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that the most appropriate diagnosis for this patient would be Obsessive-CompulsiveDisorder. An alternative diagnosis would be Major Depressive Episode. According to DSM IV Criteria, theprimary features characteristic of Obsessive-Compulsive Disorder are either obsessions or compulsions. Here the patient experiences recurrent, persistent thought, impulses or images that are intrusive andcause marked anxiety or distress, that go beyond normal worrying about real life problems, and which theperson realizes are irrational and attempts to suppress or deal with through some thought or action. Alternatively, the person may experience repetitive behaviors which they feel compelled to perform. These behaviors are directed toward reducing anxiety or preventing some feared event or situation. Theseobsessions or compulsions are seen by the patient as being excessive or irrational, cause markeddistress, and interfere with the patients ability to function. It is obvious that Sara shows both obsessions and compulsions. Her obsessions take the form ofintrusive thoughts and impulses related to her arming her child. Her compulsive behaviors take the formof behaviors which represent attempts to ward off or prevent such threatening things from happening. Other characteristics of this patient might be seen as suggestive of a Depressive Disorder whichmight be considered as an alternative diagnosis. In this regard it can be noted that the patient reportsfeelings of depression, shows a loss of interest in most activities, describes a lack of energy, andevidence of weight loss and sleep disturbance. All of these features are associated with DepressiveDisorder. While these features are clearly present, it could be argued that the primary diagnosis forthis patient should be Obsessive-Compulsive disorders it seems to be the case that depressive featureshave occurred secondary to the distress resulting from her obsessions and compulsions and the disruptionin her personal and family life that has resulted. Treatment of this patient would likely involve dealing with several issues. The treatment ofobsessive-compulsive disorder has been approached through the use of pharmacological treatments as in theuse of antidepressant drugs such as Prozac. Psychological treatment where the patient is exposed tosituations likely to result in increased compulsive behavior and where they are not allowed to engage incompulative behaviors have also been found to be useful. Either of these types of treatment might beuseful with this patient. DEAN WANNAMAKERThis case seems to present the most difficulties in terms of making a differential diagnosis. Itseems clear that this patient displays a substance abuse disorder of some type. Two specific diagnosesappear to most likely characterize his symptoms. The first is Substance-induced Psychotic Disorder. Myhypothesis is that this is the most appropriate primary diagnosis. The second is Substance-induced MoodDisorder with Depressive Features. The primary symptoms of Substance-induced Psychotic Disorder include prominent hallucinations ordelusions. It is suggested that there should be evidence that these symptoms developed during or withina month of substance intoxication or withdrawal, that symptoms are not better accounted for by anon-substance-induced psychotic disorder and that symptoms do not occur just during a delirium. For thisdiagnosis to be made it is also the case that the hallucinations or delusions should not be recognized bythe patient to be the result of substance abuse. This patient appears to clearly meet these criteria. First of all, he shows evidence of auditoryhallucinations that began when he was in his early 40 s. These hallucinations began after the onset ofbouts of heavy drinking and are described by his girlfriend as only occurring after he has been drinkingfor a while. The patient shows no insight into the fact that the voices he hears are related to hissubstance abuse. Of special concern is the fact that the voices he hears now speak to him regarding thetopic of death. This would raise concern over possible suicide attempts later. The patient also seems to meet the criteria for the alternative diagnosis of Substance-inducedMood Disorder with Depressive Features. He shows significant depression by his crying, weight loss sleepdisturbance, loss of interest in sex, and loss of energy. His recent thoughts about dying are alsosuggestive of significant depression. His girlfriend s statement that he has been depressed most of thetime for the last month and a half – not quite as long as he d been drinking suggests that the patient sdepression likely developed subsequent to alcohol abuse.Treatment might well involve participation in a substance abuse treatment program and helpingdevelop more adequate ways of coping with major stress so that he is less likely to abuse alcohol inattempting to cope with this stress. Psychotherapy would seem likely to be helpful in this regard. Given that both the psychotic symptoms and depression are substance abuse could be dealt with these othersymptoms (e.g., hallucinations, depression) should be greatly diminished.