Help Needed

7 Obsessive-Compulsive and Related Disorders

Disorders

The partition of Obsessive-Compulsive and Related Disorders (OCRDs) from the anxiety section and the inclusion as a new chapter reflects the connection that these diverse disorders have to each other in terms of core features as well as to the anxiety disorders that precede them. Although anxiety is a core symptom to many of the disorders in this section, it is also an integral component across a variety of mental disorders.

   The first disorder in this section, Obsessive-Compulsive Disorder (OCD) is characterized by the presence of recurrent obsessions and/or compulsions. Obsessions are intrusive and persistent thoughts, ideas, urges, or images that are associated with marked anxiety or distress. The specific content of obsessions does not usually involve any real-life problems (as would be seen with generalized anxiety disorder). Additionally, the individual tries to ignore, repress, or counteract the urges/obsession by performing some routine or ritual routines. Compulsions are repetitive behaviors or mental acts (e.g., thought suppression) that are performed to prevent or reduce anxiety/distress. Such actions are aimed at preventing distress or some unwanted situation although they are not rational and/or are excessive. The obsessions/compulsions are laborious and cause clinically significant distress/impairment. A broad range of insight (e.g., good/ fair, poor, absent/delusional) can characterize OCD and needs to be identified via a specifier as well as a Tic-related subtype of OCD. An individual's insight has great clinical utility, as poor insight has been associated with higher symptom severity and poorer outcomes ( APA, 2013 ).

   Body Dysmorphic Disorder (BDD) is characterized by a preoccupation with slight or imagined defect in appearance. The individual employs repetitive behaviors (e.g., excessive appearance checking, excessive grooming) or obsessive mental acts (constant comparison to others) in response to this concern that causes clinically significant distress or impairment. Additionally, the preoccupation needs to be differentiated from symptoms that meet the diagnostic criteria for eating disorders. In addition, insight regarding perceived defects/preoccupation must be detailed through specifiers (good/fair, poor, absent/delusional) as well as if present with muscle dysmorphia (e.g., excessive preoccupation with one's muscularity and/or fitness level) ( APA, 2013 ).

   Hoarding is now a separate diagnosis in the DSM-5. Hoarding disorder symptoms include persistent difficulty discarding possessions (regardless of value) or need to save items due to the distress associated with parting with them. This difficulty discarding items results in the accumulation of a large number of possessions that clutter active living areas (and, if uncluttered, it is only because of the efforts of others). Additionally, symptoms must cause clinically significant distress or psychosocial impairment including whether or not the individual is able to maintain a safe environment. Furthermore, the hoarding symptoms cannot be attributable to a general medical condition, substance induced or symptoms of another mental disorder. Clinicians must specify if client's difficulty discarding is accompanied with “excessive acquisition,” which needs to be coded as well as client's insight into hoarding beliefs and behaviors ( APA, 2013 ).

   Two body-focused repetitive disorders will be included in this category. The first, Trichotillomania (hair-pulling disorder) involves habitual hair pulling with frequent efforts to discontinue this behavior that results in hair loss. The second, Excoriation (skin-picking disorder) involves habitual skin picking with recurrent attempts to end this behavior that results in skin lesions. For both criteria necessitate that the behaviors result in clinically significant distress or impairment in social, occupational, or other important areas of functioning. Also, the symptoms cannot be the result of another general medical condition or mental disorder ( APA, 2013 ).

   Substance/Medication-Induced Obsessive-Compulsive and Related Disorder and Obsessive-Compulsive and Related Disorder Due to Another Medical Condition are rather self-explanatory and should be coded when the obsessions, compulsions, or body-focused repetitive behaviors are substance/medication-induced or related to another medical condition. For details refer to the DSM-5 ( APA, 2013 ).

   The final two disorders in this chapter, Other Specified Obsessive- Compulsive and Related Disorder and Unspecified Obsessive-Compulsive and Related Disorder, are used when the symptoms do not meet the full criteria for diagnosis for any of the disorders in this category. The first disorder is used when the clinician chooses to specify the reason that diagnosis did not meet criteria. Examples are included such as some cultural concepts of distress (e.g., koro). The later is employed when the clinician chooses not to provide an explanation for why the symptoms and distress did not meet criteria. For further explanation refer to the DSM-5 ( APA, 2013 ).

Assessment

Assessment of many of the obsessive-compulsive and related disorders (OCRDs) located in this chapter is challenging due to the diverse nature of the underlying disorders as well as their frequent comorbidity with each other as well as other mental disorders. For example, according to the DSM-5, nearly 75% of individuals with hoarding disorder frequently have a comorbid major depressive disorder or an anxiety disorder and 20% co-occurring OCD ( APA, 2013 ). During initial assessment, it is important to rule out other diagnoses and to be mindful of the various developmental stages when considering rituals and behaviors. Furthermore, research has lead to the acknowledgment of common symptom dimensions (e.g., cleaning/contamination, symmetry/counting) that accompany these disorders as well as the variety of insight in afflicted individuals (good to absent insight/delusional beliefs).

Assessment Instruments

Adults The Obsessive-Compulsive Scale (OCS;  Gibb, Bailey, Best, & Lambirth, 1983 ) is a 20-item instrument designed to specifically address the presence of obsessive thoughts and/or compulsive behaviors. It is a general measure and does not provide separate scores for obsessive thoughts or compulsive behaviors. Scores range from 0 to 20, with higher scores indicating more compulsivity. The scale has high internal consistency and good stability (.82 test–retest reliability over a 3-week period). The OCS has evidenced good concurrent validity ( Corcoran & Fischer, 2013 ).

   The Obsessive Compulsive Inventory-Revised (OCI-R;  Foa, et al., 2002 ) is an 18-item, self-report, condensed version of the original Obsessive Compulsive Inventory (OCI;  Foa, Kozak, Salkovskis, Coles, & Amir, 1998 ) that measures symptoms of obsessive-compulsive disorder (OCD) on a 5-point Likert scale (from 0 to 4). This instrument produces 6 subscales (washing, checking, ordering, obsessing, hoarding, and neutralizing) that assess distress associated with a particular symptom as well as a total score that can be calculated by adding all items (total range from 0–72). A recommended cutoff score of 21 has been validated to help diagnose the presence of OCD. The OCI-R is a validated measure with adequate to satisfactory psychometrics for the subscales and total score as well as convergent validity ( Abramowitz & Deacon, 2006 ;  Foa et al., 2002 ;  Hajcak, Huppert, Simmons, & Foa, 2004 ).

   The Dimensional Yale–Brown Obsessive–Compulsive Scale (DY-BOCS;  Rosario-Campos et al., 2006 ) is a dimensional approach to measuring the presence and severity of obsessive-compulsive (OCD) symptoms based on the original Yale–Brown Obsessive–Compulsive Scale (Y-BOCS; Goodman et al., 1989a,b) for use with children and adults. This instrument contains both an 88-item self-report checklist and a clinician-administered section that rates the presence and severity of symptoms across 6 dimensions (and includes avoidance questions) as well as a global severity measurement of obsessions and compulsions. The 6 dimensions include: (1) harm due to aggression/injury/ violence/natural disasters and related compulsions; (2) sexual/religious obsessions and their related compulsions; (3) symmetry obsessions and ordering/ arrangement compulsions; (4) contamination obsessions and cleaning compulsions; (5) hoarding/collecting obsessions and compulsions; and (6) miscellaneous obsessions and related compulsions (e.g., superstitions obsessions). DY-BOCS total score was highly correlated (Pearson r = 0.82, P<0.0001) with those of the Y-BOCS score ( Rosario-Campos et al., 2006 ). Excellent psychometrics supporting the author's original validation has been reported by Pertusa, Fernández de la Cruz, Alonso, Menchón, & Mataix-Cols, ( 2012 ).

   The Y-BOCS modified for Body Dysmorphic Disorder (BDD-YBOCS;  Phillips et al., 1997 ) is a 12-item, clinician-rated scale for assessing BDD symptom severity as well as treatment outcomes. This brief questionnaire takes under 15 minutes to administer and includes items measuring preoccupations (5 questions), compulsive behavior (5 questions), insight (1 question), and avoidance (1 question) scored on a 5-point Likert scale. Total scores range from 0 to 48 with higher scores indicating greater severity. This scale has been shown sensitive to change with good internal consistency and inter-rater reliability as well as convergent and discriminant validity ( Phillips et al., 1997 ). A minimum cutoff score of 20 is recommended for diagnosis ( Phillips, 2009 ). An adolescent and adult version of this scale is available.

   The Saving Inventory-Revised (SI-R;  Frost, Steketee, & Grisham, 2004  is a 23-item, self-report instrument that contains 3 subscales that measure 3 dimensions of compulsive hoarding, including clutter (9 items), difficulty discarding/saving (7 items), and acquisition (7 items). Scores from the 3 subscales are combined to produce a total score with 40 being the suggested threshold signifying compulsive hoarding. Frost, Steketee, & Grisham ( 2004 ) reported excellent internal consistency for the SI-R total score (α = .92) and for the 3 subscales (α = .87 to .91), and it appears to be a reliable and valid measure ( Rodriguez et al., 2012 ).

   A commonly used and validated self-report measure for hair pulling in adults is the Massachusetts General Hospital Hair Pulling Symptom Severity Scale (MGH-HPS;  Keuthen et al., 1995 ). This 7-item scale measures hair-pulling severity by rating actual pulling (3 items), urge to pull (3 items), and distress from pulling (1item) over the past week. Items are scored on a 5-point Likert scale (from 0 to 4). Items are summed to produce a total score (range from 0 to 28) with higher scores indicating greater severity. The MGH-HPS has strong psychometrics with good internal consistency, excellent test–retest reliability, and strong convergent validity as well as sensitivity to changes in hair-pulling symptoms ( Keuthen et al., 2007 ).

   The Skin Picking Impact Scale (SPIS;  Keuthen et al., 2001 ) is a brief, 10-item, self-report questionnaire that measures the psychosocial impairment related to skin picking. Each item is rated on a Likert scale from 0 (none) to 5 (severe) with total score ranging from 0 to 50. A threshold score of 7 has been suggested for identifying self-injurious from non-self-injurious skin picking. Higher scores indicate greater psychosocial impairment. The scale demonstrated good internal consistency and adequate validity ( Keuthen et al., 2001 ;  Tucker, Woods, Flessner, Franklin, & Franklin, 2011 ).

Children The Children's Yale–Brown Obsessive–Compulsive Scale (CY-BOCS;  Scahill et al., 1997 ) is among the most widely utilized measure for assessing obsessive- compulsive disorder (OCD) symptom severity in children (ages 5–17). The CY-BOCS is a modified version of the adult Y-BOCS ( Goodman et al., 1989a ,b). This 10-item, clinician-rated semi-structured interview (of both child and parent) consists of 2 subscales: obsessions (5 items) and compulsions (5 items) and produces 2 subscale scores and a total score. Each item is rated based on the previous week on a 5-point Likert scale from 0 to 4 (0 = none to 4 = extreme). A total score (range 0 to 40) is calculated by summing all items with higher scores indicating greater severity of symptoms ( McKay et al., 2003 ). CY-BOCS has shown good to adequate internal consistency for total score and subscales, good inter-rater reliability, and validity ( Scahill et al., 1997 ;  Storch et al., 2004 ). Further, 6 ancillary items of the CY-BOCS may be useful in measuring constructs that are related to cognitive-behavioral therapy outcomes in youth with OCD ( Lewin, Caporino, Murphy, Geffken, & Storch, 2010 ). However, some studies question the reliability of the 5-itemed obsessions subscale ( Freeman, Flessner, & Garcia, 2011 ). Good to adequate psychometrics (internal consistency, inter-rater reliability, and convergent and divergent validity) were reported for total score and both severity scales in a study of adolescent with autism spectrum disorder ( Wu, McGuire, Arnold, Lewin, Murphy, & Storch, 2013 ). A Spanish adaptation (CY-BOCS-SR) is available.

   The Child Saving Inventory (CSI;  Storch et al., 2011 ) is a 21-item, parentrated scale designed to measure hoarding behaviors in children. This measure was modeled after the adult Saving Inventory-Revised (SI-R;  Frost, Steketee, & Grisham, 2004 ) and includes 4 subscales (e.g., discarding, clutter, acquisition, and distress/impairment) as well as a total score with higher scores indicating greater severity. The CSI has demonstrated favorable psychometrics, the internal consistency for the total score and subscale scores was good, 1-week test–retest reliability was excellent and convergent, and discriminant validity was evidenced.

Emergency Considerations Isolation, stigma, and functional impairment are all too common in individuals suffering from the mental disorders contained in this chapter. When treating individuals with an obsessive-compulsive related disorder (OCRD), which often overlap with other diagnoses, it is important to address suicide risk. Although the research on OCD and suicide is limited and at times contradictory, assessment of the suicide ideation and intent may be warranted. One study of suicide and OCD by Kamath, Reddy, and Kandavel ( 2007 ) reported a 10–27% lifetime suicide attempt rate as well as high rates of suicidal ideation. Similarly, Fawzy and Hashim ( 2011 ) concluded that suicidal ideation in OCD is more prevalent than was earlier believed, and it is strongly interrelated with sociodemographic factors. Yet another study found that although suicide behavior in OCD is not highly common, it poses a greater risk in individuals who were diagnosed with OCD, unmarried, with comorbid depression and symmetry/ordering obsessions and compulsions ( Alonso et al., 2010 ). These results are consistent with the findings on other OCRDs. Studies on BDD show it is often associated with high rates of suicidal ideation, attempts, and completion at 45 times the rate of the general population ( Phillips, 2007 ).

   In the National Guidelines Clearinghouse's “Practice guideline for the treatment of patients with obsessive-compulsive disorder” published by the Agency for Healthcare Research and Quality, enhancing the safety of the patient with OCD is paramount to practice as these individuals have a higher suicide attempt rate than the general population. They also point out that individuals with OCD rarely perpetrate violent behavior. Assessing the risk of self-harm and suicide from intrusive thoughts and compulsions (i.e., Do they have an active plan and intent?) can be challenging particularly if accompanied by co-occurring disorders and poor insight. Care must be taken when evaluating individuals for suicide risk as aggressive/sexual themes can often be misinterpreted as indicating risk.

Cultural Considerations

Although the prevalence and clinical features of OCD is relatively equal worldwide ( Staley & Ward, 1995 ) research shows that ethnic minorities (African Americans, Asians, and Hispanic/Latinos) in the United States are less likely to receive treatment for OCD and are underrepresented in OCD clinical trials ( Chow, Jaffee, & Snowden, 2003 ;  Himle et al., 2008 ;  Williams, Powers, Yun, & Foa, 2010 ;  Williams, Turkheimer, Schmidt, & Oltmanns, 2005 ). The same was found for ethnic minority children. Without treatment, ethnic minorities are more likely to suffer lifelong disability and impairment despite effective treatments.

   An explanation for this access to treatment disparity between the majority and minority populations may be a function of cultural, racial, and ethnic differences. Cultural factors can influence the mental health of racial/ethnic minorities, especially in terms of help-seeking behaviors. Williams, Domanico, Marques, Leblanc, and Turkheimer ( 2012 ) found that major treatment barriers for African Americans included fear and distrust about the therapist and therapeutic process as well as the stigma and judgment associated with a diagnosis of a mental disorder. For many Asian and Hispanic Americans, cultural barriers include stigma and shame as well as language and acculturation barriers and traditional family structure that relies on the family to handle problems without outside assistance ( APA, 2007a ,  b ;  Kramer, Kwong, Lee, & Chung, 2002 ). Also, considering the vast cultural heterogeneity of African/Black, Hispanic/Latino, and Asian populations the lack of culturally appropriate services may also be a deterrent.

   Another possibility for this disparity may be measurement bias and the possibility that differences in responses to questions about mental health are a function of cultural/racial/ethnic differences. Research suggests that current selfreport instruments for OCD may be inadequate for assessing diverse racial/ethnic groups. Replicating earlier studies, it was demonstrated that African Americans score significantly higher on levels of cleaning symptoms using contamination scales of OCD than European Americans (even higher than those reporting a diagnosis of OCD). Often, this symptom expression did not meet the diagnostic criteria for OCD, as it did not always result in reports of anxiety or distress ( Williams et al., 2005 ). Research on this self-reporting difference suggests that it should not be attributed to greater psychopathology in African Americans and may be the result of correlations with nonpathological attitudes. In effect, a greater concern with cleanliness may be a cultural norm for African Americans ( Williams & Turkheimer, 2007 ). In general, the most common obsessions are fears of contamination and cleaning/washing compulsions. Implications for practice include a focus on subjective distress and time spent on compulsions rather than specific behaviors ( Williams, Turkheimer, Magee, & Guterbock, 2008 ).

   Although the core clinical features of OCRDs appear independent of cultural variations, cultural differences can be found in the presentation and expression of illness symptoms/behaviors. However, information is limited on how culture, race, and ethnicity can impact symptom expression in these disorders. For example, studies of highly religious cultures (Christian, Jewish, Muslim) from around the world (Middle East, Asia, and the United States) have demonstrated that religion and culture can affect OCD symptom expression manifesting in religious obsessions and compulsions including cleaning rituals and compulsive praying. In religious cultures, religion can provide an excellent method of concealment for ritualizing. However, it is important to note that religion does not increase the prevalence of OCD in the very religious; rather it is often the outlet of choice for symptom expression.

   Although the prevalence of BDD and clinical features appears to be similar in many different cultures around the world (approximately 1–2%) and has been documented for over a century, research on cultural, racial, and ethnic differences is very limited. Some data suggest that cultural factors (i.e., appearance preferences) may influence symptom presentation in BDD. For instance, Phillips ( 2004 ) found eyelid concerns and the fear of displeasing others by being unattractive a common symptom in Japan but rare in Western countries. As with all disorders, clinicians need to be mindful of the possible overlap of symptoms with culture-bound syndromes. For instance, taijin kyofusho and koro, both culture-related syndromes occurring in Japan and southeast Asia have similarities to BDD but differ in duration, fears, and response. As noted in the DSM-5 ( APA, 2013 ), a disorder known as shubo-kyofu translated as the phobia of a deformed body, may bear a close resemblance to BDD in terms of symptomatology.

   The prevalence of clinically significant hoarding in the general population ranges from 1.4% to 5%, which appears to be two times the rate of OCD ( Mataix-Cols et al., 2010 ;  Pertusa et al., 2010 ). Research is very limited on how hoarding, hair-pulling, or skin-picking disorders present within different racial and ethnic groups. More cross-cultural research is needed to learn the extent to which these disorders are universal or culturally specific. Current evidence indicates a significant amount of equivalence across cultures. Hoarding in children appears to be consistent with studies of adults with OCD and hoarding symptoms. ( Plimpton, Frost, Abbey, & Dorer, 2009 ;  Storch et al., 2007 ).

Gender

Gender differences have been reported among the obsessive-compulsive and related disorders. Studies of OCD show that males are more likely to be single, have earlier onset, and a more chronic course with greater impairment. Further, gender-related social roles may affect the content of obsessions and compulsions. Males tend to report more religious/sexual and aggressive symptoms and females more contamination/cleaning symptoms ( de Mathis et al., 2011 ). Research on gender differences in BDD is limited and prevalence ratios by gender vary with data showing more similarities than differences. Males were more likely to be older, single/living alone, have a comorbid substance use disorder with excessive body concerns around thinning hair/balding, genitals, and muscularity. Females tended to have a greater number of body concerns, have comorbid eating disorder with greater distress over excess body hair, and weight/body composition. These concerns carried out in BDD behaviors with males reporting more weight lifting behaviors and women more camouflaging techniques and mirror checking behaviors. Of interest, Phillips, Menard, and Fay ( 2006 ) reported inconsistent findings when comparing scores by gender on three BDD severity measures. After controlling for the presence of eating disorders the higher scores found for females on one scale was eliminated. One possible explanation for the higher score by females on some scales may be that the items endorsed were measuring appearance dissatisfaction, which tends to be of greater weight for women than men in our society. In general women tend to endorse more symptoms of BDD than men, and sexual minorities endorsed more symptoms than heterosexuals ( Boroughs, Krawczyk, & Thompson, 2010 ). Further, muscle dysmorphia, a variant of BDD is more prevalent in males.

   Although hoarding behavior occurs in other psychotic disorders most of the research on this behavior is in relation to OCD (of which it was previously a subtype). These studies find gender differences with males reporting more aggressive, sexual/religious obsessions and with checking compulsions comorbid with generalized anxiety disorder and tics. Females had more comorbidity including BDD and skin picking ( Samuels et al., 2008 ). Hair pulling in females was found to have earlier onset, less comorbidity, and more disability than males ( Lochner, Seedat, & Stein, 2010 ). There is very little data available about the gender differences in the remaining disorders.

Social Support Systems

The prevalence of OCD and related disorders, which once were considered rare, are associated with significant distress and impaired psychosocial functioning. As a result, individuals with these disorders often have a significant reduction in the quality and quantity of social relationships and often live in social isolation. For many, the shame and stigmatization they feel can lead to attempts to hide symptoms and avoidance of social situations. For example, the compulsions, behaviors, and rituals of OCD can be difficult to understand, even for family members, and often negatively impact one's ability to form relationships. Individuals with OCD typically experience pervasive self-doubt and often try to hide their symptoms from others. For young children OCD symptoms can hinder social development. Likewise, for sufferers of BDD the fear of being negatively perceived by others can adversely affect interpersonal relationships and can lead to social avoidance as well as a higher suicide risk. Many people with a hoarding disorder live in fear and embarrassment concerning their hoarding symptoms but are less likely to be successful at hiding symptoms if sharing a living space, which often leads to interpersonal conflict. For many individuals with skin-picking and hair-pulling symptoms, the fear of being discovered may also negatively impact family, work, and social relationships. In general, social isolation has been correlated with an increase in stress and worsening of symptoms.

   Social support is a crucial component to the treatment of OCD and related disorders. Individuals suffering from a mental illness as well as their families and significant others often experience stigmatization and discrimination. Participating in a support group (either online or in person) may provide the opportunity to increase social connections while decreasing feelings of loneliness, stigmatization, and social isolation. By providing the chance to share with others who are dealing with similar challenges and struggles, participants come to see that they are not alone in facing the challenges of their condition. Also, the chance to be mentored as well as to mentor can help build confidence and self-esteem.

   Support groups are as diverse as the individuals they serve. Some support groups are professionally led, while others are user-led; some are only for individuals with mental health issues, while others may be only for family/caregivers; and still some are a mixture of both. For example, Psychoeducational support groups offer education about the disorder and focus on symptom coping strategies and problem-solving skills while offering emotional support, hope, and encouragement. Participants can include the affected individual, family member(s), or both. Other support groups may focus on social skills training to help individuals develop interpersonal skills and learn how to develop a network of social supports. Therapy support groups usually offer members some form of cognitive-behavioral therapy (CBT), usually exposure and response prevention (ERP) therapy and are most often run by a therapist but can also be self-help and/or user-led. Still others, like online peer support groups, offer the opportunity to talk and share within a supportive environment.

   Online support groups have eliminated some of the barriers to support for many individuals. The anonymity provided by the Internet often helps to shield some members from the shame and stigma of mental disorders. For individuals with contamination obsessions, perceived body issues, or social anxiety, this format may be less intimidating. Also, access to a support group is not as dependent on location and transportation (or lack thereof) or time constraints (internet is available 24/7). However online support groups are not without their drawbacks, some are financial (i.e., must have access to a computer/internet) while others may be personal (i.e., ability to read/write). Also, there is the risk that messages may be misinterpreted or impersonal as the format lacks body language cues given the nature of the internet. In addition, there is the risk of harassment and the format may cause problems for individuals with addictive issues. Finally, as with any information gathered over the internet, it is important to use trusted sources, usually national nonprofit mental health organizations are great resources. Once again supports groups work best when the decision making involves the patient. For instance, when family interactions consist of criticism and blame, their involvement may be contraindicated. Support works best when empathy and positive motivation are involved in order to encourage behavioral changes. In this case family-education may be the first line of treatment. A comprehensive listing of social support is listed below:

·   www.nimh.nih.gov : The National Institute of Mental Health's mission is to provide information on the understanding and treatment of mental illness including research programs and clinical trials.

·   www.ocfoundation.org : The International OCD Foundation (IOCDF) is an international not-for-profit organization for people with Obsessive-Compulsive Disorder (OCD) and related disorders, as well as their families, friends, professionals, and others. They provide educational resources, advocacy services, support groups, and research support for OCD and related disorders.

·   www.adaa.org : The Anxiety and Depression Association of America provides educational information, training, and research for anxiety and stress-related disorders.

·   www.rhodeislandhospital.org : The Body Dysmorphic Disorder Program at Rhode Island Hospital offers information about clinical services as well as research studies for the treatment of BDD.

·   www.massgeneral.org/bdd : BDD Clinic and Research Unit at the Massachusetts General Hospital offers information, clinical services, and research studies for the treatment of BDD.

·   www.ocfoundation.org/hoarding : International OCD Foundation (IOCDF) Hoarding Center offers educational information, advocacy, research, and resources for Hoarding and other Obsessive-Compulsive Related Disorders.

·   www.clutterersanonymous.net : Clutters Anonymous is a 12-step program for people who desire to stop cluttering.

·   www.trich.org : Trichotillomania Learning Center (TLC) is a nonprofit advocacy group for sufferers of hair pulling and skin picking. It offers resources for support groups and recovery communities, educational events, professional training, and treatment referrals.

·   www.suicidepreventionlifeline.org : The National Suicide Prevention Lifeline provides free and confidential emotional support to people in suicidal crisis or emotional distress (24/7) by calling 1-800-273-TALK (8255).

Case 7.1

Identifying Information

Client Name: Carly Ramos

Age: 15 yrs old

Ethnicity: Hispanic

Educational Level: Ninth grade, currently in a Juvenile Detention Center

Parent: Single Mother, Christina Ramos (father uninvolved)

Intake Information

Carly, a 15-year-old Hispanic female, is currently detained in a Texas Juvenile Detention Center for repeat juvenile offenses including illegal trespassing and petty theft on school grounds. Carly is a “frequent flyer” in detention, with additional chronic runaway charges and truancy. Carly's mother (Christina Ramos) is a single parent, working three jobs, and finds herself stretched thin while trying to care for Carly and her two younger brothers. At Carly's most recent court hearing, Carly's petty theft and trespassing charges were dropped. However, the judge ordered Carly to be placed in an “Intensive Probation Unit” in which a new Probation Officer will be assigned to check in on Carly daily at school, with a minimum of three home visits per week. The judge warned Carly that if she re-offends or breaks any terms of her probation guidelines, she will be placed into the temporary custody of Child Protective Services and will be placed into a secured residential behavioral treatment facility from 1 to 3 months. After instructing Carly's Probation Officer to make arrangements for supportive services for Carly's re-entry into her school setting and to gather supportive services for Carly's mother, the judge detained Carly (who was expecting to be released) for 10 days, while services are setup.

   You are the lead counselor in the Detention Unit. It is your responsibility to assess and assure the safety and well-being of all juveniles housed in detention. You frequently receive not only self-referrals made by the detained juveniles to discuss fears, feelings, and so on, but you also often receive referrals from unit Detention Officers, Probation Officers, parents, and Detention nursing staff. You know Carly well and have always been pleased to see how well she handles herself with her peers and authority figures when detained, not an uncommon occurrence for juveniles needing intensive structure.

