Help Needed

4 Bipolar and Related Disorders

Bipolar and Related Disorders (BP) is now an independent category in the DSM-5, separating it from Depressive Disorders with placement immediately after Schizophrenia Spectrum and Other Psychotic Disorders. This move reflects a growing understanding of dimensionality in many disorders, with overlap in terms of symptoms and other risk factors along a continuum of severity. The seven mental disorders covered in this section are characterized as chronic, taxing, disruptive, and multifactorial involving mood lability and extremes of behavior. The term multifactorial disorder refers to one caused by the interaction of genetic and environmental factors. Mood lability is defined as frequent or intense changes or shifts in mood over a short time period ( APA, 2013 ).

   This section of the DSM-5 is generally organized around three different types of episodes that, in turn, serve as building blocks for determining specific diagnoses. An episode is a period of time during which a client evidences a particular set of symptoms and as a result, experiences a pronounced alteration in mood and/or a change in his or her social, vocational, and recreational functioning. Specifically, the three episodic states are major depressive, manic, and hypomanic. Some changes from the previous version of the DSM include replacement of the Mixed Episode criteria with a Mixed Features Specifier that can be applied to all episode types in Bipolar I and/or Bipolar II disorder. Also, With Anxious Distress Specifier was added for use when at least two out of five anxious distress symptoms are present (see criteria,  APA, 2013 , p. 149) during the majority of the most recent episode (depressive, manic, hypomanic) as it was associated with greater suicide risk, lengthier illness period, and partial to nonresponse in treatment. Additionally, the criteria for mania and hypomania were refined to help alleviate some confusion around what constitutes an episode across the entire developmental spectrum, including the addition of changes in energy/activity as a core symptom. The goal was to imbue a lifespan perspective and to adjust diagnostic criteria to achieve a better fit when treating individuals with bipolar disorder ( APA, 2013 ).

   The most disruptive disorders in this cluster include Bipolar I (manic and major depressive episodes) and Bipolar II (hypomanic and major depressive episode). Each is diagnosed based on the number and pattern of episodes the individual has experienced in his or her lifetime. In the coding of each disorder, attention is given to the severity of symptoms and specific characteristics of the most recent episode. Cyclothymic Disorder represents a more chronic condition that is generally less disruptive to the individual's functioning. By definition, a set of symptoms severe enough to meet criteria for one of the three major episodes is not present. In Cyclothymic Disorder, an alternating pattern of mood states is present but not as severe as major depressive or hypomanic episodes ( APA, 2013 ).

   Two of the diagnoses in this section are determined by the etiological factors relevant to the illness. Specifically, Substance/Medication-Induced Bipolar Disorder is used when the problematic bipolar episode is directly related to the use of a recreational drug, prescribed medication, or a toxin (e.g., lead, carbon monoxide). Similarly, Bipolar and Related Disorder due to Another Medical Condition is used when a bipolar episode is directly related to a diagnosable organic problem ( APA, 2013 ).

   The final two diagnostic categories in this chapter include Other Specified Bipolar and Related Disorder and Unspecified Bipolar and Related Disorder. First, Other Specified Bipolar and Related Disorders category is used when an individual's symptoms fail to fit any of the more specific diagnoses in this category and the clinician wishes to provide the reason for this, which must also be provided. This category may be especially helpful when assessing children, whose bipolar symptom presentation may not meet the specific criteria for another bipolar disorder. Some examples of such presentations include: “Short-duration hypomanic episodes (2–3 days) and major depressive episodes; Hypomanic episodes with insufficient symptoms and major depressive episodes; Hypomanic episode without prior major depressive episode; and Short-duration cyclothymia (less than 24 months)” (for details see  APA, 2013  p. 148). Meanwhile, Unspecified Bipolar and Related Disorder is used when the individual's symptoms are similar to bipolar related disorders but they fail to meet the full criteria for any disorder in this category and the clinician chooses not to specify the reason. This usually happens when there is insufficient information to make a more specific diagnosis and/or more time is needed, for example, when there is uncertainty over whether substances or medical illness is causing symptoms ( APA, 2013 ).

   The Bipolar and Related Disorder section in the DSM-5 includes a comparatively large number of specifiers, including some that are reflected in the fourth and fifth digit of the numeric coding. Specifiers provide extra insight on the underlying disorder (e.g., course, severity), and a full description of the relevant specifiers is included in the DSM ( APA, 2013 , pp. 149–154).

   Advances in science and clinical research over the last quarter of a century have deepened our understanding of the diagnosis and treatment of debilitating mental conditions including bipolar disorder. Individuals experiencing psychotic symptoms of either Depression or Mania, which often coexist with other conditions, will likely not seek treatment independently. However, their behavior may well result in others arranging involuntary mental health treatment on their behalf. The clarification of diagnostic criteria in the DSM-5 for bipolar and related disorders is expected to help in clinical assessment and treatment.

Assessment

There are many challenges and complexities to diagnosing bipolar disorder. Individuals assessed on the basis of current clinical features alone (versus past history) are often misdiagnosed because of symptom overlap, especially with depression. This is further complicated by data that shows nearly 35% of individuals with bipolarity have to wait at least 10 years between first seeking treatment and receiving the correct diagnosis ( Garcia-Castillo et al., 2011 ;  Hirschfeld, Lewis, & Vornik, 2003 ;  Kaye, 2005 ;  Phillips & Kupfer, 2013 ). Recent findings suggest higher prevalence rates for bipolar disorders of 3–5% in contrast to earlier estimates (1–1.1%) drawing attention to the underdiagnosis of this devastating illness ( Angst et al., 2010 ;  Angst et al., 2012 ;  Kupfer, 2005 ). Adding to this complexity is the heavy financial burden of bipolar and related disorders, which was estimated to be US $151 billion in 2009 ( Dilsaver, 2011 ).

   In addition, the reliability of self-report is very uncertain if someone is experiencing psychotic symptoms. The stigma of mental illness and the fear of psychiatric treatment may lead to underreporting symptoms. Consequently, it is often helpful to gather data from collateral sources, such as close friends or relatives, employers, or other professionals, to specify both the timing and severity of symptoms. Assessment may be further complicated by co-occurring conditions (medical, psychiatric, and substance problems). Being able to differentiate age-appropriate behaviors from the symptoms of bipolarity is especially important when dealing with children. Knowledge of diagnostic specifiers and their pharmacological implications is key to successful assessment and will greatly improve the treatment of this lifelong disorder. Furthermore, research is limited on the effects that race/ethnicity, gender, and/or age may have on standardized screening measures and assessment tools. Appreciating these cultural differences and understanding any bias that may exist is essential to decreasing disparities in diagnosis and treatment.

Assessment Instruments

Depression When assessing depressive symptoms in bipolar disorder, many rating scales and tools can be useful. The Patient Health Questionnaire (PHQ-9) is a simple, self-administered screening measure of depression that was developed and studied in primary care settings. It generally takes under 10 minutes to complete. The PHQ-9 combines 8 questions related to DSM-IV depression diagnostic criteria ( APA, 2000 ) along with 1 question about suicidal ideation, which are summed to produce a total score. Also, an additional question on functional status (which is not scored) is provided to help with treatment planning. Individuals rate their problems/feelings over the “past 2 weeks” on a 4-point scale (from 0 = not at all to 3 = nearly every day) with total scores ranging from 0 to 27. When total score is under 5, depression severity is seen as none to minimal. Totals ranging from 5, 10, 15, and 20 represent thresholds for mild, moderate, moderately severe, and severe depression, respectively (Kroenke & Spitzer, 2002).

   The PHQ-9 has excellent internal consistency and strong psychometrics including criterion and convergent validity. At the recommended cutoff score of 10 or higher, the PHQ-9 has a sensitivity of 88% and specificity of 88% for identifying patients with a major depressive episode ( Kroenke, Spritzer, & Williams, 2001 ). Also, in comparison to 9 other measures of depression, the PHQ had a positive predictive value of 7.1 versus 2.9, meaning that the PHQ had a higher chance of catching major depression ( Kroenke & Spritzer, 2002 ). It demonstrated good sensitivity (89.5%) and specificity (77.5%) at a recommended cutoff of 11 or above in adolescents, which was similar to adult studies ( Richardson et al., 2010 ). The PHQ was able to detect major and minor depression among geriatric primary care patients ( Lamers et al., 2008 ) and effective in ethnic and racially diverse patients ( Chung, Kroenke, Delucchi, & Spitzer, 2006 ).

   For those instances in which an adult is unable or unwilling to take a self-report instrument, the Hamilton Rating Scale for Depression (HAM-D; Hamilton, 1967) is an assessment instrument completed by the interviewer. It is normally used when the interviewer has some knowledge of the client's affective status and strong evidence of symptoms of depressive disorder. The HAM-D scale has been widely used in clinical trials and takes about 30 minutes by a trained interviewer to administer. The 21-item (but scoring is based on the first 17) and other versions (with more and less items) are available. Eight items are measured on a 5-point Likert scale (0 = not present to 4 = severe); the remaining nine are scored from 0–2 (0 = none/absent to 2 = severe). The HAM-D addresses the issues of depressed mood, suicide, anxiety, general somatic symptoms, and loss of interest in work and recreational pursuits. This difference in weighting reflects the author's belief that some symptoms carry more importance (e.g., depressed mood and suicidal ideation). To obtain a Total Score, items are summed with higher scores indicative of greater severity (anchor points from 0–7 = normal; 8–13 = mild; 14–18 = moderate; 19–22 = severe depression; and above 23 equates to very severe depression). Psychometrics for HAM-D-17 from various studies report an internal consistency of .83, inter-rater reliability range of .80–.98, and test–retest reliability of .81 ( Cusin, Yang, Yeung, & Fava, 2009 ). Although, the HAM-D is extensively utilized as a standard for measuring depression, it has some important liabilities from questions about inter-rater reliability, as is often the case when clinical judgment is involved, to failure to include all symptom domains, particularly reverse symptoms along with uneven weighting of symptoms ( Cusin et al., 2009 ;  Khullar & McIntyre, 2004 ;  Kobak, Lipsitz, & Feiger, 2003 ).

   When older adults are being assessed, the presentation of depressive symptoms may vary somewhat from those of other adults. The Geriatric Depression Scale (GDS;  Brink et al., 1982 ) is a well-known instrument designed to assess depressive symptoms in older adults. It is available in 30-item, 15-item, 10-item, 4-item, or 1-item versions. With the exception of the 1-item version of the GDS, all of the shorter versions are highly correlated with the original 30-item version ( D'Ath, Katona, Mullan, Evans, & Katona, 1994 ). The GDS has high internal consistency (.94 with 1-week test–retest score .85) and has been validated in a large number of studies with excellent concurrent validity. The scale has been found reliable and valid for depression screening across different age, gender, and ethnic populations and is in the public domain.

   The Clinical Global Impressions Scale–Bipolar Version (CGI–BP;  Spearing, Post, Leverich, Brandt, & Nolen, 1997 ) is a modification of The Clinical Global Impressions Scale (CGI;  Guy, 1976 ). This simple, clinician-rated tool is used to assess global illness severity and treatment response in individuals with bipolar disorders when self-reported scales may not be feasible. The original scale was revised to help quantify manic and depressive symptoms/episodes with severity scores ranging from 1 (normal/not ill) to 7 (most severely ill). The CGI–BP can measure illness phases (e.g., manic, depressive, and total illness) as well as evaluate treatment response in bipolar illness (both acute and long-term prevention). Changes were made to clarify definitions, time periods, and variables in an effort to standardize framework. However, limitations remain due to the instruments very design bias, and the author cautions about the need to gather additional information from self-report and symptom-driven scales as well as longitudinal measures ( Spearing et al., 1997 ).

Mania In order to assess manic symptoms in adults, two self-report instruments have been shown to have excellent reliability and validity. The Internal State Scale (ISS) ( Bauer, Crits-Cristoph, & Ball, 1991 ) is a 15-item instrument in which clients indicate the intensity of their mood by marking a line denoting the level of severity of symptoms. The scale has four subscales, including well-being, perceived conflict, depression, and activation. Mania is assessed by a well-being score equal to or higher than 125 and an activation score equal to or greater than 200. Each item is “biphasic.” For example, on the items indicating well-being, clients who mark the lower end of the line (scale) are assessed to have depressive symptoms, whereas clients who mark the upper end of the line are assessed to have manic symptoms.

   The Self-Report Manic Inventory (SRMI) ( Shugar, Schertzer, Toner, & Di Gasbarro, 1992 ) is a 47-item scale that includes statements that clients mark “true” or “false” depending on the presence or absence of symptoms during the prior month. The instrument has been validated as a screening tool for the severity of manic symptoms in adults. The scale has a maximum score of 47.

   The Mood Disorder Questionnaire (MDQ;  Hirschfeld, et al., 2000 ) is a brief, 15-item screening instrument for the occurrence or absence of bipolar disorder that takes under 10 minutes to complete. Each affirmative answer is assigned one point and all points are summed for a total score (from 0 to 13). For a positive screen the respondent needs to answer “yes” to 7 out of 13 items on question 1; “yes” to co-occurrence in question number 2; and “moderate” or higher on question 3 ( Hirschfeld et al., 2000 ). The MDQ was found to have a .73 (sensitivity) and .90 (specificity) in psychiatric outpatients ( Hirschfeld et al., 2000 ) and a sensitivity of .28 and a specificity of .97 in the general population (Das, Olfson, Gameroff, Pilowsky, & Blanco, 2005). In a study of primary care patients being treated for depression sensitivity/specificity was .58 and .93, respectively ( Hirschfeld, Cass, Holt, & Carlson, 2005 ). Furthermore, the MDQ was determined better at screening for bipolar I than for bipolar II due to question number 3 and how hypomania presents ( Kaye, 2005 ).

   Tuckman's Mood Thermometers (MT;  Tuckman, 1988 ) is an easy, 5-item tool designed for use with adolescents that measures affect on 5 dimensions: tension (panicky to tranquil), confusion (befuddled to certain—which is reversed measured), anger (vicious to loving), fatigue (exhausted to vigorous—which is reversed measured), and depression (depressed to ecstatic). Each item is rated from 0 (absence of symptoms) to 100 (extreme level of symptoms) to produce an index score or combined to produce two composite scores. MTs show good concurrent validity ( Corcoran & Fischer, 2013 ). In a small study of adolescents with a history of suicide attempts and depression, Carlson ( 2006 ) found the MT had good internal consistency (alpha .88) for each variable and (alpha .887) for an overall mood score. Reliability analysis via test–retest measures ranged from .50 to .64 (.57 average) suggesting that the variables measure “state” versus “trait” symptoms ( Carlson, 2006 , p. 88).

   For bipolar clients who are unable to complete a self-report instrument, the Young Mania Rating Scale (YMRS;  Young, Biggs, Ziegler, & Meyer, 1978 ) can be completed by a skilled practitioner. This scale is used to evaluate manic symptom severity and treatment response and takes approximately 30 minutes to complete. The scale contains 11 items measuring internal mood states and behaviors experienced by the client and reported to the practitioner. Each item is rated by severity on a scale with “0” equal to an absence of symptoms/ normalcy to “4 or 8” indicating extreme deviation. There are four items that are graded on a 0 to 8 scale (irritability, speech, content, and disruptive-aggressive behavior) and given greater weight, while the remaining seven items are graded on a 0 to 4 scale (elevated mood, increased motor activity-energy, sexual interest, sleep, language–thought disorder, appearance, and insight). Scores may range between 0 and 60 with higher scores indicating greater symptom severity and more psychopathology.

   YMRS has shown validity in the assessment of mania in adult inpatients and research demonstrates that it may be useful in assessing the severity of mania in adolescents. Young et al., ( 1978 ) reported good internal consistency (.80) and excellent inter-rater reliability (.93) and correlation with similar validated measures of mania. Other studies of adolescents (ages 5–17) and pediatric outpatients found good internal consistency (alpha from .80 and .91) ( Serrano, Ezpeleta, Alda, Matalí, & San, 2011 ;  Youngstrom, Danielson, Findling, Gracious, & Calabrese, 2002 ). The YMRS is a well-utilized assessment measure of bipolar disorders in adults and children. However, three items (dealing with sexual interest, appearance, and insight) showed low rates of endorsement in children and should be reevaluated for use in a juvenile measure ( Youngstrom et al., 2002 ).

Emergency Considerations

Assessing and managing suicide risk is one of the most important components of clinical practice, especially when treating individuals with bipolar and related disorders. Having a Bipolar and Related Disorder is a risk factor for both suicide attempts and the primary cause of premature death from suicide ( Gonda et al., 2012 ;  Kupfer, 2005 ). A large epidemiological study by Simon, Hunkeler, Fireman, Lee, & Savarino ( 2007 ) showed among individuals treated for bipolar disorders; 1 per 1,000 person-years die by suicide; 5.6 per 1,000 person-years attempt suicide leading to hospitalization and almost 14% attempt suicide not leading to hospitalization. These numbers were echoed in World Mental Health Survey Initiative, which showed that 1 in 4 individuals with BP-I and 1 in 5 individuals with BP-II have a history of suicide attempts ( Merikangas et al., 2011 ). Furthermore, when differentiating between individuals with bipolar II disorder and those with bipolar I disorder or unipolar depression the major clinical feature is the risk of suicide ( MacQueen & Young, 2001 ). For both adults and adolescents, having a bipolar disorder is a predictive factor for completed suicide, and early illness onset is a risk factor for suicidal behavior ( Borges, Angst, Nock, Ruscio & Kessler, 2008 ;  Goldstein et al., 2012 ).

   In some situations, people experiencing severe emotional distress may constitute a danger to themselves or others. Suicidal thinking is part of the diagnostic criteria for a major depressive episode. In some major depressive episodes, and in most manic episodes, some degree of psychosis is present. In these situations, practitioners must attend to issues about the client's safety and secure whatever level of supervision and treatment is necessary. A comprehensive suicide risk assessment will help identify the major risk factors for suicidal behavior. Suicidal and emotionally distressed individuals are often not reliable sources for self-report. This can impede risk assessment and heighten the need to seek information from others including family and friends. The risk of suicide attempts increases if the individual has a comorbid anxiety disorder and/ or substance abuse disorder, and the risk of suicide mortality increases if the client has a co-occurring anxiety disorder ( Simon et al., 2007 ). Risk management strategies must be ongoing and should include a crisis plan that involves emergency resources such as emergency departments, telephone crisis centers, and local inpatient/outpatient mental health services. Internet resources can be efficiently exploited.

Cultural Considerations

Cultural variations impact symptom expression and, therefore, they can affect the diagnostic process. Addressing cross-cultural and gender differences is paramount when treating individuals who suffer from bipolar disorder. Cultural attitudes also influence whether individuals will seek help and which treatment approaches may be most effective. Multiple studies have found that individuals from Hispanic and Asian backgrounds are more likely to report physical ailments and less likely to report emotional symptoms when suffering from mental illness. In many cultures, the stigma surrounding mental illness is very strong, and the pressure “not to shame the family” often leads to underreporting symptoms. Cultural sensitivity education and training for English-speaking practitioners are important aspects of competent mental health practice.

   In keeping with findings from the previous National Comorbity Survey (NCS) data from the National Comorbidity Survey Replication (NCS-R) showed that disadvantaged ethnic groups have a lower lifetime risk for psychiatric disorders. However, new data emerged revealing that this lower risk emerges at a very young age (typically before age 10), and although they have a lower lifetime risk, they are more likely to be persistently ill. The lower prevalence for non-Hispanic Blacks and Hispanics over non-Hispanic whites held true for all mood disorders (including depression) except for the lifetime prevalence of bipolar and related disorders (4.9%, 4.3%, and 3.2%, respectively) ( Breslau et al., 2006 ).

   Another caution relates to the tendency for minority group members to receive more serious or more stigmatized psychiatric labels. For example, there is some evidence that Caucasians are more likely to be diagnosed with Bipolar I Disorder, while minority clients with the same symptom presentation are diagnosed with schizophrenic disorders ( Neighbors, Trierweiler, Ford, & Muroff, 2003 ). Also, African Americans with bipolar disorder tend to present with more severe psychotic symptoms and be more likely prescribed antipsychotics (Kupfer, Frank, Grochocinski, Houck, & Brown, 2005; Strakowski, McElroy, Keck, & West, 1996). Many feel the symptom expression of bipolarity in African Americans may be misconstrued. For example, Gonzalez et al., ( 2010 ) uses the example of how a persecutory delusion might be assessed as motivated by anxiety rather than as a symptom of psychosis. A study of data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; 2001–2002) suggest that clinician biases rather than fundamental racial/ethnic differences in symptom presentation are responsible for the misdiagnosis of bipolar disorders (Perron, Fries, Kilbourne, Vaughn, & Bauer, 2010).

   Several studies report racial and ethnic differences in regards to access to care and service utilization, with African Americans and Hispanics receiving fewer psychiatric medications and fewer referrals for psychiatric treatment than for Whites. Additionally, when referred for care they had a higher rate of inpatient hospitalization versus outpatient services ( Gonzalez et al., 2010 ;  Harris, Edlund, & Larson, 2005 ;  Hatzenbuehler, Keyes, Narrow, Grant, & Hasin, 2008 ;  Nejtek, Kaiser, Vo, Hilburn, Lea, & Vishwanatha, 2011 ) especially for poor, inner-city clients with dual-diagnosis for mood and substance abuse disorders. Additionally, data showed that Blacks and Hispanics with co-occurring mood and substance abuse disorders were five times less likely to receive psychotropic medication than Whites, and less likely to receive psychiatric treatment services ( Nejtek et al., 2011 ). These findings underscore the need to address racial and ethnocentric bias during the diagnostic and treatment process.

