Presenting Problem: Miles Vorkosigan is a 29-year-old white male who appears older than his reported age. He is of below-average height and weight, and has visible disabilities affecting his legs and back. He wore a military uniform, and his grooming and hygiene were above average (normal for Barrayaran military.) His speech and movements were very energetic, and he appeared restless and fidgety. Upon initial questioning, he appeared cooperative but irritated.
The client relaxed when he was assured that the contents of the meeting were not only confidential but top secret, and was quoted back (by advance permission) Imperial Security Chief Simon Illyan’s comment, “I don’t want to fix him. I just want to know what makes him tick.”
The client then confirmed that he was present due to an experimental pilot program bringing in Betan therapists to assess and, if necessary, treat members of Barrayaran Imperial Security. He rapidly diagnosed himself as “a bit bipolar, hyperactive, split personality, and megalomania,” then laughed when it was pointed out that the last two are not diagnoses.
Client stated that he has a history of depressive episodes and combat-related flashbacks, but neither interferes with his job performance. He stated that he has satisfying relationships with his family, is happy with his work, and has ongoing romantic relationships. Upon closer questioning, he admitted to a suicide attempt as a teenager and frustration over being unmarried. Client denies current suicidal ideation.
Personal History: Serious physical disabilities. Social prejudice due to ableism. Satisfying and very successful military career. High-stress life, but client stated that he enjoys this. Client seems very invested in his secret identity.
Family Background: Good relationship with parents and extended family. History of conflict with deceased grandfather. Recently learned of existence of clone-brother, but clone-brother cut off contact, to client’s regret. Father has history of alcoholism, depression, and self-destructive behavior including possible suicide attempts.
Psychiatric/Treatment History: No previous diagnoses. Client said that he has never been treated for a mental illness, and speculated that he is probably allergic to all psychiatric medications.
Differential Diagnosis: Described manic and hypomanic states to client, and asked if he was having one now. Client stated that he is “always like this” except when he is having a depressive episode. Acquired client’s permission to call his mother, who agreed that client’s baseline met all the clinical criteria for hypomania, except for the existence of a non-hypomanic baseline. Client’s mother described client’s behavior as a child, which met the criteria for Attention-Deficit/Hyperactivity Disorder, Predominately Hyperactive/Impulsive Type. Client and client’s mother stated that the client has never had a manic episode except while under the influence of a substance.
Symptoms of PTSD are concentrated on the reexperiencing and increased arousal axes. Avoidance symptoms are missing, but reexperiencing ones (dreams, flashbacks, psychological distress, and physiological reactivity) are sufficiently intense as to justify the diagnosis.
Rule out Dissociative Identity Disorder. Client’s over-investment in his secret identity is common in military operatives, and there is no amnesia present.
Rule out Narcissistic Personality Disorder. Client’s grandiosity and sense of specialness don’t seem unrealistically inflated given his circumstances, and he shows no more entitlement and arrogance than is common among wealthy, high-status people. Other symptoms are not present.
Recommendations: 1. Individual therapy services to address his PTSD and Major Depressive Disorder. Recommend a cognitive-behavioral approach.
2. A complete medical examination to rule out possible physiological or medication-based causes for his conditions.
3. A medication consultation. NOTE: See extensive list of allergies. Be aware that while the therapist did not diagnose Bipolar II, it could be present in a non-diagnosable form.
4. Individual therapy services from a Jungian perspective to address issues of Persona and Self.
Axis I (clinical disorders): Major Depressive Disorder, Recurrent, With Catatonic Features. Posttraumatic Stress Disorder.Attention-Deficit/Hyperactivity Disorder, Predominately Hyperactive/Impulsive Type.
Axis II (personality disorders and mental retardation): : No diagnosis.
Axis III (general medical conditions): : See attached files.
Axis IV (psychosocial and environmental problems): : High-pressure occupation. Ongoing search for wife.
Axis V (GAF: Global Assessment of Functioning): : 65 (Some distressing symptoms, but generally functioning well.)