Anxiety disorders and obsessive-compulsive disorders (OCD) have a devastating impact on an individual’s ability to live, work, and conduct relationships. These disorders are often harder to identify than other conditions. Difficulty in diagnosis is compounded by the fact that expressions of anxiety differ widely from culture to culture. Anxiety is often co-occurring with depression and with OCD, as well as with trauma disorders. The boundaries between these illnesses can be blurred.

This week you examine those boundaries by analyzing a case from the anxiety and OCD spectrums. You also consider cultural idioms and the cultural formulation interview (CFI) of the DSM-5. The CFI is designed to help a social worker adapt diagnosis and treatment both to cultural variations and to the individual experience of a person within that culture. Given that anxiety may manifest in diverse ways due to cultural influences, you practice using the CFI to guide treatment conceptualization for anxiety.

Social workers take particular care when diagnosing anxiety due to its similarity to other conditions. In this Discussion, you carefully assess a client with anxiety disorder using the steps of differential diagnosis. You also recommend an intervention for treating the disorder.

To prepare: Read “The Case of Emily P.” Review the decision trees for anxiety and OCD in the Morrison (2014) text and the podcasts on anxiety. Then access the Walden Library and research interventions for anxiety.

Post a 300- to 500-word response in which you address the following: Provide the full DSM-5 diagnosis for Emily. Remember, a full diagnosis should include the name of the disorder, ICD-10-CM code, specifiers, severity, and the Z codes (other conditions that may be a focus of clinical attention).  Keep in mind a diagnosis covers the most recent 12 months. Explain the diagnosis by matching the symptoms identified in the case to the specific criteria for the diagnosis. Discuss other disorders you considered for this diagnosis and eliminated (the differential diagnoses). Describe an evidence-based assessment scale that would assist in ongoing validation of your diagnosis. Recommend a specific intervention and explain why this intervention may be effective in treating Emily. Support your recommendation with scholarly references and resources.  Note: You do not need to include an APA reference to the DSM-5 in your response. However, your response should clearly be informed by the DSM-5, demonstrating an understanding of the risks and benefits of treatment to the client. You do need to include an APA reference for the assessment tool and any other resources you use to support your response.

Morrison, J. (2014). Diagnosis made easier (2nd ed.). New York, NY: Guilford Press. Chapter 12, “Diagnosing Anxiety, Fear, Obsessions and Worry” (pp. 167–184)

 The Case of Emily P. 

Emily is a 62-year-old, single, heterosexual, African American female who seeks treatment for anxiety. She says she is very concerned since she recently has been pulling her hair out, and it has become noticeable on top of her head. She is taking to wearing hats, which she finds acceptable. She worries about many things, which is not new to her, and she finds that scrubbing her home clean is her best therapy to ease her anxiety. Emily reports that germs have been a regular concern of hers since adolescence, when she learned in health classes about the risks of serious diseases including sexual transmittable disease. Emily presented with meticulous grooming, although the knees of her pants were noted as worn. She has arthritis in her spine and knees and uses a walker to help her manage mobility safely. With her physical disabilities it is challenging sometimes to scrub clean the house daily. This worries her should she get a visitor and the house is not in order as she would like it. She is no longer working, so the amount of time it takes her to scrub the house clean doesn’t delay her daily schedule as it used to. Emily receives Social Security income and is not employed. Although the Social Security is acceptable, her living expenses are always a concern to her. She lives alone in a subsidized apartment in the same building as her 72-year-old, unmarried sister, so rent should not increase. Emily and her sister shared an apartment for over 30 years, beginning when each of their marriages dissolved. Emily reported that when her sister began a romantic relationship 5 years ago, Emily began to feel very anxious and started to cry often. Emily moved into an apartment down the hall in the building and began to pull the hair from her head, hiding her hair loss by wearing wigs. This behavior occurred at different times and resulted in scabbing. Emily said she feels better after but does not always notice how much she is pulling. Her sister learned of Emily’s hair pulling after her wig slipped off one evening to reveal bald spots. She set up a schedule over the past few months with her sister to help stop the hair pulling. Sometimes it works and sometimes it does not. She is worried that she will be disappointing her sister by not sticking to the schedule to reduce her hair pulling. Her sister encouraged Emily to seek treatment rather than “hiding her ways.” Emily is reliant upon her sister for transportation and for a sense of social and emotional connection. Emily worries about bothering her sister due to her transportation needs, and she worries that without her sister she would be helpless. She knows she is edgy with her sister often and worries that might be from a lack of good sleep. She agreed to this session even though she is pessimistic about anything working. During our initial visit at our local mental health center, Emily shared that when she was 2 years old her mother died from tuberculosis, and the following year her father, an army officer, died from colon cancer. After his death, Emily lived with her paternal aunt, from whom she felt no love. Her older brother and sister were placed in an orphanage and Emily was permitted to see them on Sundays. When it became apparent that the children were entitled to death benefits, Emily’s aunt agreed to take custody of all three  siblings. The household then consisted of Emily’s paternal aunt, her husband (who Emily described as an alcoholic), their three children, and Emily and her two older siblings. Emily was briefly married in her early 20s (4 years) but was disappointed and hurt by her husband’s infidelity. She moved in with her sister at that time. Emily reported it as an “anxious” time but denied hair pulling then. Emily also enrolled in a cosmetology school and liked her work. She had to stop working “for health reasons” when she was 58 years old. With all this going on in her life now, Emily feels tired a lot from trying to keep up with the cleanliness of the house, especially with her lack of mobility. She finds herself napping often. This then interferes with a restful sleep at night. When asked about her behaviors concerning her hair pulling, Emily reluctantly admitted that if she cannot get to her hair she will pick at a scab or skin. Generally, she avoided social situations so that her behavior is not exposed and worried what others would think of her. She denied other behavior rituals but became noticeably anxious at this question. When asked about “goals” if treatment was to be effective for her, Emily stated that she wanted to “cope better. Emily was collaborative during this assessment and engaged after a reluctant start. 

Adapted from: Plummer, S.-B., Makris, S., & Brocksen, S. (2013). Social work case studies: Concentration year. Baltimore, MD: Laureate Publishing.