Question

This week's discussion forum is based on your reading on Personality Disorders chapters. Thus, the case vignette enclosed portrays Henry Smith who suffers from two personality disorders. Make sure to justify your diagnoses for your chosen case vignette. This case suffers from two personality disorders therefore you need to justify both diagnoses with specific behaviors. Do not diagnose these cases with any other disorders except personality disorders.

CASE: Case Vignette #2 – Henry Smith

            Henry Smith, a 19-year old college sophomore, was referred to the student health center by a teaching assistant who noticed that he appeared odd, worried, and preoccupied and that his lab notebook was filled with bizarrely threatening drawings.

            Henry appeared on time for the psychiatric consultation.  Although suspicious about the reason for the referral, he explained that he generally “followed orders” and would do what he was asked.  He agreed that he had been suspicious of some of his classmates, believing they were undermining his abilities.  He said they were telling his instructors that he was a “weird guy” and that they did not want him as a lab partner.  The referral to the psychiatrist was, he said, confirmation of his perception.

            Henry described how he had seen two students “flip a coin” over whether he was homosexual or straight.  Coins, he asserted, could often predict the future.  He had once flipped a coin and “heads” had predicted his mother’s illness. He believed his thoughts often came true.  

            Henry had transferred to this out-of-town university after an initial year at his local community college.  The transfer was his parents’ idea, he said and was part of their agenda to get him to be like everyone else and to attend parties and hand out with girls. He said all such behavior was a waste of time.  Although they had tried to push him into moving into the dorms, he had refused, and instead lived by himself in an off-campus apartment.

            With Henry’s permission, his mother was called for collateral information. Henry insisted that he should be present when the call was made to ensure that the psychologist was talking to his mother and not his instructors.  His mother said Henry had been quiet, shy, and reserved since childhood. He had never had close friends, and never dated, and had denied wanting to have friends.  He acknowledged feeling suspicious and anxious at times, but these feelings did not improve when he was around other people and only got worse. He was teased by other kids and would come home upset.  His mother cried while explaining that she always felt bad for him because he never really “fit in”, and that she and her husband had tried to coach him for years without success.  She wondered how a person could function without any social life.

            She added that ghosts, telepathy, and witchcraft had fascinated Henry since junior high school.  He had long thought that he could change the outcome of events like earthquakes and hurricanes by thinking about them.  He had consistently denied substance abuse, and two drug screens had been negative in the prior 2 years.  She mentioned her grandfather had died in an  “insane asylum” many years before Henry was born, but she did not know his diagnosis.

            On examination, Henry was tall, thin, and dressed in jeans and a T-shirt. He was alert and wary and, although nonspontaneous, he answered questions directly.  His affect was flat during the interview and he would often go on tangent and overelaborate on minor details.  He denied feeling depressed or confused.  Henry denied having any suicidal thoughts, plans, or attempts.  He denied having any auditory or visual hallucinations, panic attacks, obsessions, compulsions, or phobias.  His intellectual skills seemed above average and he had a perfect score on his Mental Status Examination.

Answer 1

Considering DSM 5 Criteria following personality disorders are given as diagnosis

1. Schizotypal Personality Disorder 301.22

following criteria met

a) Odd beliefs or magical thinking that influences behavior and is inconsistent wit subcultural norms -: Ghosts, telepathy, and witchcraft had fascinated Henry since junior high school.  He had long thought that he could change the outcome of events like earthquakes and hurricanes by thinking about them.

b) Odd thinking and speech :- On Cliniical interview he would often go on tangent and overelaborate on minor details.

c) Suspiciousness and paranoid ideation :- He was suspicious about the reason for the referral. He agreed that he had been suspicious of some of his classmates. Henry insisted that he should be present when the call was made to ensure that the psychologist was talking to his mother and not his instructors.

d) Inappropriate or constricted affect :- His affect was flat during the interview.

e) Behaviour or appearance that is odd , eccentric or peculiar :- He was referred to the student health center by a teaching assistant who noticed that he appeared odd, worried, and preoccupied and that his lab notebook was filled with bizarrely threatening drawings.

f) Lack of close friends or confidants other than first degree relatives :- His mother said Henry had been quiet, shy, and reserved since childhood. He had never had close friends, and never dated, and had denied wanting to have friends.

g) Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negatie judgement about self :- He acknowledged feeling suspicious and anxious at times, but these feelings did not improve when he was around other people and only got worse.

These occur not in the course of schizophrenia , bipolar disorder or depressive disorder with psychotic features or autism spectrum disorder.

2. Paranoid personality disorder 301.0

Following criteria are met

a) Suspects , without sufficient basis that others are exploiting , harming or deciving :- He was suspicious about the reason for the referral, he explained that he generally “followed orders” and would do what he was asked.

b) Is preoccupied with unjustified doubts about loyalty or trustworthiness of friends or associates :-  He agreed that he had been suspicious of some of his classmates, believing they were undermining his abilities.  He said they were telling his instructors that he was a “weird guy” and that they did not want him as a lab partner.  

c) Is reluctant to confide in others (because of unwarranted feaar that the information will be used maliciously against him) :- He agreed that he had been suspicious of some of his classmates, believing they were undermining his abilities. His mother said Henry had been quiet, shy, and reserved since childhood. He had never had close friends, and never dated, and had denied wanting to have friends.  He acknowledged feeling suspicious and anxious at times, but these feelings did not improve when he was around other people and only got worse.

d) Reads hidden meaning or threatening meanings into benign remarks or events :- Henry described how he had seen two students “flip a coin” over whether he was homosexual or straight.  Coins, he asserted, could often predict the future.  He had once flipped a coin and “heads” had predicted his mother’s illness. He believed his thoughts often came true.  

These occur not in the course of schizophrenia , bipolar disorder or depressive disorder with psychotic features or autism spectrum disorder.