Case vignettes

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PTSD case study. Please see instructions attached!

CSWE’s Core Competencies and Practice Behavior Examples in this text

Professional Identity

Practice Behavior Examples…

Serve as representatives of the profession, its mission, and its core values 3

Know the profession’s history

Commit themselves to the profession’s enhancement and to their own professional conduct
and growth

Advocate for client access to the services of social work

Practice personal reflection and self-correction to assure continual professional development

Attend to professional roles and boundaries 12

Demonstrate professional demeanor in behavior, appearance, and communication

Engage in career-long learning

Use supervision and consultation

Ethical Practice

Practice Behavior Examples…

Obligation to conduct themselves ethically and engage in ethical decision-making

Know about the value base of the profession, its ethical standards, and relevant law

Recognize and manage personal values in a way that allows professional values to guide
practice

11

Make ethical decisions by applying standards of the National Association of Social Workers’
Code of Ethics and, as applicable, of the International Federation of Social Workers/International
Association of Schools of Social Work Ethics in Social Work, Statement of Principles

12

Tolerate ambiguity in resolving ethical conflicts

Apply strategies of ethical reasoning to arrive at principled decisions 5

Critical Thinking

Practice Behavior Examples…

Know about the principles of logic, scientific inquiry, and reasoned discernment

Use critical thinking augmented by creativity and curiosity

Requires the synthesis and communication of relevant information

Distinguish, appraise, and integrate multiple sources of knowledge, including research-based
knowledge, and practice wisdom

4, 8, 9, 10

Analyze models of assessment, prevention, intervention, and evaluation 1

Demonstrate effective oral and written communication in working with individuals, families,
groups, organizations, communities, and colleagues

6

Competency Chapter

Adapted with the permission of Council on Social Work Education

CSWE’s Core Competencies and Practice Behavior Examples in this text

Competency Chapter

Diversity in Practice

Practice Behavior Examples…

Understand how diversity characterizes and shapes the human experience and is critical to the
formation of identity

2

Understand the dimensions of diversity as the intersectionality of multiple factors including age,
class, color, culture, disability, ethnicity, gender, gender identity and expression, immigration
status, political ideology, race, religion, sex, and sexual orientation

6

Appreciate that, as a consequence of difference, a person’s life experiences may include
oppression, poverty, marginalization, and alienation as well as privilege, power, and acclaim

8

Recognize the extent to which a culture’s structures and values may oppress, marginalize,
alienate, or create or enhance privilege and power

1, 5, 7

Gain sufficient self-awareness to eliminate the influence of personal biases and values in working
with diverse groups

Recognize and communicate their understanding of the importance of difference in shaping life
experiences

7, 10

View themselves as learners and engage those with whom they work as informants

Human Rights & Justice

Practice Behavior Examples…

Understand that each person, regardless of position in society, has basic human rights, such as
freedom, safety, privacy, an adequate standard of living, health care, and education

Recognize the global interconnections of oppression and are knowledgeable about theories of
justice and strategies to promote human and civil rights

Incorporates social justice practices in organizations, institutions, and society to ensure that
these basic human rights are distributed equitably and without prejudice

5

Understand the forms and mechanisms of oppression and discrimination 2

Advocate for human rights and social and economic justice

Engage in practices that advance social and economic justice

Research-Based Practice

Practice Behavior Examples…

Use practice experience to inform research, employ evidence-based interventions, evaluate their
own practice, and use research findings to improve practice, policy, and social service delivery

1, 4

Comprehend quantitative and qualitative research and understand scientific and ethical
approaches to building knowledge

Use practice experience to inform scientific inquiry

Use research evidence to inform practice 9

CSWE’s Core Competencies and Practice Behavior Examples in this text

Human Behavior

Practice Behavior Examples…

Know about human behavior across the life course; the range of social systems in which people
live; and the ways social systems promote or deter people in maintaining or achieving health
and well-being

Apply theories and knowledge from the liberal arts to understand biological, social, cultural,
psychological, and spiritual development

2

Utilize conceptual frameworks to guide the processes of assessment, intervention, and
evaluation

4, 8, 11,13

Critique and apply knowledge to understand person and environment. 4, 7, 13

Policy Practice

Practice Behavior Examples…

Understand that policy affects service delivery and they actively engage in policy practice

Know the history and current structures of social policies and services; the role of policy in
service delivery; and the role of practice in policy development

Analyze, formulate, and advocate for policies that advance social well-being 7, 9

Collaborate with colleagues and clients for effective policy action 8

Practice Contexts

Practice Behavior Examples…

Keep informed, resourceful, and proactive in responding to evolving organizational,
community, and societal contexts at all levels of practice

Recognize that the context of practice is dynamic, and use knowledge and skill to respond
proactively

Continuously discover, appraise, and attend to changing locales, populations, scientific and
technological developments, and emerging societal trends to provide relevant services

9, 11

Provide leadership in promoting sustainable changes in service delivery and practice to improve
the quality of social services

10

Competency Chapter

CSWE’s Core Competencies and Practice Behavior Examples in this text

Engage, Assess Intervene, Evaluate

Practice Behavior Examples…

Identify, analyze, and implement evidence-based interventions designed to achieve client goals

Use research and technological advances

Evaluate program outcomes and practice effectiveness

Develop, analyze, advocate, and provide leadership for policies and services

Promote social and economic justice

A) ENGAGEMENT

Substantively and effectively prepare for action with individuals, families, groups, organizations,
and communities

3

Use empathy and other interpersonal skills 13

Develop a mutually agreed-on focus of work and desired outcomes

B) ASSESSMENT

Collect, organize, and interpret client data

3

Assess client strengths and limitations 2, 12

Develop mutually agreed-on intervention goals and objectives 5

Select appropriate intervention strategies

C) INTERVENTION

Initiate actions to achieve organizational goals

Implement prevention interventions that enhance client capacities 12

Help clients resolve problems

Negotiate, mediate, and advocate for clients 5

Facilitate transitions and endings

D) EVALUATION

Critically analyze, monitor, and evaluate interventions

3, 6

Competency Chapter

Mental Health
in Social Work

A Casebook on Diagnosis and Strengths-
Based Assessment

Jacqueline Corcoran
Virginia Commonwealth University

Joseph Walsh
Virginia Commonwealth University

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S e c o n d E d i t i o n

DSM-5 update

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Library of Congress Cataloging-in-Publication Data
Corcoran, Jacqueline.
Mental health in social work : a casebook on diagnosis and strengths based assessment /
Jacqueline Corcoran, Virginia Commonwealth University, Joseph Walsh, Virginia Commonwealth
University. — Updated second edition.
pages cm
Includes bibliographical references and index.
ISBN-13: 978-0-205-99103-7 (alk. paper)
ISBN-10: 0-205-99103-3 (alk. paper)
1. Community mental health services—Case studies. 2. Psychiatric social work—Case
studies. 3. Medical social work—Case studies. I. Walsh, Joseph (Joseph F.) II. Title.
RA790.6.C64 2015
362.2’2—dc23

2013038117

10 9 8 7 6 5 4 3 2 1

ISBN-10: 0-205-99103-3
ISBN-13: 978-0-205-99103-7

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Contents

Preface xii

Part OnE: aSSESSmEnt

1. Diagnosis and the Social Work Profession 1
The DSM Classification System 3
Mental Status Examination 4

Rationale for the Diagnosis 5
Limitations of the DSM 6

2. Biopsychosocial risk and resilience and Strengths assessment 8
Definitions and Description 8
Individual Factors 9

Biological Mechanisms 9
Psychological Mechanisms 11

Social Mechanisms 12
Family 12
Neighborhood 14
Social Support Networks 15

Societal Conditions 15
The Health and Mental Health Care System 16
Poverty 17
Ethnicity 17

Guidelines for Eliciting and Enhancing Client Strengths 18
Conclusion 22

Part tWO: nEurODEvElOPmEntal DiSOrDErS

3. autism Spectrum Disorder 23
Prevalence and Comorbidity 24
Assessment 24
Biopsychosocial Risk and Resilience Influences 28

vii

viii Contents

Onset 28
The Course of Autism Spectrum Disorder 30

Interventions 31
Special Education 31
Family Education, Support, and Involvement 32
Behavioral Management 32
Medication 32
Social Skills Training 33
Complementary and Alternative Treatments 33
Interventions for Adolescents and Adults 33

Critical Perspective 34

4. neurodevelopmental Disorders 39
Prevalence and Comorbidity 40
Assessing ADHD 40
Biopsychosocial Risk and Resilience Influences 43

Onset 43
Course and Recovery 45

Intervention 46
Psychosocial Intervention 46
Medication 47

Critique 47
Critical Perspective 48

Part thrEE: SChizOPhrEnia SPECtrum anD OthEr
PSyChOtiC DiSOrDErS

5. Schizophrenia 52
Prevalence and Comorbidity 52
Assessment 53
Biopsychosocial Risk and Resilience Influences 56

Onset 56
Biological Influences 56
Course and Recovery 58

Intervention 59
Medications 59
Psychosocial Interventions 60

Critical Perspective 64

ix Contents

Part FOur: BiPOlar anD rElatED DiSOrDErS

6. Bipolar and related Disorders 68
Prevalence and Comorbidity 69
Assessment of Bipolar Disorder 71
Biopsychosocial Risk and Resilience Influences 72

Onset 72
Course and Recovery 73

Intervention 76
Medications 76
Psychosocial Interventions 78

Critical Perspective 79

Part FivE: DEPrESSivE DiSOrDErS

7. Depressive Disorders 85
Prevalence and Comorbidity of Depression 85
Assessment 86
Biopsychosocial Risk and Resilience Influences 89

Onset 89
Course and Recovery 90

Intervention 91
Psychotherapy 92
Medication 93

Critical Perspective 96

Part Six: thE anxiEty, OBSESSivE-COmPulSivE, anD trauma
anD StrESSOr-rElatED DiSOrDErS

8. the anxiety, Obsessive-Compulsive, and trauma and Stressor-related
Disorders 100

Prevalence and Comorbidity 102
Assessment of the Anxiety Disorders 102

Assessment Concerns Specific to PTSD 103
Biopsychosocial Risk and Resilience Influences 105

Onset 105
Course and Recovery 107

Intervention 108
Psychosocial Interventions 108
Medication 110

Critical Perspective 110

x Contents

Part SEvEn: FEEDing anD Eating DiSOrDErS

9. Eating Disorders 114
Prevalence and Comorbidity 115
Assessment 116
Biopsychosocial Risk and Resilience Influences 118

Onset 118
Course and Recovery 121

Intervention 123
Treatment Settings 123
Psychosocial Interventions 123
Medication 125

Critical Perspective 125

Part Eight: DiSruPtivE, imPulSE COntrOl, anD COnDuCt
DiSOrDErS

10. Oppositional Defiant Disorder and Conduct Disorder 130
Prevalence and Comorbidity 130
Assessment of Odd and CD 130
Biopsychosocial Risk and Resilience Influences 133

Onset 133
Course and Recovery 135

Interventions for Odd and CD 135
Psychosocial Interventions 135
Medication 136

Critical Perspective 137

Part ninE: SuBStanCE-rElatED anD aDDiCtivE DiSOrDErS

11. Substance-related and addictive Disorders 142
Prevalence and Comorbidity 142
Assessment 143
Biopsychosocial Risk and Resilience Influences 147

Onset 147
Course and Recovery 149

Intervention 150
Psychosocial Treatments 151
Pharmacologic Interventions 153

Critical Perspective 155

xi Contents

Part tEn: nEurOCOgnitivE DiSOrDErS

12. alzheimer’s Disease 159
Prevalence and Comorbidity 160
Assessment Guidelines 160
Biopsychosocial Risk and Resilience Influences 162

Onset 162
Course and Recovery 163

Intervention 165
Goals 165
Psychosocial Interventions 165
Nutritional Interventions 167
Medications 167
Interventions for Caregivers 168

Critical Perspective 168

Part ElEvEn: PErSOnality DiSOrDErS

13. Borderline Personality Disorder 174
Characteristics of Personality Disorders 175
Borderline Personality Disorder 176
Prevalence and Comorbidity 176
Assessment 177
Biopsychosocial Risk and Resilience Influences 179

Onset 179
Course and Recovery 181

Intervention 183
Psychosocial Interventions 183
Medications 185

Critical Perspective 186

Appendix: Case Workbook 191
Index 268

xii

Preface

Mental Health in Social Work: A Casebook on Diagnosis and Strengths-Based Assessment is a
graduate-level textbook that will help students and professionals learn to understand clients
holistically as they proceed with the assessment and intervention process. A major purpose
of Mental Health in Social Work is to familiarize readers with the American Psychiatric
Association’s Diagnostic and Statistical Manual (DSM) classification of mental disorders.
The primary reasons that social workers need to become conversant with the DSM are
the following: (1) to offer clients appropriate referrals and treatment; (2) to communicate
effectively with other mental health professions; and (3) to be eligible for third-party
reimbursement.

The learning in Mental Health in Social Work primarily occurs through a case study
method; students are asked to respond to case illustrations that are presented in each
chapter. Cases (two to three in each chapter) have been selected to represent the diversity
of people with whom social workers intervene. Answers to the questions posed about each
case are provided in an instructor’s manual and should be discussed in class and/or through
feedback on case study assignments. Note that in order to complete the diagnosis in each
case, readers will have to use the DSM-5.

While gaining competence in DSM diagnosis, the reader is also taught to maintain a
critical perspective on the various DSM diagnoses and the medical model as promulgated
through the DSM. The field of social work has a focus not just on the individual, but on
the person within an environmental context, and concerns itself with strengths as well
as problems. Additionally, social work has a traditional commitment to oppressed and
vulnerable populations. Because the DSM is limited in these areas, Mental Health in
Social Work includes the biopsychosocial risk and resilience perspective, which takes into
account both risks and strengths at the individual and environmental levels. Each chapter
then explores the relevant risk and protective influences for each disorder, highlighting
some of the particular risks for special populations, including children, women, the elderly,
minorities, people with disabilities, gay and lesbian individuals, and those from low socio-
economic strata. Students are asked to complete risk and resilience assessments for the case
studies presented.

Another emphasis in Mental Health in Social Work is evidence-based treatment, a
recent movement in social work and various other health and mental health disciplines.
The meaning of evidence-based practice can be debated (Norcross, Beutler, & Levant,
2006), but has been generally defined as the prioritization of research evidence when
social workers consider how to best help clients. However, client preferences and avail-
able resources must also be part of the process of clinical judgment in addition to research
studies (Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000). In considering the
hierarchy of evidence, whenever possible we rely on systematic reviews and meta-analyses,
which are considered “first-line evidence” (Petticrew & Roberts, 2006). These systematic
reviews aim to comprehensively locate and synthesize the treatment outcome literature in
a particular area. If the review lends itself to combining the results of primary studies in a
quantitative way, then it is referred to as meta-analysis (Petticrew & Roberts, 2006).

From these reviews of the literature, Mental Health in Social Work presents treatment
guidelines for each disorder covered in the book, and through the case studies, students
will learn how to form evidence-based treatment plans. At the same time, in keeping with

xiii Preface

the importance of the environmental context, interventions address the broad nature of
the concerns that people bring to social work professionals. For instance, if socioeconomic
problems, such as lack of health insurance and unemployment, are part of the client’s pre-
senting problems, then intervention will appropriately address these concerns, as they are
critical to a person’s well-being and healthy functioning.

The Council on Social Work Education has implemented educational policy and accred-
itation standards that involve competencies and the practice behaviors associated with them
that social workers are to learn. As a result, Mental Health in Social Work has become part of
the Advancing Core Competencies series. The following table demonstrates how the competen-
cies and practice behaviors are an integral part of this book. Additionally, each chapter includes
critical thinking questions that exemplify the competences and practice behaviors.

In summary, this book takes a case study approach, with students applying evidence-
based information on mental disorders to build their social work competency in terms of
assessment and treatment of mental illness.

Social Work Competencies Addressed in Casebook Exercises
Competency Practice behaviors Casebook application

Competency 2.1.1—
Identify as a profes-
sional social worker
and conduct oneself
accordingly

P.B. 2.1.1a: Readily identify
as social work professionals
P.B. 2.1.1c: Manage
assessment interviews with
clients, using the person-
in-environment perspective

The social work perspective is balanced with the
biomedical perspective of DSM with the risk and
resilience biopsychosocial assessment. An overall
critique of DSM is offered in chapter 1 and for
each DSM disorder.

Competency 2.1.4—
Engage diversity and
difference in practice

P.B. 2.1.4a: Research
and apply epidemiologi-
cal knowledge of diverse
populations and their
mental/behavioral disorders

A chart for each mental disorder with a discussion
of socially diverse populations.

P.B. 2.1.4.Fa: Recognize the
extent to which a culture’s
structures and values may
oppress, marginalize,
alienate, or create or
enhance privilege and power

A critique of the DSM and its association with our
culture’s power structures is presented in chapter 1.

Directions for each case study include Critical
Perspective: Formulate a critique of the diagnosis
as it relates to the case example. Questions
to consider include the following: Does this
diagnosis represent a valid mental disorder from
the social work perspective? How does oppres-
sion, discrimination, and trauma play out in
the development of the disorder? Your critique
should be based on the values of the social work
profession (which are incongruent in some ways
with the medical model) and the validity of the
specific diagnostic criteria applied to this case
(i.e., is this diagnosis significantly different from
other possible diagnoses?).

Competency
2.1.3—Apply critical
thinking to inform
and communicate
professional
judgments

P.B. 2.1.3c: Identify and
articulate clients’ strengths
and vulnerabilities as part of
the assessment

Directions for each case study include
Biopsychosocial Risk and Resilience Assessment:
Formulate a risk and resilience assessment, both
for the onset of the disorder and for the course of
the disorder, including the strengths that you see
for this individual and the techniques you would
use to elicit them.

xiv Preface

Competency Practice behaviors Casebook application

Competency 2.1.5—
Advance human
rights and social and
economic justice

P.B. 2.1.5a: Use knowledge
of the effects of oppression,
discrimination, and trauma
on development of clients’
mental/emotional/behav-
ioral disorders

Directions for each case study include Critical
Perspective: Formulate a critique of the diagnosis
as it relates to the case example. Questions to
consider include the following: Does this diag-
nosis represent a valid mental disorder from the
social work perspective? How does oppression,
discrimination, and trauma play out in the devel-
opment of the disorder? Your critique should be
based on the values of the social work profession
(which are incongruent in some ways with the
medical model) and the validity of the specific
diagnostic criteria applied to this case (i.e., is this
diagnosis significantly different from other pos-
sible diagnoses?).

Competency
2.1.6—Engage in
research-informed
practice

P.B. 2.1.6a: Use research
knowledge to inform clinical
assessment/diagnosis

Evidence-based assessment and practice guide-
lines are presented based on the latest research
for each disorder.

Competency 2.1.7—
Apply knowledge
of human behav-
ior and the social
environment

P.B. 2.1.7a: Synthesize and
differentially apply biologi-
cal, developmental, social,
and other theories of etiol-
ogy associated with specific
mental, emotional, and
behavioral disorders

The latest research on etiological factors associ-
ated with mental disorders in general (chapter 2)
and for each mental disorder is presented.

P.B. 2.1.7b: Use a
biopsychosocial-spiritual
perspective and diagnostic
classification system to for-
mulate differential diagnoses

Directions for each case study include Diagnosis:
Prepare the following: a diagnosis, the rationale
for the diagnosis, and additional information you
would have wanted to know in order to make a
more accurate diagnosis.

P.B. 2.1.7.Fa: Utilize
conceptual frameworks
to guide the processes of
assessment, intervention,
and evaluation.

Strengths-based assessment techniques, solution-
focused therapy, and motivational interviewing
are covered in chapter 2. Theories of evidence-
based intervention are covered for each mental
disorder.

P.B 2.1.7b: Critique and
apply knowledge to
understand person and
environment

Directions for each case study include
Biopsychosocial Risk and Resilience Assessment:
Formulate a risk and resilience assessment, both
for the onset of the disorder and for the course of
the disorder, including the strengths that you see
for this individual and the techniques you would
use to elicit them.

