The Case of O
DEMOGRAPHIC DATA: This was an emergency, voluntary admission for this 28-year-old
single white female. This was her fourth psychiatric hospitalization. O lives with a 24-yearold female roommate in New York City. She has a bachelor’s degree in art history and is
employed by a major New York museum. O is of Jewish ancestry.
CHIEF COMPLAINT: “My therapist said I was decompensating because I broke my leg, and
I was despondent.”
HISTORY OF PRESENT ILLNESS: O reported that she began an Optifast diet and,
although she was supposed to be eating 600 calories a day, she was only eating between
200 and 400 calories a day. She also admitted to purging and frequent use of laxatives. O
reported her weight was being monitored, and she had lab work done to be sure she
remained healthy. In 3 months, O lost approximately 80 pounds.
O reported that she has a very stressful job. She stated that approximately one month
prior to admission, she started to “decompensate” and had difficulty maintaining control
at work. She had several altercations with coworkers. One week prior to admission, O
reported that her NA sponsor “said something nasty, and I lost it.” According to her mother,
the sponsor made a reference to O being overweight. O reported that she was angry and
“hit everything I knew I could—but that did not help.” She then kicked a brick wall,
fracturing her right leg. O also reported being under stress due to applying for her master’s
degree in art history and difficulties with her boyfriend.
O complained of depression with insomnia and sleeping only a few hours per night, feeling
confused, decreased concentration, irritability, anger, and frustration. She admitted to
suicidal ideation. She complained of feeling paranoid over the past few weeks and believed
the police were after her and that she heard them outside her door. She believed the police
had her under surveillance. O also complained of a fear of dirt, taking time to frequently
bathe and brush her teeth. O reported she was emotionally abused as a child and suffered
from post-traumatic stress disorder, but she denied a history of flashbacks or nightmares.
She also complained of panic attacks and reported that she controlled them by taking
Klonopin, but there was no clear information about this. She reported a history of bulimia
since the age of 17. O also reported a history of drug and alcohol use, but she stated that
she has been clean and sober for two years.
PAST PSYCHIATRIC HISTORY: O’s mother reported that O saw a clinical social worker
briefly when O was 10 years old. O reported that she was hospitalized at a New York
hospital 3 years ago for 3 months. Six months after that, O took an overdose of Halcion
and was treated at the same hospital, and then was transferred to a state hospital. After
discharge in the next month, O attended a partial hospitalization program for drugs and
alcohol every day for 5 weeks. She also saw a psychiatrist for 2 years. Two years after
that, O saw a clinical social worker and psychiatrist and continues to the present with them.
O admitted to using marijuana, cocaine, opiates, and hallucinogens in the past. She
denied IV drug use but admitted to “skin popping” cocaine. O has abused alcohol in the
past. According to her mother, O has also abused prescription medications in the past. O
reported that she has been sober for the past 2 years and attends AA and NA meetings
MEDICAL HISTORY: At 17 years old, O suffered from bulimia with bingeing, purging, and
the use of laxatives. She reported she had not purged for 3 years until she began the
Optifast diet 3 months ago. Although O is currently not bingeing, she admitted to purging
and using laxatives. O is allergic to penicillin and has a lactose intolerance. She wears
glasses for reading.
PSYCHOSOCIAL AND DEVELOPMENTAL HISTORY: O’s parents were married when her
mother was 19 years old, and O was born the following year. O’s mother described O as a
wonderful, even-tempered, and happy baby. Two years later, O’s sister was born; mother
stated O’s personality changed; she became stubborn and difficult. O’s mother said that O
began biting and having temper tantrums and has been moody since then. O’s mother
stated her marriage was conflicted because she has a communication problem with her
husband and he was “never an active parent.” O’s mother reported that O “adores her
father” because he is not the disciplinarian. O frequently caused conflict between her
parents. When O was 12 years old, her parents separated for 2 weeks. O reported her
mother quit college after O’s birth and returned to college after her sister’s birth. She said
her father worked all the time, and there was a housekeeper who cared for the children.
O reported that the family moved to Arizona when O was in sixth grade, where she
began using marijuana that she reported stealing from her parents. The family returned
to New York when O was in seventh grade.
O’s mother reported that when O was in high school, her maternal aunt, who was dying
of cancer, came to live with the family and that this was very stressful for O. During
those years, O told the school counselor that her mother was abusive, and school
officials visited the family. During the visit, O had a temper tantrum and there was no
O reported she was always an above-average student who rarely studied. She said she
was always hyperactive and had difficulty sitting in school. O stated that in college she
had a 3.8 GPA and was on the Dean’s list. O is currently applying for admission to
graduate school and has taken some courses toward her master’s degree. O was
always an athlete (soccer) in school, and according to her mother, she was a champion.
O reported that in high school, most of her friends were athletes. She stated that she
had one close friend. Currently, O is friendly with her roommate but does not have any
other friends. “I don’t trust anybody.” O’s mother reported that when O lived in
Connecticut during college, O had many friends and was active in NA and AA. O’s
mother stated that she was surprised when O returned to New York. O agreed that she
was happy living in Connecticut and felt returning to Queens was “a stupid mistake.” O
hoped to return to Connecticut in the future. O’s mother reported that when O returned
to New York, she at first moved in with her parents. Conflict increased in the household,
and O’s parents began marital therapy. O’s mother stated that she and her husband
became united and finally asked O to move out. O’s mother stated that within 6 weeks
of moving out, O was doing well and seemed happy. O’s mother felt O has difficulty
accepting adult responsibilities and felt O needed to separate from her parents. O’s
mother stated that they do not want O to return home to live, but O stated that she
wants to return home.
O’s mother reported O worked during summer vacation while in high school. She baby
sat during college and worked as a graduate assistant. Since graduating from college, O
has been employed by a museum. O reported that she currently has financial problems
because of money owed to her therapist and the hospital in New York.
MENTAL STATUS EXAMINATION: O presented as an overweight, somewhat disheveled,
white female who had a cast on her right leg. She was relaxed but very restless during the
interview. Her facial expression was mobile. Her affect during the initial interview was
constricted and her mood dysphoric. In subsequent interviews, her affect was full range and
her mood very liable. O’s speech was pressured and often circumstantial or tangential, and
she spoke in a loud voice. At times her thinking was logical, and at other times it was
illogical. O denied hallucinations but complained of hearing policemen outside her door
prior to admission. She denied homicidal ideation and initially admitted to suicidal ideation
but in subsequent interviews denied this.
O was oriented to person, place, and time. Her fund of knowledge was excellent. O was
able to calculate serial sevens easily and accurately. O repeated 7 digits forward and 3 in
reverse. Her recent and remote memory were intact, and she recalled 3 items after five
minutes. O was able to give appropriate interpretations for 3 of 3 proverbs. Her social
and personal judgment were appropriate. O’s three wishes were: “To be skinny, to have
a big house where I can take in all the stray cats, and for a million more wishes.” When
asked how she sees herself in 5 years, O replied, “Hopefully graduating from graduate
school.” If O could change something about herself, she would “make myself thin.”
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