Cazuri Clinice

CAZUL 1:
Client Description
Amanda was 31 when she presented for treatment. She was a sophomore at a local 2-year
college, ha!ng dec!ded to ret"rn after a long h!at"s from school. Amanda was res!d!ng w!th her
h"s#and and fo"r ch!ldren !n a near#y r"ral town. She was referred after her yo"ngest da"ghter
"nderwent a psycholog!cal eal"at!on. Amanda was ad!sed #y the cl!n!c!an who tested her
da"ghter to see$ help for her own an%!ety and seem!ngly constant worry!ng.
History of the Disorder or Problem
&hen as$ed a#o"t her d!ff!c"lt!es, Amanda reported that she remem#ered ha!ng #een 'nero"s'
s!nce the f!rst grade. After she #egan ha!ng ch!ldren at age 21, her an%!ety symptoms reportedly
worsened and her worry reached o"t to !ncl"de her ch!ldren. She also reco"nted a fear of
tornadoes that she had when she was yo"nger, and stated that she later deeloped an e%treme fear
of th"nderstorms. S"#se("ently, she went to her phys!c!an #eca"se she tho"ght that a constant
heay feel!ng !n her chest and constr!ct!on of her #reath!ng were related to a med!cal cond!t!on
s"ch as #ronch!t!s. )n add!t!on, she reported constant headaches. *er phys!c!an d!agnosed her
w!th +, and -A, and prescr!#ed ."spar
/
, wh!ch she cont!n"ed to "se een tho"gh !t d!d not
s!gn!f!cantly red"ce her symptoms. 0!nally, ep!sodes of e%treme fear #egan to occ"r !n s!t"at!ons
other than those !nol!ng !olent weather, and she reported that these attac$s somet!mes
appeared to 'come o"t of the #l"e.'
Presenting Complaints
Amanda1s c"rrent d!ff!c"lt!es centered on her grow!ng fear of pan!c and constant worry. She
reported that she worr!ed a#o"t her grades and schoolwor$, a#o"t the safety of her ch!ldren, and
a#o"t the nat"re of her relat!onsh!p w!th her h"s#and 2who was rarely home d"e to h!s 3o# and
h!s pass!on for act!!t!es s"ch as h"nt!ng and f!sh!ng4. She had #ecome s"sp!c!o"s that her
h"s#and was 'cheat!ng' #eca"se he was so rarely at home. &hen as$ed a#o"t her pan!c
symptomatology, Amanda reported that her fear of pan!c was ca"s!ng her to ao!d more and
more s!t"at!ons !n wh!ch she tho"ght an attac$ m!ght occ"r. At the same t!me, concern for the
safety of her ch!ldren prompted fre("ent contacts w!th them and w!th those !noled !n the!r
care. *er fear of pan!c attac$s and constant worry!ng had c"lm!nated !n rel!ance on safety
s!gnals-she wo"ld not leae the ho"se "nless she had her cell"lar telephone and med!cat!on w!th
her.
Assessment Methods Used
)n add!t!on to a standard !nta$e !nter!ew 2from wh!ch the !nformat!on a#oe was gathered4 and
5ental Stat"s 6%am, Amanda was adm!n!stered the A,)S-)7-L mod"les for pan!c d!sorder,
agorapho#!a, and general!8ed an%!ety d!sorder. Amanda also completed fo"r self-report meas"res
germane to her pan!c symptomatology 2the An%!ety Sens!t!!ty )nde%, the Agorapho#!c
Cogn!t!ons 9"est!onna!re, the .ody Sensat!ons 9"est!onna!re, and the Al#any +an!c and +ho#!a
9"est!onna!re4 and three meas"res to assess -A,-related worry 2the +enn State &orry
9"est!onna!re, the &orry ,oma!ns 9"est!onna!re, and the &hy &orry Scale-))4. She also
engaged !n selected symptom !nd"ct!on tests to assess fears of phys!cal sensat!ons. :"ts!de of the
off!ce, she completed self-mon!tor!ng forms pert!nent to her pan!c and worry. Cons"ltat!on w!th
her phys!c!an helped r"le o"t compl!cat!ng med!cal cond!t!ons. Psychological Assessment
Protocol
;he !nta$e !nter!ew d!d not s"ggest that Amanda was e%per!enc!ng any other psycholog!cal
d!stress other than that related to +,A and -A,. She d!d not endorse depress!e
symptomatology or s"!c!dal !deat!on. She den!ed recent changes !n her eat!ng and sleep!ng ha#!ts
and "se of !ll!c!t s"#stances. She was or!ented to person, place, and t!me. Short- and long-term
memory appeared !ntact. She den!ed e%per!enc!ng psychot!c symptoms. A phone conersat!on
w!th her phys!c!an !nd!cated that, #ased on a recent phys!cal e%am, #loodwor$, and present!ng
pro#lems, he d!d not #el!ee Amanda to #e s"ffer!ng from any med!cal cond!t!ons that wo"ld
m!m!c or e%acer#ate her an%!ety symptoms or !nterfere w!th e%pos"re treatments.
Amanda1s responses to the A,)S-)7-L !nd!cated that she met cr!ter!a #oth for +,A and -A,.
She reported that, oer the last month, she had fre("ently worr!ed and #een seerely
apprehens!e a#o"t ha!ng another pan!c attac$ 2< on a scale of =4. She endorsed moderate to
seere symptoms of heart palp!tat!ons, shortness of #reath, cho$!ng sensat!ons, na"sea, d!88!ness,
t!ngl!ng sensat!ons, and a fear of dy!ng as feat"res of her pan!c attac$s. She reported that fear of
dy!ng and fear of #e!ng "na#le to o#ta!n ass!stance largely droe her ao!dance of s!t"at!ons !n
wh!ch she feared she wo"ld e%per!ence pan!c.
Amanda1s responses to the fo"r +,A self-report meas"res were !nd!cat!e of s!gn!f!cant pan!c-
related symptomatology. :n the An%!ety Sens!t!!ty )nde%, Amanda scored a 3>, wh!ch
appro%!mates the mean score of 32.1 2S, ? 11.34 for those who hae pan!c d!sorder w!th
moderate or seere agorapho#!a 2@apee, .rown, Antony, A .arlow, 1BB24. :n the Agorapho#!c
Cogn!t!ons 9"est!onna!re, Amanda1s mean score of 2.<B sl!ghtly e%ceeded the mean score of
2.32 2S, ? C.>>4 for a gro"p of o"tpat!ents w!th agorapho#!a reported #y Cham#less and
colleag"es 21B=D4. Amanda scored a mean of 3.2B on the .ody Sensat!ons 9"est!onna!re, aga!n
sl!ghtly e%ceed!ng the mean of 3.CE 2S, ? C.=>4 for o"tpat!ents w!th agorapho#!a 2Cham#less et
al.4. *er score of 2B on the agorapho#!a s"#scale of the Al#any +an!c and +ho#!a 9"est!onna!re
far e%ceeded the mean of 12.= 2S, ? B.=4 for a gro"p of o"tpat!ents w!th +,A reported #y @apee
and colleag"es 21BBE4. *er score of 1< on the !nterocept!e s"#scale of th!s meas"re also
e%ceeded the mean of B.> 2S, ? B.24 !n the same +,A gro"p 2@apee et al.4.
:n the three self-report meas"res related to -A,, Amanda1s scores were !nd!cat!e of chron!c
and e%cess!e worry across seeral doma!ns. :n the +enn State &orry 9"est!onna!re, Amanda
scored a <D, sl!ghtly a#oe the mean score of ><.>> 2S, ? =.=>4 o#ta!ned #y a gro"p of -A,
cl!ents 25ol!na A .or$oec, 1BBD4. :n the &orry ,oma!ns 9"est!onna!re, Amanda scored a >E,
well a#oe the mean score of DC.C3 2S, ? 1B.=4 reported !n a -A, sample 2;all!s, ,aey, A
.ond, 1BBD4. ;he oerall score o#ta!ned on the &hy &orry Scale-)) was EE, wh!ch was sl!ghtly
a#oe the mean score of D>.B 2S, ? 22.E4 o#ta!ned #y a gro"p of !nd!!d"als w!th a pr!nc!pal
d!agnos!s of -A, !a the A,)S-@ 2Lado"ce"r, .la!s, 0reeston, A ,"gas, 1BB=4 and well a#oe
the mean score of D3.3 2S, ? <.B4 o#ta!ned #y college st"dents d!agnosed #y self-report
("est!onna!res 20reeston et al., 1BBD4.
;he A,)S-)7-L mod"les and self-report meas"res conf!rmed that Amanda was s"ffer!ng from
#oth +,A and -A,, and helped the therap!st character!8e the phenomenology of her pan!c and
worry. *er responses to the pan!c-related meas"res !nd!cated that she was e%per!enc!ng
s!gn!f!cant fear related to #od!ly sensat!ons of pan!c, and that catastroph!c th!n$!ng was t!ed to
these #od!ly sensat!ons. She also reported s!gn!f!cant an%!ety when !n s!t"at!ons where she
deemed pan!c l!$ely, s"ch as !n the mall, !n the s"permar$et, and wh!le dr!!ng. *er responses to
the three -A, meas"res !nd!cated that her worry was chron!c, e%cess!e, and e%per!enced as
"ncontrolla#le. A re!ew of her responses s"ggested that she mostly worr!ed a#o"t relat!onsh!ps
and was pess!m!st!c a#o"t the f"t"re. @e!ew!ng her responses !nd!cated also that she perce!ed
her worry as preent!ng "npleasant o"tcomes, as protect!ng her from aderse emot!ons !n the
eent of s"ch o"tcomes, and as mot!at!ng her to act!on.
At the end of the f!rst assessment sess!on, Amanda was !nstr"cted to complete two self-
mon!tor!ng forms thro"gho"t the follow!ng wee$. ;he f!rst form was des!gned to !dent!fy the
fre("ency of her pan!c attac$s, #od!ly sensat!ons, and cogn!t!ons e%per!enced d"r!ng each attac$,
whether the attac$ was e%per!enced as "ne%pected or s!t"at!onally-c"ed, and the ma%!m"m
an%!ety 2C-=4 e%per!enced d"r!ng each attac$ 2Cras$e A .arlow, 2CCC4. She was !nstr"cted to
also note on the form the s!t"at!on !n wh!ch the attac$ occ"rred and wh!ch, !f any, safety s!gnals
were present. Amanda was enco"raged to complete the form een !f she #ecame afra!d of ha!ng
a pan!c attac$ #"t d!d not act"ally e%per!ence one. A second form, a &orry :"tcome ,!ary
2.or$oec et al., 1BBB4, was pro!ded to assess the fre("ency, content, and feared o"tcomes of
her worry, as well as the act"al o"tcome of the s!t"at!on she had #een worry!ng a#o"t. *er
compl!ance !n complet!ng s"ch forms was d!sc"ssed as #e!ng cr"c!al to deelop!ng an acc"rate
p!ct"re of her pro#lem and as an !mportant pred!ctor of treatment o"tcome.
:ne wee$ later, her compl!ance and responses were re!ewed. She reported ha!ng two pan!c
attac$s and fo"r !nstances !n wh!ch she was afra!d of ha!ng an attac$ #"t d!d not. *er pan!c
attac$s and fear of pan!c$!ng d"r!ng the wee$ pr!mar!ly occ"rred when !n large p"#l!c places and
when she was alone, and she reported carry!ng her med!cat!on and cell"lar telephone w!th her at
all t!mes. ,"r!ng the attac$s, the pr!mary phys!cal symptoms reported were shortness of #reath,
heart palp!tat!ons, and d!88!ness. *er most fre("ently-reported cogn!t!e themes were #e!ng
afra!d that she was go!ng to d!e and los!ng control oer her #eha!or. She reported that these
symptoms and tho"ghts res"lted !n her feel!ng that she needed to escape the s!t"at!on
!mmed!ately. Fot s"rpr!s!ngly, a s!gn!f!cant port!on of the worry noted on the -A, mon!tor!ng
form was t!ed to her fear of ha!ng a pan!c attac$. Add!t!onal so"rces of worry thro"gho"t the
preced!ng wee$ were related to her ch!ldren1s health, the!r performance !n school, her
relat!onsh!p w!th her h"s#and, and her fear of not grad"at!ng from college. )t was helpf"l to
contrast w!th Amanda the feared o"tcomes she noted and the act"al o"tcomes of the s!t"at!ons
she had #een worry!ng a#o"t. )n seen of the e!ght recorded !nstances, the feared o"tcome neer
occ"rred. ;he e%cept!on to th!s was that her son fa!led a math test, as she worr!ed he m!ght
#eca"se he had not #een do!ng all of h!s homewor$.
0ollow!ng a re!ew of her self-mon!tor!ng forms, the last half of the second assessment sess!on
was deoted to symptom !nd"ct!on tests des!gned aro"nd her reported fears of phys!cal
symptoms. +r!or to each e%erc!se, Amanda rated her self-eff!cacy 2C-1CC4 that she wo"ld #e a#le
to complete the e%erc!se w!tho"t ha!ng a pan!c attac$G afterward she pro!ded fear rat!ngs 2C-
1CC4 of the h!ghest leel of fear she e%per!enced d"r!ng each e%erc!se. ;hree e%erc!ses were
chosen to !no$e the feared phys!cal sensat!ons: #reath!ng solely thro"gh a straw for one m!n"te
2shortness of #reath4, r"nn!ng !n place for 3 m!n"tes 2heart palp!tat!ons4, and sp!nn!ng rap!dly !n
a sw!el cha!r for one m!n"te 2d!88!ness4. ;hese e%erc!ses pro!ded pretreatment meas"res for
fears of phys!cal sensat!ons assoc!ated w!th pan!c.
Targets Selected for Treatment
;he f!rst targeted pro#lem area was Amanda1s fear of #od!ly sensat!ons 2!nterocept!e an%!ety4,
wh!ch was treated !a symptom !nd"ct!on e%erc!ses and was cont!n"o"sly eal"ated w!th fear
and self-eff!cacy rat!ngs. A h!erarchy was deeloped for !ncreas!ngly feared #od!ly sensat!ons,
and Amanda reprod"ced the sensat!ons at each leel of the h!erarchy !a symptom !nd"ct!on
e%erc!ses "nt!l she reported m!n!mal fear. ;he second targeted pro#lem was her agorapho#!c
ao!dance and rel!ance on safety s!gnals, wh!ch was treated !a !n !o e%pos"re !n a shopp!ng
mall, two s"permar$ets, and other places !n wh!ch she feared a pan!c attac$ m!ght occ"r. At f!rst,
carry!ng her cell"lar phone and med!cat!on was perm!tted, #"t as !n !o e%pos"re tr!als
cont!n"ed these safety s!gnals were w!thdrawn. ;he f!nal pro#lem area related to +,A was her
pan!c-related cogn!t!ons and tendency toward fearf"l catastroph!8!ng, wh!ch were challenged
"s!ng cogn!t!e restr"ct"r!ng techn!("es.