Competency 2.1.3—
Apply critical thinking
to inform and com-
municate professional
judgments
P.B. 2.1.3.b: Analyze
models of assess-
ment, prevention,
intervention, and
evaluation (S)

P.B. 2.1.3.a: Distinguish,
appraise, and integrate
multiple sources of
knowledge, including
research-based knowledge,
and practice wisdom (S)

Directions for each case study include Goal
Setting and Treatment Planning: Given your risk
and resilience assessments of the individual, your
knowledge of the disorder, and evidence-based
practice guidelines, formulate goals and a pos-
sible treatment plan for this individual.

xv Preface

acknowledgments

The case studies that make up this book are based on our clinical practice and the
contributions of our students and other professionals. As the application of assessment
competencies is a core element of this book, we are truly grateful to the following students
who offered case contributions: Susan Bienvenu, Treva Bower, Lindsay Doles, Martha Dunn,
Gidget Fields, Lisa Genser, Carolynn Ghiloni, Christine Gigena, Dana Gilmore, Kristine
Kluck, Elizabeth Lincoln, Pamela McDonald, Jodee Mellerio, Cynthia Ormes, Kristi Payne,
Constance Ritter, Zoe Rizzuto, Heather Roberts, Anne Ross, Amelia Schor, Tina Shafer,
Rebecca Sorensen, Megan Vogel, Raquelle Ward, and Dallas Williams. We are also indebted
to the following social work professionals: Kim Giancaspro, Kris McAleavey, and Adina
Shapiro. Most of all, we want to thank Shane Fagan for tirelessly reading over case studies
and offering her valued clinical opinions.

We thank the reviewers for their suggestions: Chrystal Baranti, California State
University; Laura Boisen, Augsberg College; Daphne S. Cain, Louisiana State University;
Rebecca T. Davis, Rutgers University; and Judith H. Rosenberg, Central Connecticut State
University.

As always, thanks to Patrick Corcoran for his diligent and conscientious proofreading,
helping us to prepare the best book we can put forward.

This text is available in a variety of formats—digital and print. To learn more about our
programs, pricing options, and customization, visit www.pearsonhighered.com.

Competency Practice behaviors Casebook application

Competency
2.1.10—Assess
with individuals,
families, groups,
organizations, and
communities

P.B. 2.10.d: Collect,
organize, and interpret
data (P)

Directions for each case study include Diagnosis:
Given the case information, prepare the
following: a diagnosis, the rationale for the
diagnosis, and additional information you would
have wanted to know in order to make a more
accurate diagnosis.

P.B. 2.10.e: Assess client
strengths and limitations (P)

Directions for each case study include
Biopsychosocial Risk and Resilience Assessment:
Formulate a risk and resilience assessment, both
for the onset of the disorder and for the course of
the disorder, including the strengths that you see
for this individual and the techniques you would
use to elicit them.

P.B. 2.10.g: Select
appropriate intervention
strategies (P)

Directions for each case study include Goal
Setting and Treatment Planning: Given your risk
and resilience assessments of the individual, your
knowledge of the disorder, and evidence-based
practice guidelines, formulate goals and a pos-
sible treatment plan for this individual.

This page intentionally left blank

1

Diagnosis and the Social Work
Profession

Henry Williams, a 59-year-old African American, was in the hospital after undergoing surgery for
removal of a brain tumor. His past medical history included seizures, insulin-dependent diabetes
mellitus, and pancreatitis (an inflammation of the pancreas that causes intense pain in the upper
abdomen). Currently, Mr. Williams was taking several medications, including Dilantin (used to
treat epilepsy), insulin, and steroids (to decrease swelling around his tumor).

About six days after the surgery, Mr. Williams woke up in the middle of the night and
was very loud in “casting the demons out,” as he called it. The nurse tried to calm him, but
Mr. Williams was so incensed that he picked up a small monitoring machine next to his bed and
threw it at her. Security officers and the on-duty physician assistant were called to calm the patient.

The next morning, the neurosurgery team requested a psychiatric exam, but because it
was a Friday Mr. Williams was not examined until the following Monday. His family visited over
the weekend, and he repeatedly became agitated, even accusing his wife of cheating on him.
He was upset and emotional during those visits, and it took him a while to calm down after his
family left.

On Sunday night, Mr. Williams got up at midnight and threatened his roommate.
Mr. Williams yelled that his roommate was cheating on him with his wife and they were plotting
to kill him. Because his roommate feared for his safety, he was moved to another room, while
the nurse tried to calm Mr. Williams.

When the psychiatric team, accompanied by the social work intern, finally examined
Mr. Williams, he said he felt great but was hearing voices, most prominently that of his pastor.
He reported that he saw demons at night and was attempting to fight them off. He also stated
that he thought someone wanted to kill him to benefit from his life insurance policy. In addition,
Mr. Williams told the psychiatrist that his wife had not come to visit him for some days (this was
not true; she had been there twice over the weekend) but that his son had been at his bedside
in the morning and that he had enjoyed the visit.

Mr. Williams’s wife heard about the incident with the roommate and said she would not
take Mr. Williams home because she was afraid of him. She told the social work intern that
Mr. Williams had behaved similarly in the past. She would sometimes wake up in the middle of
the night and find him standing next to the bed or leaning over her body, staring at her. When
she confronted her husband, he would pass it off as a joke, saying he was making sure she was
really in bed and had not gone out. (They had separate bedrooms.) She also told the intern that
although she had never cheated on her husband, he had had an affair several years ago. After
she found out, they went to marriage counseling together, but the marriage had been “rocky”
ever since.

C h a p t e r 1

Part One: Assessment2

T
he case described is one in which the client, Mr. Williams, appears to have a men-
tal disorder. Almost half of all Americans (46.4%) meet the criteria for a mental,
emotional, or behavioral disorder sometime during their lives (Kessler, Berglund

et al., 2005). The various disorders are catalogued and described in the Diagnostic and
Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric
Association (APA). The DSM is the standard resource for clinical diagnosis in the United
States. The first edition of the DSM was published in 1952, and the manual has undergone
many revisions during the last 60 years. The latest version is DSM-5, published in May 2013.

The definition of mental disorder in DSM-5 (APA, 2013) is a “syndrome character-
ized by clinically significant disturbance in an individual’s cognition, emotion regulation,
or behavior that reflects a dysfunction in the psychological, biological, or developmen-
tal processes underlying mental functioning” (p. 20). Such a disorder usually represents
significant distress in social or occupational functioning. The DSM represents a medical
perspective, only one of many possible perspectives on human behavior. The medical defi-
nition focuses on underlying disturbances within the person and is sometimes referred to
as the disease model of abnormality. This model implies that the abnormal person must
experience changes within the self (rather than create environmental change) in order to be
considered “normal” again.

In its desire to promote the “objectivity” of its manual, the APA does not recognize the
notion of mental illness as a social construction. A social construction is any belief system
in a culture that is accepted as factual or objective by many of its members, when in fact
the belief system is constructed by influential members of that society (Farone, 2003). The
medical profession holds great influence in Western society, so when mental health diagno-
ses are presented as scientifically based disorders, many people accept them as such. Social
constructionism asserts that many “accepted” facts in a society are in fact ideas that reflect
the values of the times in which they emerge.

The foregoing information may explain why the DSM classification system does
not fully represent the knowledge base or values of the social work profession, which
emphasizes a transactional, person-in-situation perspective on human functioning. Still,
the DSM is extensively used by social workers, for many positive reasons. Worldwide,
the medical profession is preeminent in setting standards for mental health practice, and
social workers are extensively employed in mental health settings, where clinical diagno-
sis is considered necessary for selecting appropriate interventions. In fact, social workers
account for more than half of the mental health workforce in the United States (Whitaker,
2009). Competent use of the DSM is beneficial to social workers (and clients) for the
following reasons:

• Social workers are employed in a variety of settings, not just mental health agencies
and facilities, where they meet people who are vulnerable to mental health disorders
because of poverty, minority status, and other social factors. No matter what
their setting, social workers should be able to recognize the symptoms of possible
disorders in their clients and appropriately refer them for treatment services.

• The diagnostic system provides the partial basis of a comprehensive bio- psycho-
social assessment.

• An accurate diagnosis facilitates the development of a suitable intervention plan
(although many interventions are available for persons with the same diagnosis).

• The diagnostic categories enable social workers to help clients, and possibly also
their families, learn about the nature of the client’s problems. Although stigma is
often attached to the assignment of a diagnostic label, many people take a certain
comfort in learning that their painful experiences can be encapsulated in a diagno-
sis that is shared by others. It validates their experience and offers hope that their
problems can be treated.

Diagnosis and the Social Work Profession 3

• Use of the DSM allows practitioners from various disciplines to converse in a
common language about clients.

• The DSM perspective is incorporated into professional training programs offered
by a variety of human service professions and portions of state social worker
licensing examinations.

• Insurance companies usually require a formal DSM diagnosis for client
reimbursement.

For these many reasons, social workers need to gain competence in DSM diagnosis,
and enabling them to do so is a major purpose of this book. To that end, each chapter cov-
ers a particular mental disorder and is illustrated with two to three case studies on which
readers can practice their skills and knowledge. Cases have been selected to represent the
diversity of people with whom social workers intervene. The disorders chosen for this book
are those that social workers may see in their employment or field settings and that have
sufficient research information behind them. For instance, reactive attachment disorder is
not included, even though child clients may carry this diagnosis, because there has been
relatively little research on the disorder itself, despite the fact that data have been gathered
throughout the years on attachment theory and attachment styles.

We now turn to an overview of the DSM classification system, using the case that
opened the chapter as an illustration. We will later describe some of the tensions involved
in DSM diagnosis as practiced by social workers and discuss how this book will help
develop social workers’ skills in ways that will overcome some of the limitations of the DSM
approach to clinical practice.

The DSM ClaSSifiCaTion SySTeM

Following is a description of the DSM classification system of mental disorders, along with
some general guidelines for its use (APA, 2013).

Beginning with the problem that is most responsible for the current evaluation, the
mental disorder is recorded. Most major diagnoses also contain subtypes or specifiers
(e.g., “mild,” “moderate,” and “severe”) for added diagnostic clarity. When uncertain if a
diagnosis is correct, the social worker should use the “provisional” qualifier, which means
he or she may need additional time or information to be confident about the choice. It is
important to recognize that more than one diagnosis can be used for a client, and medical
diagnoses should also be included if they are significant to the client’s overall condition.
Social workers cannot make medical diagnoses, of course, but they can be included if they
are noted in a client’s history or the client reports their existence. Further, if a person no
longer meets criteria for a disorder that may be relevant to his or her current condition, the
qualifier “past history” can be used, although this would not be the primary diagnosis. For
example, if a woman seeks help for depression while she is pregnant, it may be important
to note if she had an eating disorder history. Social and environmental problems that are
a focus of clinical attention may also be included as part of the diagnosis. A chapter in the
DSM titled “Other Conditions That May Be a Focus of Clinical Attention” includes a list of
conditions (popularly known as V-codes) that are not considered formal diagnoses but can
be used for that descriptive purpose.

Following is a list of “hierarchical principles” that can help the practitioner decide
which diagnoses to use in situations where several might be considered:

• “Disorders due to a general medical condition” and “substance-induced disorders,”
which include not only substances people consume but also medications they are
prescribed, preempt a diagnosis of any other disorder that could produce the same
symptoms.

Part One: Assessment4

• The fewer diagnoses that account for the symptoms, the better. This is the rule of
“parsimony.” Practitioners need to understand the “power of the diagnostic label,”
in its negative as well as positive aspects, and use diagnostic labels judiciously. For
example, posttraumatic stress disorder (PTSD) and reactive attachment disorder
are sometimes diagnosed simultaneously in children. Although they share some
presentation, when they are used together, the diagnostic picture becomes impre-
cise and does not lead to a coherent treatment plan.

• When a more pervasive disorder has essential or associated symptoms that are
the defining symptoms of a less pervasive disorder, the more pervasive disorder
is diagnosed if its criteria are met. For example, if symptoms of both “autism
spectrum disorder” and “specific communication disorder” are present, the social
worker should use the former diagnosis, because its range of criteria overlaps with
the latter one (see chapter 3 for case examples).

The principles outlined earlier are, of course, applied only after a comprehensive client
assessment is carried out. Each chapter in this book includes assessment principles relevant
to specific disorders, but here we present some general guidelines for the assessment of a
client’s mental, emotional, and behavioral functioning.

MenTal STaTuS exaMinaTion

A Mental Status Examination (MSE) is a process by which a social worker or other human
services professional systematically examines the quality of a client’s mental functioning.
Ten areas of functioning are considered individually. The results of the examination are
combined with information derived from a client’s social history to produce clinical
impressions of the client, including a DSM diagnosis. An MSE can typically be completed
in 15 minutes or less. One commonly used format for an MSE evaluates the following areas
of client functioning (Daniel & Gurczynski, 2003):

• Appearance. The person’s overall appearance in the context of his or her cultural
group. These features are significant because poor personal hygiene or grooming may
reflect a physical inability to care for one’s physical self or a loss of interest in doing so.

• Movement and behavior. The person’s manner of walking, posture, coordination,
eye contact, and facial expressions. Problems with walking or coordination may
reflect a disorder of the central nervous system.

• Affect. This refers to a person’s outwardly observable emotional reactions and may
include either a lack of emotional response or an overreaction to an event.

• Mood. The underlying emotional tone of the person’s answers.
• Speech. The volume of the person’s voice, the rate or speed of speech, the length of

answers to questions, and the appropriateness and clarity of the answers.
• Thought content. Any indications in the client’s words or behaviors of hallucina-

tions, delusions, obsessions, symptoms of dissociation, or thoughts of suicide.
• Thought process. The logical connections between thoughts and their relevance to

the conversation. Irrelevant detail, repeated words and phrases, interrupted thinking,
and illogical connections between thoughts may be signs of a thought disorder.

• Cognition. The act or condition of knowing. The social worker assesses the per-
son’s orientation with regard to time, place, and personal identity; long- and short-
term memory; ability to perform simple arithmetic (counting backward by threes
or sevens); general intellectual level or fund of knowledge (identifying the last five
presidents, or similar questions); ability to think abstractly (explaining a proverb);
ability to name specified objects and read or write complete sentences; ability to
understand and perform a task (showing the examiner how to comb one’s hair or

Diagnosis and the Social Work Profession 5

throw a ball); ability to draw a simple map or copy a design or geometrical figure;
ability to distinguish between right and left.

• Judgment. The social worker asks the person what he or she would do about a
commonsense problem, such as running out of a prescription medication.

• Insight. A person’s ability to recognize a problem and understand its nature and
severity.

Abnormal results for an MSE include any evidence of brain damage or thought dis-
orders, a mood or affect that is clearly inappropriate to its context, thoughts of suicide,
disturbed speech patterns, dissociative symptoms, and delusions or hallucinations.

Directions: Now that you have read a description of the diagnostic system,
hierarchical principles, and an MSE, can you work out a diagnosis for Henry
Williams before reading ahead?

Diagnosis

Diagnosis of Mr. Williams

292.12 Medication-induced psychotic disorder, with onset during intoxication,
severe

F19.959 without use disorder
250.01 Insulin-dependent diabetes mellitus
225.2 Meningioma (cerebral)
345.10 Seizure disorder
577.1 Pancreatitis
V61.10 Relational distress with spouse

Rationale for the Diagnosis

Medication (steroid)–induced psychotic disorder was diagnosed because Mr. Williams’s
symptoms began a few days after he started to take the medication. Steroids can affect the
limbic system, causing aggression and emotional outbursts. Although this diagnosis would
have to be made by medical personnel, the social worker should be aware that the symp-
toms of apparent mental disorders may result from a medical condition or from medication
used to treat the condition. A diagnosis of psychotic disorder due to a medical condition
was excluded because Mr. Williams did not show symptoms before or immediately after
the craniotomy was performed. They developed six days after the surgery.

The “with onset during intoxication” specifier was used because the symptoms devel-
oped after Mr. Williams began taking the medication, rather than after he terminated it
(which would be a withdrawal state). The “severe” specifier indicates that the symptoms
(delusions and hallucinations) are dramatic, present, and severe. (The delusions may have

Part One: Assessment6

a basis in reality, even though he was the one who had had an affair. Projection of his
own behavior onto his wife may have caused the delusion.) It should also be noted that
Mr. Williams had just had a brain tumor removed; changes in mood and affect are fairly
common in these patients. Finally, the “without use disorder” specifier indicates that
Mr. Williams does not have an existing substance use disorder apart from what he is now
experiencing. (We also note here that some, but not all, specifiers have numerical codes, as
is true in this case.)

While four other diagnoses refer to Mr. Williams’s medical condition, the final nota-
tion (“relational distress with spouse”) is included to indicate that his marital situation will
be a focus of the overall intervention.

liMiTaTionS of The DSM

Any classification of mental, emotional, and behavioral disorders is likely to be flawed, as
it is difficult for any system to capture the complexity of human life. As noted earlier, the
DSM classification system is based on a medical model of diagnosis, while the profession
of social work is characterized by the consideration of systems and the reciprocal impact of
persons and their environments on human behavior. That is, for social workers the quality
of a person’s social functioning should be assessed with regard to the interplay of biological,
psychological, and social factors. Three types of person-in-environment situations likely
to produce problems in social functioning include life transitions, relationship difficulties,
and environmental unresponsiveness (Carter & McGoldrick, 2005). Social work interven-
tions, therefore, may focus on the person, the environment, or, more commonly, both.
Some other limitations of the DSM from the perspective of the social work profession are
described on the following pages. Additionally, each chapter offers critiques of the particu-
lar DSM diagnosis and the medical perspective underlying it. Readers are encouraged to
offer a critical perspective when presented with each of the case illustrations.

One of the criticisms of the DSM is that the reliability of diagnosis (agreement among
practitioners about the same clients) is not high for some disorders, and generally has
not risen significantly since DSM-II (Duffy, Gillig, & Tureen, 2002). Second, psychiatric
diagnoses are often based on cultural notions of normality versus abnormality (Maracek,
2006). For example, homosexuality was considered a mental disorder until 1974, when
political pressure on the creators of the DSM was successfully applied (Kutchins & Kirk,
1997). Gender dysphoria was considered to be a disorder (gender identity disorder) until
the publication of DSM-5. It had been classified as a sexual disorder but now occupies its
own chapter in the text and the term disorder is no longer affixed to it.

Third, arising as it does from the psychiatric profession, the DSM may overstate the
case for biological influences on some mental disorders (Cooper, 2004; Healy, 2002;
Johnston, 2000). For instance, heritability for both major depression and anxiety is about
30 to 40% (Hettema, Neale, & Kendler, 2001; Sullivan, Neale, & Kendler, 2000); for
substance use disorders heritability is about 30% (Walters, 2002). Although other biolog-
ical factors may play a role in the development of mental disorders aside from genetics
(e.g., complications at birth, exposure to lead), social factors (family environment,
community, social support, income levels) certainly play a large role.

Fourth, in a related vein, the DSM tends to view clients in isolation and decontex-
tualizes the disorder from the person and the life circumstances that have given rise to
it (Westen, 2005). Generally speaking, the DSM does not highlight the roles played by
systems in the emergence of problems. Some parts of the DSM do so, however, such as
with the “adjustment disorders,” in which people are seen as having difficulty adjusting to
environmental stressors. Further, social workers have the opportunity to make diagnostic

Diagnosis and the Social Work Profession 7

reference to personal and the social aspects of life in the diagnosis through the use of
V-codes.

Fifth, some feminists argue that the DSM is gender-biased, according a much higher
prevalence of many disorders to women than men (notably depression, anxiety, and many
of the personality disorders) (Wiley, 2004). The DSM has been criticized for blaming
women for their responses to oppressive social conditions (Blehar, 2006).

Sixth, because not all symptoms need to be met for any diagnosis to be made, two
people with the same diagnosis can have very different symptom profiles. There is also an
acknowledged abundance of “sub-threshold cases” (those that do not quite meet the mini-
mum number of symptom criteria), even though these may produce as much impairment
as those that meet full diagnostic criteria (Gonzalez-Tejara et al., 2005). This problem of a
lack of specificity has been dealt with in part by the addition over time of new subtypes of
disorders, and also by the introduction of severity qualifiers (mild, medium, severe).