   After Carly's last court appearance, Carly has ceased writing self-referrals to meet with you, however referrals by Detention Officers have been increasing, stating that Carly is acting out, arguing with peers and staff, and seems to be preferring to have behavioral consequences, sitting in “timeouts” in her cell, spending as much time alone as possible. Detention officers doing room checks have noticed increasing piles of hair strands on her blankets and on the floor. You have just returned to work on a Monday and have received 2 nighttime staff referrals, 1 day-time staff referral and a referral by the nursing staff, all stating that Carly has been witnessed as increasingly anxious and irritable during the daytime when around her peers and has been seen pulling strands of hair from the nape of her neck and forehead. The evening staff mentioned that at the time of room clean-up, they noticed large amounts of hair in the custodial broom after Carly swept out her room. You also received a referral from the nursing staff due to Carly complaining about not being able to sleep. The nurse indicated observing redness not only where there were patches of missing hair on Carly's head but noted Carly's increased pulling out of eyelashes and eyebrows.

Initial Interview

You have received a radio call from a detention officer stating that Carly has received her third time-out for the morning. They believe that she is isolating in order to avoid participating in unit morning activities and group process time. You sense a drastic change in Carly's disposition as she is usually talkative, gossiping about peers on unit, and about plans to help take better care of herself and her younger brothers when she gets out of detention. She generally enjoys talking with you about her plans for how she is going to succeed and not come back to detention.

   You approach Carly's unit, speak to referring Detention staff and approach Carly's cell. As you observe her through her cell door for a brief minute or so without her realizing, you notice Carly crying, rocking on her bed, and squeezing her hands together. She appears very agitated and anxious. Within a couple of minutes, you see Carly begin to pull out her eyelashes. At first observation, she appears extremely anxious while she randomly begins to try to pull hair from both her eyelashes and eyebrows. Unable to soothe herself, she then moves to pulling large strands of hair from her forehead. Within a considerably short amount of time, she has compiled a pile of long hair strands neatly stacked beside her on her bed cot. As she proceeds and places her hair strands beside her, she begins to calm her body agitation and seems to be settling down, internally.

   You announce yourself to Carly and unlock her cell door. You ask if you can come in and talk with her and she doesn't respond. (You note to yourself how unusual this is, as Carly is usually very excited to spend one-on-one time in counseling check-ins with you.) You enter her room, sit beside her on the cot and begin to speak.

   “Carly, you have a lot of people in here who care about you. You know how I know that? When I came in this morning, I had several notes asking me to check in on you. From their notes, it seems that you've got a lot on your mind and are getting easily irritated by others. We are also noticing that you're starting to pull out your hair in different areas. Would you mind if we sit for a bit and talk about what you're thinking about and see if we can work through some of your feelings?”

   Carly doesn't respond, but pulls her sweatshirt up over her face and puts her hands up to intentionally cover the bald patches on her forehead. You don't press for a response, but just sit quietly for a few minutes, communicating to Carly that you aren't going to go anywhere and that you will wait until she is ready to talk. After several minutes have gone by, you ask Carly if she would like for you to come back after you visit another detained juvenile. Carly quietly says, “No. Please stay with me.”

   You read to Carly the referrals, reminding Carly that you are never there to judge her, reminding her that you believe in her, and reinforce to her that she is in a safe space right now.

   Carly slowly pulls her sweatshirt down from her face, looking at the ground and seems more approachable. “Will you please stay with me? I don't know what is wrong with me.”

   “Carly, you have been detained several times. This last court hearing seems to having you extremely upset and I'm worried for you. I see you pulling out your hair and can tell that you are in a lot of pain inside. What has changed for you in the last two days?”

   Carly begins to cry and tells you that she hasn't always been telling you the truth about why she keeps getting into trouble and returning to detention. “Miss, I don't really want to be running away so much, but the stress at home is so hard. I love my mom and my baby brothers. I know she is working hard to take care of us, but sometimes I just want my own life and my own time. I try to help my brothers out and try to give them advice, and all they yell back is that I'm not their mother, to stay out of their lives and that I have no room to be giving them advice.” She pauses and looks to you to see if you are still listening to her.

   You notice her glance and respond, “Carly, I'm not going anywhere. Take your time.”

   She continues. “Miss, my stealing isn't for bad things. It's for my family. I know I don't go to school like I should, but when my brothers are sick, or my mom needs my help, I just don't go, to stay and help out. Teachers don't understand how hard it is to “just stay in school” when there are more important things going on in my life than learning about stupid math, that won't help fix my family!!!” She continues, “My petty theft charge was for money for myself and my brothers for food.”

   You begin to notice Carly beginning to wrap strands of hair around her fingers again as she continues to talk, but you don't stop her as she is not pulling her hair out. You want her to continue sharing and you know if you divert your attention to her behavior, she will most likely shut down again, potentially feeling judged.

   “Carly, it must be really hard being 15 years old and feeling like everyone is depending on you. I can bet that being so far behind in school makes it even harder to want to go back at any time. Can you tell me about your running away so much? I hear you and think I can see your resistance to going to school when you are feeling this overwhelmed. But why do you feel like running away so much? We usually do things over and over if we are getting something out of it. What are you getting out of? Does it make you feel better?”

   Carly begins speaking, “I'm tired of taking care of my brothers. My mom expects me to be a second mom. When I run away, it's because I think my mom would have less trouble with one less kid to feed and worry about. I'm not a good kid and just make things worse for her. I feel like an adult, so I figure I can take better care of myself on my own . . . and let her just worry about my brothers.”

   You notice Carly beginning to become more aggressive while twisting her hair strands and has begun to actually pull out pieces and tuck them into the palm of her hands, trying to hide them.

   “Carly, what you are sharing with me is very important and I thank you for helping me to understand better, what your challenges are. I think your heart is in the right place, but there are things you are doing that are definitely making it harder for yourself. You, your mom, and I have usually been able to talk well with each other, and I want to talk later today about how we can all come up with some ways for you to share your feelings with her and make some changes that will help you to not feel so overwhelmed. You obviously care deeply for your family. And I want us to keep talking about that; however, right now, seeing you hurting yourself, pulling out your hair this way, I am wondering what your hands are trying to tell me?”

   “Miss, I don't know. I'm angry but I don't want to fight anybody. I chose to runaway. I chose to steal. I chose to not go to school. I don't have anyone else to blame but myself. I don't know why I do this. I used to see other girls on the unit doing this and thought it was just because they were bored. They looked so ugly, having no eyelashes . . . then trying to say it was some new gang identification thing. I know gangs . . . WHATEVER! They are so dumb. After the judge told me that this is the last chance I have, it scares me to death because I know that I'm going to run away again. I just can't take it. I came back to the unit, some stupid girl asked me what happened, I told her to shut up time-out and just lost it!

   “What happened when you felt like you were losing it? Usually I can depend on you requesting to see me, Carly,” you respond imploring her to think.

   “It was too much. I knew I was on my own this time. I was feeling so anxious that I started crying. I thought of those girls without their eyelashes. What do I care anymore? I started pulling and the more I pulled, the better I felt. I don't know why. It doesn't feel good. Then my eyelashes weren't enough and it started getting weird, like if I didn't pull enough hair out, I wasn't going to calm down enough. I'm not hurting anyone and who gives any care to what I do to my own hair. I'll go bald if I feel better.”

   “Carly, tell me how you feel before you start pulling on your hair?”

   “I hate myself. I know it will make me look stupid. I know I'm crazy. Who wants to be bald? But Miss, I'm so stressed. I guess I just give in and start doing it and then I just feel better. But then when I look at the mess in my fingers, or on my bed, I feel worse after I feel better and I tell myself I won't ever do it anytime. Do I have a disease, Miss? I don't want to keep doing this. None of the boys will ever look at me. My mom will be embarrassed and mad and my brothers will know for sure that I'm crazy and ‘no-good.'”

   You gently reach for the strands of hair on Carly's bed and pick them up. You say to Carly, “You know what? This hair doesn't say disease or crazy to me. These strands of hair and the bald patches say to me that you are a 15-year-old teen trying to figure life out, have made some choices that need to be different, that you're afraid, hurt, and angry. We can work on this, Carly.”

   Carly puts her hands in her lap and promises to ask for an immediate check-in the next time she begins to feel stressed to the same point again. You tell Carly that you will not only check on her when she asks for you, but that you will check on her twice a day, in addition. You also tell her that you want to begin working with her on ways to help her manage her anxiety.

   Carly asks you before you leave if it would be okay for you to tell the Detention staff that she has permission to sit at a table and write or draw when she gets upset. She tells you that when she was younger, sometimes writing things helped her, but that right now she isn't really sure what to write about, she just wants to try.

   You leave Carly's room, taking the hair strands with you (to show medical), tell her that you will look into her getting writing supplies and that you would like to have the nurse come see her for lotion or cream to help her skin irritation from where she has pulled out her hair.

· 7.1–1 What are some of Carly's strengths?

 

· 7.1–2 What are some of the barriers to Carly resolving the issues she currently has?

 

· 7.1–3 What are some resources that could be useful to Carly when she is released from detention?

 

· 7.1–4 What is Carly's primary diagnosis?

 

· 7.1–5 List the psychosocial and cultural factors that may be impacting Carly at the present time.

 

Case 7.2

Identifying Information

Client Name: Maya Pena

Age: 23 years old

Ethnicity: Hispanic

Marital Status: Single

Intake Information

Maya Pena is a 23-year-old Hispanic female who currently resides in Houston, Texas. She was born and raised in “the Valley,” the southernmost region of the state. Maya is the youngest of three children. Her parents have been married for 32 years and continue to live in the Valley. They recently moved from McAllen to Brownsville after living in their previous home for over 25 years. Her oldest sister is married and has a baby girl. Maya's middle sister is married and lives in Houston. Maya is 8 years younger than her middle sister.

   Immediately following high school, Maya attended a community college in her hometown. After 2 years, she was admitted to a larger university in Houston where she received a degree in history and philosophy. After completing her college education, Maya returned to her hometown to work while living with her parents. She obtained a job at the McAllen Chamber of Commerce. Approximately 6 months ago, Maya returned to Houston, where she is currently working for a temporary agency while she looks for a permanent job. Maya enjoys reading, dancing, going to bookstores, and writing.

Information Received from a Former Therapist

Maya gave your agency permission to contact a former therapist she saw for a couple of years in junior high school. The therapist forwarded you her records.

   The records indicated that Maya began having problems around the age of 10. When Maya was confronted with stressful situations, she would begin counting under her breath, washing her hands several times every hour, and checking behind her every time she stood up. In addition, Maya's parents reported that she began collecting a variety of items in her bedroom that she kept under her bed. These items included stuffed animals, rocks, and old candy wrappers. Her need to wash her hands frequently created problems for her in the classroom, as she was constantly asking permission to leave the class and go to the bathroom. It would take her 5 to 10 minutes to wash her hands, and she began missing large segments of each class period. The teacher informed the school counselor of this problem, and Maya was referred to an outside therapist for counseling. Maya told the counselor that besides the hand washing, she had a feeling sometimes that she had to count. The counselor also noticed that Maya had to check behind herself every time she stood up. When pushed to explain these behaviors, Maya would vaguely respond that they kept “bad things” from happening. During the time that she was seeing the counselor, the symptoms seemed to recede somewhat, although under stress, the symptoms would intensify. The counselor's notes indicated that she had used some behavior modification techniques with Maya in order to reduce the symptoms she was displaying.

Interview with Maya

Maya arrives for her appointment with you a few minutes early and sits quietly in the waiting room reading a book. She is of average height, has long dark brown hair tied back in a ponytail, and is slightly below average weight. She is wearing a pair of brown trousers with matching shoes and socks and a tan blouse. She is carrying a small brown purse and is exceptionally neat in her appearance. She smiles when you greet her in the waiting room and readily walks with you to your office.

   Maya states that she isn't sure why she made the appointment and feels a bit silly for being there. You ask her what made her think about making the appointment, and she states: “There have been some things bothering me lately, and I thought it would help to talk to someone.”

   You suggest that it can be helpful at times to talk to someone who can be objective. “Why don't we start by you telling me a little about yourself and what you're doing right now?”

   “Well, right now, I'm working for a temporary agency as a secretary, but it's not what I want to do. I just took the job until I can find something else that I really want to do.”

   “What is it you're interested in doing?” you ask.

   “Well, I'd really like to work for a museum, I think. I majored in history and philosophy and working at a museum, like a natural history museum, sounds like a very interesting job to me. There aren't too many jobs in that area, though. I've also thought about going back to school to get my master's degree in something a little more useful than history, but I've got to save up the money before I can go back to school.”

   “Have you thought about other jobs you'd like to have for a year or two until you can save the money to go back to school?” you inquire.

   “I think I'd like a job in a bookstore or library. I read a lot, and I'd be good at helping people pick out books to read. I definitely don't want to work in a hospital. I did that for a while, and it really bothered me.”

   “What bothered you about it?” you ask.

   “I just couldn't handle all the germs in that place. I guess it's one thing I wanted to talk to you about. I feel this urgent need to wash my hands all the time. See how red they are? That's because I'm constantly washing them. I feel like there are germs everywhere and I can't ever get clean enough. Some days I spend most of my time just washing my hands, and then the minute I touch something that I think has germs on it, I have to wash them again. It's hard to get anything done because of all these thoughts and feelings inside about needing to get rid of the germs. It's kind of driving me crazy these days.”

   “How long have you had these feelings like you need to wash your hands?”

   “Really, for a long time, since I was a little girl. But sometimes it doesn't bother me so much. In fact, it seems to almost go away, and I'm not so worried about germs. Then, for no reason, those feelings come back, and no matter how hard I try, I still feel like I need to wash my hands.”

   “What do you do if you can't wash your hands?” you ask.

   “Then, I count. I just begin counting, and I don't feel like I can stop until I reach a certain number. Other times, I just count up to 25 over and over again. I know it probably sounds crazy, but I just can't stop it.”

   “Are there any other things you have an urgent need to do?”

   “Ever since I was a little girl, I've felt the need to check behind me every time I stand up. I really have no idea why I feel a need to do that, but I always do.”

   “Do you feel better after you've engaged in one of these activities like washing your hands or counting or checking behind you?”

   “Oh, yes, absolutely. I have a big sense of relief for a little while, but then I feel the urge to do it again.”

   “Do all of these activities get in the way of other things you're doing?” you ask.

   “Sometimes they do. When I was at the hospital, it was a real problem because I couldn't stop thinking about all the germs. Sometimes, I just allow time for needing to wash my hands, but I'm not always in a situation where I can make the time. Then, it becomes a big problem. Sometimes it doesn't seem to get in the way too much, but I'm embarrassed if someone notices me doing one of these things.”

   “It sounds like you're a very insightful and intelligent person who tends to be on the quiet side. How would you characterize your mood most of the time?”

   “I've had times when I feel real depressed about my life. I've always felt this huge responsibility toward my family. Even when I was young, I thought it was my job to take care of all of them. Right now, I feel terrible because I'm not earning enough money to send some home to my parents. I feel like I should be able to take care of them, especially when they get old. It makes me tense just thinking about it. Sometimes, I feel like I should be working two jobs just so I could help them out some. They don't have much, and I always thought that when I grew up, I'd get them things they've always wanted.”

   “Have you felt depressed recently?” you ask.

   “No, not really. More anxious than depressed. I'm always anxious, it seems. I worry about everything.”

   “Do you ever take anything to control the anxiety?” you ask.

   “Like what?” she says.

   “Some people have a drink or take some kind of drug, like marijuana or a prescription or even an herbal remedy.”

   “No, I've never done anything like that. My family is very strict about things like that.”

   “What about friends? Do you have friends you do things with?” you ask.

   “I've gotten to know one person at work a little bit, but she's married so she doesn't have much time to do anything. It's been one of my problems. I think people think I'm weird or something because of all these urgent feelings I have. It's been hard to have friends because all my time is taken up with these activities,” Maya says sadly.

   Because the session is almost over, you ask Maya what her goals for therapy may be. She states that she would like to get more control over her urges so they don't run her life and that she would like to feel less tense all the time. You suggest to Maya that you would like to meet for eight sessions and then evaluate her progress during the eighth session. If she needs to continue in therapy at that time, then you will make those decisions with her after the eighth visit. You also explain to Maya that there may be more information you'd like to obtain at a later time, but you feel that counseling could be beneficial to helping her resolve some of the issues you've discussed. Maya ends the session by telling you that her aunt Juanita wants to give you more information about her. She signs a release of information so that you will be able to speak with the aunt when she calls.

· 7.2–1 At this point, what are some possible diagnoses you would consider for Maya?

 

Information Received from Maya's Aunt in Houston

Maya's aunt, Juanita Garza, calls you to express her concern about Maya's behavior. She begins by saying that she has spent a great deal of time with Maya since her first move to Houston. Juanita is an art therapist at a rehabilitation hospital and has some background in psychology.

   She tells you that she has been very concerned about Maya over the years. Maya appears to go through periods of depression that aggravate her symptoms of washing, checking, and counting. She states that Maya has always been a good child, easy to get along with but somewhat shy, reserved, and easily prone to depressed moods.

   The aunt states, “There is one thing that's always frustrated me about Maya. Even though she has always been petrified of germs, she never cleans out her apartment and becomes very irritated when I offer to help.”

   “Are you saying that Maya is a poor housekeeper?”

   “No, not exactly. She cleans all the time but she never throws anything away.”

   “Do you mean she has trash piled up in her home?”

   “No, I'm just saying there's so much stuff that she holds onto that it's hard to even find a place to sit down in her apartment.”

   She goes on to tell you that Maya was always very responsible, even as a young child. She worked part-time through high school and financed her way through college with student loans and a job.

   She states that the last 2 years of college were difficult because Maya was working full-time 3 P.M. to 11 P.M. at the hospital in Houston while attempting to go full-time to school. Juanita tells you that during Maya's senior year, she became very withdrawn and was washing her hands so much they were rough and red. “When I asked her about her hands, she said that she felt a need to wash her hands frequently due to all the germs in the hospital.” Juanita feels that the job in the hospital was not ideal for Maya but that she needed the money to cover her school expenses. She states that Maya often will go to the restroom when they are out at a restaurant, wash her hands, and then take the paper towel and open the door with the towel in order to avoid touching the door handle.

· 7.2–2 Based on the aunt's phone call, what are some questions you might like to pursue in the next session with Maya?

 

· 7.2–3 What are some of Maya's strengths?

 

· 7.2–4 What are some possible diagnoses you would like to rule out in Maya's case?

 

· 7.2–5 How might a physician be of assistance to you in this case?

 

· 7.2–6 Following your conversation with Maya's aunt, what is your preliminary diagnosis for Maya?

 

Case 7.3

Identifying Information

Name: Emar Amari

Age: 65 years old

Ethnicity: Middle Eastern

Occupation: Retired

Background Information:

Emar Amari, a retired shop owner, was referred to you by his physician for anxiety and depression. Mr. Amari retired approximately a year and a half ago when he sold his store to his cousin's son. Although he maintained a middle class lifestyle, Mr. Amari's store never made more than a small profit each year, which Mr. Amari put away in savings for retirement. Mr. Amari is married to Poojha Amari and the couple has 3 grown children who no longer live at home. You are a practitioner who specializes in gerontology.

   You meet Mr. Amari in the waiting room of the Sky View Gerontology Center. He is looking through the magazines on the table.

   “Good afternoon, Mr. Amari, my name is Sarah. Would you like to come back to my office?” you begin. Mr. Amari looks up and says, “Oh yes, yes, you have some interesting magazines here,” Mr. Amari replies as he gathers his coat and follows you to your office. He sits in the chair next to your desk and comments on the picture on the wall. “This is a very nice office. You have a lovely painting there.”

   “Thank you,” you reply. “We moved to this location about a year ago. Mr.Amari, I understand that you've been having some uncomfortable feelings lately. Can you tell me a little about how you've been feeling?” you ask.

   “Well, I don't know what to tell you. I retired from my work about a year or so ago and it just hasn't been the same. I have to have something to do all the time. I worked all my life and now, nothing. What do I do with myself? I always thought that retirement would be a wonderful time in my life and now, I think, all I do is drive my wife crazy.”

   “I understand,” you reply. “Retirement can be quite a major transition in your life, and it can take some time to get used to being retired. What are some things you've been doing with your time?” you ask.

   “Well, when I had my shop, I bought and sold items for your home,” Mr. Amari muses. “So I can't seem to help myself, I still rummage around for little knick-knacks for the home and find some very unique items.”

   “Wow, that sounds very interesting,” you reply. “Can you tell me about some of the things you find?” you ask.

   “Well, just the other day, I was rummaging and found an old cake tin that only had a small bend on one side. I also found an old fashioned lamp shade that just had a little tear in it. And they were just lying in the dumpster, so I pulled them out and took them home. I probably find 15 or 20 good items in the dumpster every week!”

   “I see, so help me understand. What do you do with these things after you bring them home?” you query.

   “Well, I put them in piles,” Mr. Amari replies. “For example, I have a pile of magazines and a pile of newspapers and a pile of old shoes and a pile of picture frames.”

   “Okay, what do you plan on doing with these things after you put them in piles?” you ask.

   Mr. Amari looks perplexed. “Well, I'm not really sure. I don't think I could sell them but maybe someone would like some of this stuff. Maybe I'll take it to a flea market some day. Not really sure what to do with it, if you want to know the truth.”

   “Hmm, so doesn't this stuff get in your way with all these piles in your home?” you ask.

   Mr. Amari smiles, “Well, I just push them out of the way or walk around them.”

   “Mr. Amari, how does your wife feel about you collecting all these objects?” you ask.

   Mr. Amari scowls, “She says the house looks like a junk pile and she can't stand all the mess. But she doesn't realize that some of this stuff may be valuable. You know you hear about someone finding an old vase and when they have it appraised it's worth a lot of money!”

   “I'd be interested in seeing your collection,” you say. “I wonder if the next time we talk if you'd be willing to bring some pictures of the piles you've found.”

   “Sure, I'd be happy to or if you're really interested you could come over to the house and look through the stuff yourself.”

   “Okay, why don't we start with pictures and then maybe I'll make a home visit later,” you suggest.

   “Sounds fine to me,” Mr. Amari agrees.

   “Would next Tuesday be a good day around 2 P.M.? you ask.

   “That should be fine,” Mr. Amari responds. “I don't have much on my schedule anymore.”

· 7.3–1 What is your preliminary assessment of Mr. Amari?

 

Second Session

At the beginning of the second session, you greet Mr. Amari in the waiting room and immediately notice that he has a very large garbage bag with him. You ask him about the bag and he tells you that he brought some of his wares for you to see. He also tells you that his wife is very angry with him because she thinks it's inappropriate for him to bring this stuff to your office.

   “Wow, that is a really big bag of stuff you brought with you today,” you remark.

   Mr. Amari glances at the bag. “My wife and I got into a big argument. She said you wouldn't want to see the “trash” I collect. I told her it wasn't trash. It could be valuable. Besides my camera doesn't work. She doesn't understand how important my collection is to me. I think I'd be climbing the walls if I didn't have my collecting to do. She said if I don't get rid of this “trash” she will have to go live with Asaya, my oldest daughter. What does she want me to do? Sit and stare out the window all day?” Mr. Amari looks gloomily at the bag.

   “Why don't you show me what you've brought?” you suggest.

   Mr. Amari brightens up a bit as he unties the bag. “These are just a few of the items that I have found but they are some of the best. First, I have a perfectly good tea kettle,” he says pulling it out of the bag. “It's first rate. It will last for years. Next, I have a stuffed animal that is only missing an eye and some hair. Well, it needs to be thrown in the washing machine but it's a great toy for a child. Then, I have a faucet for a sink. All you need are a few screws and it should work like new.” Mr. Amari continues to pull things out of the bag remarking how each one could be useful. As he gets to the bottom of the bag, he sighs. “Finally, I have this heirloom fur scarf. I know people don't wear fur that much anymore and it's a little moth eaten, but maybe someone could make ear muffs out of it. Wouldn't it make great ear muffs?” Mr. Amari asks holding up the scarf for you to assess.

   “Wow, it's quite an assortment of items,” you comment. “Collecting all this stuff must keep you very busy.”

   Mr. Amari looks at you sadly. “My wife thinks I spend too much time rummaging and not enough time helping her around the house. If I try to help her, she just tells me that I'm getting in her way and to get rid of the piles in the house if I want to be of some help. Then we start yelling at each other. My nerves can't stand it. I have to get out of the house. I was always working and would be gone most days for 12 or sometimes 16 hours at the shop. Why can't she understand that I have to get out of the house?”

   “Sounds like if you're not rummaging, you begin to feel anxious? Would that be an accurate assumption?” you ask.

   Mr. Amari looks pensively out the window. “I've always been a worrier,” he finally replies. “I worried all the time about the shop. Would I be able to pay the rent? How much do I buy? How much can I sell? Should I be advertising? How do I arrange the stuff? Always worrying. Then I worried about my children. How they were doing in school. Would they get into college? How would I pay for college? It was always something.”

   “Those sound like important things that a lot of people might worry about,” you reply. “Do you ever find yourself worrying about little things that might not be so important?”

   “You mean like will it rain tomorrow?” Mr. Armari asks. “Truthfully, yes. Large or small I have always been a worrier.”

   “Okay, I'm wondering if you'd be willing to complete this questionnaire called the State Trait Anxiety Inventory. It might provide us with some useful information about your worries. It's not very long and before you leave today you can fill it out. Would that be okay with you?” you ask.

   Mr. Amari nods. “Sure, but please don't tell my wife. She will just say ‘I told you so’ and I don't want to hear it.”

   “I can assure you that unless you give me permission, I won't tell your wife what we talk about unless you tell me you are going to harm yourself or others.”

   “You got yourself a deal,” Mr. Amari says.

   “Great, I'll go get the questionnaire for you to fill out and we'll schedule our next appointment,” you say.

· 7.3–2 What additional information would you want to gather regarding Mr. Amari's situation?

 

· 7.3–3 What are some resources that might be beneficial to Mr. Amari?

 

· 7.3–4 What is your diagnosis for Mr. Amari?

 

· 7.3–5 List the cultural and psychosocial factors as V codes (and Z codes) that are impacting this diagnosis for Mr. Amari.

 

References

Abramowitz, J. S., & Deacon, B. J. (2006). Psychometric properties and construct validity of Obsessive- Compulsive Inventory- Revised: Replication and extension with a clinical sample. Anxiety Disorders, 20, 1016–1035.

Alonso, P., Segalàs, C., Real, E., Pertusa, A., Labad, J., Jiménez- Murcia, S., et al. (2010). Suicide in patients treated for obsessive-compulsive disorder: A prospective follow-up study. Journal of Affective Disorders, 124(3), 300–308. doi:10.1016/j.jad.2009.12.001

American Psychiatric Association. (2007a). Mental health in Asian Americans and Pacific Islanders. Let's Talk Facts about Healthy Minds Healthy Lives [Brochure]. Retrieved March 10, 2014 from  http://www.psychiatry.org/mentalhealth/lets-talk-facts-brochures

American Psychiatric Association. (2007b). Mental health in the Hispanic/Latino community. Let's Talk Facts about Healthy Minds Healthy Lives [Brochure]. Retrieved March 10, 2014 from  http://www.psychiatry.org/mentalhealth/lets-talk-facts-brochures

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.

Boroughs, M., Krawczyk, R., & Thompson, J. (2010). Body dysmorphic disorder among diverse racial/ethnic and sexual orientation groups: Prevalence, estimates and associated factors. Sex Roles, 63(9/10), 725–737. doi:10.1007/ s11199-010-9831-1

Chow, J. C. C., Jaffee, K., & Snowden, L. (2003). Racial/ethnic disparities in the use of mental health services in poverty areas. American Journal of Public Health, 93(5), 792–797

Corcoran, K., & Fischer, J. (2013). Measures for clinical practice and research: A sourcebook. Volume 2: Adults (5th ed.). New York: Oxford University Press.

de Mathis, M., de Alvarenga, P., Funaro, G., Torresan, R., Moraes, I., Torres, A., et al. (2011). Gender differences in obsessive-compulsive disorder: A literature review. Revista Brasileira de Psiquiatria, 33(4), 390–399.

