Dr. Steve Miller IV sat in his office with his laptop, accessing his files. Descending from a number of prominent psychiatrists, he had just completed his residency, spent his first week at his private practice, and had appointments with 14 new patients. He knew he must have a plan of treatment for each patient the following week, and needed to sort through who might benefit from medication and whom should be referred to a psychologist for cognitive-behavioral therapy. He stared at his notes, and remembered what his first step must be to provide quality treatment for his patients. These are excerpts from his notes.
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1. Patient has recently suffered from a severe depressive disorder, but without psychotic features.
2. Patient is unable to sleep and wake at the times required for normal work, school, and social needs. She is generally able to get enough sleep if allowed to sleep and wake at the times dictated by her own body clock. When she can sleep, she sleeps normally.
3. Patient is a 25 year old male who believes he is a man trapped in a woman's body. He has a strong and persistent identification with the opposite gender.
4. Patient has a pattern of unstable relationships, poor or negative sense of self, inconsistent moods, and significant impulsivity. She also has a fear of abandonment, and has engaged in self-cutting.
5. Patient acts in a very emotional and dramatic way that draws attention to herself. She is preoccupied with her appearance and dresses overly seductively.
6. Patient was previously diagnosed with Bipolar 1 Disorder, but has only had a single manic episode. He is currently in partial remission.
7. Patient appears to have a neuropsychiatric disorder with onset in childhood, characterized by multiple physical motor tics and vocal tics.
8. Patient has a distinct inability to conform to society's rules. He has engaged in criminal activity and has a compulsion to set fires.
9. Patient compulsively pulls out her own hair, and has experienced significant hair loss as a result.
10. Patient is described by parents as having had lost touch with reality. He often has delusions and hears voices. He believes that others are "out to get him", including government officials and agencies.
11. Patient's self-concept revolves around a pattern of grandiosity, need for admiration, and sense of entitlement. He feels superior to most others and demands praise and admiration. He lacks empathy for other individuals, and often takes advantage of others to reach his own goals.
12. Patient has deliberately and purposefully set fires several times.There is typically tension or heightened arousal prior to the act and gratification or relief afterward. The fire setting is not done for monetary gain or an expression of anger, vengeance, personal gain, or psychosis. Patient does not have antisocial personality characteristics.
13. Patient has periods of highs often followed by periods of major depression. However, the highs are hypomanic, rather than manic, while the lows are markedly low. Her depressive episodes have been more frequent and are more intense than her hypomanic episodes. Her symptoms are not severe enough to cause marked impairment in social or occupational functioning and have never required hospitalization.
14. Patient has previously been diagnosed with Adjustment Disorder. He has periods of mixed anxiety and depressed mood.