 2 weeks ago, while in class, she was called on by the teacher
and gave the wrong answer. She says that she felt “humiliated” and has not gone back to the
classroom since then. She describes a lifelong history of being painfully shy. She admits that she
would like to have a boyfriend but that she is afraid to meet anyone because “I’ll get dumped.”
She describes herself as “socially retarded” and avoids going out with anyone new. She has two
close friends and does go out to dinner with them weekly, which she enjoys. She denies trouble
sleeping or with her appetite, although she does admit to feeling ashamed of her social
ineptitude. She is worried that she will be unable to finish college because of her problems.
1. What is the most likely diagnosis?
2. What is the best therapy for this patient?

Case-4
A 45-year-old man is admitted to a cardiac intensive care unit after suffering a heart attack.
Twenty-four hours after admission, the consultation psychiatrist is called in to make an
evaluation because the patient is trying to sign himself out against medical advice. When the
psychiatrist enters the patient’s hospital room, she finds him getting dressed and yelling at the top
of his lungs, “I won’t be treated in this manner! How dare you!” The patient does agree to sit
down and speak with the psychiatrist, however. He tells the psychiatrist that staff members are
simply rude and do not treat him “in the manner to which he is accustomed.” He says that he is a
small business owner, but that he is on the way up and “as soon as people realize my full
potential, I will be a millionaire.” He cannot understand why the staff will not bring food up from
an outside cafeteria for him because the food in the hospital is so bad. He asks the psychiatrist
whether, after the interview, she will get some food for him, and he becomes angry when she
declines. He then eyes her new, expensive watch enviously. On a mental status examination, the
psychiatrist finds no disorders of thought process or content, and the patient is found to be
oriented to person, place, and time.
1. What is the most likely diagnosis?

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2. What would be the most successful approach in dealing with this patient?

Case-5
A 42-year-old man comes to see a psychiatrist stating that his life is “crashing down around his
ears.” He explains that since his girlfriend of 2 months left him, he has been “inconsolable.” He
says that he is having trouble sleeping at night because he is mourning her loss. When asked to
describe his girlfriend, the patient states, “She was the love of my life, just beautiful, beautiful.”
He is unable to provide any further details about her. He says that they had five dates, but that he
simply knew that she was the one for him. He claims that he was often in the “depths of despair”
in his life, but that he also felt “on top of the world.” He denies any psychiatric history or any
medical problems. On a mental status examination, the patient is dressed in a bright, tropical
pattern shirt and khaki pants. He leans over repeatedly to touch the interviewer on the arm as he
speaks, and he is cooperative during the interview. He sometimes sobs for a short period of time
when talking directly about his girlfriend but smiles broadly during the interview when asking
the interviewer questions about her. His speech is of normal rate, although at times somewhat
loud. The patient describes his mood as “horribly depressed.” His affect is euthymic the majority
of the time, and full range. His thought processes and thought content are all within normal
limits.
1. What is the most likely diagnosis?
2. What is the best initial treatment for this patient?
Case-6
A 15-year-old adolescent girl is brought to your office by her family after a recent hospitalization
for a suicide attempt. She made this attempt shortly after a party she attended the previous
weekend. At this party, she reportedly argued with her best friend and left very angry. Her history
at admission shows a several month history of irritability, worsening performance in school, poor
sleep, anhedonia, anergia, and isolation from her family and friends. Her discharge summary has
an admitting diagnosis of major depression for which she was started on fluoxetine (Prozac). She
sees you 2 weeks after her 3-day hospitalization and is quite cheery, energetic, and happy. She
reports no problems and dismisses her earlier suicide attempt as a childish act to get attention.
She reports that the staff at the hospital were absolutely wonderful and helped her solve all her
problems. She says that she was so impressed with them that she has decided to go into
psychiatry herself so she can help others. Later, while meeting with the parents, they report that

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at home she is sleeping well and appears in a good mood. Nevertheless, they are concerned
because they also report that she is worried about whether there were cameras in the doctor’s
office that were recording her. She also reports that she believes she is being stalked by several
of the boys at her school.
1. What is the most likely diagnosis?
2. What is the best therapy for this condition?
3. Should this patient be hospitalized?