Due to this limitation, many people have argued that mental disorders (e.g., anxiety,
depression, and personality disorders) should be assessed through a dimensional approach,
on a continuum of health and disorder. Many measurement instruments assess symptoms
in a dimensional context rather than through a categorical system like the DSM, in which a
person either meets certain criteria or does not. Several systems of this type are included in
Part III of the DSM (e.g., with personality disorders) but they have not yet been adopted for
“official” use. In this book we may occasionally mention measures that might be useful for
assessment, but the focus is on DSM diagnosis. The interested reader is encouraged to refer
to other books that focus on measurement instruments (Corcoran & Walsh, 2010; Fischer
& Corcoran, 2007; Hersen, 2006).

Seventh, the problem of comorbidity, in which a person may qualify for more than one
diagnosis, is a point of confusion among practitioners. The reader will note that, through-
out this book, comorbidity rates for disorders are often substantial. The DSM encour-
ages the recording of more than one diagnosis when the assessment justifies doing so. But
many disorders (e.g., anxiety disorders and depression) correlate strongly with one another
(Kessler, Chiu, Demler, & Walters, 2005). It may be that an anxious depression differs from
either a “pure” major depressive disorder or anxiety disorder in critical ways. In addition,
research on treatment generally confines itself to people without comorbid disorders, so
that results are often not generalizable to the treatment population at large.

Finally, the DSM makes no provisions for recording client strengths. Strengths-
oriented practice implies that practitioners should assess all clients in light of their
capacities, talents, competencies, possibilities, visions, values, and hopes (Guo & Tsui, 2010;
Saleeby, 2008). This perspective emphasizes human resilience—the skills, abilities, knowl-
edge, and insight that people accumulate over time as they struggle to surmount adversity
and meet life challenges. In chapters 2 and 3, we will discuss the appraisal of strengths—at
both individual and environmental levels.

References

8

C h a p t e r 2

Biopsychosocial Risk and Resilience
and Strengths Assessment

This book is organized with a biopsychosocial risk and resilience framework for understanding
and intervening with persons who have mental disorders. In this chapter, we first describe this
framework and its advantages for social work assessment. Next, we detail a number of risk
and protective factors at the biological, psychological, and social levels that may contribute
to or inhibit the development of mental disorders. In the last section of the chapter, we cover
techniques that social workers can use to elicit and build upon strengths of individuals and their
social environment, going beyond naturally occurring protective factors.

Definitions anD DesCription

Although the biological and psychological levels relate to the individual, the social aspect
of the framework captures the effects of the family, the community, and the wider social
culture. The processes within each level interact, prompting the occurrence of risks for
emotional or mental disorders (Shirk, Talmi, & Olds, 2000) and the propensity toward
resilience, or the ability to function adaptively despite stressful life circumstances. Risks can
be understood as hazards occurring at the individual or environmental level that increase
the likelihood of impairment developing (Bogenschneider, 1996). Protective mechanisms
involve the personal, familial, community, and institutional resources that cultivate indi-
viduals’ aptitudes and abilities while diminishing the possibility of problem behaviors
(Dekovic, 1999). These protective influences may counterbalance or buffer against risk
(Pollard, Hawkins, & Arthur, 1999; Werner, 2000) and are sometimes the converse of risk
(Jessor, Van Den Bos, Vanderryn, Costa, & Turbin, 1997). For instance, at the individual
level, poor physical health presents risks while good health is protective. It must be noted
that research on protective influences is limited compared with information on risks for
various disorders (Donovan & Spence, 2000).

The biopsychosocial emphasis expands one’s focus beyond the individual to a
recognition of systemic factors that can both create and ameliorate problems. The
nature of systems is such that the factors within and between them have transactional
and reciprocal influence on one another, with early risk mechanisms setting the stage for
greater vulnerability to subsequent risks. The development of oppositional defiant disor-
der and conduct disorder (see chapter 10) is a case in point that shows how the presence
of certain risk or protective mechanisms may increase the likelihood of other risk and
protective influences.

Biopsychosocial Risk and Resilience and Strengths Assessment 9

Although precise mechanisms of action are not specified, data have begun to accu-
mulate that four or more risk influences may overwhelm an individual and represent a
threat to adaptation (Epps & Jackson, 2000; Frick 2006; Garmezy, 1993; Runyan et al.,
1998). Although some have found that the more risks, the worse the outcome (Appleyard,
Egeland, van Dulmen, & Sroufe, 2005), others have argued that risk does not proceed in a
linear, additive fashion (Greenberg, Speltz, DeKlyen, & Jones, 2001). Nor are all risk factors
weighted equally. The associations between risk and protection and outcomes are complex
and may involve changing conditions across a person’s development.

The biopsychosocial framework holds a number of advantages for the assessment of
mental disorders. It provides a theoretical basis for social workers to conceptualize human
behavior at several levels and can assist them in identifying and bolstering strengths as well
as reducing risks. The framework offers a balanced view of systems in considering both
risks and strengths, as well as recognizing the complexity of individuals and the systems in
which they are nested.

The chapters in this book delineate the risk and protective influences for both the
onset of particular disorders and an individual’s adjustment or recovery. Some of the influ-
ences discussed in each chapter are nonspecific to that particular disorder; in other words,
certain risks and protective mechanisms play a role in multiple disorders. These common
mechanisms, discussed at the individual and social levels, are good targets for intervention
and prevention and are given an overview here.

inDiviDual faCtors

Individual factors encompass the biological and psychological realms. Within biology we
will discuss genes, neurotransmitters, temperament, physical health, developmental stage,
and intelligence. At the psychological level we will explore individual patterns of behavior.

Biological Mechanisms

Genes and heritability
Genes determine the extent of internal risk for the development of disorders (Bulik, 2004).
Although information on the genetic influences of all mental disorders is not available, the
disorders differ in the extent to which genetic causes are attributed to them. For instance,
heritability for major depression ranges from 31 to 42% (Sullivan, Neale, & Kendler, 2000);
similarly, many anxiety disorders seem to be moderately heritable. Certain other disorders,
such as bipolar disorder and schizophrenia, are more heritable (U.S. Department of Health
& Human Services [DHHS], 1999).

For most disorders, specific genetic markers have not been delineated, and genetic
models for many disorders increasingly include a number of genes (Williams, Reardon,
Murray, & Cole, 2005). Even for disorders assumed to have genetic causes, those conditions
result not only from abnormalities in inherited genes but also from certain gene combina-
tions or other errors in genes caused during pregnancy by such events as infections and
exposure to x-rays (Arc, 2007). Finally, it is widely hypothesized that a genetic vulnerability
may be activated by the presence of adverse environmental events (Williams et al., 2005).

Neurotransmitters
Many people describe mental disorders as caused by “chemical imbalances in the
brain.” Neurotransmitters are the chemicals that convey communication between neu-
rons. These substances are naturally regulated by breaking down in the spaces between
cells or through reuptake into transmitting cells. Problems with neurotransmitter action

Part One: Assessment10

have been associated with various mental disorders. For example, low levels of serotonin
have been associated with depression, anxiety (Ebmeier, Donaghey, & Steele, 2006), and
borderline personality disorder (Ni, Chan, & Bulgin, 2006), while high levels have been
linked to autism spectrum disorder (Waldman & Gizer, 2006). Inflated levels of norepi-
nephrine have been associated with borderline personality disorder (Gurvits, Koenigsberg,
& Siever, 2000), and problems with dopamine have been correlated with schizophrenia
(Finlay, 2001) and attention-deficit hyperactivity disorder (ADHD) (Levy, Hay, & Bennett,
2006). However, the notion of a “chemical imbalance” as the cause of a mental disorder is a
reductionistic way to view disorders, as most arise from a complex interplay of biological,
psychological, and social processes. In addition, correlation should not be confused with
causality. That is, psychosocial events can affect brain functioning and the action of neuro-
transmitters (Andreasen, 2001; Cozolino, 2002).

Temperament
Temperament provides the foundation for personality. It includes qualities that are bio-
logically driven, observed from infancy, and moderately stable across the life span and in
different contexts (Deater-Deckard, Ivy, & Smith, 2005). Temperament involves activity
level, intensity, attention span, quality of mood (irritability or explosiveness), adaptability,
flexibility, and rhythmicity (the regularity of sleep-wake cycles, eating, and elimination)
(Barkley, 2000). To a certain degree, a child’s temperament will elicit behaviors from care-
givers that will crystallize these traits and increase the likelihood that these behavior pat-
terns endure over time (Johnson et al., 2005). “Children who are irritable, easily distressed
by changes in the environment, and more distractible may be less able to cope with adver-
sity and more likely to attract or elicit harsh and rejecting parenting” (Deater-Deckard et al.,
2005, p. 52). On the other hand, positive temperamental traits, such as good-naturedness,
precociousness, maturity, inquisitiveness, willingness to take risks, optimism, hopefulness,
altruism, and personableness, help people cope with life stress and attract others to them
(Henggeler, Schoenwald, Borduin, Rowland, & Cunningham, 1998).

Another temperamental style associated with mental disorders is temperamen-
tal sensitivity, which is characterized by a range of emotional reactions toward negativ-
ity including fear, worry, sadness, self-dissatisfaction, and hostility (Donovan & Spence,
2000). This tendency predisposes people to both anxiety and depression, which often occur
together. Certain temperaments may present risk or protection. For example, behavioral
inhibition, which involves timidity, shyness, emotional restraint, and withdrawal when
introduced into unfamiliar situations (Kagan et al., 1988, as cited in Donovan & Spence,
2000), puts a person at risk for many anxiety disorders but protects against the development
of oppositional defiant and conduct disorders (Burke, Loeber, & Birmaher, 2002).

Physical health
Good physical health is a protective mechanism for many disorders; this includes perinatal
health (the periods just before and after child delivery) and birth complications (Werner,
2000). Complications during pregnancy and delivery may place individuals at risk for men-
tal disorders, including ADHD (Bhutta, Cleves, Casey, Cradock, & Anand, 2002; Root &
Resnick, 2003); eating disorders (Favaro, Tenconi, & Santonastaso, 2006), bipolar disorder
(Kinney, Yurgelun-Todd, Tohen, & Tramer, 1998); and schizophrenia (Verdoux et al., 1997).
Further, certain maternal behaviors during pregnancy may increase the child’s risk for some
disorders. A pregnant mother’s prenatal drug use, excessive alcohol intake, and malnutrition
during pregnancy are risk influences for the onset of intellectual disability (Arc, 2007).

Cigarette smoke exposure is associated with a higher risk of school-aged children
developing behavioral problems, such as hyperactivity, attention deficits, or peer relation-
ship problems (Rückinger et al., 2010). Controlling for other social influences, children who

Biopsychosocial Risk and Resilience and Strengths Assessment 11

were exposed to tobacco smoke only prenatally have a 1.9 times higher risk of developing
abnormal behavioral symptoms in comparison to children without any exposure. The risk
for such children first exposed to tobacco smoke after birth is 1.3 times higher. Further,
children who were exposed to tobacco smoke while in the womb and while growing up
had twice the risk of developing abnormal behavioral symptoms. Similarly, Ekblad, Gissler,
Lehtonen, and Korkeila (2010), in a Finnish study, found that the rate of psychotropic
medication use in young adults was highest in those whose mothers smoked more than 10
cigarettes a day while pregnant (16.9%), followed by youths whose mothers smoked fewer
than 10 cigarettes a day (14.7%) and unexposed youths (11.7%).

Developmental stage
Mental disorders often emerge early in life. About 50% of cases have their onset by age
14, and 75% begin by age 24 (Kessler et al., 2005). The risk of mental disorders continues
to be high through the age category 30 to 44; prevalence then declines for people who
have matured out of this high-risk age range. For example, the borderline and antisocial
personality disorders may remit as afflicted individuals mature into their 40s (Paris, 2003).

In Werner and Smith’s (2001) longitudinal study on resilience, many people whose
lives had been characterized by adversity and mental health or learning disabilities in their
teens were able to make a positive adjustment by age 40. Protective influences for positive
adaptation involved education at community colleges, educational and vocational skills
garnered during military service, a stable marriage, active participation in a religious faith,
and the experience of life-threatening accident or illness.

Intelligence
A high intelligence quotient (IQ) is a protective factor, resulting in higher school
performance despite life stress and more effective problem solving in peer social situations
(Wachs, 2000). Conversely, low IQ is a central risk factor for antisocial behavior, over and
above socioeconomic status (SES) and race. More specifically, reading and reasoning skills
have been identified as critical to a child’s long-term development (Werner & Smith, 2001).
Parental education is also key, extending from adjustment in childhood, all the way into
middle age (Werner & Smith, 2001).

psychological Mechanisms

Self-efficacy and self-esteem
Children with positive self-concepts and a self-perception, characterized by an internal
sense of control, a belief that they can influence their environment, and effective coping
strategies, are better equipped to face life stressors (Wachs, 2000; Werner & Smith, 2001).

Self-regulation and emotion regulation
A child who can listen, pay attention, follow instructions, and persist on a task, even if
faced with stressful life events, will achieve greater success in school (Sektnan, McClelland,
Acock, & Morrison, 2010). When controlling for other risk factors, children whose parents
and teachers reported that they had strong self-regulation in preschool and kindergarten
did significantly better in math, reading, and vocabulary at the end of first grade.

Emotional regulation refers to the ability of the child to identify, tolerate, express a range
of emotions, and to be able to recover from a challenging emotional state and return to a
level of equilibrium (Davila, Ramsay, Stroud, & Steinberg, 2005). The ability to self-regulate
is generally assumed to evolve from secure caregiving. When caregivers are unable to
regulate their children’s and their own emotional states, the children do not have opportuni-
ties to develop effective strategies for responding to their own emotions or those of others.

Part One: Assessment12

Coping strategies
A tendency toward rigid belief systems and certain cognitive distortions puts people at
risk for mental disorders. For example, depression is related to significant cognitive dis-
tortions, such as Beck’s conceptualization of the “cognitive triad” of depression: thoughts
about the self as worthless, the world as unfair, and the future as hopeless (Beck, Rush,
Shaw, & Emery, 1979). In addition, youth with conduct problems display distortions in
how they perceive and code their social experiences (called cognitive processing) (Kazdin,
2001). These conduct problems include the inability to produce a variety of strategies to
manage interpersonal problems, difficulty figuring out ways to achieve a particular desired
outcome, difficulty identifying the consequences of a particular action and its effects on
others, a tendency to attribute hostile motivations to the actions of others, and misunder-
standing of how others feel. The combination of perceived threat and limited options for
managing social situations makes antisocial youth more likely to respond with aggression
rather than with more productive problem-solving strategies.

The nature of one’s coping strategies is also a general risk or protective mechanism.
For example, certain coping strategies are problematic for the development of anxiety and
depressive disorders. One type of problematic coping pattern involves avoidance coping.
For instance, some anxiety disorders develop partly because individuals avoid situations
that trigger anxiety. They do not allow themselves to tolerate a situation until the anxiety
begins to dissipate. Unfortunately, a style of avoidance for dealing with depression might
lead a person to experience more life stress and depressive symptoms as a result (Holahan,
Moos, Holahan, Brennan, & Schutte, 2005).

Rumination is another detrimental coping pattern. Rumination is the proclivity to
focus on the symptoms of a distressed mood, or to mull over the reasons for its occurrence
in an incessant and passive way (Nolen-Hoeksema, 2002), rather than using problem-
solving strategies to resolve it (Hino, Takeuchi, & Yamanouchi, 2002). It is not only the
internalizing disorders that are linked with problematic coping; conduct problems in girls
have also been associated with poor coping skills (Burke et al., 2002).

Interpersonal skills can also be subsumed under the category of coping strategies.
These skills involve the ability to create and maintain relationships and to communicate
effectively and assertively (Henggeler et al., 1998).

soCial MeChanisMs

Family factors have a major influence on whether an individual with a biological vulner-
ability develops a mental disorder. For instance, family characteristics explain more of the
variance in conduct disorder (Dekovic, 1999) and adolescent substance use than do any
other factors (Hopfer, Stallings, Hewitt, & Crowley, 2003). Families transmit both genetic
material and an environmental context for children (Wachs, 2000), although the extent to
which heredity or the family environment explains its influence is not always well under-
stood. Other important influences in the social environment include neighborhood, church,
school, and other community resources available to families. The influence of each of these
mechanisms will be discussed, although it is important to point out that these aspects of the
community context interact with one another (e.g., schools are part of the neighborhood)
and with other levels (e.g., individuals and families make up neighborhoods).

family

Several patterns are indicative of families in which mental disorders develop, among them
hostility, conflict, isolation, low cohesion, enmeshment, and an absence of nurturing.
Certain family variables center on the parent–child relationship. Parental rejection of the

Biopsychosocial Risk and Resilience and Strengths Assessment 13

child, inconsistent and ineffective discipline, lack of supervision, and lack of involvement
in the child’s activities are also mechanisms of risk.

Parent–infant attachment is especially central. The developing child requires a sense
of security that caregivers will respond in warm, consistent, and sensitive ways to his
or her needs (Bowlby, 1969, 1973, 1980). Early attachment is hypothesized to result “in
the development of ‘working models,’ schemata about the self, others, and relationships
that will guide functioning across the life span” (Davila et al., 2005, p. 216). Indeed,
attachment style has been shown to afford stability into adulthood (Hazan, Campa, &
Gur-Yaish, 2006).

Further risks in the context of the family involve instability and parental conflict, such
as discord, separation and family violence, and high parental stress (Loeber, Farrington,
Stouthamer-Loeber, & Van Kammen, 1998). Chronic marital discord and family violence
are associated with risks to maternal mental health, increased incidence of depression and
PTSD (Golding, 1999), aversive parenting practices (Krishnakumar & Buehler, 2000), and
the development of mental health disorders in children (Briggs-Gowan et al., 2010). Any
psychopathology afflicting parents that compromises their abilities also constitutes a risk
(Steinberg, 2000). Serious mental illness in parents relates to an increased risk of mental
health disorders in children (Milne et al., 2009).

Conversely, family stability, a stable parental relationship (including parental agree-
ment on values and discipline), and social support for parents are seen as protective.
Families that have effective discipline skills, healthy cohesion, and positive communica-
tion help buffer their children against the development of mental disorders. Further,
adolescents whose parents provide emotional support and structure the environment
with consistent rules and monitoring tend to group with peers who share similar family
backgrounds (Steinberg, 2000). Supportive parenting in turn affects the characteristics of
the child, in that he or she learns to regulate emotional processes and develop cognitive
and social competence (Wachs, 2000). Individual characteristics of parents are also key;
parents who have problem-solving ability and resourcefulness, experience low stress, and
demonstrate frustration tolerance and patience are more effective in their role as parents
(Henggeler et al., 1998).

Household composition
Household composition refers to familial structure and includes size of the family, the num-
ber of parents in the home, and the spacing of children’s births. Larger family size (more
than three children) is a risk factor, as precious family resources are then spread among
many children (Werner, 2000). Living in a single-parent family has also been identified as
a risk factor. Compared to teens with married or cohabiting parents, those with divorced
parents are at higher risk for a mental health disorders, especially anxiety, behavior, and
substance use disorders (Merikangas et al., 2010). Whereas in two-parent families two
adults can provide financial security, guidance, and emotional support, single parents are
more likely to work full time and therefore are not as available for supervision, monitoring,
or time spent with their children. Rapid childbearing (defined as less than a two-year spac-
ing between children) further presents risk, as it limits the amount of time devoted to the
first child (Klerman, 2004).

Another risk for some mental disorders is the structure of Western society, in which
the upbringing of most children is limited to one or two primary caregivers, without
additional consistent parent figures available to “fill in” when these caregivers prove to
be inadequate (Alarcon, 2005). In contrast, in some cultural groups, such as Latinos and
African-Americans, extended family may routinely provide major parenting roles. Western
society’s reliance on the nuclear family fails to provide opportunities for children to have
“second chances” to develop healthy attachments when these might be developmentally

Part One: Assessment14

beneficial. Characteristics of the extended family that offer protection include the provi-
sion of material resources, child care, supervision, parenting, and emotional support to the
child (Henggeler et al., 1998).

