Question

19. Using the vignette provided below entitled "FAILURE TO LAUNCH", provide a DSM-5 diagnosis (diagnoses) for this (these) disorder(s) along with your reasons for the appropriateness of the diagnostic category (categories) chosen. Complete answers must include reasons for disqualifying (i.e., ruling out) alternative diagnoses.

Failure to Launch. Lana White is a pale, stooped woman of 37 years, with childlike facial features surrounded by scraggly auburn pigtails tied with pink ribbon. She was referred for a psychiatric evaluation for possible hospitalization by her family doctor, who was alarmed by her low level of overall functioning. Lana’s only complaint to him was, “I have a decline in self-care and a low life-energy level.” Her mother reports that in fact Lana has shown a decline, but that this decline has occurred over several years. In the last few months Lana has remained in her room, mute and still. A review of Lana’s history reveals that 12 years ago she was employed as a supervisor in the occupational therapy department of a major hospital, and had been living in her own condo. She had been engaged to a young man. When he broke off the engagement, and she became increasingly disorganized, and began to wander aimlessly throughout the neighborhood dressed in mismatched clothing. Eventually, Lana was fired from her position at the hospital, and the police were called in to hospitalize her. They broke into her apartment, and discovered it to in shambles, filled with papers, piles of food, and broken objects. Little information is available about this hospitalization other than it was for a three-month period and that Lana was discharged to her mother’s house with some sort of prescription medication that was never filled. Following her discharge, her family was hopeful that Lana would somehow “get herself together” and embark on a real life, but instead, over time Lana became increasingly withdrawn and less functional. She spent much of her time watching TV and cooking. Her cooking often consisted of mixing bizarre combination of ingredients, such as broccoli and cake mix, then cooking them and eating them alone –as no one in the family cared to share these prepared items with her. Lana collected cookbooks and recipes, cluttering her room up with stacks upon stacks of them. When Lana’s mother would enter her room, Lana would quickly pick up a magazine and pretend to be reading, when in fact she would just be staring into space. Lana had stopped bathing and brushing her hair or teeth. Her mother reported Lana was eating less and less and although Lana denied a loss of appetite, she had lost 20 pounds over the last several years. She would sleep at odd hours. Eventually her sleep included enuresis –wetting her bed frequently and filling the room with the pungent odor of urine. On admission of the psychiatric hospital, Lana sat with her hands tightly clasped in her lap and she avoided looking at the doctor who interviewed her. She answered questions readily enough and did not give the appearance of being overtly suspicious or guarded, but her affect was notably shallow. Lana denied depressed mood, delusions, or hallucinations. However, over the course of the interview, her answers became increasingly irrelevant and idiosyncratic. She responded to a question about her cooking with “She did not wish to discuss recent events in Russia.” Lana then added that (in regards to her cooking) “…the order of the cooking was well-defined in advance by the cheferons who placed the knowledge within her.” When discussing her decline in functioning, she said: “There’s more of a take-off mechanism when you’re younger.” Asked about ideas of reference, she said, “I doubt it’s true, but if one knows the writers involved, it could be an element that would be directed in a comical way.” Her answers were interspersed with the mantra, “I’m safe. I’m safe.”

Answer 1

Lara is showing symptoms of Schizophrenia. More accurately symptoms of that of hebephrenic or disorganized schizophrenia. It is a former subtype of Schizophrenia and is now longer considered a separate form of Schizophrenia in the new edition of DSM. The symptoms described in vignette matches that of hebephrenic Schizophrenia. The symptoms being:

1. Disorganized speech - Giving irrelevant answers to questions asked.
2. Lack of personal hygiene - no brushing, showering, etc.
3. Childlike behavior - bed wetting, childlike features and behaviors
4. Socially withdrawn - locking herself in the house or her room
5. Lack of emotion - avoidance of eye contact, shallow affect
6. Impaired or declining functional skills - cooking, self-care
7. Poor performance in job leading Lara to get fired

According to DSM 5 - Criterion A lists the 5 key symptoms for that of psychotic disorders, which being:

1) Hallucinations, 2) delusion, 3) negative symptoms, 4) disorganized or catatonic behavior, and 5) disorganized speech.

To qualify as having Schizophrenia at least 2 out of these 5 symptoms are required AND at least 1 of the symptom must be from hallucinations, delusions, or disorganized speech.

Therefore, according to DSM 5 Lara will be diagnosed as being having Schizophrenia, because she is satisfying the 2 symptoms required (Negative symptoms and disorganized behavior) with the symptom of disorganized speech symptom.

When it comes to Schizophrenia, there can be Differential Diagnosis (other or alternative diagnosis). But these can be disregarded due to the following differences:

DIFFERENTIAL DIAGNOSIS	DIFFERENCE FROM SCHIZOPHRENIA
Developmental Disorder (mental Retardation, Autism, etc.)	Low IQ or any form of intelligence retardation is not mentioned (prior to acquiring Schizophrenia) Formed speech, even if it is disorganized Fully developed skills and motor ability, even if it is getting impaired now
Bipolar Disorder and related Disorders (dysthymia, cyclothymia, etc.)	Mood swings duration (takes days or weeks from one pole to other) symptoms are reflection of mood and they change (not constant)
Personality Disorder	Presence of different identities, or loss of flexibility of personality For one's with personality disorders, their personalities are living in reality, schizophrenics lose touch with reality. Mood shifts and shift of view about self is dependent on personality
Substance induced psychosis and schizophrenia	Duration of the presence of delusions and hallucinations. Here no delusions or hallucinations are present. Symptoms are present only when substance is used, otherwise not present
Other forms of psychotic disorders (schizoaffective, schizophreniform, delusional, etc.)	Mood disturbances and presence of mood disorder Duration of the presence of delusions and hallucinations. Here no delusions or hallucinations are present.
Psychosis	Major symptom is delusion and hallucination Schizophrenia has other symptoms too
Dementia and Amnesia	Cognitive functions deteriorate as time goes on Eventually individual forgets everything (even about self, and their basic livelihood skills)