Case-7
A 32-year-old man comes to a psychiatrist with a chief complaint of being depressed since he
broke up with his girlfriend 2 weeks ago. The patient explains that although he loves his ex-
girlfriend, he broke up with her because his mother did not approve of her and would not allow
him to marry her. He says that he cannot go against his mother because she “has taken care of me
all these years.” He states he could never fend for himself without his mother and alternates
between being angry with her and feeling that “maybe she knows best.” He has lived at home his
entire life except for one semester away at college. He returned home at the end of the semester
because he was homesick, and did not go back. The patient reports no loss of appetite,
concentration, or energy. The patient claims that he performs “adequately” at work and has no
job related problems. He works for an accounting firm in an entry-level position even though he
has been there for several years. He says that he has turned down promotions in the past because
he knows that he “couldn’t possibly supervise anyone or make decisions for them.” The patient
has two close childhood friends whom he talks to on the telephone nearly every day and says he
“feels lost without them.” The results of his mental status examination are normal except for
revealing a depressed mood (although affect is full range).
1. What is the most likely diagnosis?
2. What is the best treatment?

Case-8
A 37-year-old woman is referred to your office for psychotherapy. She is preoccupied with
thoughts of her husband leaving her and being left alone with nobody to take care of her. She
feels sad and hopeless when alone, lacks self-confidence, and has great difficulty making
decisions. You believe she suffers from a personality disorder. In which cluster does the patient’s
most likely diagnosis belong?

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A. Cluster A
B. Cluster B
C. Cluster C
D. None of the above
Case-9
A 24-year-old woman was admitted to the obstetrical service for the delivery of a full-term baby
boy. One day after the delivery, the obstetrics service requested a consultation from the
psychiatrist on duty to “rule out schizophrenia.” The psychiatrist interviews the patient and finds
out that the pregnancy was the result of a rape the patient suffered 9 months previously. The
patient is planning to give the baby up for adoption. She claims that she has never seen a
psychiatrist and has never felt a need to do so. She speaks at length about how the rape was
“written in the stars” for all to see; she is an avid astrologer. She denies having recurrent thoughts
or nightmares about the rape itself. She states that she has very few close friends, preferring to
study astrology and astral projection at home by herself. She believes strongly in reincarnation,
although she knows that her family thinks this belief is strange. She admits that she has worked
intermittently as a “crystal ball gazer” but has never held a steady, full-time, paying job. During
the mental status examination, the patient sits upright in her hospital bed dressed in three hospital
gowns and a robe, which she is wearing backward. Her hair is neatly combed, although one side
is in braids and the other is not. She is cooperative with the interviewer. She states that her mood
is good, and her affect is congruent although constricted. She has tangential thought processes
and ideas of reference but no suicidal or homicidal ideation, hallucinations, or delusions.
1. What is the most likely diagnosis?
2. What should your recommendations to the obstetrics service be?
Case-10
Which of the following is an associated disorder in the family histories of patients with
schizotypal personality disorder?
A. Alcohol dependence
B. Bipolar disorder
C. Hypochondriasis
D. Panic disorder
E. Schizophrenia

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Case-11
Which of the following features must be present in a patient’s history for schizotypal personality
disorder to be diagnosed?
A. The patient must have a history of active substance use.
B. The patient must have a history of auditory hallucinations.
C. The patient must have a history of cognitive and perceptual distortions.
D. The patient must have a history of intense, short-lived friendships.
E. The patient must have a history of suicidal ideation
Case-12
A 36-year-old man visits his primary care physician complaining that he has been “stressed out”
since a job change 2 months ago. The patient states that he was doing well in his job as a
software developer, until he was told that his position was being phased out and that in order to
stay with the company, he would need to switch to the sales department. The patient agreed
because he did not want to lose his insurance benefits and retirement plan, but now states that he
“can’t stand all those people.” He notes that his previous position allowed him to be on his own
for most of the work week. However, his new job requires almost constant interaction with
colleagues and clients, something he hates. The patient says that he has almost no friends, except
for a cousin that he has been close to since childhood. He reports that he has never had a
significant romantic relationship or sexual encounter, but does not miss not having had these
experiences or not having friends. He states that he most enjoys spending hours surfing the
Internet or playing computer games by himself. He has never seen a psychiatrist and sees no
reason to do so. On a mental status examination, the patient appears notably detached and aloof
toward the examiner. He exhibits little eye contact. His mood is reported as “stressed,” but his
affect is not congruent with this. He appears calm, and his emotional range is flat. No other
prominent symptoms are noted during the mental status examination.
1. What is the most likely diagnosis?
2. What is the best initial treatment?