   The prevalence of bipolar disorder is relatively equal by gender. However, studies show that the lifetime rates of BP-I and subthreshold BP are greater in males, while females had higher rates of BP-II ( Merikangas et al., 2011 ). Findings from the National Depressive and Manic-Depressive Association 2000 Survey show that females are more likely to be misdiagnosed with depression and males are more likely to be misdiagnosed with schizophrenia ( Hirschfeld et al., 2003 ). This may be due to the fact that female gender is a significant risk factor for being diagnosed with depression, even when scores on validated screening measures of depressive symptoms are similar to males ( WHO, 2002 ). However, recent studies have found no gender differences in the distribution of depressive episodes or time spent in depression, or in the rates of antidepressant use ( Baldassano et al., 2005 ;  Diflorio & Jones, 2010 ). However, some studies report that women were more likely than men to receive psychotropic medications ( Nejtek et al., 2011 ). Other differences exist in terms of suicidal behaviors; women have a higher rate of suicide attempts, but men have a higher rate of death by suicide ( Simon et al., 2007 ). Gender differences are also reported in comorbidity patterns, with women more likely to have cooccurring eating disorder and males more likely to have comorbid substance use disorder ( Suominen et al., 2009 ). In terms of substance-related disorder, more men report a lifetime history of alcohol abuse, but when compared to the lifetime risk for alcoholism in the general population, women with bipolar disorder have a greater risk for alcoholism (Frye et al., 2003). Furthermore, using data from the NESARC (2001–2002) Goldstein & Levitt ( 2008 ) determined that approximately 30% of individuals of both genders with bipolar disorder have a lifetime comorbid anxiety disorder (which is associated with poorer treatment response and increased global illness severity, functional impairment, and suicidality), and comorbid substance use disorder (which is associated with delayed recovery, relapse, symptom burden, and increased disability), and that early identification and treatment of these comorbid conditions may help ease illness severity and the burden of bipolar disorder. Finally, one of the most pronounced gender differences between men and women with bipolar disorder seems to be the effect that childbirth appears to have on triggering postpartum bipolar episodes in women ( Diflorio & Jones, 2010 ).

   Gender differences in mental health utilization and symptom reporting as well as gender roles and stereotypes can affect accurate diagnosis and treatment of psychological disorders. Conformity to traditional gender roles for men, which emphasize emotional fortitude and self-reliance, may negatively impact the expression of symptoms, need for support, and willingness to seek help. Women are socialized to be more emotionally expressive and are more likely to disclose symptoms and seek help. Gender sensitivity training and strategies aimed at decreasing biases and barriers to help seeking have important diagnostic and therapeutic implications. Treatment adherence can have a positive effect for individuals with bipolar disorder. Kriegshauser et al., ( 2010 ) examined gender differences in this domain and reported that for women, fear over medication related weight gain has a negative effect, as did alcohol abuse as a form of self-medication for men. No gender differences were found in terms of the experience of stigma, drug abuse as a form of self-medication, or for the desire to decrease irritability/impulsivity. Both genders valued social supports, but women ranked more meaningful relationships higher suggesting that it could be employed as a positive factor more readily. Authors propose involving family and close friends in treatment strategies for women, whereas men could possibly benefit from support groups especially those aimed at substance use. These gender differences could be used as motivating factors with clients and used to inform clinical practice.

Social Support Systems

Bipolar and related disorders are serious, recurring, chronic illnesses that can overwhelm support resources and cause impairment in social, occupational, or other areas of functioning. Recent studies have found that social impairments in individuals with bipolar and related disorders were similar in type and severity to those seen in individuals with schizophrenia ( Dickerson, Sommerville, Origoni, Ringel, & Parente, 2001 ). Providing support for an individual with a chronic illness is inherently stressful. Conflicts between family, friends, and the person with the disorder can arise due to disruptive thoughts and behaviors and extreme mood swings on the part of the symptomatic individual. Caregiver burden is high and largely neglected in bipolar disorder (Ogilvie, Morant, & Goodwin, 2005). Research attests to the low rates of treatment in important areas of personal functioning. The assessment of social functioning is a significant criteria feature of the Diagnostic and Statistical Manual ( APA, 2013 ). The goals for treatment must be more than compliance for many bipolar patients. Providing clients and caregivers with realistic expectations and practical advice on illness management along with sources of support, such as peer and psychoeducational support groups, can help mitigate the impact of the illness. Caregivers should be encouraged to meet with others to share coping strategies. Joining a group can be hard for individuals experiencing symptoms of the disease. Treatment strategies for individuals with bipolar disorder must consider the stigma associated with the disease, the impact of symptoms on social functioning, and the risk of not maintaining positive social networks, which is high in this population. Some Internet resources for support, education, and advocacy are listed below.

·   www.nami.org : Web site of the National Alliance on Mental Illness, a grassroots advocacy group, with clear and basic information on full array of mental disorders, support, and awareness.

·   www.mentalhealthamerica.net : Mental Health America's advocacy Web site addressing the full spectrum of mental and substance use conditions including information on cultural, gender, and ethno-specific issues.

·   www.dbsalliance.org : Largest national education and advocacy group on Mood Disorders.

·   www.isbd.org : Clinical education and research resource from The International Society for Bipolar Disorders.

   Suicide and Emotional Crisis Hotlines 1-800-SUICIDE (1-800-784-2433) 1-800-723-TALK (1-800-723-8255)

Differential Diagnosis

Bipolar and related disorders are complex illnesses and this carries over to differential diagnosis separation. The most common challenge in making diagnoses among bipolar disorders relates to the rule-out criteria included in nearly all of the disorders in this chapter. Specifically, clinicians are expected to ensure that the symptoms are not generated through the direct physiological effects of a substance (e.g., recreational drugs, prescription drugs, toxins) or by a general medical condition. As the research bears out, these disorders go primarily underdiagnosed due to misdiagnosis, often as major depressive disorder (MDD). Other disorders involved in differential diagnosis include: other psychotic disorders, such as schizophrenia or schizoaffective disorder; anxiety disorders; conduct disorders; and Attention Deficit/Hyperactivity Disorder, especially in children. Just as giving an antidepressant without a mood stabilizer (primary treatment for unipolar depression) may destabilize someone with bipolar disorder; giving a stimulant (primary treatment for ADHD) can lead to mood destabilization in children with bipolar and related disorders. Often children suffering with bipolar related symptoms fell short of meeting criteria, which is one of the reasons given for the use of the “Other Specified Bipolar and Related Disorder” category.

   There is, however, a strong tendency among clinicians to assume non-physiological etiology as evidenced by the case examples in this chapter. Only in Case 4.1, Helen Stonewall, were physiological considerations made, and these efforts were clearly not generated by the mental health practitioner.

· 4.DD–1 Choose one case from among Cases 4.2, 4.3, and 4.4. List four questions you would ask to help rule out physiological causes.

 

   Inherent in making bipolar and related disorder diagnoses is differentiating the intensity and length of symptoms. For example, the symptoms for cyclothymic disorder are similar but not as intense or as debilitating as those for a bipolar 1 disorder. Also, the distinction between hypomanic and manic episodes is simply that in Hypomania, the intensity of mood disturbance is not sufficient to cause serious psychosocial impairment and/or result in hospitalization. Similarly, a set of symptoms that has not lasted for the requisite time period to meet criteria may well result in an unspecified bipolar diagnosis (at least until the time frame is reached).

Case 4.1

Identifying Information

Client Name: Helen Stonewall

Age: 32 years old

Ethnicity: African American

Marital Status: Married

Children: Sonya, age 5

Background Information

You are a caseworker in the emergency room of a large urban hospital. You work the day shift from 8 a.m. to 5 p.m. Several hours before you came to work, the police brought the client to the emergency room in restraints. The following information was gathered from the police at intake.

Intake Information

The police state that Helen Stonewall, a 32-yearold African-American woman, was found dancing half naked in the middle of a busy intersection in the center of the city at approximately 2 a.m. She appeared to be high on drugs when the police approached her. She told the police that she hadn't taken any drugs and that she was “just high on life.” She said she wasn't doing anything wrong, just “having a party.” Witnesses stated that Helen had started the evening at a local restaurant and bar. She had been with a couple of gentlemen who seemed to know her. She began telling jokes and buying everyone at the bar drinks.

   At first, she seemed like a person just having fun, but she kept getting louder and more rowdy as the night progressed. The two men left, but she stayed at the restaurant telling them loudly, “I'm just getting warmed up here.” She sang and danced and finally ended up shoving all the glasses onto the floor and standing on the bar talking as fast as she could. Customers got irritated, and the bartender asked her to leave. She ignored his request and started singing at the top of her lungs. Finally, the bartender had to force her off the bar and push her out the door. At that point, she began dancing and singing in the street. The bartender told police that she had no more than two drinks throughout the evening. When the police attempted to get Helen out of the road, she became belligerent and began swearing at the officers. They had to take her out of the middle of the intersection by force and handcuff her to get her into the police car.

   Lab tests indicated no evidence of excessive alcohol or other drugs. The physician on duty had prescribed a sedative, and Helen went to sleep at approximately 5 A.M.

· 4.1–1 Based on the intake information alone, which psychiatric disorders seem most likely? What type(s) of information will you be interested in during the initial interview to help you narrow down the choices of diagnoses?

 

Initial Interview

You go to see Helen at 9:30 a.m. She is lying in bed quietly staring at the ceiling. She seems very subdued in comparison to the description of the previous night. Helen glances at you as you enter the room but makes no attempt to sit up. You tell her who you are and your reasons for wanting to talk to her. Helen makes no response to your introduction. You ask Helen if she has any relatives you could call for her. Helen looks over at you and says, “I just want to die. If it weren't for my baby, I'd've been dead a long time ago.”

   “What's your baby's name?” you ask.

   “Sonya,” Helen replies. “I'm such a lousy mother lying here like this. I should be home taking care of her.”

   “Where is Sonya now?” you ask.

   “She's with my sister. She stayed with my sister last night,” Helen responds. “I knew I was racing so I took her over to my sister's house.”

   “You were racing?” you query.

   “Yeah, you know, I start racing sometimes, feeling real good and full of energy like nothing can stop me,” Helen says. “But not now; I feel lousy now, like I just want to be left alone to die.”

   “Can you tell me what happened last night?” you ask.

   “It's like living on a roller coaster,” Helen tells you. “One minute you're way up there, and the next minute you're in the blackest hole you can imagine.”

   “And last night, you were way up there?” you query.

   “Yeah, I was just feeling good and having a good time. It's like you're racing and you can't slow down. Like you're high or something, but I didn't take any drugs. I don't do drugs. This just comes over me sometimes, and I feel like I could take on the world.”

   “Have you ever felt this way before?” you ask.

   “Oh yeah, up and down, that's how I am,” Helen says.

   “So, sometimes you feel really good and up, and then, sometimes you feel really down. Is that right?” you ask.

   “Yeah, I'm scared I'm beginning to crash now. It's bad when you come down. It feels real bad,” Helen says. “It lasts for weeks and weeks . . . just down all the time.”

   “How often does this happen, going from one extreme to another?” you ask. “Once a day or once a week or once a month?”

   “See, for a few weeks I feel great. I can do anything—stay up all night having a good time. I don't sleep or eat or slow down. I just keep on going for a week, maybe two. Then, I begin to crash.”

   “Do you hear voices or see things when you're feeling high?” you ask.

   “No, except for my own voice. I can't stop talking either. Gets me into trouble, sometimes,” Helen admits.

   “What else happens when you're feeling high?” you ask.

   “I want to party. I can party all night when I'm high. I'm the life of the party,” Helen says glumly.

   “Have you ever gotten in trouble before, like you did last night?” you ask.

   “Oh yeah,” Helen agrees. “I've gotten thrown out of places lots of times, but I usually just move on down the street.”

   “Are you employed?” you ask Helen.

   “I've tried to keep a job. Just can't seem to stick with it,” Helen replies.

   “How are you feeling right now?” you query.

   “Feel like hell,” Helen tells you. “This is a rotten way to live, I'm telling you.”

   “How long does the crashing last?” you ask Helen.

   “Sometimes a few days, sometimes a few weeks,” Helen says bleakly.

   “Describe for me what these down times are like for you,” you ask.

   “It's like I'm a balloon and someone stuck a needle in me. I'm so sad that nothing looks good. It's hard to get out of bed and face the world . . . I sleep and sleep and sleep. When I do get up, I'm so tired that it feels like I'm carrying around invisible weights.”

   “What kinds of things go through your mind when you feel like this?”

   “I can't think of anything I want to do,” Helen tells you. “I can't seem to make myself think anything all the way through. Like making a decision about something no matter how trivial is just impossible. Sometimes, I just wish I were dead.”

   “Are you wishing you would die now?” you ask.

   “Not yet . . . but it usually does get to that point when I crash.”

   “Have you ever seen a doctor for these changes in your mood?” you ask.

   “One doctor told me it was just a female thing,” Helen states.

   “Maybe it's more than a female thing,” you suggest. “Maybe there's some medication that could help even out your moods. Would you be willing to talk to a doctor about how you've been feeling?” you ask.

   “Okay. I guess it wouldn't hurt,” Helen says.

· 4.1–2 To what extent do you think Helen may be a danger to herself? What other information would be useful in determining her risk?

 

· 4.1–3 What would you like to know about Helen's social support system? Are there any steps you would take (given the client's permission) to assure that her support system stays intact?

 

· 4.1–4 What internal and external strengths do you see in Helen's case?

 

· 4.1–5 What is your primary diagnosis?

 

· 4.1–6 What specifiers would you include with your diagnosis?

 

· 4.1–7 What psychosocial and cultural factors could impact your diagnosis?

 

Case 4.2

Identifying Information

Client Name: Connie Kellogg

Age: 36 years old

Ethnicity: Caucasian

Marital Status: Married

Occupation: Homemaker

Children: Three children; currently pregnant with her fourth child

Intake Information

Little information was obtained from a phone call interview with Mrs. Kellogg by the intake worker. She stated that her psychiatrist in Massachusetts had referred her to Dr. Browning in Southfork, Oklahoma, for prescription monitoring. Dr. Browning has referred her to the Southfork Counseling Center to see a therapist. She requested an appointment with a therapist and said only that she had been hospitalized recently in Massachusetts before moving with her husband and children to Oklahoma. She stated that it was very important that she begin therapy immediately but did not want to discuss any details of the problems she has been experiencing lately. The intake worker scheduled her for the first available appointment with you later in the week.

Initial Interview

Connie Kellogg is an attractive, 36-year-old woman whose warm and effervescent personality is apparent from the first meeting. You notice that Connie is several months pregnant. Connie appears eager to get to your office and asks you how long you have lived in Southfork. You explain to her that you moved to Southfork after completing your master's degree 2 years ago.

   “When did you move to Southfork?” you ask. Connie wriggles in her chair and enthusiastically begins talking about her husband being relocated to Oklahoma to accept a new position with his company, which develops software for computer companies. She states that she's never lived in the Midwest, having grown up in Boston. She moved to another town in Massachusetts when she got married 10 years ago.

   “We've been in Southfork for 3 months, and I feel like a fish out of water,” Connie tells you. “I've got most of the responsibility for taking care of my three children and as you can see, I'm about to have another one. Bob, my husband, travels 3 or 4 days a week with his job, so I'm stuck at home with my children most of the time . . . not that I'm complaining. Bob has a good job and he has to travel, but it's a lot of work for me, and I haven't made a lot of friends yet. When I lived in Revere, Massachusetts, I had a lot of neighbors who were young mothers like me with kids, and we'd get together and babysit for each other and take our children to different activities. It was nice until I got sick.”

   “What happened when you got sick?” you ask Connie.

   “Well, I've always been a pretty optimistic, upbeat type person with a lot of energy. Then, suddenly, I had no energy. I was drained. I was so tired I couldn't move and just got completely depressed. I was suicidal and felt hopeless about everything. I thought here I am with three little children and I can't get off the couch to take care of them. I felt like a complete failure as a mother, just completely worthless. I didn't want to do anything except sleep and block out the entire world. I wasn't interested in sex with my husband. I didn't care if I lived or died. It just got so bad that the psychiatrist I was seeing put me in the hospital.” Connie slinks down in her chair and sighs deeply.

   She takes a deep breath and then begins talking again. “Everything just looked so black. I couldn't imagine feeling any worse . . . and my poor kids. All I could think about was that I would die and they would be motherless. And then I began to feel better. I mean like overnight I felt a whole lot better. I had plenty of energy, and thoughts and ideas just flew through my head and I was on top of the world again. I told the doctor I was just fine and he should let me go home.”

   “How long had you been in the hospital when you began feeling so much better?” you inquire.

   “About 4 weeks,” Connie sighs. “Then I was okay—or so I thought.”

   “So initially, you were really depressed when you went into the hospital, and then you began to feel much better. Were you taking any medication?” you ask.

   “Well, that's the really scary part about this problem I have. You see, the feeling of being on top of the world didn't last very long. Pretty soon, I was in the depths of despair again, and the medicine I was on wasn't working. So, the doctor said I really needed to be on Lithium. I didn't want to take anything because by then, I knew I was pregnant again. But I was so depressed I didn't know what else to do. I'm so worried about the medicine affecting the baby. The doctor has put me on a low dosage until the baby is born. I'm just keeping my fingers crossed the baby will be okay. Do you think that makes me a bad mother?”

   “It sounds as if the psychiatrist thinks you really need to be taking Lithium right now,” you respond. “You're trying to take care of yourself.”

   “He told me it was absolutely necessary if I wanted to stay out of the hospital,” Connie replies. “I never want to go through that experience again. And I'm not sure it's really helping. I have to go get my blood tested every 2 weeks, and I'm not sure I've got enough of the medication in me to do me any good. I have days when I feel like I can function pretty well, and then there are other days when I feel like I'm sliding into a black hole and can't get out of it. It's an awful feeling.”

· 4.2–1 At this point in the interview, what diagnoses are you considering? What information do you feel you need to complete your initial assessment?

 

   “These feelings of depression just started about a year ago? Is that correct?” you inquire.

   “Yes, I never felt down in the dumps and completely hopeless like I have this year. You know, I remember as a child, my father would have periods of deep depression. He was like Dr. Jekyll and Mr. Hyde. Some days he'd be great to be around and he'd play with us and laugh. Other times, he was really scary. He'd sit in a dark room and stare out the window for hours, and if any of us kids did anything that perturbed him, he'd get so angry that he'd take us behind the house and give us all a whipping with his belt. You could never tell what kind of mood he'd be in. I was scared of him my whole childhood. I sure hope I'm not turning into someone like him.”

   “Did your father ever see a doctor about his moods?” you ask.

   “No, he thinks only crazy people see psychiatrists. I told Bob not to tell my parents I was in the hospital. They would have disowned me. They are strict, conservative Catholics, and believe me, they wouldn't ever understand. They'd tell me I'd be okay if I went to confession.”

   It seems to you that Connie identifies with her father's mood swings to some degree, and you decide to get more information about Connie's family of origin at this time. “Tell me what it was like for you growing up in Boston,” you say.

   Connie sits back in her chair and looks out the window. “Well, it was your typical Catholic family growing up in the sixties and seventies, I guess. I have five siblings—two older brothers, an older sister, and two younger sisters. My parents were strict and fairly religious. We went to confession on Saturdays and Mass on Sundays every week without fail. My mother cared for us while my father worked. We were a middle-class family, I guess. We never had a lot of money, but we weren't starving to death either. My parents sent us all to a Catholic school that cost more than public school but wasn't like a private school. I think I bought into all the Catholic guilt thing and have a real problem with feeling guilty about everything. My father reinforced that feeling of guilt all the time. He was very distant and authoritarian. We got punished a lot as children, and although I don't think I really thought so at the time, it was pretty harsh punishment by today's standards. And it seemed like I was always in the way when my father got mad, and I got punished more than my sisters and brothers.”

   “How do you feel about that time growing up?” you inquire.

   “I guess I consider it a pretty normal childhood,” Connie suggests. “All the kids in the Catholic school I attended grew up much the same way as I did. I think my mother saved us all from my father's wrath on many occasions. She had a way of diverting his attention away from us when we were in the line of fire.”

   “And what is your relationship like now, with your parents?” you ask.

   “Since I've been in the hospital, I've discovered I have all this anger toward my father,” Connie states. “I've been scared of him my whole life, and I'm tired of feeling that way and I hate how he made me feel. I've never really had any self-esteem and have always felt like I'm cowering in the corner afraid of my own shadow because of what he did to me.”

   “And your mother? How do you get along with her?” you ask.

   “We get along well. We always have. I think we have a lot in common and she's had to put up with a lot, too,” Connie says with a smile.

· 4.2–2 Discuss how much support Connie is likely to receive from her family of origin. Preliminarily, do you have any thoughts about how that support could be maximized?

 

   “Do you feel that the way you were raised has something to do with the depression you've been experiencing, or do you think it's unrelated to your childhood experiences?” you ask.

   “I don't really know,” Connie states. “It's something I want to figure out. The doctor told me some of this could be a neurochemical problem. Sometimes, I feel great and full of energy. In fact, it's hard to slow down. I become really talkative and friendly. It's like everything speeds up. Thoughts run through my head really fast, and I can't even sleep when I feel that good. It's like being high.”

   “How often does that happen?” you ask.

   “It seems to happen about once a month after I've been really depressed,” Connie states. “But it doesn't last as long as the depressed periods.”

   “Do you ever feel that you place yourself in highrisk or dangerous situations when you have a ‘high’ feeling?” you query.

   “No, I don't think so,” Connie reflects. “I have some pretty fantastic thoughts, but I don't actually do anything. I've got to think about my children and the one on the way.”

   “Okay, so you feel depressed a lot of the time, and sometimes, about once a month, you feel pretty good and full of energy. How long do you usually have that ‘high’ feeling?” you ask.

   “It can last from 3 or 4 days up to a week before I begin sliding downward again,” says Connie. “I always hope it will last longer, but it never does.”

   “So, it sounds like one of your goals is to learn how to cope with some of these ups and downs you've been experiencing?” you ask.

   Connie says enthusiastically, “Yes, exactly, I need some help with the best way of coping with these moods, especially during this pregnancy.”

   “Would it be all right with you if I talked to the psychiatrist who is prescribing the medication for you?” you inquire. “I'll need you to sign a consent form.”

   “Absolutely. I'll give you his phone number,” Connie asserts.

   “And would you like to make an appointment on a weekly basis?” you ask.

   Connie nods her head vigorously and says, “I'm so glad I've found someone I can talk to who doesn't look at me as if I'm crazy. I definitely want to come once a week to talk to you.”

   “Okay. We'll schedule an appointment for next week,” you reply.

   Connie leaves your office with a little bounce in her step and talks about going to shop for the new baby as you walk her to the reception area.

· 4.2–3 From this preliminary interview, it would seem that Connie may not have much social support in Southfork. How would you go about exploring that issue? How important do you think securing local support would be?

 

· 4.2–4 What is your primary diagnosis?

 

· 4.2–5 What specifiers would you include with your diagnosis?

 

· 4.2–6 What psychosocial and cultural factors could impact your diagnosis?

