7 Obsessive-Compulsive and Related DisordersDisordersThe parti.docx

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
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
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.
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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),

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