;wo pro#lem areas related to -A, were !dent!f!ed for treatment. ;he f!rst was an%!ety
symptoms per se, wh!ch were treated !a m"sc"lar rela%at!on tra!n!ng and #reath!ng retra!n!ng.
;he second -A, pro#lem area was her !rrat!onal #el!efs. Some targeted #el!efs were a#o"t the
f"nct!ons of worry, s"ch as her #el!ef that worry sered to preent aderse o"tcomes. :ther
!rrat!onal #el!efs were related to her tendency to oerest!mate the l!$el!hood of feared o"tcomes.
;reat!ng s"ch !rrat!onal #el!efs !noled cogn!t!e therapy 2restr"ct"r!ng, challeng!ng a"tomat!c
tho"ghts, etc.4 and reg"lar "se of the &orry :"tcome ,!ary to demonstrate that feared o"tcomes
rarely occ"rred 2and those that d!d occ"r had #een largely o"t of her control4.
Assessment of Progress
Amanda was readm!n!stered the A,)S-)7-L mod"les and the ar!o"s self-report meas"res after >
wee$s and after 12 wee$s of treatment. *er !n!t!al scores on these meas"res were "sed as
standards for compar!son. ;he symptom !nd"ct!on tests and assoc!ated eff!cacy and fear rat!ngs
were "sed thro"gho"t treatment #oth as a form of e%pos"re therapy and as a way to mon!tor
Amanda1s lessen!ng fear of phys!cal pan!c symptoms. 0ollow-"ps at 3 and > months !ncl"ded
adm!n!ster!ng the self-report meas"res and ha!ng Amanda engage !n #oth symptom !nd"ct!on
and !n !o e%pos"re e%erc!ses. ;he releant A,)S-)7 mod"les were readm!n!stered at follow-
"ps !n order to determ!ne whether she st!ll met cr!ter!a for +,A andHor -A,.
CAZUL 2:
Client Description
5r. I !s a 2<-year-old, marr!ed, Cathol!c, Ca"cas!an male w!th no ch!ldren. *e has a h!gh school
ed"cat!on and wor$s as a sales manager at an a"to parts store. *e has no pre!o"s psych!atr!c
h!story #y h!s report and !s see$!ng ser!ces for the f!rst t!me at the s"ggest!on of h!s w!fe.
History of the Problem
5r. I was !n a seere motorcycle acc!dent at age 23, pr!or to meet!ng h!s w!fe, wh!ch res"lted !n
seeral #ro$en #ones, a p"nct"red l"ng, and a 1-month stay !n the hosp!tal. ;he acc!dent
occ"rred when an oncom!ng tr"c$ swered !nto h!s lane and he had to t"rn s"ddenly to ao!d
h!tt!ng !t. 0ollow!ng th!s acc!dent, 5r. I reported da!ly n!ghtmares, !rr!ta#!l!ty, w!thdrawal from
fr!ends and fam!ly, and !ncreased alcohol "se. *e was f!red from h!s 3o# as an ass!stant manager
at a conen!ence store d"e to fre("ent a#sences related to dr!n$!ng. *e then moed !nto h!s
parents1 home for seeral months wh!le wor$!ng ar!o"s part-t!me 3o#s. ;he year follow!ng the
motorcycle acc!dent, 5r. I sold h!s motorcycle, sec"red a 3o# at the a"to parts store where he
c"rrently wor$s, moed !nto an apartment, and met h!s w!fe at a local #ar. Altho"gh he cont!n"ed
to dr!n$ hea!ly on wee$ends and to hae occas!onal n!ghtmares of the motorcycle acc!dent, he
was a#le to !mproe h!s wor$ f"nct!on!ng and recently sec"red a promot!on to manager. *!s
symptoms hae worsened oer the past D months, s!nce h!s w!fe #egan enco"rag!ng h!m to start a
fam!ly.
5r. I was self-referred to the cl!n!c, #"t stated that h!s w!fe had prompted h!m to come d"e to
h!s sleep pro#lems, depressed mood, and fre("ently m!ss!ng wor$. *e compla!ned of feel!ng
'too restless to sleep' and ha!ng n!ghtmares related to the motorcycle acc!dent seeral t!mes per
month. *e stated that he was also concerned a#o"t los!ng h!s 3o# d"e to arg"ments w!th h!s
cowor$ers and "s!ng all of h!s s!c$ days. 0"rther !n("!ry d"r!ng the f!rst meet!ng reealed that he
also s"ffers from chron!c $nee and #ac$ pa!n as a res"lt of h!s acc!dents. ;he pat!ent howeer,
d!d not !mmed!ately report a connect!on #etween pa!n and h!s mental health stat"s. *e also stated
that he ao!ds dr!!ng and that he !s worr!ed a#o"t start!ng a fam!ly #eca"se he does not want h!s
ch!ld to r!de !n a car. 2Comment: !nd!!d"als s"ffer!ng from een relat!ely seere tra"ma-related
pathology may see$ mental health care only after enco"ragement #y another fam!ly mem#er and
then !n!t!ally present w!th a few seem!ngly m!nor compla!nts.4
Assessment Methods
As descr!#ed pre!o"sly, recommended methods for +;S, eal"at!on #eg!n w!th assessment of
tra"ma h!story and the !dent!f!cat!on of any eents meet!ng Cr!ter!on A. ;h!s !s typ!cally
followed #y self-report screen!ng for +;S, symptoms, depress!on, and s"#stance a#"se, then a
str"ct"red !nter!ew for +;S, and poss!#ly other d!sorders. Collateral !nformat!on from a spo"se
or other close fam!ly mem#er !s often al"a#le, tho"gh not always aa!la#le.
Self-Report Measures
;he self-report meas"res chosen assessed 5r. I1s f"ll h!story of tra"ma e%pos"re 2w!th the L!fe
Stressor Chec$l!st4G screened for +;S, symptoms, depress!on, and alcohol a#"se pr!or to
!nter!ew 2w!th the +CL, 5!ss!ss!pp! Scale, .,), and AU,);4G and assessed h!s response style
and presentat!on of psychopathology !n m"lt!ple doma!ns 2w!th the 55+)-24. *!s w!fe was
as$ed to complete the collateral ers!on of the 5!ss!ss!pp! Scale w!th regard to her !mpress!on of
her h"s#and1s symptoms, part!c"larly g!en 5r. I1s report that he had so"ght treatment at her
re("est.
Interview
A CA+S !nter!ew and the SC), mod"les for depress!on, dysthym!a, and dr"g and alcohol "se
were g!en to the pat!ent. ;he CA+S !nter!ew was "sed to determ!ne !f 5r. I1s !mmed!ate
responses to the motorcycle acc!dent met Cr!ter!on A re("!rements and to caref"lly assess each
+;S, symptom !n terms of !ts fre("ency and !ntens!ty. SC), mod"les were added to pro!de a
thoro"gh assessment of the depress!e symptoms and s"#stance "se that 5r. I reported !n the
screen!ng !nter!ew assessment of h!s present!ng compla!nts.
Psychological Assessment Protocol (Inclding Testing !eslts"
@es"lts of the L!fe Stressor Chec$l!st !nd!cated that !n add!t!on to the motorcycle acc!dent, 5r. I
was the target of a ro##ery when he was wor$!ng at a conen!ence store. ,"r!ng th!s ep!sode, the
ro##er d!splayed a g"n, #"t d!d not f!re !t. Fo other potent!ally tra"mat!8!ng eents were
!nd!cated. )n add!t!on, 5r. I1s score of >> on the +CL !s cons!stent w!th +;S,, altho"gh th!s
scale also !s h!ghly correlated w!th meas"res of depress!on. A #r!ef !tem-#y-!tem ("ery of the
+CL !nd!cated that most symptoms or!g!nated soon after the motorcycle acc!dent. 5r. I1s score
of 11C on the 5!ss!ss!pp! !s a#oe the emp!r!cally der!ed c"toff score for !nd!cat!ng +;S,.
@es"lts of the collateral 5!ss!ss!pp! Scale completed #y 5r. I1s w!fe were generally cons!stent
w!th h!s responses, #"t !nd!cated that she perce!es these symptoms as occ"rr!ng w!th greater
!ntens!ty than he does. .,) @es"lts !nd!cated a score of 22, cons!stent w!th a moderate leel of
depress!on. 2Comment: moderate-to-h!gh scores s"ch as th!s are not "ncommon for !nd!!d"als
w!th +;S, een !n the a#sence of ma3or depress!on.4 At th!s po!nt f"rther !n("!ry was cond"cted
to determ!ne the onset of depress!e symptoms !s-J-!s the tra"ma and to assess pretra"ma
h!story of depress!e symptoms. ;h!s !n("!ry reealed e!dence that s!gn!f!cant depress!e
symptoms were present pr!or to thtra"ma desp!te the !n!t!al negat!e report of the pat!ent
regard!ng premor#!d psych!atr!c h!story.
*!s score on the AU,); was 12, wh!ch !s a#oe the emp!r!cally der!ed threshold for pred!ct!ng
alcohol related pro#lems. ;h"s, !t was dec!ded that the Alcohol A#"seH,ependence mod"le of the
SC), wo"ld #e adm!n!stered. @es"lts conf!rmed the presence of alcohol a#"se !n the last year
w!tho"t dependence.
55+)-2 scores for al!d!ty !nd!ces !nd!cated aerage eleat!ons for L, 7@)F, and ;@)F,
s"ggest!ng that 5r. I responded cons!stently and openly. Scores for scale 0 and the 0-K !nde%
were s!gn!f!cantly eleated. *oweer, an eleat!on of >2 on the 02p4 scale s"ggested that
eleat!ons on the 0 and K scales were l!$ely !nfl"enced #y reported psychopathology and not
!nd!cat!e of an !nal!d prof!le. 5r. I prod"ced a <-2 prof!le on the cl!n!cal scales wh!ch !s
cons!stent w!th that of !nd!!d"als who descr!#e themseles as an%!o"s, tense, depressed, and
constant worr!ers. ;hey tend to #e g"!lt-r!dden and preocc"p!ed w!th the!r personal def!c!enc!es
desp!te e!dence of the!r personal ach!eements. .eca"se of the!r w!ll!ngness to e%am!ne the!r
own #eha!or, they tend to #e e%cellent cand!dates for psychotherapy. :n the s"pplementary
scales, 5r. I1s h!ghest eleat!ons were on scales des!gned to assess +;S, 2+K A +S raw scores
? 3< and DD, respect!ely4.
Interview Assessment
@es"lts of CA+S !nter!ew s"pported a c"rrent d!agnos!s of +;S, assoc!ated w!th the
motorcycle acc!dent. @egard!ng the pre!o"s month, 5r. I reported da!ly !ntr"s!e memor!es of
the acc!dent and three n!ghtmares of the tr"c$ speed!ng toward h!m. After each n!ghtmare, he
remem#ered wa$!ng coered !n persp!rat!on and #e!ng "na#le to ret"rn to sleep. )n the pre!o"s
month, he reported that he has ao!ded tal$!ng a#o"t the acc!dent w!th anyone, has ao!ded
dr!!ng e%cept to wor$ and #ac$, and that he has !ncreased h!s alcohol "se when he !s "pset #y a
memory of the acc!dent. *e also reported d!ff!c"lty gett!ng to sleep two to three t!mes per wee$,
!rr!ta#!l!ty and s"dden o"t#"rsts of anger two to three t!mes !n the past month, and e%cess!e
worry a#o"t h!s and h!s w!fe1s safety assoc!ated w!th dr!!ng or r!d!ng !n a car. CA+S res"lts
!nd!cated that h!s c"rrent +;S, symptoms were pr!mar!ly assoc!ated w!th the motorcycle
acc!dent, #"t that he also has !ntr"s!e memor!es of the ro##ery a#o"t once per month !f he goes
!nto a s!m!lar store or hears a#o"t an armed ro##ery !n the news.
SC), res"lts s"pported add!t!onal c"rrent d!agnoses of 5a3or ,epress!e ,!sorder, @ec"rrent,
5oderate, and Alcohol A#"se. 5r. I endorsed depressed mood, loss of appet!te, low energy,
feel!ngs of hopelessness, fre("ent tho"ghts of death 2w!tho"t c"rrent s"!c!dal !deat!on4, and
!nsomn!a as occ"rr!ng most of the day, nearly eery day for more than 2 wee$s !n the past month.
*e also descr!#ed three pre!o"s s!m!lar ep!sodes of depress!on s!nce he was a teenager that each
lasted 2 to D months. @egard!ng h!s c"rrent alcohol "se, 5r. I stated that he has cont!n"ed to
dr!n$ een when !t has led to arg"ments w!th h!s w!fe and d!ff!c"lt!es at wor$. *oweer, h!s
alcohol-related d!ff!c"lt!es d!d not meet f"ll cr!ter!a for dependence.
@es"lts of assessment !nd!cated that 5r. I met cr!ter!a for c"rrent +;S,, rec"rrent 5a3or
,epress!on, and c"rrent Alcohol A#"se. *!s alcohol pro#lems were targeted as the f!rst stage of
+;S, treatment !n order to red"ce the r!s$ of h!s !ncreas!ng h!s dr!n$!ng !n response to d!stress
assoc!ated w!th e%pos"re to tra"ma mater!al !n therapy sess!ons. ;hro"gho"t treatment, h!s
alcohol "se and depress!e symptoms were mon!tored as well as h!s +;S, symptoms.
0ollow!ng > wee$s of wee$ly treatment foc"sed on h!s alcohol a#"se, 5r. I was a#le to red"ce
h!s dr!n$!ng from an aerage of three to fo"r dr!n$s da!ly, to one dr!n$ eery een!ng and no
more than s!% on wee$ends. *e was also a#le to attend wor$ for one month w!tho"t m!ss!ng a
day d"e to dr!n$!ng or hangoers. *oweer, he reported #e!ng late to wor$ f!e t!mes d"e to lac$
of sleep. .eca"se h!s management of h!s alcohol cons"mpt!on was !mproed, he was referred to
the care of a psych!atr!st to #e eal"ated for med!cat!on. *e was "lt!mately prescr!#ed Zoloft,
wh!ch !s one of the few 0,A approed psychotrop!cs for the treatment of +;S,. ,"r!ng the f!rst
s!% wee$s of treatment, 5r. I1s score on the .,) !mproed sl!ghtly, #"t h!s +;S, symptoms
e!ther rema!ned at the same fre("ency and !ntens!ty or worsened 2e.g., he reported fewer ho"rs of
sleep after red"c!ng h!s een!ng alcohol cons"mpt!on4. 5r. I1s +;S, symptoms were targeted !n
the ne%t 1C wee$s of treatment wh!le mon!tor!ng of h!s dr!n$!ng cont!n"ed. *e was tra!ned !n
#reath!ng and m"scle rela%at!on techn!("es, and th!s was com#!ned w!th g"!ded !magery
e%pos"re to h!s tra"mat!c motor eh!cle acc!dents. At the end of th!s per!od of treatment, 5r. I
reported a f"rther red"ct!on !n h!s dr!n$!ng and depress!e symptoms, and reported !mproed
sleep, wh!ch he attr!#"ted to the "se of #oth rela%at!on techn!("es and med!cat!on.