Fawzy, N., & Hashim, H. (2011). Prevalence and risk factors of suicide among patients with obsessive-compulsive disorder. Middle East Current Psychiatry, 18(1), 18–22. doi:10.1097/01.XME.0000392844.09854.26. Retrieved February 4, 2014, from  http://journals.lww.com/mecpsychiatry/Fulltext/2011/01000/Prevalence_and_risk_factors_of_suicide_among.4.aspx

Foa, E. B., Huppert, J. D., Leiberg, S., Langner, R., Kichic, R., Hajcak, G., et al. (2002). The Obsessive-Compulsive Inventory: Development and validation of a short version. Psychological Assessment, 14(4), 485–496.

Foa, E. B., Kozak, M. J., Salkovskis, P. M., Coles, M. E., & Amir, N. (1998). The validation of a new obsessive-compulsive disorder scale: The Obsessive-Compulsive Inventory. Psychological Assessment, 10, 206–214.

Freeman, J., Flessner, C. A., & Garcia, A. (2011). The Children's Yale-Brown Obsessive Compulsive Scale: Reliability and validity for use among 5 to 8 year olds with obsessive-compulsive disorder. Journal of Abnormal Child Psychology, 39(6), 877–883. doi:10.1007/s10802- 011-9494-6

Frost, R. O., Steketee, G., & Grisham, J. (2004). Measurement of compulsive hoarding: Saving Inventory-Revised. Behaviour Research and Therapy, 42, 1163–1182.

Gibb, G. D., Bailey, J. R., Best, R. H., & Lambirth, T. T. (1983). The measurement of the obsessive-compulsive personality. Educational and Psychological Measurement, 43, 1233–1237.

Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C., Fleischmann, R. L., Hill, C. L., et al. (1989a). The Yale– Brown Obsessive Compulsive Scale: I. Development, use, and reliability. Archives of General Psychiatry, 46, 1006–1011.

Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C., Delgado, P., Heninger, G. R., et al. (1989b). The Yale– Brown Obsessive Compulsive Scale: II. Validity. Archives of General Psychiatry, 46, 1012–1016.

Hajcak, G., Huppert, J. D., Simons, R. F., & Foa, E. B. (2004). Psychometric properties of the OCI-R in a college sample. Behavior Research & Therapy, 42, 115–123.

Himle, J. A., Muroff, J. R., Taylor, R., Baser, R. E., Abelson, J. M., Hanna, G. L., et al. (2008). Obsessive-compulsive disorder among African Americans and blacks of Caribbean descent: Results from the National Survey of American Life. Depression & Anxiety (1091-4269), 25(12), 993–1005. doi:10.1002/da.20434

Kamath, P., Reddy, Y. C. J., & Kandavel, T. (2007). Suicidal behavior in obsessive-compulsive disorder. Journal of Clinical Psychiatry, 68, 1741–1750.

Keuthen, N. J., Deckersbach, T., Wilhelm, S., Engelhard, I., Forker, A., O’Sullivan, R. L., et al. (2001). The Skin Picking Impact Scale (SPIS): Scale development and psychometric analyses. Psychosomatics, 42(5), 397–403.

Keuthen, N. J., Flessner, C., Woods, D., Franklin, M., Stein, D., & Cashin, S. (2007). Factor analysis of the Massachusetts General Hospital Hairpulling Scale. Journal of Psychosomatic Research, 62(6), 707–709.

Keuthen, N. J., O’Sullivan, R., Ricciardi, J., Shera, D., Savage, C., Borgmann, A., et al. (1995). The Massachusetts General Hospital (MGH) Hairpulling Scale: 1. Development and factor analyses. Psychotherapy and Psychosomatics, 64(3–4), 141–145.

Kramer, E. J., Kwong, K., Lee, E., & Chung, H. (2002). Cultural factors influencing the mental health of Asian Americans. Western Journal of Medicine, 176(4), 227–231.

Lewin, A. B., Caporino, N., Murphy, T. K., Geffken, G. R., & Storch, E. A. (2010). Understudied clinical dimensions in pediatric obsessive compulsive disorder. Child Psychiatry & Human Development, 41(6), 675–691. doi:10.1007/ s10578-010-0196-z

Lochner, C., Seedat, S., & Stein, D. J. (2010). Chronic hair- pulling: Phenomenology-based subtypes. Journal of Anxiety Disorders, 24(2), 196–202. doi:10.1016/j.janxdis. 2009.10.008

Mataix-Cols, D., Frost, R. O., Pertusa, A., Clark, L., Saxena, S., Leckman, J. F., et al. (2010). Hoarding disorder: A new diagnosis for DSM-V? Depression & Anxiety (1091- 4269), 27(6), 556–572. doi:10.1002/da.20693

Mckay, D., Greisberg, S., Piacentini, J., Graae, F., Jaffer, M., Miller, J., et al. (2003). The Children's Yale–Brown Obsessive– Compulsive Scale: Item structure in an outpatient setting. Psychological Assessment, 15(4), 578–581. doi:10.1037/1040-3590.15.4.578

National Guideline Clearinghouse (NGC). Guideline summary: Practice guideline for treatment of patients with obsessive compulsive disorder. In: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); [cited 2013 December 26]. Available:http://www.guideline.gov/content.aspx?id=11078

Pertusa, A., Fernández de la Cruz, L., Alonso, P., Menchón, J., & Mataix-Cols, D. (2012). Independent validation of the Dimensional Yale–Brown Obsessive–Compulsive Scale (DY-BOCS). European Psychiatry: The Journal of the Association of European Psychiatrists, 27(8), 598–604. doi:10.1016/j.eurpsy.2011.02.010

Pertusa, A., Frost, R., Fullana, M., Samuels, J., Steketee, G., Tolin, D., et al. (2010). Refining the diagnostic boundaries of compulsive hoarding: A critical review. Clinical Psychology Review, 30(4), 371–386. doi:10.1016/j. cpr.2010.01.007

Phillips, K. A. (2004). Body dysmorphic disorder: Recognizing and treating imagined ugliness. World Psychiatry, 3(1), 12–17.

Phillips, K. A. (2007). Suicidality in body dysmorphic disorder. Primary Psychiatry, 14(12), 58–66.

Phillips, K. A., Hollander, E., Rasmussen, S. A., Aronowitz, B. R., DeCaria, C., & Goodman, W. K. (1997). A severity rating scale for body dysmorphic disorder: Development, reliability and validity of a modified version of the Yale– Brown Obsessive Compulsive Scale. Psychopharmacology Bulletin, 33, 17–22.

Phillips, K. A., Menard, W., & Fay, C. (2006). Gender similarities and differences in 200 individuals with body dysmorphic disorder. Comprehensive Psychiatry, 47(2), 77–87.

Phillips, K. A. (2009). Understanding Body Dysmorphic Disorder: An Essential Guide. New York: Oxford University Press.

Plimpton, E. H., Frost, R. O., Abbey, B. C., & Dorer, W. (2009). Compulsive hoarding in children: 6 case studies. International Journal of Cognitive Therapy, 2, 88–104.

Rodriguez, C., Herman, D., Alcon, J., Chen, S., Tannen, A., Essock, S., et al. (2012). Prevalence of hoarding disorder in individuals at potential risk of eviction in New York City: A pilot study. The Journal of Nervous and Mental Disease, 200(1), 91–94. doi:10.1097/NMD.0b013e31823f678b

Rosario-Campos, M. C., Miguel, E. C., Quatrano, S., Chacon, P., Ferrao, Y., Findley, D., et al. (2006). The Dimensional Yale–Brown Obsessive–Compulsive Scale (DY-BOCS): An instrument for assessing obsessive-compulsive symptom dimensions. Molecular Psychiatry, 11(5), 495–504.

Samuels, J. F., Bienvenu, O., Pinto, A., Murphy, D. L., Piacentini, J., Rauch, S. L., et al. (2008). Sex-specific clinical correlates of hoarding in obsessive-compulsive disorder. Behaviour Research & Therapy, 46(9), 1040–1046. doi:10.1016/j. brat.2008.06.005

Scahill, L., Riddle, M., McSwiggin-Hardin, M., Ort, S., King, R., Goodman, W., et al. (1997). Children's Yale–Brown Obsessive Compulsive Scale: Reliability and validity. Journal of the American Academy of Child and Adolescent Psychiatry, 36(6), 844–852.

Staley, D., & Ward, R. (1995). Obsessive-compulsive disorder: A review of the cross-cultural epidemiological literature. Transcultural Psychiatry, 32(2), 103–136.

Storch, E. A., Lack, C., Merlo, L., Geffken, G., Jacob, M., Murphy, T., et al. (2007). Clinical features of children and adolescents with obsessive-compulsive disorder and hoarding symptoms. Comprehensive Psychiatry, 48(4), 313–318.

Storch, E. A., Murphy, T. K., Geffken, G. R., Soto, O., Sajid, M., Allen, P., et al. (2004). Psychometric evaluation of the children's Yale–Brown Obsessive–Compulsive Scale. Psychiatry Research, 129(1), 91–98. doi:10.1016/j.psychres. 2004.06.009

Storch, E. A., Muroff, J., Lewin, A. B., Geller, D., Ross, A., McCarthy, K., et al. (2011). Development and preliminary psychometric evaluation of the children's saving inventory. Child Psychiatry & Human Development, 42(2), 166–182. doi:10.1007/s10578-010-0207-0

Tucker, B. T. P., Woods, D. W., Flessner, C. A., Franklin, S. A., & Franklin, M. E. (2011). The skin picking impact project: Phenomenology, interference, and treatment utilization of pathological skin picking in a population-based sample. Journal of Anxiety Disorders, 25(1), 88–95. doi:10.1016/j.janxdis.2010.08.007

Williams, M. T., Domanico, J., Marques, L., Leblanc, N. J., & Turkheimer, E. (2012). Barriers to treatment among African Americans with obsessive-compulsive disorder. Journal of Anxiety Disorders, 26(4), 555–563. doi:10.1016/j.janxdis.2012.02.009

Williams, M. T., Powers, M., Yun, Y., & Foa, E. (2010). Minority participation in randomized controlled trials for obsessive-compulsive disorder. Journal of Anxiety Disorders, 24(2), 171–177.

Williams, M. T., & Turkheimer, E. (2007). Identification and explanation of racial differences on contamination measures. Behavior Research & Therapy, 45(12), 3041–3050.

Williams, M. T., Turkheimer, E., Magee, E., & Guterbock, T. (2008). The effects of race and racial priming on self-report contamination anxiety. Personality and Individual Differences, 44(3), 746–757.

Williams, M. T., Turkheimer, E., Schmidt, K. M., & Oltmanns, T. F. (2005). Ethnic identification biases responses to the Padua Inventory for Obsessive-Compulsive Disorder. Assessment, 12(2), 174–185.

Wu, M., McGuire, J., Arnold, E., Lewin, A., Murphy, T., & Storch, E. (2013). Psychometric properties of the Children's Yale–Brown Obsessive Compulsive Scale in youth with autism spectrum disorders and obsessive-compulsive symptoms. Child Psychiatry and Human Development. Retrieved July 5, 2013, from  http://link.springer.com/article/10.1007%2Fs10578-013-0392-8#page-1

8 Trauma- and Stressor-Related Disorders

The diagnoses in this new chapter “Trauma- and Stressor-Related Disorders” are classified in terms of psychological symptoms and behaviors that emerge in response to an external event/stressor, which is a critical diagnostic condition ( APA, 2013 ). These disorders often share overlapping symptoms on the diagnostic spectrum with the surrounding chapters (e.g., anxiety, obsessive compulsive, and dissociative disorders). Although anxiety and fear may be part of symptom expression, other characteristic symptoms include “anhedonic and dysphoric symptoms, externalizing angry and aggressive symptoms, or dissociative symptoms” ( APA, 2013 , p. 265). These related disorders all share this diversity of symptoms and range in severity from Reactive Attachment Disorder and Post Traumatic Stress Disorder to the milder Adjustment Disorder ( APA, 2013 ).

   The first two rare disorders are associated with social neglect, which is defined as” the absence of adequate caregiving during childhood” ( APA, 2013 , p. 265). Reactive Attachment Disorder (RAD) was split into two separate disorders with the namesake representing the inhibited subtype and the characteristic internalizing symptoms associated with depression such as withdrawal; and the new diagnosis Disinhibited Social Engagement Disorder (DSED) based on the disinhibited subtype and characteristic externalizing symptoms such as social disinhibited behaviors and attention-seeking. RAD and DSED are often found in maltreated, institutionalized children and refugee populations, where many children either have been abandoned or have lost their parents. In RAD, the core feature is undeveloped attachment to caregivers. Additionally, there is inhibited/withdrawn behavior (e.g., rarely asks for or responds to comfort when upset). Also, these children exhibit emotional and social disruptions over long periods of time, as evidenced by two or more of the following behaviors: diminished positive emotions (e.g., blunted pleasure), limited emotional or social responsiveness to others (e.g., lack of empathy) and unexplained displays of fear, sadness and/or irritability that are not suitable to circumstances. Also, a pattern of “insufficient care” is needed (for examples see DSM-5,  APA, 2013 , p. 266), which is presumed to be responsible for the disturbed/disrupted attachment behaviors. For diagnosis, the child must have a developmental age of at least 9 months, with the inhibited attachment behaviors evident before the age of five, and the criteria for Autism Spectrum Disorder have not been met ( APA, 2013 ).

   In DSED, the primary feature is inappropriate and exceedingly friendly behavior with a person who is unfamiliar to the child. The social disinhibited behavior must include at least two of the following criteria: willingness to interface with unfamiliar adults; unduly familiar physical or verbal behavior (violating age appropriate and culturally sanctioned social rules); minimal use of social safety skills (e.g., checking in with caregivers after going off with strangers); and eagerness to leave with unfamiliar adults without diffidence. Moreover, as in RAD, for diagnosis exposure to “insufficient care” is needed (with criteria now including rearing in institutions with high child-to-caregiver ratios) and seen as responsible for the child's behavior. Of note, in children with DSED the focus is on “socially disinhibited behavior” not on the social impulsivity that may be found in children with ADHD (who typically present with hyperactivity and attention deficits as well). For diagnosis, the child needs to have a developmental age of at least 9 months, with DSED typically occurring in children from age two through pre-adulthood. For both disorders the clinician must specify if “persistent” (e.g., present for over a year) as well as current symptom severity level ( APA, 2013 ).

   The next two diagnoses are associated with exposure to traumatic events involving death or threatened death, serious injury or sexual violation to the client or another person. A key feature of both disorders is the development of a diverse array of symptoms and significant clinical distress following exposure to a traumatic event. Exposure includes: directly experiencing the traumatic event; personally witnessing an event involving others as it takes place; discovering that a traumatic event (with the additional criteria of violence or accidental death) happened to a close relative/friend; and direct exposure to repeated trauma due to employment or service (e.g., paramedics, firefighters, police officers). It is important to note that exposure does not include witnessing traumatic events on TV or other electronic media unless the exposure is occupational ( APA, 2013 ).

   In Posttraumatic Stress Disorder (PTSD), the symptoms must follow exposure and have persisted for at least 1 month, although the exposure to trauma may have occurred at any time prior to symptom onset. Additionally, symptoms must cause substantial distress and/or impairment and cannot be the direct results of a substance (e.g., alcohol, drugs, or medication) or another medical condition (e.g., traumatic brain injury). The following diagnostic criteria apply to individuals 6 years or older. Specifically, this disorder is characterized by at least one intrusive symptom (e.g., persistent reexperiencing of the traumatic event, recurrent dreams, flashbacks) and at least one symptom of avoidance of stimuli associated with the trauma (e.g., avoidance of thoughts/feelings, or external reminders such as people/situations). Further, the client evidences at least two symptoms of negative changes in thoughts and mood (e.g., dissociative amnesia for an important aspect of the event, pervasive negative beliefs/attitudes, distorted thoughts and self blame, negative emotions). In addition, the individual experiences at least two persistent symptoms of arousal (irritability, aggressive and/or self-destructive behavior, sleep disturbance, etc.) that were not present before the traumatic event or worsening after the traumatic event ( APA, 2013 ).

   To help identify very young children suffering from PTSD, a “preschool” subtype was created, which reflects the developmental differences and behavioral benchmarks of this population in terms of symptom expression. This preschool subtype is for use with children 6 years and younger ( APA, 2013 ). Research supports the use of developmentally appropriate criteria when working with children ( Scheeringa, Zeanah, Drell, & Larrieu, 1995 ) as well as the psychometric soundness of the preschool PTSD criteria ( Scheeringa, Zeanah, Myers, & Putnam 2003 ;  Scheeringa, Zeanah, Myers, & Putnam, 2005 ). Overall, the major difference between the adult and preschool subtypes is the lowering of diagnostic criteria in order to accommodate developmental differences ( Scheeringa, Zeanah, & Cohen, 2011 ; Scheeringa, Myers, Putnam, & Zeanah, 2012). For example, in the current version of the DSM only one symptom of either avoidance (e.g., of activities or people) or negative alterations in cognitions and mood (e.g., sadness, reduced play) is required for children versus a total of three in adults (for full criteria see  APA, 2013 , pp. 272–273). Likewise, a dissociative subtype was added to help demarcate when PTSD is accompanied by dissociative symptoms (e.g., depersonalization and/or derealization). Furthermore, the specifier “with delayed expression” is used if the full diagnostic criteria are not met until 6 months or more after the event ( APA, 2013 ).

   In Acute Stress Disorder (ASD), symptoms usually begin during or immediately after the trauma exposure (meeting criteria discussed earlier), and must last for at least 3 days and up to 1 month after trauma exposure. Individuals must exhibit at least 9 out of 14 listed symptoms from the following five symptom categories including: intrusive (e.g., disturbing memories, dreams, flashbacks); negative mood (e.g., inability to feel positive emotions such as joy or happiness); dissociative (e.g., breakdown in awareness or memories); avoidance (of thoughts/feelings, people/places associated with trauma); and, arousal (e.g., sleep problems, hypervigilance, irritability/agitation, excessive startle reactions and poor concentration). Of note, children may use repetitive play to reenact trauma. It should be noted that if the symptoms are not resolved in the stated time period, another diagnosis is in order (e.g., a depressive disorder, other anxiety disorders, substance-use problems) ( APA, 2013 ).

   The next category is used when an individual's normal coping mechanisms prove to be ineffective in response to a stressful life event. Specifically, Adjustment Disorders (ADs) may occur when emotional and/or behavioral difficulties arise in reaction to an identifiable stressor(s). There are 6 different subtypes, each corresponding to the underlying symptoms such as with depressed mood, with anxiety (for examples see  APA, 2013 , p. 287). To meet diagnostic criteria the stress-related symptoms must cause clinically significant distress and/or impairment and begin within 3 months from exposure to the stressor(s), lasting no more than 6 months after the stressor(s) or its consequences abate. Also, the resulting stress symptoms cannot meet the criteria for any other mental disorder; represent the worsening of a preexistent mental disorder or denote typical grief and bereavement (which is social/culturally dependent). Both children and adults can be diagnosed with an Adjustment Disorder. Furthermore, the identified stressor(s) in this disorder may be a single event (e.g., birth of a child), a recurrent event (e.g., harassing phone calls from a former spouse), a chronic or continuous event (e.g., financial problems), or correspond to developmental events (e.g., entry into adolescence, in the case of an individual; or when all the children leave home, in the case of the family) ( APA, 2013 ).

   The final two disorders in this chapter pertain to presentations that have stressor-related symptoms and meet the clinical distress/impairment requirements but do not meet the full criteria for any other disorder in this chapter. Specifically, “Other Specified Trauma- or Stressor-Related Disorder” is used when the clinician chooses to record why full diagnostic requirements were not met, for instance, when a client's distress and symptoms appear more than 3 months after the emergence of a stressor (see examples  APA, 2013 , p. 289). Furthermore, Unspecified Trauma- and Stressor-Related Disorder is applied under similar circumstances, but when the clinician chooses not to indicate the circumstances why full criteria were not met, typically useful for times when the clinician lacks pertinent information to making a more specific diagnosis ( APA, 2013 ).

Assessment

The disorders brought together in this new chapter have in common a stressful or traumatic event that must precede a change in an individual's affective states, cognitions, and behaviors resulting in impairment and significant distress. When diagnosing a stressor-related disorder, the clinical assessment should be as comprehensive as possible and include multiple sources of information when available (e.g., family/friends, medical/military records) in order to best evaluate the client's emotional state and behavior before and post trauma/stressor(s) as well as coping mechanisms and strategies. For example, a detailed family history would be useful when making a diagnosis requiring “extremes of insufficient care” (e.g., RAD, DSED). On the other hand, a mental status exam might be useful when working with elderly individuals to help screen for cognitive deficits. Moreover, given that traumatic events can increase an individual's risk for suicide and the high suicide risk associated with PTSD and AD, a complete assessment should include screening for suicidal behavior to help ensure the physical and psychological safety of the client. Individuals suffering from Trauma and Stress-Related Disorders often experience a wide range of debilitating symptoms (e.g., emotional/physical detachment, withdrawal/avoidance, hyperarousal) that may negatively impact interpersonal relationships while impairing coping skills. Frequently individuals develop comorbid substance use disorders (e.g., alcohol, prescription medication, recreational drugs) in an attempt to deal with the trauma and resulting symptoms, which unfortunately can lead to problems (e.g., legal and occupational issues). Other challenges include identifying symptoms in young children or the elderly, which can be exacerbated by developmental issues or symptoms in persons suffering from a Traumatic Brain Injury (TBI). Many assessment instruments are available and often the choice is dependent on the clinical goal. For example, for screening purposes you might want a brief, self-report measure. However, for treatment purposes, you may want a tool with greater sensitivity to change, such as a semistructured interview tool. Along with the instruments mentioned below, the DSM-5 has included a listing of helpful cross-cutting symptom measures as well as disorder specific symptom measures for adults and children (see Section III,  APA, 2013 ) as well as additional online measures ( www.psychiatry.org ).

Assessment Instruments

The Clinician-Administered PTSD Scale (CAPS;  Blake et al., 1995 ) is considered the “criterion” for measuring traumatic stress with a structured clinical interview. This 30-item instrument evaluates PTSD based on DSM-IV diagnostic criteria ( APA, 1994 ) as well as symptom frequency and severity ( Weathers, Keane, & Davidson, 2001 ). An update is expected to correspond to the DSM-5 ( APA, 2013 ) diagnostic criteria. This scale can provide a PTSD diagnosis (over the past month and/or lifetime) as well as a dimensional measure of PTSD symptom severity (over the past week) relative to earlier assessments. Also, this tool can be used to assess the essential features of ASD (based on DSM-IV criteria;  APA, 1994 ). Training is required to administer the CAPS, and it usually takes 45 to 60 minutes to complete.

   Many valid scoring rules exist;  Weathers, Ruscio, and Keane (1999)  suggest that the choice should rely on the intended assessment purposes (e.g., screening, research, treatment). The most commonly used rule is to count a symptom present if it has a frequency of 1 or more (on 5-point scale; with 0 = “none” to 4 = “most of the time”) and an intensity of 2 or more (with 0 = “none” to 4 = “extreme”). Severity scores are calculated by summing the frequency and intensity ratings for each symptom and/or for the core symptom clusters. Total score ranges from 0 to 136. The CAPS has almost 20 years of psychometric validity for PTSD diagnostic status and symptom severity across a diverse range of research settings and clinical trauma populations. The CAPS demonstrates high internal consistency, test–retest reliabilities and inter-rater reliability, along with excellent convergent and discriminant validity. For detailed ranges see  Weathers et al. (2001) .

   The PTSD Checklist (PCL;  Weathers, Litz, Herman, Huska, & Keane, 1993 ) is a brief, 17-item “self-report” measure reflecting DSM-IV ( APA, 1994 ) symptoms of PTSD. As with most self-report scales, the PCL is best for use as a screening tool (versus formal diagnosis). There are 3 versions with slight adjustments, including PCL-M (military), which is specific to PTSD symptoms caused by military experiences and for use with active service members and Veterans; PCL-C (civilian), which can be used with any traumatic event for use with all populations; and, PCL-S (specific), which is anchored to a specific traumatic event (e.g., sexual assault, vehicle accident, natural disaster). Respondents rate each item using a 5-point scale where 1 equals “not at all” to 5 “extremely” indicating the degree to which they have been bothered by that particular symptom over the past month. Although scoring is the same for all three versions, different scoring procedures may be used to yield either a total score of PTSD symptom severity (range = 17–85; with suggested threshold score of 50 as good predictor of PTSD) or as a symptom indicator of diagnostic status corresponding to the DSM diagnostic criteria, typically requiring a score of 3–5 (Moderately or above) as symptomatic and responses 1–2 (below Moderately)as non-symptomatic. Typically higher scores indicate greater severity ( Forbes, Creamer, & Biddle, 2001 ).

   The psychometric properties of the PCL are strong with much research supporting its validity. Estimates of internal consistency range from .97 in the original study by  Weathers et al. (1993)  to .96 for the full scale, and .94 for cluster B symptoms, .91 for cluster C symptoms, .92 for cluster D symptoms ( Keen, Kutter, Niles, & Krinsely , 2008 ). Test–retest reliability has been reported as .96 at 2–3 days ( Weathers et al., 1993 ) and.88 at 6–9 days; and, .68 at 12–14 days ( Palmieri, Weathers, Difede, & King, 2007 ;  Ruggiero, Del Ben, Scotti, & Rabalais, 2003 ). The PCL has been shown to correlate positively with other measures of PTSD symptom severity.  Blanchard, Jones-Alexander, Buckley, and Forneris, (1996)  reported PCL total score correlated .929 with the CAPS total score with good sensitivity and specificity. Others have shown good convergent validity with the Mississippi Scale for Combat-Related PTSD and CAPS ( Keen et al., 2008 ). In a study by  Adkins, Weathers, McDevitt-Murphy, and Daniels (2008)  the PCL-S was among the strongest in discriminating PTSD from depression, social phobia, and anxiety. However, more research is needed to test discriminant validity ( Wilkins, Lang, & Norman, 2011 ).

   A commonly used instrument for combat exposure is the Mississippi Scale for Combat-Related PTSD (M-PTSD;  Keane, Caddell, & Taylor, 1988 ). This 35-item scale has demonstrated both reliability and validity and has been recommended as a good self-report instrument for combat veterans in a review of the literature ( Watson, 1990 ). It usually takes under 20 minutes to administer with a total score produced by summing items (after reversing some positively worded items) ranging from the original suggested total of 107 to 121, which may offer better differentiation ( Orsillo, 2001 ).

   In contrast, the Impact of Event Scale Revised (IES-R;  Weiss & Marmar, 1996 ) is a revision of an older 15-item measure (IES;  Horowitz, Wilner, & Alvarez, 1979 ) that allows the client to focus on any particular event that has been traumatic. Several new “hyperarousal” items were added to this scale to closer match DSM-IV-TR ( APA, 2000 ) diagnostic criteria for PTSD. This brief, 22-item measure is best utilized for screening purposes rather than as a PTSD diagnostic test. Items are rated on a 5-point scale ranging from 0 (“not at all”) to 4 (“extremely”). The IES-R delivers a total score (ranging from 0 to 88) with higher scores signaling greater symptomatology. Subscale scores can also be calculated for various symptoms. A total IES-R score of 33 is the suggested cutoff score for suggesting further testing of PTSD ( Creamer, Bell, & Failla, 2003 ). The IES-R has demonstrated good psychometric properties (alpha = .96 for IES-R total score; alpha = .94 Intrusion subscale; alpha = .87 Avoidance subscale; alpha = .91 Hyperarousal subscale). Convergent validity was shown with consistent and high correlations between the IES-R total and subscale scores, and related measures of PTSD.