 

Case 4.3

Identifying Information

Client Name: Gloria Suarez

Age: 31 years old

Ethnicity: Hispanic

Educational Level: High school diploma

Marital Status: Divorced

Children: Jose, age 4; Aubriana, age 2

Intake Information

Gloria Suarez is a 31-year-old single mother who contacted the Gulf Coast Counseling Center concerning therapy for herself. She told the intake worker that she was feeling very down and exhausted and needed to see someone soon. The intake worker scheduled an appointment for her with you, her counselor, in 2 days. Gloria arrived on time for her appointment with you.

Intake Interview

Gloria presents as a quiet, young woman who smiles shyly and shakes hands with you in the waiting room. She says that she doesn't really know why she came today except that she's been so tired recently. Gloria indicates that she works as a cashier for Ding Dong Discount and has been separated for the past 3 years because she can't afford a divorce. She feels that since her separation her life has been spinning out of control.

   A year ago, her older sister died of hepatitis after a long battle with drugs and alcohol. Gloria describes her as a sweet but completely crazy sister. She hasn't had any contact with her parents since she left home at 18 years old. She states that her father was also an abusive alcoholic and her mother never protected Gloria or her sister from the abuse.

   When you ask her about her mood, she tells you it's generally been “blue.” “I seem to be exhausted all the time. Between trying to take care of my kids and working shifts at Ding Dong, I barely know whether its night or day.

   Do you ever have times when you feel okay or more like you did before the separation?” you ask.

   Gloria sighs deeply and says, “Actually, yes, every once in a while I have times when I have a lot more energy, but I also get extremely irritable. I scream at my kids and feel very frustrated with my job, but I'm not so tired and down in the dumps. I even go out dancing and enjoy hanging out with my friends.”

   “How often do you feel that way over a period of a year?” you ask.

   “Like I said, it's every once in a while. Most of the time I'm exhausted. I'd say maybe 2 or 3 times a year.”

   “How long has this feeling of exhaustion been going on this time?” you query.

   “Probably for the past 3 months,” Gloria responds.

   “I begin to feel real hopeless about my life and feel like I have nothing to look forward to.”

   “Do you ever think about suicide?” you question carefully.

   “To be perfectly honest, I have thought about just taking a bunch of pills and going to sleep forever, but my kids keep me from doing it.”

   “Have you seen a doctor and gotten a physical exam recently?” you ask.

   “I took my kids for shots before school started but I don't have much money,” she responds as she stares out the window.

   “Have you been feeling suicidal recently?” you ask.

   “No, it's been quite a while since I've been that down but I try not to think about it. I know my kids need me and that's what keeps me going.”

   “What about your appetite?” you ask.

   “I don't feel like eating when I get so down but when I'm feeling better, I make up for it,” she says with a smile.

   “And how well have you been sleeping?” you ask.

   Gloria seems to relax a bit and says, “I could sleep all the time if I didn't have to work and get up with my children.”

   “It sounds like you've been coping with all these emotional ups and downs for quite a while. Tell me about how you've handled all of this. It sounds like a whole lot to deal with as a single parent.”

   “Well, I'll tell you one thing for sure. After my sister died, I wouldn't touch drugs, and alcohol just reminds me of my dad and how abusive he was.”

   “You know, you've told me a lot about yourself today and it sounds like you could really use someone to talk to further about how to begin feeling better. But, first, I'd really like you to see a doctor for a complete physical and I know someone you could see for a very low cost. Would you be willing to start by going to the doctor?” you ask.

   “You're probably right. It's been a long time since I've had a physical,” Gloria responds. “But I'd like to see you again, too.”

   “Absolutely, we will schedule another appointment for next week and I will give you a card so you can call the doctor's office and make an appointment with her.”

   Gloria looks relieved and says, “I'm glad I came in today. I almost skipped it.”

   “I'm really glad you came today, too,” you respond. “I think I can help you with some of these challenges you've been dealing with on your own. There's times when we all need some extra help.”

· 4.3–1 What are some of Gloria's strengths?

 

· 4.3–2 What diagnoses would you want to rule out in this case?

 

· 4.3–3 What resources might be valuable to utilize in this case?

 

· 4.3–4 Do you think Gloria should be referred to other professionals for further evaluation? If so, to whom would you make a referral?

 

· 4.3–5 What is your primary diagnosis for Gloria Suarez?

 

· 4.3–6 What psychosocial and cultural factors could be impacting Gloria?

 

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5 Depressive Disorders

Disorders

The diagnoses in the Depressive Disorders section of the DSM-5 ( APA, 2013 ) are characterized by changes in a person's emotional state (e.g., sadness, irritability) that coincide with somatic symptoms (e.g., aches, insomnia) and cognitive disturbances (e.g., negative thinking, poor concentrating) that are sufficiently severe to cause significant clinical distress and/or disruption in psychosocial functioning. This category contains diagnoses that were previously listed in the DSM-IV-TR ( APA, 2000 ) under the Mood Disorders Category and later divided into two groups “Depressive Disorders” and “Bipolar Disorders” due to differences in etiology and treatment approaches. Depression like mania is a mood disorder that can influence and disrupt an individual's normal functioning. The term mood refers to an internally experienced emotional state that influences an individual's thinking and behavior. A related term, affect, refers more specifically to the external demonstration of one's mood or emotions. This distinction is important because affect and mood may differ; that is, people do not always display accurately in their affect what their mood actually is.

   This section of the DSM-5 is organized around eight Depressive Disorders, some of the most prevalent and often chronic but also treatable mental health conditions. Research has led to an understanding that the chronicity of depression as well as severity can cause serious impairment and this change is reflected in the DSM-5.

   Other more controversial changes include the elimination of the “bereavement exclusion” for major depressive episodes in recognition that often grief and depression co-occur with a detailed note to aid differentiation. This change acknowledges that typical bereavement often has a much longer duration than the previous two-month duration. In addition, new dimensional cross-cutting symptom measures can be found in Section III of the DSM-5 ( APA, 2013 , pp. 733–744) and online at ( http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures ). The Depressive Disorder section in the DSM-5 includes a comparatively large number of specifiers. The inclusion of descriptive (e.g., with melancholic features), severity (e.g., mild), and course (e.g., in partial remission) specifiers is testimony to the variety that is evident in depressive disorders and to the desire to bolster clinical utility. For example the new “with anxious distress” descriptive specifier is used when anxiety is present during a major depressive episode, and “with mixed features” for use when manic/ hypomanic symptoms co-occur. Although a listing of the relevant specifiers is included in each disorder's diagnostic criteria, it can be confusing to try to determine which apply. Therefore, practitioners are encouraged to familiarize themselves with detailed descriptions provided for each disorder. For a complete listing see the DSM-5 ( APA, 2013 , pp. 184–188).

   The most serious disorders in this chapter include Disruptive Mood Dysregulation Disorder (DMDD), Major Depressive Disorder (MDD), both single episode and recurrent, and Persistent Depressive Disorder (Dysthymia). In the coding of each disorder, attention is given to the severity of symptoms, the frequency of temper outbursts (in the case of DMDD), and the length and timing of depressive episodes (in the case of MDD and Dysthymia). The newly introduced “Disruptive Mood Dysregulation Disorder (DMDD)” was added to help differentiate unrelenting irritability and frequent severe emotional/behavioral outbursts from the symptoms of childhood bipolar disorder in order to help reduce misdiagnosis. Children with this disorder often develop depressive or anxiety disorders as they grow ( APA, 2013 ). It is diagnosed before 10 years of age with the stipulation that the child must be developmentally at least 6 years of age, and validated in children from ages 7 to 18. These outbursts must occur 3 or more times per week for over a year and be grossly disproportionate in terms of magnitude/duration to the circumstances, coincide with anger/irritability that is present for the majority of most days, with both symptoms observed in at least two out of three settings such as living, academic, and social ( APA, 2013 ). For a listing of differential diagnoses and other criteria see the DSM-5 ( APA, 2013 , p. 156).

   The hallmark illness of depression is Major Depressive Disorder. Few changes were made to this diagnosis outside of bereavement as discussed earlier. Detailed directions are provided to help distinguish grief from this disorder (see  APA, 2013 , p. 161). For diagnosis, five or more symptoms (one of which is either depressed mood or anhedonia) must occur for 2 weeks and signify a departure from preceding functioning. Of note, in children depressed mood is often demonstrated by irritability. The symptoms must result in significant clinical distress impairing personal, vocational, or other areas of functioning. Also, the disorder cannot result from the biological effects of a substance or another medical problem ( APA, 2013 ). Coding follows from whether singular or recurrent episode and includes the descriptive/features, severity, and course status specifiers (for guidelines see  APA, 2013 , p. 162). By recurrent, “there must be an interval of at least 2 consecutive months between separate episodes in which criteria are not met for a major depressive disorder” ( APA, 2013 , p. 162).

   Dysthymic Disorder (DSM-IV-TR) was merged with Chronic Major Depressive Disorder to create a new diagnosis called Persistent Depressive Disorder ( APA, 2013 ). Research has shown that in terms of personal burden this condition can be as disabling as major depression. By definition, this is a chronic condition requiring both a continuous depressed mood and the presence of 2 or more out of 6 criteria symptoms (e.g., hypersomnia, poor concentration). Given the habitual nature and often inward expression of these symptoms, especially in early-onset cases, clinicians may need to inquire directly about the presence of criteria symptoms. Both criteria must present for a period of 2 or more years (1 year in children), with a period of no more than 2 months where these criteria are not met ( APA, 2013 ). The impairment must be clinically significant and disrupt functioning in social, employment, or other consequential realms. With this edition, major depressive disorder may also be present for 2 years with this diagnosis but it is coded via specifiers (for a listing see  APA, 2013 , p. 169). Criteria exclusions include no manic/hypomanic episodes, the impairment cannot be better explained by cyclothymic or schizophrenia spectrum or other psychotic disorder or attributable to the effects of a substance or another medical condition ( APA, 2013 ).

   Premenstrual Dysphoric Disorder is a now a diagnosis moving from the appendix section for further study in the DSM-IV-TR ( APA, 2000 ). This disorder's predominant features include psychological symptoms like mood shifts and irritability along with physical symptoms (tender breasts) in relation to the timing of menses. Diagnostic criteria require that for most menstrual cycles within a consecutive 12-month period, at least five symptoms must present in the week before the occurrence of menstruation, show betterment within days of onset, and remit within a week post onset. Of the five symptoms, at least one must be from Criterion A including: rapid changes in mood and their expression (e.g., tears, sensitivity to rejection), irritability and or anger, depressed mood and anxiety, and at least one from Criterion B including: decreased interest, lack of energy, difficulty thinking, changes in appetite, feeling out of control or overwhelmed, insomnia/hypersomnia, and physical symptoms. Again, symptoms must cause clinically significant distress, not just the normal fluctuations in emotional and physical symptoms due to menses experienced by most women. Although this disorder may arise with another depressive and/or mental disorder, the symptoms cannot be just a worsening of symptoms from another disorder. Also, diagnosis requires that the symptoms are not the result of a substance (of abuse or medication) and are not due to another mental or medical disorder ( APA, 2013 ).

   Two of the diagnoses in this section are determined by the etiological factors relevant to the depressive disorder. First of all, Substance/Medication-Induced Depressive Disorder is used when the problematic depressed mood is directly related to the use of a substance such as a commonly abused drug, prescribed medication, or a toxin (e.g., lead, carbon monoxide). Similarly, Depressive Disorder Due to Another Medical Condition is utilized when the depressed mood is understood to be directly connected to the effects of another medical condition ( APA, 2013 ).

   Finally, two categories are used in the event of diagnostic uncertainty. First, Other Specified Depressive Disorder category is used when symptoms associated with a depressed mood resulting in significant impairment and distress do not meet the full diagnostic criteria for any disorder in this chapter. This category is used to convey the explicit explanation for why the presentation fails to meet criteria, which is identified in the diagnosis. For example, if symptoms last for more than 4 days but less than the required 14 days, “short-duration depressive episode” would be used. Other example applications are included in the DSM-5 ( APA, 2013 , p. 183). Finally, Unspecified Depressive Disorder is similar to the prior diagnosis in that it too has symptoms that do not quite fit the diagnostic criteria requirements, but in this case, the clinician lacks information to be able to specify the reason, typically in emergency care settings ( APA, 2013 ).

Assessment

When assessing someone who you suspect may have a depressive disorder, particular attention will be focused on the person's emotional functioning. Although a thorough history of the presenting problem is required to make a diagnosis of a depressive disorder, it may be difficult for the client to present detailed and accurate information. People who are severely depressed can be virtually mute, or those experiencing mixed mood states may be unable to express themselves coherently. Someone with a history of psychiatric treatment may fear rehospitalization and deliberately minimize symptoms. Consequently, it is often helpful to gather data from collateral sources, such as close friends or relatives, employers, or other professionals, to specify both the timing and severity of symptoms.

Assessment Instruments

Anger One of the key symptom criteria for DMDD is severe irritability/angry mood. The State-Trait Anger Expression Inventory-2 for Children and Adolescents (STAXI-2 CA;  Brunner & Spielberger, 2009 ) is a developmentally sensitive self-report measure to assess both state and trait anger with scales for expression and anger control in children aged 9 to 18 years (with the Spanish version validated on children aged 7–17 years). This 35-item measure (in its second edition) is based on the longer adult version of the State-Trait Anger Expression Inventory (STAXI,  Spielberger, 1988 ; STAXI-2;  Spielberger, 1999 ) rated on a 3-point Likert scale from 1 (not at all/hardly ever) to 3 (very much/often). The STAXI-2 CA takes under 15 minutes to administer/score and includes 5 scales: Trait Anger, Anger Expression-Out, Anger Expression-In, State Anger, Anger Control, and 4 subscales (e.g., state anger feelings, trait angry temperament). A Spanish version is available with strong psychometrics ( del Barrio, Aluja, & Spielberger, 2004 ). Numerous studies have validated this instrument ( Brunner & Spielberger, 2009 ), and Gambetti and Giusberti ( 2009 ) have reported good-to-excellent construct validity.

   For adults, the State-Trait Anger Scale (STAS;  Spielberger, Jacobs, Russell, & Crane, 1983 ) can be used to evaluate feelings of anger both as a “state” (e.g., an individual's experience of anger in the immediate present), which tends to be subjective and varies in intensity, and as a personality “trait” (e.g., the individual's tendency or frequency to feel anger in general), which tends to be relatively stable. This instrument contains 30 items, 15 items make up the state-anger scale (SAS) and 15 items comprise the trait-anger scale (TAS). Items are rated on a 4-point Likert scale; for the SAS 1 = not at all to 4 = very much so; for the TAS 1 = almost never to 4 = almost always. Scoring is accomplished by summing all items for each scale. A 10-item short form for both scales is also available. Higher scores equate to greater state and trait anger respectively. Each scale has shown good reliability and internal consistency and has been validated on high school aged students through adults ( Corcoran & Fischer, 2013b ).

   The Anger Expression Scale for Children (AESC;  Steele, Legerski, Nelson, & Phipps, 2009 ) is a 26-item questionnaire that measures anger expression and hostility in children aged 6 to 18 years. This self-report measure is a composite of items from existing and validated anger/expression scales (e.g., STAXI,  Spielberger, 1988 ) as well as newer items and uses a 4-point Likert scale from 1 = almost never to 4 = almost always with higher scores indicating greater experience and expression of anger. The AESC includes four subscales: Trait Anger, Anger Expression, Anger In, and Anger Control and has been found to be a reliable measure in the initial validation study but further research is warranted ( Steele et al., 2009 ).

Depression The most widely known and extensively utilized assessment instrument for ascertaining depressive symptomatology in adults is the Beck Depression Inventory II (BDI-II;  Beck, Steer, & Brown, 1996 ). This brief, self-administered instrument consists of 21 items and takes under 10 minutes to complete, presented in a multiple-choice format that measures both the presence and degree of depression in adolescents and adults (ages 13 and above). Items are rated on a Likert scale from 0 to 3, with higher scores indicative of greater levels of depression. It has excellent reliability with test–retest coefficients above .90; internal consistency studies have demonstrated coefficients of .86 or higher ( Beck, Steer, Ball, & Ranieri, 1996 ). Numerous research studies have been conducted using the Beck Depression Inventory (BDI) and its revisions for nearly five decades attesting to its concurrent and criterion validity. Studies with geriatric ( Segal, Coolidge, Cahill, & O'Riley, 2008 ;  Steer, Rissmiller, & Beck, 2000 ) and adolescent populations ( Osman, Kopper, Barrios, Gutierrez, & Bagge, 2004 ) also show validity and reliability. The computerized version shares similar psychometrics to the traditional paper administered ( Schulenberg & Yutrzenka, 2001 ). A 13-item short form BDI (BDI-SF) has also demonstrated strong correlations with the BDI-II and has been validated with inpatients ( Furlanetto, Mendlowicz, & Romildo Bueno, 2005 ). Additionally, a 7-item BDI fast screen (BDI-FS), formerly BDI Primary Care, has been validated with various populations including medical patients ( Scheinthal, Steer, Giffin, & Beck, 2001 ) as well as in adolescent populations ( Winter, Steer, Jones-Hicks, & Beck, 1999 ).

   Another commonly used instrument to measure depression is the Center for Epidemiologic Studies-Depression Scale (CES-D;  Radloff, 1977 ). This self-report questionnaire consists of 20 items that measure the frequency and duration of depressive symptoms over the previous week. Items are rated in a Likert format (0 = rarely/none of the time to 4 = almost or all of the time) with higher scores indicating greater levels of depression. The CES- D has been found to be highly reliable and valid as a screening instrument with populations of varying ages, ethnicities, and cultures ( Beals, Manson, Keane, & Dick, 1995 ). A shortened, 10-item version is available, which has been mainly validated measuring symptom severity in elderly samples with similar reliability/validity to the original ( Cheng & Chan, 2008 ;  Irwin, Artin, & Oxman, 1999 ). Other measures exist for detecting depression including the HAMD-17 “observer rating scale” for use when assessing severity once depression has been diagnosed and the PHQ-9 “self-administered” depression scale for use as a diagnostic and severity scale. When older adults are being assessed, the presentation of depressive symptoms may vary somewhat from those of other adults. The Geriatric Depression Scale (GDS;  Brink et al., 1982 ) is a well-known instrument designed to assess depressive symptoms in older adults. All three can be found in chapter 4 on bipolar disorders.

   Additionally, cross-cutting symptom measures are included in the DSM-5 ( APA, 2013 ). These tools included a general measure “level 1” which can be applied to anyone regardless of diagnosis as well as symptom specific “level 2.” For example, a level 1 tool that assesses depression includes an adaptation of the PHQ-9 for children and adolescents (ages 6–17) as well as adults (ages 18 and older). There is only a “level 1” symptom measure for suicidal ideation and suicide attempts included (but no specific level 2 suicide symptom scale). These symptom tools can be found in Section III ( APA, 2013 , pp. 733–744). There are many assessment tools available to help with the evaluation of suicidal thoughts and behaviors. However, like most screening tools and instruments they are not intended to be used as the sole method of assessing suicide risk and should never replace clinical interview, of which both training in the administration of and experience with is necessary.

   A persistent and salient mental health issue for adolescents and adults is suicide and non-suicidal self-injurious behavior. The Self-Harm Behavior Questionnaire (SHBQ;  Gutierrez, Osman, Barrios, & Kopper, 2001 ) is a brief, self-report, 5-item questionnaire with follow-up questions for a total of 26 items (dichotomous and open-ended answer formats) designed to assess suicidal thoughts and suicide-related behaviors in adolescents and young adults. The SHBQ takes less than 10 minutes to complete and produces 4 factors: selfharm (non-suicidal/self injury), suicide attempts, suicide threats, and suicide ideation. Total and four factor/subscale scoring norms are available (including coding of open-ended responses) from the authors. The SHBQ has very strong psychometrics with internal consistency on 4 scales (from .89 to mid .90s) and good convergent validity for the subscales to other measures of suicide behavior including the BDI. Two subscales (suicidal threats and suicidal ideation) correlated significantly with scores on the Suicide Probability Scale ( Corcoran & Fischer, 2013b ). Also, the SHBQ appears applicable across diverse populations with convergent validity shown for Caucasian, African-American, and Hispanic adolescents ( Muehlenkamp, Cowles, & Gutierrez, 2010 ).

   For younger children, the Hopelessness Scale for Children (HSC;  Kazdin, French, Unis, Esveldt-Dawson, & Sherick, 1983 ) is designed to measure thoughts concerning hopelessness, depression, and suicidal ideation. Seventeen true-false statements assess the child's level of depression as well as his or her self-esteem. It can be used with children who are aged 7 years and older. Although reliability coefficient alphas of .70 and .71 are considered only fair, they are within the acceptable range for children's instruments ( Corcoran & Fischer, 2013a ). Studies have indicated that the scale can discriminate between suicidal and non-suicidal children.

Emergency Considerations

Many people who suffer from the symptoms of depression do not seek treatment, especially when suicidal behavior is involved, which may well result in others arranging involuntary mental health treatment on their behalf. Also, when individuals do seek help, it is often from their general medical practitioner rather than a mental health specialist. This help-seeking behavior may further be complicated by the stigma that is often associated with mental illness. Assessment of the risk factors for suicide is crucial in treatment planning. In some situations, people experiencing the more severe depressive disorders may constitute a danger to themselves or others. Thoughts about self-destruction are among the criteria for determining the presence of a major depressive episode and are not at all uncommon. An assessment of suicide risk is of paramount importance in these cases, both at the time of initial contact and on a consistent, ongoing basis throughout treatment. Practitioners must develop skills in this area or utilize emergency assessment resources that are available in any community (e.g., local community mental health services, emergency rooms).

   In these situations, practitioners must attend to issues about the client's safety and secure whatever level of supervision and treatment is necessary. In some situations, severe depression can occur with some psychosis. When this occurs the client's safety is paramount. Again, familiarity with local resources for managing psychiatric emergencies is essential to ensuring safety. In such cases, the practitioner may not be able to complete a more broad-based, psychosocial assessment; the appropriate focus is on resolving the crisis and ensuring safety.

Cultural Considerations

Cultural, ethnic, and gender factors can affect the expression of depression as well as the way it is recognized and diagnosed. The practitioner should be aware of common variations in symptom presentation across cultures and genders. To this end, the DSM includes the Cultural Formulation Interview (CFI), which provides guidelines for making cultural evaluation easier (see  APA, 2013 , pp. 749–759). However, it is imperative when formulating cultural features to be wary of transforming them into stereotypes.