CAZUL 3:
Client Description
;he pat!ent 2Anne4 was a 3=-year-old marr!ed *!span!c female. She had #een marr!ed for 1B
years and had three da"ghters, ages E, B, and 1=. At the t!me of assessment Anne was a
homema$er, #"t was pre!o"sly employed !n ar!o"s secretar!al pos!t!ons. Anne had a tenth
grade ed"cat!on. At !nta$e she was or!ented !n all spheres, w!th ade("ate groom!ng and hyg!ene.
*er mood was dysthym!c and psychomotor retardat!on was e!dent. Anne1s tho"ght process was
log!cal and goald!rected and there was no e!dence of percept"al a#normal!t!es. *er speech
ol"me, rate, and tone were w!th!n normal l!m!ts. Anne presented w!th depress!e symptoms that
!ncl"ded depressed mood, decreased sleep and appet!te, anhedon!a, concentrat!on d!ff!c"lt!es,
and feel!ngs of g"!lt and low self-worth. She also reported seeral o#sess!e-comp"ls!e
symptoms that were related to a core fear of ac("!r!ng head l!ce.
History of the Disorder
Anne !nd!cated that she had felt depressed for as long as she co"ld remem#er, w!th the most
seere symptoms man!fest!ng oer the past decade. *er h!story was "nremar$a#le as far as
s!gn!f!cant psychosoc!al stressors. She had always res!ded !n the same comm"n!ty, had pos!t!e
peer and parental relat!onsh!ps, had no recollect!on of ch!ldhood a#"se or neglect, and no
s!gn!f!cant med!cal h!storyG howeer, she d!d report a fam!ly h!story of 2maternal4 depress!on.
Anne reported that the last 2 years had #een part!c"larly d!ff!c"lt, follow!ng the loss of her 3o#
and s"#se("ent f!nanc!al pro#lems. Anne1s fam!ly moed !nto a low-!ncome ho"s!ng pro3ect that
had deplora#le l!!ng cond!t!ons, !ncl"d!ng rat and m!ce !nfestat!on as well as s!gn!f!cant sewage
pro#lems. ,"r!ng the!r t!me at th!s res!dence, Anne !nd!cated that her B-year-old contracted l!ce
from one of her schoolmates, wh!ch then ("!c$ly spread to other fam!ly mem#ers. &hen Anne
f!rst d!scoered l!ce !n her da"ghter1s ha!r she e%per!enced her f!rst pan!c attac$ and a mar$ed
worsen!ng of depress!e symptoms. Anne reported no h!story of !npat!ent or o"tpat!ent
psycholog!cal 2or pharmacolog!cal4 treatment. &!th the e%cept!on of her mother and a"nt, Anne
den!ed a fam!ly h!story of depress!on, an%!ety, and psychos!s. She d!d report a fam!ly h!story of
polys"#stance a#"se, part!c"larly w!th her #rother and grandfather. Anne reported that she dr!n$s
w!ne !nfre("ently 2!.e., tw!ce per month4, smo$es 1 pac$ of c!garettes per day, and dr!n$s
#etween 2-3 c"ps of coffee per day. She den!ed "se of other psychoact!e s"#stances.
Anne presented w!th coe%!stent depress!e and an%!ety symptoms. ,epress!e symptoms
!ncl"ded anhedon!a, dysthym!c mood, !nsomn!a, we!ght loss, and fre("ent cry!ng spells.
+hys!olog!cal symptoms of an%!ety !ncl"ded trem#l!ng, persp!rat!on, !ncreased heart rate,
shortness of #reath, na"sea, and d!ff!c"lty swallow!ng. Cogn!t!e symptoms !ncl"ded a
prono"nced fear of 'e!ther myself or my da"ghters o#ta!n!ng l!ce,' the poss!#!l!ty of wh!ch was
e("ated w!th a core fear of '#e!ng a #ad and worthless mother.' .eha!oral symptoms !noled
ao!dance of seeral s!t"at!ons that !ncl"ded mo!e theaters, resta"rants, playgro"nds, f"rn!t"re
2fa#r!c4, and contact w!th other ch!ldren. &hen these s!t"at!ons co"ld not #e ao!ded, !ntense
phys!olog!cal and cogn!t!e an%!ety, as well as !ncreased dysphor!a was e%per!enced. @!t"al!st!c
#eha!ors !n the form of e%cess!e hand wash!ng, #low!ng, sha$!ng, and tapp!ng also were
apparent. S"ch #eha!ors almost !nar!a#ly res"lted !n mar!tal confl!ct, a fa!l"re to ma!nta!n
ho"sehold respons!#!l!t!es, and an assoc!ated !ncrease !n depress!e symptoms. &hen an%!ety-
el!c!t!ng s!t"at!ons co"ld s"ccessf"lly #e ao!ded, Anne reported !mmense g"!lt and sadness
related to the restr!ct!ons she was !mpos!ng on her ch!ldren.
L Cl!n!c!an rat!ngs
L An%!ety ,!sorder )nter!ew Sched"le 2A,)S-)7G .rown et al., 1BBD4
L *am!lton @at!ng Scale for ,epress!on 2*@S,G *am!lton, 1B>C4
L Unstr"ct"red cl!n!cal !nter!ew
L Self-report rat!ngs
L .ec$ ,epress!on )nentory 2.,)G .ec$ A Steer, 1B=<4
L .ec$ An%!ety )nentory 2.A)G .ec$ A Steer, 1BB34
L +A,UA )nentory 2+)G Sana!o, 1B==4
L +ersonal!ty Assessment )nentory 2+A)G 5orey, 1BB14
L 9"al!ty of L!fe )nentory 29:L)G 0r!sch, 1BBD4
L .eha!oral o#serat!ons 2Le3"e8 et al., 2CC14
L ,a!ly d!ar!es, 7al"e Assessment
L .eha!oral Chec$o"t
L @esponse +reent!on Chec$l!st
L 0"nct!onal analys!s.
Psychological Assessment Protocol
At the !n!t!at!on of assessmentHtherapy, the pat!ent "nderwent a #r!ef "nstr"ct"red cl!n!cal
!nter!ew followed #y adm!n!strat!on of the A,)S-)7. @es"lts of th!s !nter!ew s"ggested that
Anne met ,S5-)7-;@ cl!n!cal cr!ter!a for ma3or depress!on and o#sess!e-comp"ls!e d!sorder.
0"rther s"pport!ng the d!agnos!s of ma3or depress!on, Anne rece!ed a score of 33 on the *@S,.
Seeral self-report !nstr"ments also were completed d"r!ng the !n!t!al assessment. ,escr!#ed !n a
pre!o"s sect!on 2see @ange of Assessment Strateg!es4 Anne scored a 3= on the .,) 2seere
depress!on4. Anne also completed the +ersonal!ty Assessment )nentory 2+A)4, an o#3ect!e self-
report meas"re of personal!ty and psychopatholog!cal ar!a#les. *er prof!le was al!d and
!nterpreta#le. S!gn!f!cant eleat!ons were noted on the depress!on 2; ? <24, An%!ety 2; ? <=4, and
An%!ety-@elated ,!sorders 2; ? =24 cl!n!cal scales, as well as on all depress!on and an%!ety
s"#scales 2!.e., cogn!t!e, affect!e, phys!olog!cal4. ;he A@,-: 2An%!ety-@elated ,!sorder:
:#sess!e-Comp"ls!e4 s"#scale also was s!gn!f!cantly eleated 2; ? =34. :n the self-report
an%!ety meas"res, Anne scored a 3D on a meas"re of cogn!t!e and somat!c an%!ety 2.A)G .ec$
A Steer, 1BB34 and was s!gn!f!cantly eleated on three of the fo"r scales of the +ad"a !nentory,
wh!ch assess seer!ty of o#sess!e-comp"ls!e symptoms M!mpa!red control of mental act!!t!es
22D4, contam!nat!on 2334, chec$!ng 2134, and worr!es of los!ng control oer motor #eha!ors 22,
ns4. :n the 9:L), wh!ch assesses l!fe sat!sfact!on on ar!o"s l!fe doma!ns 2e.g., health,
relat!onsh!ps, money4, Anne scored !n the 'low' range of l!fe sat!sfact!on 29:L) total ? -D4.
As a pretreatment assessment strategy and part of a #r!ef #eha!oral act!at!on treatment for
depress!on 2.A;,G Le3"e8 et al., 2CC1, 2CC24, Anne also completed a da!ly d!ary for one wee$
2*op$o et al., !n press4. ;h!s ass!gnment was "sed to: 2a4 pro!de a #asel!ne meas"rement #y
wh!ch to compare progress follow!ng treatment, 2#4 ma$e Anne more cogn!8ant of the ("ant!ty
and ("al!ty of her act!!t!es, and 2c4 pro!de Anne w!th some !deas w!th regard to !dent!fy!ng
potent!al act!!t!es to
target d"r!ng treatment. ,a!ly mon!tor!ng reealed that Anne was lead!ng a relat!ely pass!e
l!festyle, character!8ed #y s"ch act!!t!es as tele!s!on !ew!ng, dayt!me napp!ng, and a!mless
)nternet s"rf!ng. &hen ("er!ed a#o"t the reward 2or re!nforcement4 al"e of s"ch act!!t!es, Anne
!nd!cated that m!n!mal pleas"re was #e!ng e%per!enced. *er da!ly rat!ngs of the reward al"e of
act!!t!es conf!rmed th!s appra!salG :n a L!$ert scale rang!ng from 1 2'm!n!mally reward!ng'4 to
D 2'e%tremely reward!ng'4, her aerage rat!ng was 2.1 2S, ? 1.34.
0ollow!ng th!s mon!tor!ng e%erc!se, the assessment process sh!fted to !dent!fy!ng Anne1s al"es
and goals w!th!n a ar!ety of l!fe areas that !ncl"ded fam!ly, soc!al, and !nt!mate relat!onsh!ps,
ed"cat!on, employmentHcareer, ho##!esHrecreat!on, ol"nteer wor$Hchar!ty, phys!calHhealth !ss"es,
and sp!r!t"al!ty 2*ayes et al., 1BBB4. .ased on th!s eal"at!on, an act!!ty h!erarchy was
constr"cted !n wh!ch 1E act!!t!es were rated rang!ng from 'eas!est' to 'most d!ff!c"lt' to
accompl!sh. ;hese act!!t!es were o"tl!ned on a master act!!ty log 2ma!nta!ned #y the cl!n!c!an4
and a #eha!oral chec$o"t 2ma!nta!ned #y Anne4 to mon!tor progress thro"gho"t each wee$ of
treatment. ;he #eha!oral chec$o"t !s presented !n 0!g"re E.1. As part of the e%pos"re and
response preent!on proced"re that was !mplemented to treat Anne1s o#sess!e-comp"ls!e
#eha!ors, she also was re("!red to ma!nta!n a response preent!on chec$l!st. ;h!s chec$l!st
spec!f!ed #oth appropr!ate and !nappropr!ate #eha!ors 2e.g., wash!ng, chec$!ng4 and re("!red
that Anne !nd!cate on a da!ly #as!s whether she s"cceeded or d!d not s"cceed !n follow!ng each
of the recommendat!ons.
&ee$ly .,) scores and act!!ty complet!on.
0!nally, f"nct!onal analyt!c proced"res were cond"cted !a "nstr"ct"red !nter!ews w!th the
pat!ent and s!gn!f!cant others 2!.e., parent, oldest da"ghter4 to !dent!fy en!ronmental factors that
may #e ser!ng to ma!nta!n depress!e symptomsH#eha!ors. ;hese !nter!ews reealed that
Anne1s depress!e #eha!ors were at least part!ally ma!nta!ned #y pos!t!e conse("ences that
followed. 0or e%ample, when Anne wo"ld l!e mot!onless on the co"ch, wh!ch per!od!cally was
accompan!ed #y cry!ng, her da"ghter fre("ently wo"ld pro!de a s!gn!f!cant amo"nt of sympathy
and concern and wo"ld proceed to complete ho"sehold tas$s s"ch as prepar!ng d!nner and
wash!ng d!shes.
;he f!rst treatment goal was to systemat!cally !ncrease response cont!ngent pos!t!e
re!nforcement #y fac!l!tat!ng !ncreased e%pos"re to pleasant act!!t!es that were cons!stent w!th
Anne1s al"eHgoal assessment. ;o accompl!sh th!s o#3ect!e, Anne engaged !n a #r!ef #eha!oral
act!at!on treatment for depress!on 2.A;,G Le3"e8 et al., 2CC14. Anne moed thro"gh a
constr"cted #eha!oral h!erarchy !n a progress!e manner, mo!ng from the eas!er #eha!ors to
the more d!ff!c"lt. 0or each act!!ty, Anne and the cl!n!c!an colla#orat!ely determ!ned what the
f!nal goal wo"ld #e !n terms of the fre("ency and d"rat!on of act!!ty per wee$. ;hese goals were
recorded on the master act!!ty log that was $ept !n the possess!on of the therap!st. &ee$ly goals
were recorded on the #eha!oral chec$o"t form that Anne #ro"ght to therapy each wee$. At the
start of each sess!on, the #eha!oral chec$o"t form was e%am!ned and d!sc"ssed, w!th the
follow!ng wee$ly goals #e!ng esta#l!shed as a f"nct!on of Anne1s s"ccess or d!ff!c"lty. @ewards
were !dent!f!ed on a wee$ly #as!s as !ncent!e for complet!ng the #eha!oral chec$o"t. A
component of th!s treatment also !ncl"ded address!ng rewards for depress!e #eha!or as
reealed thro"gh f"nct!onal analys!s. ;hro"gh the "se of #eha!oral contract!ng proced"res,
Anne and her da"ghter clearly spec!f!ed how m"ch t!me wo"ld #e spent d!sc"ss!ng Anne1s
negat!e affect and when th!s wo"ld occ"r 2!.e., 1E m!n"tes !n the morn!ng and 1E m!n"tes #efore
#edt!me4. .oth !nd!!d"als also agreed that !t was #etter !f Anne1s da"ghter d!d not reward
pass!e #eha!or #y complet!ng Anne1s ho"sehold respons!#!l!t!es. As s"ch, the agreement stated
that her da"ghter wo"ld prepare d!nner and wash d!shes only tw!ce a wee$ 25onday and
;h"rsday4. 0or s"ccessf"l adherence to th!s contract"al agreement, Anne was rewarded #y #e!ng
a#le to p"rchase a small amo"nt of mater!als for her scrap-#oo$!ng ho##y.
