Case “A”
Juanita Delgado is a single, unemployed Hispanic woman, who sought therapy at age 33 from treatment of depressed mood, chronic suicidal thoughts, social isolation, and poor personal hygiene. She spent the prior 6 months isolated in her apartment, lying in bed, eating junk food, watching television, and doing more online shopping than she could afford. Multiple treatment yielded little effect.
Ms. Delgado was the middle of three children in an upper-middle-class immigrant family in which the father reportedly valued professional achievement over all else. She felt isolated throughout her school years and experienced recurrent periods of depressed mood. Within her family, she was known for angry outbursts. She did well academically in high school but dropped out of college because of frustrations with a roommate and a professor. She attempted a series of internships and entry-level jobs with the expectation that she would return to college, but she kept quitting because “bosses are idiots. They come across as great and they all turn out twisted.” The “traumas” always left her feeling terrible about herself (“I can’t even succeed as a clerk?”) and angry at her bosses (“I could run the place and probably will”). She dated men when she was younger but never let them get close physically because she became too anxious when any intimacy began to develop.
Ms. Delgado’s history included cutting herself superficially on several occasions, along with persistent thoughts that she would be better off dead. She said she was generally “down and depressed” but that she had dozens of 1 to 2 day “manias” in which she was energized and edgy and pulled all-nighters. She tended to “crash “the next day and slept for 12 hours.”
She was in psychiatric treatment since age 17 and was psychiatrically hospitalized three times after overdoses. Treatments consisted primarily of medication: mood stabilizers, low dose neuroleptics, and antidepressants that were prescribed in various combinations in the context of supportive psychotherapy.
During the interview, she was casually groomed and somewhat unkempt woman who was cooperative, coherent, and goal directed. She was generally dysphoric with a constricted affect but did smile appropriately several times. She described shame at her poor performance but also believe she was “on Earth to do something great.” She described her father as a spectacular success, but he was also a “Machiavellian loser who was always trying to manipulate people.” She described quitting jobs because people were disrespectful. For example, she said that when she worked as a clerk at a department store, people would often be rude or unappreciative (“and I was there only in preparation to become a buyer; it was ridiculous”). Toward the end of the initial session, she became angry with the interviewer after he glanced at the clock (“Are you bored already?”). She said she knew people in the neighborhood, but most of them had “become frauds or losers.” There were a few people from school who were “Facebook friends,” doing amazing things all over the world. Although she had not seen them in years, she intended to “meet up with them if they ever come back to town.”
(Please number your answers)
What is the most likely diagnosis for this patient?
What subjective and objective information leads you to this diagnosis?
What is in your differential diagnoses?
Is there anything else you would like to know in order to solidify your choice of diagnosis?
Case “B”
Jody Rohmer, a 52-year-old salesperson, presented to a psychiatric provider as part of a court proceeding that was intended to legally reassign her gender to female.
Jody was born with male genitals and raised as a boy. In contrast to a more gender-typical older brother, Jody was seen as a “sissy” since early childhood, generally preferring the company of girls to boys. She considered herself a bisexual male through her teen years. Around age 19, during a romantic relationship with a man, she became aware of a strong desire to be a woman. The relationship ended, but the desire to be a woman evolved into a strong sense that she was born into the wrong gender. She tried to figure out whether this sense existed earlier, but all she could recall was occasionally wishing she were a girl to fit in more comfortably with her friends. She recalled, however, that by age 19 or 20, she was very unhappy with being seen as a man and viewed her genitalia as “repugnant” and a “mistake of nature.” Between ages 22 and 24, Ms. Rohmer lived as a female, including changing her name and exclusively wearing women’s clothes. She also dated. Gay and straight mend were generally uninterested, so she primarily dated lesbians or people at various stages of cross-sex treatment.
At age 24, Ms. Rohmer was evaluated by two experienced court-assigned psychiatrists, who agreed with her perspective. In the same year, she had sex reassignment surgery, followed by a legal sex change from male to female. The results of her sex reassignment surgery were not very satisfactory. She lived as a woman for over 15 years, but the experience did not live up to her expectations. A tall, muscular person, she was frequently identified as a transsexual rather than a woman like any other women. She found this constant public scrutiny to be “exhausting.” Although she dated regularly during this period, she was routinely disappointed in relationships with both male and female sexual partners.
At age 42, Ms. Rohmer consulted a plastic surgeon and asked him to remove her breast implants. She hoped that her life would be “easier and more relaxed” in the male role. She was also curious and excited about the prospect of integrating “male personality traits,” which she saw as increased assertiveness and dominance. After the breast surgery, she began to take male hormones, which made her more active and aggressive.
The shift did not, however, help her feel better. She missed her male genitals and was aware that they could never be satisfactorily reconstructed. The male hormones stimulated her sexual appetite, but she was left without the possibility of achieving a normal male orgasm. Instead of being relaxed after a sexual encounter, she felt tense and dissatisfied. Furthermore, dating became more complicated. She was still bisexual but primarily attracted to men. Most gay men were uninterested in a relationship (and/or sex) with someone with female genitalia. She gravitated to lesbian circles but was unable to find a girlfriend. She also found that male hormones made her edgier and more aggressive at work, which led to a job loss and welfare, which was an embarrassing decline from her previously successful professional career.
Ms. Rohmer stopped taking male hormones at age 51 and found that her female identity was still very strong and even stronger than she herself had anticipated. She calmed down, found a new job, and concluded that her new femininity was now irreversible. At age 52, she got new breast implants and applied to the court to again assign her legally as a woman.
Ms. Rohmer said she was “depressed” in her early 20/s and found psychotherapy to be helpful. She said she was anxious person, generally worried that people were judging her negatively. She added that she also thought her perspective was accurate, that most people would immediately identify her as a man in a woman’s body and think about her critically. She described a period during her 30s when she drank alcohol every evening to put herself to sleep but denied negative consequences. She denied suicide attempts, arrests, and self-injuries such as cutting. She said she had “almost” given up on having a successful relationship but was “somehow” still optimistic that something would work out. She denied that her relationships had been particularly stormy or difficulty; typically, she said, the other person would be initially intrigued but then become uninterested.
(Please number your answers)
What is the most likely diagnosis for this patient
What subjective and objective information leads you to this diagnosis?
What is in your differential diagnoses?
Is there anything else you would like to know in order to solidify your choice of diagnosis?