Traumatic events and loss
These experiences are grouped with family factors because events such as sexual abuse and
physical abuse often occur in the context of the family. Child maltreatment is a risk factor
for mental health disorders in both childhood and adulthood (Scott, Smith, & Ellis, 2010).
When abuse and neglect are severe, children may be removed from their own homes and
placed into foster care, and these situations put them at further high risk for mental health
problems (Fazel, Doll, & Langstrom, 2008). Childhood adversities (defined as physical and
sexual abuse, neglect, family violence, parental mental illness, substance use disorders, and
criminality) may be associated with up to 45% of all mental disorders that have an onset in
childhood, and at least 25% of disorders with later onset (Green et al., 2010).

neighborhood

Although individual and family characteristics are major contributors to child and young
adult outcomes, neighborhood factors are also key (Ellen, 2000; Leventhal & Brooks-Gunn,
2003). Living in poor and disadvantaged communities creates substantial risks of antisocial
behavior in children. Such risks include poverty, unemployment, community disorganiza-
tion, availability of drugs, the presence of adults involved in crime, overcrowding, commu-
nity violence, and racial prejudice (Hill, 2002; Loeber, Burke, Lagey, Winters, & Zera, 2000;
McGee & Williams, 1999). Parenting abilities are often challenged by the many stressors
that attend to living in a low socioeconomic stratum, among them unemployment, under-
employment, the lack of safe child care, the lack of transportation, inadequate housing, and
exposure to crime. These stressors may not only negatively affect parenting but may also
inhibit access to general health and mental health care services.

An extensive review of the literature on neighborhood effects (Leventhal & Brooks-
Gunn, 2003) found evidence that living in a disadvantaged neighborhood had negative
consequences for young children’s mental health functioning. Moreover, a large-scale study
of 2,805 children found that those living in poor neighborhoods were more likely to have
mental health problems, particularly internalizing disorders (Xue, Leventhal, Brooks-Gunn,
& Earls, 2005). Over time, as children mature, effects become more deleterious. For adoles-
cents, impaired mental health, criminal behavior, early sexual activity, and teenage pregnancy
are associated with living in poor neighborhoods (Leventhal & Brooks-Gunn, 2003).

Neighborhoods can, however, represent a source of protection. Although neighbor-
hood peers may exert negative influences on such behaviors as drug and alcohol use and
criminal activity, some studies have found that adult neighbors who offer structure and
monitoring can be an important source of support for children experiencing risks in their
own families (Werner & Smith, 2001). In addition to providing informal social control and
social cohesion, neighbors involved in local organizations help to sustain the mental health
of children who live in neighborhoods marked by disadvantages (Xue et al., 2005). Stud-
ies have also shown that middle-class and affluent neighborhoods have generally positive
effects on educational attainment and achievement for adolescents, and neighbors of high
SES contribute to younger children’s verbal ability, IQ, and academic achievement.

Finally, frequent changes in residences while growing up are associated with poor
outcomes in youth in terms of both attempted and completed suicide (Qin, Mortensen,
& Pedersen, 2009). Repeated separations from peers and familiar activities, the stress of
facing a new environment, and the potential unavailability of parents due to their own
stress may overwhelm a youngster’s ability to cope.

Biopsychosocial Risk and Resilience and Strengths Assessment 15

social support networks

Social support is a multidimensional concept, commonly defined as the availability of a
network of people on whom a person can rely in times of need (Hankin & Abela, 2005).
Different types of social support include emotional, financial, informational, or enacted
support. Social support networks can provide risk or protective influences. Although posi-
tive social support acts as a buffer against the development of many mental disorders, it
also plays a strong role in adjustment for all the disorders discussed in this book. The
number and variety of social supports (extended family, friends, neighbors, coworkers,
and church members) appear to be important (Henggeler et al., 1998). For youths, such
supports encourage involvement in a peer group that is engaged in prosocial activities,
hobbies, and interests.

A particular type of social network involving church or religious participation has been
associated with positive physical and mental health, as well as with buffering the effects of
neighborhood risks (Taylor, Ellison, Chatters, Levin, & Lincoln, 2000; Werner & Smith,
2001). Religious attendance and religiosity have also been significantly associated with a
decreased likelihood of drug use among adolescents (Miller, Davies, & Greenwald, 2000).
In addition, for African-American youth, religious involvement may buffer the impact of
neighborhood risk on criminal offending (Johnson, Jang, Li, & Larson, 2000). Research
further indicates a positive relationship between religious involvement and adult health
outcomes and coping with stress (McCullough, Larson, Hoyt, & Koenig, 2000).

More formal support systems may also enhance protection. Research has shown that
participation in out-of-school activities and availability of community supports has posi-
tive outcomes for children in terms of educational attainment and health status. Empiri-
cally validated programs, such as Big Brothers and Big Sisters (Thompson & Kelly-Vance,
2001), Head Start (Currie & Thomas, 1995), and other youth organizations present substan-
tial protective factors (Werner, 2000).

soCietal ConDitions

The United States has “overarching social, political, legal, economic, and value patterns”
(Greene & Livingston, 2002, p. 79) that can both contribute to individual problem situa-
tions and provide protection against risk. These macro-level influences, however, do not
occur in isolation from risk and protective mechanisms at the other levels. For example,
employment may open opportunities for interactions with others and expansion of social
support networks, which in turn may help the family provide a safe and secure home. As
noted earlier, the nature of systems is that the processes within each system influence one
another.

On the protective side, social policies can have positive effects on the income and
employment of individuals. For example, Social Security payments to older adults have a
significant effect on reducing the percentage of those who are poor, while Medicare covers
many of their major health care costs. For the working poor, economic supports include
such programs as the earned income tax credit and food stamps, which help them meet
household expenses (for a review of income support policies, see Scholz & Levine, 2000).
Strong child-support policies have also been shown to improve the income of single-
mother families (Garfinkel, Heintze, & Huang, 2001).

Poverty, discrimination, and segregation are risks that affect individual-level
functioning, whereas social and income supports, tax policies, and legal sanctions pro-
vide protection against these risks. We will now explore further some of the risks in
U.S. culture associated with being poor, being a member of an ethnic minority, and
being female.

Part One: Assessment16

the health and Mental health Care system

In the United States, the system of mental health care consists of a patchwork of ad hoc
services (DHHS). There are four chief sectors for mental health care:

1. The specialty mental health sector, including mental hospitals, residential treat-
ment facilities, psychiatric units of general hospitals, and specialized community
agencies and programs (e.g., community mental health centers, day treatment
programs, and rehabilitation programs). The Substance Abuse and Mental Health
Services Administration (2009) indicated that an average of 28.8 million adults
received traditional types of mental health treatment (i.e., inpatient care, outpa-
tient care, or prescription medication). In their survey of child and adolescent
mental health disorders, Merikangas and colleagues (2010) found that overall, 55%
of those with a disorder had consulted with a mental health professional, which is
seen as an improvement in treatment seeking from the past.

2. The general medical and primary care sector. This sector is responsible for regular
prenatal care, childhood immunizations, and routine developmental screenings
that protect against the development of disorders, such as intellectual disability
(Arc, 2007) and for the early detection of others, such as autism spectrum disor-
der. General practitioners are responsible for a great deal of medication care for
persons with certain disorders, such as ADHD, depression, and anxiety. Often
this means that people receive substandard care. For example, ethnic disparities
in the diagnosis and treatment of depression are present in the primary care sys-
tem, where many people from ethnic minority groups are served for their mental
health needs (Stockdale, Lagomasino, Siddique, McGuire, & Miranda, 2008).

3. The human services sector, which comprises social welfare (housing, transporta-
tion, and employment), criminal justice, educational, religious, and charitable
services. It is not until some adolescents reach the juvenile justice system that they
are identified as having a mental illness (Fazel et al., 2008).

4. The voluntary support network, including self-help groups and organizations
devoted to education, communication, and support. An annual average of 2.4
million adults aged 18 or older (1.1% of the population) received support from a
mental health self-help group in a year (Goldstrom et al., 2006; Substance Abuse
and Mental Health Services Administration [SAMHSA], 2009).

Unfortunately, there is no systematic way for people to obtain needed mental health
services. Often those with the greatest and most complex needs, and the fewest resources,
are underserved. The lack of access to health care and health insurance is a principal
factor in limiting adequate treatment for serious and chronic conditions (Tondo, Albert,
& Baldessarini, 2006). For example, among people who made an effort to get treatment for
substance use disorders, 42.5% reported cost or insurance barriers (SAMHSA, 2006).

Typically, people do not receive timely treatment for mental disorders. The median
delay across disorders for receiving treatment is nearly a decade (Wang et al., 2005). If peo-
ple are left untreated, they may be more vulnerable to future episodes that may be even
more severe in nature and more resistant to treatment.

Several factors have been associated with treatment delay (Wang et al., 2005). Early
onset of a disorder, defined as child or adolescent onset, is of particular concern, because
untreated early-onset disorders can result in school and subsequent occupational failure,
early childbearing and marriage, and marital problems. Other factors associated with treat-
ment delay include male gender, minority status, lower education (except for substance use
disorders), being married, and having social support (presumably because of lesser need
for support from formal sources).

Biopsychosocial Risk and Resilience and Strengths Assessment 17

poverty

Low SES is associated with the development of a number of mental disorders, such as
oppositional defiant disorder and conduct disorder (Hill, 2002), anxiety disorders, depres-
sion, and schizophrenia (Wadsworth & Achenbach, 2005; Mulvany, O’Callaghan, Takei,
Byrne, & Fearon, 2001). People of the lowest SES have a two-to threefold likelihood of
having a mental disorder compared with the general population (DHHS, 2001) and this
is also true of children and adolescents (Merikangas et al., 2010). Those living in poverty
are more exposed to stressful circumstances such as crime; violence; availability of drugs;
and lack of safe child care, convenient transportation, quality health care, and adequate
housing. Poverty is a risk factor for intellectual disability because of its association with
malnutrition, disease, inadequate prenatal and general medical care, and environmental
health hazards (Arc, 2007). The poor are also less likely to be protected against these stress-
ors by social or material resources. Finally, because the presence of a mental disorder, such
as schizophrenia, usually results in academic and occupational impairment, those with
mental disorders may end up living in poverty.

ethnicity

Overall, ethnic minorities have rates of mental disorder similar to those among the White
mainstream population. Some minorities, however, especially African Americans, are over-
represented among certain subgroups that are vulnerable to mental disorders, including
people who are homeless, incarcerated, or in the foster care system (DHHS, 2001). Many
people in these subpopulations are not counted in national surveys of mental disorders.
In addition, ethnic minorities are disproportionately poor and are therefore subject to the
attendant risks that have been detailed earlier. Further, “minorities’ historical and present
day struggles with racism and discrimination . . . affect their mental health and contribute to
their lower economic, social, and political status” (DHHS, 2001, p. 4). Perceived discrimina-
tion has a strong association with measures of stress and mental health (Kessler, Mickelson,
& Williams, 1999). Moreover, “racial stereotypes and negative images can be internalized,
denigrating individuals’ self-worth and adversely affecting their social and psychological
functioning” (DHHS, 2001, p. 39). Even though the prevalence of mental disorders among
most ethnic minority groups is similar to the White mainstream, minorities are underserved
when it comes to treatment (Merikangas et al., 2010; Meyer, Zane, Cho, & Takeuchi, 2009).

As well as a lack of access to health care, minorities may hold even more stigmatizing atti-
tudes toward mental illness than the general population, making them less likely to seek treat-
ment (DHHS, 2001). Moreover, minorities are more likely to turn to the general health care
system for problems they experience. Primary care providers typically do not have the time or
the expertise to diagnose and treat mental disorders, especially when their patients already have
physical disorders that they can recognize and treat (DHHS, 2001). Minorities may also seek
help from informal sources such as family, friends, religious leaders, and indigenous healers.

Other barriers to the treatment of mental illness include the fragmented organiza-
tion of mental health services in the United States, providers’ “lack of awareness of cultural
issues, bias, or inability to speak the client’s language, and the client’s fear and mistrust
of treatment” (DHHS, 2001). In addition, although the helping professions have recently
begun to move toward evidence-based practice, there is a shortage of research on treat-
ment outcomes for the major mental disorders among people from different ethnic groups
(DHHS, 2001). Further, there has been a call for “cultural competence,” which involves
sensitivity to culture and the development of “skills, knowledge, and policies to deliver
effective treatments” (p. 36). Few models of culturally sensitive services have been tested,
however, so we know little about either the key ingredients needed or their effect on treat-
ment outcomes for ethnic minorities.

Part One: Assessment18

Area of Functioning Risks and Problems Strengths and Resources

Treatment history Previous treatment history What was helpful/not helpful?

Personal history Developmental milestones
Medical history
Diet, exercise
Physical, emotional, sexual abuse

Physical, psychological, social, spiritual,
environmental assets
How did you cope? How were you able
to survive that time? What needs to
happen so that you are safe?

Substance abuse history Patterns of use: onset, frequency,
quantity
Drugs/habits of choice: Consequences:
physical, social, psychological

Periods of using less and periods of
abstinence. What are the advantages/
disadvantages of use?

Suicide risk Previous suicide attempts
Current suicidality

If you’ve had thoughts of hurting
yourself, what did you do to get past
that point? Things sounded really hard
then. How did you manage? How did
you stop things from getting even
worse? What needs to happen now so
that you feel a bit better?

Family history Description of relationships; history of
illness, mental illness

Supportive relationships

Community involvement Legal history
Neighborhood risk
Problematic relationships

Cultural and ethnic influences
Community participation
Spiritual and church involvement
Other social support
Neighborhood assets

Employment and
education

Educational history
Employment history

Achievements, skills, and interests

Goals Goals Future without the problem
What do you want to get out of
treatment? What will your life look like
when treatment is successful?

Sources: Bertolino & O’Hanlon, 2002; Graybeal, 2001.

Balanced Assessment of Strengths and Risks
Table
2.1

GuiDelines for eliCitinG anD enhanCinG
Client strenGths

Thus far, we have been focusing on the biopsychosocial perspective for understanding
human functioning, and the fact that the risk and resilience framework is useful for pro-
viding social workers with a means of assessing the occurrence of problems, as well as
strengths. We now more greatly elaborate upon the latter to prepare the social worker to
help people recognize and build upon strengths they may have so that they may recover
from or functionally adapt to any mental health disorders. Our view, reflected in Table 2.1,
is that we must assess for both problems and strengths in the clients we serve.

Biopsychosocial Risk and Resilience and Strengths Assessment 19

The first guideline for the social worker is to develop an awareness of strengths and
recognize them in clients. Many possible strengths and protective influences have been
identified earlier in this chapter, and each subsequent chapter lists protective mechanisms
pertinent to particular disorders. These strengths should be openly conveyed to clients.
Often, by the time people seek help from a social worker, the problem may have enveloped
them to such an extent that they have lost sight of their resources. For example, if a person
seems to have a solid social support system, he or she needs to be told (or reminded) that
this is a strength critical to adjustment. One could take this intervention a step further and
ask about the resources people have used to develop these strengths. Such a client could
be asked, “What would your husband say makes you a good partner?” or “Why do your
friends like to be around you?”

The social worker must further be alert to the strengths individuals bring to other con-
texts, such as work settings (e.g., organizational skills, assertiveness, problem-solving abili-
ties), hobbies (e.g., gardening, crafts, handiwork, sports), and pastimes (e.g., churchgoing,
socializing with friends). The social worker can also ask directly about strengths: “What do
you do well?” “What are your best qualities?” “What would other people say you do well or
is good in you?”

It must be emphasized that when people talk about the suffering and pain they have
undergone, these experiences need to be validated. They can then be asked about the resil-
ient qualities they have shown to “make it this far, despite the pain in their life.” The social
worker can inquire about aspects of the client’s life that are still intact despite the problem,
such as relationships, hobbies, interests, employment, and academics. The social worker
can plumb for the resources that were drawn upon in these areas. Inquiry can further cen-
ter on personal or family qualities or strengths that have developed as a result of dealing
with the illness. A quantitative review found that when people are able to find benefits
after a major stressor, they experience less depression and a greater sense of well-being
( Helgeson, Reynolds, & Tomich, 2006). These lines of inquiry show that many facets of dif-
ficult circumstances can be explored to find the strengths that arise with them.

Another way of validating the extent to which people have struggled is through the use
of the solution-focused intervention strategy of coping questions (deJong & Berg, 2008).
Questions such as the following encourage clients to reflect upon the resources they have
used to manage their struggles:

• “How have you coped with the problem?”
• “How do you manage? How do you have the strength to go on?”
• “This has been a very difficult problem for you. How have you managed to keep

things from getting even worse?”

A major intervention using solution-focused therapy is exception finding (deJong &
Berg, 2008), which involves inquiry about symptom-free periods or times that were “a little
bit better.” Even the most severe mental illnesses include periods of remission or at least a
reduction in symptom severity. On a daily basis, there may be at least brief periods when
the problem is not as bad.

When people are seeing a social worker for help with a possible mental disorder, they
tend to experience their symptoms as all-encompassing and all-consuming. For example,
a depressed person typically sees the past as depressing and the future as hopeless. These
are biased perceptions based on present mood. By asking questions about what the person
did during these times that made a difference and the supports that were used, people get
in touch with the strengths and resources on which they have drawn to deal with difficult
circumstances.

Sometimes people will respond by crediting situations, events, and people outside
themselves for any improvements they have made. The social worker should find a way to

Part One: Assessment20

allow clients to recognize their own responsibility for any changes made. For instance, if a
client says he or she remained sober only while incarcerated, the social worker can respond
that people who are interested in abusing substances seem to be able to still find a way to
do so, even when they are “inside.” So what caused them to commit to sobriety this time?

Another way to identify problem-free times is through a technique called externalizing
the problem (Bertolino & O’Hanlon, 2002; White & Epston, 1990), in which a linguistic
distinction is made between the presenting problem and the person. Through language, the
problem behavior is personified as an external entity (the depression, the mood swings, the
voices), rather than being seen as a dysfunction integral to the individual. The purpose is to
free the person from the belief that the problem is a fixed and inherent quality. It introduces
fluidity into a problem that may have become rigid and seemingly fixed, so that the oppres-
sive nature of the problem is lifted, and more options for behavior may be revealed.

After identifying the externalized entity, the next step is to empower people to fight
against it by asking what are referred to as relative influence questions (when do they have
influence over their problems and when do their problems have influence over them?).
Individuals can be invited to extend their awareness of how they combat their problems
through the following questions:

• What’s different about the times you’re able to control . . . (the mental health
symptoms, the diagnostic label)?

• When are you able to overcome the temptation to . . . ?
• What percentage of the time do you have control over . . . ? What are you doing

during these times?

An additional technique of solution-focused therapy is to inquire about past help
seeking. People with mental health problems are often demoralized by extensive treatment
histories. A line of questioning such as the one detailed next offers several benefits. First,
it validates people’s efforts to help themselves. It acknowledges that they have been trying
to overcome their problems. Second, it informs the social worker about what the client has
already tried. If one already knows what is not helpful for a client, that particular interven-
tion should not be repeated. Third, it conveys that the client is the expert on himself or
herself. The following questions convey the resources people bring to past help-seeking
efforts:

• What did you find helpful about previous therapy (individual, couples, family,
group, etc.)?

• What did the therapist do that was helpful?
• How did that make a difference for you?
• What wasn’t so helpful?

Although medication is a critical element of the treatment protocol for many mental
disorders, the case for medication is sometimes overstated. For example, less than half of
consumers experience a 50% reduction in depressive symptoms as a result of being on anti-
depressants (Trivedi et al., 2006), and most (74%) discontinue antipsychotic medications
because of the side effects they experience (Lieberman et al., 2005).

Many consumers have an external locus of control toward medication; that is, they
attribute changes in their behavior to the effects of medication rather than being empow-
ered to see the changes as a result of their own efforts and qualities. The social worker can
ask questions such as these if the client is currently or has previously been on psychotropic
medication:

• How was the medication helpful to you? How was it not helpful?
• What, if anything, did the medication allow you to do that you wouldn’t have been

able to do otherwise?