;he second treatment goal was to red"ce Anne1s ao!dance #eha!ors 2that res"lted from an%!ety
el!c!t!ng st!m"l! and also !ncreased depress!e affect4 thro"gh e%pos"re and response preent!on
26@+4 strateg!es for :C, 2Stanley A Aer!ll, 1BB=4. ;hro"gh !mag!nal e%pos"re strateg!es
followed #y !n !o techn!("es, Anne was enco"raged to confront a ar!ety of feared st!m"l! that
!ncl"ded a p!llowcase, com#, da"ghter1s #ed, f"rn!t"re fa#r!c, and her da"ghter1s fr!ends. 6!dent
!n the #eha!oral chec$o"t, #eha!ors targeted for change were somet!mes addressed !a m"lt!ple
treatment strateg!es. 0or e%ample, ta$!ng the ch!ldren to a mo!e or ha!ng l"nch w!th a fr!end
#oth were !ntended to !ncrease e%pos"re to reward!ng act!!t!es and to alle!ate depress!e
symptoms #"t also !noled !ncreas!ng contact w!th feared st!m"l! 2e.g., fa#r!c, other ch!ldren4 to
e%t!ng"!sh an%!ety-related respond!ng.
+rogress was assessed !a pre-post compar!sons on the self-report and #eha!oral o#serat!on
methods. As presented !n ;a#le E.1, Anne made fa!rly ro#"st !mproement d"r!ng the 1E-wee$
com#!ned .A;,-6@+
TA#$% &'(' Compar!son of +re- and +ostassessment 5eas"res
Assessment Measre Pretest Post)Test
*@S, 33 22
.,) 3= 1<
+A) 2;-Scores4
,epress!on Scale <2 E<
An%!ety Scale <= >E
An%!ety-related ,!sorder Scale =2 >D
.A) 3D 21
+A,UA
5ental Act!!t!es 2D =
Contam!nat!on 33 1D
Chec$!ng 13 >
Control 2 2
9:L) -D -2
,a!ly ,!ar!es 2.1 2.<
@esponse +reent!on Chec$l!st
S"ccessf"l .eha!ors 1D 2wee$ 14 2B 2wee$ 1E4
treatment !nterent!on. Anne also completed a .,) on a wee$ly #as!s, wh!ch was plotted aga!nst
her wee$ly #eha!oral chec$o"t data 2!.e., the n"m#er of act!!t!es she s"ccessf"lly completed
d"r!ng the pre!o"s wee$4. ;hese data s"ggested a strong relat!on #etween !ncreased act!!ty and
alle!at!on of depress!e symptoms 2see 0!g"re E.24.
CAZUL D:
Client Description
6l!8a#eth !s a 23-year-old, "nmarr!ed Ca"cas!an woman w!th a 2-year-old son. ;he cl!ent !s
wor$!ng as a hostess at an "pscale resta"rant, wh!le attend!ng act!ng classes part-t!me at a local
comm"n!ty college. She was somewhat oerdressed, appeared yo"nger than her stated age,
d!splayed n"mero"s p!erc!ngs on her ears, and had a tattoo of a flower on her left an$le.
6l!8a#eth arr!ed to the sess!on 3E m!n"tes late, appeared !rr!tated, and offered no apology or
e%planat!on for the delay. &hen greeted !n the wa!t!ng area, she ref"sed to sha$e the cl!n!c!an1s
hand and !n("!red, '*ow long !s th!s go!ng to ta$eN' &hen !nformed of the length of the
eal"at!on, she added angr!ly, 'Oo" $now !t !s ra!n!ng o"ts!de, don1t yo"N' ;he cl!ent appeared
dysphor!c d"r!ng the !nter!ew and was often teary wh!le descr!#!ng her s!t"at!on.
History of the Disorder or Problem
6l!8a#eth reported #e!ng the only ch!ld of "nmarr!ed parents who separated when she was E
years old. She descr!#ed ha!ng a 'ery t"m"lt"o"s' relat!onsh!p w!th her mother thro"gho"t her
l!fet!me and no contact w!th her #!olog!cal father. She also descr!#ed #e!ng se%"ally a#"sed on
two occas!ons #y one of her mother1s n"mero"s #oyfr!ends when she was 1D years old. She neer
reealed the a#"se to her mother or the a"thor!t!es #eca"se of feel!ngs of em#arrassment and
g"!lt. 6l!8a#eth #egan c"tt!ng her th!ghs w!th a ra8or when she left home for college at age 1=
2and cont!n"es to do so wee$ly4. ,"r!ng her f!rst semester, she reported dr!n$!ng e%cess!ely,
occas!onally #!nge eat!ng, and engag!ng !n seeral one n!ght stands. :ne of the enco"nters
res"lted !n a pregnancy and s"#se("ent a#ort!on. *er grades were terr!#le her f!rst semester and
she conse("ently dropped o"t. She ret"rned home and fo"nd wor$ as a wa!tress and part-t!me
model. ,"r!ng the ens"!ng fo"r years, 6l!8a#eth l!ed !n three d!fferent states as a res"lt of short-
l!ed relat!onsh!ps w!th men. She descr!#ed each relat!onsh!p as 'ery chaot!c,' 'h"ge m!sta$es,'
and occas!onally !olent. She descr!#ed #e!ng conf"sed a#o"t why she stayed w!th these men
s!nce she $new they 'were so #ad for me.' She reported oerdos!ng on sleep!ng p!lls after the
end of one of the relat!onsh!ps, altho"gh she den!ed that !t was a s"!c!de attempt. She also
descr!#ed d!ff!c"lty controll!ng her anger, wh!ch has res"lted !n loss of employment. 6l!8a#eth1s
son was the res"lt of a short-l!ed affa!r w!th her former #oss who was marr!ed w!th ch!ldren.
6l!8a#eth descr!#ed three pre!o"s "ns"ccessf"l therapy attempts start!ng at age 1=. She
descr!#ed two pre!o"s therap!sts as '!ncompetent,' '"ncar!ng,' and !ncapa#le of "nderstand!ng
her. She descr!#ed her f!rst co"nselor !n college as 'the greatest.' ,esp!te th!s, she descr!#ed
#e!ng 'ery attached' to each of them and the term!nat!on of therapy as 'totally tra"mat!c.'
6l!8a#eth reported that she has #een pre!o"sly d!agnosed w!th 'depress!on,' 'an%!ety,' and
'some sort of personal!ty d!sorder.'
6l!8a#eth stated that she was see$!ng treatment #eca"se she saw an art!cle a#o"t repressed
memor!es of a#"se !n a women1s maga8!ne at wor$. )n add!t!on, she reported feel!ng 'depressed
and an%!o"s all the t!me.' She also stated that she always seems to 'end "p w!th the wrong g"y'
and that her profess!onal and soc!al l!es are 'a total mess.' 6l!8a#eth also gae a ag"e
descr!pt!on of feel!ng l!$e ') am go!ng cra8y.' She stated that she wants to f!g"re what !s 'wrong'
w!th her and f!g"re o"t what to do w!th her l!fe.
;he methods "sed to assess 6l!8a#eth1s case !ncl"ded
Unstr"ct"red cl!n!cal !nter!ew 2w!th !nformants4
Sem!str"ct"red d!agnost!c !nter!ew 2select mod"les of )+,64
;ra!t- and symptom-#ased self-report !nstr"ments 2)+:, ,A++-.9, A)A9, .S)4
;he assessment of th!s cl!ent #egan w!th the sched"l!ng of the appo!ntment oer the phone.
,esp!te her !ns!stence that she wanted 2and needed4 help, the cl!ent made !t e%tremely d!ff!c"lt to
sched"le a t!me to meet. &hen offered seeral t!mes from wh!ch to choose, she re3ected each one
and repeatedly acc"sed the cl!n!c!an of #e!ng !nfle%!#le and controll!ng. ;he cl!n!c!an felt a p"ll
to ma$e spec!al accommodat!ons for her, ma$!ng h!m feel as !f he were #e!ng controlled #y her.
;h!s feel!ng, com#!ned w!th her !ntense anger and !rr!tat!on, !mmed!ately alerted the cl!n!c!an to
the poss!#!l!ty of an A%!s )) cond!t!on. *er late arr!al and react!on !n the wa!t!ng area also
pro!ded !mportant data a#o"t her poss!#le d!agnos!s and personal!ty str"ct"re.
;he cl!n!cal !nter!ew was cond"cted !n an "nstr"ct"red manner, g"!ded #y hypotheses generated
from the pre!o"s !nteract!ons w!th the cl!ent. )t #egan w!th an attempt at gather!ng !nformat!on
a#o"t the cl!ent1s c"rrent symptomatology, w!th spec!al emphas!s placed on determ!n!ng the
reasons for the cl!ent1s s"!c!dal and self-m"t!lat!ng #eha!or. Spec!al emphas!s was also placed on
determ!n!ng the nat"re of the cl!ent1s mood symptoms, wh!ch d!d not meet cr!ter!a for e!ther
ma3or depress!e ep!sode or dysthym!a. *er depress!e symptoms were determ!ned to #e short-
l!ed and react!e and d!d not !ncl"de ne"ro-egetat!e symptoms 2e.g., sleep d!st"r#ance,
we!ght ga!nHloss, psychomotor retardat!on4 !nd!cat!e of an A%!s ) d!sorder. She also den!ed
feel!ngs of worthlessness or g"!lt, altho"gh she d!d report chron!c feel!ngs of empt!ness. )t also
#ecame clear that her s"!c!dal #eha!or d!d not occ"r d"r!ng per!ods of depressed mood and were
mot!ated #y attempts to ao!d a#andonment #y her #oyfr!ends. A d!sc"ss!on of her cont!n"ed
s"#stance "se, eat!ng d!st"r#ance, and se%"al act!!ty reealed mar$ed !mp"ls!!ty and appeared
to #e s"#threshold for an A%!s ) d!sorder. *er concern a#o"t 'go!ng cra8y' was addressed and she
reealed m!ld, trans!ent parano!a when "nder a great deal of stress. ;he cl!n!cal !nter!ew then
foc"sed on a d!sc"ss!on of her s!gn!f!cant relat!onsh!ps, as well as her own concept!on of herself.
;h!s descr!pt!on of herself and others res"lted !n a p!ct"re of profo"nd !dent!ty d!st"r#ance and a
peras!e pattern of alternat!ng #etween !deal!8at!on and deal"at!on w!th her mother,
#oyfr!ends, therap!sts, and een her son. ;he !nformat!on from the cl!n!cal !nter!ew strongly
s"ggested #orderl!ne personal!ty pathology.
.eca"se of the cl!ent1s late arr!al, a second sess!on was sched"led to cont!n"e the !n!t!al
assessment. She w!ll!ngly agreed to #e seen the ne%t day and offered no res!stance regard!ng
sched"l!ng. She was as$ed 2and granted4 perm!ss!on to spea$ to her most recent therap!st. ;he
cl!ent was g!en two self-report !nentor!es 2)+: and ,A++-.94 to ta$e home w!th her, f!ll o"t,
and #r!ng w!th her the ne%t day. She was pro!ded w!th !nstr"ct!ons, as well as an e%planat!on for
the ("est!onna!res. 6l!8a#eth ended the f!rst sess!on #y stat!ng that she had neer felt 'so
"nderstood !n my whole l!fe.'
TA#$% *'(' An :er!ew of the +at!ent1s Assessment
A%!s ) 7<1.CB Fo d!agnos!s or cond!t!on on A%!s )
A%!s )) 3C1.=3 .orderl!ne +ersonal!ty ,!sorder
3C1.EC *!str!on!c +ersonal!ty ,!sorder
A%!s ))) Fone
A%!s )7 )nade("ate soc!al s"pport
A%!s 7 -A0?D1 2C"rrent4
-A0?D= 2*!ghest leel !n past year4
0or the second sess!on, the cl!ent arr!ed 1C m!n"tes early, was ery cheerf"l and oerly fam!l!ar,
referr!ng to the cl!n!c!an #y h!s f!rst name. )n order to conf!rm the s"spected d!agnoses, the
#orderl!ne, h!str!on!c, and dependent cr!ter!a on the sem!str"ct"red )nternat!onal +ersonal!ty
,!sorder 6%am!nat!on were adm!n!stered. ;he res"lts of the sem!str"ct"red !nter!ew reealed
that 6l!8a#eth d!d meet ,S5-)7 d!agnost!c cr!ter!a for #orderl!ne and h!str!on!c personal!ty
d!sorder, #"t was s"#threshold for dependent. A d!sc"ss!on w!th her pre!o"s therap!st conf!rmed
the !nter!ew f!nd!ngs and reealed add!t!onal s"!c!dal gest"res that 6l!8a#eth d!d not report.
)nterpretat!on of the )+: self-report reealed 6l!8a#eth to #e h!ghly !dent!ty d!ff"sed and
pred!sposed to the "se of pr!m!t!e defens!e mechan!sms, #"t her leel of real!ty test!ng
appeared to #e normal 2see ;a#le >.14.
;he follow!ng were the pr!nc!pal pat!ent #eha!ors selected for treatment:
L Self-m"t!lat!ng #eha!or
L S"!c!dal gest"res
L )nappropr!ate anger
L Affect!e !nsta#!l!ty
L )dent!ty d!st"r#ance
+rogress toward therape"t!c goals was assessed w!th the per!od!c adm!n!strat!on of symptom
spec!f!c and personal!ty str"ct"re self-report !nstr"ments !ncl"d!ng the .r!ef-Symptom )nentory
2.S): ,erogat!s, 1BB34, the Anger, )rr!ta#!l!ty, and Assa"lt 9"est!onna!re 2A)A9G Coccaro,
*arey, K"psaw-Lawrence, *er#ert, A .ernste!n, 1BB14, and the )+:.
