Read the following case: Which is the most probable diagnosis?Explain your choice and provide a five Axis- DSM-IV-TR classification.
Laura K. is a 42-year-old white divorced woman referred to a psychiatric unit by her internist for treatment of depression and suicidal thoughts. “I can’t go on like this”, she said. “I feel so empty. Like my life is nothing. I am nothing.” Ms. K. had moved to the city six months earlier to complete her MBA degree. At the time of her evaluation, she was finishing an internship with a small, local company. The internship was not going well because of frequent fights with coworkers and administration. She had been reprimanded several times by the woman who was her immediate superior and was threatened with dismissal. She was finally given an ultimatum: to get psychiatric treatment or to be fired. Ms. K. felt that her supervisor treated her with disrespect and condescension, that she “was on a power trip” and wanted things done her way just to prove that she could exercise control. Once or twice a week, Ms. K. would become so enraged that she would bang furniture, throw papers, scream obscenities at her supervisor, and storm out of the office. The next day she would feel very ashamed about what had happened but still felt justified in her behavior. Over time, she came to believe that her supervisor was deliberately antagonizing her in the hopes of provoking her anger and making her loose control so as to be able to gain even more power over her.
Ms. K. also described chronic feelings of emptiness and loneliness, particularly on weekends and vacations. The feelings reached such intensity at times that she thought of suicide. Although she denied any specific plans or actions, she at various times had thoughts of taking an overdose; cutting her wrists, throat, or abdomen; or jumping in front of a subway car. She was troubled by nightmares (recurrent themes were being pursued or dismembered) and had difficulty both in falling asleep and staying asleep. Some nights she would force herself to stay awake as long as possible to avoid possible nightmares. She described her appetite as normal, but she dieted and exercised scrupulously to maintain the same weight she had in her twenties.
Ms. K. had one brief trial of psychotherapy. It lasted only a few months and ended because of fighting between her and the therapist. She had never taken a psychiatric medication. She had never had hallucinations, but over the years had often felt that other people (especially boyfriends or employers) wanted to hurt her or humiliate her and that they would try to provoke her rage to make her look crazy and out of control.
Ms. K. was the youngest of three daughters born to a well-to-do family. Both parents were alcoholics. Her father sexually abused her from age 8 until she left home for boarding school at age 16. He began having intercourse with her when she was in her early teens and would on occasion threaten her with a knife. The day after such episodes, he would deny that anything had happened. Her mother, usually in a constant state of alcoholic stupor, either ignored or was unaware of what was happening. Ms. K. once mentioned the abuse to an older sister, who told her she was crazy. In school, she had few close friends. She began experimenting with cocaine, marijuana and heroin and spent most of her time with other girls who used drugs or engaged in petty criminal activity, such as shoplifting. She moved to another part of the country for college, where she did well academically and drastically curtailed her drug use. She developed a steady romantic relationship with a man in her class, and they were married shortly after graduation. Although her husband was not abusive, she began to feel taken for granted. She was particularly annoyed under the expectation that she would do housework while he worked in business. They stopped having sexual relations and began to live somewhat separate lives. She left him one night without warning while he was sleeping and moved to another city.
Over the years, her life was characterized by many brief, intense relationships, sometimes with alcoholic men who became physically abusive. She held a series of different jobs and had virtually no close, nonromantic friends. She joined the army for two years in an effort to force change in her life and relieve the nagging sense of emptiness.
Ms. K. had had two abortions during her thirties, with infection complicating the second. There was no other significant medical history, and at the time she came for psychiatric treatment she was not using drugs or alcohol at all. She lived alone and had no friends.
She was an attractive woman who wore no makeup. She was dressed in loose-fitting slacks and shirt. She appeared thin but not significantly underweight. Her speech was soft, and she often mumbled. She looked extremely anguished, with frequent tearfulness, and described her mood as horrible. Although suspicious of others’ motives, she was not delusional and did not have hallucinations. Her thinking was logical and goal directed. She was alert and fully oriented, and her memory was good. Concentration was poor and statements were often interrupted by tears.
Ms. K. began psychotherapy and medication with an SSRI antidepressant. The early phase of therapy was marked by great turbulence. She was alternately enraged at the therapist for minor or imagined shortcomings or felt very dependent on him and fearful that he would leave or terminate her therapy. Once, when her therapist misremembered her age she left a lengthy, obscene outburst on his office answering machine. After a year of treatment, an antipsychotic drug was added with considerable benefit. The nightmares stopped, she felt less fearful and suspicious of others, and she had much better control over her anger. She completed her graduate degree and began working for another company. Her mood became more stable, although she would usually experience a strong resurgence of depression during her psychotherapist’s vacations. The chronic empty feeling persisted.
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