   The Brief Traumatic Brain Injury Screen (BTBIS,  Schwab et al., 2006 ) is a new 3-item screening measure to help determine the presence of a Traumatic Brain Injury (TBI).  Bryant (2011)  points out that PTSD and TBI often coexist and asserts that it might be a risk factor for PTSD, often complicating diagnosis because of overlapping symptoms. This simple measure could help facilitate early self-report of probable TBI, but further studies on its psychometric properties are warranted.

   To date, there are limited validated assessment measures of ASD. The Acute Stress Disorder Interview (ASDI;  Bryant, Harvey, Dang, & Sackville, 1998 ) is considered the benchmark (and sole structured clinical interview) to diagnose ASD based on DSM-IV ( APA, 1994 ) criteria. This 19-item instrument is dichotomously scored with either 0 (equal to symptom absence) or 1 (equal to symptom presence). Summing positive responses provides a total score (range 1–19). The ASDI was independently validated against a sample of 65 clinically diagnosed trauma survivors with both ASD and PTSD.  Bryant et al. (1998)  reported excellent internal consistency (r = .90 for the total scale) and good test–retest reliability (r = .95), sensitivity (91%), specificity (93%).

   Another measure, the Acute Stress Disorder Scale (ASDS;  Bryant, Moulds, & Guthrie, 2000 ) is a 19-item, self-report inventory that indexes ASD and predicts PTSD. The ASDS includes 5 dissociative, 4 reexperiencing, 4 avoidance, and 6 arousal symptoms items. Respondents rate each item on a 5-point scale (1 = not at all to 5 = very much) and summing items provides “Total” and subscale scores. It has good internal consistency, test–retest reliability and construct validity. Alphas ranging from .88 to .96 for total score, and from .62 to .94 for subscale scores for dissociation, re-experiencing, avoidance, and hyperarousal symptoms ( Bryant et al., 2000 ;  Helfricht et al., 2009 ). The ASDS correlates highly with symptom clusters on the ASDI.

   Additionally, the National Stressful Events Survey Short Scale (NSESSS) disorder specific severity measures are available for both PTSD and ASD ( Kilpatrick et al., 2013 ) for children (ages 11–17) and adults ( APA, 2013 ). These tools are for screening/monitoring purposes only and not for clinical diagnosis. Details on both can be found online at the DSM-5 website  http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures .

   Although the diagnosis of AD is generally made from a clinical, psychosocial assessment, the severity of the emotional response can be measured with standardized assessment instruments that have been discussed in other chapters of this workbook. This would, of course, be most appropriate when the practitioner is uncertain whether the level of symptoms constitutes a more serious diagnosis. Generally speaking, the most appropriate assessment instrument is clinical judgment, as many clinical interviews do not diagnose and in order to diagnose you must rule out other diagnoses ( Casey & Bailey, 2011 ).

   Depressed moods and anxiety are the two negative emotional reactions specified in conjunction with ADs. For adults who seem to have more depressive symptoms, the Hamilton Rating Scale for Depression or Patient Health Questionnaire (PHQ-9) would be recommended choices; for children, the PHQ-9 modified for Adolescents (PHQ-A), or the Hopelessness Scale for Children is recommended (see  Chapter 5  for details regarding these instruments). For anxiety symptoms, the state subscales from the State-Trait Anxiety Inventory (for adults) or the State-Trait Anxiety Inventory for Children would be excellent choices (see  Chapter 6  for more details).

   Disturbances of Conduct—that is, behavioral symptoms—may also be specified in conjunction with ADs. There is no comprehensive survey of adult behaviors to use in this regard. However, for children the Child Behavior Checklist would be appropriate (for details see below under children instruments).For help in differential diagnosis, see  Chapter 15  on Disruptive, Impulse-Control, and Conduct Disorders.

   Also, clinicians can use the Level 1 and/or Level 2 Cross-Cutting Symptom Measures (e.g., Depression and/or Anxiety scales PROMIS Emotional Distress Short Forms) and/or Disorder-Specific and Clinician-Rated Severity Instruments found in Section III of the DSM-5 ( APA, 2013 ) or online (see  http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures ). For example, The Clinician-Rated Severity of Conduct Disorder is designed to help assess the presence and severity of conduct problems ( APA, 2013 ). These instruments (self-, parent/guardian- and clinician-report) are age specific (e.g., adult, adolescent, and child versions) and for screening purposes only.

   Because some clients may be focused on a single psychosocial stressor when, in fact, multiple stressors are occurring simultaneously, it can be useful to use a standardized approach to assessing the amount and type of stress in a person's life. The Social Readjustment Rating Scale (SRRS;  Holmes & Rahe, 1967 ) examines 43 different increasingly stressful life events and assigns a value to each item. Scores above a cutoff point can help to assess the probability of a problem in adjustment or a related health problem in the near future. It is important to recognize that the scale contains several “positive” items (e.g., marriage, vacation, holidays) that can also be experienced as stressful life events.

   At present, there is no recognized standard for the assessment of RAD and dsed DAD ( O'Connor & Zeanah, 2003 ;  Zeanah & Gleason, 2010 ). For this reason a multifaceted approach is encouraged when evaluating attachment disorders, whereby clinical judgment is supplemented through direct observation, extensive histories (family and academic), as well as interviews with the individual, family, and friends when appropriate ( O'Connor & Zeanah, 2003 ;  Sheperis et al., 2003 ). However, some measures can be useful in screening for possible issues in children's emotional and behavioral development.

   A well-validated measure of broad behavioral and emotional problems in children is the Child Behavior Checklist (CBCL;  Achenbach & Edelbrock, 1983 ;  Achenbach, 1991 ;  Achenbach & Rescorla, 2000 ;  Achenbach & Rescorla, 2001 ; Achenbach System of Empirically Based Assessment-ASEBA;  Achenbach et al., 2008 ) of which self-, parent- and teacher-reports are available. The parent-completed CBCL standardized questionnaire is considered one of the most widely used children's behavioral rating scales ( Ebesutani et al., 2010 ). The preschool CBCL (99-items for ages 1.5–5) and the school age CBCL (118-items for ages 6–18) include problem behaviors that can be scored by parents of children aged 1–18 years. Scoring uses Likert scale (0 = not true to 2 = very/often true) and open-ended questions for parent elaboration and takes 10 to 20 minutes to administer. The CBCL produces a total score, internalizing and externalizing problem scores, Syndrome subscale scores, and DSM-oriented scores based on age and sex that can be compared to normal and clinical populations. A total problem score (internalizing and an externalizing scores) is computed by summing scores for individual items and Syndrome and DSM-oriented scale scores can also be calculated, with T-scores/percentiles available for all scales/scores. The CBCL has shown sound reliability and validity across racially and ethnically diverse sample ( Achenbach & Rescorla, 2001 ;  Gross et al., 2006 ;  Sivan, Ridge, Gross, Richardson, & Cowell, 2008 ).

   The Syndrome scales for preschool CBCL (e.g., emotionally reactive, anxious/depressed, somatic complaints, withdrawn, sleep problems, attention problems, and aggressive behavior) demonstrated internal consistency that ranged from .66 to .95 ( Achenbach & Rescorla, 2000 ;  Frick, Barry, & Kamphaus, 2010 ). The DSM-oriented scales (DSM-IV,  APA, 1994 ) in the preschool instrument were condensed into five categories (e.g., affective, anxiety, pervasive developmental, attention deficit/hyperactive and oppositional defiant disorders) and showed good internal consistency with a range from .63 to .86 and good test–retest reliability ranging from .74 to .92 ( Archenbach & Rescorla, 2000 ;  Frick et al., 2010 ). The Syndrome scales of the school age CBCL (anxious/depressed, withdrawn/depressed, somatic complaints, social problems, thought problems, attention problems, rule-breaking, and aggressive behaviors) had an internal consistency (.78 to .97) and (.72 to .91) reliability on the six (e.g., affective, anxiety, somatic, attention/hyperactivity, oppositional defiant, and conduct problems) DSM-oriented scales ( Archenbach & Rescorla, 2000 ;  Frick et al., 2010 ). However, problems with construct validity for some DSM-oriented scales have been noted ( Ferdinand, 2008 ). Still, the revised CBCL has been shown useful for measuring RAD like behaviors due to its inclusion of internalizing and externalizing scales ( Sheperis et al., 2003 ). Some studies demonstrate that the CBCL DSM-oriented scales were able to differentiate children with and without relevant DSM diagnoses ( Ebesutani, et al., 2010 ;  Nakamura, Ebesutani, Bernstein, & Chorpita, 2009 ). However, the testing of the DSM psychometric properties is ongoing and warrants continued study.

   A promising new questionnaire developed for use in primary care settings and screens for possible mental health problems in very young children (aged 1 to 5 years) is the Early Childhood Screening Assessment (ECSA;  Gleason, Zeanah, & Dickstein, 2010 ). This brief, 40-item parent-report (a child's report is also available) includes 36 questions on the child's symptoms (which are scored) and the final 4 questions on parental distress/depression. Parents can also indicate any items that they want further help with. All scored items are rated on a 3-point, Likert scale with 0 = never/rarely, 1 = sometimes/somewhat, and 2 = always/almost always. Scored items are summed with a total score range from 0 to 72. For the 36 scored items, the suggested cutoff score of 18 is considered positive with further screening suggested. A score of 1 or more on parent depression score (items 39 and 40) warrants further screening ( Gleason, Dickstein, & Zeanah, 2006 ). This instrument has good preliminary psychometrics with internal consistency alpha of .91; and test–retest reliability of .81. ECSA had a strong correlation with the parent-report CBCL total score (Spearman's ρ =.81, p ≤ .01) ( Gleason et al., 2010 ).

   The Disturbances of Attachment Interview (DAI;  Smyke & Zeanah, 1999 , as cited in  Smyke, Dumitrescu, & Zeanah, 2002 ) is a 12-item, semistructured interview given to parents/guardians of young children to report on signs of disturbed or disordered attachment (including RAD). Also, it allows the concurrent observation of the child if present. There are three sections to this instrument: Indiscriminately Social/Disinhibited Type (3 items); Emotionally Withdrawn/Inhibited Type (5 items); and Secure Base Distortions (4 items). Items are coded on a 3-point scale, where 0 = “clearly” demonstrates the behavior, 1 = “sometimes or somewhat” demonstrates the behavior, and 2 = “rarely or minimally” demonstrates the behavior. This interview takes about 20 minutes and scored by summing each scales items. The total for the social disinhibited scale ranges from 0–6, and the total for the emotionally withdrawn scale ranges from 0–10. Higher scores suggest more signs of the measured behavior. The DAI scales have demonstrated strong internal validity for both social/disinhibited and emotionally withdrawn/inhibited RAD with alphas = .80 to .83. Inter-rater reliability for the DAI was demonstrated to be excellent .88 ( Smyke et al., 2002 ). Findings showed emotionally withdrawn/inhibited RAD was distinct from the indiscriminately social/disinhibited type of RAD, and both associated with poorer caregiving quality and were inversely associated with attachment security ( Gleason et al., 2011 ).

   The Clinician-Administered PTSD Scale for Children and Adolescents (CAPS-CA;  Nader et al., 1996 ) is a modified version of the adult CAPS to screen, assess and diagnose PTSD based on DSM-IV diagnostic criteria (both current and lifetime) in children ages 8 to 18 as well as symptom severity. This 33-item, semistructured interview can take from 30 to 60 minutes to administer requiring training in the instrument as well as knowledge of PTSD and in interviewing children. Items are scored on 5-point scale for frequency (e.g., from 0 = “None of the time” to 4 = “Most of the time”) and intensity (e.g., from 0 = “Not at all, none” to 4 = “A whole lot”) for the past month. A frequency score of 1 and an intensity score of 2 is required for an item to meet criterion (based on adult data,  Weathers et al., 1999 ). A severity score for each symptom is calculated by summing the frequency and intensity scores, which can then be summed for 17 symptom questions and/or for the three symptom clusters. The CAPS-CA is based on the CAPS for adults (see adult instruments above) and has proven strong psychometric properties.

   For younger children, the Diagnostic Infant Preschool Assessment (DIPA;  Scheeringa & Haslett, 2010 ) is clinician-administered interview of parents/caregivers of preschool children (aged 1–6 years). According to the author, it can be easily applied to children up to 8 years when necessary but the lower age limits of this instrument with younger infants has not been established ( Scheeringa, 2004 ). DIPA assesses the presence of children's symptoms corresponding to all 13 DSM-IV ( APA, 1994 ) disorders including PTSD. Functional impairment is assessed as well for each disorder in terms of relationship to parents, siblings, teachers/daycare, and peers. Each disorder is self-contained and can provide a DSM-IV-based categorical diagnosis or continuous measure of symptoms. The PTSD component (186 items) also includes a traumatic events screen (e.g., frequency, first onset, last event). Changes corresponding to the DSM-5 diagnostic criteria are forthcoming. It takes approximately 1 to 2 hours to administer. The DIPA has shown good reliability with a higher test–retest scores for the continuous measure (>.50) and acceptable validity/reliability of the diagnostic measure, but additional psychometric validation and testing is called for ( Scheeringa & Haslett, 2010 ). Additionally, The Young Child PTSD Checklist (YCPC;  Scheeringa, 2012 ) is a brief, 24-item, screening checklist for preschool children (aged 1–6 years). This instrument is intended for screening/referral purposes only, and never to diagnose or replace a structured interview when available. All DSM-IV PTSD symptoms are covered (items 1–19) as well as additional symptoms that have been shown relevant to traumatic stress in young children ( Scheeringa, 2011 ). Psychometric data is not yet available, but scoring and administration can be found at  http://www.infantinstitute.org/measures-manuals/ .

   The Child Report of Posttraumatic Symptoms and Parent Report of Posttraumatic Symptoms (CROPS/PROPS;  Greenwald & Rubin, 1999 ) were developed to screen for posttraumatic symptoms in children (ages 6–18) as self-reported by both the child and parent/guardian. The children's measure “CROPS” contains 25 self-report items and “PROPS” contains 30 parent-report items of posttraumatic symptoms consistent with those found in the DSM-IV ( APA, 1994 ). As the research literature demonstrates, children are often poor sources of reporting on and observing on their own behavior, and seeking collateral information can enhance reporting. Each item is rated on a 3-point Likert scale (0 = none, 1 = some, 2 = lots) producing a total score with higher scores indicating greater posttraumatic stress. Scores are calculated by summing all items for a “Total Score,” which ranges from 0 to 52 for CROPS and 0 to 60 on PROPS. The measures demonstrate strong psychometrics with excellent internal consistency for CROPS (.91) and for PROPS (.93); and good reliability, 4–6 week test–retest scores for CROPS (.80) and for PROPS (.79). Also, CROPS/PROPS demonstrated good concurrent validity in comparison to the Lifetime Incidence of Traumatic Events Checklist (LITE), with suggested cutoffs based on LITE to be 19 for CROPS and 16 for PROPS ( Corcoran & Fischer, 2013 ).

   The Acute Stress Checklist for Children (ASC-Kids;  Kassam-Adams, 2006 ) is a brief, self-report measure of acute traumatic stress reactions in children and adolescents aged 8–17. This 29-item questionnaire is designed to assess the presence (or absence) of ASD reflecting DSM-IV ( APA, 1994 ) diagnostic criteria as well as to provide a symptom severity score within the first month after trauma exposure. In total, 25 items assess DSM-IV ASD symptom criteria; with 4 additional items included for clinical utility. The ASC-Kids Symptom Scale is the summed score of 19 ASD symptom items (5 through 23) representing the overall severity of ASD symptoms. All items are rated on a 3-point scale (0 = Never/Not at all; 1 = Sometimes/Somewhat; 2 = Often/Very much) with 2 items reverse scored. The author suggests that the questionnaire be read to children under the age of 9, or to older children needing help. Administration and scoring each takes about 5 to 10 minutes. When assessing the presence of DSM-IV diagnostic criteria, an item rated as “2” (often/very much) is to be counted positive for that symptom. The ASC-Kids demonstrated strong psychometrics: internal consistency alpha = .85 for the 19-item ASD Kids Symptom Scale and .86 for the sum of all 29 items. Test–retest reliability over a 1 week period = .76 for the 19-item ASD Kids Symptom Scale and .83 for sum of all 29 items. Both the ASC-Kids Symptom Scale and the sum of all 29 items showed strong convergent and predictive validity with the Child and Adolescent Trauma Survey symptom scale – acute and follow-up (CATS;  March, Amaya-Jackson, Terry, & Costanzo, 1997 ) ( Kassam-Adams, 2006 ).

   The Beck Scale for Suicide Ideation (BSS;  Beck & Steer, 1991 ) is one of the most commonly employed measures for identifying the presence and severity of suicidal ideation, suicidal thoughts as well as suicidal plans over the previous week ( Cochrane-Brink, Lofchy, & Sakinofsky, 2000 ). The BSS has demonstrated sensitivity to suicidal behaviors and has shown utility in terms of predicting future suicide attempts ( Joiner & Gutierrez, n/d; Wiebe, Sauceda, & Lara, 2012 ). This brief 21-item scale can be clinician-administered or self-report with only the first 19 items rated on a 3-point scale (from 0 to 2) with the last 2 items on suicide attempts unrated. Any positive response on the first 5 screening questions merits further investigation through the administration of the remaining items. Rated items are summed to produce a total score that ranges from 0 to 38. These ratings are then summed to yield a total score, which ranges from 0 to 38. Higher scores reflect greater suicide risk. The BSS has been comprehensively researched and validated in people aged 17 and above. The BSS has demonstrated high internal reliability and good test–retest stability ( Beck, Brown, & Steer, 1997 ) and good concurrent validity ( Beck, Steer, & Ranieri, 1988 ). Training in this instrument is required before administration.

Emergency Considerations

When working with individuals exposed to stressful and traumatizing conditions, the issue of safety and stabilization is paramount. Research indicates that there is an increased risk of self-harm (e.g., cutting, burning) as well as suicidal ideation and attempts when working with traumatized individuals ( Krysinska & Lester, 2010 ;  Sareen, Houlahan, Cox, & Asmundson, 2005 ). Psychiatric comorbidity also increases the risk for suicidal behaviors, especially when substance abuse or depressive symptoms coexist. Patients with comorbid major depressive episode and PTSD were more likely to have attempted suicide ( Oquendo et al., 2003 ). Further, individuals with PTSD who also had a history of childhood abuse (both sexual and physical) of both genders were at greater risk for suicidal behaviors, and this risk increases further if they also suffer from a substance use disorder ( Knox, 2008 ;  Spokas, Wenzel, Sirman, Brown, & Beck, 2009 ). Also, combat trauma may increase risk as well as military sexual trauma; therefore, the assessment for suicidal behaviors in such military and veteran populations would be of benefit ( Kimerling, Gima, Smith, Street, & Frayne, 2007 ;  Knox, 2008 ). In one study on refugee trauma survivors, having PTSD significantly increases the risk of suicidal behavior compared to trauma survivors diagnosed with other mental illness or no psychopathology ( Ferrada-Noli, Asberg, Ormstad, Lundin, & Sundbom, 1998 ). PTSD was the strongest predictor of suicide attempts in developing countries and among the top three predictors in developed countries ( Nock et al., 2009 ). Moreover,  Casey and Bailey (2011)  report that over half of the adults and a quarter of adolescents with an adjustment disorder diagnosis engage in suicidal behavior.

   Ongoing suicide risk assessment is crucial, specifically in terms of asking about suicidal ideation, intent, and plans as well as past suicide attempt(s) as they are one of the strongest predictors of future suicide attempt(s). However, many suicidal individuals are reluctant to report suicidal thoughts or behaviors. The stigma and shame that often accompany mental illness coupled with illness symptoms (e.g., isolation, hyperarousal, increased aggression, irritability, sleep disturbances) can add to the individual's difficulties with disclosure and overwhelm their coping skills. In particular, hyperarousal symptoms have been demonstrated to increase suicide risk ( Nye & Bell, 2007 ;  Steyn, Vawda, Wyatt, Williams, & Madu, 2013 ). Of note, when working with children, access to developmentally appropriate measures, coexisting conditions (e.g., attention deficit disorder), pre-existing impairments (e.g., learning disabilities) as well as the safety and quality of the family environment may present challenges.

Cultural Considerations

Exposure to trauma and stress can evoke an amalgamation of symptoms and psychological behaviors characterized by the diverse diagnoses in this chapter. Such symptoms have been noted since biblical times and found in ancient myths and civilizations. Today, research and literature bear out the cross-cultural applicability of many trauma-related disorders, akin to cultural variations in the clinical presentation of other psychological disorders (e.g., anxiety, depression). At the same time, research also demonstrates that symptom expression and presentation, as well as the interpretation of distress and psychopathology can vary widely and that such cultural variations are relevant to clinical practice. Clinicians should consider how the individual interprets the traumatic events (e.g., do they believe in destiny/fate) along with the meaning they attributed to symptom phenomena (e.g., flashbacks, nightmares) as well as whether the proposed interventions and available resources (e.g., psychoeducation, psychotherapy) mesh with their values/culture ( Hinton & Lewis-Fernández, 2011 ).

   Data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; 2004–2005) show that the lifetime prevalence of PTSD was highest among Blacks (8.7%), followed by Hispanics and Whites (7.0% and 7.4%) and lowest (4.0%) among Asians ( Roberts, Gilman, Breslau, Breslau, & Koenen, 2011 ). Moreover, this data showed lower rates of treatment-seeking for PTSD among U.S. racial and ethnic minorities, with only 35.3% of Blacks receiving treatment (although they account for a larger portion of lifetime risk); 42.0% Hispanics; 32.7% of Asians; and, Whites receiving 53.3% of treatment (although they had one of the lowest PTSD lifetime risk). These findings highlight the need for accessible and culturally sensitive treatment options.

   Other studies report ethnoracial and cultural differences in exposure to traumatic events and stressors.  Pole, Gone, and Kulkarni (2008)  found evidence that African Americans and Latinos had higher rates of PTSD and more severe PTSD compared to non-Latino European Americans. However, when differences in trauma exposure (e.g., amount of combat exposure, seriousness of injuries/hospitalization) were statistically controlled, the higher rates of PTSD in African Americans compared to European Americans were drastically reduced. They also reported PTSD diagnoses and severity of symptoms varied within ethnic minority subgroups. Their findings suggest that race, ethnicity, and cultural differences, especially in relation to trauma exposure may be important considerations in the diagnosis and treatment of PTSD.  Ford (2008)  suggests a reexamination of the categories used to classify people/groups based on race, and ethnicity and proposes that the elevated reports of PTSD among racial and ethnic minorities could be due to the role that racism may play in terms of being a cultural risk factor for exposure to trauma and PTSD as well as a traumatic stressor itself with the ability to influence future generations. He issues directives to ensure culturally competent practice, including the further study of these factors (e.g., racism and ethnocultural categories) as well as instruments and practices that do not replicate racial biases.

   Still, another study examining ethnoracial and cultural differences in symptom severity of PTSD, found that although both Black and Hispanic groups showed greater degrees of trauma exposure contrasted to the White groups, the severity of their trauma was not fully responsible for this ethnoracial variances in traumatic distress. Furthermore, Black groups report less depression, which was significantly correlated to their race as well as greater religiosity and positive coping. No significant differences were found in PTSD symptoms of Hispanics compared to Whites. Further research is needed to understand these racial and ethnic differences in depression, what protective factors aid positive coping, and/or the validity of self-report measures to fully capture depressive symptoms in different ethnic/racial groups and cultures ( Ghafoori, Barragan, Tohidian, & Palinkas, 2012 ).

   Stressors that may affect people adversely and the symptoms they elicit differ among ethnic groups and cultures. For example, an event that might be perceived and labeled as stressful to an Anglo American individual may not be considered stressful to an individual living in South America, Japan, China, or the Congo. Research on trauma and stress responses in PTSD has revealed ethnocultural differences in the avoidance symptoms that are involved in the presentation of PTSD ( Pole et al., 2008 ;  Zayfert, 2008 ). For example, using longitudinal data on ethnic difference in PTSD symptomatology,  Marshall, Schell, and Miles (2009)  showed that Hispanics report higher rates of positive symptoms (e.g., unwanted thoughts, lack of motivation, and being on guard) versus non-Hispanic Caucasians, but lower negative symptoms (e.g., emotional numbing, impaired concentration, insomnia). Moreover, these symptoms were spread over three different DSM-IV diagnostic criteria, which the author proposes may explain why Hispanics are more apt to meet diagnostic criteria than non-Hispanic Caucasians even though they often do not report an increase in all PTSD symptoms. This higher reported rate of some symptom clusters versus reporting perhaps all symptoms in a single cluster in Hispanics may account for significantly higher rates of PTSD. No significant differences were found between Hispanics and African Americans. These findings may illuminate the possibility that posttraumatic distress symptoms present differently in this high-risk subgroup. On a slight variation, research on PTSD in non-Western and traditional cultures (e.g., Cambodian refugees) demonstrates the prevalence of somatic symptoms, which are not listed among diagnostic criteria for PTSD ( Hinton & Otto, 2006 ;  Hinton & Lewis-Fernández, 2011 ). Yet, other studies suggest that somatization of depression and anxiety is universal and not characteristic of any specific ethnocultural group ( Kirmayer, 2001 ). In conclusion, consideration of these varied and significant findings on trauma exposure and symptomology by race, ethnicity, and culture is needed to inform practice and guide further research and treatment.

   For clinicians, cultural competency amounts to taking into account the nuances that are part of symptom expression, while being respectful of the cultural meaning of symptoms/emotions to the individual ( Marsella, 2010 ). Many cultures employ idioms of distress, one such example is “khyal cap,” which are anxiety related somatic sensations that often co-occurs with PTSD (for details see  APA, 2013 , p. 834); and if treated alongside significantly improve PTSD symptoms ( Hinton & Otto, 2006 ; Hinton & Lewis-Fernández, 2011). The DSM-5 ( APA, 2013 ) includes many culture-related syndromes that may coexist with or otherwise relate to the disorders in this and other chapters. And, still there remains the view that all disorders are culture-bound, including all Western disorders codified in the DSM, since all diseases are created by and in cultures.

   In recent years, researchers have turned their attention to the relationship between sociocultural factors and identifiable stressors experienced by people of different ethnic and social backgrounds in the United States and other countries worldwide. The relationship between stress and socioeconomic status has been examined in relation to PTSD. Lower socioeconomic status and lower educational attainment puts one at risk for PTSD ( Brewin, Andrews, & Valentine, 2000 ;  DiGrande et al., 2008 ;  Pole et al., 2008 ;  Read, Ouimette, White, Colder, & Farrow, 2011 ). Additionally, having PTSD may further complicate socioeconomic status as evidenced in veteran studies that show suffering from PTSD (treated and untreated) may adversely affect long-term income and employment outcomes ( Harrison, Satterwhite, & Ruday, 2010 ;  Murdoch, van Ryn, Hodges, & Cowper, 2005 ). However, the role that racial/ethnic and cultural differences may have on this relationship between socioeconomic status and educational attainment on PTSD is unclear and warrants further study ( Alcántara, Casement, & Lewis-Fernández, 2013 ). Sociocultural factors (e.g., race, ethnicity) affect how individuals respond to traumatic stressors; therefore, future research should include inter-group variability studies of trauma exposure and PTSD ( Triffleman & Pole, 2010 ). It is important to be sensitive to cultural differences in this regard and not label symptoms as pathological when they may not be considered so in other cultures. By the same token, practitioners need to be cognizant of their own cultural biases and stereotypical ideas. Either minimizing or maximizing symptoms because of a person's cultural background alone could result in an inappropriate psychosocial assessment. For example,  Hollifield et al. (2002)  found that in studies (over 150) of refugee populations, over three-quarters (78%) relied on instruments developed on Western populations. Ensuring the cross-cultural sensitivity of diagnostic criteria and assessment tools can help uncover these differences so that clinicians can adjust their practices (e.g., linguistic matching), assessment measures (e.g., culturally appropriate) and procedures (e.g., call for more cross-cultural research) as appropriate.