CAZUL E:
Client Description
;ed !s a 21-year-old, wh!te male, referred #y h!s phys!c!an #eca"se of cont!n"!ng compla!nts of
an%!ety. ;ed comes from an !ntact #l"e-collar fam!ly. *!s father !s a factory wor$er and h!s
mother !s a ho"sew!fe. *e has two older #rothers and one yo"nger s!ster. *e c"rrently s"pports
h!mself #y wor$!ng as a #"s#oy at a h!gh-end local resta"rant. *e has wor$ed as a #"s#oy for
nearly 2 years. *e also !s try!ng to attend college. *e l!es alone !n a rented apartment.
;ed reported that he has always #een "ncomforta#le aro"nd people other than h!s !mmed!ate
fam!ly and one or two fr!ends he has had s!nce ch!ldhood. ;ed descr!#es h!mself as e%tremely
shy. *e has !!d memor!es of #e!ng teased as a ch!ld #y h!s s!#l!ngs and peers #eca"se he was
so aw$ward !n soc!al s!t"at!ons. As a res"lt, he spent most of h!s free t!me alone to ao!d
em#arrass!ng h!mself !n soc!al s!t"at!ons and r!s$ #e!ng teased. S!nce adolescence, he has
real!8ed that he !s more fearf"l of soc!al s!t"at!ons than others. ;ho"gh he p"shes h!mself to face
the !ne!ta#le soc!al enco"nters of school and wor$, he does so w!th mar$ed and pers!stent
an%!ety and d!stress.
;ed reported that he #ecomes ery an%!o"s !n nearly all soc!al s!t"at!ons. *e !s most an%!o"s
when meet!ng new people or tal$!ng to yo"ng women. *e tends to ao!d eye-contact and
conersat!on w!th most people, e%cept for fam!ly and close fr!ends. At wor$, he stated that he
e%per!ences h!gh leels of an%!ety when he m"st enter the d!n!ng room and !nteract w!th
c"stomers. )n fact, he #eg!ns to #ecome an%!o"s long #efore he #eg!ns wor$. &hen an%!o"s, he
feels h!s heart po"nd!ng and h!s tho"ghts rac!ng, and #ecomes con!nced that others w!ll detect
how an%!o"s he feels.
;ed !s also a st"dent at a local techn!cal college, #"t has dropped o"t each of the past three
semesters after a few wee$s of attend!ng classes. *e reported #e!ng e%tremely an%!o"s wal$!ng
down a crowded hall, !nteract!ng w!th other st"dents, and espec!ally when tal$!ng !n class.
Altho"gh he ao!ds all soc!al enco"nters at school and has neer dated, ;ed w!ll 3o!n cowor$ers
for a dr!n$ after wor$. *e also goes o"t w!th h!s ne!gh#or, a l!felong fr!end who has a large c!rcle
of fr!ends and often !n!tes ;ed to 3o!n h!m. ;hese o"t!ngs "s"ally !nole go!ng to a #ar and ;ed
always dr!n$s 'a few #eers' !n order to feel more comforta#le. ;ed also reported that he w!ll
occas!onally smo$e mar!3"ana when w!th h!s ne!gh#or1s gro"p of fr!ends.
Assessment Methods Used and Psychological Assessment Protocol
$e+el (, Screening
,"r!ng the second sess!on, ;ed was g!en the ."rns An%!ety )nentory 2."rns, 1BB34 to eal"ate
the e%tent and nat"re of ;ed1s an%!ety. *e scored a E2, !nd!cat!ng e%treme an%!ety and pan!c. ;h!s
meas"re was "sed to str"ct"re the d!sc"ss!on a#o"t h!s an%!o"s symptoms. *!s h!ghest scores
related to rac!ng, an%!o"s tho"ghts 2')1ll ma$e a fool of myself' or ';hey1ll th!n$ )1m st"p!d'4 and
pan!c symptoms when !n h!ghly stressf"l s!t"at!ons. *e had deeloped a m!%ed pattern of
ao!dant #eha!ors. At wor$, he p"shed h!mself to complete an%!ety-prod"c!ng tas$s #"t r"shed
thro"gh them. ;h!s often res"lted !n acc!dents, wh!ch re!nforced h!s an%!o"s #el!efs. *e #egan
each of the last three school semesters end"r!ng h!s an%!ety #"t eent"ally fell #eh!nd !n the class
wor$ and ended "p dropp!ng o"t. *e ao!ded all soc!al s!t"at!ons at school, and was a#le to
tolerate go!ng o"t w!th fr!ends or cowor$ers only !f he dran$. ;ho"gh he reported smo$!ng
mar!3"ana, th!s d!d not help ease h!s an%!ety #"t rather made h!m more 'parano!d,' more fearf"l
of how others were 3"dg!ng h!m. As ;ed reported dr!n$!ng as a reg"lar part of h!s !nolement !n
soc!al s!t"at!ons, h!s alcohol cons"mpt!on seemed to warrant f"rther !nest!gat!on.
$e+el -, #rief Problem Assessment
,"r!ng the th!rd sess!on, ;ed was as$ed to g!e a more deta!led p!ct"re of h!s dr!n$!ng. )n
response to ("est!on!ng, he reported that on a typ!cal een!ng o"t he wo"ld hae > to = #eers, and
somet!mes 2once or tw!ce a month4 he wo"ld hae 2 to D shots of whateer l!("or the gro"p was
dr!n$!ng !n add!t!on to the #eers. ;wo or three t!mes a wee$ he went o"t for a dr!n$ after wor$
and dran$ two or three #eers !n a 2-ho"r per!od. *e also reported smo$!ng mar!3"ana once or
tw!ce a month #"t d!d not !ew th!s as a pro#lem. *e neer #o"ght mar!3"ana h!mself, d!d not
care for the way !t made h!m feel, #"t wo"ld smo$e when offered some !n order to 'f!t !n.'
$e+els . and /, Diagnosis and Comprehensi+e Assessment
)n add!t!on to the soc!al an%!ety pro#lems that #ro"ght ;ed to treatment, f"rther e%plorat!on of
;ed1s s"#stance "se seemed warranted. As ;ed reported a pattern of #!nge dr!n$!ng !n soc!al
s!t"at!ons 2that !s, dr!n$!ng more than E dr!n$s at one s!tt!ng4, he was as$ed to complete a #attery
of s!% !nstr"ments. *!s scores on these s!% !nstr"ments and the!r !nterpretat!on are g!en #elow:
1. :n the Alcohol Use ,!sorders )dent!f!cat!on ;est 2AU,);G .a#or et al. 1BB24, ;ed scored
12, !nd!cat!ng a moderate leel of pro#lems compared to others see$!ng help for a dr!n$!ng
pro#lem.
2. :n the Alcohol ,ependence Scale 2A,S, S$!nner A Allen, 1B=24, ;ed scored 2,
!nd!cat!ng a low leel of pro#lems d"e to h!s dr!n$!ng.
3. :n the ,r!n$er1s )nentory of Conse("ences 2,r)nC, 5!ller et al. 1BBE4, ;ed scored D-C-
C->-2 2for the phys!cal, relat!onsh!p, personal, !mp"ls!e, and soc!al respons!#!l!ty scales,
respect!ely4, !nd!cat!ng few pro#lems related to dr!n$!ng e%cept !n the areas of phys!cal
health and !mp"ls!e act!ons.
D. :n the Alcohol A#st!nence Self-6ff!cacy 2AAS6G ,! Clemente et al. 1BBD4, ;ed scored
1E, 1<, 1B, and 2 2for the "npleasant emot!ons, pos!t!e soc!al s!t"at!ons, phys!cal concerns,
and "rges and temptat!ons scales, respect!ely4 conf!rm!ng that he was most tempted to
dr!n$ !n soc!al s!t"at!ons and to manage h!s feel!ngs of an%!ety and worry.
E. :n the ,es!red 6ffects of ,r!n$!ng 2,6,G F)AAA, !n press4, ;ed scored h!gh on three
scales, !nd!cat!ng that he dran$ to feel good 2>4, to
fac!l!tate soc!al s!t"at!ons 2=4, and to manage negat!e feel!ngs 2B4. :n all other scales he
scored C to 2.
>. :n the @ead!ness to Change 9"est!onna!re 2@;C9G *eather et al., 1BB34, ;ed scored
h!ghest on the precontemplat!e scale, !nd!cat!ng he d!d not see h!s dr!n$!ng as a pro#lem
and was not c"rrently th!n$!ng a#o"t ("!tt!ng.
;ed completed these meas"res !n the last half ho"r of the th!rd sess!on and the therap!st too$ 1C
to 1E m!n"tes to score and complete the feed#ac$ form. )n add!t!on, E to 1C m!n"tes were "sed to
gather the spec!f!c !nformat!on on h!s dr!n$!ng and mar!3"ana "se !n order to pro!de feed#ac$
spec!f!c to h!s pattern of dr!n$!ng 2"s!ng a mod!f!ed 0orm BC4. An add!t!onal E m!n"tes were
needed to conert th!s !nformat!on !nto standard dr!n$s per wee$ and est!mated #lood alcohol
leel "s!ng the .ACC*AS 25ar$ham, 5!ller, A Arc!n!ega, 1BB14 comp"ter program. All these
assessments were #!lled as part of the th!rd sess!on.
.ased on these assessment data, ;ed was g!en the follow!ng d!agnoses:
A%!s ): 3CC.23: Soc!al +ho#!a, -eneral!8ed
3CE.CC: Alcohol A#"se
2B2.=B: Canna#!s )nto%!cat!on
A%!s )): Fone
A%!s ))): Fo health pro#lems reported
A%!s )7: Stress of school, wor$, soc!al enco"nters
A%!s 7: -A0 EE
$e+el &, 0eedbac1 and Treatment Selection
0eed#ac$ was presented !n the fo"rth sess!on and "sed to str"ct"re the d!sc"ss!on of h!s dr!n$!ng
and how !t related to h!s an%!ety. As ;ed was !n the precontemplat!e stage of change 2!.e., d!d
not see h!s dr!n$!ng as a pro#lem and was not cons!der!ng chang!ng h!s dr!n$!ng #eha!or4, the
therap!st foc"sed on enhanc!ng h!s read!ness to change h!s dr!n$!ng #eha!or as well as pro!d!ng
#as!c !nformat!on a#o"t alcohol and dr!n$!ng pro#lems, !ncl"d!ng: #!nge dr!n$!ng, tolerance,
dependence, and alcohol1s #!phas!c effects on an%!ety.
;he feed#ac$ pro!ded !nformat!on !n three areas: dr!n$!ng, pro#lem seer!ty, and a f"nct!onal
analys!s.
Drinking
)n a typ!cal month, ;ed dran$ 1D o"t of 3C days. :n = of these days he dran$ hea!ly 2E or more
dr!n$s4 and on > he reported l!ght dr!n$!ng. )n a typ!cal wee$, ;ed dran$ 21.> standard dr!n$sG at
th!s rate, he was dr!n$!ng more than B1P of other men !n the Un!ted States 2th!s compar!son was
made "t!l!8!ng data from the Fat!onal Alcohol S"reyG Caetano A ;am, 1BBE4. *!s est!mated
.AL was C.C=D mgHP on h!s typ!cal heay dr!n$!ng days and C.1DB mgHP on the hea!est
dr!n$!ng day that he reported. ;ed reacted most strongly to the total n"m#er of dr!n$s he had
each wee$ and how th!s n"m#er compared w!th other Amer!can men.
Problem Severity
;ed scored 12 on the AU,);, !nd!cat!ng a moderate leel of pro#lems compared to others
see$!ng help for a dr!n$!ng pro#lem, and 2 on the A,S, !nd!cat!ng a low leel of pro#lems. *!s
scores on the ,r)nC !nd!cated few pro#lems related to dr!n$!ng e%cept !n the area of phys!cal
health and !mp"ls!e act!ons. &hen d!sc"ss!ng these f!nd!ngs, ;ed related an !nc!dent where,
after e%cess!e dr!n$!ng, he had #een $!c$ed o"t of a #ar for harass!ng female c"stomers. *e
adm!tted that h!s dr!n$!ng contr!#"ted to h!s pro#lems at school: after a n!ght of dr!n$!ng he
wo"ld m!ss classes the follow!ng day and fall #eh!nd !n h!s homewor$.
Functional Analysis
;he AAS6 showed that ;ed was most tempted to dr!n$ !n soc!al s!t"at!ons and to manage
feel!ngs of an%!ety and worry. ;he ,6, fo"nd that he dran$ to feel good, fac!l!tate soc!al
s!t"at!ons, and manage negat!e feel!ngs. ;he @;C !nd!cated that ;ed d!d not see h!s dr!n$!ng as
a pro#lem and had not tho"ght of chang!ng h!s dr!n$!ng. ;ed agreed that he dran$ pr!mar!ly !n
soc!al s!t"at!ons and that he "sed alcohol to help h!m manage h!s an%!ety. *e was rel"ctant to
g!e "p dr!n$!ng #eca"se !t helped h!m f"nct!on !n soc!al s!t"at!ons that he wo"ld otherw!se
ao!d. ;h!s led to a d!sc"ss!on of the #!phas!c effect of alcohol on an%!ety. 0!nally, the treatment
of soc!al an%!ety was d!sc"ssed. ;he therap!st shared concerns that dr!n$!ng wo"ld !nterfere w!th
;ed1s learn!ng new s$!lls to manage an%!ety and #"!ld!ng h!s conf!dence when "s!ng these s$!lls
!n soc!al s!t"at!ons.
;he feed#ac$ sess!on was #!lled as the fo"rth treatment sess!on.
Target Selected for Treatment
;ed agreed to a#sta!n from alcohol wh!le !n treatment for soc!al an%!ety. *e was as$ed to $eep an
an%!ety log, !n wh!ch he wo"ld record h!s an%!ety leel !n a ar!ety of s!t"at!ons "s!ng a score
from C-1CC and descr!#e the s!t"at!on. *!s mar!3"ana "se was not addressed d!rectly, tho"gh ;ed
agreed to cont!n"e to mon!tor #oth dr!n$!ng and mar!3"ana "se as part of h!s an%!ety log. )n th!s
way, he and h!s therap!st co"ld see !f h!s mar!3"ana "se !nterfered w!th treatment and co"ld $eep
trac$ of h!s compl!ance w!th h!s a#st!nence goal. ;ed also agreed to a psych!atr!c cons"ltat!on for
med!cat!on as he had #een "s!ng alcohol to manage h!s an%!ety. Lastly, ;ed and h!s therap!st
agreed that, after an%!ety treatment, therapy wo"ld foc"s on help!ng ;ed deelop s$!lls to
moderate h!s dr!n$!ng and to !dent!fy #eha!ors that m!ght !nd!cate h!s dr!n$!ng was #ecom!ng a
pro#lem 2!.e., that he was not a#le to moderate h!s "se of alcohol4.
