For each of the following cases, answer these questions:

What is the most probable diagnosis?

Why? Which symptoms of this disorder are present? Which are absent?

What further information would help you ascertain if this were the correct diagnosis? Name at least two, and how they would help.

Would you add any specifiers? If so, which would you choose and why?

Which conditions that the DSM-5 recommends for a differential diagnosis list would you need to consider? And why?

1. Mark is a 31-year-old single male with no children. He shows no signs of physical ailments or other health problems, and has no history of drug or alcohol abuse. He presently works for a large, national insurance company as a homeowner’s claim adjuster, but has been on a leave of absence for the last month. He took the leave because he has been experiencing considerable difficulty completing his work to his usual high standards, although his supervisor never complained or hinted at dissatisfaction with his efforts. Mark’s high, and some would say “exacting” standards, have been a feature of his since childhood, and have gradually intensified over the years.

According to Mark, his parents were very strict and over-protective when he was a child. Mark’s mother passed away two years ago, and they were quite close. She strongly encouraged – and even strictly demanded at times – that he study hard and do well in school. His father abandoned the family when he was in kindergarten, and the mental health history of both parents are not known. Mark’s brother, Jason, is a “clean freak” and has a tic, but has never sought help. They get along alright, but Jason moved several states away and they no longer see each other very often. Mark thinks he has an uncle with a history of depression, but that’s all he knows. He has few friends, and he has not seen them much over the last few months as work has consumed more and more of his time.

Recently, Mark has been persistently down on his work, and finds his thoughts often turning to the failures he sees in it. He finds the prospect of others seeing those failures, and the possibility of those errors being quite costly to either the policy holders or to his employer, to be intensely embarrassing. These thoughts often just pop into his head, even when he isn’t currently focused on his work. He has always been a careful proofreader, and in recent years he has found himself proofreading the same document over and over to check for mistakes. This seems to make him feel better, and gets

those thoughts out of his head for a while. This comes with a cost though: reports that should take him 30 minutes to complete sometimes take as long as two hours as he hunts through them for the tiniest of mistakes. This has, naturally, made it difficult to maintain the kind of productivity his manager has come to expect from him, and so he has begun working 12-14 hour days and on weekends to compensate.

This heavy workload has left Mark feeling burnt out and irritable. Because of the amount of time he spends at work, he has little time or energy to keep his house neat and tidy as he prefers. Part of the reason for his leave request was to take care of the disorder in his home, which was becoming unbearable. His appetite has remained steady throughout this stressful time, though he thinks he may be losing weight. He fears he may be getting depressed, but hasn’t yet decided whether he should talk to someone about it.

2. Mary is a 55-year-old Caucasian woman. She has an undergraduate degree in fashion design from a prestigious institution. During the course of her professional career, she has acted, appeared in television and print commercials, and owned and operated upscale art boutiques. Eleven years ago she was married for the first time to John, who is 12 years older. John had been married previously and had four children from his first marriage. He retired shortly after they married, and they moved from a large West Coast city to a rural Central Plains area where he grew up and still owned a 1,200-acre farm.

Mary had never lived in the country before. She used her creative talents to decorate and furnish a beautiful new home, but she never quite got over leaving the city and her career. She and John had a good relationship, but she never was able to establish connections with his adult children. Living out in the country, she had few opportunities to meet new people and her social circle consisted only of John’s old childhood friends. She never attempted to resume working or start a new business, given the distance of their home to the nearest large town.

Mary once had had a lot of energy and was engaged in many artistic and creative activities, including painting, refurbishing furniture, and decorating. She longed for the days when she ran her trendy boutiques and went on buying trips to San Francisco. She once or twice floated the idea that they leave the country and move to a small city, where she might open a shop or even work in one, or find other outlets for her creativity. The financial drain and constant work on the farm caused her to feel some resentment. After all, the farm was John’s dream, not hers.

Mary was at the neurologist’s office which was her fourth medical specialist to visit this year. In addition to medical doctors, she had been to a chiropractor, a massage

therapist, and an acupuncturist. Though these practitioners gave her some relief for a short time, she never felt better for long. In fact, she was getting worse. John was worried about her, of course, but he was getting tired of going from doctor to doctor, as Mary searched for a diagnosis and treatment for her persistent problems.

Mary had several physical complaints. She felt extremely tired all the time and she had no energy. Sometimes she spent the entire day in bed. She suffered from muscle aches in various parts of her body, including her shoulders, arms, and legs. Lately, she had developed a pain in one hip and she complained that her hip occasionally “went out”. She felt like it was buckling under her. However, the orthopedic physicians sheconsulted couldn’t find anything wrong with her hip.

Mary spent hours on the Internet researching her symptoms. She had found all kinds of possible causes for her problems, but each time she went to a specialist, he or she ruled out her theories. For example, she had read that the estrogen she had been taking since a hysterectomy a few years earlier might be affecting her hip muscle. Her gynecologist told her that this was a rare phenomenon and certainly not her problem. A chiropractor manipulated her hip and she felt fine for a day or so, but then she was so sore she could not move. Lately, she often ends her day in tears, wondering why no one can figure out what’s wrong with her body.