Practice Case Example I Carol, a 20-year-old woman and her girlfriend were walking through their college campus one night when a man jumped out of the bushes, pointed a gun at them, and ordered them to give him their money. The friend protested and the gunman knocked her to the ground, grabbed both women’s purses, and ran off. Carol’s friend was shaken but unhurt. The two women immediately went to the campus security office to report the robbery. Carol found it difficult to describe what happened. She felt numb and dazed as if she had experienced a dream. The entire event seemed unreal, and Carol had difficulty remembering what the gunman looked like. During the next week Carol had recurrent thoughts of the episode and difficulty sleeping. Every little noise seemed to startle her. She avoided walking near the site of the robbery because it made her anxious. Carol felt depressed, had problems concentrating in class and when doing her homework. She felt irritable and found herself getting angry with friends and family. Answer to Case Name of the Disorder Acute Stress Disorder Description of the Symptoms of the Psychological Disorder Criterion A: Exposure to actual or threatened death, injury, or sexual violence in one (or more) of the following ways: - 1. Being directly involved in the traumatic event 2. Witness the events 3. Learning of events that have occurred to a close family member 4. Experiencing repeated or extreme exposure to unpleasant details of the traumatic event Criterion B: Any 9 or more symptoms from the 5 categories of: - - Intrusion Symptoms: o 1. Reoccurring, involuntary, and intrusive distressing memories of the traumatic event o 2. Recurrent distressing dreams in which the content or affect of the dream is related to the event o 3. Dissociative reactions such as flashbacks in which the individual feels or acts as if the traumatic event were reoccurring o 4. Intense or prolonged psychological distress or marked physiological reactions in response to internal or external cues that symbolize or resemble an aspect of the traumatic event Negative Mood: o 5. Persistent inability to experience positive emotions Dissociative Symptoms: - - o 6. An altered sense of reality of one’s surroundings or oneself o 7. Inability to remember an important aspect of the traumatic event Avoidance Symptoms: o 8. Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event o 9. Efforts to avoid external reminders that arose distressing memories, thoughts, or feelings about or closely associated with the traumatic event Arousal Symptoms: o 10. Sleep disturbance o 11. Irritable behavior and angry outbursts, typically expressed as verbal or physical aggression toward people or objects o 12. Hypervigilance o 13. Problems with concentration o 14. Exaggerated startle response Criterion C: 3 days to 1 month after trauma exposure Criterion D: Experience causes notable distress or impairment in social, occupational, or other important areas of learning Criterion E: The disturbance is not attributable to the physiological effects of a substance or another medical condition and is not better explained by a psychotic disorder Explanation Why the Person Has the Disorder Criterion A: Carol and her girlfriend directly experienced the traumatic event, by having a gun held at them. Criterion B: 9 of the following symptoms she experienced involved reoccurring thoughts, distressing dreams which caused difficulty sleeping, she felt depressed or unable to experience happiness, she felt numb and dazed, she had trouble remembering what the shooters appearance was, she avoided the place of the robbery because it was an external reminder of what had happened and it made her anxious, she felt irritated at family around her family and friends, she also had trouble concentrating on her homework and in class, and finally every noise seemed to startle. Criterion C: Within the next week, Carol was already experiencing re-occurrent thoughts and having sleeping problems. Criterion D: Carol has had problems concentrating in class and when doing her homework which has caused an impairment in her areas of learning. She has also felt irritable and found herself getting angry with friends and family which has caused a strain on her social life. Criterion E: The condition cannot be explained better by another psychological effect of a substance or another medical condition. Differential Diagnosis Carol does not have panic disorder because she did not have panic attacks or worry for more than a month about having another panic attack, she also didn’t worry about the implications of a panic attack or change her behavior in a maladaptive way because of a panic attack. She does not have a dissociative disorder because there is no evidence Carol is suffering from consciousness, perception, or identity. She does not suffer from posttraumatic stress disorder because the symptoms have not been occurring for more than a month. Carol does not have obsessive compulsive disorder because although she has reoccurring thoughts, they are not enough to meet the definition of obsession. Her thoughts are also related to the experienced traumatic event unlike in OCD. She does not have a psychotic disorder because she is not experiencing illusions, hallucinations, or other perceptual disturbances. Lastly, she does not have a traumatic brain injury because she was not pushed down and did not experience any head trauma and is not experiencing dizziness, sensitivity to light or sound, or headaches. Practice Case Example 2 John a 27-year-old married electrician complains of dizziness, sweating palms, heart palpitations, and ringing of the ears for more than 18 months. He has