;ed !n!t!ally was a#le to a#sta!n from alcohol, #"t had three ep!sodes of dr!n$!ng as he #egan !n
!o e%pos"re to an%!ety-proo$!ng soc!al s!t"at!ons. *e reported no "se of mar!3"ana d"r!ng h!s
treatment, stat!ng that th!s was relat!ely easy #eca"se he had not #een dr!n$!ng when he was
offered mar!3"ana. 0"nct!onal analyses of each of h!s three dr!n$!ng ep!sodes showed that ;ed
was "s!ng alcohol to manage h!s an%!ety. )n add!t!on, !n one !nc!dent he d!d not attempt to "se the
an%!ety-red"c!ng s$!lls he had learned !n sess!on and !n two !nc!dents he d!d not perseere !n h!s
attempts to "t!l!8e these s$!lls. .ased on these analyses, ;ed was a#le to recomm!t to h!s dec!s!on
to a#sta!n d"r!ng the co"rse of treatment. After D months, he was a#le to red"ce h!s an%!o"s
symptoms s"ccessf"lly !n a ar!ety of soc!al s!t"at!ons. *e had enrolled !n classes and was
conf!dent that he wo"ld #e a#le to complete the semester. Altho"gh he d!d ret"rn to dr!n$!ng, ;ed
was a#le to moderate h!s "se. *e reported dr!n$!ng once or tw!ce a wee$ and dr!n$!ng one to
three dr!n$s any t!me he dran$. &hen he f!rst came to treatment, ;ed1s -A0 was >E. At the end
of treatment, h!s -A0 was =C.
;ed was g!en th!s d!agnos!s at term!nat!on:
A%!s ): 3CC.23: Soc!al +ho#!a, -eneral!8ed, !n early rem!ss!on
3CE.C3: Alcohol A#"se, !n rem!ss!on
2B2.=B Canna#!s )nto%!cat!on, !n rem!ss!on
A%!s )): Fone
A%!s ))): Fo health pro#lems reported
A%!s )7: Stress of school, wor$, soc!al enco"nters
A%!s 7: -A0 =C
CAZUL >:
Client Description
Amy, age 21, presented at a hosp!tal-#ased program for eat!ng d!sorders, prompted #y her
parents1 concern a#o"t her we!ght stat"s and eat!ng ha#!ts. )t was !mmed!ately apparent that Amy
co"ld #e class!f!ed as 'low we!ght stat"s.' She reported that her mother was concerned a#o"t her
d!ff!c"lt!es w!th eat!ng and pers"aded her to enter a program for eat!ng d!sorders. Altho"gh Amy
agreed, she was apprehens!e a#o"t part!c!pat!ng !n a str"ct"red treatment program that re("!red
eat!ng meals on a sched"led #as!s.
Amy reported that when she was a yo"ng ch!ld, her mother was oerwe!ght and often d!eted. As
she entered adolescence, Amy #egan to hae some worry a#o"t #e!ng oerwe!ght. She reported
that as she entered p"#erty, she ga!ned we!ght and was teased #y peers at school a#o"t her #ody
shape and s!8e. Add!t!onally, her #oyfr!end at the t!me dec!ded to #rea$ "p w!th her and she felt
that the #rea$"p was ca"sed #y e%cess!e #ody we!ght. She reported that th!s !nc!dent made her
feel #ad a#o"t herself and she #egan to th!n$ !t was a good !dea to try to lose we!ght. At f!rst, she
tr!ed to d!et and e%erc!se to lose we!ght. 6ent"ally, she lost some we!ght and rece!ed pra!se and
compl!ments from peers a#o"t her th!n #ody s!8e and shape. Amy reported that there were t!mes
when she was "nmot!ated to e%erc!se and that she wo"ld p"rge !a self-!nd"ced om!t!ng and
"se la%at!es to preent we!ght ga!n. She also reported that at t!mes she was a#le to s"sta!n
restr!ct!e eat!ng for a few days at a t!me. She den!ed s!gn!f!cant #!nge eat!ng. Amy reported that
th!s pattern of #eha!or cont!n"ed for seeral years, and that her c"rrent eat!ng ha#!ts were the
worst !n her l!fe. At the t!me of assessment, she no longer "sed la%at!es or p"rgedG she s!mply
d!d not eat often. She reported that !t had #ecome easy to restr!ct food !nta$e and that her #ody
we!ght had dropped from 1DC to B> po"nds. She reported d!88y spells, cessat!on of her menstr"al
cycle, chest pa!ns, and !ntense fat!g"e. *er parents had #eg"n to worry a#o"t her health, tho"gh
she d!d not share th!s concern.
)n the !nta$e !nter!ew, Amy reported fears of #e!ng fat, restr!ct!e eat!ng, p"rg!ng occas!onally
!a self-!nd"ced om!t!ng and e%cess!e e%erc!se, and the "se of la%at!es to control #ody
we!ght. She reported depressed mood and symptoms of an%!ety. Amy reported that she wo"ld
l!$e to stop ha!ng o#sess!e tho"ghts a#o"t food and eat!ng and res"me the l!fe she had #efore
worry!ng so m"ch a#o"t #ody s!8e and shape, howeer, she wanted to rema!n th!n.
;he ),6,-)7 was "sed !n con3"nct!on w!th a cl!n!cal !nter!ew of h!story to ac("!re a clear
descr!pt!on of the h!story and c"rrent d!agnos!s. Amy e%pressed a fear of fatness and a den!al of
the ser!o"sness of her low #ody we!ght. She endorsed restr!ct!e eat!ng patterns, somet!mes
go!ng seeral days w!tho"t eat!ng at a t!me. ;he 5A6,S meas"red a #asel!ne leel of: fear of
fatness 2t ? =C4, restr!ct!e eat!ng 2t ? <E4, #!nge eat!ng 2t ? EE4, p"rgat!e #eha!or 2t ? <C4,
depress!on 2t ? <34, and ao!dance of fear foods 2t ? <E4. ;he .5A 2.C was "t!l!8ed to meas"re
Amy1s leel of #ody d!ssat!sfact!on and #ody s!8e oerest!mat!on 2c"rrent ? >>, !deal ? 3D4.
;hese data !nd!cated that Amy oerest!mated her #ody s!8e, had a strong dr!e for th!nness, and
was d!ssat!sf!ed w!th her c"rrent #ody s!8e, desp!te #e!ng s!gn!f!cantly "nderwe!ght. .ased on
these data, !t was determ!ned that Amy met cr!ter!a for anore%!a nerosa, #!ngeHp"rge type, and
ma3or depress!e d!sorder. ;here was no e!dence for the presence of a personal!ty d!sorder.
*e!ght and we!ght were meas"red to determ!ne .5), wh!ch was 1<.EG class!fy!ng Amy !n the
'low we!ght category.' A #!oelectr!c !mpedance meas"re of #ody compos!t!on showed that
Amy1s #ody fat was 13.EP.
;he h!story and cl!n!cal !nter!ew 2),6,-)74 were cond"cted f!rst, !n order to esta#l!sh rapport
w!th Amy. )t was apparent that she was apprehens!e a#o"t d!sclos!ng personal !nformat!on, so
mot!at!onal !nter!ew!ng techn!("es, s"ch as reflect!e l!sten!ng and open-ended ("est!ons,
were "sed to e%press "nderstand!ng of her s!t"at!on. Amy came forth w!th more deta!ls as t!me
progressed. ,"r!ng the !nter!ew, Amy endorsed many symptoms of an eat!ng d!sorder and some
leel of d!scord w!th her c"rrent ("al!ty of l!fe. ;he 5A6,S and the .5A 2.C were then
adm!n!stered to collect #eha!oral and att!t"d!nal data. Amy1s he!ght, we!ght, and #ody
compos!t!on were meas"red to complete the assessment.
0ollow!ng assessment, a case concept"al!8at!on and treatment plan were o"tl!ned. ;argets
selected for treatment !ncl"ded: 214 refeed!ng and sta#!l!8at!on of n"tr!t!on, 224 we!ght ga!n and
sta#!l!8at!on of we!ght #etween B2P and 1CCP of !deal #ody we!ght, 234 !mproement of
depressed mood, 2D4 red"ct!on of fear s"rro"nd!ng eat!ng, 2E4 red"ct!on of an%!ety related to
#ody !mage and eat!ng, 2>4 red"ct!on of fears of fatness, 2<4 decreased dr!e for th!nness, 2=4
cessat!on of restr!ct!e eat!ng, and 2B4 cessat!on of p"rg!ng !a self-!nd"ced om!t!ng and
e%cess!e e%erc!se.
;hro"gho"t treatment, #ody we!ght and #ody compos!t!on were reg"larly assessed thro"gh
#!oelectr!cal !mpedance. ;he 5A6,S was adm!n!stered each wee$ to assess progress oer t!me.
5A6,S scores were compared oer t!me to eal"ate trends s"ggest!ng !mproement, sta#!l!ty,
or worsen!ng on each scale, w!th a spec!al !nterest !n those eleated at #asel!ne assessment 2!.e.,
fear of fatness, ao!dance of fear foods, restr!ct!e eat!ng, p"rg!ng, and depress!on4. 0!nally, the
.5A was "t!l!8ed to assess progress w!th oerest!mat!on of #ody s!8e, dr!e for th!nness, and
d!ssat!sfact!on w!th #ody s!8e and shape.
CAZUL <:
.renda and -reg 2pse"donyms4 had #een marr!ed for 1E years pr!or to enter!ng treatment. ;hey
reported #e!ng !ncreas!ngly d!ssat!sf!ed oer the seeral years #efore com!ng to therapy. .renda
also reported seeral per!ods of depress!on, !ncl"d!ng the present, and #oth spo"ses tho"ght that
the!r d!ff!c"lt!es !ncreased when .renda was depressed.
-reg and .renda met wh!le wor$!ng for a transportat!on company. ;hey #egan dat!ng after -reg
left a ser!o"s romant!c relat!onsh!p and after .renda had separated and d!orced from her
h"s#and at the t!me, altho"gh they also dated others. After a t!me, -reg #ecame m"ch more
attent!e #eca"se of the compet!t!on of another man who .renda was dat!ngG th!s c"lm!nated !n
h!s as$!ng her to marry h!m. She fended off these offers for 2 years #eca"se she en3oyed #e!ng
s!ngle. ;hey l!ed together for 3 years after meet!ng #efore they marr!ed, and reported !n!t!al
confl!cts from that t!me concern!ng ho"se$eep!ng and -reg1s wan!ng attent!on to .renda.
;he co"ple1s pro#lems started early !n the!r relat!onsh!p. .renda descr!#ed the!r rec"rrent mar!tal
confl!cts as occ"rr!ng #eca"se of -reg1s decreas!ng attent!on, and -reg1s !ncreased foc"s on
wor$. -reg ac$nowledged that he somet!mes adopted a 'trad!t!onal' s!ng"lar foc"s on h!s wor$,
descr!#!ng !t as 'p"tt!ng #l!nders on.' *e stated he #ecame "nhappy that he had to assert h!mself
too !goro"sly 2e.g., ') had to go to the mat for eeryth!ng'4. :ther stressors d"r!ng the f!rst
seeral years of the!r marr!age !ncl"ded career changes, the #!rth of the!r two ch!ldren, and
.renda1s rec"rrent depress!on.
Presenting Complaints and Indi+idal Histories
;he foc"s of the co"ple1s compla!nts were the!r er#al confl!cts, espec!ally when .renda was
depressed and had ta$en a few dr!n$s. .renda foc"sed a great deal on the !nterference of -reg1s
3o#, and the long and errat!c wor$ ho"rs. Compl!cat!ng th!s pro#lem was -reg1s ao!dance of
d!sc"ss!ng pro#lems w!th .renda, h!s procrast!nat!on, and from .renda1s po!nt of !ew, h!s lac$
of p"nct"al!ty at most fam!ly eents or appo!ntments. .renda ac$nowledged that her dr!n$!ng
was often pro#lemat!c, and often res"lted !n her worsen!ng mood and an arg"ment #etween
them.
-reg !s the yo"ngest of three ch!ldren, #"t he was essent!ally ra!sed as an only ch!ld #eca"se h!s
s!#l!ngs were at least 1C years older than he. *e descr!#ed h!s parents as s"pport!e #"t
oerprotect!e 2!.e., no foot#all4. *!s father was 'trad!t!onal' and st"##orn, and h!s mother had a
'w!c$ed' temper. .eca"se of h!s s!8e and self-!mposed !solat!on, he was ass"med to #e a '#"lly'G
h!s academ!c s"ccess and o"ts!de !nterests 2e.g., play!ng class!cal p!ano4 were !n contrast w!th h!s
rep"tat!on. -reg tended to "se cl"msy metaphors to e%press h!mself 2e.g., .renda was a sol!d
person, 'l!$e a #attlesh!p'4. *e often monopol!8ed conersat!ons w!th top!cs of !nterest only to
h!mself 2e.g., && )) a!rplanes4. *e reported no psych!atr!c h!story, #"t reported c"rrent
dysphor!a and occas!onal #ac$ pa!n. *e had not #een marr!ed pr!or to h!s marr!age to .renda,
altho"gh he had #ro$en an engagement #eca"se of seere confl!cts w!th h!s f"t"re mother-!n-law
at the t!me.
.renda !s the oldest of three ch!ldrenG her s!#l!ngs are 2 and 3 years yo"nger. She descr!#ed her
fam!ly role as a 'goody-two-shoes' espec!ally !n contrast to her yo"nger s!ster. She descr!#ed her
father as a"thor!tar!an and the sole pro!der, whereas her mother 'act"ally ran eeryth!ng.' *er
n!che !n h!gh school was as a cheerleader. .renda reported seeral per!ods of depress!on-as a
ch!ld, aro"nd the t!me of her separat!on and d!orce from her f!rst h"s#and, wh!le she was at
home w!th two yo"ng ch!ldren, and at the t!me of her c"rrent treatment. She was treated w!th
psychotherapy d"r!ng the f!rst two reported depress!e ep!sodes wh!le she was an ad"lt. .renda
descr!#ed her f!rst h"s#and as a 'patholog!cal l!ar' who p"rs"ed her act!ely, then #"!lt "p h"ge
f!nanc!al de#ts and was "nfa!thf"l w!th a fr!end of hers. )n her c"rrent treatment, .renda
presented as ery dysphor!c and angry w!th -reg for h!s decreased attent!on, #"t attr!#"ted m"ch
of her emot!onal!ty to her depress!on. She met d!agnost!c cr!ter!a for a moderately seere cl!n!cal
depress!on. *er alcohol "se was moderate 23-D glasses of w!ne 3 t!mesHwee$4, and often led to a
worsen!ng of her mood.
