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Exam 2 Abnormal Psychology
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Exam 2 Abnormal Psychology
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Case Study 1: Depersonalization/ Derealization (Cannabis Induced Derealization)

A college-aged woman presented to my unit after her mother called for a wellness check after the patient reported self-harm. She had been self-harming for the past week with deep lacerations covering her arms. During her first day on the unit, she explained to me that she had been feeling dissociated and completely detached from her own body; it felt as though she was walking through an artificial world. The self harm in a way, brought her back to reality, she explained. She spoke slowly and would stare off in the distance. There was an air of something not being quite right behind what she was saying, as if she were in a dreamland, trying hard to piece her thoughts together.

I spent a lot of time simply sitting with her in the day room, watching TV together, and talking about schoolwork. She explained that this had happened before and was always triggered by her smoking marijuana. She thought it would stop after she got on medication and she could smoke again, but she was sadly mistaken. These episodes lasted months and greatly impacted her schoolwork, as well as isolating her from her friends. It was very clear that this dissociation was terrifying for her, not knowing how long it would last and not being able to be present in the world around her.

What stood out the most were her self-soothing techniques and coping skills. She was equipped with grounding/ coping skills that helped her be even a little more present in the moment. She was prescribed antipsychotics and antidepressants, which seemed to help significantly. She was discharged and agreed with me that she needed to stop smoking, as it would only result in another visit to the hospital. She did not return for the next 6 months I worked there, and I hope she is doing well.

DSM Derealization Diagnostic Requirments

  • Persistent or recurrent episodes:

    The person experiences ongoing or recurring feelings of depersonalization (detachment from oneself) or derealization (detachment from one's surroundings). 

  • Intact reality testing:

    During these episodes, the individual is aware that the experiences are not real. They have not lost touch with reality. 

  • Significant distress or impairment:

    The symptoms cause significant distress or interfere with social, occupational, or other important areas of functioning. 

  • Exclusion of other causes:

    The symptoms are not due to another medical condition. 

  • Exclusion of other mental disorders:

    The symptoms are not better explained by another mental disorder, such as schizophrenia, panic disorder, or PTSD. 

Further Explanation

““It does not matter how slowly you go as long as you do not stop””
— Confucius

Impact and Importance…

Derealization and depersonalization make people feel cut off from their own mind or the outside world. These feelings are usually caused by stress, trauma, or using substances like marijuana. If not treated, it may lead to self-harm, suicidal thoughts/actions, or even harm to others. When people misunderstand these conditions, it can add to stigma and isolation, making it harder to get help and exacerbating symptoms. Immediate support, grounding exercises, therapy, medication management, and kindness are the most supportive things you can provide for someone experiencing these symptoms. Without this support, patients may be driven to suicide or take drastic actions that can destroy their lives and cause harm to those around them.

Case Study 2: Anorexia Nervosa

DSM Anorexia Nervosa Diagnostic Requirements

  • Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.

  • Intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain, even though at a significantly low weight.

  • Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

During my rotation on the adolescent unit, I met a 14-year-old girl who was quiet and shy, very different from the more outspoken kids on the children’s unit. I was assigned to stay with her because she was considered a fall risk. Her anorexia had weakened her so much that she would faint if she stood up too fast. Despite everything she faced, she was one of the kindest patients I have ever cared for.

Meal times were always hard. She would sit at the table and just stare at her food, looking overwhelmed. I tried to help by talking about her favorite shows, music, or what we had planned for the day, hoping to make things easier. If she still wouldn’t eat, I would gently ask, “Just one bite, and then we’ll stop,” or “Just try to finish the yogurt.” Sometimes she agreed, but I could see how much she struggled, even to eat a little. Other times, her fear turned into anger or frustration. She would get angry at me, push her food away, and refuse to eat. It wasn’t defiance like some might think. It was panic, frustration, and the illness taking over her thoughts.