   In some cultures, individuals are more likely to communicate emotions and affect in somatic terms. This may be related to concerns that emotions like depression or anxiety will be interpreted as weakness or labeled “crazy.” Therefore, in some cultures it is customary to complain of physical symptoms rather than to disclose negative moods. The physical symptoms of depression (e.g., aches and pains) in Hispanics, African Americans, and Asians are widely acknowledged but not always recognized which can adversely affect diagnosis ( Kalibatseva & Leong, 2011 ;  Uebelacker, Strong, Weinstock, & Miller, 2009 ;  Williams & Mohammed, 2009 ). Culturally diverse populations are more likely to report somatic symptoms and seek help in a primary care setting where somatic symptoms and a clinical focus on organic causes may delay the diagnosis of depression ( Noöl, 2012 ;  Stockdale, Lagomasino, Siddique, McGuire, & Miranda, 2008 ;  Tylee & Gandhi, 2005 ).

   Some studies report somatic presentations of depression are more common in Hispanics than in other ethnic groups ( Canino, Rubio-Stipec, Canino, & Escobar, 1992 ;  Cucciare, Gray, Azar, Jimenez, & Gallagher-Thompson, 2010 ). Research shows that cultural idioms such as “ataque de nervios” are often part of the cultural expression of depression and anxiety in Hispanic Americans and Latinas/os ( Guarnaccia, et al., 2010 ). This pattern of somatic symptoms coupled with cultural idioms of distress may lead to underdiagnosis of depression in Hispanics ( Lewis-Fernéndez, Das, Alfonso, Weissman, & Olfson, 2005 ). The same relationship may hold true for other ethnic-racial minorities, especially if a language barrier exists. Practitioners need to recognize that depression is often experienced through a cultural lens as somatic symptoms and instructed to ask about possible underlying psychological symptoms when working with diverse cultures. But clinicians are also cautioned about overgeneralizing and stereotyping when working with heterogeneous groups like Hispanic/Latino Americans, African Americans, and Asian Americans.

   Understanding cultural variations in the presentation of depression intra- and inter-culturally should be considered when working with diverse populations. Even within similar ethnic subgroups, cultural influences such as immigration and acculturation may impact diagnosis ( Grant, et al., 2004 ). For example, The National Comorbidity Survey (NCS) revealed that US-born Hispanics had a significantly higher risk of psychiatric disorder than foreign-born Hispanics ( Ortega, Rosenheck, Alegría, & Desai, 2000 ). Similar results were found with data from the National Epidemiological Survey of Alcohol and Related Conditions (NESARC) for second-generation Asian Americans ( Breslau & Chang, 2006 ). The stress from acculturation is also a risk factor for depression in Latin American and Asian-American immigrants ( Mui & Kang, 2006 ;  Revollo, Qureshi, Collazos, Valero, & Casas, 2011 ). Understanding cultural variations in the presentation of depression intra- and inter-culturally should be considered when working with diverse populations.

   By the same token, care must be taken when measuring cross-cultural symptoms of a heterogeneous disorder such as depression to ensure shared meaning and validity, especially in terms of communication and language barriers and/ or bias. For example, the NCS and the National Comorbidity Survey Replication (NCS-R) were only available in English, which may have resulted in response bias due to nativity and acculturation since it excluded many recent immigrants who are often primarily Spanish speakers ( Alegría, et al., 2004 ). Bilingual clients may appear to have more or less symptomatology depending on the language spoken during the interview, as well as the primary language of the practitioner ( Malgady & Zayas, 2001 ). Research supports integrating culturally specific interventions (e.g., incorporating religious explanations of illness for some Latina/o individuals) when working with individuals from diverse cultures ( Caplan, et al., 2011 ). Another problem may be with the cultural validity of the instrument. For example, depressive symptoms (including somatic) may load on different factors on the CES-D for Asian Americans ( Kalibatseva & Leong, 2011 ). This may point to weakness and cultural bias where the cultural expression of depression for the dominant Western culture (e.g., psychological symptoms) is favored over those of minority cultures (e.g., physical symptoms).

   Debate surrounds the prevalence rates of depressive disorders, with some studies showing racial and ethnic minorities having lower rates and others showing higher rates. But most of this disparity may be due to the difference between lifetime prevalence and chronic depression. Breslau, Kendler, Su, Gaxiola-Aguilar, & Kessler ( 2005 ) established that compared to Whites, non-Hispanic Blacks had a lower lifetime risk of having a mood disorder but Hispanics and non-Hispanic Blacks had a higher risk for chronic mood disorder once diagnosed. This finding was supported by data from the National Survey on American Life (NSAL) that included over 6,000 individuals and was completed between 2001 and 2003, which found lower lifetime prevalence of major depressive disorder among African Americans and Caribbean Blacks compared with non-Hispanic Whites but a higher risk of the persistence of MDD ( Williams et al., 2007 ).

   Some researchers feel that the consequences of psychosocial stressors like ethnic and racial discrimination need to be studied in order to better understand and prevent these disparities in mental health services and chronicity ( Brondolo, Gallo, & Myers, 2009 ). Race and ethnicity were shown to be important factors in determining which individuals are provided access to care, as well as whether that treatment met recommended guidelines for the care of depression ( González, Vega, Williams, et al., 2010 ). Once again, data demonstrated that the lifetime prevalence rates for depressive disorders was lower for racial/ethnic groups including African Americans and Asian Americans, but that they tend to receive less treatment for depression and of a lower quality than Whites ( Kalibatseva & Leong, 2011 ). Furthermore, the tendency for minority group members to receive more serious and more stigmatized psychiatric labels suggests that depression may be underestimated in ethnic minorities, which would also contribute to inadequate care and treatment ( Zeber, Gonzalez, Van Dorn, & Interian, 2011 ).

   Another explanation holds that clustering heterogeneous racial and ethnic subgroups in national studies (e.g., Hispanics, Latinos, Blacks, Asians) may be responsible for the divergence in prevalence rates as contrasted with using specific ethnic subgroups (Mexican, Puerto Rican, Caribbean, Vietnamese). González, Tarraf, Whitfield, & Vega ( 2010 ) employing the National Institute of Mental Health's Collaborative Psychiatric Epidemiology Surveys (CPES), which combines data from the NSAL, NCS-R, and NLAAS to show that chronic major depression was higher among Mexican Americans, Puerto Ricans, and African Americans in contrast to White Americans. And, when comparing rates for major depression, although Cuban and Puerto Rican Americans demonstrated significantly higher prevalence, Mexican Americans (who comprise the largest portion of Latino Americans) and White Americans showed nearly equal rates. Furthermore, their data showed that Vietnamese, African, and Mexican Americans were less likely to receive adequate care, and suggest that this finding might relate to their higher disease burden. Also, this study was able to replicate findings from earlier studies in regards to lower prevalence of major depression among foreign-born versus U.S.-born co-ethnic groups. However, what has become known as the “healthy immigrant paradox” did not hold into older age, with the authors implying that socioeconomic disadvantage and acculturation stress builds up and overwhelms coping skills and limited resources in later life as possible reasons for this outcome.

   In the same way, Hirschfeld and Weissman ( 2002 ) propose that this inconsistency in prevalence rates may be nullified by controlling for socioeconomic and educational factors. An individual's socioeconomic status has been shown to influence depression, with low status linked to higher prevalence ( Lorant, et al., 2003 ). For instance, in a study using data from the U.S. National Longitudinal Survey of Youth (NLSY79), which included diverse ethnic groups, Walsh, Levine, and Levav ( 2012 ) found that lower paternal socioeconomic status during an individual's adolescence increased their likelihood of developing depression 27 years later, irrespective of ethnic group membership and gender. Along these lines, Green and Benzeval ( 2011 ) suggest that the early treatment of anxiety and depression symptoms may prevent the later development of persistent depression, and moreover, that such an approach could help reduce socioeconomic inequalities in depression. However, Hudson, Neighbors, Geronimus, and Jackson ( 2012 ) found that although socioeconomic position was associated with an increased risk for depression, unemployment was a better predictor for African-American men.

   The estimated 12-month prevalence rate for a major depressive disorder is 6.7% for adults, with women 70% more likely than men to experience depression over their lifetime (National Institute of Mental Health, n./d.). Gender is a primary factor in regards to being diagnosed with depression, with women at least twice as likely as men ( Hirschfeld & Weissman, 2002 ;  Kessler, et al., 2003 ;  Leach, Christensen, Mackinnon, Windsor, & Butterworth, 2008 ). Women are roughly 1.5 to 3 times as likely as males to develop depression usually beginning as early as adolescence ( APA, 2013 ). The American Psychiatric Association defines gender as “the public and (usually legally recognized) lived role as man or woman” whereby, biological factors acting together with social and psychological factors result in gender development ( APA, 2013 , p. 822). Some cultures have more rigid gender roles that define expected behavior. In the United States, men have been raised to minimize emotional expression regardless of their internal state due to proscriptive gender norms. On the other hand, women have been taught to use emotional expression. Clinicians need to be mindful when making a diagnosis to be cognizant of possible gender-related bias and stereotypes in order to avoid misdiagnosis of both women and men with depression.

   The causes for gender differences in depression are not definitive. Studies using national epidemiological data confirm the higher incidence of a type of depression associated with somatic symptoms (e.g., fatigue, pain, and anxiety) among women over men ( Silverstein, 2002 ). Nolen-Hoeksema ( 2001 ) proposes that because women are exposed to certain life stressors more often than men (e.g., victimization, sexual discrimination) they may be likely to develop depression in response to these stressors, and this may be related to gender differences in biological responses (e.g., hyperresponsive) as well as psychological responses (e.g., rumination, self-mastery, and coping). Furthermore, they propose that males' coping strategies tend to involve more active/positive forms of distraction (e.g., physical activities), while females' coping more often involves activities that may fuel rumination (e.g., overthinking), which negatively impacts coping. Leach et al. ( 2008 ) set out to study earlier identified possible mediators for gender differences in depression and anxiety. They singled out a number of factors/mediators that were constant for both symptoms across age groups (except for anxiety in the 20s, which begs further study for this age group). Firstly, two health-related factors (e.g., poorer physical health and less physical activity) were reliable risk mediators for possible gender difference in both depression and anxiety for all age groups. Psychological factors associated with gender differences included lower levels of mastery and higher levels of ruminative style. In terms of social factors, interpersonal problems (especially with family) were associated with being female as well as with depression and anxiety. Of note, it appears that relationship instability and more negative interpersonal events may contribute to the development of depression in young women. However, these results are not inconclusive and further research in causality is necessary. Furthermore, disparities in mental health treatment also impact gay, lesbian, bisexual, and transgender (GLBT) populations and these too warrant further research and clinical attention.

   It is important to note, that possible cultural and gender differences may be due to the use of self-report and interviewer-rating scales that are based on symptom criteria, which may be biased to social/gender norms, Western culture, and English speakers ( Kerr & Kerr, 2001 ). Cultural and gender sensitivity, education and training are essential to competent practice. Failure to acknowledge cultural differences as well as possible gender biases can lead to misdiagnosis and delays in treatment.

Social Support Systems

Depressive Disorders are considered serious mental illnesses. Symptoms associated with depression may cause severe impairment in the client's social and occupational functioning. Family members and close friends of a person with an affective disorder can feel confused, frustrated, fearful, or angry about the person's dramatic change in mood and inability to cope with daily life events. Families and friends may not understand the problem and why the client can't just “snap out of it.” Conflicts between family, friends, and the person with the disorder can arise due to disruptive thoughts and behaviors and mood swings on the part of the symptomatic individual. Some findings indicate that “poor family relationships” may contribute to the likelihood for depression ( Shim et al., 2012 ). In addition to an assessment of the symptomatic individual, an assessment of the person's family or friends is important for the clinician to obtain an understanding of the support available to the person coping with the illness. Family members and friends need to have accurate information about the disorder, as well as about how to cope with a loved one's symptoms and where to obtain help in a crisis situation. Families and friends can be a valuable source of fiscal and emotional support while the individual's mood is stabilized through medication and psychological treatment.

   Social support has been shown to have a positive effect on reducing the risk for depression ( Shim et al., 2012 ). A psychoeducational group for individuals with similar problems may be an additional source of support for the person suffering from depression. There are many support groups for people suffering from or affected by depression. These groups provide individuals with a sense of belonging, education concerning the illness, and mutual support. Mental health practitioners conduct some support groups; other groups are organized and run by persons who have previous experience with the disorder (either clients themselves or family members of clients). With the recent increases in knowledge concerning depression there has been a corresponding increase in the numbers of organizations and agencies providing specialized support for individuals with these depressive disorders.

   For many people with depressive disorders, joining a group may be problematic because of the person's symptoms and/or because of group availability. Similar constraints may also apply to members of the person's social support system. The Internet contains a wealth of information, including organizations specializing in the support and treatment of persons with depressive disorders, online chat rooms and bulletin boards, and current reports and articles related to particular disorders. The following list includes some useful Internet resources.

·   www.nami.org : National Alliance on Mental Illness (NAMI) website for mental health education with support services and resources.

·   www.mentalhealth.net : Provides information on all mental disorders, including overview and treatment issues, resources, books, and scales.

·   www.helpstartshere.org : National Association of Social Workers (NASW) professional resource for information on all areas of health and wellness including inspiring stories and a social work directory.

·   www.iFred.org : International Foundation for Research and Education on Depression (iFred) website, which provides an overview of depressive disorder and treatment resources.

·   www.findingoptimism.com : Free mental health apps for self-tracking depression, bipolar, anxiety, and PTSD for desktops and iphone/ipads.

Differential Diagnosis

Making a differential diagnosis when the client is exhibiting psychotic symptoms can be challenging as well. For example, the lack of affect and withdrawal that can accompany schizophrenia may be easily confused with the negative symptoms common in depressive episodes, particularly with major depressive disorder. Generally, a thorough history of the previous course of symptoms, knowledge of medication use (and the client's response to various medications), and/or family history can help in distinguishing these disorders. This approach may not be possible in the initial phases of psychiatric symptoms, and in those cases, it is not unusual for a number of different diagnoses to be made before a clear pattern emerges.

   Another consideration involves the presentation of symptoms typical in certain age groups. For example, depressive disorders among the elderly are often mistaken for dementia. In this instance, a careful consideration of the onset of symptoms (particularly the temporal sequencing of depressive and cognitive issues) and a thorough medical history (and possible examination) can be particularly useful.

   Similarly, among children, either general distractibility in depressive states, or the agitation, impulsivity, and/or poor judgment associated with manic or hypomanic episodes can be mistaken for ADHD. Although considering the age of onset can be useful in making the distinction between ADHD and depression, the primary distinguishing feature involves determining whether the course of symptoms is more chronic than episodic.

   Furthermore, children have increasingly been diagnosed with bipolar disorder and subsequently given medication for this rare childhood disorder. The DSM-5 task force made an intentional decision to include the diagnosis of DMDD under Depressive Disorders as an alternative diagnosis for children who are displaying emotional and behavioral symptoms related to depression. It is important to remember that bipolar disorder involves a biochemical imbalance, whereas DMDD is an emotional and behavioral disorder. The practitioner should be careful in making this differential diagnosis and obtain a full understanding of the family situation. Some children can display manic symptoms when they are under stress. These symptoms may disappear once the stressful situation is remedied.

Case 5.1

Identifying Information

Client Name: Maggie Weinzapfel

Age: 26 years old

Ethnicity: Caucasian

Marital Status: Single

Intake Information

Maggie, a 26-year-old Caucasian female, contacted the Family Guidance Center after breaking up with her fiancé, whom she had been dating for the last 4 years. Maggie is a mechanical engineer at a fiber optics corporation in a small Southern town. She makes a good salary, owns her home, and recently bought a new car. Maggie moved from the large, metropolitan area in the Northeast where she had met her boyfriend to this rather small Southern town approximately 1 year ago when she procured her present job. Her parents and siblings also live in the Northeast. Maggie has two sisters, both in their 20s, and two teenage brothers who still live with their parents.

   When Maggie called the clinic, she stated that she desperately needed to talk with someone as soon as possible. The intake worker wrote in her notes that the client “sounded panicky” when making an appointment to see a counselor. You are scheduled to see Maggie the day after she called.

Intake Interview

You meet Maggie in the waiting room at the agency. Maggie appears very disheveled. Her baggy pants and sweatshirt are wrinkled, and it looks as if she forgot to brush her long, wavy hair. She is pacing slowly back and forth and appears to be staring at her feet. She runs her hands through her hair continuously and looks generally distressed. Every now and then, she sighs deeply and shakes her head as if responding to some internal dialogue. You greet Maggie in the waiting room by introducing yourself and shaking her hand, which feels sweaty and limp. As you and Maggie walk down the hall to your office, Maggie bursts into tears and says, “Oh, I'm so embarrassed; I don't know what I'm doing here.” As you and Maggie enter your office, you reassure Maggie that it's safe for her to express her feelings with you, offer her a chair, and provide her with a box of tissues.

   You begin by gently asking Maggie where she would like to start. Maggie states that she broke off her engagement with her boyfriend, Leonardo, approximately 6 weeks ago. She says they had been arguing constantly for the past 6 months about where they were going to live. She wanted to keep her job and live in a small town, but he wanted to live in a large city and didn't want to leave his family in the North. He told her that Italian families are very close: “We stick together and want to see each other. I grew up in this city; I've been to the same church my whole life; and I intend to die in this city. If you're going to be my wife, you have to be willing to join my family because I'm not leaving.”

   Maggie tells you that she chose her current job partly because the insurance company that Leonardo worked for had offices in this town and he could transfer to the South and keep his job. Maggie says, “During the past year, I've been going up there to see Leonardo at least once a month for a weekend. I only had 2 days with him, and we spent all day Sunday at his mother and father's house. His mother treats him like a baby and does everything for him. I think she resents me for taking away her little boy. She's friendly enough, but there's tension between us. Lately, his parents have been talking a lot about us getting a house down the street from them. I just couldn't stand that!” Maggie states that she began feeling like an outsider and an intruder. “Leonardo was unhappy unless I agreed to everything he wanted,” Maggie says glumly.

   Maggie states that since the breakup she has had great difficulty sleeping. She often sleeps only 2 or 3 hours a night. She states that she has also lost her appetite and has dropped 15 pounds in the past month. In a very shaky voice, she tells you, “I've been having so much trouble with my job lately. I can't focus on what I'm doing for more than 3 minutes before I'm off thinking about Leonardo. It's so hard it makes me want to cry.” She says she's missed work completely on four occasions during the last month when she just stayed in bed all day and watched soap operas on TV. Since the breakup with Leonardo, she says she feels ugly, unlovable, and hopeless about ever getting married.

· 5.1–1 At this point in the conversation, what things would you like more information about concerning Maggie?

 

   You decide to find out more about Maggie's difficulties over the past month. You ask her if there are any other ways in which the breakup with her boyfriend has affected her. She tells you that she is normally a very avid reader of mystery books and lately hasn't been able to get past the first chapter. She also likes to go to community events on the weekends with friends, but since she has lived in this town, she has been so consumed with her work and her relationship with Leonardo that she hasn't made any good friends. “Oh, you know, I've gotten acquainted with some people, but I don't know them very well and it just seems so hard to pick up the phone and call them. I doubt if they'd want to do anything with me anyway. I think I'm just a loser all the way around.”

   You ask her if she really thinks it's over with Leonardo. She states that the last time he called, they just got into a shouting match. “By the end of the conversation I decided I just had to end this relationship and get on with my life,” Maggie says despondently. “I really believe that, too. I just don't know where I'm going to find the energy to do it. When I do sleep, I have nightmares about fights with Leonardo. It's begun to take its toll on me, I think.”

   You say, “Maggie, you've mentioned having problems sleeping, and I was wondering whether you were having trouble going to sleep or problems waking up in the middle of the night and not being able to get back to sleep.” Maggie states that her biggest problem is her inability to sleep through the night. She says she wakes up around 2 a.m. and often cannot get back to sleep until it's almost time to get up. “Then I feel groggy and unable to function very well the rest of the day,” she hesitantly tells you in a quiet voice.

   You also ask her if she's had any suicidal thoughts or had any plans for hurting herself due to this upsetting situation. Maggie responds that she has thought about just wanting to end all this pain, especially at night when she is alone. You ask her if she has taken those thoughts any further and considered how she might “end it all.” She tells you that she doesn't think she could ever actually hurt herself since it is against her religion and she believes it would be wrong to commit suicide. You explain to Maggie that if she ever begins having thoughts of how she might hurt herself that it would be important for her to talk with you about those thoughts and feelings. Maggie agrees that she will discuss those issues with you should they arise.

   When you ask Maggie about her family of origin, she states that she's always gotten along well with everyone in her family except her mother. She says that ever since she was little, her mother has wanted her to always act like the oldest. “She always tells me that I have to be the responsible one because I'm the oldest, and I don't think she really cares about whether I'm happy or not.” When Maggie told her mother that the relationship with Leonardo had ended, her mother just told her to grow up and get over it. Maggie says she's never been able to go to her mother with a problem. “I'm not sure my mother is a very happy person. She's more concerned about what the neighbors will think than whether or not we are content with our lives. Ever since I was little, my mother would get in one of her moods and close herself in the bedroom and not come out for days.” Maggie states that she has a much closer relationship with her father, who has called several times to see if she's okay.

   Before leaving your office, Maggie tells you she's really glad she came to talk today. She says, “It's taken a big load off my shoulders.” Maggie states that this is the first time in several weeks that she can remember not having a headache. She agrees to come back and see you at the same time next week.

· 5.1–2 What behaviors would you have Maggie track during the week?

 

· 5.1–3 What do you see as some of Maggie's strengths?

 

· 5.1–4 Describe two or three approaches Maggie might use to develop a local social support system.

 

· 5.1–5 What diagnosis would you give Maggie after this initial interview?

 

Case 5.2

Identifying Information

Client Name: Kathy Claybourne

Age: 45 years old

Ethnicity: Caucasian

Educational Level: B.S. degree in nursing

Marital Status: Divorced

Children: Tommy, age 14; Betty, age 12

Intake Information

Kathy Claybourne is a 45-year-old single mother who contacted the Family Counseling Center concerning counseling for herself and perhaps, later, for her two children. She stated that she feels “very alone right now” and needs someone to talk to about “how my life is going.” She didn't want to go into the reason for an appointment with a counselor over the telephone. The intake worker scheduled an appointment for her with you, her counselor, for the following week. Kathy arrived on time for her appointment with you.