   In addition to ethnocultural differences, gender, sexual orientation, and age-related differences need to be examined in relation to PTSD. Data from the National Comorbidity Survey (NCS;  Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995 ) and National Comorbidity Survey Replication (NCS-R;  Kessler, Berglund, Demler, Jin, & Walters, 2005 ) show women were more than twice as likely as men to develop PTSD over their lifetime. This higher ratio for female gender has been consistent across studies. Being female is an acknowledged risk factor for PTSD(Kessler et al., 1995, Kimerling et al., 2010;  Lilly, Pole, Best, Metzler, & Marmar, 2009 ). A considerable amount of research shows that women have higher risk and rates of PTSD than men ( Tolin & Foa, 2006 ;  Luxton, Skopp, & Maguen, 2010 ;  Ditlevsen & Elklit, 2010 ). In addition, there are gender differences in exposure to trauma, posttraumatic symptomatology as well as comorbidities. Although, in the general population women report being “exposed to trauma” less often than men, it is more likely to be “sexual related trauma” (abuse/assault), which is more likely to result in PTSD, whereas men report greater nonsexual trauma exposure ( Tolin & Breslau, 2007 ) and less PTSD. This was different for incarcerated populations, which showed that any interpersonal violence/trauma (sexual or nonsexual) had the greatest relationship to PTSD symptoms ( Komarovskaya, Loper, Warren, & Jackson, 2011 ). Moreover, women are at higher risk of adverse outcomes (e.g., chronicity, attempted suicide) than men with this disorder ( Breslau, 2002 ;  Holbrook, Hoyt, Stein, & Sieber, 2002 ;  Oquendo et al., 2003 ).

   In terms of posttraumatic features and outcomes, women report more numbing and avoidance symptoms and have more comorbid mood and anxiety disorders; whereas, men report more symptoms of irritability and impulsiveness with comorbid substance use disorders ( Breslau, Kessler, & Chilcoat, 1998 ;  Breslau & Kessler, 2001 ;  Kessler et al., 1995 ). However, women are more likely to use alcohol to manage trauma-related symptoms (e.g., intrusive memories and dissociation) and report more peritraumatic dissociation ( Kimerling, Prins, Westrup, & Lee, 2004 ;  Olff, Langeland, Draijer, & Gerson, 2007 ). For female service members/veterans, combat exposure was a risk factor post-deployment for symptoms of depression and PTSD compared to men. ( Luxton et al., 2010 ). Still, other studies of gender differences in combat exposure show similar reports of depression and posttraumatic symptoms for both genders, but that women report more anxiety ( Vogt, Pless, King, & King, 2005 ). Sexual orientation differences exist in terms of risk for PTSD. Findings from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) showed that Lesbian, Gay, Bisexual and Transgender (LGBT) survivors of interpersonal violence are more likely to develop PTSD than heterosexuals without same sex attraction/partners; and to report greater exposure to violence (interpersonal and maltreatment) beginning in childhood ( Roberts et al., 2010 ).  Mays and Cochran (2001)  suggest that the higher experience of perceived discrimination for sexual orientated minorities may put them at greater risk for stress-sensitive psychiatric disorders.

   Adolescence is associated with a greater risk of experiencing trauma and potentially traumatic experiences (PTE) in comparison to adulthood or earlier childhood ( Nooner et al., 2012 ;  McLaughlin et al., 2013 ). Research indicates that this may be due to age-related differences in PTE exposure. As such, adolescence is a time of higher likelihood for PTSD among those exposed to PTEs ( McLaughlin et al., 2013 ). PTSD in adolescence is associated with greater risk for suicide, substance abuse, poor supports, and health ( Nooner et al, 2012 ).  Perkonigg et al. (2005) , in a longitudinal study showed an association between “exposure to new traumas” and PTSD chronicity (but not for early onset and/or number of traumas) in DSM-IV PTSD diagnosed adolescents aged 14 to 24.  McLaughlin et al. (2013)  using data from the National Comorbidity Survey Replication Adolescent Supplement (NCS-A; 2001–2004) showed that later traumatic exposures “PTEs” after initial trauma was significantly associated to PTSD chronicity. In addition, findings showed that adolescent PTSD was strongly associated with PTEs involving interpersonal violence (e.g., rape, kidnapping, sexual assault). Furthermore, greater vulnerability to PTEs was associated with adolescents not living with both biological parents and with pre-existing behavior disorders.

Social Support Systems

The importance of supports in fostering resiliency after trauma exposure is well supported ( Southwick, Vythilingam, & Charney, 2005 ;  Ozbay et al., 2007 ). A negative correlation has been demonstrated in trauma research between symptoms of PTSD and social supports ( Brewin et al., 2000 ;  Clapp & Beck, 2009 ;  Ozer, Best, Lipsey, & Weiss, 2003 ). Research by  Kotler, Iancu, Efroni, and Amir (2001)  suggests that PTSD puts one at higher risk for suicide and that social support may reduce this risk. Such evidence draws attention to the importance of assisting individuals in building, mobilizing, and utilizing as many support systems as possible. For example, studies of combat veterans with high levels of social support were shown to be less at risk for depression, trauma-related problems, and suicide ( McCarthy, Thompson, & Knox, 2012 ). Furthermore, for women more so than men, social support may act as a protective factor against posttraumatic symptoms and psychosocial difficulties ( Vogt et al., 2005 ).

   The impact of Trauma and Stressor-Related Disorders on an individual's social support system can vary dramatically and affects not only the diagnosed individual but their family and friends as well. For this reason, caretakers and significant others may play a crucial part in the recovery process after trauma exposure. A primary consideration in assessing the impact is the degree to which one or more members are also being affected by the situation. A person who is not directly affected may be more willing to extend support. At the same time, this less involved individual may find it harder to really empathize with the client's situation. Clearly, when the issues are relational, the possibility of continued (and even escalating) conflict could result in other members of the social support systems withdrawing or aligning themselves with one of the parties. Families, friends, and/or significant others may feel overwhelmed by illness symptoms as well as stigmatization. Because of this, efforts should be made to minimize burnout and loss of support network members.

   Support groups can provide critical resources in situations where more formal treatment is not available (or desired). Whether sponsored independently or as part of church-related or nonprofit organizations, most of the resources are organized around a particular concern. For example, support groups are available for Trauma and PTSD, Veterans and PTSD, LGBT and PTSD, Abuse Survivors, Attachment Disorders to just name a few. There is a unique value in sharing experiences related to stressful situations with mutual-aid support groups. Such safe and confidential environments reduce shame, stigma, guilt, burden, and fear among members. Psychoeducational intervention groups (for individual and family) may improve outcomes for those coping with the symptoms of trauma and stress disorders. Such groups offer information about the underlying illness that can help build peer and familial supports as well as problem-solving techniques for managing related symptoms and behaviors. Often, a combination of individual therapy sessions, group therapy, and peer support groups can lead to satisfactory outcomes for the individual. The following list suggests other resources that can be found on the Internet.

·   www.nctsn.org : Established by Congress in 2000, The National Child Traumatic Stress Network is a collaboration committed to raising the standard of care, awareness, and improving access to services for traumatized children, their families, and communities in the United States.

www.childtrauma.org : The Child Trauma Academy (CTA) is a not-for-profit organization based in Houston, Texas, working to improve the lives of high-risk children through direct service, research, and education. Articles are available for caregivers and professionals on a wide range of topics from Abuse and neglect to Attachment and Trauma and PTSD.

www.istss.org : International Society for Traumatic Stress Studies (ISTSS) is an international, interdisciplinary professional organization that promotes advancement and exchange of knowledge about traumatic stress.

www.ptsd.va.gov : This National Center for PTSD website, part of the United States Department of Veterans Affairs, provides research and education on the prevention, understanding, and treatment of PTSD and all types of trauma–from abuse, combat exposure, natural disasters, terrorism to violence.

www.traumacenter.org : The Trauma Center, a program of Justice Resource Institute, is a nonprofit organization that offers information, clinical services, training and education, consultation, and research to traumatized children, adults, and their caregivers.

www.helpguide.org : A nonprofit organization dedicated to providing mental health information (ad-free) to individuals and their families on a wide range of topics including Abuse, Attachment, PTSD and Trauma, Stress, and Suicide Prevention.

www.athealth.com : Describes the symptoms and accompanying treatment issues associated with this many of the disorders found in this chapter.

www.psychcentral.com : Discusses the symptoms and psychotherapeutic treatments available to help individuals experiencing many mental health problems including PTSD, Acute Stress, Attachment, and Adjustment Disorders.

www.mentalhealth.com : Internet Mental Health is an online encyclopedia of mental health information including access to a fee-based, computerized diagnostic program on some of the most common mental disorders, treatments, and research.

Differential Diagnosis

There are several differential diagnoses related to PTSD. Adjustment disorders differ from PTSD in that the stressor is usually of lesser severity and the type of stressor doesn't qualify as a life-threatening event. If the stressor were of sufficient severity to meet Criterion A of PTSD, the client would be diagnosed with an adjustment disorder as long as the other criteria for PTSD were not met. The distinguishing factor that differentiates ASD from PTSD is the length of time that symptoms are present. In the case of a client who displays anxiety or depressive symptoms that may overlap with some of the PTSD diagnostic criteria, only the client who has experienced a traumatic event and meets the full criteria could be diagnosed with PTSD. Other clients who have not experienced a traumatic event may warrant a diagnosis of an anxiety or depressive disorder. Although personality disorders and dissociative disorders can result from a person experiencing a traumatic event especially in childhood, the relationship issues related to personality disorders are independent of the trauma. Dissociative symptoms may or may not co-occur with PTSD. If a client meets the full criteria for PTSD and has dissociative symptoms, a diagnosis of PTSD dissociative type may be indicated.

   With both ADs and V-codes, unsuccessful coping can indeed lead to more serious diagnoses. For example, in the case of bereavement, grief following the loss of a loved one is a normal emotional process that may involve some depression or insomnia. The length of the bereavement period differs among individuals and cultures. However, if the person experiences symptoms of a major depressive episode after several months of grief, a diagnosis of Major Depressive Disorder would be used for that individual. Similarly, if an Adjustment Disorder with Depressed Mood continues and symptoms escalate, the Major Depressive Disorder diagnosis will become more appropriate. When differentiating V-codes from other clinical disorders, a child diagnosed with a V-code of “Child abuse” would not constitute a mental disorder. However, over a period of time, the child may display symptoms of PTSD and could eventually develop the full criteria for a diagnosis of PTSD.

Case 8.1

Identifying Information

Client Name: Nicole Gibson

Age: 25 years old

Ethnicity: African American

Marital Status: Single mother

Children: 2 children, ages 5 and 6

Background Information

Nicole Gibson is a 25-year-old single mother who has two children, a boy and a girl, aged 5 and 6, respectively. Nicole works for a nonprofit organization supported by AmeriCorp that offers self-improvement programs for at-risk youth. Green House is an organization designed to teach young people home-building skills while they earn minimum-wage salary and an annual stipend of $4,000 to pay for college tuition and books. Additionally, the program provides paid time off to pursue a GED or high school diploma along with individual or group counseling opportunities several times a week. Nicole also participates in a program that allows her to live independently in a low-income housing unit while attending school and working.

   Nicole is raising her two children on a salary of $800 per month and an infrequent child-support check of $200 per month. She has no telephone or car and must travel by public transportation to work and the day-care center. Traveling from her apartment to work, including dropping her children at the day-care center, requires her to take six buses each way every day. Nicole must get up at 4:30 A.M. in order to get her children to day care and herself to work by 8:30 A.M. She gets home at 7:30 at night, despite the fact that she finishes her work day at 4:30 in the afternoon.

   As a case manager at the housing unit, you meet Nicole during a home visit. Nicole expresses a desire to obtain counseling to assist her with her life skills and family-of-origin issues that have made it difficult for her to function well at work. You agree to see her for counseling once a week for 2 hours. One hour will be used to assist Nicole with life skills such as parenting and home maintenance skills. The second hour will be utilized for counseling.

Progress Note from Your First Session with Nicole

As a child, Nicole lived in New Orleans with her parents and older sister, Marcia. Nicole's parents remained married until she was a teenager. Nicole's father sexually abused her from the time she was 8 years old through her mid-teens. He forced her to have sexual intercourse with him approximately three times a week. Several of her father's friends were allowed to sexually abuse her as well.

   Nicole's mother was physically, verbally, and mentally abusive, often striking her, calling her names, reading her private journals out loud to other family members, and watching her in the bathroom. On one occasion, Nicole's mother struck her across the face with a belt buckle, leaving a permanent scar above her upper lip. On another occasion, Nicole's mother took a poem that Nicole had written and submitted it to a magazine under her own name. Her mother claimed a prize but never acknowledged the fact that it was Nicole's poem. Her older sister was also physically and verbally abusive to her.

   Nicole left home when she was 18 years old and married the father of her two children. She referred to this as “getting married to escape hell,” stressing the fact that although she couldn't stop the “torture” of her family situation, she could leave it behind by getting married. She stated that she left the marriage because her husband was a very “passive” person, and she didn't want to turn into someone like her mother.

   Before her marriage, she fell in love with a man named Douglas with whom she now has an estranged relationship. Nicole and Douglas were never sexually involved even though they have been intimately involved on and off for about 8 years. Nicole stated that sex makes her feel “dirty, ashamed, and sick to her stomach.” She hasn't spoken with or seen Douglas for about 6 months, as he will not return her calls.

   Nicole has severed all ties with her family of origin since if she speaks with them she will only end up “feeling like dirt and getting real mad.” Although Nicole is not involved at the present time in an intimate relationship, she does find support at her job with coworkers and has one close friend, Vickie, in whom she can confide.

   Nicole has had difficulties at her job, however. She stated that she gets very upset when anyone gets “in her space.” When the pressures at work become more than Nicole can handle, she feels angry and panicky and “just wants to be left alone.”

   During the first session, Nicole stated that she didn't want to do anything but lie in bed. She stated that she often cries all weekend, becomes easily angered by her children, and often resorts to yelling and spanking them.

   Nicole also stated that she was having difficulty doing chores (e.g., going to the Laundromat or grocery store, cooking, cleaning). There were piles of laundry in her bedroom and trash everywhere, including old food, which reeked. She stated she has had difficulty sleeping at night due to recurrent nightmares of “childhood stuff” and always feels “too tired.” She avoids any situation that reminds her of “family stuff” but is afraid that she's turning out just like her mother.

   Nicole possesses a great deal of intelligence and has the ability to seek out support and help when it is needed. She also has a very good sense of humor that she displayed throughout the interview.

· 8.1–1 What diagnoses are you considering at this time? What will be your primary area(s) of exploration at the next session?

 

Second Session with Nicole

Nicole begins the second session with you by describing a situation that occurred during the week at work. A male coworker asked her if she would like to go out for dinner after work one evening, and when Nicole declined the invitation, the coworker lightly touched her shoulder and said, “Oh, come on Nicole, you need a little fun in your life.” Nicole states that she overreacted to this gesture by swinging at the man and striking him on his chest. She tells you she doesn't know what came over her, but she felt like she was warding off an attack of some kind and couldn't tolerate having this man touch her.

   When you ask her if this type of thing has happened on other occasions, she admits that she doesn't like to be touched by anyone. “It even bothers me sometimes if my own kids grab me when I'm not prepared for it.”

   Nicole states that she was so upset by this incident that she stayed home from work the next day because she was just “too tired” to get there on time. “My supervisor gets real mad when I'm late, even though I tell him I can't do anything about it if the bus isn't running on time. I just didn't want to deal with it the other day.”

   You ask her why she thinks she reacted so strongly to her coworker's touching her the other day. Nicole pauses for several moments and then sighs deeply. “I think it's related to all that ‘childhood stuff’ with my father. I just can't get it out of my head. I think it's going to haunt me for the rest of my life.”

   Nicole describes several depressive episodes to you in which she felt she just couldn't move because it took too much energy. During those times, she would forget to eat and would be unable to get to sleep until early in the morning. Her children would constantly ask her, “What's wrong, Mommy? Why can't you play with us?” Nicole states that her children's comments made her feel like a “terrible mother.”

   When you ask her about her goals for the future, Nicole states that she really doesn't have any goals, although she would like to go to college and become a teacher. She says she isn't sure she'll live long enough to complete an education.

· 8.1–2 What are some of Nicole's strengths?

 

· 8.1–3 Are you concerned about the potential for Nicole to commit suicide? If so, how would you assess the potential for danger in her situation?

 

· 8.1–4 What resources might be available to assist Nicole?

 

· 8.1–5 What would be your preliminary diagnosis for Nicole?

 

· 8.1–6 What cultural and psychosocial factors may be impacting this diagnosis?

 

Case 8.2

Identifying Information

Client Name: Celia Fernandez

Age: 30 years old

Ethnicity: Hispanic

Marital Status: Single

Occupation: Computer customer representative

Intake Information

Celia Fernandez, a 30-year-old Hispanic woman, contacted the Family Crisis Center on the referral of her physician and her employer, First Express Computers. She stated that she would like to see a counselor to discuss her job situation and something that happened while she was working. She didn't want to give any further details. An appointment was scheduled for her to see you the following week.

Initial Interview and Assessment

Celia appears to be a young, attractive woman with long brown hair and a slender build. She is dressed in a light blue suit and jumps up from her chair when you greet her in the waiting room. She appears to be somewhat anxious about the session but also seems very willing and eager to talk with you. She tells you on the way to your office that she has been given time off from her job to come see you but that she only has an hour before she has to be back at work.

   You ask her if she'd like something to drink, and she accepts a glass of water. “What brings you to the Family Crisis Center?” you begin.

   Celia hesitates for a moment and then says, “My boss thinks it might be helpful if I come talk to you about some things that happened while I was attending a training session in Careyville for my job at the computer center. It was about 3 weeks ago.”

   You are familiar with Careyville, a large city approximately an hour north of town. Celia sounds anxious about what she is about to disclose, and you decide to slow her down a little so she doesn't tell you too much, too fast.

   “So, you work for the computer center. What is your position there?” you ask.

   “Right now, I am a customer representative. I've been there for 2 years, since I finished my associate degree in business from the community college. I have been working on the help line, which is a pretty stressful job, but I went to the main office in Careyville to get trained so I could become a software specialist.”

   “So, the computer center sent you for the training? Is that correct?” you inquire.

   “Yes, it was a 4-week training. I was staying in Careyville during the week and coming home on the weekends,” Celia tells you. “I live with my parents in Oakdale just north of town.”

   “Okay, and you're single. Is that right?” you say to Celia.

   “Yes, I was dating someone, but I broke up with him about 2 or 3 weeks ago,” Celia says with a dismal look on her face.

   “Did something happen while you were in Careyville for the training?” you surmise.

   “Well, yes, that's what I thought I'd better talk to someone about. You see, the company put me at this motel that was close to downtown so I could walk to the training every day. It wasn't a very nice motel, and it wasn't in a good part of town. It's especially dangerous at night. Anyway, I had been there the week before and gone home for the weekend. Then I came back for the second week of training. On Tuesday, I had been in a training session from 8 A.M. until 6 P.M., and by the time I got back to the motel it was around 7 P.M. I was really tired and decided I'd just call out for pizza since I didn't feel like going out to eat. The motel didn't have a restaurant or anything—just a front desk. So I called the pizza delivery place, and they said it would be about half an hour. Well, I took a shower and put on comfortable clothes, and there was a knock on the door. Since I was expecting the pizza delivery person, I just opened the door, and this guy just pushed his way into my room and slammed the door shut. I was absolutely terrified. He grabbed me and forced me onto the bed and told me he had a gun. I've never felt so scared in my entire life.”

   Celia stares out the window. Her eyes are full of tears. She has been talking in a steady voice and doesn't appear to be in distress. In fact, she appears to be lacking the affect that you would normally expect to see in someone describing a terrifying event such as this one.

   “Take your time, Celia,” you say in a comforting voice. “If it gets too uncomfortable for you, you can stop anytime.”

   “I'm okay,” Celia replies. “He told me to take off my clothes. When I hesitated, he grabbed my shirt and ripped it down the front. I didn't want to make him angry, so I took off my blouse and my skirt. He lay down on top of me and jerked my underwear down, and he raped me—first with his hand, and then he took off his pants and forced me to have intercourse with him. I was afraid he was going to kill me.”

   “That must have been a terrifying experience for you,” you say gently.

   “It was horrible, the worst day of my life,” Celia says evenly. “I guess I've just been telling myself I'm lucky to be alive. The phone rang.”

   “The phone rang?” you say.

   “Yes, the phone rang, and the guy asked me who was calling me,” Celia said. “I told him it was my husband. He got the idea that I lived there and my husband must be in another room at the motel. I told him he would be coming to the room to get me for dinner if I didn't answer the phone. Then there was a knock on the door, and it must have been the pizza delivery person. He put his hand over my mouth so I wouldn't scream. For some reason, that scared him, and he grabbed me and threw me in the bathroom and closed the door. A minute or two later, I heard the outer door slam shut.”

   “So, he left you in the room alone?” you ask.

   “Yes, I waited a few more minutes—it felt like an eternity—and then I opened the bathroom door and he was gone,” Celia tells you.

   “Then what did you do?” you ask.

   “I had seen these two girls who looked like they were in town on business, and they had the two rooms next to mine. I didn't trust the guy at the front desk, so I called the girl in the room next to me and was screaming that I had just been raped and needed help. She came flying out of her room and got her friend who started running down the street looking for the guy. They called the police and an ambulance, and I was rushed to the hospital.”

· 8.2–1 What diagnoses are you considering? How do you hope to direct the interview from this point?

 

   Celia continues to remain very calm while she describes the events of that night. She blinks back her tears and says, “You know the thing that's bothering me the most right now is that I have these times throughout the day when I don't feel real. It's the worst feeling.”

   “What exactly do you mean when you say you ‘don't feel real?’” you ask.

   “Well, it's like I'm observing myself from a distance. I'm watching myself like a third, disinterested party. It's hard to describe, but it's a very unreal feeling. Sometimes, I feel like I'm real but nothing else is. Like everything in my surroundings is unreal, like in a dream or something.”

   “That sounds pretty disturbing. Does it happen when you're thinking about your experience in Careyville?” you ask.

   “There doesn't seem to be any rhyme or reason as to when it happens,” Celia says calmly. “It just happens periodically throughout the day. I can be talking to a customer on the phone and suddenly feel like this conversation isn't really happening. Like I'm watching myself and I look like a cartoon character rather than a real person. It's like I'm not really in the picture or I'm watching my body go through the motions, but my real self isn't there at all.”

   “Let me see if I understand. Sometimes you feel like you're watching yourself from a distance, and at other times, you feel like things outside yourself aren't real. Is that right, so far?” you ask.

   “Yes, and I guess I just feel numb, almost like I'm made of rubber rather than flesh and blood a lot of the time these days,” Celia states.

   You notice that Celia doesn't look upset or anxious when telling you about these horrible events. In fact, she appears to be almost in a state of shock. “Can you tell me how you've been feeling since this terrifying incident took place?” you ask.

   “Well, I've had to go back to Careyville on two occasions to talk to the investigators. The first time was before they had a suspect, and the second time I had to pick a man out of a lineup at the police station and give a positive identification,” Celia tells you with little expression in her voice.

   “How did that make you feel to have to do that?” you ask.

   “A little nervous, I guess, but I knew he couldn't see me, so it wasn't too bad,” Celia replies. “I just want to forget about all of this and get on with my life.”

   “How have you been feeling since you've been back to work?” you ask.

   “I've been okay except for that feeling like nothing is real or I'm not real. That bothers me a lot. I feel like I'm going ‘crazy’ or something. Sometimes, I have to lock up the store at night, and that makes me nervous. I told my boss I don't want to be the only one left alone if I've got to lock up. It reminds me of being alone at the motel, and I start to ‘relive’ that night.”

   “How have you been sleeping since this incident occurred?” you ask.

   “The first few nights after I came back from Careyville, I had a hard time getting to sleep, but after a week or so, it was better. But I'm still not able to sleep through the night without waking up with weird dreams that really scare me,” Celia says. She slowly uncrosses her legs as though it requires a great deal of effort.

   “Are there any other things that have become hard for you?” you ask.

   “I did have some problems with my boyfriend touching me. I just didn't want anyone to touch me because it made me feel ‘unreal,’ and I don't think he could understand that at all. This whole thing just threw him for a loop, and I told him I didn't think we should see each other for a while. It was just too much for me to handle.”

   “Have you been feeling depressed or anxious about things?” you ask.

   “I've been concerned about my job. My boss has been extremely nice to me since this incident happened, and I think it's because the company is worried that I'll sue them since it happened while I was working. It wasn't a good motel, and it was not in a good part of town, and they should have put me in a safer environment. I don't want to jeopardize my job, though, and the other women who work there are talking behind my back and making me real uncomfortable.”

   “What are they saying about you? Do you know?” you ask.

   “Well, a friend of mine said she overheard a group of them talking about what happened to me and that I was getting special treatment now,” Celia says glumly. “I'm hoping I'll get transferred to another department soon, though, and get away from them.”

   “What about your family?” you ask. “How have they reacted to you?”

   “My parents have been very supportive, but they think I should just put it behind me. I think they've tried to make me feel safe at home. They won't leave me there alone at night. That's probably good right now. I'd probably get nervous at night if I were by myself.”

   “Do you think about it a lot?” you ask.

   “I try not to think about it at all. I try to get my mind on other things. I haven't been out much with my friends since this happened, and I probably need to start doing things with them pretty soon. I've just felt so weird and unreal that I haven't wanted to do much of anything,” Celia says.

   “Okay, so let me see if I can summarize what you've been telling me today. A man who broke into your motel room raped you while you were working in Careyville a little less than a month ago. Since then, you've been having feelings of observing yourself from a distance or feeling like everything is kind of unreal. Sometimes, you feel somewhat nervous about being alone either at work or at home, and you're not real sure about going out yet because of some of these ‘unreal’ feelings you've been experiencing. Is that correct so far?”

   “Yes, exactly,” Celia says.

   “You've also been feeling kind of numb, like rubber almost. Is that correct?” you ask.

   “Yes, like I'm not quite real,” Celia says.

   “But you haven't had any nightmares about the incident or felt real anxious or depressed? Is that right?” you ask.

   “Yes, just numb, I guess,” Celia responds.

   “And you've been concerned about your job,” you say.

   “Yes, not that I think I'll lose my job, just what other people are thinking about me, I guess,” Celia haltingly explains.

   “Okay, and are there any other feelings you've had since the incident?” you ask one more time.

   “No, that's about it,” Celia says.

   “Okay Celia, I'm really glad you felt you were able to come in and talk to me today. You are a very courageous person. It takes a lot of strength to deal with a traumatic event like the one you've been through. From what you've told me today, I think I can help you with those ‘unreal’ feelings you've been having. Those feelings don't mean you're ‘crazy.’ It's not unusual for someone who has been through such a terrifying experience to have feelings like you're having.”

   Celia sits back in her chair and looks relieved for the first time during the session. “I'm so glad you don't think I'm crazy,” she says. “And I feel better just having talked to you about the whole thing.”

   “I think it might be helpful if we set up an appointment for 1 day a week so we can work on those feelings of unreality. Would that be okay with you?” you ask.

   “Yes, I'd like to come talk, and my boss said he'd give me the time off to come here,” Celia states.

   “Okay, we'll set up an appointment and see how things are going next week,” you respond.

· 8.2–2 What impact has the sexual assault had on Celia's social support systems?

 

· 8.2–3 Are there aspects of her environment that you would like to explore more at the next session? Are you thinking of any particular areas that might require intervention?

 

· 8.2–4 What is your preliminary diagnosis for Celia?