also experienced dry mouth and throat, periods of extreme muscle tension, becoming easily fatigue even without much exertion, and difficulty concentrating, and a constant “edgy” and watchful feeling that has often interfered with his ability to concentrate. These feelings have been present most of the time over the prior 2 years. Although these symptoms sometimes make John feel “discouraged,” he denies feeling depressed and continues to enjoy activities with his family. He has seen a family practitioner, a neurologist, and neurosurgeon because of these symptoms, but they have ruled out a physical cause. John has had many worries for the past two years that are present all the time. He constantly worries about the health of his parents. His father, in fact, had a heart attack 2 years ago, but is doing well. John also worries about whether he is “a good father,” whether his wife will leave him (there is no indication she is dissatisfied with the marriage) whether his co-workers like him, and whether he will be fired from his job (In fact, he receives good job evaluations). Although John recognizes that his worries are often unfounded, he can’t stop worrying. For the past 2 years, John has had few social contacts because of his nervous symptoms. Although he has sometimes had to leave work when his symptoms because intolerable, he continues to work for the same company he joined for his apprenticeship following high-school graduation. John tends to hide his symptoms from his wife and children, to whom he wants to appear “perfect,” and reports few problems with them as a result Answer to Case Name of the Disorder Generalized Anxiety Disorder Description of the Symptoms of the Psychological Disorder Criterion A: Excessive anxiety and worry occurring more days than not for at least 6 months, about a number of events or activities Criterion B: Individual finds it difficult to control the worry Criterion C: The anxiety and worry are associated with 3 or more of the following 6 symptoms: - 1. Restlessness or feeling keyed up or on edge 2. Being easily fatigued 3. Difficulty concentrating or mind going blank 4. Irritability 5. Muscle tension 6. Sleep disturbance Criterion D: Anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning Criterion E: Disturbance is not attributable to the psychological effects of a substance or other medical condition Criterion F: The disturbance is not better explained by another mental disorder Explanation Why the Person Has the Disorder Criterion A: John is constantly worrying about something. His symptoms have been going on for more than 6 months occurring more days than not. He is worried about things like whether his wife is going to leave him, his father, and whether his coworkers like him or not. Criterion B: John knows that his worries are unfounded and have no foundation or basis to go off of, but he can’t get himself to stop worrying about things that are out of his control. Criterion C: John expresses the symptoms of being easily fatigued without much exertion, muscle tension, and feeling on edge or irritable constantly which has interfered with his ability to concentrate. Criterion D: John has had significant distress or impairment in his social life. Because of his constant worrying he has had limited social contacts. It has also affected his occupation by having to leave work when his worrying becomes too intolerable. Criterion E: There is no sign that this is attributable to the effects of a substance or other medical condition. Criterion F: This is not better explained by another mental disorder. Differential Diagnosis This is not an anxiety disorder due to another medical condition because although he has been seen by many doctors, nothing shows up and a physical cause has been ruled out. It is also not a substance or medication induced anxiety disorder because there is no sign, or it has not been stated that he takes any medication for his anxiety or has a caffeine induced anxiety disorder. John does not have social anxiety disorder because although he has left work a couple of times, he continues to work for the same company that he joined for his apprenticeship right out of high school. He doesn’t have to worry whether he is going to be evaluated in upcoming social situations. He doesn’t have separation anxiety disorder because he doesn’t worry excessively about being separated from attachment figures. John does not have panic disorder because he did not have panic attacks or worry for more than a month about having another panic attack, he also didn’t worry about the implications of a panic attack or change his behavior in a maladaptive way because of a panic attack. John does not have illness, anxiety disorder and somatic symptom disorder because he is not only worried about his own illness or other somatic symptoms. He does not have obsessive compulsive disorder because although he worries about the forthcoming problems, he does not create obsessions or unwanted and intrusive thoughts, urges, or images. He does not have posttraumatic stress disorder and adjustment disorders because it is not better explained by the symptoms of PTSD and an adjustment disorder occurs within 3 months of the onset of the stressor and doesn’t persist for more than 6 months after the termination of the stressor. However, John is constantly worrying. He does not have depressive, bipolar, or psychotic disorders because he is not sad or experiencing many different feelings. He wants to present himself as “perfect” to his family. He does not experience comorbidity but often times generalized anxiety disorders are likely to have met the criteria for other anxiety or unipolar disorders.