Intake Interview

Kathy presents as a polite, well-groomed, middleaged woman who smiles and shakes hands with you in the waiting room. She says that she is very glad to have someone to discuss things with after spending much of her time talking to her children. Kathy indicates that she has been divorced for the past 3 years. She works as a nurse for four nephrologists in town who also have a kidney dialysis center connected to their practice. She has been a nurse for the past 20 years and loves her profession but lately has been feeling “burned out” on the job and has had difficulty concentrating on her work.

   She feels that since her divorce, her life has been going downhill. A year after her divorce, her mother died of liver cancer, and several months later, her father was diagnosed with prostate cancer. She took care of her mother during her illness and is currently caring for her father. Over the past 2 years, she has felt increasingly despondent, isolated, and “blue” most of the time. She states that many of her “so-called friends” rejected her following the divorce because they were also friends with her ex-husband. She also feels that she hasn't had much time for a social life since her part-time job became full-time following the divorce.

   When you ask her about her mood, she tells you it's generally been “blue.” “I don't seem to have any energy some days. It's just hard to get up and face the day.” Kathy states that she feels lethargic most of the time and has difficulty doing everyday tasks that she once found easy to accomplish.

   “How has your sleeping been over the past year?” you ask. Kathy states that she has had difficulty falling asleep. She wakes up very early in the morning hours and is unable to get back to sleep.

   Approximately 6 months ago, Kathy reports “feeling so bad that I went to my physician to see if anything was really wrong with me.” She states that he found nothing physically wrong and recommended she get some exercise. At that time, she joined a health club and began working out. “I think I felt better for a while when I was going to the club, but after about 2 months, it became too much of an effort to get myself there to exercise.” She rubs her forehead and states that she probably should go back but doesn't feel she has the energy.

   She also tells you that her biggest worry is that she's not really “present” for her children. She has a hard time focusing on her children's activities and has lost interest in what they are doing. “I just feel bored with everything—my children, my job, my life. I'm too tired to cook when I get home from work so I often stop at McDonald's and get them hamburgers, which they're happy with, but I don't even feel like eating. I've lost about 20 pounds in the last year without even trying.”

   When you ask for background information, Kathy states that the problems she has been experiencing began shortly after her divorce from her husband approximately 2½ years ago. However, she suggests that she often struggled with feeling down and despondent throughout her 30s, prior to her divorce. She attributes those feelings to communication problems with her husband and states that she just couldn't “give in to them because of the children.”

   “I got married right after I finished nursing school at the age of 21 and moved from my parents' home to my husband's home. He was 10 years older than I was and already had established business and social relationships that I was invited to participate in. At the time, it seemed great to me, and I thought the world revolved around him since he seemed older and wiser and could take care of me. I worked part-time as a nurse, not because I had to, but because I wanted to have a profession. Gradually, I began feeling like our relationship was falling apart. He began traveling a lot on business, and I was home with the children. He didn't seem interested in anything but work. We socialized with friends that he knew because of his business, and I felt that he just wanted me around to make him look good. This didn't all happen overnight, you understand, but by my mid-30s I was having periods of utter despair over the kind of distant relationship I had with my husband and the total responsibility for my kids. His only goal in life was to make money, and he didn't care about anything or anyone else.”

   Kathy states that from the age of 32 onward, she can't really remember a time when she felt like her old self. “When I was a teenager, I was happy, outgoing, and enthusiastic about life. When I got into my 30s, everything seemed dreary most of the time.”

   Kathy states that she never was unable to function at her job or as a mother but always felt sad and negative about the future. Kathy also tells you that she thinks her mother suffered from the same type of problem when Kathy was growing up. “If my mother could find a negative way to view a situation, she would find it.” She remembers her mother would often tell her and her sister that they had to go outside to play because her mother had to take a nap. “I always thought it was strange that she was sleeping in the middle of the day, but for my mother, it was normal for her to always be tired.” Despite the problems her mother may have had, Kathy states that she had a good childhood and often felt happy and full of life. “It seems like adulthood has ruined my mood,” Kathy says glumly.

   During your interview, Kathy often looks out the window, rather wistfully, when recalling the happier days of her childhood. She seems overwhelmed and obviously has difficulty coping with her feelings.

   She summarizes that she is requesting help with her overall mood and that she is able to function adequately but not up to the level that she has in the past. She seems concerned about not being an adequate mother for her children and the activities in which they are engaged.

   She spends most of the interview twisting the straps on her purse and only makes eye contact a few times throughout the session. She has apparently been experiencing these feelings for an extended length of time and is seeking help at this point because she worries about her job and her children. She doesn't see the future as being very bright at the present time.

   You schedule another appointment for her in a week. She states as she leaves your office, “I'm so glad I finally made the decision to get some help. That was the hardest thing to do.”

· 5.2–1 What are some of Kathy's strengths?

 

· 5.2–2 What diagnoses would you want to rule out in this case?

 

· 5.2–3 What resources might be valuable to utilize in this case?

 

· 5.2–4 Do you think Kathy should be referred to other professionals for further evaluation? If so, to whom would you make a referral?

 

· 5.2–5 What is your preliminary diagnosis for Kathy Claybourne?

 

Case 5.3

Identifying Information

Name: Lucy Johnson

Age: 15 years old

Ethnicity: Caucasian

Educational Level: 10th grade

Referral Information

The 10th-grade high school science and homeroom teacher has referred Lucy Johnson to you due to frequent school absenteeism, falling grades, and withdrawn behavior. Lucy is 15 years old and usually an A student. After several attempts to reach her mother by phone, you decide to make a home visit.

Home Visit

Lucy lives in a rural area approximately 10 miles outside a small town in Virginia. Her mother, Judy, works a rotating shift at a hosiery factory in town. Judy is a single mother with three daughters ages 12, 15, and 17. When you arrive in the vicinity of her house, you discover she lives in a run-down trailer park without numbers to identify the residences. You stop at the first trailer and ask where Ms. Johnson lives. The woman tells you the trailer is at the end of the road. As you drive up to the Johnson trailer, you see Lucy sitting on the steps with her head in her hands.

   She looks up and waves when you get out of the car. She seems surprised to see you there. She walks over to your car and asks you why you're at her house. “You've missed a lot of school lately, and Ms. James has been worried about you,” you reply. “Can we talk somewhere?”

   “My mother is busy inside right now, but we can walk down the road if you like,” Lucy suggests. She begins walking down the road, and you follow her.

   “Why have you missed so much school?” you ask her.

   Lucy tells you that her mother's car has been in the shop and she didn't want to take the bus with the little kids. Her boyfriend, Joe, has been taking her to school on days when he doesn't have to be at work early. Lucy looks very unhappy and tired.

   You ask her if there are other things going on that she'd like to talk about. She shakes her head and says she'll be at school the next day.

   You tell Lucy that she can come by your office anytime if she wants to talk. She glances at you and says, “All right, just not now.”

   You ask her if you can visit with her mother now, and Lucy quickly and emphatically tells you that her mother really can't be disturbed. “Please don't go into the trailer right now. I'll tell her you came by and give her your phone number. Okay?”

   “Are you sure everything is all right, Lucy?” you implore.

   “Yes, everything is fine. My mother just can't be disturbed right now. She'll call you,” Lucy says with a look of determination in her eyes.

   Because Lucy seems so concerned about you intruding, you agree to leave and talk to her mother later.

   The following day, you check and find Lucy is at school as she said she would be. You try calling her mother at home, and once again, there is no answer. At lunch, Ms. James tells you that Lucy seems somewhat despondent but has made it to all her classes that morning.

Interview with Lucy

About a week later, as you're getting ready to leave for the day, you notice Lucy standing in the hallway outside your office. You ask her if she'd like to come in for a few minutes and talk.

   Lucy walks into your office, and as you close the door, she bursts into tears. You guide her to a chair where she slumps down and continues to sob. You sit down opposite her and give her some time to calm down.

   After crying hard for a few minutes, Lucy looks at you and says she doesn't know why she's so upset. “I'm just so very sad these days. I don't feel like doing anything except sleeping or crying. I've been crying for 3 days and can't seem to stop.” She looks around the room for a tissue as she continues to apologize for getting upset.

   “What do you think all those tears are about?” you ask.

   “I'm really not sure. It seems ridiculous to me, but I just can't stop,” Lucy sobs.

   “Maybe you could tell me a little about what's been going on with you lately, and we can figure it out together,” you suggest.

   Lucy begins talking very rapidly as though she has been waiting for someone to help her for a long time. “You see, I live with my mother and sisters in the trailer, only they aren't ever home. My mother works a lot of hours, and when she gets home she's always tired. My father lives in Florida somewhere, but we don't ever see him. He was in jail for a while because someone pressed charges against him for child molestation. Terry, my older sister, dropped out of school and lives with her boyfriend most of the time. She got shot in the head and has a plate in her head now. She doesn't care about school or anything. Just her boyfriend. My younger sister, Sally, stays over at her friend's house a lot. So, it's just me at home and my mom. She has a lot of boyfriends who come over and spend the night. It just bothers me that they are always there. I just try to stay outside down by the river.”

   “And you mentioned you had a boyfriend, too, I believe. Does he come over to see you?” you ask.

   “Well, on the weekends, when he's not working. Joe is 19 and works at the hosiery mill where my mom works. That's how I met him,” she says.

   “How long have you been seeing Joe?” you ask Lucy.

   She tells you that she's been dating Joe for the past 3 months. After some hesitation, she tells you that Joe smokes a lot of pot and that they often go down to the river so that he can smoke.

   “Do you smoke pot with him, Lucy?” you ask.

   “Sometimes I have. It seems to make me feel weird and upset though. I always end up feeling down after I've smoked pot,” she explains.

   “Have you been smoking any pot lately?” you ask.

   “A little, but please don't tell my mom. She'd kill me. I think it's why I'm in this state right now. I just feel like I'm losing control of myself. I don't think this relationship with Joe is good for me, but he's the only one who pays any attention to me. I just don't want to end up like my sister has. Dropping out of school and everything.”

   “Tell me what you mean by feeling like you're ‘losing control’ of yourself,” you query.

   “I just feel like I'm not myself sometimes. I'm usually a happy kind of person, and I really like to come to school. Lately, I just haven't been able to keep my mind on what's going on here. I'm worried about my mother and her finances. She's always scared she's going to lose her job if she doesn't work overtime, and she's always tired. And I'm worried about my sister, Terry. Her boyfriend isn't a very nice person, and he can be really mean to her. And I'm worried about my little sister, too. She's been getting into trouble lately because she never comes home when she's supposed to and my mom gets worried. I feel like I have to be there to take care of everyone. Sort of like a mother.”

   “Is there any other family around who could give you some help?” you ask.

   “There's my aunt. She lives in town, though, and she works at the taxi company as a dispatcher. She has a daughter my age, and we get along real well. I really wish we could live in town like my aunt. I can talk to my aunt better than I can talk to my mother,” she confides.

   “So, you're feeling very responsible for your whole family, like you have to take care of them. Is that correct?”

   “Yes, I feel that way most of the time,” she says.

   “Do you ever get to do anything for fun?” you ask.

   “I like to read and walk in the woods,” Lucy tells you. “But I haven't felt like doing anything lately except sleeping.”

   “How would you describe yourself, Lucy, when you're feeling okay?” you ask.

   “I think I'm a fairly happy person most of the time. I like doing things outdoors, and I'm pretty outgoing. I like having friends, and I'm sort of a tomboy. I like to swim and run and hike in the woods and ride bikes. I used to play touch football with the neighbors and go on camping trips with my friends' families, but I haven't done anything like that lately. I also like school. I'm really good at math, foreign language, and literature. I read all the time when I'm feeling good. I think most people like me,” Lucy says with a little smile.

   This description makes you think that under normal circumstances, Lucy has good self-esteem and is intelligent and insightful. “Why do you think you've been so sad lately?” you continue.

   “I think it's because of where we're living and my mother's boyfriends and Joe. I sometimes think I would be better off living with my aunt in town. I think I'd be happier and not so bored all the time. I'll tell you something else if you promise not to tell anyone,” Lucy implores.

   “Lucy, I have to explain to you that if you tell me anything that makes me think you might harm yourself or someone else, then I have to tell someone else. Also, if you tell me someone is hurting you, then I might have to tell someone else. Do you understand that?” you ask.

   “No, this isn't about anyone getting hurt,” Lucy exclaims. “It's just about the day you came to the trailer. You know, the reason that you couldn't see my mother was that she was in the bedroom with one of her boyfriends. I always have to go outside when she's with her boyfriends. It really gets to me sometimes. That's why I'd like to go live with my aunt,” Lucy reflects.

   “I see. So it bothers you when your mother has her boyfriends over at the trailer. Is that right?” you say.

   “Yes, it really brings me down, like my mother doesn't care about me or how I feel,” Lucy remarks.

   “Have you ever talked to your mother about this issue?” you ask.

   “Yes, and she just tells me she's got to have a life, too,” Lucy replies.

   “Maybe she doesn't know how upset you feel about her activities with her boyfriends,” you suggest.

   “Maybe,” Lucy replies. “I think she's just caught up in her own world and doesn't really care about anyone else that much. She's not like my aunt at all.”

   “Do you think your mother or your aunt would be willing to come talk to me about this situation?” you query.

   Lucy thinks about this question for a moment and then says she'll ask her mother, but she doesn't think it will do any good.

   At this point, you ask Lucy how she's feeling now. She tells you she's relieved someone else knows what is happening in her life. She adds that she doesn't mind if you talk to her mother or aunt, but it's going to be hard to get in touch with them. They both work long hours. You ask her if you could contact them at work to set up an appointment. Lucy tells you that her aunt can be reached at her office, but her mother can't take calls at the hosiery mill.

· 5.3–1 What other information would you like to obtain from Lucy's mother or aunt?

 

· 5.3–2 What are some of Lucy's strengths?

 

· 5.3–3 What are some of Lucy's limitations?

 

· 5.3–4 What is your preliminary diagnosis for Lucy?

 

Case 5.4

Identifying Information

Client Name: Jacob Tooley

Age: 10 years old

Ethnicity: Caucasian

Educational Level: Fifth grade

Parent: Scott Tooley

Deceased Mother: Teresa Tooley

Background information

You are a school Social Worker at an elementary school in Coral Gables, Florida. School has been in session since August and the holidays have passed. You have been approached by a fifth-grade school teacher who has shared concerns for the well-being of one of her male students, Jacob Tooley. Jacob is 10 years old, a fifth grader in her gifted and talented class. Jacob has always been an excellent student, but has always seemed quite shy and reserved in his classes. Jacob's fifth-grade teacher, Mrs. Sandra Simmons comes to you with Jacob's student file and reviews with you the following: Jacob's fourthgrade student file has very favorable comments from Jacob's teachers, including especially stellar comments from his fourth-grade teacher, up until the second half of the school year of fourth grade. Mrs. Simmons shares with you that Jacob has always been well-liked by both teachers and his peers. Mrs. Simmons states that past teachers have noted some inconsistencies when trying to reach Jacob's mom for parent conferences, but past teacher notes indicate that when Jacob's parents did respond and visit with his teachers, the parents were responsive and positive about Jacob's school performance. Mrs. Simmons directs you to several of the last teacher comments towards the end of Jacob's fourth-grade school year, indicating that Jacob's mother, Teresa Tooley, had begun not returning phone calls or responding to notes sent home regarding missing homework. Teacher comments share concerns that when Jacob was questioned about missing homework, or progress notes requiring parent signatures were beginning to not be returned, Jacob would grow unusually negative, telling his teacher that his mom was sick, his dad was working extra jobs and to stop trying to bother them. The comments also reflected a change in Jacob's demeanor with his classmates. Mrs. Simmons tells you that at the beginning of the school year, she had the class do a journal writing assignment about “What I did over the summer.” She shows you a copy of Jacob's journal entry. The picture showed Jacob, his brother, and his dad, all with sad faces. When the children were asked to share their assignments, Jacob refused. Mrs. Simmons explains that she set up a teacher-parent conference and found out that Jacob's mother had passed away over the summer. Mrs. Simmons explains that she and Mr. Tooley hoped that Jacob's behavior would improve if he had some time to mourn, but things have only gotten worse. You agree to meet with Jacob to find out more.

   Jacob walks into your office with a sullen look on his face and flops onto a seat. You ask if he would like to play with any of the toys in your office and he glares at you.

   “I don't even like any of these baby toys,” he says.

   “Well, good thing I have some tough action figures for older boys,” you reply, pulling down a box from your shelf.

   “I guess these are OK,” he grudgingly admits, “but my big brother says toys are for little wimps. He's right.”

   “Do you spend a lot of time with your brother?”

   “Maybe,” Jacob retorts, glancing at you from the corner of his eye with suspicion.

   “What kind of stuff do you all do together?” you ask.

   “None of your business!” Jacob retorts.

   You try to engage Jacob a few more times, but he consistently refuses to give any detailed information about what's going on at home.

   After finding that Jacob's home phone has been disconnected and hearing that Jacob's father drops him off at school, you decide to wait outside to quickly talk to Mr. Tooley in the morning. When Mr. Tooley drives up in the morning, . . . introducing yourself, you explain that you would love to sit down with him one day before or after school because of concerns about the changes in his son's mood. Mr. Tooley looks exhausted but concerned. He agrees to come in the next week, as long as it doesn't take too long because he has work.

   Mr. Tooley looks equally exhausted the next week as he appears in your office doorway.

   “I'm so glad you could come in today. I wanted to talk to you about some of the changes the teachers have noticed in Jacob's behavior,” you begin.

   Mr. Tooley explains that life has been very hard since his wife died. You inquire about what this has meant for him and his family.

   “Because of all the bills that have piled up, I started working a second job. Jacob's 15-year-old brother, Brandon, has been looking after Jacob most of the time. It's just how it has to be for right now.”

   You mention that Jacob seems to think that toys are for babies, which confused you for a child his age. Mr. Tooley shifts in his seat uncomfortably and clears his throat. After a moment, he tells you that the other issue with all the debt is they could not afford rent and were evicted from their home.

   “Jacob has been sad for a while. I get that—he's a kid who lost his mom. What I don't understand are these angry outbursts. They're about the most minor things. I took Jacob for his physical in the fall, and asked the doctor about him acting up. The doctor said he could not find any sort of problem that would explain Jacob's outbursts. He just told me to be patient. I didn't know it was getting so bad at school. Working two jobs, I have a hard time keeping up.”

   You ask Mr. Tooley to tell you a little more about his son's behavior at home.

   He shares that Brandon complains constantly about having to care for Jacob, and that it has only gotten worse.

   “He'll start screaming if I don't make his breakfast just the way his mom did, for example,” Mr. Tooley explains. You ask how Brandon handles caring for Jacob, and Mr. Tooley shakes his head.

   “Brandon has struggled ever since his mom died. He's pretty hard on Jacob, but then again Jacob is so difficult. I wouldn't leave Jacob with him if I had any options. I just can't afford any of these after school programs.”

   After hearing about all of Mr. Tooley's experiences, you tell him, “It sounds like you care about your children very much and are doing what you can to provide for them. Because Jacob seems to be in a difficult spot right now, I want to make sure I support you in getting him what he needs. Do you think that you'd be interested in taking him to a place that can give him weekly counseling to help resolve some of these complications from losing his mother?”

   Mr. Tooley nods his head. “I didn't even know there were places for kids to get special help like that. I think I'd almost given up because life is just so impossible this last year. I'm worried about the costs and my work schedule, but I'll do whatever I can to get him there.”

   You assure that the Children's Guidance Center has a sliding scale. He wonders how referrals like this work. “If you give me permission and sign this form, I can contact a social worker at the Child's Guidance Center and give her your name.”

   “Thank you very much.”

· 5.4–1 What resources could help Mr. Tooley with the difficult situation in which he finds himself?

 

· 5.4–2 What are Mr. Tooley's strengths?

 

· 5.4–3 What are some factors that may be impacting Jacob's emotional and behavioral issues?

 

· 5.4–4 What are some possible diagnoses you are considering for Jacob?

 

· 5.4–5 What are some possible referral sources you might make for Jacob and his family?

 

· 5.4–6 What is your primary diagnosis for Jacob and give your rationale for this diagnosis?

 

· 5.4–7 List the V codes associated with this diagnosis?

 

Case 5.5

Identifying Information

Client Name: Sissy Stone

Age: 10 years old

Ethnicity: Caucasian

Educational Level: Fifth grade

Parents: Melissa and Todd Stone

Foster Parent: Mrs. Nash

Background information

You are a CPS (Child Protective Services) Social Worker working for the state of New York. You have been assigned a case involving a 7-week-old infant female, Cherie, and her 10-year-old sister, Sissy. Cherie was born with a high toxicity level of crack/cocaine. You have already found a temporary emergency placement in CPS custody for both Cherie and Sissy, while further family assessments are being completed. Unfortunately, the children's placements are not with the same families. You have been contacted by Sissy's temporary foster mother, Mrs. Nash, indicating that Sissy is having an extremely difficult time and is refusing to go to school.

Intake Information

Mrs. Nash is a 45-year-old, Caucasian, single mother with a high school son, Grant, and a collegeaged daughter, Natalie. She works as a foster parent for New York Child Protective Services and has three foster children currently living in her home. Sissy Stone was placed with Mrs. Nash and her three other foster children. Mrs. Nash states that Sissy is avoiding all interaction with the foster family, is crying most of the time, and is not eating well. You agree to visit with Sissy at the foster home this day. After meeting with Mrs. Nash for 30 minutes, you ask to meet individually with Sissy.

Initial Interview with Sissy

Mrs. Nash goes to the backyard and calls Sissy to come into the house. Sissy has been swinging alone on the swing set for the past 30 minutes. You approach her in the backyard and ask her to come and sit on the porch with you.

   “Hi Sissy, do you remember me? I'm the social worker who is helping you and your family while you're staying here at Mrs. Nash's home.”

   “Hi,” Sissy responds despondently.

   “Do you like to swing?” you ask.

   “Yeah, sometimes,” Sissy tells you.

   “I understand from Mrs. Nash that you seem to be really sad. I'm hoping that we can talk about your sad feelings and help you feel better.”

   “When can I go home?” Sissy questions.

   “You miss your Mom and Dad?” you query.

   “I miss my room and my stuffed animals and all my stuff,” Sissy says flatly. She looks down at the ground and you can tell she's trying not to cry.

   “What about your parents?” you ask.

   Sissy looks up and says, “You know Todd isn't my real dad. My real dad died in a motorcycle crash when I was four years old. He was Todd's brother.”

   “Your Dad was Todd's brother?” you query.

   “Yeah, my Mom married Todd after my Dad died,” Sissy replies. “That's why my name is the same.”

