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Case Example – Emily*
“Only upon the repeated and fervent insistence of her parents did 19-year-old Emily reluctantly agree to see a psychiatrist. “It’s not me you want to see,” Emily proclaimed emphatically. “It’s my insane parents who need your help.” Emily did not offer a chief complaint, aside from the concern that her parents were driving her “crazy.” She added, “Everything is going great in my life. I have plenty of friends, go out almost every night, and always have lots of fun.”
While Emily was taking some time away from “the so-called real wired,” her sister was attending Duke University, her younger brother was excelling at a competitive private high school, and both her parents seemed to enjoy their careers as radiologists. She asked, “Don’t you think that’s enough strivers for one family?”
Emily agreed to have her parents join the session, and they told a different story. They tearfully disclosed that their daughter had become irritable, unproductive, and oppositional. She drank to intoxication almost every night, often not returning home for an entire weekend. In searching her room, they had found small amounts of marijuana, alprazolam (Xanax), cocaine, and prescription stimulants. The parents described the changes in Emily’s personality as “an adolescent nightmare” and described her friends as “losers who do nothing but dye their hair, get tattoos, and hate everything.” Emily’s attitudes and behavior contrasted markedly with those of her parents and siblings. “We don’t mind that she is doing her own thing and that she isn’t conservative like the rest of us,” her father said, “but it’s like we don’t even recognize who she’s become.”
According to her parents, Emily’s “adolescent nightmare” began 4 years earlier. She had apparently been a studious 15-year-old girl with a lively sense of humor and a wide circle of “terrific friends.” “Almost overnight,” she began to shun her longtime friends in favor of “dropouts and malcontents” and began to accumulate traffic tickets and school detentions. Instead of her former brightened curiosity, Emily manifested a lack of interest in all her academic subjects, and her grades dropped form As to Ds. The parents were at an absolute loss to explain the sudden and dramatic change.
The abrupt change in performance led the psychiatrist to ask Emily to take a battery of neuropsychological tests so the results could be compared with those of test she had taken when she had applied to a private high school several years earlier. In particular, Emily retook two high school admissions tests: the System for Assessment and Group Evaluation (SAGE), which measures a broad array of academic and perceptual aptitudes, and Differential Aptitude Tests (DAT), which focus on reasoning, spelling, and perceptual skills.
On the SAGE, her average percentile scores dropped from the upper 10% for a 13 -year-old to the bottom 10% for an adult (and the bottom 20% for a 13-year-old). When Emily took the DAT at age 13, she scored in the highest range for ninth graders across almost all measures. Her worst result had been in spelling, where she scored at the second-highest level. Upon repeating the test at age 19, she scored below the high school average in all measures.
EEG, brain CT, and T2-weighted brain MRI images did not show evidence of structural brain damage, However, fluid-attenuated inversion recovery (FLAIR) T2-weighted MRI displayed a clear lesion in the left frontal cortex, highly suggestive of previous injury to that region.
Upon further questioning about the crucial period in which she seemed to have changed, Emily admitted to being in a traffic accident with her now ex-boyfriend, Mark. Although Emily did not recall much from this episode, she remembered that she hit her head and that she had bad headaches for many weeks thereafter. Because Emily was not bleeding and there was no damage to the car, neither Mark nor Emily reported the incident to anyone. With Emily’s permission, the psychiatrist contacted Mark, who was away at college but a willing and excellent historian. He remembered the incident well. “Emily hit her head very, very hard on the dashboard of my car. She was not totally unconscious but very dazed. For almost 3 hours, she spoke very slowly, complained that her head hurt badly, and was confused. For about 2 hours she didn’t know where she was, what day it was, and when she had to get home. She also threw up twice. I was really scared, but Emily didn’t want me to worry her parents since they’re so overprotective And then she broke up with me, and we’ve hardly spoken since.”
*From DSM 5 Clinical Cases, Barnhill, J. (Ed.), 2014.