For a few days, her vital signs got so bad that she had to be moved to the hospital for a feeding tube. Watching her leave the unit on a stretcher, while the other kids looked on with worry, made it clear how much this illness affects not just the patient, but everyone around them.

Over time, I learned that anorexia is rarely about vanity. It is usually about control. For her, saying no to food was the only way she felt safe and in control amid a difficult home life. Her parents’ divorce left her searching for ways to make her own choices, and she found that control in what she ate.

I still think about her and how much this disorder took over her life. After three weeks, she was discharged and sent to an outpatient program. Anorexia is a daily struggle. Unlike substance abuse, you can’t just avoid your triggers—you have to face them at every meal. For her, healing wasn’t just about eating. It was about finding new ways to take control of her life.

Awareness can be life-saving…

Learning about anorexia nervosa can make a real difference. People with anorexia often avoid eating, fear gaining weight, and see their bodies in a distorted way. This illness is often connected to anxiety, depression, trauma, and a need for control. Some people wrongly believe anorexia is a choice or just about vanity, but these ideas are harmful. Those with anorexia are almost six times more likely to die than people without the disorder, and 5–10% die within ten years if they do not get treatment. These false beliefs add to stigma, cause shame, and make it harder for people to recover. Anorexia affects physical health, relationships, and daily life. Responding with understanding and education is crucial. When we see that anorexia often comes from trauma or deeper struggles, not defiance, it helps treatment teams and support systems address the real issues and possibly save lives.

““Recovery is about progress, not perfection”.”
— Dr. Carolyn Costin (Eating disorder specailist)
Learn more

Case Study 3: Substance Withdrawal Syndrome

By far the most impactful patient of my career was a 20-year-old man admitted to the detox unit withdrawing from fentanyl. The moment he arrived, I could tell just how much damage the drug had done to him. He was vomiting, unable to control his bowels, running into walls, and asking where he was every hour or so. The first few days of his stay, he was experiencing hallucinations that left him terrified. Even after his physical detox had ended, he was still experiencing extreme hallucinations and delirium. I walked in on him during night shift on the floor, crying a week into his stay. I asked him what was wrong, and he started yelling, “You have to Narcan her”. No one was there.

He was never aggressive towards staff or other patients, and you could tell he was a very kind man (not an evil bone in his body). He had moments where he could hold a conversation, but for the most part, his brain was permanently damaged. Watching him attempt to hold a conversation or handle day-to-day tasks was heartbreaking, because I knew there was very little chance of him ever having a full recovery. Every day, I sat with him, fed him, and bathed him. And every day, I hoped to see improvement that would never come.

By the end of his stay, the psychiatrists made plans for him to be discharged into his mother's full-time care, as he would be unable to take care of himself. Witnessing his pain showed me how fentanyl impacts people firsthand. It's not just dangerous because of the potential for overdose, but because of the serious and permanent damage it can do to your brain.

AA and NA Support Groups

Importance.

Understanding substance abuse disorders is essential because of the devastating and often permanent effects fentanyl can have on the brain and body, even beyond a deadly overdose. Withdrawal can leave someone completely disoriented, hallucinating, and incapable of basic self-care, essentially ruining their lives and taking away their self-efficacy. Understanding these effects is essential for families, healthcare providers, and the public. It is not just about treating addiction, but preventing irreversible damage and saving lives. My patients' struggles illustrate that fentanyl and other substances are not just physically addictive, but can corrode the mind, and that recovery is not guaranteed. Witnessing how vulnerable someone becomes in withdrawal portrays the urgency of compassionate care and public awareness. This is why educating people about the actual dangers of fentanyl isn’t optional; it can be the difference between life and death.

““Recovery is an acceptance that your life is in shambles and you have to change.””
— Jamie Lee-Curtis

Case Study 4: Insomnia Disorder

A patient in his 30s presented to my unit after not being able to sleep for three days straight. According to his chart, he had been struggling with insomnia for the past two years, where he would be unable to sleep for days at a time. He had been escorted to the hospital by police after he became aggressive towards his roommate, which was likely caused by his lack of sleep.