   “Do you miss your dad?” you ask.

   “Yeah. A lot. I wish he was still here. No one talks about him at all. It's like everyone has forgotten him. Well, I haven't!”

   “Are there special things about him that you remember?”

   “Yeah. He would do fun things with me. Like make me pizza. He would cut my pizza into funny shapes,” Sissy answers softy, but tries to smile.

   “How much fun! What a great memory. You mentioned Todd. Does he or your mom do fun things with you? Like your dad did with the pizza?” you ask.

   “No. After my dad died, all my mom cares about is being with Todd. And doing whatever stuff she does with all these people that come in and out of the house.”

   “So your mom has a lot of friends that come over and hang out?”

   “No. Not really. There is just a lot of different, weird people that come over and see my mom a lot.”

   “Have you met them? Do you like your mom's friends that come over?”

   “I don't know them. I don't even know if they are friends. My mom usually sends me over to the neighbors when they come over.”

   “What does your mom do with your friends?” Sissy says, “I think they are bringing her medicine.”

   You say, “Medicine? Is your mom sick?”

   “I don't know, but she says the bags they bring are her medicine . . . and then she hides them.” You wait to see if Sissy wants to continue. She stops talking, so you ask, “How old were you when your mom married Todd?”

   “I think I was six years old,” Sissy says and moves a little closer to you. “I remember I was in first grade with Mrs. Levett. She was a really nice teacher.”

   “And you're in fifth grade this year. How do you like the teacher this year?” you ask.

   “She's O.K. She keeps calling to see if I'm coming to school. I just don't feel like going,” Sissy remarks emphatically. She closes her eyes and holds her head between her hands. “I just wish everyone would leave me alone.”

   “What are your favorite things to do? What do you like to play with?” you ask.

   “Nothing anymore; I used to have a best friend, but she told me that she can't come over to my house anymore because her mom said so.”

   You respond, “Did she tell you why?”

   Sissy answers, “She said that her mom said she didn't like my mom and dad because they are never at home with me. She said that she can't even talk to me at school anymore.”

   You lean in to Sissy and gently respond, “That must hurt you and make you feel really sad. Do you ever get angry about that?”

   “All the time! I get mad at her mom for not letting her play with me! My mom and Todd don't like to be around me and now my friends don't like to be around me, but I don't care because I don't like them either. I guess I'm not a good kid. No one wants to ever be around me. Even my mom and Todd. The baby probably won't either.” she answers.

   You ask, “I don't know. Does your mom or Todd ever tell you they don't want to be around you?”

   She answers, “They yell a lot when they come home at night and think I'm asleep. My mom yells at Todd for not helping her and that she can't take care of me and gets mad at him about the new baby and not having money. All she cares about is the baby now. I know she doesn't want to be around me. I don't think she ever has.” Sensing Sissy is getting angry, you ask,

   “Do you ever get angry at your mom and dad?”

   Sissy doesn't answer.

   “It is okay to tell me, Sissy. Sometimes we get mad at the people we love. Do you ever get mad at them?” you say. Crying, Sissy responds, “Yeah, a lot. But it's my fault. I make my mom mad. Sometimes she cries and I know it's my fault.”

   “You know, Sissy, I know how hard it's been for you having to get used to living here and not being at home with your mom and Todd, but you've told me how much you have liked going to school before. It sounds like being at school is a good thing for you to do. All children have to go to school. Does it bother you being away from your mom or Todd?”

   “No. It never bothers me to be away from my mom and Todd, if that's what you're thinking. They never pay attention to me anyways. They are always so busy and don't have time for me, you know. It's like they wish I would disappear. Sometimes I just feel like I'm in the way.”

   “What do you do when you feel like you're in the way?” you ask quietly.

   “I just go to my room and play with my stuffed animals or draw pictures or watch TV,” Sissy says. “They don't really care. All they talk about is the baby.”

   “What about the baby?” you ask.

   “Like how much it's going to cost and stuff like that,” Sissy says.

   “So how do you feel about having a baby sister?” you ask.

   “I don't know. I guess it's O.K. Maybe they'll stay home if the baby is there.”

   “Do they go out a lot?” you ask.

   “Uh huh, they go out almost every night and tell me to go to the next door neighbor's house. Sometimes I go and sometimes I just stay in my room,” Sissy tells you.

   “How does it make you feel when they go out and leave you at home?” you ask.

   “Sort of alone,” Sissy says.

   “Does your mom fix you dinner before they go out?” you ask.

   “Sometimes, but mostly she just tells me to make a sandwich.”

   “So, what about here at Mrs. Nash's house?” you ask. “It sounds like Mrs. Nash would like to fix meals for you, but you're not eating much.”

   “I'm just not hungry. Sometimes she wants me to come eat breakfast with everyone, but I'm tired and just want to be by myself,” Sissy responds.

   “You've mentioned several different things. I care about you and want to make sure I understand better. You said you were tired and want to sleep. Does this happen a lot?” you ask.

   Sissy looks up at you in an apprehensive way, and says, “Why? Are you a doctor?”

   “No, just someone who wants to help you feel better,” you answer.

   “Sometimes I get bored and fall asleep. Sometimes I talk to my stuffed animals and fall asleep with them. I used to have some best friends and we would play a lot together. But I don't like the same games and stuff anymore and would rather play by myself” she says. Sissy pauses and looks away, starting to cry, hiding her face, and says, “I don't like people to see me crying. So I cry by myself where they can't see me.”

   You continue and ask, “Do you feel better when you cry?”

   “I don't know. I just do it. I can't help it. Sometimes I just cry. Sometimes I just fall asleep,” she answers.

   “When do you cry the most, Sissy?” you ask.

   Sissy waits to answer. Finally, she says, “When my mom and Todd forget about me” (pausing as she starts to wipe her eyes).

   “Are there any other times you cry?” you ask.

   Sissy answers, “When I'm at school and see everyone playing and having fun. Like I used to. My friends don't play with me anymore because I don't like to do anything. They just want to run and chase boys on the playground. They're all stupid. They yell, ‘Sissy is a Sissy. Sissy is a Sissy.’ So I sit alone a lot. And sometimes I cry in the bathroom when kids pick on me.”

   “It must be very hard to be made fun like that. I'm so sorry that kids can be so mean. I didn't like to be made fun of in school when I was your age and I still don't like it. I still really get mad when I see kids picking on each other,” you say.

   Surprised, Sissy asks, “You do?”

   “Sure I do. Especially when I hear that they are picking on a new friend of mine,” you answer.

   “Am I your friend?” she asks.

   “Yes, you are. I hope you will be my friend also,” you say.

   Sissy scoots as close to you as she can, answering, “I like you. I think I would like to be your friend.”

   You respond, “Since we are friends, are you okay if we keep talking for a little while?”

   Sissy shrugs and says, “Yeah, but is it okay if we go swing?”

   “How about if we sit here for a while and talk some more and then go swing?” you answer.

   Sissy nods yes.

   “Great,” you say. “Before kids started teasing you, did you use to like school, Sissy?”

   “Yeah. A lot. It was my favorite place to be. I had lots of friends and I like to read and go to art class. It's not that I don't like being at school, I just don't want to go now. I'm scared about my mom. She has to take her medicine and I don't know why. I'm scared about my new baby sister. I haven't seen her yet. No one will tell me anything about anybody. They don't care about me. No one does, but they should because, well, because I'm the big sister. I can help, but no one is letting me.”

   You and Sissy sit quietly for a little while. She finally speaks up and says, “I'm glad you are my new friend.”

   “I am too, Sissy. I am going to work really hard at getting your family back together again. I think that you are going to be the BEST big sister in the whole world. You have so much to teach your new baby!” you say.

   Sissy slumps back down, “I don't feel like that.”

   You wrap your arm around Sissy's shoulder for the first time and say, “I bet you will soon. Thank you for letting me sit and talk with you.”

   “That's ok. It hasn't been that bad,” she answers.

   “Do you want to go inside or would you rather stay outside and swing some more?” you ask.

   Sissy looks down, glances over at the swing set and begins to walk to the swings. “Can I talk to you again?” she asks you.

   You answer, smiling, “Anytime you want to, Sissy. I will be visiting you, but Mrs. Nash has my phone number and you can call me anytime. Also, can I come swing with you?”

   Sissy smiles and says “Yes!”

Additional Information from Teacher and School Counselor

Following the home visit with Sissy, you decide to schedule an appointment with Sissy's teacher and the elementary school counselor. From meeting with them, you learn the following:

· 1. Sissy's teacher, Miss Alexander, states that Sissy has always been a good student. She is friendly, outgoing, and a responsible child. She appears at times to be somewhat more mature, and at the same time, overly sensitive compared to her peers. In addition, she states that Sissy has seemed very unhappy and withdrawn at school. . . . noting that she isn't participating in activities or playing much with friends. Miss Alexander appears to be very fond of Sissy and is concerned about her current situation. She has made phone calls to check on her and is willing to help get her back in school.

· 2. Mrs. Gaylord, the school counselor, states that up until recently, she has not had much contact with Sissy or her family. She says that several weeks ago, Miss Alexander visited with her and shared her concerns about Sissy, including the fact that Miss Alexander has not been able to reach either of Sissy's parents. As well, her parents have never come to a child-teacher conference, nor any of the classroom parties. She told Mrs. Gaylord that while Sissy is outgoing in her classroom, when asked about her family life, Sissy generally stays fairly quiet. You inform Mrs. Gaylord of Sissy's current situation, sharing with her that she is in temporary foster care. You thank Mrs. Gaylord for her time and give her your contact information and let her know that you will keep her updated on Sissy's status.

· 5.5–1 What additional information would you like obtain from Mrs. Stone's neighbor?

 

· 5.5–2 List five symptoms you observed in Sissy.

 

· 5.5–3 List environmental factors that you might have to overcome in order to help Sissy.

 

· 5.5–4 What are the possible diagnoses you are considering for Sissy?

 

· 5.5–5 What is your primary diagnosis, and how did you come to this decision?

 

· 5.5–6 List the cultural and psychosocial factors as V or Z codes associated with this diagnosis.

 

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6 Anxiety Disorders

Disorders

Anxiety is a normal human emotion that is often adaptive and is recognized as the anticipation of a prospective threat (that may or may not happen). For example, many of us may study for an examination because of anxiety about failing (rather than because of a real love of learning). The diagnoses in the “Anxiety Disorders” section of the DSM-5 ( APA, 2013 ) represent more chronic and extreme states of anxiety as well as behaviors developed to forestall anxiety. In any event, the specific diagnoses presented in this section relate to anxiety that is sufficiently severe to cause significant clinical distress and/or disruption in psychosocial functioning. Differentiation of anxiety disorders, from one another and other mental disorders (e.g., depressive disorder with anxious distress) can be accomplished by focusing on “the types of situations that are feared or avoided and the content of the associated thoughts or beliefs” ( APA, 2013 , p. 189). For all the diagnoses mentioned in this chapter supporting criteria require that the anxiety must cause clinically significant distress or impairment, which cannot be the result of either another medical/mental disorder or substance induced.

   The first two disorders are more prevalent in children but can occur at anytime in the life cycle. Separation Anxiety Disorder can be diagnosed in adults and children with the only difference being the length of time that the anxiety/fear or avoidance is present with duration criteria being at least one month for children and a minimal of 6 months for adults. The anxiety experienced by the individual is extreme and developmentally inappropriate occurring when separated from home or loved ones/parents/caregivers. For diagnosis, 3 out of 8 symptoms (e.g., excessive distress surrounding separation from home/family) must be present. For example, a child may fear that something “awful” will happen to loved ones if he or she is not present. The child may become so fearful that he or she cannot stay away from home (e.g., at school or camp) without being extremely upset. Adults experience the same symptoms, but the circumstances may differ. For example, a spouse may worry excessively about their significant other and/or children, to the point that it disrupts their own work life or social relationships. The anxiety associated with being away from home is excessive for the developmental level of the individual. Often, parents misinterpret this disorder as being fear associated with school when, in reality, it is a fear of leaving home or loved ones. Since children with this disorder often come from enmeshed families, it is often difficult for parents to “let go” and allow the child to experience the discomfort necessary in order to overcome this problem. Parents may also identify a physiological reason (e.g., stomachaches) rather than the psychological reason for the problems the child is experiencing ( APA, 2013 ).

   The other disorder more frequent in childhood (but found in adults as well), Selective Mutism, is diagnosed when an individual willingly fails to speak in situations where speech is expected and is not due to lack of language skills. In some children, it appears to be a coping mechanism for dealing with anxiousness. For diagnosis of this less common disorder, the speech disruption must last at minimum one month (and should not be limited to the first month of school) and must hinder academic or work-related achievement or social/communication skills ( APA, 2013 ).

   The next two anxiety disorders are related to better-specified, anticipated fears. Although some clients suffering from these disorders may experience panic attacks (see panic attack specifier below), others may simply feel a heightened level of anxiety. For example, in Specific Phobias, the client fears some specific object or situation. Consequently, he or she predictably experiences increased anxiety or a panic attack whenever exposed to the feared stimuli and coded based on the specific phobic stimuli (e.g., animal, natural environment). Frequently, the phobia is directly related to a discernible event and is understood by the client to be an “overreaction.” Similarly, in Social Anxiety Disorder (previously social phobia), the specific fear involves at least one type of social or performance situation that involves being “judged” by others (e.g., public speaking, parties). The duration of the social anxiety must last for 6 months or more to meet diagnostic criteria. In children, the anxiety may be conveyed through crying, clinginess, or failure to verbally communicate in social situations and must occur in peer relationships and not just in relations with adults. Furthermore, a “performance only” specifier has been introduced for situations when the disturbance is explicitly related to public speaking or performance ( APA, 2013 ).

   The next diagnosis is more common in adults, with onset usually in the early twenties. Panic Disorder represents recurrent, unexpected panic attacks that cause 4 or more out of 13 symptoms, which may not include any accompanying culture-specific symptoms (e.g., tinnitus) for diagnosis. A panic attack may be defined as an episode of anxiety usually lasting less than a half hour during which the client experiences a number of physical complaints and/or cognitive fears about the outcome of the “attack.” For diagnosis, the disturbance must lead to excessive worry and/or behavioral changes to avoid more attacks with duration of at least one month's time. In contrast, a panic attack although not a mental disorder, often accompanies many mental disorders (e.g., anxiety, depressive, post-traumatic, etc.) as well as medical conditions and should be coded as a specifier when appropriate ( APA, 2013 ).

   Agoraphobia involves intense anxiety focused on two or more, out of five circumstances or places, from which the client may not be able to escape and/or receive help if the anxiety and panic-like symptoms were to become too acute. This criterion is important when differentiating from panic disorder. Additionally, with agoraphobia the client develops patterns of avoiding the situations or places or enduring exposure to them with significant distress or requiring support (e.g., a companion) in order to “handle” the anxiety. Further, the fear, anxiety, and avoidance symptoms that occur are disproportionate to the circumstance and must be persistent, lasting 6 months or more. Often panic attacks and panic disorder co-occur with this disorder, as well as the reverse ( APA, 2013 ).

   At the other extreme, the anxiety and worry associated with Generalized Anxiety Disorder is not focused on the specific fears listed above. In this disorder, exorbitant concern is usually focused on everyday events and tends to shift over a number of events or activities. Moreover, this anxious distress must be linked with at least 3 out of 6 symptoms (e.g., sleep disturbance, muscle tension, irritability) that have persisted over the past 6 months. For children only one symptom is required to meet diagnosis. Although the client may not view the worries as excessive, he or she does experience distress associated with an inability to control the concerns ( APA, 2013 ).

   Two of the diagnoses in this section are determined by the etiological factors relevant to the anxiety disorder. Specifically, Anxiety Disorder Due To Another Medical Condition is used when the anxiety is directly related to a diagnosable organic problem. Similarly, Substance/Medication-Induced Anxiety Disorder is used when the problematic anxiety is directly related to the use of recreational drugs, prescribed medications, or a toxin (e.g., lead, carbon monoxide). When using this diagnosis, the anxiety/panic attack symptoms must be a primary feature that occurs after taking medication known to cause such symptoms and/or with substance intoxication/withdrawal (all which are detailed via specifiers). When a coexisting substance use disorder is present, it is coded along with the severity (mild to moderate/severe) as well as the absence of such a disorder. Furthermore, the symptoms cannot be restricted to a psychotic episode (e.g., delirium). Finally, a diagnosis of Other Specified Anxiety Disorder is included for when an individual's symptoms fail to fit any of the more specific diagnoses but clearly are related to increased levels of anxiety. This allows the clinician to make clear the rationale behind the lack of diagnosis. Whereas, Unspecified Anxiety Disorder is used when the anxiety symptoms fail to meet criteria, but the clinician lacks enough information to denote why ( APA, 2013 ).

   People suffering from an anxiety disorder do not necessarily seek treatment even when symptoms become fairly disruptive. Several issues contribute to this lack of help-seeking behavior. The course of most anxiety disorders tends to be variable, and many clients attain some symptom relief through avoidance strategies. The natural waxing and waning of symptoms is frequently related to stress. Further, “self-medication” is not uncommon for clients experiencing anxiety disorder. Whether relieving symptoms with prescription or recreational drugs, transient symptom relief is quite possible.

   Stigma may also play a significant role in treatment avoidance, with some clients being embarrassed by their anxieties and thereby being reluctant to acknowledge their symptoms. Similarly, some clients may view their symptoms as childish or something they “should be over by now.” Particularly for clients who experience panic attacks, the message from medical practitioners that their symptoms are not indicative of a physical disorder may be interpreted by the client as a dismissal and/or judgment.

Assessment

When assessing someone whom you suspect may have an anxiety disorder, particular attention will be focused on the person's fears and worries. Although a thorough history is required to make a diagnosis of a specific anxiety disorder, it may be difficult for clients to present detailed and accurate information. They may deliberately minimize symptoms because of internalized stigma. It may be difficult for them to discern their internal thought processes. They may be embarrassed by details that, in their minds, are clearly excessive (and perhaps “crazy”).

   Because fear and worry are primarily internal processes, consulting collateral sources may not be useful, particularly in cases when stigma is high. Clients may actively hide the details of their anxieties or may minimize the impact of their situation. Significant others may be “fooled” by such strategies or may actively collude in minimization.

   It should be noted that, particularly, when panic attacks are involved, collateral medical referrals are warranted. Even in situations where the client seems healthy, ruling out serious medical problems is an essential part of the assessment process. To aid assessment, both cross-cutting dimensional measures and diagnostic specific severity measures of anxiety have been included in Section III of the DSM-5 ( APA, 2013 ). These tools can be found on their website as well ( www.dsm5.org ).

Assessment Instruments

Adults The State-Trait Anxiety Inventory (STAI;  Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983 ) is among the most commonly used and researched selfreport general measure of anxiety for adults. It consists of two separate scales, the state anxiety scale and the trait anxiety scale. The state anxiety scale is intended to measure transitory feelings of nervousness, worry, tension, and/or apprehension. In contrast, the trait anxiety scale reflects individual differences in the characteristic response to stress. Generally, an individual with strong trait anxiety is more likely to experience strong state anxiety when exposed to stress. Both subscales have shown sound psychometric properties; however, the state subscale is used more commonly than the trait subscale in clinical settings. The internal consistency for the state subscale is very high, with median alpha coefficients of .90. It has shown good concurrent and discriminant validity.

   A number of more focused scales are commonly used. The Mobility Inventory for Agoraphobia (MIA;  Chambless, Caputo, Jasin, Gracely, & Williams, 1985 ) is a 27-item instrument designed to measure agoraphobic avoidance and the frequency of panic attacks. Specifically, 26 items address avoidance (both when the client is alone and when accompanied), and the final item defines panic and asks the respondent to report the number of panic experiences during the previous week. Estimates of internal consistency have ranged above .90 for this scale, and test–retest reliability has been good over a 1-month period. Known-groups validity has also been demonstrated ( Corcoran & Fischer, 2013 ).

   For a more detailed examination of panic attacks, the Panic Attack Symptoms Questionnaire (PASQ;  Clum, Broyles, Borden, & Watkins, 1990 ) is a 33-item instrument that covers symptoms of panic attacks by having the respondent indicate the duration of symptoms. In addition, the scale allows clients to list additional symptoms and to estimate the frequency of attacks in the past week, month, 6 months, and year. The scale has shown good internal consistency, with a coefficient alpha of .88 and known-groups validity ( Corcoran & Fischer, 2013 ).

   The Social Phobia Scale (SPS;  Mattick & Clarke, 1998 ) and the Social Interaction Anxiety Scale (SIAS;  Mattick & Clarke, 1998 ) are two companion measures for assessing social phobia fears. Both scales were shown to possess high levels of internal consistency and test–retest reliability. They discriminated between social phobia, agoraphobia, and simple phobia samples, and between social phobia and normal samples. The scales correlated well with established measures of social anxiety but were found to have low or nonsignificant correlations with established measures of depression, state and trait anxiety, locus of control, and social desirability. The scales were found to change with treatment and to remain stable in the face of no treatment. Initial validation showed strong to excellent internal consistency and retest reliability and further research confirms strong psychometrics and clinical utility ( Mattick & Clarke, 1998 ;  Rodebaugh, Woods, Heimberg, Liebowitz, & Schneier, 2006 ;  Safren, Turk, & Heimberg, 1998 ). Cutoff scores to help differentiate clinical from nonclinical samples have been reported. ( Carleton et al., 2009 ). However, one limitation of both measures is the absence of items measuring avoidance symptoms, which has been shown to intensify impairment ( Letamendi, Chavira, & Stein, 2009 ). Additionally, a 6-itemed, shortened version of both measures is available (e.g., the SIAS-6 and the SPS-6), which correlate to the original measures and may be of use as a brief screening tool for social anxiety ( Peters, Sunderland, Andrews, Rapee, & Mattick, 2012 ).

   The Social Avoidance and Distress Scale (SAD;  Watson & Friend, 1969 ) is a 28-item, dichotomous, self-report measure of social anxiety defined in terms of distress, discomfort, fear, and anxiety as well as the avoidance of social situations. Items rated as true are scored as a “1”; all others are given the value “0.” Total score (range 0 to 28) is calculated by summing items with higher scores indicative of greater social anxiety. Good internal consistency (.77) and excellent reliability (.94) were reported ( Corcoran & Fischer, 2013 ).