-reg and .renda !n!t!ally pro!ded data releant to the!r treatment !n the conte%t of an
assessment st"dy cond"cted #y the a"thor. S"#se("ently, they entered treatment and agreed to
pro!de the self-report and cl!n!cal data reported here. ;he assessment targeted seeral doma!ns,
!ncl"d!ng the spo"ses1 mar!tal sat!sfact!on 2@SA;4, the!r c"rrent leels of depress!e symptoms
2.ec$ ,epress!on )nentory, M.,)QG Kendall, *ollon, .ec$, *ammen, et al., 1B=<4, and the!r
percept!ons of mar!tal confl!ct 2C+94. .eca"se cl!n!cal !nter!ew s"ggested that the co"ple
e%h!#!ted a demand-w!thdraw pattern of !nteract!on, w!th the w!fe !n the 'demand' role and the
h"s#and !n the 'w!thdraw' role, we e%am!ned the correspond!ng ,emand-&!thdraw s"#scale as
well as the 5"t"al +ro#lem Sol!ng s"#scale. A d!agnost!c !nter!ew was cond"cted to assess
whether e!ther of the spo"ses met cr!ter!a for any psych!atr!c d!sorder. )n order to s!mpl!fy the
presentat!on, the res"lts of other meas"res also o#ta!ned at the t!me hae #een e%cl"ded.
+retreatment al"es on the assessment #attery s"ggested that the spo"ses were d!ssat!sf!ed w!th
the relat!onsh!p, moderately dysphor!c, and e%h!#!ted a m!% of dysf"nct!onal comm"n!cat!on and
f"nct!onal comm"n!cat!on as rated #y the spo"ses. As shown !n 0!g"re 1C.1, the !n!t!al self-report
al"es for relat!onsh!p sat!sfact!on and depress!on were pro!ded well !n adance 2!.e., treatment
day ? -E>4 of the !n!t!at!on of the cl!n!cal assessment 2!.e., treatment day ? -=4. ;he w!fe1s and
h"s#and1s !n!t!al self-report scores were as follows: w!fe-@SA; ? 2B, .,) ? 32G h"s#and-@SA;
? DC, .,) ? 21. ;he spo"ses1 @SA; scores were well #elow the c"toff for mar!tal d!stress 2!.e.,
appro%!mately D> for h"s#ands and w!es, *eyman et al., 1BBD4 and #oth spo"ses had .,)
scores a#oe

0I2U!% (3'(' 5ar!tal sat!sfact!on 2@SA;4 and depress!on 2.,)4 for h"s#and and w!fe.
0I2U!% (3'-' &!fe ,emand, h"s#and w!thdraw and m"t"al pro#lem sol!ngG self-report
C+9 s"#scales.
the "s"al c"toff of 1> that !nd!cates a moderately h!gh leel of depress!e mood 2Kendall et
al., 1B=<G see 0!g"re 1C.14. )n add!t!on, the spo"ses1 C+9 s"#scale for ,emand-&!thdrawal
was >.<, and the!r s"#scale score for 5"t"al +ro#lem Sol!ng was >.2. ;hese scores were
assessed at the t!me of the !n!t!at!on of the cl!n!cal assessment, and are close to the 'ery
l!$ely' 2!.e., 'B'4 end of the d!mens!on on wh!ch each C+9 !tem !s rated 2see 0!g"re 1C.24.
Cople Interaction Patterns and Conceptali4ation
.renda and -reg e%h!#!ted an e%treme 'demand-w!thdraw' pattern of !nteract!on. .renda
e%pressed her d!scontent oc!fero"sly and -reg w!thdrew and ao!ded confl!cts, w!th occas!onal
o"t#"rsts of anger. -reg had d!ff!c"lty !dent!fy!ng, la#el!ng, and e%press!ng h!s own emot!ons
effect!ely, and !nstead 3"st!f!ed h!s pos!t!on, or e%pressed somat!c compla!nts. .renda had
d!ff!c"lty moderat!ng her anger, and her depress!on !nterfered w!th f!nd!ng ade("ate sol"t!ons to
her mood pro#lems or to the mar!tal confl!cts. She was fr"strated and h"rt regard!ng -reg1s
m!n!mal attent!on to the!r relat!onsh!p and lac$ of effort !n address!ng the!r confl!cts. ;he co"ple
spent l!ttle le!s"re t!me w!th one another and had per!od!c er#al o"t#"rsts. .oth of the!r teenage
ch!ldren were concerned a#o"t the!r parents d!orc!ng.
-reg often lapsed !nto a defens!e pos!t!on when .renda was angry and ocal !n her cr!t!c!sms
a#o"t a spec!f!c !ss"e. .renda1s depress!on and !rr!ta#!l!ty was also e%acer#ated #y alcohol "se.
-reg somewhat cons!stently adopted a !ct!m1s role, ac$nowledg!ng ha!ng d!ff!c"lty w!th
confront!ng confl!ct. 6arly learn!ng that poss!#ly contr!#"ted to these roles !ncl"ded .renda1s
adopt!ng from her mother the role of the act!e pro#lem soler, as well as her anger at tw!ce
#e!ng p"rs"ed #y men only to #e !gnored after assent!ng to a comm!tted relat!onsh!p. -reg1s
#el!ef !n the trad!t!onal role of the father as pro!der and -reg1s mother1s angry style may hae
contr!#"ted to h!s own tendency to w!thdraw from confl!ct. ;he!r lac$ of comm"n!cat!on s$!ll
!nh!#!ted them from address!ng relat!ely #as!c concerns s"ch as wor$ and home sched"les,
home respons!#!l!t!es, and the ma!ntenance of relat!onsh!p !nt!macy.
After two assessment sess!ons, the co"ple rece!ed n!ne treatment sess!ons "s!ng a #eha!oral
co"ples approach for depressed spo"ses 2e.g., .each, Sm!th, A 0!ncham, 1BBD4. ;he f!rst step !n
treatment cons!sted of d!sc"ss!ng the concept"al!8at!on of the!r pro#lems, the treatment rat!onale,
and #"!ld!ng a colla#orat!e set. ;he early emphas!s !n treatment was on !ncreas!ng pos!t!e
!nteract!on "s!ng a s!mple cl!n!cal form !n wh!ch each spo"se l!sted the other1s pos!t!e #eha!or
and the!r own er#al response to !t. )n add!t!on, the co"ple was enco"raged to engage !n other
shared pos!t!e eents, and these eents were e%tens!ely d!sc"ssed and trac$ed. )n later sess!ons
the co"ple was ta"ght reflect!e l!sten!ng s$!lls and pro#lem-sol!ng s$!lls. .renda was also
ta$!ng +ro8ac 22C mg4 when co"ples therapy started and then sw!tched to +a%!l 22C mg4 >3 days
after !n!t!at!ng treatment. ;he !ss"e of how the spo"ses were attr!#"t!ng changes or
!mproements !n the!r relat!onsh!p to med!cat!on ers"s sh!fts !n comm"n!cat!on patterns was
d!sc"ssed thro"gho"t treatment.
.renda and -reg showed an !n!t!al #oost !n opt!m!sm, an !ncrease !n mar!tal sat!sfact!on, and
rap!d !mproement !n .renda1s mood 2see 0!g"res 1C.1 and 1C.24. *oweer, .renda was
#ecom!ng more aware that she was h!ghly cr!t!cal #"t she co"ld not always moderate her
e%press!on of anger. -reg had d!ff!c"lty !dent!fy!ng and e%press!ng feel!ngs w!tho"t #e!ng
defens!e. .oth spo"ses had d!ff!c"lty stay!ng foc"sed on sol"t!ons d"r!ng pro#lem sol!ng. An
!mportant sh!ft occ"rred #etween therapy sess!ons at 3D and D1 days after !n!t!at!ng treatment,
when -reg e%pressed a great deal of anger at .renda1s h!gh cr!t!c!sm. ;h!s eent was
accompan!ed w!th #oth a temporary decrease !n sat!sfact!on and changes !n perce!ed !nteract!on
style. )t also st!m"lated "sef"l d!sc"ss!ons a#o"t the!r styles of handl!ng anger, and ways of
handl!ng these types of cr!t!cal eents. ;he co"ple cont!n"ed to !mproe from that po!nt,
term!nat!ng when -reg1s wor$ sched"le made appo!ntments d!ff!c"lt for them to $eep.
,ata showed s!gn!f!cant ar!a#!l!ty across the assessment and treatment sess!ons, pr!mar!ly
#eca"se of the !nstr"ct!ons to the spo"ses to complete the forms !n reference to the t!me per!od
s!nce the last assessmentG th"s, spo"ses d!d not pro!de glo#al !mpress!ons of a longer per!od of
t!me. *oweer, !t !s poss!#le to see how ha!ng the complet!on of #r!ef meas"res pr!or to each
sess!on can pro!de a 'snapshot' of the co"ples1 wee$ pr!or to the sess!on. *a!ng th!s
!nformat!on can help the therap!st prepare h!s or her approach to sess!on management when !t !s
poss!#le that the co"ple !s e%per!enc!ng a rap!d pos!t!e sh!ft !n the!r relat!onsh!p, or !s c"rrently
!n a cr!s!s. ,ata for spo"ses for the c"rrent case e%ample pro!de doc"mentat!on for pos!t!e
changes the co"ple e%per!enced. 5oreoer, data added s"pport to the !nformal !mpress!on of
the!r progress. 0"rthermore, data for -reg also demonstrated that he cont!n"ed to hae
"ncomforta#le leels of depress!e symptoms, pro#a#ly assoc!ated w!th somat!c pro#lems he
descr!#ed d"r!ng treatment. )f cont!n"ed treatment were poss!#le, !t m!ght hae foc"sed on these
pro#lems !n order to ens"re !mproed f"nct!on!ng on h!s part as well as long-term sta#!l!ty of the
relat!onsh!p.
CAZUL =:
;he follow!ng case !ll"strat!on pro!des an e%ample of psycholog!cal assessment for p"rposes of
#oth !dent!fy!ng a ch!ld w!th mental retardat!on and deelop!ng a hypothes!s to g"!de !n the
des!gn of a #eha!or !nterent!on plan to remed!ate h!s pro#lem #eha!or.
Client Description
Reff was a B-year-old Afr!can-Amer!can male who l!ed w!th h!s a"nt and rece!ed spec!al
ed"cat!on ser!ces !n an !ncl"s!e general ed"cat!on classroom. *e had recently moed from
another state where he was enrolled !n a self-conta!ned 65@ classroom for st"dents w!th m!ld
mental retardat!on.
Reff had #een la#eled w!th m!ld mental retardat!on #ased "pon h!s scores on the &)SC-))). A year
earl!er he had o#ta!ned a 7er#al )9 of >C, a +erformance )9 of >=, and a 0"ll Scale )9 of >C.
&h!le these scores are clearly w!th!n the m!ld range of mental retardat!on, !t was reported that he
was c"lt"rally and ed"cat!onally depr!ed, wh!ch may hae negat!ely !nfl"enced h!s scores. *!s
records !ncl"ded no ment!on of scores on a meas"re of adapt!e #eha!or. Reff had a h!story of
#eha!or pro#lems and had #een s"spended from school the pre!o"s year follow!ng a f!ght w!th
another st"dent.
Reff1s teacher re("ested ass!stance !n manag!ng h!s d!sr"pt!e #eha!or !n class, and compla!ned
that h!s '#ell!gerent, d!srespectf"l att!t"de' created a classroom en!ronment that !nterfered w!th
her other st"dents1 a#!l!ty to learn. Reff1s a"nt re("ested that he #e reeal"ated #eca"se she felt he
was not mentally retarded, and that the st!gma and shame assoc!ated w!th th!s la#el was the ca"se
of h!s #eha!oral d!ff!c"lt!es !n school.
Reff1s !ntellect"al performance and adapt!e s$!lls were assessed w!th the Un!ersal Foner#al
)ntell!gence ;est 2UF);4 and the Adapt!e .eha!or Assessment System 2A.AS4. A f"nct!onal
assessment !nter!ew that !ncl"ded complet!on of the 5ot!at!on Assessment Scale 25AS4 was
carr!ed o"t, and classroom o#serat!ons were cond"cted "s!ng the 0"nct!onal Assessment
:#serat!on 0orm des!gned #y :1Fe!ll and colleag"es 21BB<4.
Assessment Protocol
S!nce pr!or lang"age assessment !nd!cated def!c!ts !n a"d!tory process!ng, and there were
concerns a#o"t poss!#le c"lt"ral #!as related to h!s earl!er test!ng w!th the &)SC-))), the UF);
was selected to reassess Reff1s !ntellect"al a#!l!ty. A f"ll scale )9 of >> was o#ta!ned, and h!s
other UF); compos!te scores fell w!th!n th!s same range.
Adapt!e #eha!or was assessed w!th the A.AS, "s!ng Reff1s a"nt and teacher as !nformants. *!s
a"nt1s rat!ngs 2adapt!e compos!te score of >=4 were h!gher than h!s teacher1s rat!ngs 2adapt!e
compos!te score of E>4, #"t st!ll w!th!n a range compat!#le w!th the d!agnos!s of mental
retardat!on. ;h!s res"lt, co"pled w!th the res"lt of !ntellect"al assessment, s"pported the earl!er
d!agnos!s of m!ld mental retardat!on.
0"nct!onal assessment !ncl"ded an !nformal !nter!ew w!th Reff1s teacher to !dent!fy the spec!f!c
pro#lem #eha!ors that were of concern. Reff ref"sed to follow h!s teacher1s commands to
complete ass!gnments, espec!ally !n the area of lang"age arts, and responded to her repeated
re("ests #y somet!mes throw!ng h!s note#oo$ and ma$!ng comments s"ch as, ')f yo" want !t
done, yo" do !t,' and '.ac$ off, teacherS' ,"r!ng the !nter!ew the 5AS was completed to help
determ!ne the f"nct!on of Reff1s #eha!or. )t was hypothes!8ed that h!s #eha!or pro!ded escape
from tas$s he fo"nd too d!ff!c"lt. Classroom o#serat!ons cond"cted w!th the 0"nct!onal
Assessment :#serat!on 0orm conf!rmed th!s hypothes!s and also !nd!cated that Reff1s o"t#"rsts
were more l!$ely !f h!s teacher threatened h!m w!th d!sc!pl!nary act!on or transfer to a 'more
appropr!ate' class.
A #eha!or !nterent!on plan was des!gned #ased "pon the res"lts of the f"nct!onal assessment.