Biopsychosocial Risk and Resilience and Strengths Assessment 21

• What percentage of the change you’ve experienced is a result of the medication,
and what percentage do you think is your own doing?

• What qualities do you possess that enabled you to work with the medication to
improve things for yourself ?

The social worker should further be alert for opportunities to build client motivation.
Motivational interviewing, a brief treatment model (one to four sessions), was formulated
to produce rapid change by mobilizing the client’s motivation. It was designed for sub-
stance use disorders but adapted to other problems in which there is ambivalence about
change (Miller & Rollnick, 2012).

Empathic listening and affirming statements are used in a systematic way to direct the
process toward building client motivation. The social worker selectively reflects and affirms
change talk and asks the client to elaborate on statements about change. Additionally, to
bolster one’s motivation for change (Miller & Rollnick, 2012), the social worker highlights
any discrepancies between the client’s values and goals, such as long-term mental health,
and the problem (failing to do things that one knows will help resolve the disorder) that
stands in the way of these goals.

The interested reader is encouraged to pursue other sources for more information
about motivational interviewing (see Miller & Rollnick, 2012); we will emphasize one tech-
nique here, called the decisional balance, which is aimed at getting the client to weigh the
advantages and disadvantages of the problem behavior. In this technique, the social worker
asks the client to recount some of the pros of the problem behavior: “What do you get
out of drinking?” “How is the eating disorder working for you?” When people feel some-
one else understands the reasons they seek out problematic behaviors, they are less likely
to show defensiveness against change. The practitioner can then switch to asking about
“the not so good things” about drinking/purging/isolating from social contact/not taking
medication. The client then details the advantages and disadvantages of changing. The pro-
cess of gathering this information provides a great deal of information about the problem
behavior necessary for diagnosis. It also makes it easier for clients to argue for their own
change as they weigh the pros and cons of their current behaviors and their perceptions
about change.

As the final part of the assessment, the social worker can help clients to orient toward
the future and build a vision of a problem-free future. Sometimes when people are mired in
their symptoms, they have difficulty seeing beyond their current unhappy circumstances.
Asking people what their lives will look like after their problems are solved frees them
from these circumstances to consider a different future. This process may fuel a sense of
hope and may also help individuals develop a blueprint for what changes need to be made.
Future-oriented questions include the following:

• Imagine yourself in the future when the problem is no longer a problem. Tell me
where you are, what you are doing and saying, and what others around you are
doing and saying.

• When you do succeed in getting past this and are looking back on it now, what
most likely is it that worked? How did it happen?

These techniques show how the social worker, while collecting relevant informa-
tion for the formulation of a diagnosis, can also keep focused on the strengths and
resources of the individual. People who are empowered with regard to their strengths
are more likely to feel a sense of hope about themselves and their future. If strengths and
resources are galvanized during the assessment process, the client can begin a process
in which a different perspective (about the self, about the problem) can inspire changes
in behavior. People who feel empowered and hopeful are also more motivated to engage
in intervention.

Part One: Assessment22

ConClusion

The social work profession is distinguished by its holistic attention to the biological,
psychological, and social influences on the functioning of all people. With this broad
perspective, social work practitioners can complete comprehensive assessments to deter-
mine the nature of their clients’ problems, which may include the mental disorders described
in this book. Additionally, the social worker’s knowledge of the risk and resilience influ-
ences associated with the mental disorders helps focus his or her intervention onto the
relevant areas of the client’s life. Finally, the strengths perspective encourages social workers
to build on the client’s areas of real or potential resilience in recovering from, or adapting
to, mental disorders, and in so doing helps the client develop a greater sense of self-efficacy.
All of these themes will be incorporated into the subsequent chapters of this book.

references

23

Autism Spectrum Disorder

Emmanuel is a five-year-old Guatemalan boy who has just started kindergarten. He is an artistic
and active child who enjoys playing in the playground, listening to music, and doing puzzles.
On his first day of school, Emmanuel had a hard time separating from his parents. He cried
almost continuously through the day, tried to run away from the classroom and playground,
and threw tantrums when the classroom teacher tried to redirect him. Emmanuel continually
asked for his mom or dad and could not be calmed down. The teacher reported that he seems
to have difficulty with transitions, such as from the classroom to the cafeteria, and he does not
follow directions unless the teacher or her assistant directs him through the individual steps. The
teacher also noted that Emmanuel appears to have difficulty in other areas of development. His
speech is functional but not pragmatic, meaning that he is able to form the words necessary
for speaking but cannot use them as a social tool to interact verbally with others. He does not
approach other children and does not react to their attempts to play or talk.

A
utism spectrum disorder (ASD) encompasses what used to include (in DSM-IV)
autistic disorder, Asperger’s disorder, childhood disintegrative disorder, and per-
vasive developmental disorder not otherwise specified (PDD-NOS). ASD is a

neurological-developmental disorder with an onset during the first three years of life. The
child with ASD demonstrates serious impairments in social interaction and communica-
tion, as well as odd repetitive behaviors and restricted interests (Schreibman, Stahmer, &
Akshoomoff, 2006). More than anything else, ASD is characterized by impairments in
social relatedness (Volkmar, Charwanda, & Klin, 2004). These include a lack of awareness
of the feelings of others, an inability to express emotions, and the absence of a capacity for
social and symbolic (imaginative) play. On the other hand, persons with ASD often possess
impressive isolated skills such as memorization, visual and spatial awareness, and attention
to details.

Autism spectrum disorder is experienced with different levels of severity (Akshoomoff,
2006). In DSM-5, the three levels of severity are characterized as requiring support, requiring
substantial support, and requiring very substantial support. At a moderate level of impair-
ment, early cognitive and language development are apparently normal, but the child has
unusual interests that he or she pursues with intensity. The child’s attachment patterns to
family members are well established, but he or she does not tend to attach to peers and new
adults. Because the behavioral abnormalities are less pronounced, the child’s referral for
assessment is usually later than other persons with suspected ASD. These social difficulties
are lifelong, but such persons are more likely to secure employment, live independently,
and establish a family (Volkmar, Charwanda, & Klin, 2004). In its mildest form, the deficits

C h a p t e r 3

Part Two: Neurodevelopmental Disorders24

in social and other skills are even less severe, and such persons have a fair prognosis for
independent functioning (Howlin, 2005). It should be mentioned that a new DSM disorder,
social pragmatic communication disorder, characterizes persons who have persistent diffi-
culty with verbal and nonverbal communication that cannot be explained by low cognitive
ability. Some persons previously diagnoses with PDD-NOS may now meet the criteria for
this disorder.

PrevalenCe and Comorbidity

The reported incidence of autism spectrum disorder has increased worldwide in recent
years. This increase may be due to a broader application of the criteria and an increased
alertness to assessing children for the disorder (Shattuck & Grosse, 2007). There is even
some diagnostic variability across states (Mandell & Palmer, 2005), which is believed to
be an indicator of differences in the training of education professionals, the availability of
pediatricians, and the accessibility of health care resources.

A review of prevalence studies indicates that the rate for ASD is about 20 per 10,000
(Williams & Brayne, 2006). The Centers for Disease Control and Prevention found that
the prevalence of ASD was 6.6 per 1,000 children in the United States (Rice, 2007). The
number of students aged 6–21 years identified in the ASD reporting category in U.S. special
education grew between 1994 and 2005 from 18,540 to 165,552 (Safran, 2008). Autism spec-
trum disorder occurs in all social classes and races, although Caucasian children are more
likely to be diagnosed than African American children. The reason for this difference is not
understood, but may be due to a greater likelihood for Caucasians to be evaluated for the
disorder. Studies consistently find that ASD occurs more often in males than in females,
with a ratio of 4.3:1 (Rice, 2007).

On average, the rate for ASD in eight-year-old males is 11.5 per 1,000 and 2.7 per 1,000
for females. The available data suggest that children and adolescents with ASD experi-
ence a range of comorbid disorders. Precise data are not available on these rates, however,
because there are no formal ASD assessment instruments that include attention to comor-
bid disorders (Matson & Minshawi, 2006). Common comorbid disorders include intellec-
tual disability (severe in 50% of cases, mild to moderate in 30% of cases), seizure disorders
(25 to 30%), depression (4 to 57%), anxiety disorders (7 to 84%), overactivity and attention
problems (21 to 72%), and tic disorders (7 to 29%) (Bernard, Young, Pearson, Geddes, &
O’Brien, 2002; Matson & Minshawi, 2006; Rice, 2007; Schopler, 2001). The likelihood of
comorbid disorders is largely due to the broadly debilitating features of ASD, their associ-
ated medical disorders, and the problematic life experiences related to having the disorder.
Aggression and self-injury (head banging, finger or hand biting, head slapping, and hair
pulling) are common behavioral symptoms for children with comorbid pathologies. These
behaviors are rarely intentional, but are due to biological factors (such as seizures), cog-
nitive and emotional impairments (leading to impulsivity and low frustration tolerance),
inability to communicate anger verbally, difficulty managing change, learned behaviors to
avoid certain tasks or situations, and a misreading of others’ intent as threatening (Gadow,
DeVincent, & Schneider, 2008).

assessment

With ASD, the goals of assessment are to determine first whether a child has the disorder
and then to offer appropriate interventions to maximize the child’s potential for change
(Rogers & Vismara, 2008). Professionals must set the stage for a long-term collaborative
relationship with parents and help them become better-informed advocates for their child.

Autism Spectrum Disorder 25

A recent thrust in health care is the early diagnosis of ASD so that intervention can begin
as soon as possible. Early diagnosis is associated with urban residence, middle socioeconomic
status (SES), pediatric referral to a specialist, having a child with severe language deficits,
having an IQ of 70 or lower, and symptoms such as hand flapping and toe walking (Shattuck
et al., 2009). Later diagnosis is associated with rural residence, low SES, oversensitivity to pain,
hearing impairment, female gender, and having seen at least four primary care providers (Landa,
Holman, & Garret-Mayer, 2007). Parental concern is a more important factor than pediatric
testing in identifying a child with ASD (Mandell, Novak, & Zubritsky, 2005). Studies show that
90% of parents of such children recognize a significant abnormality in the child by the age of
24 months (Volkmar, Lord, Bailey, Schultz, & Klin, 2004).

The symptoms of autism spectrum disorder do not usually appear until the child is
6–12 months of age (Ozonoff et al., 2010). During the first year of life the child typically
displays unusual social development, being less likely to imitate the movements and vocal
sounds of others, and exhibits problems with attention and responding to external stimu-
lation (Landa et al., 2007). Between one and three years of age, when parents are most
likely to seek evaluation, differences from peers are readily apparent, and the child’s idio-
syncratic, self-absorbed behaviors and communication problems are striking (Harrington,
Rosen, Garnecho, & Patrick, 2006). Parents report their child’s regression from a higher
level of functioning in 20 to 40% of cases (Volkmar, Lord, et al., 2004). Often, neurolo-
gists and developmental pediatricians are responsible for diagnosing ASD, with primary
pediatricians doing so only 12% of the time (Harrington et al., 2006). Some reasons for the
low rate of pediatrician diagnosis include the physician’s feeling unequipped to do so, time
constraints on conducting screenings, and fears of labeling a child prematurely (Dosreis,
Weiner, Johnson, & Newschaffer, 2006).

Researchers at the Centers for Disease Control and Prevention found that children
with ASD were initially evaluated at a mean age of 48 months but were not diagnosed until
61 months (with no differences by gender or SES) (Wiggins, Baio, & Rice, 2006). More
severely impaired children were diagnosed earlier. Most practitioners (70%) did not use a
diagnostic screening instrument in the process, and 24% of children were not diagnosed
until after entering school.

Assessment is a challenging process, because no biochemical tests are available to
assess for the disorder; nor does a single behavior or set of behaviors unequivocally denote
autism spectrum disorder (Holter, 2004). Assessment should be multidisciplinary in nature,
including evaluations by a clinical or school psychologist, medical doctor, and speech and
language pathologist as well as a social worker. A core assessment for ASD comprises the
following (Bishop, Luyster, Richler, & Lord, 2008; Johnson & Myers, 2007):

• Information from parents about the mother’s pregnancy, labor, and delivery; the
child’s early neonatal course; the parents’ earliest concerns about their child; fam-
ily history of developmental disorders; symptoms in the areas of social interaction,
communication/play, and restricted or unusual interests; the presence of problem
behaviors that may interfere with intervention such as aggression, self-injury, and
other behavioral oddities; and the child’s prior response to any educational pro-
grams or behavioral interventions.

• Direct observations in structured (school) and unstructured settings (home) and in
interactions with peers, parents, and siblings.

• A medical evaluation, which includes information about possible seizures, visual
and hearing examinations for possible sensory problems, and testing for lead levels
if the child has had exposure.

• Cognitive assessment to establish the level of intellectual functioning.
• An assessment of adaptive functioning and social skill development.
• A speech and language assessment.

Part Two: Neurodevelopmental Disorders26

Neuropsychological testing might also be indicated for children with some verbal abil-
ity in order to gain a sense of their strengths and limitations for treatment and education
planning (Ozonoff, Rogers, & Hendren, 2003).

Professionals are encouraged to use formal instruments to assist in their diagnostic
assessments. A variety of instruments are available for this purpose (Ozonoff, Goodlin-
Jones, & Solomon, 2007; Volkmar, Charwanda, & Klin, 2004; Volkmar, Lord, et al., 2004).
Two instruments, both clinician-administered, are considered the “gold standards” for
assessment of ASD: the Autism Diagnostic Interview-Revised (Lord, Rutter, & LeCouteur,
1994) and the Autism Diagnostic Observation Schedule (Lord, Risi, & Lambrecht, 2000).
Another recommended measure is the Social Communication Questionnaire, which is a
parent report version of the Autism Diagnostic Interview-Revised (Berument, Rutter, Lord,
Pickles, & Bailey, 1999; Rutter et al., 2003). Other well-known assessment tools include the
Checklist for Autism in Toddlers (Baron-Cohen, Ring, & Bullmore, 2000), the Pervasive
Developmental Disorders Screening Test (Siegel & Hayer, 1999), and the Screening Tool
for Autism (Stone, Coonrod, & Ousley, 2000). Some newer instruments that assess neuro-
developmental disabilities include the Social Responsiveness Scale (Constantino & Todd,
2003) and the Children’s Communication Checklist (Bishop, 1998).

Although Emmanuel started kindergarten this year and has never been in a preschool
setting, he can write all the letters of the alphabet, as well as his own and his sister’s name.
He is also able to write numbers and recite up to three-digit numbers. His handwriting is
artistic and almost looks like a form of calligraphy, especially his numbers. His family states
that they never taught him any of these skills.

Emmanuel uses very few of his own words and sentences but repeats what other peo-
ple say (echolalia) and sometimes recites whole conversations from cartoons. An example
of echolalia is when he answers questions like, “Are you hungry?” with “Are you hungry?”
instead of giving an affirmative or negative answer. This affects his interaction with people,
as he responds the same way to questions they pose. For example, if asked, “What is your
name?” his answer would be, “What is your name?” Further, Emmanuel confuses pronouns
(he says, “You want to go home” instead of “I want to go home”). When upset, Emmanuel
makes guttural noises or screams unintelligibly. He also seems very sensitive to certain sen-
sory inputs, especially loud noises, such as laughter or the hubbub of many people speaking
at the same time. These seem to bother him greatly, and he reacts by covering his ears and
screaming as if in pain.

Generally, Emmanuel seems to have no interest in his peers. He maintains very little
eye contact and does not pick up social cues. For example, he is unable to play tag because
he does not understand what to do when he is “it”; he cannot follow his classmates’ example
of getting in line. He prefers to play on his own and does not engage in imaginative play.
When Emmanuel gets excited, he will flap his hands rapidly, clap his thighs and crotch, and
tap his face. In comparison with his peers he appears aloof or in a world of his own.

Despite his lack of social skills, Emmanuel can manage many one-on-one situations
with adults. He is able to interact in a limited way with one person at a time and participates
in activities suggested by that person if those activities interest him. It is in these situations
that he displays what resembles a sense of humor, although he seems to be amused only
by his own jokes and does not react to other people’s funny remarks or faces. The social
worker who assisted him during the first two days of school reports that he has limited
interests. He is content with writing numbers and letters over and over and was willing to
take turns with the social worker. He appeared to enjoy naming the numbers she wrote
but showed distress when she did not use the same calligraphic style of handwriting that
he himself used. The social worker also reported that Emmanuel frequently writes down
numbers to soothe himself after getting upset.

Autism Spectrum Disorder 27

Emmanuel’s parents report that he acts rather impulsively at times. They state that he
likes to “help” with chores at home. On one occasion he attempted to do the laundry and
emptied a whole bottle of bleach on a basket of colored clothes, thus ruining them. They
say he is not aggressive, however.

Emmanuel’s school personnel completed a thorough assessment, which included
a review of his medical history. They conducted a series of tests, including a speech and
language evaluation, the Wechsler Intelligence Scale, the Childhood Autism Rating Scale,
the Developmental Behavior Checklist, the Vineland Adaptive Behavior Scale, educational
evaluation and observation, and collected his social history. These revealed an average
IQ (95) but below-average language skills. Instead of using words of his own, Emmanuel
employs idiosyncratic expressions. He lacks social skills and shows some developmental
delays in areas of self-help and adaptation. For example, he becomes easily frustrated when
he cannot unzip his jacket and does not accept certain school rules, like putting his back-
pack in his locker, if they go against his usual pattern of behavior.

Emmanuel comes from a caring family. Family members have been aware of
Emmanuel’s atypical development but related it to his lack of schooling and interaction
with peers. They also report that his language development was delayed—he didn’t babble
until the age of two and a half. He started imitating others and reciting sentences by age
four. His parents attributed this delay to the fact that two languages (English and Spanish)
are spoken in the home. They assumed that this lack of consistency led to Emmanuel’s
difficulties with language development. At this point, his mother speaks to him in Spanish,
while all other family members go back and forth between English and Spanish. Emmanuel
himself speaks English, which he started using at the age of two and a half. He understands
Spanish, but speaks it only when distressed.

The parents are open to treatment and agreed to the special education eligibility
process. All family members demonstrate affection toward and concern for Emmanuel.
His mother and sister report some inconsistency in parenting, however, as his father
seems to give in to all of Emmanuel’s wishes. Emmanuel is clearly his father’s favorite
child. His father carries Emmanuel home from school although he is a physically strong
and healthy boy, and he will always interrupt his activities if Emmanuel demands his
attention. His mother tries to use a more structured approach to discipline and reports
letting him cry if he does not get what he wants, such as when he demands candy in a
store. According to Emmanuel’s mother, these differences in parenting are a source of
marital disputes.

The family resides in a three-bedroom apartment in a working-class neighborhood.
The family is living in the United States legally and receives disability benefits due to the
father’s medical condition (a job-related leg injury). Up to this point, Emmanuel stayed at
home with his father while his mother worked as a maid. His sister (age 17) attends the local
community college and his brother (age 13) is a seventh grader at a public middle school.
The parents understand little English and need the assistance of their daughter or a transla-
tor to engage in meetings with school personnel. Extended family live in the area, and large
family gatherings are common. The family is also involved in their Catholic church and has
access to support services there.

Directions Part I, Diagnosis: Given the case information, prepare the following:
a diagnosis, the rationale for the diagnosis, and additional information you would
have wanted to know in order to make a more accurate diagnosis.

Part Two: Neurodevelopmental Disorders28

Diagnosis

Rationale

Additional Information Needed

bioPsyChosoCial risk and resilienCe
influenCes

onset

Autism spectrum disorder is at its core a genetic, neurobiological disorder, although its
specific causes have not yet been identified (Lam, Aman, & Arnold, 2006). There is no
association of ASD with any psychological or social influences in the absence of biological
mechanisms. Still, certain populations are more at risk for the disorder because of their bio-
logical characteristics or tendency to have a later age of diagnosis (see Box 3.1). Although
ASD has many potential causes, in this discussion we will explore risks due to heredity and
brain abnormalities.