   The Generalized Anxiety Disorder 7-item scale (GAD-7;  Spitzer, Kroenke, Williams, & Löwe, 2006 ) is a brief screening questionnaire that assesses generalized anxiety disorder by measuring 7 anxiety symptoms based on DSM-IV-TR ( APA, 2000 ) criteria, which are basically unchanged in the DSM-5 ( APA, 2013 ). Items are rated on a Likert scale from 0 = “not at all” to 3 = “nearly every day” and scored by summing to produce a Total Score (range from 0 to 21) with higher scores interpreted as greater severity. Good psychometric properties have been reported using the cutoff point of 10, with sensitivity (.89) and specificity (.82) among primary care participants ( Kroenke, Spitzer, Williams, Monahan, & Löwe, 2007 ).

Children The most widely used self-report anxiety scales for children have been derived from adult scales. For example, the State-Trait Anxiety Inventory for Children (STAIC;  Spielberger, 1983 ) was derived from the adult scale mentioned previously. Reliability coefficients for state and trait anxiety were α = .85 and α = .83, respectively ( Spielberger, 1973 ). Although this scale has been used in numerous research and clinical settings, it has not reliably distinguished anxious children from children with other disorders ( Perrin & Last, 1992 ). In particular, these scales based on adult models tend not to distinguish between anxiety disorders and ADHD. The STAIC was originally validated in upper elementary aged children (9–12 years). However, a modified version has been validated in children aged 7 to 9 years ( Nilsson, Buchholz, & Thunberg, 2012 ).

   The Multidimensional Anxiety Scale for Children (MASC;  March, Parker, Sullivan, Stallings, & Conners, 1997 ) was designed specifically for use with children and adolescents. The MASC consists of 39 items distributed across four major factors, three of which can be parsed into two subfactors each: (1) physical symptoms (tense/restless and somatic/autonomic); (2) social anxiety (humiliation/rejection and public performance fears); (3) harm avoidance (perfectionism and anxious coping); and (4) separation anxiety. A brief 10-item version is also available. Test–retest reliabilities have generally been greater than .85. Most important, the MASC has demonstrated discriminant validity among samples of anxious and ADHD children ( March et al., 1999 ). In one study by  Silverman and Ollendick (2005) , the MASC was found to be better than other self-report instruments for discriminating between youth with anxiety disorders and those with other mental disorders (e.g., depression).

   Also, the Child Behavior Check List (CBCL;  Achenbach, 1991 ) is a widely used parent-measure to assess child emotional and behavior problems. See chapter on depressive disorders for full description.

   Interestingly, studies have consistently demonstrated low concordance between child self-reports and parent or teacher ratings in terms of anxiety ( Greenhill, Pine, March, Birmaher, & Riddle, 1998 ). This suggests that the typical reliance on adult reports to diagnose children may be inappropriate with anxiety disorders.

Cultural Considerations

As anxiety is a normal part of the life experience, culture undoubtedly influences what is viewed as anxiety-provoking. For example, the interpretation of unfortunate occurrences may be conceived as witchcraft and, consequently, viewed with intense anxiety by those cultures that subscribe to beliefs in magic (e.g., Haitian and other Caribbean cultures). Similarly, in cultures that have traditionally shielded women from public contact (e.g., some Asian and Arabic cultures), women may exhibit marked fearfulness in certain social interaction, at least initially.

   Also, culture can influence what level of anxiety is considered problematic. For example, worrying can be normative in some cultures, and there may not be a level of worry that is viewed as pathological. Among other cultures displays of emotions are discouraged and a relatively low level of anxiety might be judged pathological.

   Symptoms need to be evaluated in terms of an individual's culture and racial/ethnic background. For example, some collectivistic societies (e.g., Japan, Korea) may report high levels of social anxiety but a low prevalence of social anxiety disorder ( APA, 2013 ). And, although the cultural syndrome taijin kyofusho (interpersonal fear) shares similarities with social anxiety it is understood to be a broader concept and includes criteria for body dysmorphic and delusional disorders. Other cultural syndromes are associated with anxiety disorders, such as trung gio (hit by the wind), which is associated with panic attacks in Vietnamese cultures, and ataque de nervios (attack of nerves), which is associated with panic disorders among Latin Americans ( APA, 2013 ). Therefore, when considering differences in prevalence rates and symptom expression, clinicians need to remember that they may be influenced by possible problems with the validity of diagnostic criteria or differences in measurement equivalence ( Lewis-Fernandez, et al., 2010 ).

   Racial/ethnic factors can impact diagnosis as well. For example, African Americans have significantly more functional impairment in panic disorder than non-Latino Whites. Whereas, non-Latino Whites, African Americans and Native Americans report higher rates of specific phobia over Asians and Latinos ( APA, 2013 ). For many anxiety disorders cultural variations can be seen in symptom presentations such as the predominance of somatic or cognitive symptoms ( APA, 2013 ). Still others submit that somatization of anxiety is universal and should not be depicted exclusively to any particular ethnocultural group ( Kirmayer, 2001 ).

   Typically, the standards for displays of emotion vary by gender. This, in turn, may influence the occurrence of certain conditions. Among anxiety disorders, there is a gender differential with higher prevalence rates reported for women. For example, in the United States, among the general population with social anxiety disorder the female ratio is higher and ranges from 1.5 to 2.2 compared to males. This greater lifetime prevalence for women has been found for most anxiety disorders from specific phobia, agoraphobia, panic disorder, and generalized anxiety disorder as well. New research is proposing that sex differences in receptors for the stress hormones may play a role in this gender difference for anxiety ( Bangasser, 2013 ). Other studies propose that the interplay between biological and psychosocial factors might explain gender differences in anxiety disorders ( Bal, Cakmak, & Uguz, 2013 ). National epidemiological data shows that women diagnosed with an anxiety disorder were more prone to report another anxiety disorder, eating disorder, and depressive disorder ( McLean, Asnaani, Litz, & Hofmann, 2011 ). In contrast, men with anxiety disorders were more likely to self-medicate and have a comorbid substance use disorder ( Bolton, Cox, Clara, & Sareen, 2006 ; McLean et al., 2011; Robinson, Sareen, Cox, & Bolton, 2009). The co-occurrence of substance use disorders with anxiety and mood disorders were positive and significant (<.05) demonstrating them to be amongst the most prevalent psychiatric disorders in the United States ( Grant et al., 2004 ). However, statistics from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; N = 43,093) shows that over the last twenty years this gender differential is diminishing from 5:1 to 3:1 male to female ratio ( Greenfield, Back, Lawson, & Brady, 2010 ).

   Age-related differences are notable among anxiety disorders. For many disorders, such as generalized anxiety disorder and panic disorder, there is greater prevalence in adulthood. For separation anxiety and social anxiety disorders, onset is higher in childhood and adolescence. In agoraphobia, onset is initially late adolescence and young adulthood and reemerges after age 40. Of note, in older individuals clinicians must rule out organic and/or underlying medical conditions ( APA, 2013 ).

Social Support Systems

Anxiety disorders typically do not cause disruptions in psychosocial functioning as serious as those caused by mood or schizophrenic disorders. Many people suffering from anxiety disorders can manage their lives while still avoiding the “triggers” of their anxiety. In these instances, only close friends or family members may be aware of the person's fears.

   However, there are individuals for whom an anxiety disorder results in profound occupational and social impairment. Some of the specific phobias may rule out a realm of occupational choices. Certainly, agoraphobia (with or without a history of panic disorder) puts tremendous strain on most social support systems. Even though in the computer age there may be more occupational choices for someone suffering from agoraphobia, at least some limitations in occupational functioning should be expected in most instances.

   There is also wide variation in how the symptoms of anxiety disorders affect clients' social support systems. Although many clients may acknowledge that their fears are unreasonable, such insight does not usually change behavior. Some people in the social support system may become frustrated that the person can't just put his or her fears aside. In other instances, one or more members of the client's social support system might actually bring some symptom relief by their presence. In these instances, there is some danger that such dependency could disrupt the relationship.

   The social isolation that usually accompanies agoraphobia or social anxiety may affect partners and family members as well. It may limit their social interactions, or they may feel guilt if they continue more “normal” social activities. A number of symptoms (e.g., panic attacks, compulsions) may be viewed as embarrassing and lead to avoiding the symptomatic person. For social anxiety disorder in particular, social supports may prove especially helpful ( Ham, Hayes, & Hope, 2005 ). Furthermore, older adults, particularly males, are less likely to request mental health services for anxiety or reach out to others for support.

   The following are a listing of Internet resources available for individuals suffering from anxiety disorders.

·   www.adaa.org : Anxiety and Depression Association of America is a nonprofit organization dedicated to the advocacy, research, and cure of Anxiety Disorders.

www.nami.org : The National Alliance on Mental Illness is the nation's largest grassroots mental health organization dedicated to Americans affected by mental illness including anxiety disorders.

www.nimh.nih.gov : The National Institute of Mental Health is dedicated to clinical research in an effort to improve the understanding and treatment of mental illness.

Differential Diagnosis

Differential diagnosis can be challenging because in the DSM-5, any mental disorder can have panic attacks as a specifier. For example, panic attacks may occur among people diagnosed with depressive disorders, eating disorders, personality disorders, or any other mental disorder. In these instances, no anxiety disorder diagnosis will be made if the person doesn't meet the full critieria for the disorder. If these symptoms are present, both disorders should be diagnosed, and the clinician must decide which is the principal one in each case.

   Within panic disorder, it is critical to distinguish between expected and unexpected attacks. For example, although the diagnosis of panic disorder depends on a history of panic attacks, at least some of those prior attacks must be unexpected. It should be noted that some people with panic disorder have expected attacks as well. In contrast, expected panic attacks are common in both specific phobias and social phobias. In those instances, unexpected panic attacks would be extremely unusual. Similarly, situationally predisposed panic attacks would be most common in diagnoses like generalized anxiety disorder or PTSD. Most important to differential diagnosis is a careful discussion of the focus and thought content associated with the panic attack.

· 6.DD-1 For Cases 6.4, Mark Abbott, and 6.3, Sam Barnes, construct a brief narrative that you think would accurately reflect the circumstances under which each might experience a panic attack.

 

   Self-medication triggered by panic attacks may lead to comorbid substance-related disorders. However, if anxiety symptoms occur only when a client is under the influence of a substance, the diagnosis would be substance-induced anxiety disorder. To make the differential diagnosis when substances are involved in anxiety disorders, the practitioner must take a careful history of both the anxiety symptoms and substance use.

· 6.DD-2 What are some questions you would ask Rachel Steffenbaum (Case 16.5) to determine whether she has or has had an anxiety disorder?

 

   Finally, a common challenge in making diagnoses relates to ruling out diagnoses that could account for the symptoms of anxiety. Specifically, clinicians are expected to ensure that the symptoms are not generated through the direct physiological effects of a substance (e.g., recreational drugs, prescription drugs, toxins) or through a general medical condition.

· 6.DD-3 In which of the cases in this chapter do you believe that the clinician has adequately addressed the etiological alternatives for the disorder?

 

· 6.DD-4 Pick one case in which the possibility of either a substance-induced or general medical condition cause has not been adequately addressed. List the questions, procedures, and/or referrals that would allow you to rule out these other possible diagnoses.

 

Case 6.1

Identifying Information

Client Name: Gloria Kuhlenschmidt

Age: 33 years old

Ethnicity: Caucasian

Marital Status: Married

Occupation: Computer sales representative

First Contact

Gloria Kuhlenschmidt, a 33-year-old Caucasian female, is a sales representative for a large computer corporation and has made an appointment with you to talk about a new software package designed specifically for mental health counselors. While she is in the waiting room, she picks up several brochures related to anxiety and depression and places them in her notebook.

   You meet Gloria in the waiting room. She is a very attractive, stylish-looking businesswoman who is dressed in a dark gray suit, pumps, and a matching shoulder bag. She has long dark hair, a light complexion, and beautiful brown eyes. She would be considered thin for her height of approximately 5 feet 8 inches. She greets you enthusiastically and seems eager to tell you about her company's software.

   In her discussion about the software product she is selling, Gloria appears to be a very engaging and self-confident woman. However, after conducting her sales pitch for about 15 minutes, she tells you that she really doesn't want to push you to buy the software and to take your time and think about it.

   Gloria then slips the brochures out from her notebook and asks you if you could help someone who had some of the symptoms in the pamphlets. You ask her if she could give you a little more information. Gloria opens one of the brochures and says, “Well, if someone had feelings of shortness of breath, shakiness, numbing sensations, dizziness, heart pounding, and chest pain, do you think you could help the person?”

   You state that you work with a lot of people with a variety of emotional issues and that you have successfully worked in the past with people with those symptoms. Gloria's eyes brighten and she says, “Then, can I make an appointment to see you?”

   You ask rather tentatively, “So, you have had some of these symptoms?”

   Gloria emphatically explains, “Oh, yes, I've been taking Xanax 4 times a day for the last 8 months ever since this incident when I wound up in the emergency room at the hospital thinking I was having a heart attack. The doctor said everything checked out normal but gave me these pills to take. Now, I'm afraid to leave home without them, and I don't know if I want to be on them the rest of my life.”

   “Did the doctor recommend you see a therapist?” you query.

   Gloria states that he just told her to go to her family doctor for a refill of the prescription, but somehow she feels medicated all the time and often feels very tired even at the beginning of the day.

   You decide to set up an appointment for Gloria for the following week.

· 6.1-1 At this point, what kind(s) of disorder do you think Gloria might have?

 

First Session

The following week, Gloria arrives for her appointment 10 minutes early. She, once again, is dressed in a very businesslike manner and appears to be very organized.

   You start the session by asking her how and when these symptoms first occurred.

   Gloria tells you that she got married for the third time a year and a half ago to a man who is also in computer sales. He is a very gregarious man who loves his job. He also loves to race dogs, which he does on the weekends. She, on the other hand, is a musician. She loves to stay at home and play the piano and cook when she has the time. Gloria states that one night she and her husband, John, went to a concert and halfway through the show, she began to have this feeling that her heart was pounding too hard and she couldn't catch her breath. She said she had to leave the concert with John almost carrying her out, which she found very embarrassing. He took her to the emergency room, where the doctor ran some tests, said she was perfectly okay, and gave her Xanax to take 4 times a day. “He said to go to my family doctor when the prescription ran out. My family doctor ran all kinds of tests and kept asking me if I was using drugs or alcohol! I told him my husband and I don't even drink beer or wine, much less do drugs! Finally, he said I was perfectly healthy and just wrote another prescription, asking me if I felt like I had been under a lot of stress lately.” Gloria states that this incident occurred about 8 months ago.

   Gloria states that several of these incidents have occurred since the first one at the concert. She tells you that once her heart starts pounding and she feels like she can't breathe, then she gets shaky, and sometimes it takes a couple of hours to get over the feeling. She states that she worries about having more attacks and is most fearful of an incident happening when she is out. To try to make sure she'll be safe, she has been taking Xanax for the past 10 weeks before she leaves the house.

   You ask her how these feelings have affected her job. She states that she really isn't cut out to be a sales representative. Her previous jobs have involved working with people, but she doesn't like making “cold calls” and feels a lot of pressure to sell since she works solely on commission. “My husband just doesn't understand why this job is so hard for me,” she sighs. “I feel that he doesn't think I try hard enough. He gets up at the crack of dawn and can't wait to go out and sell all day long. Maybe I just don't have the right attitude. I don't really want to push people to buy a product they aren't interested in. I'm afraid my husband also thinks I'm just lazy. I have a very hard time getting up in the morning, and he doesn't like that trait of mine. He almost drags me out of bed. I guess I should get up and get going, but it's just hard for me to do.”

   You ask Gloria how long she has known her husband. She states that they dated for 3 years before they got married. “He's 10 years older than I am, and sometimes he treats me like I'm a child. I feel like I have to do everything perfectly, or I'll get in trouble. He is somewhat of a perfectionist and wants the house clean and everything put away before we go to work in the morning. If I were to do that, I'd have to get up at 3 A.M.”

   Gloria tells you that since these incidents have occurred, her husband doesn't push her so much to get everything done and get out of the house so early in the morning. She states that it seems to take her forever to get out of bed, showered, dressed, and the house cleaned up before she can leave for work. “I feel that everything has to be in perfect order, or he'll be upset.”

   You decide to explore this issue concerning her husband and ask her to explain further what she means when she says, “He'll be upset.” Gloria assures you that it's just a feeling and that he actually never has gotten upset with her. “He's never really said anything about it. He just is always trying to get me to be more motivated to schedule my day like he schedules his day.”

   Gloria states that both she and her husband have a college education and that both of their families are from the eastern part of the state. They don't plan on having children since her husband has a child by his first marriage whom he sees every other weekend. John's son is 17 years old and gets along with Gloria quite well. John and his son go to the racetrack on weekends when they are together. John's participation in dog racing takes up a lot of his free time. Gloria states that she goes along with them occasionally and that it's really an enjoyable way to spend the weekend.

   You suggest that perhaps the pressure of her job might have something to do with these incidents she has been experiencing. Gloria says that she has never thought about that possibility, but “it's food for thought.” You tell Gloria that you believe you can help her figure out what might be triggering these episodes and ways to help her be more relaxed. She states that she would like to continue to see you for at least 10 sessions.

· 6.1–2 What further information would you want to get from Gloria the next time you meet with her?

 

· 6.1–3 What are some of Gloria's strengths?

 

· 6.1–4 Would you want to see Gloria with her husband, John, for a session? Why or why not?

 

· 6.1–5 What is your primary diagnosis for Gloria?

 

· 6.1–6 List the cultural and psychosocial factors that may impact Gloria's diagnosis.

 

Case 6.2

Identifying Information

Client Name: Megan Coleman

Age: 6 years old

Ethnicity: Caucasian

Educational Level: First grade

Parents: Sue and Don Coleman

Background Information

You are a clinical social work practitioner for a children's mental health agency in a large metropolitan area in the Midwest. You have a meeting scheduled with Sue and Don regarding their 6-yearold daughter, Megan.

Intake Information

Sue, age 33, called to make the appointment due to her escalating concerns about Megan's inability to attend school because of constant headaches and stomachaches. She told the intake worker that the pediatrician had seen Megan on three occasions in the past 8 weeks and could find no evidence of illness. The physician had given her a referral to the Child Guidance Center. The intake worker suggested that, if possible, Megan's father, Don, should attend the initial interview along with Sue.

Initial Interview

You meet Sue and Don in the waiting room of the agency. Both look anxious and are sitting on the edges of their seats. When you introduce yourself, they both jump up immediately and hurriedly walk down the hall to your office with you. When they sit down in your office, they are still sitting on the edges of their seats, clutching the armrests of their chairs, and tapping their feet on the floor. You note their anxious expressions and behaviors as you begin the initial interview.

   “I'm glad you could make the appointment today. You both look like you might have a lot on your minds, but before we begin, let me tell you a little bit about the agency and what I do here. The Child Guidance Center is a nonprofit, United Way agency that runs on a sliding-scale fee system, which means that the fee you pay for the services we provide here is based on your income. There is someone here who will talk to you more about that when we are finished here today. We have several programs at this agency, and I'm involved with the Counseling Program. We also have a Big Brothers/Big Sisters Program and a Domestic Violence Program. Do you have any questions so far?”

   Both Sue and Don shake their heads indicating “no.”

   “Great. I want to find out what brought you to the agency today, but first I want to explain to you that everything we talk about here is confidential. I will not share any of the information we discuss today with anyone other than my supervisor, with two exceptions: If you tell me you are going to hurt yourself, I have to tell someone about that; or if you tell me you are going to hurt anyone else, I have to report that also. If I need to talk with anyone else, like a physician or the school, I will get your permission to do that before moving forward. Is all of this information clear to both of you?” you ask.

   Sue and Don both say, “Yes.”

   “Good. I understand that you have some concerns about your 6-year-old daughter, Megan. Can you tell me what's been going on with her?”

   Sue begins, “Well, Megan is a very sweet child. She has always been our angel and has never caused any problems out of the ordinary for us. She is really very bright and has already learned the alphabet and is beginning to read a little, like easy reading books. She also is mesmerized by the computer and has learned her numbers and beginning addition with the computer games. She loved kindergarten last year. We sent her to our church kindergarten, and she really seemed to enjoy being with the other kids and learning new things. But this year has been a completely different story.”

   “What's happened this year?” you ask. “She's started first grade, I assume.”

   “Oh yes, she started in August, so it's been about 3 months now, and she was doing fine the first week.” Sue rolls her eyes and rubs her forehead.

   “And then what happened?” you prompt.

   “Well, on the Monday morning of the second week of school, she woke up and said her stomach hurt. I suggested maybe she was hungry and would feel better after breakfast. She got up and ate breakfast, and the minute she finished she said her stomach hurt even more. I suggested she go get dressed for school and see if she didn't feel better, and she burst into tears and said she had a stomachache and she felt terrible and she couldn't get dressed. She threw a regular tantrum, and so I decided she must really be sick and told her that maybe she needed to get back in bed and stay home that day. She immediately stopped crying and went to her bedroom and climbed into bed. Since this just isn't how she usually acts, I thought she must really not be feeling well.

   “So, she stayed in bed all morning and watched TV, and by lunch time she was feeling much better. She got up and helped me around the house and played all afternoon. Then she ate a good dinner. And I thought everything was okay. But the next morning the same thing happened. She started complaining about her stomach hurting as soon as she got up and started screaming when I said I thought she'd be okay at school, although I told her if she wasn't, she could have the teacher call me.”

   “She stayed home the second day?” you ask.

   “Yes, and the third day, and that's when I made an appointment at the doctor's office.”

   You ask Don what his thoughts and feelings were regarding Megan's stomachaches.

   “Well, I didn't know what to think. Maybe she was really sick. Maybe she got food poisoning or something. I agreed with Sue that Megan needed to go to the doctor, but the doctor said he couldn't find anything wrong. The next day after seeing the doctor, we really pushed her to go to school. Sue was going to take her in the car, and Megan got as far as the front door of the school and began crying hysterically, saying she had a bad stomachache again. Sue didn't have much choice but to take her home. But now things are out of control. Megan has been home for 8 weeks and to the doctor three times, and he says there's nothing physically wrong with her. He says he thinks there is something psychological going on and we need to come here. I don't know; maybe we need to take her to a specialist,” Don replies.

   You ask Sue if she agrees with her husband's perspective on things.

   “Yes, he's got it right except he's not home when she suddenly gets better every afternoon and is ready to go outside and play. I'm so frustrated and confused by all of this I don't know what to do anymore. And, in the meantime, she's missing all this school.”

· 6.2–1 Write a short summary of the presenting problem.