 

· 8.2–5 Are there additional diagnoses that you would “watch out for” in working with Celia?

 

Case 8.3

Identifying Information

Client Name: Nancy Kauffman

Age: 49 years old

Ethnicity: Caucasian

Marital Status: Separated

Occupation: High school teacher

Children: Two children, ages 23 and 25

Intake Information

Nancy Kauffman called the Family Support Center and requested an appointment with you after getting your name from a friend and coworker at the local high school. Nancy's friend was a former client who had come to the Family Support Center for counseling regarding her daughter when she was an adolescent. Nancy stated that she needed to talk to someone about her recent problems with her marriage. She specifically requested an appointment with you.

Initial Interview

Nancy is a petite, attractive woman who arrives for her appointment wearing a white tennis skirt and top. Her hair is pulled back with a light blue headband that matches her blue-and-white tennis shoes. She appears to be an active and energetic woman. She is standing in the waiting room reading a brochure when you meet her. Nancy smiles and firmly shakes your hand as she makes your acquaintance. She immediately explains her appearance by telling you that she has a tennis match scheduled following your appointment and wouldn't have time to go home and change clothes.

   You converse with Nancy for a few moments about the game of tennis. You discover that Nancy has been playing tennis since she was a teenager and she coaches the girls' tennis team at the high school where she teaches. Nancy plays tennis several times a week at a racquet club in town. She has won several women's tournaments over the past 10 years. Nancy is obviously very enthusiastic about the sport and engages easily with you in conversation.

   After she is comfortably seated in your office, you begin the session by asking her if she's ever been in counseling in the past. Nancy tells you that she went to see a therapist several times about 10 years ago when her daughter was having some difficulties in school. It seemed to benefit her daughter, and she felt she communicated better with her daughter following therapy.

   You ask her about her teaching position at the high school. “You teach French and history—is that correct?” you ask.

   “Yes, I've been teaching juniors and seniors for the past 25 years. I teach advanced French as well as ancient history,” Nancy tells you.

   “Wow, those are difficult subjects,” you remark.

   Nancy nods her head in agreement and tells you that in most cases, she likes the teenagers she teaches and enjoys her job very much. She especially likes coaching the girls' tennis team.

   “So, what's been going on that made you decide to make an appointment?” you ask.

   “Well, I just felt like I could use some help right now,” Nancy states. “You see, I've just recently separated from my husband. We have been married for 25 years, and I've been feeling very alone with no one to talk to lately.”

   “When did you separate from your husband?” you ask.

   “About 2 months ago,” Nancy says sadly. “He just came home one night from school and said he didn't want to be married anymore. I couldn't believe it. I was completely caught off guard. Right up until that moment, I thought we had a good marriage. In fact, I said to him, ‘If this is your idea of a joke, it's a very bad one.’ He wasn't joking at all. Jay is 52 years old. He's the soccer coach at the high school. He seemed to be going through something, you know, like a midlife crisis or something. He wanted to buy a Mustang convertible. I didn't object. I thought it was a phase and it would pass. If he could be happy with a new car, it was okay with me. But I guess it wasn't that simple.” Nancy looks down at her hands and looks very discouraged.

   “That must have been a real shock for you. Did he give you any further explanation for why he didn't want to be married?” you inquire.

   “No, he just said he wanted to live alone and that he had put down a deposit on an apartment that afternoon. He said he'd pack his bags and leave the next day. I pleaded with him to go to counseling with me and work it out, but he wasn't interested. He's not the type who would ever go to counseling, but I didn't know what to do. He was determined to leave, so there was nothing I could do about it,” Nancy replies.

   “It sounds like a very difficult situation for you. How have you been coping with the situation since he left?” you inquire.

   “Well, I've been working a lot. But it's been difficult since we both work at the same school. I end up seeing him several times a week. Lately, I've just been feeling very depressed about the whole thing. I'm fine when I'm at school, but I go home to a fairly large house, and I just feel so alone walking around those empty rooms. I haven't ever lived alone my entire life. I got married right after graduate school, and I lived with my family or a roommate before I got married. The last couple of months have been very difficult for me.” Nancy begins crying softly. “Oh, I just don't know what's wrong with me,” she says.

   “So, before Jay left, you weren't feeling down and depressed?” you ask as you hand her a box of tissues.

   “Right, I'm usually a bubbly, outgoing person. It's just been since he left that I've felt so low. I'm having difficulty concentrating on my work and teaching. Some days I walk into class and have no idea what I'm going to teach that day. I've never been like that before. I'm always prepared for class.”

   “Are you and Jay communicating at all?” you ask.

   “We've talked some, but he's not interested at all in coming home or working on our relationship. I feel pretty pessimistic about getting back together with him. I think he'll ask me for a divorce soon,” Nancy says glumly. “I'm beginning to feel angry now, too. How could he do this to me after so many years?”

   “How are you sleeping?” you ask.

   “When I get to bed, I'm sleeping fine. I've never really had difficulty sleeping. My problem is that I just don't go to bed until late and I have to be up early. I'm usually at school by 7 A.M. So I'm not getting much sleep, but I guess if I'd just get to bed at a decent hour, it wouldn't be a problem. I just hate going to bed alone,” Nancy replies.

   “Okay. And how has your appetite been lately? Have you gained or lost weight since Jay decided to move out?” you ask.

   “If anything, I might have lost a few pounds. That might be the only benefit to this situation,” Nancy says with a smile. “I've been playing so much tennis lately that I don't really have to worry about what I eat. I just haven't been fixing meals lately. I'll stop on my way home and get a couple of things at the store, but I rarely fix a whole meal.”

   “It sounds as if it might help to have someone to talk to as you're coping with this situation,” you suggest.

   “I think it would help a lot if you want to know the truth. I don't know why it took me so long to make that phone call to your office. All my friends are Jay's friends since we work at the same place. It makes me feel like I can't talk to anyone since I don't want to put them in the middle of this mess.”

   You schedule another appointment with Nancy for the following week.

Letter from Nancy, Received between First and Second Sessions with Her

It's after midnight and I'm still rumbling around this house thinking about what we talked about the other day when I came to see you. I thought it might be helpful if I gave you a little history of my relationship with Jay.

   Jay and I met 29 years ago when we were both aspiring teachers in graduate school at Yale University. It was the 1970s. Jay had long hair and wore bell-bottoms, and I had long hair and wore miniskirts. We were both on a mission to save the world through education. We believed in peace and love, and we joined in several marches and sit-ins against the fighting in Vietnam. We were the flower children of that generation. It's amazing any of us actually graduated with a degree. College campuses were fraught with tension, students were at war with the establishment, and we were all involved in politics.

   Jay and I were no exception. We attended antiwar demonstrations and marched through the campus mall on a weekly basis. We moved in with each other about 6 months after we first met. We lived in a run-down apartment in an old house where five other couples lived. We believed we were going to make a difference in the world and shared the same personal and political values. We spent hours and hours sitting in our makeshift living room having serious discussions about society and how we were going to change it. I think we were happier during those days than we have ever been since.

   We graduated from college and easily got jobs teaching and decided to get married in 1975 after I got pregnant. Lucy and Leo were born 2 years apart, and it definitely changed our lives. Now we were working to put food on the table rather than to further our lofty values about society. We also began focusing on the children rather than on ourselves.

   During that time, Jay had an affair with another teacher at school. It was a devastating experience for me, but I wanted to hold our marriage together. My parents divorced when I was only 10 years old, and I didn't want that for my children. We muddled our way through it, and Jay finally gave up the affair and promised to be faithful forever. We managed to move on, but I think Jay resented being married and could never fully commit himself to it. He enjoyed being the superstar soccer coach and getting a lot of attention. He couldn't understand why I had to spend so much time with the children when they were little. You would think a teacher would know what children require, but he didn't seem to want to share my attention with anyone, including the children.

   His way of coping was to just leave the house when I couldn't give him my undivided attention. He would become despondent when I couldn't attend to his every need. My way of coping was to become even more involved with the children and their activities. I was the primary caregiver, and Jay was the soccer star. I see this retrospectively because I think we both denied there was a problem at the time. He was highly involved with teaching and soccer, and I was equally involved with teaching, tennis, and the children.

   When the kids were 15 and 17 years old, it happened again. He had another affair that I found out about through a lifelong friend of mine. She told me that while she was at a teaching conference in another city, she had seen Jay at a restaurant with his arms wrapped around another woman. I confronted him about it, and he said it was nothing—just a fling. He wasn't interested in her, and it just happened out of the blue at the conference. I told him if he didn't stop it right away, I was leaving him. Surprisingly, the thought of me leaving him scared him. And I honestly don't think he's had another affair since that time at the conference.

   Now I think he's confronted with the fact that he's getting older and is not as attractive as he once was. He can't stand the idea that he might not be able to get all the attention. He's down on his job because he's no longer the young, attractive soccer coach that everyone adored. There are a couple of assistant coaches now that have moved in on his territory.

   In essence, I think he's depressed. It worries me that he's moving into an apartment by himself. I'm not sure it's so good for him to be alone right now. If this is a midlife crisis, I hope he comes to his senses quickly.

   So, I'm coping as well as possible with the current situation. I just thought this information might help you better understand what's happened prior to our separation.

· 8.3–1 What would you consider the identifiable stressors in Nancy's current situation?

 

· 8.3–2 What support mechanisms are in place that Nancy can utilize? What additional support might be beneficial to Nancy?

 

· 8.3–3 What are some of Nancy's strengths? Would you refer Nancy to any other health professionals? Why or why not?

 

· 8.3–4 What is your diagnosis for Nancy?

 

· 8.3–5 What other disorders would you want to watch for and/or rule out?

 

· 8.3–6 What are the cultural and psychosocial factors that might impact your primary diagnosis?

 

Case 8.4

Identifying Information

Client Name: Dorie Phillips

Age: 8 years old

Ethnicity: Caucasian

Educational Level: Third grade student

Referral Information

Lynn Phillips, a 36-year-old mother, contacts you at the request of the school guidance counselor over concerns about changes in her 8-year-old stepdaughter's behavior at school. Dorie is a thirdgrader at Clayton Elementary School.

   Lynn tells you that her husband, Scott, age 38, gained custody of Dorie when he divorced his alcoholic and drug-abusing wife 7 years ago. Scott and Lynn got married when Dorie was 3 years old, so Lynn feels that she is the only mother Dorie has really known. She states that Dorie has always been a bright and bubbly child who is normally full of energy.

   Recently, Dorie's teacher has seen a noticeable drop in Dorie's energy level as well as school performance. Lynn wants to make an appointment for you to see Dorie and evaluate her. You suggest that, before you see Dorie, you would like to talk with Lynn and Scott about what they have observed at home in terms of Dorie's behavior and mood. You schedule an appointment for Lynn and Scott Phillips.

Initial Interview

The following week you meet with Lynn and Scott Phillips. From outward appearances, they seem to be a wholesome, hardworking couple. Scott works for an auto parts supplier in the southeast region, and Lynn works as a secretary for a local bank. Lynn and Scott both shake hands with you and seem eager to talk.

   Scott tells you that he and Dorie have a special bond between them due to the divorce and inability of Dorie's mother to care for her. He states that for 2 years, he took care of Dorie by himself (although his mother baby-sat for him while he was at work). He took Dorie everywhere with him even after he met Lynn. He states that Dorie has always liked to fish and hike with him, ride on the back of his motorcycle, go bowling, or just play ball in the yard. Dorie is on the girls' softball team at school, and Scott coaches the team along with several other fathers. Scott is a husky, blond-haired, blue-eyed man who towers over Lynn.

   Lynn, on the other hand, is petite, approximately 5 feet 2 inches tall, and has dark brown hair and brown eyes. Lynn states that she began noticing a difference in Dorie's behavior about a month and a half ago. “She usually loves to talk about school and everything that happened during the day, and lately, she comes home and doesn't say a word about school or what she did there. Her appetite also seems to be off. You know, she's picking at food she usually likes a lot. She seems bored with schoolwork that she has always been excited about in the past. Dorie is really smart like her dad. She likes to read and do math and always gets very involved in projects. Like one time she built a relief model of Antarctica out of plaster of paris; we had to go to the hardware store and get all the supplies, and she spent hours working on it. Now, it doesn't seem she cares much about anything like that. I've asked her several times if there's anything that's bothering her, and she just shrugs her shoulders and says, ‘Not really.’ She also seems to get real whiny, almost like a baby, when she gets frustrated by something. She did that when she was little but hasn't been like that for a long time. I just don't know what's going on anymore.”

   Scott agrees with his wife's observations and adds that Dorie has just withdrawn into “her own little shell.” Scott feels like Dorie is going backward instead of forward. When you ask him exactly what he means, he states that Dorie is acting a lot younger than she used to rather than more grownup. “Like she cries over silly little things that you would expect a much younger child to get upset about.”

   “Are there any other feelings or behaviors that you've noticed are different lately?” you ask the couple.

   Scott and Lynn look at each other, and Scott says that the only other thing is that she seems to be having more nightmares and wants to come sleep with them several nights a week. “It just breaks my heart to see her standing at our door scared to death. She doesn't want to go back to her bed, and we don't make her. Of course, then we don't get much sleep with the three of us packed into a double bed like sardines,” Scott chuckles. “Lynn and I have talked about it, and it seems like the best thing to do because Dorie instantly looks relieved and curls up and goes to sleep. And she is usually fine by the next morning.”

   You suggest you'd like to get some information about Dorie when she was a baby and was growing up. Lynn says, “Well, Scott would know more about that since I didn't know Dorie until she was 3 years old.”

   “Did you adopt Dorie when you married Scott?” you ask.

   Lynn states that they'd thought about it but hadn't done anything about it. All custody rights were given to Scott when he divorced Susan, so they didn't feel it was necessary to go through the adoption process.

   “What was Dorie like as a baby, Scott?” you ask.

   “She was a very happy, normal baby who never was much of a problem. Her mother got into drinking and drugs about a year after Dorie was born. I don't think she was cut out to be a mother and never was much of one when Dorie was little. I was both mother and father to Dorie from the very beginning. I'd come home from work, and Susan wouldn't have done anything all day except sit and watch soap operas and read magazines. She didn't like to play with Dorie much, and I think she thought it was just a hassle. She took care of her okay, I guess, but she didn't like doing it. She would complain all the time about being bored and having nothing to do. If I suggested she get together with other mothers, she said she wasn't interested in ‘baby talk.’ Then she started drinking and wouldn't stop. I told her she could get a job if she didn't want to sit home all day, but nothing seemed to satisfy her. After a while she just got so she wouldn't do anything. I did all the cooking and cleaning and taking care of Dorie. I'd take Dorie with me wherever I went on the weekends, trying to give Susan a break, but it was never enough. Finally, she got hooked up with some guy who was doing a lot of drugs, and that's when I told her I was taking Dorie and leaving her. She really didn't seem to mind too much.”

   “So, you and Susan got a divorce when Dorie was just a year old?” you query.

   Scott leans back in his chair and sighs. “That's right. Dorie and I went to live in an apartment on the other side of town, and my mother helped me out with baby-sitting while I worked. It went on that way for about 2 years until I met Lynn.”

   “And how was Dorie during that time when it was just you and her together?” you ask.

   “Oh, it was probably harder on me than it was for Dorie since my mom helped out,” Scott replied with a smile. “She seemed like a happy child who loved her daddy. Of course, she had all the trying times any child has, but all in all, it seemed better for both of us. And she's real smart, so she figured things out pretty quickly. Like she was talking and walking before she was 2 years old.”

   “So then you and Lynn met?” you inquire.

   “Yes, we met at a mixed bowling league we both had joined. So, we knew each other for about 6 months before we decided to get married,” Scott reflected. “Lynn stepped right in and began caring for Dorie soon after we started dating each other. She knew we came as a package deal,” he laughed.

   “So you became a wife and mother on the same day,” you comment to Lynn. “How did things go between you and Dorie when you first married Scott?”

   Lynn states that it seemed to her that Dorie was just dying for a mother. Although initially she was a little timid around Lynn, Dorie quickly warmed up and became attached to her and began going to her instead of Scott when she needed help with something. By the time she and Scott got married, Dorie had gotten used to having Lynn around and would sometimes ask Scott why Lynn wasn't coming over every night. Lynn explained that she came from a big family with six children and she always liked kids and took care of her younger siblings growing up. “I never looked at it as a chore. It was just natural to have kids around,” Lynn states.

   After Lynn and Scott got married and were both working full-time, Dorie went to day care for 2 years before starting school. The couple described Dorie as a well-adjusted child who had no difficulties in the day-care program at the church they attended on a regular basis. Lynn became pregnant with their son, Tommy, a year after they were married. Tommy is currently 4 years old and will be going to kindergarten next year. Dorie and Tommy seem to have a normal sister-brother relationship. Dorie was excited about having a baby brother when Tommy was born.

   “So, you have really had no major problems with Dorie until just recently. Is that correct?” you ask.

   Both Lynn and Scott agree that nothing out of the ordinary had occurred until Dorie began having problems at school.

   You ask them if they have had any concerns about Dorie being abused, either at home or at school. They quickly say that there has been nothing to indicate something like that had happened. They feel that Dorie has been supervised closely at school and in the after-school program she attends until they pick her up after work.

   “One more thought,” you suggest. “Does Dorie know that you, Lynn, are not Dorie's real mother?”

   Scott and Lynn stare at each other for several seconds. Scott hesitantly states, “Well, no, she doesn't know. Lynn and I have talked about when the best time would be to tell her, but we haven't told her yet. Just never could find the right time. Since she can't remember anyone else in her life, we just decided to let it be for a while until she was old enough to understand.”

   “Is there anyone you know who might've told her, like friends or other family members?” you ask.

   “Not that we know of,” says Scott, looking perplexed. “The whole family knows that we haven't told her anything about Susan, so I don't think they would've said anything to her. And I don't think any of our other friends would have either.”

   “Okay, well, it's just something to consider. Children sometimes pick up on what adults are talking about, and it's possible that Dorie may have heard someone at school talking about it,” you state. “Before you make any decisions concerning that subject, though, I'd like to see Dorie for a session. Would that be all right with both of you?” you ask.

   They both readily agree to having Dorie come in the following day for an appointment with you.

· 8.4–1 What are some of this family's strengths?

 

Interview with Dorie

Dorie is a very cute, blond-haired, blue-eyed girl who is slumped in a chair in the waiting room next to Lynn when you meet her. She shyly tells you her name. You sit down in a chair beside her and talk to her for a few minutes about the book she has in her hands and then ask her if she'd like to come with you and play with some of the toys you have in your office. Dorie looks at Lynn. Lynn tells her that she'll be waiting right here in the waiting room and that it's okay to go with you to your office.

   Dorie quietly gets up and walks with you to your office. You tell her about the toys you have in your office, and Dorie goes over to the doll house you have in the corner and begins picking up the dolls and placing them in a line in front of the doll house. You explain to her that there is a whole family of dolls for the doll house and ask her about her family.

   She picks up the father and mother and little boy and little girl and says that these are the people in her family. She begins looking at the furniture in the house and talks out loud about each room in the house. “This is the kitchen. There's a stove and a refrigerator and a sink. This is the living room with a TV and a couch and a chair,” Dorie remarks. “And this is the little girl's bedroom and this is the little boy's bedroom and this is the mommy and daddy's bedroom.”

   Dorie places each of the dolls in its respective bedroom and says that they are going to sleep. Then, she says that it's morning and takes the little boy and the mother and father dolls down to the kitchen.

   “Why is the little girl staying in bed?” you ask.

   “She doesn't want to go to school today,” Dorie remarks.

   “Why not?” you inquire.

   “Because there are mean kids at school,” she replies. Dorie pushes the little girl doll down on the bed and says, “You don't have to go to school today.”

   “What do the kids at school do that's mean?” you ask.

   Dorie scowls and with a serious expression on her face, she takes the little boy and places him out of the house and says he's at school now.

   “They say mean things to the little girl,” Dorie states.

   “What kind of things do they say?” you inquire.

   Dorie picks up the mother and the little girl and places them face-to-face in the living room of the house. Then she gets two other dolls and holding them as though they are talking to each other says, “Your mom isn't your real mom. Your real mom was crazy and she ran away,” Dorie says with an angry expression on her face.

   “And what does the little girl say?” you ask Dorie.

   “She says that they are wrong. They are stupid dummies,” Dorie replies. She picks up the little girl and places her back in the bedroom with the mother.

   “How does that make the little girl feel?” you wonder.

   “It makes her mad and sad,” Dorie says. “I don't think I want to play this game anymore.”

   Dorie goes over to your desk and sits down in the chair. You follow her and sit down in another chair.

   “I like this chair that turns around,” Dorie states. You let her play in the chair for a few moments.

   You ask Dorie if she'd like to draw a picture with the big box of crayons you have at the desk. Dorie agrees, and you suggest that she draw a picture of herself in her family.

   Dorie draws a picture of the mother, father, and little boy standing together and a little girl off to the side with a big question mark on her shirt. You ask Dorie about the question mark, and she tells you that the little girl doesn't know if she belongs in this family.

   “Why wouldn't she belong in the family?” you inquire.

   “I don't know,” says Dorie, “maybe she belongs to someone else.”

   You ask Dorie if there's anything else that makes the little girl sad, and she goes over and picks up the girl doll in the doll house and says, “No, now the little girl is happy because she's home with her real mother.”

   You suggest to Dorie that the mother she lives with is the mother she loves, and Dorie agrees. “Yeah, the real mother is the one you love. Right?” Dorie asks.

   “That's right. Mothers are the ones that love their little girls like your mother loves you,” you suggest.

   Dorie tells you she's ready to leave, and you walk with her out to the waiting room.

· 8.4–2 What would your preliminary diagnosis be for Dorie?

 

· 8.4–3 What are the psychosocial and cultural factors that impact this diagnosis?

 

· 8.4–4 What resources would be valuable to Dorie and her parents?

 

· 8.4–5 With the parents' permission, what information would you want to impart to the school counselor?

 

Case 8.5

Identifying Information

Client Name: Dagmar Elkin

Age: 28 years old

Ethnicity: Caucasian

Educational Level: High school graduate

Intake Information

Dagmar Elkin is an inmate at Central Prison, serving a 15-year sentence for burglary and assault with a deadly weapon. He has been to the infirmary 10 times in the past year for various ailments ranging from severe stomach pain to heart problems. The physician has referred Dagmar to you, the mental health counselor at the prison, for a mental health evaluation. He has been in the infirmary for the past 2 days complaining of heart palpitations and stomach pain. The doctor cannot find any reason for Dagmar's symptoms.

Initial Interview

You enter the infirmary and tell the nurse that you are there to see Dagmar Elkin. He escorts you to the cubicle where Dagmar and another inmate are lying in bed. Dagmar's chart states that he is 5 feet 7 inches tall and weighs 140 pounds. Although small for a male, Dagmar appears to have a muscular build and ruddy complexion. You approach Dagmar's bed and tell him that you are a mental health counselor and that you need to talk with him.

   Dagmar looks over at you and says, “What do you want? Do you think I'm crazy or something?” The inmate in the bed next to him chuckles.

   “That all depends, Dagmar. Are you crazy?” you ask.

   “Nah, I ain't crazy. I'm sick. Can't you see I don't feel good?” Dagmar says with an anguished look on his face.

   “Well, the doctor wants us to talk, and I'm going to ask the officer to let you go into that room over there so we can talk privately. Would that be okay with you?” you inquire.

   “Yeah, I guess,” Dagmar moans.

   You ask the corrections officer to allow you to go into a small consulting room so that you can talk with Dagmar without others listening to your conversation. The officer opens the door and allows Dagmar to get out of bed and enter the room. He asks you if you want the inmate handcuffed, and you decline the offer.

   “So, Dagmar, why are you in the infirmary again?” you question straightforwardly.

   “Well, you see, I'm not feeling too good. Something's wrong with my heart, and it's affecting my stomach, too. I've had these bad pains in my chest, and it feels like I'm having a heart attack,” Dagmar tells you.

   “Okay, any other symptoms?” you ask.

   “Like I said, I've had these bad pains in my stomach, and I've thrown up blood,” Dagmar responds.

   “Okay. Anything else?” you ask.

   “Should there be something else?” Dagmar asks.

   “Dagmar, you've been in the infirmary 10 times in the past year for various aches and pains, and it seems that these symptoms come and go in a very convenient way. The doctor can't find anything physically wrong with you, and he's wondering why you keep coming to the infirmary. Is there something else going on that you want to talk about?” you ask.

   “Are you saying I'm lying about all this pain I'm in?” Dagmar asks incredulously.

   “I'm just saying your symptoms are convenient,” you respond. “I just want to help you out here. Why don't you tell me what's going on, and maybe I can help you find another way of coping with things.”

   “Are you going to run and tell the doctor everything I say?” Dagmar questions.

   “Only if you keep lying about being sick when you aren't,” you respond.

   “I don't know what you're talking about. I am sick!” Dagmar says emphatically.

   “Okay, so what's making you sick?” you ask.

   “Well, I think I need to be moved to a different cell,” Dagmar states.

   “Why do you say that?” you ask.

   “Because this guy in my cell, he's driving me nuts. I think I wouldn't be so sick if I had a different cell,” Dagmar implores.

   “What's the guy doing that's driving you nuts?” you ask.

   “He's always talking to himself and pacing back and forth and keeps saying I'm the ‘devil’ and ‘get away from me’ and crap like that. Where am I supposed to go? I can't get away from him no matter how much I'd like to.”

   “Do they give him meds?” you ask.

   “Nah, he just rants and raves all day and all night. Nothing seems to quiet him down unless he gets a fist in his face. Sometimes, I just can't take it no more,” Dagmar tells you. “I feel like if I don't get out of there and get some relief, I'm going to kill the guy.”

   “Have you told anyone about this situation?” you ask.

   “Nah, I'm afraid that'll just make things worse. You know how it is over on the unit. I'm not looking for no trouble. I just want to get some rest. Rollo, he's a mess. I'm afraid he is going to kill me one night thinking I'm the devil or who knows what.” Dagmar taps his foot on the floor and looks nervous. “You can't tell nobody I said anything or you know how it is. They'll make me pay for opening my mouth.”

   “So, you've been getting sick in order to get away from Rollo?” you look Dagmar directly in the eye and ask.

   “Let's just put it this way. If Rollo weren't in that cell, I might feel just fine,” Dagmar points out.

   “Now, let me tell you something,” you say. “I may not be able to get Rollo moved, but I might be able to get him some medicine to calm him down. Do you think that might help with your trips to the infirmary?”

   “Anything to get him quiet is just fine with me,” Dagmar tells you. “I just need some peace and quiet for a change. That is one scary dude in there with me.”

   “Okay. I'll see what I can do,” you say to Dagmar, “but I don't want to see you in the infirmary unless you're seriously sick again. Do we understand each other?”

   “Gotcha,” Dagmar nods once and walks out the door.

· 8.5–1 What diagnoses would you want to rule out in Dagmar's case?

 

· 8.5–2 What are some possible problems you must overcome in your interview with Dagmar?

 

· 8.5–3 What strengths do you see in Dagmar?

 

· 8.5–4 What diagnosis would you give Dagmar?

 

· 8.5–5 What are the psychosocial and cultural factors you would want to note along with the diagnosis? List these in V-code format from the DSM-5.

 

Case 8.6

Identifying Information

Client Name: Henju Lee

Age: 27 years old

Ethnicity: Asian (born in Korea)

Marital Status: Married

Educational Level: Graduate student

Occupation: Research assistant

Children: One daughter, Eunju, age 2

Intake Information

Henju Lee, a female graduate student at a U.S. university, contacted the student counseling service stating that she needed to talk with someone about her “confusion over living in America.” She stated that her husband doesn't want her to be “too independent,” and she feels that her other American friends are allowed to do more activities than she is. She said that her husband has become very angry about her behavior. “He is very strict with me and my daughter and won't tolerate when I misbehave.” The intake worker referred her to you since you have knowledge about marital relationships. Henju agreed to come to the center for an appointment with you between her classes the following day.