Heredity
Evidence that ASD is a neurodevelopmental disorder is indicated by its high rates of hered-
ity transmission. The concordance rate for ASD in identical twins ranges between 36 and
91%, depending on the diagnostic criteria used (Veenstra-Vanderweele & Cook, 2003). In
other family studies, 2 to 4% of siblings also develop ASD, which is 50 times more likely
than in the general population (Matson, Nebel-Schwaim, & Matson, 2007).

The research suggests that different genes (perhaps 3 to 10 of them) and the variety
of ways they can be manifested contribute to the symptoms of ASD (Liu, Paterson, &
Szatmari, 2008). To date there is some evidence for three loci, in chromosomes 7q, 13q,

females

• Overall, ASD is more prevalent in males than
females, but females tend to be more severely
affected because of a greater likelihood
of intellectual disability (Smith, Magyar, &
Arnold-Saritepe, 2002).

low ses

• Low SES is one of the factors associated with later
diagnosis of autism (Mandell et al., 2005).

box 3.1 autism in vulnerable and oppressed Populations

Autism Spectrum Disorder 29

and 15q (Happe & Ronald, 2008). In general, the strongest evidence points to the following
chromosomes:

• #2, which includes genes that control growth and development early in life.
• #7, which includes a region that pertains to speech and language.
• #13 and #15, both of which include genes that, when damaged, can cause behavioral

symptoms associated with ASD.
• #16, which is associated with tuberous sclerosis, a rare genetic multisystem disorder

characterized by seizures, intellectual disability, and skin lesions.
• #17, deficiencies that are associated with metabolic and serotonin deficiencies.
• The X (or sex-specific) chromosome and fragile X (a syndrome of mental retarda-

tion that features a variety of physical abnormalities).

In one recent study of several hundred subjects, it was found that advanced paternal
age (over 40), when the mother was under 30, was associated with an increased risk of
ASD (Reichenberg et al., 2006). A subsequent study found that advanced maternal age is
also a factor, regardless of the father’s age, with an 18% increase in risk for every five years
of maternal age, beginning in the mid-20s (Shelton, Tancredi, & Hertz-Picciotto, 2010).
Possible biological mechanisms include mutations associated with advancing age or altera-
tions in genetic imprinting.

Brain Abnormalities
Approximately 60 to 70% of persons with ASD experience distinct neurological abnormali-
ties and some degree of intellectual disability (Ozonoff, Goodlin-Jones, & Solomon, 2007).
Several relevant brain abnormalities have been identified. Brain imaging studies indicate
that ASD is associated with enlarged overall brain size (as much as 10% larger than non-
autistic toddlers) and decreased size and activity in specific areas of the brain (Hutsler &
Zhang, 2010; Volkmar, Lord, et al., 2004). These areas possibly include the midsagittal area
of the cerebellum, thought to be involved in the sequencing of motor activities; the lower
hippocampus (in the midbrain), associated with complex learning processes; the amyg-
dala (located in the temporal lobe), which is believed to contribute to the recognition of
faces and emotional expression; and a portion of the brain stem associated with attention.
Children with ASD may have an overgrowth of neurons, coupled with an underdeveloped
organization of neurons into specialized systems in some areas of the brain, although find-
ings have not been consistently replicated.

Problems leading to ASD symptoms may be present in a number of neurotransmitter
systems (the chemicals in neurons that send messages to each other) that include serotonin,
dopamine, norepinephrine, acetylcholine, oxytocin, endogenous opioids, cortisol, gluta-
mate, and gamma-aminobutyric acid (GABA) (Lam et al., 2006). Overall, the most empiri-
cal evidence for a role in ASD points to serotonin. There is less support for the notion that
dysfunctions of norepinephrine or the endogenous opioids are related to ASD. The role of
dopamine has not been shown to be compelling thus far, though conflicting findings sug-
gest a need for further study. Promising new areas of study include possible dysfunction of
the cholinergic system, oxytocin, and amino acid neurotransmitters. There is also a need
for studies that control for subject variables such as race, gender, and pubertal status.

With regard to deficits in brain functioning, ASD has been conceptualized in various
ways (Volkmar, Lord, et al., 2004), among them the following:

• A disorder of central coherence, in which the person is unable to process informa-
tion holistically and instead develops a bias toward part-oriented processing.

• A disorder of executive function, in which the person is unable to process bits
of information or regulate behavior, and is thus inclined toward rigid, repetitive
behaviors and impoverished interactions.

Part Two: Neurodevelopmental Disorders30

• A deficit in social cognition, in which the person fails to understand the internal
mental states of other people and has difficulty making attributions of mental states
to others and themselves.

the Course of autism spectrum disorder

Advances in nervous system assessment may eventually facilitate more effective inter-
ventions for its core symptoms, but for now social workers can best focus on the adjust-
ment of persons with ASD. With early detection and intervention, the prognosis seems to
improve.

Currently, one-third of children with ASD ultimately achieve some level of indepen-
dence and self-sufficiency in adulthood, while two-thirds require intensive care (Billstedt,
Gillberg, & Gillberg, 2005). Studies on the course of ASD over time show variable results
that depend on the severity of the condition. Several relevant prospective studies have been
conducted in Sweden. In one study, children who had been diagnosed with ASD (N = 120)
were assessed in adulthood (Billstedt et al., 2005). The majority (57%) was categorized as
having a “very poor” outcome. The next common outcome was “poor” (21%) followed by
“restricted” (13%), and “fair” (8%). None of the persons with ASD had a “good” outcome.
In another prospective study, Swedish men with severe and moderate ASD were followed
for five years after diagnosis (Cederlund, Hagberg, Billstedt, Gillberg, & Gillberg, 2008).
In the majority of cases of persons with moderate ASD the diagnosis was still valid (84%),
and even those without the ongoing diagnosis showed impairment. About a quarter of the
“moderate” group had a “poor” outcome, despite their having average IQs. Outcomes were
worse for persons in the “severe” group, with the majority (76%) having “poor” to “very
poor” outcome. The intellectual level was much lower among those in the “severe” group,
where only five (7%) persons had a normal intellectual capability at follow-up.

In the United States, a sample of 48 children diagnosed with ASD was followed up in
late adolescence (McGovern & Sigma, 2005). Almost all persons were still diagnosed with
the disorder, but their parents described improvements in the areas of social interactions,
repetitive or stereotyped behaviors, adaptive behaviors, and emotional responsiveness to
others’ distress. Adults with ASD who were able to live independently and hold jobs typi-
cally had high levels of cognitive and communication skills despite their persistent social
deficits. Barnhill (2007) studied the course of moderate ASD into adulthood and found that
persons who achieved adaptive functioning levels continued to experience some impair-
ment in employment, perception, social isolation, motor skills, and mood, with depression
being a common condition.

Other than the timing of intervention, protective influences for the course of ASD
include later age of onset (after 24 months) as well as the child’s early acquisition of non-
verbal communication, functional play skills, and speech capacity (Volkmar, Lord, et al.,
2004). Unfortunately, 50% of the ASD population does not develop speech, and a majority
fails to use speech in a functional manner. Another protective influence on the course of
the disorder is the quality of parents’ interactions with their children, which may affect the
development of language skills over time. In one 16-year longitudinal study, parents’ level of
parallel participation during play with their children had a positive impact on the develop-
ment of the child’s language skills (Siller & Sigman, 2002).

Directions Part II, Biopsychosocial Risk and Protective Factors Assessment
Formulate a risk and protective factors assessment, both for the onset of the disorder
and for the course of the disorder, including the strengths that you see for this individual.

Autism Spectrum Disorder 31

interventions

Comprehensive interventions for children with ASD include small-group or one-on-one
behavioral and educational interventions, delivered for at least 10 to 15 hours per week for
periods of time ranging from months to years (Shattuck & Grosse, 2007). Unfortunately, no
intervention has been shown to change the core features of ASD to an extent that the per-
son is able to achieve normative levels of functioning. After a thorough diagnostic evalu-
ation, however, steps may be taken to help the individual function with significant gains.
The range of interventions should include special education, family support, behavioral
management, and social skills training (for persons with higher functioning ASD). Medi-
cations may be used to control behavioral symptoms, but considerable caution should be
exercised when doing so. Some complementary and alternative medicines are available that
some parents find appealing.

special education

Federal law mandates the provision of an Individualized Educational Plan (IEP) for all
children with ASD. Ancillary services such as speech or language therapy, occupational
therapy, and physical therapy are often required as a part of this plan (Volkmar, Lord, et al.,

Risk Influences Protective Influences

Biological

Psychological

Social

Biopsychosocial Risk and Resilience Assessment for the Onset of the Disorder
Table
3.1a

Risk Influences Protective Influences

Biological

Psychological

Social

Biopsychosocial Risk and Resilience Assessment for the Course of the Disorder
Table
3.1b

Part Two: Neurodevelopmental Disorders32

2004). Continuous programming, including summer programming, is more effective than
episodic intervention, because children with ASD often regress in the absence of services.
Professionals should be prepared to collaborate with teachers and other school personnel
and to work with parents to obtain appropriate educational placements and other commu-
nity resources (Holter, 2004).

family education, support, and involvement

Parents should always be encouraged to participate in programs for their ASD children, to
enhance consistency in intervention at home and at school and to facilitate the child’s gen-
eralization of skills across settings (Rogers & Vismara, 2008). Further, grandparents often
play major roles in the detection of symptoms and family support (Hillman, 2007). Family
members can also be invited to join various parent and family groups for information and
support. Many programs are parent-mediated, meaning that the parental caregiver takes
on a primary intervention role. A systematic review of parent-implemented early interven-
tion for ASD was undertaken by McConachie and Diggle (2007) in which 12 studies were
located. The authors concluded that parent training leads to improved child communica-
tive behavior, increased maternal knowledge of ASD, enhanced maternal communication
style, enhanced parent-child interaction, and reduced maternal depression.

behavioral management

Applied behavior analysis (ABA), first developed by Lovaas (1987, 2003) involves the
examination of the antecedents of a problem behavior (the event or situation that precedes
the behavior) and its consequences (the event or situation that follows the behavior). Any
avoidable antecedents for a problem behavior are removed, and desirable behaviors are
taught, followed by positive reinforcement for the child’s performance. Seida et al. (2009)
conducted a review of meta-analyses and systematic reviews for autism interventions. The
review supported ABA in terms of improvements in adaptive, cognitive, and language skills,
as well as reductions in problem behavior. A later systematic review also found that cogni-
tive behavior therapies consistently yielded positive outcomes (Lang, Register, Lauderdale,
Ashbaugh, & Haring, 2010).

Rogers and Vismara (2008) conducted a review of the last 10 years of research on ASD
interventions, and two were found to be “probably efficacious.” One of these is the inten-
sive behavioral treatment program developed by Lovaas (1987, 2003), involving one-on-one
assistance 40 hours a week. The other intervention is known as pivotal response training
(PRT), a type of ABA taught to parents that focuses on “pivotal” aspects of the child’s func-
tioning, including motivation, self-management, initiation of interactions, and the ability
to select cues that are relevant in a given situation. PRT earned its rating based primarily on
single-subject studies, although a recent larger study was done on a diverse sample (Baker-
Ericzén, Stahmer, & Burns, 2007).

Still, the results of studies of treatment programs for ASD in general indicate that they
are not as effective as once hoped (Matson & Minshawi, 2006). One limitation involves the
challenge for families of maintaining the intensity recommended by some programs (such
as the number of hours of face-to-face involvement and regular use of specific exercises).
Despite various methodological flaws, a sufficient number of replications exist to declare
ABA methods “promising.”

medication

The core features of ASD do not respond to medication. Drug intervention may, how-
ever, help control the symptoms of aggression, self-injury, inattention, and stereotyped
movements (Volkmar, Lord, et al., 2004). It is estimated that 27% of persons with ASD

Autism Spectrum Disorder 33

take one medication, and 46% of those persons receive two medications (Matson &
Hess, 2011). A majority of persons with ASD take either a psychostimulant drug or ris-
peridone, although side effects for the latter drug (weight gain and drowsiness) are a
concern.

The effectiveness of the selective serotonin reuptake inhibitor (SSRI) medications for
adults (but not children) supports evidence that ASD is associated with abnormalities in
serotonin function (Leskovec, Rowles, & Findlay, 2008). For repetitive and maladaptive
behavior in adults, fluvoxamine has been found effective, and fluoxetine has been validated
for children’s repetitive behavior (Posey, Erickson, Stigler, & McDougle, 2006). Still, chil-
dren appear to be more sensitive to the adverse effects of the SSRI medications (including
agitation), and the weight of evidence to support their use is weak. Other medications, such
as the anticonvulsants, have been used to regulate the behaviors of persons with ASD, but
there is no compelling evidence for their utility at present (Oswald & Sonenklar, 2007).
Empirical evidence for significant reductions in hyperactive symptoms is strongest for the
antipsychotic drugs (particularly risperidone) and the psychostimulants. There is some
evidence of the effectiveness of risperidone in treating irritability, aggression, self-injury,
and temper tantrums, often without inducing severe adverse reactions (Jesner, Aref-Adib,
& Coren, 2007).

social skills training

Interventions emphasizing social skills developments for persons with ASD have
emerged as a major theme in the treatment literature in recent years (Matson & Minshawi,
2006). Much of this literature has focused on older children. These interventions can
be carried out through integrated peer groups, class-wide interventions, adult social
groups, and videotapes to help the clients perceive themselves as they try to gain new
interactional skills.

Complementary and alternative treatments

The National Center for Complementary and Alternative Medicine organizes its therapies
into four domains: mind–body medicine, biologically based practices, manipulative and
body-based practices, and energy medicine. Approximately half of families of children
with ASD use a biologically based therapy (e.g., dietary supplements), 30% use a mind–
body therapy (e.g., music therapy), and 25% use a manipulation or body-based method
(e.g., auditory integration) (Hanson et al., 2007). These same authors reported that 41% of
respondents endorsed the benefits of dietary and nutritional treatments, whereas Wong
and Smith (2006) reported that 75% of respondents found their complementary and alter-
native treatments to be helpful.

interventions for adolescents and adults

For adolescents, intervention emphasis should be placed on adaptive and vocational skills
to prepare for independent living. Sexual development in adolescence brings some addi-
tional behavioral problems, which may be addressed using education and behavioral tech-
niques. Such techniques include teaching basic social skills through operant conditioning
(introducing oneself, responding to requests, not touching other persons inappropriately)
(Holter, 2004). Among adults, the identification of community resources and supports
for long-term care planning is critical. Such resources may include foster homes, semi-
independent living situations, living with parents who may qualify for income supplements
and insurance, and supervised group living (NIMH, 2007).

Part Two: Neurodevelopmental Disorders34

CritiCal PersPeCtive

One of the major changes in DSM-5 is the recognition that what used to be termed “autistic
disorder” exists on a continuum, with varying degrees of impairment that imply differ-
ent interventions (Volkmar, Lord, et al., 2004). There has historically been some debate
about whether there are significant distinctions between autism and the formerly classified
Asperger’s syndrome and PDD-NOS, and few studies found clear support for separate clas-
sifications (Kasari & Rotheram-Fuller, 2005). The new classification allows professionals to
identify levels of disability more clearly in each of the core areas of autism and thus con-
sider ASD along a single spectrum of ability and disability. There is concern among some
consumer advocacy groups that the changes in terminology may make some persons at
least temporarily ineligible for funded services (e.g., those who have been diagnosed with
Asperger’s syndrome rather than autistic disorder) and it remains to be seen how well, or
how quickly, funding sources will make adjustments in their eligibility criteria.

Directions Part III, Goal Setting and Treatment Planning Given your risk and
protective factors assessments of the individual, your knowledge of the disorder, and
evidence-based practice guidelines, formulate goals and a possible treatment plan for
this individual.

Directions Part IV, Critical Perspective Formulate a critique of the diagnosis as it
relates to this case example. Questions to consider include the following: Does this
diagnosis represent a valid mental disorder from the social work perspective? Is this
diagnosis significantly different from other possible diagnoses? Your critique should
be based on the values of the social work profession (which are incongruent in some
ways with the medical model) and the validity of the specific diagnostic criteria
applied to this case.

Case 2: The Chung Family

Hao, a five-year-old child whose parents emigrated from Vietnam many years ago, was
recently expelled from his parochial school kindergarten class and advised to seek placement
at the public school. The reason for the expulsion was his inability to relate to other children
in class, incessant hand washing, and inability to follow instructions. Hao could not follow
the classroom routine and would stay only for activities in which he was interested, such as
those focusing on math or science topics. At times he would grow so frustrated with what
he saw as disruptions to his favored activities that he had temper tantrums at school. His
parents, Lang and An, are extremely upset over Hao’s expulsion and are not sure what the
future holds for him.

Lang and An had no previous thoughts of seeking out services for their son until now. It
was only when Hao faced the structure of the kindergarten day that problems emerged. Lang, a
43-year-old Vietnamese woman and primary informant during this assessment, enrolled Hao in
preschool at the age of four and did notice at that time that Hao was not connecting personally
with other children. She said, “Hao only wanted to play alone. He ran around the yard while
other children played together.” But when Lang asked the teachers about this, they said that

Autism Spectrum Disorder 35

Hao was a sweet little boy who displayed no unusual behaviors and that all children mature
at different rates. Lang believes that the preschool teachers’ patience served to elicit positive
behavior from Hao. Hao thrived in preschool and responded well to the staff’s consistent positive
reinforcement. Hao never had a tantrum in preschool.

Lang tried for years to conceive before having Hao. She was able to access quality prenatal
care and experienced a good pregnancy and vaginal delivery with no complications. Hao was a
healthy infant, who weighed 7 pounds, 4 ounces, at birth. He walked at 11 months of age, had
a vocabulary of about 20 words when he was 18 months old (which is considered normal), and
was toilet trained at 24 months of age. He also began to read at 24 months of age and learned
how to use a computer before he was 36 months old. Hao now dedicates a significant portion of
time to figuring out how to operate minute functions on the computer, fixing computer parts,
and playing math and science games on the computer.

Hao is also gifted musically. He can play a song on his electric keyboard after hearing it only
once. Hao was recently tested and found to have an IQ of 130. He was extremely interested
in the testing process, asking questions about the instruments. Sometimes he would ask the
psychologist questions in response to her questions.

Lang appreciates the importance of Hao’s gifts and nurtures his curiosity with books,
musical instruments, and computer games. At the same time, she and An are both concerned
about these attributes in terms of their impact on Hao’s relationships with others. They believe
Hao functions at such a high level that he would alienate peers by obsessing about his computer
and academic pursuits and not just playing like a normal five-year-old.

Lang encourages Hao to dress himself, select his own breakfast (he is able to pour his own
cereal and milk), and care for his books and toys. Her son needs help buttoning his clothing and
tying his shoes because of a slight delay in fine-motor skills.

Lang notices a difference between her more compliant nieces and nephews and Hao,
who would prefer to follow his own set of rules rather than those set forth by his family. Lang
states that mealtimes are especially difficult for their family, because Hao refuses to sit for longer
than two minutes and ignores them when they speak to him. Lang and An value order, not
unlike most Vietnamese parents, according to Lang; Hao’s frequent disruptions during meals
are difficult to bear. He sits for two minutes at a time and then gets up to draw or write in his
notebook. When he does sit at the table, Hao takes over an hour to finish a meal that should
take 30 minutes to finish.

Hao tends to ignore his parents when they try to discipline him. When Hao does not follow
instructions, he is responsive to time-outs, strong verbal communication, and direct eye contact
from Lang. Time-outs have proved a deterrent to disruptive behavior, as Hao hates receiving
time-outs. Lang and An try to be consistent in their approach to discipline. When asked how she
has managed to be patient and firm with Hao in the face of his erratic behavior, Lang stated that
it is difficult but she has to do it in order to be a good mother for Hao. She stated that Hao needs
extra attention and patience and that her faith helps her through the tough times.

Hao has suffered from severe allergies since he began eating solid foods. He is allergic to
peanuts, eggs, and milk and breaks out in eczema as a result. Lang and An are closely involved
with Hao’s pediatrician, and Lang constantly monitors his food intake. As a result, Hao has
suffered few outbreaks of eczema in recent years.

