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A 49-year-old Diana was assessed by her Primary Care Provider.

A 49-year-old Diana was assessed by her Primary Care Provider. She was a pale, neatly and plainly dressed woman. Her eyes were filled with tears during most of the interview, although she did not weep openly. She spoke slowly and so softly that at times she was inaudible. She appeared timid, abject, dependent, helpless, and hopeless, her initial report to PCP is “my nerves are busted. I can’t do anything.”

There were multiple complaints of pain, including “black ankles,” painful “knots” in her neck, “busted discs” in her back, headaches that radiated all over her body, and pelvic and abdominal pain. She described a variety of gastrointestinal and respiratory complaints that have occurred consistently in the past 2-3 years. She said that she has had a low mood most of her life, and it was getting worse over the past 3-4 years. She was sad, helpless, hopeless, and fearful. She reported no energy and did little but “sit around the house.” Limited interest in anything, and nothing gave her pleasure in life. She notes the ability to fall asleep but would awaken repeatedly during the night and be awake for good before daylight. She had no appetite and had lost 10 pounds over the preceding 2 months. She had many episodes of weight loss and gain in the past. She said she was inattentive and disinterested. “People are talking to me and I forget what they are saying right in the middle of things. Frequentepisodes of “smothering” occurred. At these times she felt she might choke to death. She would become dizzy, her heart would pound, and her hands would tingle.

Diana had never had a formal psychiatric evaluation or treatment; however, detailed observations made by her physician in her chart 25 years earlier revealed a picture similar in almost every respect to her current presentation. At the time client was going through a divorce. She had taken multiple over the counter medications over the years, to assist with sleep with limited benefit. Aside from mild, self-limited episodes of physical illness, usually infections, results of physical exams and laboratory studies have always been within normal limits,as they were at the time of this referral.

The patient was born and lived all of her life in the central Appalachian Mountains. She attended school through the 8th grade, but “could not learn.” She was unable to say how old she was when she stopped going to school and stayed at home with her mother and father. All of her siblings left home, but she stayed home and helped her mother. This was a state of affairs until she met and married her husband, at age 23. They have 3 grown daughters who visit her often and are also quite concerned about her current presentation.


What will be primary diagnosis and differential diagnosis?