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Case-13
A 36-year-old man is referred to his employment assistance agency because he has trouble
making timely decisions and is often late with important work. The patient has angrily complied
with this request although he does not believe that anything is wrong with him. He describes
himself as “so devoted to my work that I make others look bad,” believing that this is why he has
been singled out for attention. The patient says that he has worked at the company for 4 years
and during that time has put in anywhere from 10 to 12 hours of work per day. He admits that he
often misses deadlines but claims that “they are unreasonable deadlines for the quality of work
that I provide.” He states, “If more people in the country were like me, we would get a lot more
done—there are too many lazy slobs and people who don’t follow the rules.” He points out that
his office is always perfectly neat, and he says, “I know where every dollar I ever spent went.”
On a mental status examination, the patient does not reveal any abnormalities in mood, thought
processes, or thought content. His manner is notable for its rigidity and stubbornness.
1. What is the most likely diagnosis?
2. What other psychiatric disorder is this condition often confused with, and how does one tell
them apart?
Case-14
A 48-year-old woman presents to a psychotherapist. The patient lives a very secluded life, largely
consumed by working nights as a security guard and taking care of her elderly mother. She
complains of feeling lonely, and is aware that she has a great deal of difficulty relating to other
people. Which of the following conditions would most distinguish her issues from a person with
schizoid personality disorder?
A. Family history of a cousin with schizophrenia.
B. A desire to engage in interpersonal relationships.
C. Lack of hallucinations or delusional thinking.
D. Her gender.
E. A history of abstinence from alcohol
Case-15

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A 32-year-old man is seen by a jail psychiatrist after getting into a fight with another inmate over
a $5 bet. Jailed for forging bad checks, this is the patient’s fourth incarceration. Previous
incarcerations were for assaulting a police officer, stealing from a department store, and at age
13, stealing a car. The patient states that he fought with the other inmate because, “I was bored
and felt like it.” He admits that the $5 was not really his to begin with, but he shows no remorse
either about trying to take the money or about getting into a physical altercation with the other
inmate. The patient states that he has seen psychiatrists in the past (always reluctantly and always
because of demands made either by his mother or the courts) but states, “There isn’t anything
wrong with me, so why should I?” He denies using drugs or alcohol while incarcerated, but
admits that if he were not in jail, he would probably be using both. A mental status examination
indicates the patient is alert and oriented to person, place, and time. He cooperates with the
examiner. At times, he appears open and engaging, while at other times he is rude and
disrespectful. He is dressed in jail garb. His speech is normal in rate, rhythm, and tone. His mood
is described as “fine,” and his affect is congruent. He shows no disorders of thought processes or
thought content.
1. What is the most likely diagnosis?
2. What other psychiatric disorders might one suspect in this patient?
Case-16
A patient with schizoid personality disorder comes to his primary care physician with chief
complaints of polyuria and polydipsia. He is found to have insulin dependent diabetes. Which of
the following interventions by the physician is likely to be most well received by this patient?
A. Asking the patient to bring in a relative so that he can describe the treatment regimen to both
of them at the same time.
B. Referring the patient to a therapist so that he can talk about the difficult nature of the
diagnosis.
C. Giving the patient detailed written information about the disease and telling him that the
physician will be available to answer any questions.
D. Referring the patient to a group that helps its members learn about diabetes and to better deal
with their illness.
E. Scheduling frequent appointments with the patient so that all the treatment details can be
explained on a one-to-one basis.

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Case-17
An 80-year-old man undergoes an evaluation for dementia versus depression. His caregiver
describes a history of gradually worsening depressed mood and confusion, with poor appetite,
weight loss, poor self-care, and irritability. On his cognitive examination, he is alert and oriented
to person and place but not to time. His concentration is impaired, and he displays poor short-
term memory despite adequate recall. His effort is poor overall, and he often responds to
questions stating, “I don’t know.” Which of the following features is more consistent with a
depressive illness than with dementia?
A. Poor concentration
B. Poor effort during the interview
C. Poor self-care
D. Poor short-term memory

Case-18
A 79-year-old man is brought to the emergency department by his family. Although the patient is
essentially mute, his family members report that he has had a history of numerous episodes of
depression, the last occurring 6 years ago. At that time, he was hospitalized and treated with
sertraline. He has been hospitalized a total of four times for depression, but the family denies that
he has ever been treated for mania. The patient’s only current medication is hydrochlorothiazide.
However, he has refused to take it for the past 2 days. This current episode of depression, similar
to previous ones, began 3 weeks prior to the emergency department visit. The patient has had
frequent crying episodes and has complained of a decrease in energy. He has lost at least 15 lbs.
in the 3 weeks and for the past 2 days has refused to eat anything at all. Three days ago, the
patient told his family that he was “sorry for all the pain and suffering I have caused you” and
that “it would be better if I were not around anymore.” Two days ago, he stopped speaking and
eating, and for the past 24 hours he has refused to take anything by mouth including water. After
rehydration in the emergency department, the patient was admitted to the psychiatry service. The

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 results of his physical examination were essentially normal, although his blood pressure was
150/92 mm Hg, and he exhibited psychomotor slowing. The patient refused all attempts to feed
him by mouth. When asked if he was suicidal, he nodded his assent, as well as nodding to the
question, “Are you hearing voices?”
1. What is the most likely diagnosis?
2. What is the best plan of action for this patient?