Every Saturday and Sunday An brings Hao to the park, where they enjoy playing basketball,
soccer, and other sports. An becomes frustrated with Hao’s excessive laughter during these
activities. At times An loses his patience and threatens to leave the park. Lang indicated that
Hao’s loss of control is unacceptable in the Vietnamese culture; children are expected to be
more in control of their emotions by the time they are Hao’s age.

Lang and An are healthy and report no chronic physical or mental illness in themselves or
their own families. Lang is a high school graduate who is a trained hairdresser, and An is a college
graduate currently working as an information technologist. They enjoy a financially secure life

Part Two: Neurodevelopmental Disorders36

and comfortable existence. Lang has been able to stay home and care for Hao because of this
financial security but is excited about getting back into hairdressing. She knows that she will be
much happier when she is cutting hair again, in that she will have a personal and professional
outlet.

As An works long hours, Lang bears the brunt of the responsibility for Hao. She complains
of feeling exhausted and helpless. This difficulty has placed an occasional strain on Lang’s
marriage with An. Lang feels relieved when her husband is available to help. An cooks dinner
on weekends and will sometimes use his flex-leave to take Friday off, which allows Lang to have
time to herself. On weekends, Lang and An spend time with An’s family. Lang enjoys this time,
as she has a positive relationship with them. They eat meals and enjoy birthday parties together,
and sometimes Lang will go shopping with her sister-in-law.

Hao has 11 first cousins and sees them almost every weekend for birthdays, at church,
and during dinner get-togethers. Hao and his first cousin, six-year-old Thanh, get along well,
although Hao tends to focus too much on academics with Thanh. This irritates Lang, who picks
up on Thanh’s lack of interest, but Hao is unable to see it. Lang will at times firmly instruct
Thanh to ignore Hao’s questions about math, science, and reading, suggesting other toys and
games they might enjoy instead. Hao’s aunts and uncles don’t always understand why his
parents encourage his “different” personality and express distaste over what they perceive as his
unusual habits.

Lang summed up her feelings about Hao’s most pressing issue. Lang emphasized that while
Hao is gifted intellectually, he is not developing socially. Lang stated, “I don’t care if he is smart.
How is he going to have friends and someday find a wife if he is this way?”

Lang explained that both she and her husband were “boat people.” She escaped from
Communist Vietnam 25 years ago and spent three years in Cambodia until she was able to
locate a family member in the United States who was able to sponsor her. An had arrived in the
United States five years before Lang arrived. The couple met in the United States and married
15 years ago. Lang stated that her faith in God and her determination helped her to persevere
through many difficult obstacles when trying to come to the United States.

For Lang, An, and Hao, English is their second language. Vietnamese is spoken in the home,
and the family holds traditional Vietnamese values. For example, Lang explained that family
cohesiveness, spirituality, and work are important to them.

Lang reported that in Vietnam, Hao’s behavior would be considered completely
unacceptable and totally outside the norm. She stated that she was able to think “less Vietnamese
and more American” about Hao when she observed the patience of American teachers in
managing Hao. She is hopeful about the future and recognizes that she and An would not be
receiving the support for Hao in Vietnam that they receive here. In Vietnam children are warned
against bad behavior by being threatened with a wooden spoon. Often, children are hit with the
spoon if they continue to misbehave. Lang reports that she has threatened Hao with the spoon
only occasionally. Lang stated that when Hao misbehaves she gets down on her knees, uses
direct visual contact, and speaks firmly. Lang has used time-outs successfully in the past and will
continue to use them.

Lang, An, and Hao are devout Catholics and rely heavily on the guidance of their faith.
Lang indicates that she prays often and speaks to her priest when she feels overwhelmed. Lang
indicated that her priest has helped her to understand Hao better and told her that God made
him and he should be accepted and loved. Lang gets a great deal of support from her priest and
is able to find strength and patience through prayer. Lang sometimes prays at the dinner table
when Hao is not cooperating and reports that it helps her not lose her patience with him. Lang
often engages him in prayer to remedy his inattentiveness. This approach generally works, and
Lang reports that Hao will sit and pray with her for periods of up to a minute or two.

Observations of Hao in his kindergarten classroom revealed that he speaks very loudly
and in close proximity to other people’s faces. The teacher says that he is unable to retain her

Autism Spectrum Disorder 37

instructions about standing back or speaking more quietly. Typically, Hao flatly looks off into
space while the teacher speaks. His face displays little emotion. He does not react to questions or
comments made by the teacher.

Case 3: The Kindergartener

DeShon Johnson is a five-year-old African American male kindergarten student who has been
referred to his school’s Child Study Team. He is distant and aloof, does not relate to classmates
and his teacher, and rarely makes eye contact. He does not play imaginatively like the other
children in his class, although his mother says he entertains himself well, usually playing with
small household items such as kitchen utensils, pencils, or small toys such as matchbox-style
cars, for hours on end. He also likes being outside.

His mother, Mrs. Turner, reports that at times DeShon easily becomes frustrated, upset,
and defiant—crying, screaming, and throwing himself to the floor—especially when having to
transition from one activity to another. These tantrums last from 5 to 30 minutes and occur
once or twice per day. DeShon’s mother and her boyfriend react to these tantrums by ignoring,
yelling, or spanking him. Nothing, according to his mother, changes the nature of his tantrums.
At most times, his affect is flat. He is sensitive to tactile experiences, particularly with regard to
food texture. For example, DeShon refuses to eat any food items that are crunchy or hard in
consistency. He likes soft foods, such as yogurt, bananas, and soggy cereal. Although DeShon
does talk, he displays echolalia, often repeating what others say to him. He also rocks back and
forth and waves his hands in front of his face.

According to his mother, DeShon’s birth history was normal, and he was healthy upon
delivery. His mother stated that she became somewhat concerned about her son when he was
between 18 and 24 months of age. She noted that DeShon’s speech, which had apparently been
developing relatively normally, stopped progressing. The little eye contact that DeShon had
previously made became even less frequent. She also noted that DeShon seemed increasingly
uninterested in social interaction, even with her, his older siblings, and others with whom he
was quite familiar. Toilet training was reportedly an extensive, time-consuming, and difficult
process for DeShon. Despite these concerns, DeShon did not receive consistent medical care
and follow-up on referrals to specialists because of the family’s frequent moves, lack of financial
resources, and temporary homelessness. Consequently, DeShon entered kindergarten with no
formal diagnosis or treatment plan.

DeShon Johnson resides with his mother, her male partner, and two older teenage siblings.
Ms. Turner is 30 years old and attended school until the eighth grade, when she became pregnant
with DeShon’s 15-year-old brother. Each of her children has a different biological father. She is
currently unemployed but has occasionally worked in the food services field. DeShon’s biological
father (Torrence Brown) is 39 years old and has been intermittently incarcerated since the age
of 15 for drug charges. He has sporadic contact with DeShon and provides no financial support.

The family has Medicaid health coverage. DeShon’s mother tends to let coverage lapse for
a few months each year because she does not complete the required renewal paperwork in a
timely manner. At the same time, DeShon’s mother is fairly familiar with social services agencies
and how to get assistance and financial help when she is in a tight spot.

Ms. Turner’s boyfriend is 38 years old and has a tenth-grade education. At times he is
employed as a painter. He has lived with the family off and on for approximately three years but
has two children in other households living with their respective mothers.

Please go to the Additional Case Workbook for directions to this case.

Part Two: Neurodevelopmental Disorders38

DeShon’s mother is able to meet the basic needs of her children: food, clothing, bathing,
and shelter. While she obviously loves her children, she is inconsistent in disciplining them.
She and her boyfriend often become frustrated with DeShon’s challenging behaviors and
communication difficulties and tend to rely on yelling and spanking for discipline.

Ms. Turner’s stepmother and her aunt and uncle offer emotional support to the family;
in addition, she sees other extended family members on occasion, perhaps several times per
month. Most members of her family are also struggling financially, so they are not able to offer
financial aid.

The family lives in an apartment complex near DeShon’s school. Although some parents in
this area are reluctant to allow their children to play outside due to potential danger, DeShon’s
mother perceives the neighborhood as being much safer than some of her past neighborhoods.

DeShon attended no preschool or day care prior to entering public kindergarten as a five-
year-old. During the first few days of school, DeShon’s teacher recognized that not only had
DeShon lacked exposure to any form of structure in his young life, but he seemed unusually
detached from social interactions. This veteran teacher realized that DeShon was likely
developmentally delayed, and she immediately referred him to the Child Study Team for an
evaluation.

Upon learning of his behavioral characteristics and history, the Child Study Team
recommended that DeShon undergo full assessments—psychological, educational, and
sociological evaluations. This school system provides comprehensive services to children with
special needs, and the special education teachers are experienced and dedicated. DeShon’s
mother is willing to seek and accept whatever assistance the school can offer. Testing showed
that DeShon has an IQ of 60 and that his strongest learning style is through visual means. His
receptive listening skills are very poor. A medical exam indicated no known physical conditions
that could have caused his current symptoms.

Please go to the Additional Case Workbook for directions to this case.

references

39

Neurodevelopmental Disorders
Attention-Deficit Hyperactivity Disorder

Mrs. Bronsky, a 32-year-old Caucasian woman, brought her two children—Pauline, age 10, and Billy,
age 8—to the agency because her new husband’s 15-year-old nephew had sexually abused them.
Mrs. Bronsky says that Billy has always been a difficult child, independent of the sexual abuse. When
asked to do chores or homework or given any instruction, he argues and refuses point blank. If he
is doing something annoying to his mother, such as banging a toy against the wall and creating
scuffmarks, he keeps doing it, almost as if he enjoys getting on everyone’s nerves.

His teachers report that Billy argues about teacher commands and refuses to do schoolwork.
When teachers correct him on misbehavior, he blames classmates. Not surprisingly, he has
always received poor conduct grades in school. He has also barely passed each grade and is
currently scraping by. His math and science grades are now at the failing level. Mrs. Bronsky
says that he has not undergone any testing at the school, nor does he have an Individualized
Educational Plan (IEP). However, his teacher has suggested that Billy take Ritalin. Mrs. Bronsky
states that she doesn’t want her son on medication and has heard that some herbal remedies
might help him. She admits that Billy does seem to have some difficulty keeping his attention on
tasks. He is easily distracted (looking out the window at school and getting involved with what is
happening out there rather than what the teacher is saying), doesn’t seem to be listening when
someone tells him something (but Mrs. Bronsky suspects that he’s purposely being difficult),
and loses and forgets things (his math book, his homework, or what the teacher has told him).
Again, Mrs. Bronsky thinks that these are purposeful behaviors to avoid the work rather than
actual forgetfulness.

A
ttention-deficit hyperactivity disorder (ADHD) is characterized by a chronic pat-
tern of inattention or hyperactive/impulsive behavior (or both) that is more severe
than what is typically observed in peers (American Psychiatric Association [APA],

2013). Persons with the “inattention” subtype of the disorder manifest a failure to attend
to details and make many careless mistakes, whereas those with the “hyperactive” subtype
are characterized by restlessness and impulsivity. The ADHD diagnosis was once largely
restricted to children and adolescents, but it is now known that the condition can persist
into adulthood. The current diagnostic criteria reflect sensitivity to some differences in
presentation for persons aged 17 and older.

C h a p t e r 4

Part Two: Neurodevelopmental Disorders40

PrevalenCe and Comorbidity

The Centers for Disease Control and Prevention (2005) reports an ADHD prevalence
of 7.8% among children aged 4 to 17. About a third of children with ADHD also have
a comorbid disorder (Jensen et al., 2007). Most common concurrent disorders are
either oppositional defiant disorder (ODD) or conduct disorder (CD), which puts a
child at risk for poor outcomes, including the development of substance use disorders
( Barkley, 2004) and mood disorders (Biederman et al., 2008) in adolescence and young
adulthood. About 50% of youths with ADHD may have ODD or CD; this comorbid-
ity pattern is more common in the combined than in the inattentive type (Connor,
Steeber, & McBurnett, 2010).

assessing adHd

The way in which ADHD assessments are conducted depends on the age of the client.
The diagnosis is particularly difficult in preschool children because of the lack of valid
measurement tools and the difficulty of sorting out the possible psychological or environ-
mental contributors to the child’s symptoms (Shepard, Carter, & Cohen, 2000). As a re-
sult, most comprehensive assessments do not occur until elementary school. The social
worker can assume primary responsibility for certain aspects of this assessment (clinical
interviews with the child and parent, assessment of parent-child interactions, interviews
with teachers, and implementation of standardized behavior rating scales). Other aspects
of the assessment require referrals for medical and psychological evaluation. In summary,
assessment at the school-age stage should comprise the following (American Academy of
Pediatrics, 2000):

• A physical examination and a review of health records.
• Interviews with the child, parents, teachers, and any other significant persons. It must

be noted that children tend to underreport their symptoms (Pelham, Fabiano, &
Massetti, 2005). In addition, teachers are usually the first people (followed by
parents) to suggest that a child be evaluated for ADHD (Sax & Kautz, 2003), and
their judgment of a child’s symptoms tends to be valid (Mannuzza, Klein, &
Moulton, 2002).

• Rating scales completed by parents and teachers can also provide useful informa-
tion. The Swanson, Nolan, and Pelham-IV Questionnaire (SNAP-IV) (Swanson,
1992; Swanson et al., 2001) has both parent and teacher versions for children aged 5
to 11 and is available online.

• A review of school records (report cards, achievement tests, and attendance).
• Behavioral observations of the child and of parent-child interaction.

Making a differential diagnosis between ADHD and other disorders is also important.
Children with ODD behave in a way that purposely annoys and antagonizes others,
whereas ADHD symptoms are displayed without regard to others. However, as noted,
both disorders often co-occur. The practitioner must also explore any trauma history.
Common traumas include abandonment, physical or sexual abuse, or observation of
family or community violence. Some of the symptoms of posttraumatic stress disorder
(PTSD) may mimic those of ADHD (Perrin, Smith, & Yule, 2000). Chronic hyper-
arousal and physiological reactivity to cues from the traumatic event can appear as

Neurodevelopmental Disorders 41

hyperactivity and impulsivity. Intrusive thoughts of a trauma can interfere with atten-
tion and concentration.

In addition to these steps, a clinical interview with adults should include a discussion of
ADHD symptoms present in childhood and current symptoms. As will be discussed, many
of the DSM-5 criteria for ADHD are geared toward children, so adult variants of hyperactive
symptoms may include workaholism, difficulty sitting through meetings at work, unwilling-
ness to wait, and speeding (Weiss & Weiss, 2004). The clinician should further inquire about
a history of drug and alcohol use (because ADHD can be comorbid with substance abuse).
If possible, a collateral (a spouse, partner, or parent) should be interviewed to provide a more
objective appraisal of the client’s symptoms (Murphy & Adler, 2004).

The health care system is where most children with ADHD are diagnosed and treated
and so attempts have been made to educate primary care providers on appropriate prac-
tices (Wolraich, Bard, Stein, Rushton, & O’Connor, 2010). As a result, improvements have
been made, in that the majority of physicians report using the DSM criteria (81%) and
teacher rating scales (67%) to arrive at a diagnosis.

Although teacher reports are said to be important in making a diagnosis of ADHD,
elsewhere in the chapter it is argued that teacher perceptions may be skewed, and you may
have observed this phenomenon in your own experiences with clients. Given these facts,
how will you decide whether a teacher’s strong endorsement of a child having symptoms of
ADHD is contrary to the child’s caregivers’ reports?

CASE 1: The Bed Wetter

Mrs. Bronsky says she has not talked to her children about the sexual abuse, both because
they have been interviewed so many times and because they do not bring it up. She
would prefer that they all just forget about it, but the women at the children’s advocacy
center emphasized that her children will need counseling. She reports, though, that the
professionals attribute all of Billy’s problems, such as his lack of following through with rules
and his bed-wetting, to the abuse. As long as she can remember, however, Billy has had
these problems. Mrs. Bronsky denies that he has had nightmares, changes in sleep or eating
patterns, or any other specific fears since the abuse occurred. She reports that both Pauline
and Billy liked their cousin who abused them and now ask when they can play with him
again. When asked how she responds to those requests, Mrs. Bronsky says she tells them,
“Now you know after what you said that you can’t play with him ever again.” When you
explore with her what this could mean to the children, she says that she makes it clear that
the abuse was the older cousin’s fault, that he has a problem and needs a lot of counseling,
and that they did the right thing in telling her about it.

When asked about the bed-wetting, Mrs. Bronsky said that that is another long-
standing problem, that Billy wets his bed almost every night and has done so ever since
he was little. She says he rarely wets himself during the daytime. When asked how she has
tried to address the problem, she says that she tries to limit his liquid intake after a certain
time of day and makes sure he uses the bathroom before he goes to bed. She says that
for the past year, Billy has occasionally (once a month) passed feces into his clothing during
the daytime. She has had him checked medically, and no problem has been found. She
says that she sees neither the bowel movements nor his urination as oppositional behaviors,
because he is extremely embarrassed about these “accidents.” When asked, she claimed that
the doctor has given her no advice on how to handle these problems, other than to have

Part Two: Neurodevelopmental Disorders42

Billy be responsible for washing his own sheets and clothing. She notes that he sometimes
hides the sheets and clothes because he is embarrassed.

Mrs. Bronsky reports that she was married to Pauline and Billy’s father for nine years and that
he was physically abusive to her, but not to the children. She admits that they witnessed some
of the violence and would cry, but she denies that it had any lasting impact on them in terms of
nightmares, flashbacks, or other fears. She says her husband hung out with a motorcycle gang
and had a problem with “taking speed” in their early marriage, but now merely drinks heavily.
She states that he eventually left her two years ago to be with another woman.

Mrs. Bronsky reports that her children have regular visitation with her ex-husband and
have consistently denied to all who have asked that he is abusive to them. The children tell
the therapist that they like his girlfriend, and that he is not drunk when they are over there,
although he does sometimes drink beer. They enjoy their visits to his house. When asked the
reason their parents are not together anymore, they say that he went to live with his girlfriend
and do not mention the family violence.

Mrs. Bronsky says she has been married to her new husband, Don, for one year, and that
she is happy because he is so much better than her ex-husband. He is not violent to her and
holds a regular job. When asked how her new husband reacted to the report of Pauline and
Billy’s sexual abuse by his sister’s son, she said that he believes it happened but doesn’t want
any part of the whole problem. He has played as minimal a role as possible in the police and the
child protective services investigations. For example, Mrs. Bronsky has gone alone to the child
advocacy center with her children to be interviewed and to have their medical examinations.
When asked if the sexual abuse in the family has put any stress on her relationship with her
husband, Mrs. Bronsky denies it. She says her husband is very good with her children, although
when the children were alone together with the therapist in the second session, they reported,
“Don yells a lot” at them and at their mother.

When the therapist was alone with Billy for the first session, he did not talk at all and just
looked down as the therapist made various validating remarks (“It’s hard talking to someone
you don’t know,” “You’re not in here for anything you’ve done wrong,” etc.) or asked questions
related to his expectations about counseling (e.g., “What did your mom say you were coming
for?”) or told him about her role (“My job is to talk to kids about things that have happened to
them that have been hard to deal with,” etc.). No matter what the therapist tried, Billy refused
to answer. In the second session, Billy and his sister were together in the session and were more
forthcoming, as indicated by the information they provided about their father, his girlfriend, and
their stepfather. Billy was guarded when the therapist brought up the recent sexual abuse and
avoided answering any questions, whereas his sister was willing to discuss it. He denied having
bad dreams.

The social worker obtained a release from Mrs. Bronsky to talk to Billy’s teacher, who says
that in her mind, there is no doubt that Billy has ADHD. “He’s classic. He can’t sit still. He gets
out of his seat if any item attracts his attention. He always has to be fiddling with something. He
talks when I’m talking.” When asked about oppositional symptoms, she says, “He talks back if
I tell him to stop disrupting the class and makes excuses. He glowers at me and folds his arms,
refusing to do his work at all at times. The little work he finishes is a mess and full of mistakes.
Everyone else is always to blame. He’s not accountable, at all.”