Initial Interview

Henju is sitting quietly in the waiting room reading a book when you meet her. She smiles, stands, and tells you her name. She is a petite woman, approximately 5 feet 3 inches tall, and has long, dark hair. She follows you back to your office and asks permission to sit in the chair next to your desk. “Yes, absolutely,” you tell her. “Would you like a cup of coffee?”

   “Oh, no thank you,” Henju replies.

   “Okay, what made you decide to come talk to someone today?” you ask.

   “Well, I think I have confusion about being in America,” Henju replies.

   “Confusion? Can you explain what you mean a little more?” you ask.

   “Yes, you see, I am from Korea, and in Korea, women are, what is the word, less than their husband,” Henju tells you.

   “You mean subservient? They do what the husband tells them to do without questioning it?” you query.

   “Yes, the husband rules the household. The wife does not ask questions,” Henju responds. She begins looking around the room anxiously.

   “Is this kind of hard for you to talk about?” you ask.

   Henju's shoulders sag, and she says, “Yes, it is very hard to tell you since in Korea we keep the personal problems private. I do not tell anyone about, you know, my personal things.”

   “It sounds as if you have some things, though, that you really would like to talk about,” you surmise.

   “Yes, I am worried about how I misbehave and don't listen to my husband since I am in America.”

   “Okay, before you tell me about that, why don't you tell me how long you've been in America and what you're working on in school.” You feel like you should take a step back and give Henju time to feel comfortable about the counseling situation.

   “Yes, I live in Korea until I am 25 years old. I married my husband, Soekoo, ah, 2 years before I came to America. He is in engineering, a graduate student. When we come here, I am pregnant. I did not start school until my baby was born. Then I start school. We have been in America for 2 years now.”

   “Okay, and where do you live?” you ask.

   “In international student housing,” Henju tells you. She begins looking more relaxed talking about these areas of her life.

   “And what are you studying in school?” you ask.

   “I take physics and computer sciences,” Henju tells you. “I do well in these areas of study.”

   “That's very impressive. Are you studying for a master's degree or a doctorate?” you question.

   “First, a master's and then the PhD. degree,” Henju smiles. “I get both degrees and then I teach and do research.”

   “Wow, that's a lot of school. Do you plan on going back to Korea after you and your husband have finished school?” you ask.

   “Ah, we do not know. Perhaps, get a job in the U.S. but we must wait and see.”

   “Yes, of course. And how have you been managing with a small child with both you and your husband going to school full-time?”

   “My little girl, she is in the child care from 7 A.M. until 5 P.M.,” Henju replies.

   “The child care here at the University?” you query.

   “Yes, she likes it very much,” Henju tells you.

   “Good, that makes it easier for you to have her right here, I'm sure. So, let's talk a little about what you've been feeling confused about lately. Can you tell me a little more about that?”

   “Well,” Henju sighs, “I think I like better the way American women are free to do as they like, so I tell my husband I want to do things on my own.”

   “And how did he respond?” you ask.

   “He does not like that at all. He wants me to go to school and to come home. That's all. Everything else, he wants to do it with me.”

   “Can you give me an example?” you ask.

   “Well, like I say to him that I will go to the grocery store and get baby food or something. He says no; he says he must come with me to the grocery store. Or, well, I want to study with my girlfriends, and he says I have to study only at home. I don't like this at all. He goes out with his friends to study, but it is not okay for me to do the same. Do you see what I mean? I am confused. He says I misbehave. And I don't see that at all. I think I am now in America, and I want to do what my American girlfriends do in this country. Oh, he gets very angry with me.”

   “Okay, and what happens when he gets angry with you?” you ask.

   “He sometimes says I am not a good wife and that he is in charge of the household and I will do what he says. I feel very bad when he says that.” Henju sighs and sits back in her chair. She twists her hair and looks uncomfortable again.

   “So, when he gets angry at you for wanting to go out alone or with your girlfriends, he makes you feel bad. What do you do when he says those things?” you query.

   “Sometimes, I think I get mad at him. But, I should not get mad. In Korea, the wife obeys her husband.”

   “Do you ever decide to go out with your friends even if your husband doesn't want you to take part in those activities?” you wonder.

   “One time, I did that. You see, my friends decide to have a meeting because we have a big exam in the physics class. I tell my husband I need to go to the meeting so I can do well on the exam. He says, ‘No, you cannot go.’ I tell him I think this is very important and he can stay with our daughter one evening. So, I did not go home that night, and I went over to my friend's house to study. When I got home, he was so angry. He had been drinking the wine and was, how do you say, too much to drink? And he screams at me and says I am a bad wife and all, and he hits me with his belt. I was very, very upset after that for a long time.”

   “When did this happen, Henju?” you carefully ask.

   “About 1 or 2 months ago,” Henju replies.

   “Did you tell anyone about this incident?” you ask.

   “No, I felt very ashamed and did not want anyone to know,” Henju says quietly.

   “Okay, has your husband gotten angry and hit you other times?” you ask.

   “No, just the one time, but I have not felt like I could go out on my own since that time. I feel I must be at home and please my husband, or he will be very angry again.”

   “Are you fearful that he might become angry and hit you again?” you ask.

   “I am always fearful of my husband when he drinks the wine,” Henju replies. “I would like to not be so afraid all the time. And I would like to enjoy the freedom like American women do. I think maybe I should not want this, but I have tried and I cannot stop thinking I want some of this freedom like my friends.”

   “When you say ‘fearful,’ Henju, do you mean you are scared that your husband will hit you again?” you ask.

   “Only if I do something to make him very angry and drunk. If I behave the way I should as a Korean wife, then I am not afraid. I love my husband very much. He is a good person. He just does not understand American way of life for women. I feel I must learn how to obey him better and get these thoughts out of my mind.”

   “How often does your husband drink too much wine?”

   “Only on holidays and when he goes out with his Korean friends.”

   “Not every day or week?”

   “No. Not that much.”

   “So you have been living in America for 2 years now. How many times have you gone out by yourself?” you query.

   “Three times I go out. Once with my friends that I told you about; once to the pharmacy as my baby was sick and I needed the medicine; and once to buy food. My husband was not happy about these times at all. But he only hit me the one time when he had too much to drink and he became very angry that I was not home when he wanted me to be.”

   “The times that he gets angry with you but hasn't hit you, what does he do?”

   Henju thinks for a minute. “He tells me I am a bad wife and I misbehave. He yells and in Korean says bad names. Sometimes he says I am not a good mother. One time, he made me sit and meditate about my bad ways until morning.”

   “When he tells you you're a bad wife, how does that make you feel?”

   “I am very sad and ashamed of my ways. I think I should be good Korean wife. I think I should act that way for my daughter, too. But lately, I have been talking to my girlfriends, and they say I don't have to listen to my husband and that I am not a bad wife. So I have confusion.”

   “I see. This is a big dilemma for you. Have you been having trouble sleeping or eating?”

   “Sometimes I am so tense that I lie in bed without sleeping. But I eat very well,” she says with a big smile on her face, patting her belly. “I like American hamburgers and ice cream the best.”

   You smile and say, “I'm glad you like American food. But it must be hard not to be sleeping very well. How long have you had trouble sleeping?”

   “Only since my husband got so mad at me when I went to the study group. I did not think I had a problem until that time.”

   You decide that you do not want to press Henju further during the first session and that you have enough information to make an assessment of her issues. Therefore, you end the session by thanking her for coming and being honest and open with you. You schedule a follow-up session in the next few days.

· 8.6–1 What are some of Henju's strengths?

 

· 8.6–2 What acculturation issues do you think are involved with this case?

 

· 8.6–3 About which aspects of Korean culture do you need to get information in order to diagnose Henju appropriately?

 

· 8.6–4 What resources might be beneficial to Henju?

 

· 8.6–5 If you were to form hypotheses of Soekoo's issues, what would they be?

 

· 8.6–6 What is your initial diagnosis for Henju?

 

· 8.6–7 What would be your next steps with this client and family system?

 

Case 8.7

Identifying Information

Client Name: Roger Mathis

Age: 38 yrs old

Ethnicity: African American

Military Background: Enlisted at age 19 years; recent “Honorable” Discharge; Injury

Marital Status: Recently separated from wife Christy Mathis; 3 children

Employment: Part-time Clerk at Convenience Store, Austin, Texas

Current Services: Veteran's Outpatient Mental Health Clinic, San Antonio

Intake Information

Roger Mathis is 38 years old, African American, and has been active in the Army since enlisting at age 19. Roger has been married to his wife, Christy Mathis (age 36), for 12 years. Roger and Christy have 3 children: Jake (age 10), Jenna (age 7), and Joshua (age 4). Due to military assignments, Roger and his family move frequently. The family has been living in Austin, Texas, for the past 5 years. They generally live on military bases, but Christy is a school teacher in the Austin Independent School District, so the family purchased a home near the school. When on leave, Roger commutes in between Austin and the Fort Hood Army Base. The nearest relatives (Roger's mother, father, and his sister and her family) live in San Antonio, Texas. Roger's father is a retired military Captain and volunteers with injured returning war veterans at the VA Hospital in San Antonio. Roger reports that his parents and sister have been instrumental in providing support to his own wife and children when he is on deployment and states that their support helps him not to worry as much.

   Roger has been deployed in Iraq for the past 4 years. Seven months ago, Roger's military vehicle drove over a land mine while on patrol. The driver, a close friend, was killed immediately. Roger experienced severe injuries to his lower extremities and hands and has been given an “Honorable” Military discharge, due to irreversible damage to his right leg. He is currently in the process of securing his retirement and states, “My retirement is coming earlier than expected, but I am grateful to be alive and am looking forward to watching my kids grow up.”

   Roger states that he has no experience with mental health counseling or therapy, but that his father has suggested and encouraged him to seek help at the VA for his “nightmares and headaches.”

Initial Interview

The receptionist phones you in your office to let you know that a Mr. Mathis has arrived early for his appointment with you. She states to you quietly that he appears to be very nervous and seems uncomfortable sitting in the waiting room with so many other people. You go to the waiting room and observe Mr. Mathis sitting quietly, looking down, and rubbing his forehead. His foot is tapping the floor rapidly, and he appears uncomfortable.

   Once in your office, you introduce yourself and offer him the chair next to your desk.

   You start by asking, “Roger, why don't you start by telling me what brings you here today.”

   “I just seem to be having trouble with a lot of things since I've gotten home.”

   “How long have you been home?” you ask.

   “Oh, let's see, it's been about 5 months since I returned from Iraq this last time,” Roger surmises.

   “So, how many times were you in Iraq?” you ask.

   “Well, I've been in the military since I was 19 years old, so I've had many deployments, but this last time I was in Iraq for almost a year.”

   “Wow, so you're career has been the military. And I see from the intake information that you got seriously injured this last time.”

   Roger glances at his leg and begins rubbing it and states, “Yeah, it sort of ended my career, and I'm trying to figure out how to retire without losing my pension.”

   “Is that one of your concerns?” you query.

   “One of a whole bunch of stuff that's on my plate,” he responds.

   “Sounds like you've been overwhelmed lately,” you suggest.

   “Yeah, I thought Iraq was stressful, but I never dreamed I'd be in this place. I was planning on being in the military for the rest of my life. I grew up in a military family and it's all I know. Since I've gotten back, just so you know, I've separated from my wife, I've had surgery twice on my leg, I have constant nightmares and my kids are scared of me. I just don't know what to do anymore.” Roger sits back in his chair and sighs heavily. “Maybe I should have been the one to get killed instead of my buddy, Dan.”

   “Were you close to Dan?” you ask.

   Roger leans forward and stares straight ahead, “He was my best friend, and I couldn't recognize him after the explosion. It was the worst day of my life.”

   “I simply can't imagine how that must have felt and I'm so sorry for your loss,” you express empathically.

   Roger looks directly at you for the first time and says, “Thanks, it's been a living hell.”

   “So,” you say, “you mention that you are separated from your wife. How long ago did you separate?”

   Roger answers, “It seems like forever, but it's only been a couple of months. She said she just couldn't take it anymore. I know I've been difficult to live with since I got home. Everything has seemed unreal to me. I can't get the explosion and watching Dan die out of my head. It's almost like I relive that moment over and over again. It's in my dreams, and it haunts me during the day.”

   “Can you explain that a little more to me?” you ask.

   “I don't know. It's weird. It's like I'll be outside just sitting on the porch, smoking a cigarette, and suddenly my mind goes on instant replay, and I can't hit the pause button. It drives me crazy.”

   “OK, and then what happens?” you inquire.

   “Yeah, well, then sometimes it's like my head goes into fast forward and I feel like I'm in the middle of it all over again. Sometimes it gets so real that my heart begins to pound, my hands sweat and the sounds are deafening.”

   “What kind of sounds?” you ask.

   “You know, one time when we were going through this little town in Iraq on patrol, we walked up to this group of guys standing in the street and suddenly this house that couldn't have been more than 20 feet away just burst into flames. There were planes with artillery overhead and I couldn't see my hand in front of my face because of the smoke. The explosion was so loud that, for a while, I couldn't even hear my commander.

   “So, these are the kind of sounds you're still hearing?” you ask.

   “Sometimes but usually it's more like any loud noise I'm not expecting makes me really upset. It scares the crud out of me and I'm next to impossible to be around. That's when my kids get scared. I'm like a wild man. It makes me angry that I can't get control of it.”

   “Are you having any other problems,” you query.

   “I can't sleep but when I do, I have bad nightmares. My wife told me I scream and shout in my sleep but I don't remember any of it. So, instead, I decided to work nights so I won't have the nightmares. But it didn't work. At least I wasn't waking up my wife but the dreams didn't go away just because I'm sleeping during the day.”

   “Where are you working, now?” you question.

   “I work part time on the graveyard shift at the Super Stop Store. In the beginning, it worked for me because it was quieter and, with my leg injury, I needed something slower but I guess I've been moving too slow. I'm supposed to do all the paperwork for the day and I can't seem to concentrate long enough to get it done. It's weird because sometimes there's a couple of hours when no one come into the store but I just can't keep my mind on it. Same thing for reading. I take a book with me to the store because they said I could read when I don't have customers and I can't get past the first chapter. When I was in Iraq, I read tons of paperbacks and now I can't read a simple newspaper.”

   “Are there things that are distracting you?” you ask.

   Roger thinks of a moment and says, “Well, yeah, I guess so, but it's stupid things, like the lights on the sign outside flashing the price of gas or the video monitor that switches from one camera shot to the next constantly. You'd think I'd get used to those things, but they irritate me to no end.”

   “Can you give me an example of a night when it really bothered you?” you ask.

   “Yeah, just a couple of nights ago, I was there by myself and the lights were bothering me so much, I got a splitting headache. I stepped into the restroom for a few minutes to wash my face and take some aspirin. I didn't know anyone had been pumping gas until the next morning when I got called in by my boss and got into trouble because they didn't pay for the gas and just drove off. I was given a warning and was told that if it happens again, I'll lose my job,” Roger responds with agitation. You notice the tension in his body and the anxiety on this face. He looks noticeably tired and frustrated.

   “How are you doing right now, Roger?” you ask.

   “Not so great. This all just really sucks. Will this ever go away?” he asks.

   “You know you're a survivor Roger and you're also a real fighter. In addition, you had the guts to come in and talk about all of these issues that you're confronting right now. That's not easy. One thing I can tell you for sure is that the problems you're-experiencing didn't happen overnight. It will probably take some time to work out but I can assure you that you're on the right track to feeling better. If you're willing to work with me, I think we can resolve some of these roadblocks in your life.”

   “Do you think my wife and kids will come back? I miss them terribly,” Roger says.

   “I think this is something we can work on. Do you think at some point, your wife would be willing to come with you to talk to me? You inquire.

   “Yes, she has told me several times that she still believes in me and loves me. She left mostly because the kids were scared.”

   “I think we have some work to do before we can bring your wife in to a session but let's keep working in that direction.”

   “Thanks, I feel like I've got some hope now.”

· 8.7–1 What issues need to be resolved/addressed before Roger's wife can be included in couples therapy?

 

· 8.7–2 What other resources might be helpful in Roger's recovery?

 

· 8.7–3 How might Roger's cultural background and military status impact his treatment and recovery?

 

· 8.7–4 What emergency considerations would you want to consider in your assessment?

 

· 8.7–5 What other comorbid conditions would you want to screen for in your assessment?

 

· 8.7–6 What assessment instruments would you want to employ in your evaluation?

 

· 8.7–7 What are some of Roger's strengths?

 

· 8.7–8 What is your primary diagnosis?

 

· 8.7–9 What are some V-codes you would want to include in your diagnosis?

 

Case 8.8

Client name: Arturo Rodriguez

Parents: Victor Rodriguez (detained) and Elena Rodriguez

Ethnicity: Hispanic

Age: 4

You are a bilingual counselor at El Buen Samaritano, a Catholic outreach center that provides a wide variety of free services to the community.

Intake Information

Elena came into the center about a week ago and told the front desk staff that she heard from someone at church that she could come here to get some help for her son. She stated that her son had been acting very different lately and that a priest at the church said maybe someone could help. The receptionist set her up with an appointment.

Initial Interview

When you go into the waiting room to greet Elena and Arturo, Arturo runs behind his mother, clinging to her leg. Elena shakes your hand graciously and pats her son on the head, whispering to him that everything is OK. As you walk back to your office, Elena says that Arturo does this all the time and that you should not take it personally. You smile warmly and assure her that you have met many kids who are nervous around strangers. Once in your office, you explain to Elena that you would like to hear from her about what's going on, so you set up some toys for Arturo to play with.

   “What made you decide to bring in Arturo?” you inquire.

   “He is acting very different lately. He is very upset because his father is gone. Always so attached to me, like you just saw. Before he loved to meet new people, wave at them. Sometimes he got afraid of things, but now it's so much.”

   “I am so glad you decided to bring him in to see how we can help. You mentioned his father is gone, it sounds like a very difficult time.”

   Elena looks down at her hands and nods, “Yes. The priest says I can talk to you about things like I can talk to him— he said you don't work for the police.”

   “That's true, I don't. If we were worried about Arturo's safety I might need to tell someone, and it's possible a court could order me to talk to them, but otherwise I will not go to the police about whatever you tell me.”

   “Yes, okay.” Elena pauses a moment.

   “It was terrible. I was away at work— on the night shift. I come home and see all the trailers were destroyed—windows, doors broken. My own door was broken down and no one was home, but nothing was missing either. So I call my sister and she told me that Nadia— she is my niece who helps with Arturo when I am late—that Nadia had Arturo safe. I am thanking God that he is OK but then she says they handcuffed my husband, and I know they have taken him. Nadia showed them her information and told them that she could take Arturo. Thank goodness Nadia has papers!” Elena is tearing up.

   “What a horrible experience, Elena. It sounds like a very overwhelming situation.”

   “My poor little boy. He is so afraid. Whenever anyone comes to the door he leaps in the air, so fast, and starts to cry. He wakes up in the middle of the night with terrible nightmares, sobbing and screaming. I hold him and hold him but it's so hard to get him to calm down. He doesn't understand where his father went.”

   “It sounds like you love your son very much and are doing a lot to try to help him.”

   “I am, but it is just so hard.”

   “Are there any other differences you're noticing since the raid?”

   “It takes him a very long time to go to sleep, when before I could put him down easily. I don't know, Nadia is with him most of the day. I don't know what to do anymore.”

   “This is all very useful. I just want to make sure I get to know Arturo as well I can so I can be as helpful as possible.”

   You get Elena's permission to call Nadia and ask if you can spend some time with Arturo. As she signs the paperwork, you begin to play with Arturo.

   Arturo eyes you nervously as you sit down near him on the floor, but seems to be reassured by his mother's presence. You notice that he is playing with some animal figures.

   “Hi Arturo, is it OK if we play for a little while?” you ask. Arturo looks at his mom and then nods his head.

   Arturo has an elephant hidden behind a wall of blocks, and a lion and a panda are looking for the elephant but can't find him.

   “I love your animals, Arturo. Can you tell me their names?”

   “This is elephant, this is lion, and this is bear.” Arturo says, pointing to each animal.

   “It looks like they are doing some important things. What is the bear doing?” you ask Arturo.

   “Taking the lion away!!” Arturo exclaims.

   “Oh no,” you say with sincere concern, “That sounds scary.” Arturo shakes his head in agreement.

   “And what is the elephant doing?” you inquire.

   “Hiding from the bear. . . .bam, bam, bam!!!! Taking the lion away!” Arturo explains.

   “Will the elephant find the lion?” you ask.

   Arturo shrugs his shoulders and makes the lion and bear fight on the carpet and leaves the elephant on the table. You let him continue playing while you talk with Elena about scheduling another appointment and figure out a good time to call Nadia.

Interview with Nadia

Nadia is a 16-year-old Hispanic female who is caring for Arturo during her summer break. She is very soft-spoken as you ask her some questions and you can tell that she cares about Arturo a lot.

   “Nadia, thank you so much for agreeing to talk with me. Is this a good time?”

   “I am happy to. Arturo is watching Sesame Street right now.”

   “Your aunt mentioned to me that Arturo has been having a hard time lately. Have you noticed anything different?”

   “He has a lot of nightmares, most times when he is asleep he wakes up and is upset—screaming and crying. I try to ask him why he is so upset, but he doesn't know and is fine after a few minutes. He's also afraid of strangers, but especially policemen. We saw some policemen when we were walking to the grocery store and he got so upset. It took me like half an hour to calm him down.”

   “Is there anything else you've noticed?”

   “He freaks out whenever anyone comes to the door. He jumps out of his skin almost and sometimes hides in the closet. I mean, usually he gets excited when someone comes to the door, but now it's like he's completely freaked out and jumpy, and not in a happy way, you know?”

   “That is really helpful, thanks for telling me about all this. I was wondering what kind of things he likes to play.”

   “Lately he likes to pretend everything is lost and he is finding it. It's the same thing over and over, whether we're playing with his stuffed animals or his truck. He has also started using diapers again because he's had several accidents. And you know, there's one more thing, he is less cuddly than he used to be. It's weird because he used to be really sweet with me. I don't know if I'm doing something wrong with him.”

   “It sounds like you are a really good caregiver. I know that you were there to keep him safe during the raid and you help him calm down when he gets upset.”

   “Yeah, that was rough.”

   “Thank you for talking with me Nadia. Is it O.K. to call you if I have any other questions?”

   “No problem. Whatever you need. I just want to help Arturo. He's a great kid.”

   Nadia gets up and leaves your office.

· 8.8–1 Based on these interviews, what are the symptoms that Arturo displays that are of concern to you?

 

· 8.8–2 What are some potential diagnoses that you would consider based on the symptoms Arturo is currently displaying?

 

· 8.8–3 What other information would you want to obtain from the family?

 

· 8.8–4 What are the strengths of this family?

 

· 8.8–5 What resources might benefit Arturo and his mother?

 

· 8.8–6 What is your diagnosis for Arturo?

 

· 8.8–7 What are the psychosocial and cultural factors that might be impacting this diagnosis? List the DSM-5 V-codes that are appropriate for this case.

 

Case 8.9

Name: Sonny Blalock

Age: 7 years old

Ethnicity: African American

Occupational Status: 2nd grade Lanier Elementary School

Family status: Foster care for 2 years

You are a foster care specialist with the Child and Family Services of the state. Sonny has recently been placed in your caseload after being removed from his fifth foster care placement. Sonny's file indicates that he has had four other foster care placements in the last 2 years. He was removed from his family of origin due to abuse and neglect. Apparently, the abuse started at the age of 7 months when Sonny's biological mother, Cara, moved in with a boyfriend who was a violent and drug addicted man. Police were called on several occasions due to violence in the home. Cara moved in with her sister, Violet, after repeated incidents of abuse; however, after a few months, moved in with another boyfriend who locked Cara's children in a closet when she went to work at a grocery store. At the age of 5, Sonny began attending kindergarten where his teachers noted that he was hyperactive, highly distractible and impulsive. They also noted that he often asked his teacher if he could go home with her and would often wrap his arms around her legs when it was time to leave school for the day. During the summer, Cara and her boyfriend were charged with drug possession with intent to sell and Sonny was placed in foster care. Although none of the foster care parents reported conduct problems, Sonny had to be moved several times over the past 2 years. You set up a time with his current foster mother to interview Sonny.

Interview with Sonny

You arrive at Sonny's foster home late one afternoon to talk with Sonny and his foster mother, Jean. Jean provides you with a room in the house where you can talk with Sonny alone. You meet Sonny in the playroom where he is playing with Legos.

   “Hi Sonny, my name is Ms. Sherry. I'm your new social worker,” you say with a smile.

   Sonny looks up and says, “Hi” and continues to construct a building with his Legos.

   “Wow, I really like Legos. What are you building?” you ask.

   “Are you going to take me to another family?” Sonny asks in a monotone voice.

   “No, I'm just here to get to know you. I know your other social worker, Amy, was someone you really liked and was sorry she had to leave.”

   “Do you have children?” Sonny asks.

   “No, but I take care of children who are in foster care like you,” you reply.

   “Oh,” Sonny replies.

   “Do you want to play a game?” you ask as you set up the Talking, Feeling, Doing game.

   Sonny looks at the game and moves over to table. “How long are you going to be here?” he asks.

   “Today, I'm going to be here for an hour or so,” you reply. “Do you know how to play this game?”

   “Yeah, I've played it before. I like the “doing” cards,” Sonny says.

   “What are some things you like to do?” you ask.

   “Ride bikes,” Sonny replies. “I learned at that other place a long time ago.”

   “That's great,” you comment. “I think that Mary and Bill have some bikes you might be able to ride.”

   “Are there other things you like to do?” you query. Sonny stares at you with a questioning look on his face.

   “Since you don't have any children, can I go home with you?” Sonny asks.

   “No, you're going to stay here with Mary and Bill. I think you'll like being here with other kids around, don't you?” you respond.

   Sonny gets up and moves next to your chair. “Can I sit on your lap?” Sonny asks.

   You are surprised by this request since Sonny has just met you. “Why don't you move your chair next to mine if that would make you feel better,” you suggest. Sonny immediately runs over and pushes his chair as close to your chair as possible.

   As you continue to play the game with Sonny, you realize that Sonny desperately wants to be close to you. He tells you that he feels lonely most of the time. In addition, he doesn't feel that he has any friends and that he spends most of his time by himself.

   When the time is up and you get ready to leave, Sonny runs over and hugs you, saying “Don't leave. Take me with you. I want to be your little boy.” He seems almost panicked that you are not going to stay.

   “I will come back and see you again, Sonny, but right now, I have to leave.”

   “When will you come back,” Sonny exclaims in a frightened voice.

   “I will come back next Tuesday,” you say trying to reassure him. “It will be O.K. Sonny. I know this is hard getting used to a new home but I will be coming to see you every Tuesday and if you need to talk to me you can tell Mary and she will call me.”

   With some coaxing, Sonny begins to loosen his grip on you. “Let's go see Mary before I leave,” you suggest.

   “Okay,” Sonny reluctantly agrees.

   When you walk in the kitchen where Mary is standing at the stove, Sonny runs over and grabs her around her legs. Mary looks at you searchingly. You explain to Mary that Sonny is feeling lonely and that you told him you will be back next Tuesday. Mary nods and says to Sonny, “Why don't you help me make this cake we're going to have for dinner. Do you like chocolate cake?”

   Sonny nods and lets go of Mary and begins stirring the cake mix.

   “Bye Sonny,” you say as you start for the door. “See you next Tuesday.”

· 8.9–1 What information have you gained from this short session with Sonny?

 

· 8.9–2 What additional information would you like to obtain from Sonny's records?

 

· 8.9–3 What would you like to do in your next session with Sonny?