Even though he had not slept, he was extremely talkative and would sometimes sit next to me for the entire day. He continued to not sleep for days after admission and would become agitated at the slightest things, even becoming aggressive towards other patients at times. His insomnia had taken control of his life and had even cost him his job and potentially his roommate. His emotional regulation was almost completely absent, leading him to lash out inappropriately. This was a life-altering issue for him. Compassion, close monitoring, and early intervention with medication could help prevent this and help him manage.

He was discharged after a week when psychiatrists were finally able to find a medication that helped him sleep. After a few days of rest, the patient seemed stable and able to return home.

Impact/Importance

Insomnia is not simply being unable to fall asleep; it is a disorder that can impact all facets of life. It can disrupt the mind, body, and interpersonal relationships. When someone with insomnia is awake for long periods of time, their judgment, emotional control, and reality perception may deteriorate. In the long term, this can lead to decreased life expectancy, accidents, and harm to the patient or others. Recognizing this can prevent the disorder from escalating and causing further harm. Sleep is vital for mental and physical functioning, and without it, consequences may be severe.

DSM Requirements for Insomnia

Sleep complaint

  • A predominant complaint of sleep dissatisfaction regarding quantity or quality. 

Specific sleep disturbance symptoms

  • Difficulty initiating sleep.

  • Difficulty maintaining sleep (frequent awakenings or difficulty returning to sleep after waking).

  • Early-morning awakening with the inability to return to sleep. 

Frequency and duration

  • The sleep difficulty occurs at least three nights per week.

  • The disturbance is present for at least three months. 

Daytime impairment

  • The sleep disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. 

Case Study 5: Paraphilic Disorders (Exhibitionism)

A man in his 50s was brought into my unit by the Secret Service after stripping naked in front of the White House. He had done this many times and would come into the hospital every few months for the same sort of reason. On the unit, he would expose himself to female staff and seemed unaware of the discomfort he was causing. Sometimes this would cause the other patients to become violent towards him, even sending him to the medical hospital on one occasion.

The patient was lucid, aware, and did not seem to have any other conditions other than this sexual deviancy. He was never physically aggressive, nor would he try to touch anyone inappropriately. On numerous occasions, he was able to hold polite conversations and was calm on the unit for the most part. He was also able to recognize that these behaviors were harmful to others and that it was continuing to get him into legal trouble. The counselor's therapeutic approach was mainly based on working on his impulse control and discussing how these consequences were negatively affecting him.

Unfortunately, he would continue to be admitted to the hospital every month or so, regardless of the amount of therapy he received or the medication he was given. In my experience with patients with sexual disorders, they are some of the hardest to treat and maintain lasting remission.

Impact and Importance

DSM Diagnostic Requirements

This case demonstrates the negative impact that paraphilic disorders can have on those diagnosed and on those around them. Exhibitionist behavior is mainly driven by urges that are hard for a patient to control, and without treatment, it can lead to serious legal trouble and emotional harm to people around them. It is important for clinicians and families to understand that while this condition is disturbing, it is still a mental health issue that needs to be treated with compassion to make any progress. Intervening in these behaviors early is the best way to stop paraphilic disorders from progressing and can prevent long-lasting harm. The behaviors shown by these patients stem from complex psychological issues that require intense treatment and management, or they will result in serious consequences.

Distress or harm: The paraphilia is considered a disorder only if it meets one of two conditions:

  • The individual feels personal distress about their interest, separate from societal disapproval.

  • The sexual interest involves harm, injury, or psychological distress to another person, or involves unwilling or non-consenting individuals.

  • Duration: The recurrent, intense sexual fantasies, urges, or behaviors must have been present for a minimum of six months.

  • Distinction from paraphilia: The addition of "disorder" to the names in the DSM-5 was explicitly intended to differentiate between an atypical sexual interest and a clinical disorder causing distress or harm. Many people with atypical interests do not have a disorder. 

Sexual Compulsives Anon