 

   You decide you need to gather more information about the family composition. You ask Sue and Don about any other children or relatives.

   Sue responds, “We have a 2-year-old child, Donny. He's a handful. He keeps me busy 24 hours a day, 7 days a week. Little boys are so different from little girls. He is very active. I don't think he ever walked. He went from crawling to running. I have to keep my eye on him every minute.”

   Don chimes in, “My parents also live nearby. Sue's parents live in Florida, but my parents and my sister are right here. They sometimes take Donny and Megan for the evening or to spend the night so we can go out every once in a while. We all get along real well.”

   “How has it been for Megan when you leave her with your parents or a baby-sitter?” you ask.

   “Well, we haven't been able to do that for the last couple of months because we've been too worried about her being sick,” Sue responds. “So, actually, since all of this started with Megan, we haven't been out at all. One time Don's mother came over and watched the kids in the afternoon when I had a meeting to go to, but other than that, I haven't been away from them for the past couple of months.”

   “So, I assume, Sue, that you are a full-time mom and, Don, you work full-time. Is that correct?”

   “Yes, I have a job with a computer company here in town, and sometimes I have to work from 7 A.M. until 7 P.M. and some Saturdays. I'm gone a lot, so I don't see everything that goes on at home the way Sue does,” Don responds.

   “Have you noticed anything else that has been different in your family over the past year or so or with Megan?” you inquire.

   “Well, ever since the pediatrician told us we needed to come here, I've been thinking of every little thing that might've upset Megan,” Sue responds. “We really are a very close-knit family and do everything with our kids, but I did think of one thing I've noticed over the past year that's been different with Megan. You see, she seems to have developed a little resentment toward Donny. It seems to me that it happened about the time Donny started to walk. Before that time, when he was just a baby, Megan used to be my big helper and liked to play with Donny and help me feed him and get him dressed and stuff like that. But, after he started walking, Megan seemed to resent him taking my attention away from her in a way.”

   “Then you've noticed that Megan gets angry when you're paying attention to Donny. What does she do when you notice she's feeling this way?”

   “Well, for example, the other day I was playing with Donny on the floor while I was waiting for something to cook in the microwave. There were several cars and trucks on the floor, and Megan came in the room. I asked her if she wanted to play with us. Although she didn't look too happy, she sat down next to me and starting playing with some of the little cars. Then the microwave buzzed, and I went in the kitchen to fix dinner. When I came back just a few minutes later, Megan had taken all the little cars and hidden them behind the couch where Donny couldn't find them. When I asked her what happened to the toys, she just smiled and said, ‘I don't know; I guess it's time to play with the dolls now, Mommy.’ There have also been many times when I'm tending to Donny and she becomes very quiet and just goes off to a corner and sulks for a while.”

   “Sue, how long has this type of behavior been going on?” you ask.

   “Well, probably for about 6 or 8 months now.”

   “And I've noticed that she seems to get mad more often and it always seems to be related to Donny somehow,” Don offers. “I somehow thought that was just normal kid stuff though.”

   “Do you think it's possible that Megan might feel she might be missing something that's going on at home with Donny when she goes to school?” you ask.

   Sue and Don agree that this might be a possibility. You explain to Sue and Don that you think you can help Megan with the problem she's having with school, but you will need their cooperation. First, you would like to have Megan come in for a halfhour session, followed by a half-hour session with Sue and Don. They agree to this arrangement and schedule another appointment when they can bring Megan to the agency.

· 6.2–2 What strengths do you assess this family to have?

 

Initial Interview with Megan

When Megan comes to the agency for an initial play therapy session, you observe that she is sitting very close to her mother in the waiting room on the couch. Sue is reading a book to her, and when you come into the room, Megan holds on to her mother's arm when you suggest she can come back to your office and play for a short time. You tell Megan that her mother will be right here in the waiting room and won't go anywhere while you and Megan are playing together. Sue encourages Megan to go with you, and Megan, somewhat shyly, agrees to go with you.

   She tells you she likes to play dolls, and you give her the family of dolls (mother, father, girl, boy) and tell her she can make up a story for the dolls. In the first story, the little boy is bad and the little girl is good and the parents are mad at the little boy and punish him by making him sit in the corner. In the second story, the little girl goes to sleep, and the rest of the family goes away leaving the little girl alone. When you ask her about school, she says that she liked it at first and then she didn't like it at all. You ask Megan why she doesn't like school now, and she tells you that she doesn't know—it just makes her cry.

· 6.2–3 Based on this interview, what is your preliminary diagnosis for Megan?

 

· 6.2–4 List the cultural and psychosocial factors that might impact Megan and her diagnosis.

 

· 6.2–5 What steps would you initially take to try to get Megan back into school?

 

Case 6.3

Identifying Information

Client name: Sam Barnes

Age: 19

Ethnicity: Caucasian

Education: College sophomore

Background Information

You are working at a college counseling center and are scheduled for your weekly intake appointment with a student, Samuel Barnes, who called the center expressing concern about his romantic life. He denied any suicidal or homicidal ideation nor did he seem to be in crisis when he talked to the triage social worker, so he was scheduled for a regular intake appointment with you. You note that based on your computer records, this is his first visit to the counseling center.

Initial Interview

You look at Samuel's intake forms before meeting him in the waiting room. He has a 3.9 GPA and is currently taking pre-major coursework for mechanical engineering. On the intake questionnaire, Samuel indicates that he has a good relationship with his family and does not report abusing any kind of substances. However, he does rate himself as lonely. In the section of the questionnaire devoted to substances, you also see that he is not on any medications and reports that the only drugs or alcohol he consumes on average is one to two beers per month. You notice that he indicated on the form that this is his first time coming to counseling.

   Meeting Samuel in the waiting room, you see that he is cleanly dressed in jeans and a t-shirt. He smiles as you greet him. Bringing him into your office, you introduce yourself and ask what name he goes by. He clarifies that he prefers Sam. After explaining the set-up of the counseling center and discussing confidentiality, you begin talking to Sam about what brought him to the counseling center.

   “I saw that this is your first time coming into the counseling center,” you note, “Congratulations on taking this step. I know it can be a difficult decision. How are you feeling about being here today?”

   “I saw a poster on the bus, and I decided I might as well give it a try,” Sam says.

   “So what's been going on that made you decide to give it a try?” you ask.

   “Well, I've been thinking for a while that I really want a girlfriend. I just can't bring myself to talk to girls. I don't know what this flirting thing is about and I just feel like I don't get it.”

   “It sounds like you are attracted to women, but you feel a little uncomfortable trying to get to know a girl. Can you tell me more about how you feel around girls?” you wonder.

   “I just get really nervous. I'm afraid I won't say the right thing and they will just laugh at me. I'm not the smoothest guy, you know? But then, I'm afraid if I don't talk to girls at parties, people will think I'm gay or something.”

   “That sounds really stressful. How do you handle things in those situations?”

   “To be honest, I just don't go. I'd rather play video games in my dorm room than feel weird and awkward all night.”

   “Have you had any bad experiences with girls or dating?”

   “That's the thing. I'm almost 20 and I haven't even had a girlfriend. My brother Mike has had tons of girlfriends and he's like 23. I'm pretty sure there's something wrong with me.”

   “Have you ever talked to him about girls and dating?” you ask.

   “He thinks I'm a dork,” Sam says looking at the floor. “He's always told me I'm just a computer nerd and I'll never find a girl if I just sit in front of a computer all day. It's really hard, though. I don't know what to say and I feel completely out of place when I do anything socially,” Sam blushes.

   “Do you have trouble with all social situations or just when it comes to talking to girls?” you ask.

   “I'm better in small groups of guys. I have a couple of friends I hang out with occasionally but they have both gotten girlfriends in the past year so I don't see them as much as I used to. Sometimes, I think it would be easier if I had someone to go to the party with me but that never happens. My mother says I should just go and stop being so shy but when I try, I get so nervous it's not even worth it.”

   “On a scale of 1–10, how anxious would you say you get if you were to go to a co-ed party?” you ask.

   Sam thinks for a moment and then says, “Well if it's a small party probably a 7 or 8. If it's a big party I'm almost panicked so I'd say close to a 10. It's horrible. One time I almost had a panic attack and practically ran to my car to get away before anyone saw me.”

   “Sam, do you get this anxious in other situations, for example, going to class or to a movie or out to dinner?” you suggest.

   “Not if I go with someone I know,” Sam tells you. “But that doesn't happen very often.” “I don't know why I get so nervous. I try to tell myself there's nothing to be so nervous about but it doesn't really help. I'm OK going to class but I think it's because I know I can sit in the back and I don't have to talk. I'm not a loner. In fact, I hate feeling lonely. I want to have people in my life. So, why do I get so anxious?”

   “Do you feel like people are judging you?” you query.

   Sam thinks for a minute. “Yeah, I guess I do. I feel like people are looking at me and thinking “what a nerd” or “look at that weird guy over there.” When I was young, my mother always made me do things I didn't want to do. Like she made me sign up for soccer even though I hate soccer. I was miserable the whole time I was on the third string soccer team. Then she made me take dance classes when I was 12 years old. It was even worse than soccer. I would sit in a corner and only participated when the teacher dragged me onto the dance floor. What a nightmare!”

   “Sounds like you developed very negative feelings about social activities at a fairly young age,” you suggest. “And, maybe, even now when you're older, you still experience those bad feelings in anticipation of the event—like talking to girls.”

   “I never really thought about it like that,” Sam muses. “Like I'm transferring the feelings from one experience when I was younger to the present day.”

   “Yeah, and maybe you're not the same person you were when you were 10 or 12 years old,” you respond.

   “But the feelings are still there,” Sam replies waving his hand in the air. “The feelings control my life,” he says with exasperation.

   “Well, right now, they do. But maybe we can work on separating the feelings you had when you were young from the feelings you have today and at the same, time learn some strategies for when you want to engage in a conversation with a girl or go to a social event.”

   “Do you think it's something I can learn how to do?” Sam says with surprise.

   “Yes, and I think you have already figured out one possible reason why you've been having trouble,” you suggest. “Sam, how has it been talking to me today?”

   Sam smiles, “Actually, a lot easier than I expected when I walked in the door.”

   You nod and acknowledge Sam's insight. “I'd like to schedule another appointment in a week,” you suggest. “Maybe you could write down times when you feel yourself getting anxious and note the time and place. Then, in another column rate how anxious you felt on a scale from 1–10. Bring it with you the next time we meet and we can talk about it.”

   “Sure, thanks for not laughing at me.” Sam gets up looking more relaxed than earlier in the session.

· 6.3–1 What do you observe to be Sam's strengths?

 

· 6.3–2 What are some resources that could benefit Sam?

 

· 6.3–3 What is your preliminary diagnosis for Sam?

 

· 6.3–4 List the V codes for the cultural and psychosocial factors that could impact Sam's diagnosis.

 

Case 6.4

Identifying Information

Client Name: Mark Abbott

Age: 29 years old

Ethnicity: Caucasian

Marital Status: Single

Intake Information

Mark Abbott, a new surgical resident at the hospital where you work, telephoned you and stated that he has been having some difficulties with his job and would like to talk with a therapist. An appointment was scheduled for the following day for Mark to meet with you.

Initial Intake Session

Upon meeting Mark in the waiting area, you observe that he is a tall, attractive young man who appears to be nervous. He paces back and forth in front of a large window overlooking the hospital grounds. He shakes your hand but has difficulty making eye contact with you. He follows you to your office without making any conversation.

   Mark seems anxious and uncomfortable seated in a chair next to your desk. You ask him if he'd like some water, which he accepts gratefully. He glances at the pictures on the walls as he taps his foot on the floor. After explaining what you do as a counselor, you ask Mark what he wanted to discuss with you.

   Mark states that he is a first-year surgical resident at the hospital. He did well in medical school and in his internship in another, smaller hospital, but he is having difficulties with his new job as a surgical resident. He is beginning to wonder if he's chosen the wrong field.

   “Why do you think surgery might not be the right field for you?” you ask.

   “Well, it's been a difficult adjustment for me coming to this large metropolitan hospital. Maybe I'm just a small-town type of guy. I'm not used to having to perform for so many people,” Mark tells you. You notice that Mark's voice is a bit shaky.

   “What do you mean exactly that you have to perform?” you inquire.

   “Well, unlike the small hospital where I did my internship, this is a huge hospital. The operating rooms have observation booths, and there are senior physicians and medical students up there all the time watching everything I do when I'm operating,” Mark says anxiously.

   “And it bothers you that they are watching you?” you ask.

   “Well, yes, it makes me extremely nervous. In fact, it's making me so nervous my hands begin to shake, and there have been times when I didn't think I could stand up. I've got a microphone attached to my scrubs, and I'm supposed to be explaining what I'm doing. I can hear my voice shaking when I talk. It is so embarrassing, and I'm sure everyone can tell I'm nervous as a cat.”

   “How long has this nervousness been going on?” you ask.

   Mark thinks for a moment and then says, “Well, if you want to know the truth, I've always hated performing in front of other people. I'm just not good at it. I never played sports in high school or college because I didn't like the idea of people watching me perform. I learned to play the violin when I was very young, and I hated having to play in recitals. I can remember throwing up before big recitals where I was being graded. I guess some people might have considered me a nerdy kind of guy. But it never really bothered me because I always made good grades and did well in school, so I never really worried about it much before. I just didn't put myself in situations where I'd have to perform.”

   “Okay, so you can remember getting nervous when you had to play the violin in front of people when you were young, and you avoided other situations where you might have to perform in front of others. So, it's been okay until recently. Is that correct?” you inquire.

   “Yes, I've been okay until I came to this hospital a couple of months ago. I do okay with one-on-one situations. For example, if I'm talking to one other person, I'm not too nervous about it. But if I've got to get up in front of an audience, I worry about it for hours before doing it, and then I'm a mess when I'm trying to do something in front of a crowd. I know it's really ridiculous how I react, but I just can't seem to control it,” Mark responds.

· 6.4–1 What diagnoses are you considering at this point? What aspects of Mark's situation are of most interest to you to explore?

 

   “It's not that uncommon for people to feel uncomfortable when they are presenting to an audience,” you suggest. “Let me ask you some questions about your experiences when you're in front of an audience. You said that you feel very shaky and your voice trembles a little. Do you have a hard time breathing?” you ask.

   “No, but I do break out in a sweat,” Mark responds.

   “Does your heart feel like it's beating too fast?” you ask.

   “No, not really, but I'm aware of the fact that I'm nervous,” Mark responds.

   “What about nausea? Have you ever felt like you're going to throw up?” you inquire.

   “No, just overly anxious, I guess,” Mark states.

   “Have you ever felt panicky or like you're going to faint?” you ask.

   “No, I just feel like I can't control the shakiness in my voice or my hands,” Mark states. “And when I'm in the operating room, that's a big problem.”

   “I'm sure it could be,” you suggest. “What about in other situations? For example, if you go to a party, do you feel the same kind of nervousness or anxiety?” you inquire.

   “Well, honestly, I don't go to many parties. I don't really like parties much. Probably because they do make me anxious and uncomfortable. I don't mind going out with a small group of people, like if I have a date and another couple comes along. That's okay with me.”

   “Okay. Are there any other situations that you can think of that make you feel anxious?” you ask.

   “Well, the only other one is when I have to do a case presentation in front of a big group of doctors. Grand rounds, for example. That makes me very nervous, too,” Mark tells you.

   “So, it sounds as if whenever you have to get up in front of an audience and either perform or speak that it can make you feel very anxious. Is that right?” you ask.

   “Yes, exactly. I'm okay as long as I don't have to get up in front of an audience, but I can't avoid it at this hospital, so I need some help getting this anxiety under control,” Mark says.

   “Mark, I think this anxiety you're experiencing is something that can be resolved. Would you be willing to come for several sessions so we can work on it?” you ask.

   “Sure, I'll do anything to get rid of this problem,” Mark says with relief.

   You schedule another appointment, and Mark appears much more relaxed when he leaves your office.

· 6.4–2 Clearly, Mark's focus is on how his fears might influence his career. What impact do you think Mark's fears have had on his social functioning?

 

· 6.4–3 What do you see as Mark's primary strengths? Do you think he sees these as strengths?

 

· 6.4–4 Would you explore why Mark chose a big hospital for his residency even though he knew he had these performance fears?

 

· 6.4–5 What is your preliminary diagnosis for Mark?

 

· 6.4–6 List any psychosocial or cultural factors that may be impacting Mark's life.

 

Case 6.5

Identifying Information:

Client name: Peggy Wilson

Age: 45 years old

Marital Status: In a committed relationship

Occupation: Manager, casual dining restaurant

Children: Candyce, age 25, living independently

Background information

You are a hospital social worker in the cancer department. Peggy is undergoing chemotherapy for breast cancer. She attends a weekly support group for cancer patients that you lead. Lately in group she has been expressing a lot of concerns and requested to meet with you individually, at the strong suggestion of Briana, her partner. Although your position does not allow you to conduct individual therapy, you are allotted several weekly assessment appointments for ongoing clients, so that you can refer them on to an appropriate care provider. Peggy is an outgoing and intelligent manager of The Bread Factory, a casual dining restaurant. She has a very high paced, stressful job that often requires her to work 10–12 hours a day. She is concerned that she has had to take off work due to her illness. Peggy's prognosis is excellent, and she has expressed openness to examining her life, referring to her cancer diagnosis as a “wake up call.”

Assessment Interview

You meet Peggy at the cancer treatment center in a private room after her doctor's appointment.

   “Hi Peggy, come on back. I've located a room where we can talk,” you greet her in the waiting room.

   Peggy smiles and follows you to the room. She sits in a chair across from the desk. “How are you feeling today?” you ask.

   “I'm feeling pretty good today,” she responds. “Much better than last week, at least physically. My bigger problem and the reason I wanted to talk to you is that I have a hundred things on my mind that I can't seem to shake. So, if I'm not focused on one particular thing, I just take off and feel like the weight of the world is on my shoulders. I'm losing sleep because I can't shut my mind down.”

   “Okay, can you give me some examples of the type of things you're thinking about?” you ask.

   “Oh yes,” Peggy replies. “Let's just take today for example. I woke up and began immediately thinking about my job and how they weren't going to allow me to be off forever. I began thinking I should call my boss and find out what he's thinking but then I thought I didn't want to bring it up and make it an issue. Then I went from there to thinking about my daughter, Candyce, and what she must be feeling with a mother who has breast cancer. It was hard enough for her to accept the fact that Briana and I were living together but when I was diagnosed I just thought she would fall apart. On the other hand, she didn't fall apart and she's been very helpful even though she has to work and can't be here all the time. She's actually been great and seems to be a very resilient young woman. Then by the time I had my first cup of coffee, I was thinking about what happens if I get sicker and who will take care of the bills and that Briana has a lot on her plate and what happens if she decides she can't handle it and on and on. Do you see what I mean? I know some of this isn't realistic but I get myself all tied up in knots about this stuff that probably won't even happen. There are times when I am just exhausted by the end of the day and I don't think it's just because I have cancer. I think it's because I have been worried about all this little stuff all day long.”

   “Okay, it sounds like you're worrying about a lot of things that you might not have been so worried about before the cancer. Is that correct?” you respond.

   “Yes, exactly. Before I was diagnosed, I just moved through the day and was so busy I didn't have time to worry about all these little things. But, now, I can't stop worrying and it's not even important stuff a lot of times. It can even be things like whether it might rain tomorrow, for goodness sake. Why am I worrying about rain when I should be concerned about my health? I don't get it, but I can't seem to stop.”

   “Do you notice that you begin worrying about these things at certain times of the day or after certain things happen? For example, do you worry more after you've had a chemo treatment?” you inquire.

   Peggy thinks for a minute. “I don't think so. It seems pretty random to me.”

   “You know, I don't think it's that unusual to be worried after being diagnosed with cancer. And you've had a lot to be realistically worried about in terms of your treatment. Those are all very realistic concerns that anyone might have who has breast cancer. But, it sounds like your worries have gone from the big realistic worries to a lot of small worries that, if you take a step back, may not be worth worrying about. Is that the way you feel?”

   “That's exactly right,” Peggy tells you. In fact, sometimes I'm worrying about things that I know will never happen. Like I worry that Briana will be in a car accident on the way home from work. Or I worry about someone breaking into the house while I'm gone. Deep down inside, I don't really think these things will happen but I can't stop worrying about them,” Peggy states and sits back in her chair. “Like I don't have enough to worry about,” she says in a muffled voice and then smiles.

   “I wish I could go back to work. That would help a lot. When I'm sitting at home by myself, I automatically go into worry mode. When I'm working, I don't have time to worry. I just focus on what needs to be done next,” Peggy explains.

   “Do you remember a time before you had cancer that you worried a lot?” you ask.

   “Oh, yes,” Peggy says. “My mother used to say I was a “born worrier” and my sister used to call me “worry wart” when I was a teenager. I would get so wound up I'd eventually just burst into tears. I seemed to grow out of it after college and after I got a job. I always feel better when I'm working and being a manager is the perfect job for me because I'm moving and working really hard most of the time. When I have too much downtime I just sit around and worry. I've always known it's better for me to be doing something productive. I'm not good at relaxing.”

   “Okay, so let me try to summarize what you've told me today. It sounds like you feel like you're worrying about a lot of little stuff that you didn't used to worry about and that you realize at least sometimes, that it's unfounded fears. It also sounds like maybe the little worries take the place of big worries right now. By focusing on all these little things, you don't have to worry about the big things. Does that make sense?”

   “You know, I never thought of it that way but it does make sense to me,” Peggy reflects. “I also hadn't thought about the fact that it seems to be in my make up to worry a lot,” she ponders.

   “Well, the good news is that you have a lot of insight and awareness into your emotional life and I think that with a little further assistance, we can get those worries under control. I'm going to recommend a good therapist for you to contact who specializes in working with motivated clients like yourself and I think you can resolve some of these issues. How does that sound?”

   “Great, I really appreciate your help. I'm feeling better already.”

   “Good, here's the name and phone number of the therapist. With your permission, I'll give her a call and let her know that you saw me and that you will be contacting her.

· 6.5–1 What are some of Peggy's inner strengths?

 

· 6.5–2 What are some support systems that Peggy has now and what are some she may be able to utilize to help her cope with her situation?

 

· 6.5–3 What are some differential diagnoses you might consider in terms of Peggy's symptoms?

 

· 6.5–4 What is your primary diagnosis for Peggy?

 

· 6.5–5 List the cultural and psychosocial factors, V or Z codes, that might impact Peggy's diagnosis.

 

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