 

· 8.9–4 What resources might be useful in your work with Sonny?

 

· 8.9–5 What are some possible diagnoses for Sonny?

 

· 8.9–6 What additional information would you need in order to make a firm diagnosis?

 

References

Achenbach, T. M. (1991). Manual for the child behavior checklist/4-18 and 1991 profile. Burlington, VT: University of Vermont, Department of Psychiatry.

Achenbach, T. M., Becker, A., Dopfner, M., Heiervang, E., Roessner, V., Steinhausen, H. C., et al. (2008). Multicultural assessment of child and adolescent psychopathology with ASEBA and SDQ instruments: Research findings, applications, and future directions. Journal of Child Psychology and Psychiatry, 49, 251–275.

Achenbach, T. M., & Edelbrock, C. S. (1983). Manual for the child behavior checklist and the revised child behavior profile. Burlington, VT: University Associates in Psychiatry.

Achenbach, T. M., & Rescorla, L. A. (2000).Manual for ASEBA preschool forms & profiles. Burlington, VT: University of Vermont, Research Center for Children, Youth, & Families.

Achenbach, T. M., & Rescorla, L. A. (2001). Manual for the ASEBA school-age forms & profiles. Burlington, VT: University of Vermont, Research Center for Children, Youth, & Families.

Adkins, J., Weathers, F. W., McDevitt-Murphy, M., & Daniels, J. (2008). Psychometric properties of seven self-report measures of posttraumatic stress disorder in college students with mixed civilian trauma exposure. Journal of Anxiety Disorders, 22(8), 1393–1402.

Alcántara, C., Casement, M., & Lewis-Fernández, R. (2013). Conditional risk for PTSD among Latinos: A systematic review of racial/ethnic differences and sociocultural explanations. Clinical Psychology Review, 33(1), 107–119.

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

American Psychiatric Association, (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.

Beck, A. T., Brown, G. K., & Steer, R. A. (1997). Psychometric characteristics of the scale for suicide ideation with psychiatric outpatients. Behaviour Research and Therapy, 35(11), 1039–1046.

Beck, A. T., & Steer, R. A. (1991). Manual for the Beck Scale for suicide ideation. San Antonio, TX: Psychological Corporation.

Beck, A. T., Steer, R. A., & Ranieri, W. (1988). Scale for suicide ideation: Psychometric properties of a self-report version. Journal of Clinical Psychology, 44, 499–505.

Blake, D., Weathers, F. W., Nagy, L. M., Kaloupek, D. G., Gusman, F. D., Charney, D. S., et al. (1995). The development of a clinician-administered PTSD scale. Journal of Traumatic Stress, 8(1), 75–90.

Blanchard, E., Jones-Alexander, J., Buckley, T., & Forneris, C. (1996). Psychometric properties of the PTSD Checklist (PCL). Behaviour Research and Therapy, 34(8), 669–673.

Breslau, N. (2002). Gender differences in trauma and post-traumatic stress disorder. The Journal of Gender-Specific Medicine: JGSM: The Official Journal of the Partnership for Women's Health at Columbia, 5(1), 34–40.

Breslau, N., & Kessler, R. C. (2001). The stressor criterion in DSM-IV posttraumatic stress disorder: An empirical investigation. Biological Psychiatry, 50, 699–704.

Breslau, N., Kessler, R. C., & Chilcoat, H. D. (1998). Trauma and posttraumatic stress disorder in the community: The 1996 Detroit Area Survey of trauma. Archives of General Psychiatry, 55(7), 626–632.

Brewin, C. R., Andrews, B., & Valentine, J. D. (2000). Metaanalysis of risk factors for post-traumatic stress disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology, 68(5), 748–766.

Bryant, R. (2011). Post-traumatic stress disorder vs. traumatic brain injury. Dialogues in Clinical Neuroscience, 13(3), 251–262.

Bryant, R. A., Moulds, M., & Guthrie, R. (2000). Acute Stress Disorder Scale: A self-report measure of acute stress disorder. Psychological Assessment, 12, 61–68.

Bryant, R. A., Harvey, A. G., Dang, S., & Sackville, T. (1998). Assessing Acute Stress Disorder: Psychometric properties of a structured clinical interview. Psychological Assessment, 10, 215–220.

Casey, P., & Bailey, P. (2011). Adjustment disorders: The state of the art. World Psychiatry, 10(1), 11–18.

Clapp, J. D., & Beck, J. G. (2009). Understanding the relationship between PTSD and social support: The role of negative network orientation. Behaviour Research and Therapy, 47(3), 237–244.

Cochrane-Brink, K., Lofchy, J., & Sakinofsky, I. (2000). Clinical rating scales in suicide risk assessment. General Hospital Psychiatry, 22(6), 445–451.

Corcoran, K., & Fischer, J. (2013). Measures for clinical practice and research. A sourcebook: Volume 1:Couples, families, and children (5th ed., pp. 474–475). New York: Oxford University Press.

Creamer, M., Bell, R., & Failla, S. (2003). Psychometric properties of the Impact of Event Scale—revised. Behaviour Research and Therapy, 41(12), 1489–1496.

DiGrande, L., Perrin, M. A., Thorpe, L. E., Thalji, L., Murphy, J., Wu, D., et al. (2008). Posttraumatic stress symptoms, PTSD, and risk factors among lower Manhattan residents 2-3 years after the September 11, 2001 terrorist attacks. Journal of Traumatic Stress, 21(3), 264–273.

Ditlevsen, D. N., & Elklit, A. (2010). The combined effect of gender and age on post-traumatic stress disorder: Do men and women show differences in the lifespan distribution of the disorder. Annals of General Psychiatry, 9(32). Retrieved March 27, 2014, from  http://www.annals-general-psychiatry.com/content/9/1/32

Ebesutani, C., Bernstein, A., Nakamura, B. J., Chorpita, B. F., Higa-McMillian, C. K., et al. (2010). Concurrent validity of the Child Behavior Checklist DSM-oriented scales: Correspondence with DS diagnoses and comparison to syndrome scales. Journal of Psychopathology and Behavioral Assessment, 32(3), 373–384.

Ferdinand, R. F. (2008). Validity of the CBCL/YSR DSM-IV scales anxiety problems and affective problems. Journal of Anxiety Disorders, 22(1), 126–134.

Ferrada-Noli, M., Asberg, M., Ormstad, K., Lundin, T., & Sundbom, E. (1998). Suicidal behavior after severe trauma. Part 1: PTSD diagnoses, psychiatric comorbidity and assessment of suicidal behavior. Journal of Traumatic Stress, 11, 103–112.

Forbes, D., Creamer, M., & Biddle, D. (2001). The validity of the PTSD Checklist as a measure of symptomatic change in combat-related PTSD. Behaviour Research and Therapy, 39(8), 977–986.

Ford, J. D. (2008). Trauma, posttraumatic stress disorder, and ethnoracial minorities: Toward diversity and cultural competence in principles and practices. Clinical Psychology: Science & Practice, 15(1), 62–67.

Frick, P. J., Barry, C. T., & Kamphaus, R. W. (2010).Clinical assessment of child and adolescent personality and behavior (3rd ed.). New York: Springer. Retrieved March 27, 2014, from  http://www.brainm.com/software/pubs/books/ClinAssessChildAdol.pdf

Ghafoori, B., Barragan, B., Tohidian, N., & Palinkas, L. (2012). Racial and ethnic differences in symptom severity of PTSD, GAD, and depression in trauma-exposed, urban, treatment-seeking adults. Journal of Traumatic Stress, 25(1), 106–110.

Gleason, M. M., Dickstein, S., & Zeanah, C. H. (2006). Maternal concerns and disclosure about children's mental health. Presented at Pediatric Academic Societies Annual Meeting, San Francisco, CA. Retrieved March 27, 2014, from  http://www.infantinstitute.org/wp-content/uploads/2013/07/ECSA-Manual-0509.pdf

Gleason, M. M., Fox, N. A., Drury, S., Smyke, A., Egger, H. L., Nelson, C. A., III, et al. (2011). Validity of evidence-derived criteria for reactive attachment disorder: Indiscriminately social/disinhibited and emotionally withdrawn/inhibited types. Journal of the American Academy of Child & Adolescent Psychiatry, 50(3), 216–231.

Gleason, M. M., Zeanah, C. H., & Dickstein, S. (2010). Recognizing young children in need of mental health assessment: Development and preliminary validity of the early childhood screening assessment. Infant Mental Health Journal, 31(3), 335–357.

Greenwald, R., & Rubin, A. (1999). Assessment of posttraumatic symptoms in children: Development and preliminary validation of parent and child scales. Research on Social Work Practice, 9, 61–75.

Gross, D., Fogg, L., Young, M., Ridge, A., Cowell, J. M., Richardson, R., et al. (2006). The equivalence of the Child Behavior Checklist/11/2-5 across parent race/ethnicity, income level, and language. Psychological Assessment, 18(3), 313–323.

Harrison, J. P., Satterwhite, L. F., & Ruday, W. (2010). The financial impact of post-traumatic stress disorder on returning US military personnel. Journal of Health Care Finance, 36(4), 65–74.

Helfricht, S., Landolt, M. A., Moergeli, H., Hepp, U., Wegener, D., & Schnyder, U. (2009). Psychometric evaluation and validation of the German version of the Acute Stress Disorder Scale across two distinct trauma populations. Journal of Traumatic Stress, 22(5), 476–480.

Hinton, D., & Lewis-Fernández, R. (2011). The cross-cultural validity of posttraumatic stress disorder: Implications for DSM-5. Depression and Anxiety, 28(9), 783–801.

Hinton, D., & Otto, M. W. (2006). Symptom presentation and symptom meaning in Cambodian refugees with posttraumatic stress disorder and panic disorder. Cognitive and Behavioral Practice, 13(4), 249–260.

Holbrook, T., Hoyt, D., Stein, M., & Sieber, W. (2002). Gender differences in long-term posttraumatic stress disorder outcomes after major trauma: Women are at higher risk of adverse outcomes than men. The Journal of Trauma, 53(5), 882–888.

Hollifield, M., Warner, T. D., Lian, N., Krakow, B., Jenkins, J., Kesler, J., et al. (2002). Measuring trauma and health status in refugees: A critical review. Journal of the American Medical Association, 288, 611–621.

Holmes, T. H., & Rahe, R. H. (1967). The Social Readjustment Rating Scale. Journal of Psychosomatic Research, 11(2), 213–221.

Horowitz, A., Wilner, B., & Alvarez, W. (1979). Impact of Events Scale 4: A measure of subjective stress. Psychological Medicine, 41, 209–218.

Joiner, T., & Gutierrez, P. (n.d.). Toward a gold standard for suicide risk assessment for military personnel. Military Suicide Research Consortium. Retrieved March 27, 2014, from  https://msrc.fsu.edu/funded-research/toward-gold-standard-suicide-risk-assessment-military-personnel

Kassam-Adams, N. (2006). The acute stress checklist for children (ASC-Kids): Development of a child self-report measure. Journal of Traumatic Stress, 19(1), 129–139.

Keane, T. M., Caddell, J. M., & Taylor, K. L. (1988). Mississippi Scale for Combat-Related Posttraumatic Stress Disorder: Three studies in reliability and validity. Journal of Consulting and Clinical Psychology, 56, 85–90.

Keen, S. M., Kutter, C. J., Niles, B. L., & Krinsely, K. E. (2008). Psychometric properties of PTSD Checklist in sample of male veterans. Journal of Rehabilitation Research & Development, 45(3), 465–474.

Kessler, R. C., Berglund, P. A., Demler, O., Jin, R., & Walters, E. E. (2005). Lifetime prevalence and age-ofonset distributions of DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 62, 593–602.

Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52(12), 1048–1060.

Kilpatrick, D., Resnick, H., Milanak, M., Miller, M., Keyes, K., & Friedman, M. (2013). National estimates of exposure to traumatic events and PTSD prevalence using DSM-IV and DSM-5 criteria. Journal of Traumatic Stress, 26(5), 537–547.

Kimerling, R., Gima, K., Smith, M. W., Street, A., & Frayne, S. (2007). The Veterans Health Administration and military sexual trauma. American Journal of Public Health, 97, 2160–2166.

Kimerling, R., Prins, A., Westrup, D., & Lee, T. (2004). Gender issues in the assessment of PTSD. In J. P. Wilson & T. M. Keane (Eds.), Assessing psychological trauma and PTSD (2nd ed., pp. 565–599). New York: Guilford Press. Kimerling, R., Street, A. E., Pavao, J., Smith, M. W., Cronkite, R. C., Holmes, T. H., et al. (2010). Military-related sexual trauma among Veterans Health Administration patients returning from Afghanistan and Iraq. American Journal of Public Health, 100(8), 1409–1412.

Kirmayer, L. J. (2001). Cultural variations in the clinical presentation of depression and anxiety: Implications for diagnosis and treatment. Journal of Clinical Psychiatry, 62(13), 22–28.

Knox, K. L. (2008). Epidemiology of the relationship between traumatic experience and suicidal behaviors. PTSD Research Quarterly, 19(4), 1–8.

Kotler, M., Iancu, I., Efroni, R., & Amir, M. (2001). Anger, impulsivity, social support, and suicide risk in patients with posttraumatic stress disorder. Journal of Nervous and Mental Disease, 189(3), 162–167.

Komarovskaya, I., Loper, B. A., Warren, J., & Jackson, S. (2011). Exploring gender differences in trauma exposure and the emergence of symptoms of PTSD among incarcerated men and women. Journal of Forensic Psychiatry & Psychology, 22(3), 395–410.

Krysinska, K., & Lester, D. (2010). Post-traumatic stress disorder and suicide risk: A systematic review. Archives of Suicide Research, 14(1), 1–23.

Lilly, M., Pole, N., Best, S., Metzler, T., & Marmar, C. (2009). Gender and PTSD: What can we learn from female police officers? Journal of Anxiety Disorders, 23(6), 767–774.

Luxton, D. D., Skopp, N. A., & Maguen, S. (2010). Gender difference in depression and PTSD symptoms following combat exposure. Depression and Anxiety, 27(11), 1027–1033.

March, J., Amaya-Jackson, L., Terry, R., & Costanzo, P. (1997). Posttraumatic symptomatology in children and adolescents after an industrial fire. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 1080–1088.

Marsella, A. J. (2010). Ethnocultural aspects of PTSD: An overview of concepts, issues, and treatments. Traumatology, 16(4), 17–26.

Marshall, G. N., Schell, T. L., & Miles, J. N. V. (2009). Ethnic differences in posttraumatic distress: Hispanics' symptoms differ in kind and degree. Journal of Consulting & Clinical Psychology, 77(6), 1169–1178.

Mays, V. M., & Cochran, S. D. (2001). Mental health correlates of perceived discrimination among lesbian, gay, and bisexual adults in the United States. American Journal of Public Health, 91(11), 1869–1876.

McCarthy, M. D., Thompson, S. J., & Knox, K. L. (2012). Use of the air force post-deployment health reassessment for the identification of depression and posttraumatic stress disorder: Public health implications for suicide prevention. American Journal of Public Health, 102(S1, Suppl. 1), S60–S65.

McLaughlin, K. A., Koenen, K. C., Hill, E. D., Petukhova, M., Sampson, N. A., Zaslavsky, A. M., et al. (2013). Trauma exposure and posttraumatic stress disorder in a national sample of adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 52(8), 815–830.

Murdoch, M., van Ryn, M., Hodges, J., & Cowper, D. (2005). Mitigating effect of Department of Veterans Affairs disability benefits for post-traumatic stress disorder on low income. Military Medicine, 170(2), 137–140.

Nader, K., Kriegler, J. A., Blake, D. D., Pynoos, R. S., Newman, E., & Weather, F. W. (1996). Clinician-administered PTSD scale, child and adolescent version. White River Junction, VT: National Center for PTSD.

Nakamura, B. J., Ebesutani, C., Berstein, A., & Chorpita, B. F. (2009). A psychometric analysis of the Child Behavior Checklist DSM-Oriented scales. Journal of Psychopathology and Behavioral Assessment, 31, 178–189.

Nock, M. K., Hwang, I., Sampson, N., Kessler, R. C., Angermeyer, M., et al. (2009). Cross-national analysis of the associations among mental disorders and suicidal behavior: Findings from the WHO World Mental Health Surveys. PLoS Med, 6(8), e1000123. doi:10.1371/journal. pmed.1000123

Nooner, K. B., Linares, L. O., Batinjane, J., Kramer, R. A., Silva, R., & Cloitre, M. (2012). Factors related to post-traumatic stress disorder in adolescence. Trauma, Violence, & Abuse, 13(3), 153–166.

Nye, E. C., & Bell, J. B. (2007). Specific symptoms predict suicidal ideation in Vietnam combat veterans with chronic post-traumatic stress disorder. Military Medicine, 172(11), 1144–1147.

O'Connor, T. G., & Zeanah, C. H. (2003). Attachment disorders: Assessment strategies and treatment approaches. Attachment & Human Development, 5(3), 223–244.

Olff, M., Langeland, W., Draijer, N., & Gersons, B. (2007). Gender differences in posttraumatic stress disorder. Psychological Bulletin, 133(2), 183–204.

Oquendo, M. A., Friend, J. M., Halberstam, B., Brodsky, B. S., Burke, Grunebaum, M. F., et al. (2003). Association of comorbid posttraumatic stress disorder and major depression with greater risk for suicidal behavior. American Journal of Psychiatry, 160(3), 580–582.

Orsillo, S. M. (2001). Measures for acute stress disorder and posttraumatic stress disorder. In M. M. Antony & S. M. Orsillo (Eds.), Practitioner's guide to empirically based measures of anxiety (pp. 255–307). New York: KluwerAcademic/Plenum. PILOTS ID 24368

Ozbay, F., Johnson, D. C., Dimoulas, E., Morgan, C. A., Charney, D., & Southwick, S. (2007). Social support and resilience to stress: From neurobiology to clinical practice. Psychiatry (Edgmont), 4(5), 35–40.

Ozer, E. J., Best, S. R., Lipsey, T. L., & Weiss, D. S. (2003). Predictors of posttraumatic stress disorder and symptoms in adults: A meta-analyses. Psychological Bulletin, 129(1), 52–73.

Palmieri, P. A., Weathers, F. W., Difede, J., & King, D. W. (2007). Confirmatory factor analysis of the PTSD Checklist and the Clinician-Administered PTSD Scale in disaster workers exposed to the world trade center ground zero. Journal of Abnormal Psychology, 116(2), 329–341.

Perkonigg, A., Pfister, H., Stein, M. B., Höfler, M., Lieb, R., Maercker, A., et al. (2005). Longitudinal course of post-traumatic stress disorder and posttraumatic stress disorder symptoms in a community sample of adolescents and young adults. American Journal of Psychiatry, 162(7), 1320–1327.

Pole, N., Gone, J. P., & Kulkarni, M. (2008). PTSD in ethnoracial minorities. Clinical Psychology: Science and Practice, 15(1), 35–61.

Read, J. P., Ouimette, P., White, J., Colder, C., & Farrow, S. (2011). Rates of DSM-IV-TR trauma exposure and post-traumatic stress disorder among newly matriculated college students. Psychological Trauma: Theory, Research Practice, and Policy, 3(2), 148–156.

Roberts, A. L., Austin, S. B., Corliss, H. L., Vandermorris, A. K., & Koenen, K. C. (2010). Pervasive trauma exposure among U.S. sexual orientation minority adults and risk of post-traumatic stress disorder. American Journal of Public Health, 100(12), 2433–2441.

Roberts, A. L., Gilman, S. E., Breslau, J., Breslau, N., & Koenen, K. C. (2011). Race/ethnic differences in exposure to traumatic events, development of post-traumatic stress, disorder and treatment-seeking for post-traumatic stress disorder in the United States. Psychological Medicine, 41(1), 71–83.

Ruggiero, K. J., Del Ben, K., Scotti, J. R., & Rabalais, A. E. (2003). Psychometric properties of the PTSD Checklist—Civilian version. Journal of Traumatic Stress, 16(5), 495–502.

Sareen, J., Houlahan, T., Cox, B., & Asmundson, G. J. G. (2005). Anxiety disorders associated with suicidal ideation and suicide attempts in the National Comorbidity Survey. Journal of Nervous and Mental Disease, 193, 450–454.

Scheeringa, M. S. (2004). Diagnostic infant and preschool assessment (DIPA) manual: Version 8/18/10. New Orleans, LA: Tulane University. Retrieved March 27, 2014, from  http://www.infantinstitute.org/MikeSPDF/DIPA_Manual.pdf

Scheeringa, M. S. (2011). PTSD in children younger than the age of 13: Toward developmentally sensitive assessment and management. Journal of Child & Adolescent Trauma, 4(3), 181–197.

Scheeringa, M. S. (2012). Young child PTSD Checklist. New Orleans, LA: Tulane University, Institute of infant & early childhood mental health. Retrieved March 27, 2014, from  http://www.infantinstitute.org/measures-manuals/

Scheeringa, M. S., & Haslett, N. (2010). The reliability and criterion validity of the diagnostic infant and preschool assessment: A new diagnostic instrument for young children. Child Psychiatry & Human Development, 41(3), 299–312.

Scheeringa, M. S., Myers, L., Putnam, F. W., & Zeanah, C. H. (2012). Diagnosing PTSD in early childhood: An empirical assessment of four approaches. Journal of Traumatic Stress, 25(4), 359–367.

Scheeringa, M. S., Zeanah, C. H., & Cohen, J. A. (2011). PTSD in children and adolescents: Towards an empirically based algorithm. Depression and Anxiety, 28(9), 770–782.

Scheeringa, M. S., Zeanah, C. H., Drell, M. J., & Larrieu, J. A. (1995). Two approaches to the diagnosis of posttraumatic stress disorder in infancy and early childhood. Journal of the American Academy of Child and Adolescent Psychiatry, 34(2), 191–200.

Scheeringa, M. S., Zeanah, C. H., Myers, L., & Putnam, F. W. (2003). New findings on alternative criteria for PTSD in preschool children. Journal of the American Academy of Child and Adolescent Psychiatry, 42(5), 561–570.

Scheeringa, M. S., Zeanah, C. H., Myers, L., & Putnam, F. W. (2005). Predictive validity in a prospective follow-up of PTSD in preschool children. Journal of the American Academy of Child and Adolescent Psychiatry, 44(9), 899–906.

Schwab, K. A., Baker, G., Ivins, B., Sluss-Tiller, M., Lux, W., & Warden, D.(2006). The Brief Traumatic Brain Injury Screen (BTBIS): Investigating the validity of a self-report instrument for detecting traumatic brain injury (TBI) in troops returning from deployment in Afghanistan and Iraq. Neurology, 66(5, Suppl. 2), A235.

Sheperis, C. J., Doggett, R. A., Hoda, N. E., Blanchard, T., Renfro-Michael, E. L., Holdiness, S. H., et al. (2003). The development of an assessment protocol for reactive attachment disorder. Journal of Mental Health Counseling, 25(4), 291–310.

Sivan, A., Ridge, A., Gross, D., Richardson, R., & Cowell, J. (2008). Analysis of two measures of child behavior problems by African American, Latino, and non-Hispanic Caucasian parents of young children: A focus group study. Journal of Pediatric Nursing, 23(1), 20–27.

Smyke, A. T., Dumitrescu, A., & Zeanah, C. H. (2002). Attachment Disturbances in Young Children. I: The Continuum of Caretaking Casualty. Journal of the American Academy of Child and Adolescent Psychiatry, 41(8), 972–982.

Smyke, A. T., & Zeanah, C. H. (1999). Disturbances of attachment interview. Unpublished manuscript.

Southwick, S. M., Vythilingam, M., & Charney, D. S. (2005). The psychobiology of depression and resilience to stress: Implications for prevention and treatment. Annual Review of Clinical Psychology, 1, 255–291.

Spokas, M., Wenzel, A., Sirman, S. W., Brown, G. K., & Beck, A. T. (2009). Suicide risk factors and mediators between childhood sexual abuse and suicide ideation among male and female suicide attempters. Journal of Traumatic Stress, 22(5), 467–470.

Steyn, R., Vawda, N., Wyatt, G. E., Williams, J. K., & Madu, S. N. (2013). Posttraumatic stress disorder diagnostic criteria and suicidal ideation in a South African police sample. African Journal of Psychiatry, 16, 19–22.

Tolin, D. F., & Breslau, N. (2007). Sex differences in risk of PTSD. PTSD Research Quarterly, 18(2), 1–8.

Tolin, D. F., & Foa, E. B. (2006). Sex differences in trauma and posttraumatic stress disorder: A quantitative review of 25 years of research. Psychological Bulletin, 132(6), 959–992.

Triffleman, E., & Pole, N. (2010). Future directions in studies of trauma among ethnoracial and sexual minority samples: Commentary. Journal of Consulting and Clinical Psychology, 78(4), 490–497.

Vogt, D. S., Pless, A. P., King, L. A., & King, D. W. (2005). Deployment stressors, gender, and mental health outcomes among Gulf War I Veterans. Journal of Traumatic Stress, 18(2), 115–127.

Watson, C. G. (1990). Psychometric posttraumatic stress disorder measurement techniques: A review. Psychological Assessment, 2, 460–469.

Weathers, F. W., Keane, T. M., & Davidson, J. T. (2001). Clinician-administered PTSD scale: A review of the first ten years of research. Depression & Anxiety (1091-4269), 13(3), 132–156.

Weathers, F. W., Litz, B. T., Herman, D. S., Huska, J. A., & Keane, T. M. (1993). The PTSD Checklist (PCL): Reliability, validity, and diagnostic utility. Paper presented at the 9th Annual Conference of the ISTSS, San Antonio, TX.

Weathers, F. W., Ruscio, A. M., & Keane, T. M. (1999). Psychometric properties of nine scoring rules for the Clinician-Administered Posttraumatic Stress Disorder Scale. Psychological Assessment, 11(2), 124–133.

Weiss, D. S., & Marmar, C. R. (1996). The Impact of Event Scale—revised. In J. Wilson &T. M. Keane (Eds.), Assessing psychological trauma and PTSD (pp. 399–411). New York: Guilford Press.

Wiebe, J. S., Sauceda, J. A., & Lara, C. (2012). Assessing mood disorders and suicidality in Hispanics. In

L. T. Benuto (Ed.), Guide to psychological assessment with Hispanics (pp. 113–128). New York: Springer. Retrieved March 27, 2014, from  http://books.google.com/books?id=tPXchuM3VWUC&amp;pg=PA123&amp;lpg=PA123&amp;dq=difference+between+Beck&rsquo;s+BSS+and+SSI&amp;source=bl&amp;ots=3CTCbLB4R8&amp;sig=p0HnRkG2_O2e-FO7YeGQT9C-5Row&amp;hl=en&amp;sa=X&amp;ei=vv2MUtS3AeLD2AXotYHIAQ&amp;ved=0CEIQ6AEwBTgK#v=onepage&amp;q=difference%20between%20Beck&rsquo;s%20BSS%20and%20SSI&amp;f=false

Wilkins, K. C., Lang, A. J., & Norman, S. B. (2011). Synthesis of the psychometric properties of the PTSD Checklist (PCL) military, civilian, and specific versions. Depression & Anxiety (1091-4269), 28(7), 596–606.

Zayfert, C. (2008). Culturally competent treatment of post-traumatic stress disorder in clinical practice: An ideographic, transcultural approach. Clinical Psychology: Science and Practice, 15(1), 68–72.

Zeanah, C. H., & Gleason, M. M. (2010). Reactive attachment disorder: A review for DSM-5. Washington, DC: American Psychiatric Association. Retrieved March 27, 2014, from  http://www.nrvcs.org/nrvattachmentresources/documents/APA%20DSM-5%20Reactive%20Attachment%20Disorder%20Review%5B1%5D.pdf