Case-20
A 42-year-old man comes to his outpatient psychiatrist with complaints of a depressed mood,
which he states is identical to depressions he has experienced previously. He was diagnosed with
major depression for the first time 20 years ago. At that time, he was treated with imipramine, up
to 150 mg/d, with good results. During a second episode, which occurred 15 years ago, he was
treated with imipramine, and once again his symptoms remitted after 4 to 6 weeks. He denies
illicit drug use or any recent traumatic events. The man states that although he is sure he is
experiencing another major depression, he would like to avoid imipramine this time because it
produced unacceptable side effects such as dry mouth, dry eyes, and constipation.
1. What is the best therapy?
2. What are the side effects of the proposed therapy?
Case-21
A 70-year-old woman presents to her primary care provider complaining of fatigue for the past 7
weeks. She admits to difficulty falling asleep, a poor appetite with a 10-lb weight loss, and
thoughts of wanting to die. She admits to having had symptoms similar to these on several
occasions in the past, but “never this bad.” Her medical problems include asthma and high
cholesterol. She uses an albuterol inhaler only as needed. Which of the following symptoms is
necessary in order to make a diagnosis of major depressive disorder?
A. Depressed mood
B. Decreased appetite
C. Excessive guilt
D. Fatigue
E. Suicidal ideation

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Case-22
A 14-year-old adolescent boy is brought to the emergency department after being found in the
basement of his home by his parents during the middle of a school day. The parents came home
after receiving a call from the school reporting that their son had not attended school for 4 days.
The boy was furiously working on a project he claimed would solve the fuel crisis. He had
started returning home from school after his parents left for work because his science teacher
would no longer let him use the school laboratory after school hours. The patient was involved in
an altercation with the school janitor after being asked to leave the school because it was so late.
The boy claimed that the janitor was a foreign spy trying to stop his progress. The parents are
very proud of their son’s interest in science but admit that he has been more difficult to manage
lately. He can’t stop talking about his project, and others cannot get a word in edgewise. His
enthusiasm is now palpable. For the past few weeks, he reads late into the night and gets minimal
sleep. Despite this, he seems to have plenty of energy and amazes his parents’ friends with
detailed plans of how he is going to save the world. His friends have not been able to tolerate his
increased interest in his project. His train of thought is difficult to follow. He paces around the
examination room, saying “[I am] anxious to get back to my project before it is too late.”
Although he has no suspects in mind, he is concerned that his life may be in danger because of
the importance of his work.
1. What is the most likely diagnosis?
2. What is the best treatment?

Case-23
You are consulted to evaluate an 84-year-old, widowed woman on the medical ward. She has a
prior history of major depressive disorder, recurrent, and she was admitted for a syncopal
episode. She was found to be extremely malnourished, hypotensive, and in acute renal failure.
She has not been taking her antidepressant for many months. She describes having all the
neurovegetative symptoms of depression and to not eating or drinking for weeks. When

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questioned about this, she admits to purposely “starving myself” as she believes that God is
punishing her for directly causing the terrorist attacks of September 11, 2001. In fact, she has
been “following God’s instructions,” which tell her to kill herself in atonement. After medical
stabilization, which of the following treatments would be the most appropriate for this patient?
A. Antidepressant only
B. Antipsychotic only
C. Electroconvulsive therapy only
D. Psychotherapy only
E. Psychotherapy plus antidepressant
Case-24
A 20-year-old woman comes to see a psychiatrist at the insistence of her mother, who states that
her daughter just “isn’t herself.” The patient has dressed in brightly colored clothes and worn
large amounts of makeup for the past 3 weeks. She acts overtly seductive toward her colleagues
at work, is more distractible, and is easily irritated. She also sleeps less, claiming that she “no
longer needs it.” Which of the following diagnoses best fits this patient’s presentation?
A. Histrionic personality disorder
B. Borderline personality disorder
C. Bipolar disorder, mania
D. Narcissistic personality disorder
E. Delusional disorder

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