;arget #eha!ors !ncl"ded compl!ance w!th teacher commands to complete ass!gnments,
throw!ng classroom mater!als, and d!srespectf"l comments to the teacher. ;o address the
hypothes!8ed f"nct!on of Reff1s d!sr"pt!e #eha!or the d!ff!c"lty leel and length of h!s
ass!gnments were ad3"sted, and a pos!t!e re!nforcement program was set "p to reward h!m for
completed ass!gnments. ;o address the antecedents that tr!ggered Reff1s #eha!or, commands to
complete ass!gnments were to #e repeated only once after the !n!t!al re("est and teacher
warn!ngs wo"ld no longer #e pro!ded.
:ngo!ng data collect!on proced"res were set "p !n the classroom to assess the effect!eness of
the !nterent!on. ;he ass!stant teacher recorded fre("ency data on the n"m#er of ass!gnments
g!en and completed da!ly, the n"m#er of o#3ects thrown !n class, and the n"m#er of
d!srespectf"l comments made to the teacher. A meet!ng was sched"led !n 3C days to re!ew these
data, and cons!der the need for mod!f!cat!ons !n the treatment plan.
Ca8"l =:
-!en the d!ers!ty of #eha!oral d!sr"pt!ons categor!8ed as C+ !t !s d!ff!c"lt to select one cl!n!cal
case that demonstrates the 'typ!cal' or '"s"al' assessment approach. ;he case presented here !s
that of a yo"ng ch!ld w!th s!gn!f!cant C+. ;he protocol selected matched well w!th the
deelopmental leel and present!ng concerns of th!s !nd!!d"al. &h!le th!s case !ll"strates a
m"lt!method approach that can #e ("!te "sef"l w!th yo"nger ch!ldren w!th C+, mar$edly d!fferent
assessment strateg!es may occ"r w!th older ch!ldren and adolescents.
CA5U$ 6,
Client Description
;!na was a E-year->-month-old Ca"cas!an female referred to an o"tpat!ent cl!n!c foc"sed on the
assessment and treatment of ch!ldren w!th d!sr"pt!e #eha!or pro#lems. ;!na l!ed w!th her
adopt!e father and #!olog!cal mother, 5r. and 5s. A. Accord!ng to 5s. A., ;!na had had no
contact w!th her #!olog!cal father s!nce #!rth and h!s wherea#o"ts were "n$nown. 5r. and 5s. A
had #een together s!nce ;!na was 2 months old, and th"s 5r. A. was cons!dered #y ;!na to #e her
father. ;!na was the only ch!ld of #oth her mother and adopt!e father.
!ange and History of the Disorder or Problem
;!na presented w!th a ar!ety of pro#lemat!c and d!sr"pt!e #eha!ors. She reportedly was
fre("ently noncompl!ant w!th parental !nstr"ct!ons, often w!th act!e def!ance 2e.g., yell!ng
'no'4. 0"rther, she was often possess!e and wo"ld not share well w!th other ch!ldren. She also
fre("ently #ossed others aro"nd and wanted to #e !n control 2e.g., of play or other act!!t!es4. *er
parents reported that she engaged !n fre("ent tantr"ms 2e.g., stomp!ng her feet, scream!ng,
slamm!ng doors4. 5r. and 5s. A. also reported that she fre("ently dawdled, wh!ned, and
engaged !n #ac$ tal$. ;hese pro#lems reportedly had #een present for some t!me and occ"rred !n
#oth home and school sett!ngs. 0"rther, these pro#lems appeared to #e escalat!ng d"r!ng the past
> months, desp!te no o#!o"s stressor or tr!gger!ng eent. 5r. and 5s. A. reported "s!ng ar!o"s
parent!ng strateg!es to !mproe ;!na1s #eha!or, w!th l!m!ted s"ccess. 5s. A. reported attempts at
"s!ng t!me o"t. )n!t!ally attempts were made to hae ;!na s!t !n a cha!r. Accord!ng to report, th!s
was !neffect!e. ;h"s, 5s. A. attempted to hae her stand !n a corner, aga!n w!th !neffect!e
res"lts. 5r. A. span$ed ;!na !n response to seeral of her pro#lemat!c #eha!ors, part!c"larly her
#ac$ tal$. Add!t!onally, #oth 5s. and 5r. A. reported ra!s!ng the!r o!ces at ;!na when she
engaged !n pro#lemat!c #eha!ors. )n general, 5r. and 5s. A. reported "s!ng d!screpant
approaches to d!sc!pl!ne, and each e%per!enced l!m!ted s"ccess.
;o f"lly assess the #readth, fre("ency, and seer!ty of ;!na1s present!ng concerns, a m"lt!method
assessment "s!ng "nstr"ct"red and str"ct"red !nter!ews, #road#and and narrow#and #eha!or
rat!ng scales, and d!rect o#serat!ons was completed. ;he "nstr"ct"red cl!n!cal !nter!ew was
"sed to gather general #ac$gro"nd !nformat!on 2e.g., deelopmental and med!cal h!story4 as well
as spec!f!cs a#o"t the present!ng concerns. A str"ct"red !nter!ew des!gned to gather !nformat!on
a#o"t the presence of symptoms cons!stent w!th ,S5-)7-;@ d!agnoses of :,,, C,, A,*,, or
any com#!nat!on thereof was also completed, #ased on the methodology descr!#ed #y Camp#ell
6w!ng, .rea"8, and S8"mow$s! 21B=>4. ;!na1s parents !ndependently completed the C.CL and
the 6C.). 0"rther, her $!ndergarten teacher completed the C.CL-;eacher @eport 0orm 2C.CL-
;@04 and the S6S.). 0!nally, each of ;!na1s parents !ndependently !nteracted w!th her d"r!ng
three d!fferent dyad!c parent-ch!ld !nteract!ons 2!.e., ch!ld-d!rected play analog, parent-d!rect play
analog, and clean-"pG *e#ree-K!g!n A 5cFe!l, 1BBE4. ;he therap!st o#sered the !nteract!ons
#eh!nd a one-way m!rror and doc"mented #oth ch!ld and parent #eha!or "s!ng a str"ct"red
cod!ng system.
,"r!ng dyad!c parent-ch!ld !nteract!ons, ;!na engaged !n dawdl!ng and wh!n!ng #eha!ors, as
well as noncompl!ance 2e.g., say!ng 'no'4, wh!ch were reportedly m!lder !n form than what 5r.
and 5s. A. e%per!enced at home. .oth 5s. and 5r. A. demonstrated gen"!ne pos!t!e regard for
;!na thro"gh pos!t!e phys!cal !nteract!ons and nonspec!f!c pra!se when ;!na engaged !n
appropr!ate #eha!ors. ;hey d!d, howeer, g!e many !nd!rect commands as well as d!rect
commands w!tho"t allow!ng ;!na an opport"n!ty to respond. Appro%!mately <EP of all
commands g!en were !nd!rect. Add!t!onally, they #oth demonstrated tro"#le !n allow!ng ;!na to
lead the act!!t!es when as$ed to do so #y fre("ently as$!ng her ("est!ons or d!rect!ng her play.
0!nally, they often responded w!th er#al attent!on when ;!na dawdled or wh!ned.
:n the standard!8ed #eha!or rat!ng scales 2!.e., C.CL and 6C.)4, 5s. and 5r. A.1s responses
res"lted !n d!screpant f!nd!ngs. 5s. A. responses on the C.CL !nd!cated #orderl!ne s!gn!f!cant
!nternal!8!ng 2t ? >E4 and cl!n!cally s!gn!f!cant e%ternal!8!ng 2t ? <34 pro#lem #eha!ors. Spec!f!c
s"#scales that were !n the cl!n!cal range were the del!n("ent and aggress!e factors 2t ? <3 and t
? <2, respect!ely4. )n contrast, 5r. A. responses on the C.CL s"ggested that ;!na was not
e%per!enc!ng any cl!n!cally s!gn!f!cant pro#lems, g!en that no compos!te or s"#scale scores
were s!gn!f!cantly eleated.
:n the 6C.), 5s. A. !nd!cated that 22 of the 3> !tems were pro#lemat!c for ;!na. ;he !ntens!ty
score of 1E3 was h!gher than wo"ld #e e%pected of ch!ldren ;!na1s age and s"ggested she
e%h!#!ted C+ at a fre("ency l!$ely to ca"se moderate d!sr"pt!ons !n her f"nct!on!ng. Accord!ng to
5r. A., only 1C of the 3> !tems were pro#lemat!c for ;!na, w!th an !ntens!ty score of <=. ;hese
res"lts are o#!o"sly d!screpant from those o#ta!ned from 5s. A. and s"ggest ;!na may not
engage !n as many #eha!or pro#lems !n the presence of 5r. A. Alternat!ely 5r. A.1s responses
may !nd!cate that he does not !dent!fy many of ;!na1s d!sr"pt!e #eha!ors as pro#lemat!c.
;o f"rther assess ;!na1s f"nct!on!ng, #oth 5s. and 5r. A. part!c!pated !n the str"ct"red ,S5-)7-
;@ !nter!ew for d!sr"pt!e #eha!or d!sorders. ;hey !nd!cated that ;!na was engag!ng !n seeral
oppos!t!onal and !nattent!e #eha!ors of s!gn!f!cant !ntens!ty, fre("ency, or #oth. *oweer,
res"lts of the !nter!ews were !nconcl"s!e as to a d!agnos!s.
;o assess ;!na1s #eha!oral f"nct!on!ng at school, her $!ndergarten teacher, 5rs. 5., completed
the C.CL-;@0 and the S6S.). Accord!ng to her responses on the C.CL-;@0, ;!na e%per!enced
#orderl!ne s!gn!f!cant e%ternal!8!ng #eha!or pro#lems at school 2t ? ><4. Also, she !nd!cated on
the S6S.) that 1D of the 3> !tems were pro#lemat!c for ;!na. *er !ntens!ty score of 11C s"ggests
that ;!na !s ha!ng m!ld #eha!oral d!ff!c"lt!es at school.
;a$en together, assessment res"lts s"ggested that ;!na was e%per!enc!ng cl!n!cally s!gn!f!cant
oppos!t!onal and def!ant #eha!or pro#lems #oth at home and at school. Add!t!onally, res"lts
!nd!cated that ;!na may hae #een e%per!enc!ng some !nternal!8!ng #eha!or pro#lems, as
!nd!cated #y 5s. A. Altho"gh d!screpant reports were pro!ded #y 5s. and 5r. A., they d!d state
d"r!ng the !nter!ew that ;!na d!splayed more pro#lems w!th 5s. A. Add!t!onally, 5rs. 5.1s
responses on the C.CL-;@0 and S6S.) s"ggested that ;!na was e%per!enc!ng d!ff!c"lt!es at
school. ;ogether, assessment data res"lted !n a d!agnos!s of :,,.
;he !n!t!al assessment w!th ;!na and her parents !nd!cated a ar!ety of e%ternal!8!ng #eha!oral
concerns, !ncl"d!ng pass!e and act!e noncompl!ance, #ac$ tal$, #oss!ness, and possess!eness.
0"rther, her mother1s report on C.CL s"ggested that she may hae #een e%per!enc!ng some
!nternal!8!ngHemot!onal concerns as well. ;he assessment also reealed that her parents "t!l!8ed
approaches that were m!n!mally effect!e at #est, and related to the cont!n"at!on of the #eha!or
pro#lems at worse. Spec!f!cally, her parents were o#sered to "se !nd!rect commands 2e.g.,
'&o"ld yo" please p!c$ that "pN' or '&hy don1t we clean th!s "pN'4 that are "nl!$ely to promote
compl!ance !n yo"ng ch!ldren who tend to #e noncompl!ant. Add!t!onally, 5r. A. reported
react!ng to #eha!ors s"ch as #ac$ tal$ w!th er#al and phys!cal conse("ences, wh!ch may hae
perpet"ated a coerc!e parent-ch!ld !nteract!on 2+atterson, 1B=2G +atterson et al., 1BB24. 0"rther,
t!me o"t approaches "t!l!8ed !n the past were not effect!e.
.ased on the assessment res"lts, seeral ch!ld and parent #eha!ors were selected as targets of
treatment. Spec!f!cally, ch!ld #eha!ors targeted to !ncrease !ncl"ded compl!ance w!th ad"lt
!nstr"ct!ons and appropr!ate er#al!8at!ons. Ch!ld #eha!ors targeted to decrease !ncl"ded
tantr"ms, #ac$ tal$, and wh!n!ng. +arent #eha!ors targeted for decrease !ncl"ded er#al and
phys!cal react!ons to certa!n ch!ld #eha!ors and "se of !nd!rect commands. +arent #eha!ors
targeted for !ncrease !ncl"ded select!e !gnor!ng s$!lls, g!!ng d!rect !nstr"ct!ons, pro!d!ng
la#eled pra!se, and !mplement!ng t!me o"t effect!ely.
;o eal"ate progress as a res"lt of treatment, seeral assessment meas"res were "t!l!8ed. .eca"se
therapy !noled #eha!oral parent tra!n!ng, determ!n!ng !f !nterent!on affected #oth parent and
ch!ld #eha!ors was necessary. 0"rther, eal"at!ng whether ;!na1s parents learned to effect!ely
!mplement strateg!es targeted !n treatment was a goal of o"tcome assessment. ;h"s, #oth
ongo!ng assessment and pre-post assessment was cond"cted.
;o eal"ate whether ;!na1s parents were learn!ng spec!f!c parent!ng strateg!es ta"ght d"r!ng
#eha!oral parent tra!n!ng, ch!ld-d!rected play analog o#serat!ons were cond"cted for E m!n"tes
at the #eg!nn!ng of each sess!on d"r!ng the f!rst phase of treatment. ;h!s allowed for an
assessment of whether 5r. and 5s. A. were !ncreas!ng the!r a#!l!ty to create a pos!t!e, lo!ng
!nteract!on w!th ;!na. .oth parent and ch!ld #eha!ors were coded "s!ng a str"ct"red cod!ng
system, and the data were shared w!th 5r. and 5s. A. to help them foc"s on s$!lls re("!r!ng
add!t!onal attent!on. ;!na1s parents also collected data on whether they pract!ced the parent!ng
s$!lls !n the home en!ronment d"r!ng prescr!#ed s!t"at!ons thro"gho"t therapy.
+re-post o"tcome eal"at!on !noled complet!ng the core or!g!nal assessment !nstr"ments at the
end of treatment 2!.e., 6C.), C.CL, C.CL-;@0, S6S.), str"ct"red parent-ch!ld !nteract!ons4.
;h!s allowed for: 2a4 doc"mentat!on of change !n ch!ld #eha!or, 2#4 doc"mentat!on of change !n
parent!ng #eha!or, and 2c4 assessment of general!8at!on of #eha!oral !mproements to the
school sett!ng.

Cazuri Clinice

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