Diagnosing Using the DSM

Case Study Vignettes

Anxiety, Trauma, Stressor, and Obsessive Compulsive Related Disorders

1. Fred

Fred was raised in Houston. His father and mother were both successful realtors. He is the middle of three brothers, who remain close. He remembers, “We never wanted for anything.” Fred was an A student in high school and college and a top athlete. He completed medical school and now practices as an anesthesiologist at a local hospital.

Fred experienced some emotional distress a number of years ago as he considered coming out and letting his family know he is homosexual. His father initially struggled with the news but came to accept it. Fred’s father is quite amiable towards Fred’s partner. Fred’s oldest brother was nonplussed by the news. Fred and his partner are welcomed in his brother’s home. Fred’s mother’s response was “I don’t believe it. Please never mention this again.” The youngest brother’s response was to accuse Fred of hurting mom.

Fred has again been experiencing emotional distress this past year as he and his partner discuss the idea of either marrying or having a commitment ceremony. Fred is certain that he wants to do this but struggles with the question of what to tell family members and whether to even invite his mother and youngest brother.

In this context Fred complains of daily panic attacks. These generally occur when he is getting ready for work or near the end of the work day. The panic attacks started several weeks after Fred was robbed at gunpoint at a subway station. This occurred four months ago. He stated he does not think he was particularly affected by the attack but wonders because the panic attacks started soon after. Following the attack, Fred decided he is not going to use the subway anymore because it is too dangerous. Fred has been commuting by bicycle even though it is often difficult to negotiate the city streets by bike.

Fred reports that there is no mental illness that he is aware of in his immediate family. He strongly suspects that his mother’s father was an alcoholic because he remembers his grandfather smelling of alcohol during his (Fred’s) childhood and because his mother refuses to have any alcohol in her home.

2. Phil

Phil is 20. He comes in because he is “stressed” now that he is not working. Phil reports that his first job was at a restaurant, but he quit because it was “too messy.” After work he would shower for hours to get the food smells out of his hair. Even after showering he would feel greasy and dirty. He next found work at a clothing store. Phil reports that he was initially very well regarded by his boss at the clothing store at which he worked. He worked hard, always making sure displays were orderly and the clothes were perfectly folded and arranged in order by size. His boss so appreciated the attention that he took with the displays that she made him the assistant manager and put him in charge of the other employees. She was relieved that she had a second in command so that she could leave the store under his supervision.

However, the boss soon became frustrated with Phil. He did little to help manage the employees or problem-solve difficulties. He did not seem able to field customer complaints. He did a poor job on some of the managerial tasks assigned to him. But he did continue to neatly fold the clothes and arrange them by size, even after the boss told him he should delegate this to another employee so he could focus on his role. After several warnings about this, Phil was eventually terminated.

Phil reported he had been married for a year but his wife left him because she found him controlling. He is not sure what this means but notes that they often argued because he got frustrated that she did not put things away where they belonged. She would especially get upset because he would try to clean up the kitchen when she was cooking, so “things wouldn’t get too messy.”

3. Stacey

Stacey is 35 years old and lives alone.  Stacey was married when she was 20 and was married for 4 years. The couple did not have any children. Stacey’s mother describes that Stacey was shy when she was little and tended to play alone with her dolls and stuffed animals. She had a brother who was ten years older than her. The family lived in the country and had a lot of pets and other animals, such as horses and chickens. Stacey loved the animals and was good at helping to care for them.

Stacey had a close childhood friend named Anna who she met in the first grade. The two girls would sometimes get to play at each other’s houses and sometimes would spend the night. When they were in the fourth grade, Anna’s family moved out of state. Stacey was small for her age and wore glasses. She became a target for other kids to make fun.

Following Stacey’s divorce, she became more reclusive. Stacey’s former husband, Chad, was critical of Stacey and left because in his words she “was a doormat with no personality.” She currently maintains a job as a cashier at a local grocery store. She has worked there for seven years and her employers are happy with her performance. She is highly accurate and efficient at her job. When she is off of work, she tends to stay home alone with her pets.

Four years ago Stacey enrolled in college thinking she might like to become a nurse. Several of her classes required her to give presentations in front of the class, and Stacey described that she was “paralyzed with fear” in thinking about public speaking. She was afraid she would not be able to get through her speech and that her classmates and teachers would make fun of her. She dropped those classes, and therefore was unable to move forward in her education.

Stacey says that she is content with her job and with living alone with her pets. She has three dogs, two cats, and several birds. All of the pets came to her through a pet rescue agency.  She states that pets are accepting and loving and don’t criticize.