Alex would not shake hands when he came in to see the doctor.
He looked at the two chairs in the doctor's room and chose the one that he thought looked least dirty. He perched on the very edge of the seat and folded his hands.
Alex told his doctor that he was sleeping badly and that his degree work at the University was suffering. When the doctor asked about his sleep Alex told him that he would lie awake worrying whether he had switched off all the lights or pulled out all the electric plugs in the living room or locked all the doors. He would get up to check not once, not twice, but at leats ten times. If he did not get up to check these things he was overwhelmed with anxiety until he did so. In addition he was washing his hands up to twenty times a day to rid himself of germs. Whenever he went out of the house he always had to shower on his return and put on clean clothes.
He had always been a neat person and a meticulous worker. All his essays at University were word-processed and laced with detailed references. However, in the last two months he had fallen behind on the deadlines for his essays, because he had been checking and re-checking every sentence for mistakes. He was troubled by thoughts that he had become contaminated by other people. he had stopped seeing his girlfriend because he could not bear her to touch him lest she give him germs. he knew that the idea was illogical, but he could not stop thinking about contamination.
Is Alex suffering with a neurotic or a psychotic illness?
What is the most likely diagnosis?
What treatments can be offered?
Case History 2
Elaine, 60, was a passenger in a car in a road traffic accident. She sustained a broken pelvis and spent some months in hospital. When she was discharged Elaine could not face travelling in a car again. She went to her family doctor complaining of poor sleep with early morning wakening. She was also troubled with recurrent nightmares about the crash. During her waking hours she was haunted by sudden visual images of the accident coming into her mind. "It's as if it's all happening again," she said. "I am there in the car again. I can see the other car coming towards us. I can hear the crashing metal. I can't get the smell of petrol out of my mind." Anything on the television to do with cars brings the unwanted pictures and sensations back into her mind. Since television programmes and advertisements repeatedly feature cars, Elaine has stopped watching television altogether.
What additional features of Elaine's history would you want to know about?
What are the main differential diagnoses?
How could Elaine be treated?
Case History 3
Olivia, 42, had been married for twenty-two years and had two teenage daughters. According to Olivia, the family is a very close one. One day whilst shopping in town Olivia had a panic attack. She described it as 'being like a wave of anxiety that rolled my breath away. I stood there in the street shaking and staring.' She managed to get to a public telephone and called her husband at work. He came to pick her up and took her home. Ever since then Olivia has been unable to leave the house alone. Of her husband or one of her daughters accompanies her she can walk to the corner supermarket to buy small items of food. Even accompanied by other people she cannot face the weekly shopping trip to the hypermarket, or venture into town. Unless her old friends call and see her she does nor see anybody but her immediate family. Her husband's career is a demanding one, but is beginning to pay dividends. He is being asked to head overseas sales trips on the company's behalf. He is very worried that Olivia's problem will mean he has to stay at home with her and he does not wish to lose his job. In desperation her husband asked the family doctor to make a home visit to see Olivia. When the doctor arrives he finds Olivia is tearful and guilty about the 'burden' she 'imposes on the family'. Even so she is adamant that she will never be able to go out alone again.
What is your differential diagnosis?
What first line investigations would you request/perform?
What is the most likely diagnosis?
Case History 4
The family doctor was summoned by Mrs Jones' daughter at 2 am in the morning. The daughter met the doctor at the front door of her mother's house. She told the doctor how her 78-year old mother had been unwell for the past week with 'flu. In the last two days her mother had stayed in the bedroom all day, but had become agitated as night drew on. Mrs Jones had phoned her daughter (who lived two roads away) at two am the previous day complaining that a burglar was trying to get into bed with her. When her daughter and son-in-law hurried round to help they found that there was no sign of a burglar and no sign of a break-in. Mr Jones had appeared confused and called her daughter by her own sister's name. She had been very restless through the night, but as dawn came she appeared less disturbed. The daughter had called the doctor in the early hours of this morning because her mother had phoned her at midnight saying that a black mass was being held in the house opposite. When her daughter arrived she saw that Mrs Jones was talking about a man working on his car in the garage across the road. Mrs Jones described the lights in the garage as 'candles held by witches', who she said were 'chanting swear words'. the daughter had to wrestle her frightened mother back into bed. The daughter was very worried because her mother had never been like this before and had never seen a psychiatrist in her life.
What is the most likely diagnosis?
Contents pageCopyright Material
Psychiatry On-Line, 1995.
Vol.1, Issue 2, Paper 1.