Directions Part I, Diagnosis: Given the case information, prepare the following: a
diagnosis, the rationale for the diagnosis, and additional information you would like
to know in order to make a more accurate diagnosis.

Neurodevelopmental Disorders 43

bioPsyCHosoCial risk and resilienCe
influenCes

onset

Many researchers assert that ADHD represents a pattern of cognitive or neuropsychologi-
cal impairment that is manifested in the person’s deficits regarding self-regulation, behavior
inhibition, and self-control (Barkley, 2006; Johnson, Wiersema, & Kuntsi, 2009). Although
this conceptualization has not been proved, there is broad support for the fact that child
factors, rather than family, neighborhood, and other influences related to socioeconomic
status (SES), are responsible for ADHD (Ford, Goodman, & Meltzer, 2004). Risks for so-
cially diverse populations are summarized in Box 4.1.

Biological Influences
ADHD is assumed to be an inherited genetic disorder with heritability estimates at over
70% (Faraone & Khan, 2006; Polderman et al., 2007). The precise genetic mechanisms

females

• While ADHD is more prominent among boys by
a ratio of 2.5:1, girls may be underdiagnosed be-
cause they are not as disruptive as boys (Centers
for Disease Control and Prevention, 2005; Ohan &
Johnston, 2005).

• Impairment for girls with ADHD can cross many life
domains and persist over time, and by young adulthood
many suffer from antisocial, addictive, mood, anxiety,
and eating disorders (Biederman et al., 2010, p. 409;
Hinshaw, Owens, Sami, & Fargeon, 2006).

ethnic minority groups

• Although African-American children have more
ADHD symptoms, they are diagnosed two-thirds
less frequently than Caucasian children. This pat-
tern is not explained by teacher rating bias or SES,
but may be influenced by parent beliefs about
ADHD, a lack of treatment access and utilization,
and the fact that existing assessment tools may
not adequately capture ADHD manifestation in
African Americans (Miller, Nigg, & Miller, 2008).

• Lower treatment rates in African-American chil-
dren may be related to high rates of classroom be-
havior problems among African-American youths
(Miller et al., 2008).

• In the Multimodal Treatment Study of ADHD, boys
from ethnic minority backgrounds improved with
a combination of behavioral therapy and medica-
tion compared to only medication (Jensen et al.,
2007). In general, African American and Latino
parents prefer psychosocial treatment to medi-
cation for ADHD (Pham, Carlson, & Kosciulek,
2010).

• Prevalence rates for Hispanic children are
estimated at 3.3%, compared with 6.5% for
Caucasian children. The condition may go
unrecognized in Hispanics given the lack of
population-based studies performed, language
barriers, underreporting by mothers due to lack
of knowledge of symptoms, cultural differences in
developmental expectations by Hispanic mothers,
physician bias against taking concerns of parents
seriously, and a lack of access to treatment re-
sources (Bloom & Dey, 2006; Rothe, 2005).

low ses

• Lead exposure increases the risk of ADHD (Braun,
Kahn, Froelich, Auginger, & Lamphear, 2006).

• Children living in low-SES homes are more likely to
have an ADHD diagnosis than those in higher SES
groups (Merikangas et al., 2010a).

box 4.1 risks for adHd in socially diverse Populations

Part Two: Neurodevelopmental Disorders44

that contribute to the onset of ADHD are not known (Neale et al., 2010), but dopamine
transmitter and receptor genes, as well as several serotonin transporter and recep-
tor genes, have been linked to the disorder (Faraone & Khan, 2006; Gizer, Ficks, &
Waldman, 2009; Levy, Hay, & Bennett, 2006). There are also neurobiological factors,
such as the capacity to inhibit impulsive behaviors, that protect youngsters from devel-
oping ADHD in the presence of environmental risk (Nigg, Nikolas, Friderici, Park, &
Zucker, 2007).

Aside from genetics, other biological influences may influence the development
of ADHD. Children who are born prematurely are at twice the risk for ADHD as full-
term children (Bhutta, Cleves, Casey, Cradock, & Anand, 2002). Maternal smoking and
drinking during pregnancy may independently act as predisposing influences (Kahn,
Khoury, Nichols, & Lanphear, 2003). Lead exposure is also thought to have increased
the number of U.S. ADHD cases by 290,000 (Braun et al., 2006). Other environmental
toxins, including organophosphate pesticides, at levels common among U.S. children,
may contribute to a diagnosis of ADHD (Bouchard, Bellinger, Wright, & Weisskopf,
2010).

Interestingly, an Australian study tracking maternal anxiety and attention prob-
lems in children found that anxiety during or after pregnancy was associated with at-
tention problems in children at both 5 and 15 years (Clavarino et al., 2010). The effect
of maternal anxiety was cumulative; that is, the more chronic the anxiety, the more
likely the child was reported (by both mother and child) as being attention impaired.
This relationship could be biological: Genetics may be responsible for both maternal
anxiety and child ADHD. Alternatively, the child’s inherited anxiety potential could
influence his or her responsiveness to the environment through an alteration of the
hormonal and autonomic nervous systems. The association found in this study could
also be due to the parenting abilities and responsiveness of anxious mothers to their
children’s needs and behaviors.

Social Influences
Although many experts vigorously assert that ADHD is a neuropsychological disorder,
others suggest that family and social risk influences may play a causal role (Counts, Nigg,
Stawicki, Rappley, & Eye, 2005). Family dynamics in one longitudinal study, namely hostility
in family interactions at age two was predictive of child ADHD at age seven ( Jacobvitz,
Hazen, Curran, & Hitchens, 2004). For boys, enmeshed relationships with their mother
also predicted ADHD. It is unknown whether the symptoms of ADHD were already pres-
ent in those toddlers, contributing to the family dynamics.

It is likely that adversity may affect children with a genetic vulnerability to develop
ADHD (Laucht et al., 2007). For example, being reared in an institutional setting
may also be associated with ADHD symptoms years after the child has been adopted
(Stevens et al., 2008). Additionally, a U.S. survey of child and adolescent mental health
disorders showed that those living in low SES were more likely to have an ADHD diag-
nosis than those in higher SES groups (Merikangas et al., 2010a). Similarly, a Swedish
study showed that a family’s receipt of welfare benefits increased the risk of a child
being prescribed ADHD medication by 135% when compared with households not
claiming benefits (Hjern, Weitoft, & Lindblad, 2010). Moreover, mothers who did not
have university degrees were 130% more likely to have a child on ADHD medication
than women with university degrees. Finally, children were 54% more likely to be on
ADHD medication if they came from a single-parent family rather than having both
parents at home.

Neurodevelopmental Disorders 45

Critically evaluate empirically based research materials related to social work
practice and understand the differences and appropriate applications of empirical
and nonempirical professional literature.

Course and recovery

Continuance rates from childhood to adulthood ADHD are estimated to be 36% in the
U.S. population (Breslau, Miller, Chung, & Schweitzer, 2011), with 8.1% of adults meet-
ing diagnostic criteria (Kessler et al., 2005, 2006), although estimates vary (Simon, Czo-
bor, Balint, Meszaros, & Bitter, 2009). A recent study following youth diagnosed with
ADHD in childhood found them more likely to be depressed and to attempt suicide in
adolescence. Students with the combined type of ADHD, the most common type, have
a higher likelihood of dropping out than students with disciplinary problems. Further-
more, even with treatment, youths with ADHD still had significantly more academic,
social, and conduct problems than their non-ADHD ( Molina et al., 2009).

In a study following hyperactive children into young adulthood, a third (32%) had failed to
complete high school, and far fewer were enrolled in college compared with the control group
(without hyperactivity) (Barkley, 2006). In addition, the young adults with hyperactivity had
fewer friends and had more difficulty keeping friends. Sexual risk taking, in terms of both num-
ber of partners and unprotected sex, was also indicated. Moreover, adults with ADHD showed
impaired work performance, and this effect was particularly evident among blue-collar work-
ers (Kessler et al., 2005). People with ADHD have more car accidents, citations, and speeding
tickets than people without ADHD, although they do not perceive themselves as poor drivers
(Knouse, Bagwell, Barkley, & Murphy, 2005).

Long-term outcomes for persons with ADHD are influenced by the severity of the
disorder; more severe ADHD is more persistent (Kessler et al., 2005) and is associated
with worse outcomes (Barkley, Fischer, & Smallish, 2006). Any parental or family dif-
ficulties that contribute to inconsistent, coercive, or decreased efforts at managing the
child’s behavior may increase problem behaviors in the child with ADHD (Weiss &
Hechtman, 1993) and may eventually lead to the development of ODD or CD, which
presents further risk (Biederman et al., 2008). As noted earlier, family adversity, par-
ticularly marital conflict, is associated with ADHD (Counts, Nigg, Stawicki, Rappley, &
Eye, 2005). It is unclear whether these factors contribute to, or are a consequence of,
child ADHD. Another factor identified in families involves household composition. A
two-parent home may be a protective influence, because two parents are more likely to
manage successfully the stress related to having a child with ADHD (Cuffe et al., 2001). A
final factor associated with better adjustment is treatment response (Molina et al., 2009).
Those who had responded well to treatment and had maintained gains for at least two
years tended to be functioning the best at eight-year follow-up.

Directions Part II, Biopsychosocial Risk and Resilience Assessment: Formulate
a risk and resilience assessment, both for the onset of the disorder and for the course
of the disorder, including the strengths that you see for this individual. What tech-
niques could you use to elicit additional strengths in this client?

Part Two: Neurodevelopmental Disorders46

intervention

ADHD is a chronic developmental condition that requires ongoing management and
monitoring. Intervention should focus on helping clients learn to cope with, compen-
sate for, and accommodate to symptoms, as well as on reducing additional problems
that may arise as a result of these symptoms (Barkley, 2004). Goals formed usually
include improved school functioning, peer relationships, and family relationships
( Pelham, Fabiano, & Massetti, 2005).

Controversy exists about the optimal treatment methods for ADHD—whether inter-
ventions should involve medication, psychosocial treatment, or a combination of both.
Each is discussed here. It must be noted, however, that when youths treated for 12 months
were followed up after eight years, there were no differences in symptoms or functioning
among the youths assigned to medication, behavioral treatment, or the combined treat-
ment (Molina et al., 2009). This result suggests that the type or intensity of a one-year treat-
ment for ADHD in childhood does not predict future functioning.

Psychosocial intervention

Psychosocial interventions may be targeted toward parents, children, and the school sys-
tem and typically include behavioral and cognitive-behavioral strategies. Family and class-
room interventions have been shown to be more effective than individual interventions
aimed at children. The school system is a primary location for services for children with
ADHD. These services rest on a foundation provided by several federal laws (DuPaul &
Power, 2000; Root & Resnick, 2003; Tannock & Brown, 2000). These laws prohibit schools
from discriminating against people with handicaps, mandate free and appropriate public
education for children with ADHD, ensure a multidisciplinary evaluation process toward
the development of an IEP, and guarantee reasonable accommodations for persons with a
substantial limitation of a major life activity, of which learning is a part.

Behavioral Treatment
The empirical literature on psychosocial intervention for ADHD mainly involves par-
ent training (Barkley & Murphy, 2006). This is a brief treatment model involving about
12 sessions in either individual or group formats. Parents receive information about ADHD,
medications used to treat ADHD, effective parenting practices, how to reinforce children’s
coping strategies, and how to manage parental stress. Through positive reinforcements
children learn prosocial behavior such as following directions, completing homework,
doing household chores, and getting along with siblings. Parents are taught to respond to
children’s negative behaviors by ignoring or punishing the child so that he or she will suffer
negative consequences for engaging in the behavior. Parents are taught these principles
through didactic instruction, behavioral rehearsal, modeling, and role playing. Because
children with ADHD have problems with schoolwork, other interventions for parents
include structuring the home environment so that the child has a place to work relatively
free of distractions, regular teacher verification of satisfactory homework completion,
and a home-based reinforcement system featuring regular school–home note exchanges
(DuPaul & Power, 2000).

A meta-analysis of 16 studies in which parents were involved with their child’s treatment
was conducted (Corcoran & Dattalo, 2006). Compared to control conditions, parent-involved
treatment had from a low to moderate effect on ADHD and externalizing symptoms. Given that
some of the control conditions themselves involved viable treatments, such as medication and
child treatment, it is noteworthy that parent-involved treatment produced overall gains above
and beyond these control treatments. Parent-involved treatment had an even higher effect on

Neurodevelopmental Disorders 47

internalizing symptoms and family functioning. The few studies to date assessing academic
performance showed that family treatment may positively benefit academic performance.
Children’s social skills, on the other hand, were not affected by family treatment, despite the
thrust of many programs to improve such skills.

For adults, cognitive-behavioral therapy includes education about ADHD, training in
organizing and planning, learning skills to reduce distractibility, cognitive restructuring
(learning to think more adaptively in situations that cause distress), and relapse prevention
(Safren et al., 2010).

medication

Psychostimulants have a long history of being prescribed for ADHD. The primary psycho-
stimulant drugs used include methylphenidate (71% of cases), amphetamines, and pemo-
line (Bentley & Walsh, 2006). When these stimulants are compared with one another, few
differences have been found in their relative effectiveness (Brown et al., 2005).

Although the randomized, controlled trials of methylphenidate (Ritalin) for youth
have shown large treatment improvements compared to placebo, the trials conducted have
been surprisingly short in duration (an average of three weeks) (Schachter, Pham, King,
Langford, & Moher, 2001). In addition, the side-effect of decreased appetite was common.
Other researchers (Gould et al., 2009; Vitiello & Towbin, 2009) have discussed some of the
controversies involved in medication for children, including the possibility of sudden death
in rare cases. Finally, a majority of those children taking medication had stopped when fol-
lowed up at eight years (Molina et al., 2009). This trend indicates that medication may lose
its appeal over time.

If a child does not respond to an alternative stimulant after the first stimulants are
ineffective at therapeutic doses, then the recommendation is to try atomoxetine, a norad-
renergic reuptake inhibitor (Pliszka et al., 2006). Antidepressants such as bupropion and
the tricyclics (but not desipramine, which has been associated with child deaths) are a third
option if the drugs mentioned earlier have not been helpful.

Similar to the research with children, the shorter acting stimulants (namely methyl-
phenidate) were found to produce benefits over other medications for adults (Peterson,
McDonagh, & Fu, 2008). Higher doses showed more benefits. An implication is that if
adults do not experience adverse events, then they should receive a full therapeutic dose of
methylphenidate. For those who experience lack of effectiveness or intolerable side effects,
antidepressants are also used (Verbeeck, Tuinier, & Bekkering, 2009). Of all the antidepres-
sants, only bupropion (Wellbutrin) has been shown to be helpful.

Critique

ADHD is considered an inherited neuropsychological disorder, but substantive supporting
evidence about its specific nature is lacking (DeGrandpre, 1999). Social influences (e.g., at-
tachment patterns, parental stress, and poverty) and other biological contributing factors
(e.g., maternal smoking) may be underrecognized as risk mechanisms.

Directions Part III, Goal Setting and Treatment Planning: Given your risk and
protective factors assessments of the individual, your knowledge of the disorder, and
evidence-based practice guidelines, formulate goals and a possible treatment plan for
the individual.

Part Two: Neurodevelopmental Disorders48

As mentioned, primary care physicians are primarily responsible for diagnosing and
treating ADHD. However, due to time constraints and lack of training, they are often ill-
equipped to manage and treat a mental health disorder such as ADHD. Although physi-
cians may not always rely on diagnostic criteria in order to make the diagnosis, there is also
ambiguity about how hyperactive, inattentive, or impulsive a child has to be to warrant the
diagnosis, because the benchmark of normal age-group comparisons is unclear. That is,
the diagnostic criteria are neither normed nor quantified (Mayes, Bagwell, & Erkulwater,
2009). These factors mean that much variation exists among clinicians. As a result, ADHD
is both overdiagnosed (given to those who meet few symptoms of the criteria) and under-
diagnosed (not given to those who meet full criteria) (Purdie, Hattie, & Carroll, 2002). A
related problem involves the validity of the criteria for females. Fewer girls tend to be diag-
nosed with the disorder even controlling for referral bias. Females have a lower base level of
inattentiveness and hyperactivity than their male counterparts and must therefore deviate
much further from girls without symptoms in order to be diagnosed (Arnold, 1996).

A further problem of misdiagnosis of ADHD involves the age of children relative
to their classmates. Children who are the youngest in their classes are identified by their
teachers as having more ADHD symptoms (Elder, 2010). The youngest kindergartners
were 60% more likely to be diagnosed with ADHD than the oldest children in the same
grade. Similarly, when that group of classmates reached the fifth and eighth grades, the
youngest were more than twice as likely to be prescribed stimulants. Overall, this misdi-
agnosis likely accounts for about 20%—or 900,000—of the 4.5 million children currently
identified as having ADHD.

Finally, although the prevalence of ADHD is often considered to be stable across coun-
tries, rates of diagnosis and prescription stimulant use are significantly higher in the United
States. In fact, the United States consumes the majority of the world’s production of stimu-
lants, and its school-age children use as much as three times more psychiatric medica-
tion than children in the rest of the world combined. This wide variation in stimulant use
suggests that the boundaries between “normal” and “abnormal” are strongly influenced by
social, cultural, and policy variations (Mayes et al., 2009).

Another phenomenon is the increasing number of adults that are now being diagnosed
with ADHD. The diagnostic criteria have historically centered on the behaviors of children,
and DSM-5 represents the first effort by the APA to specify adult criteria (by lowering the
symptoms threshold from six to five and including some adult descriptors).

The age-of-onset criterion has also been debated (Cuffe et al., 2001; Loeber, Green,
Lahey, Frick, & McBurnett, 2002; Willoughby, Curran, Costello, & Angold, 2000), espe-
cially for adults (Faraone et al., 2006). Given the lack of empirical evidence supporting the
age-at-onset criterion, as well as difficulties in demonstrating impairment before the age of
7 in older adolescents and adults (DSM-IV), the threshold has been raised to age 12.

CritiCal PersPeCtive

Directions Part IV, Critical Perspective: Formulate a critique of the diagnosis as
it relates to this case example. Questions to consider include the following: Does this
diagnosis represent a valid mental disorder from the social work perspective? Is this
diagnosis significantly different from other possible diagnoses? Your critique should
be based on the values of the social work profession (which are incongruent in some
ways with the medical model) and the validity of the specific diagnostic criteria
applied to this case.

Neurodevelopmental Disorders 49

CASE 2: The Repairman

Wayne, a 40-year-old Caucasian male, came to see a social worker for counseling after Wendy,
his girlfriend of nine months, broke up with him. He described feeling devastated by the
breakup (which happened a week ago) and said that he had pleaded with her to take him
back. He admitted to calling her constantly since the breakup, to the point where she had
changed her phone number. He said he felt nauseated and sick, had problems sleeping, thought
about her “all the time,” and didn’t know what he was going to do without her. He also said he
was thinking that he was a “fuck-up” for losing her.

Wayne admitted that he was the reason for the breakup. He said that he couldn’t control
his temper and that “one little thing” might set him off. He described a recent incident in which
he and his girlfriend went Rollerblading in a local park. He kept stopping because he felt his
shoelaces weren’t tight enough. As the more experienced skater, she started to feel frustrated
and told him that she would skate on and that they could meet up in half an hour. He flew into a
rage, started shouting at her in public, and then stomped off. An hour and a half later, when he
had gotten over being mad, he returned to the car, where she was waiting for him. They argued
about this incident for the rest of the day. He said, “Why does she have to get so upset? She
knows I have a temper and that I’ll eventually get over it.”

Wayne, who worked as a repairman, also described himself as being very forgetful. For
example, he would often leave tools in various apartments where he was working and then
waste a lot of time trying to find them. He also left taps running in his own apartment because
something else would catch his interest.

He became easily frustrated if he had to deal with too many things at once, such as a lot
of work orders. He said Wendy had helped him to get more organized. She had bought a dry-
erase board and a calendar to remind him of things that needed to be done. Wayne admitted to
having a hard time concentrating on anything other than watching television. That’s what had
made it hard for him to do well in high school and why he didn’t consider college.

In the second session Wayne was accompanied by his ex-girlfriend Wendy, who is college
educated and works as a human resources manager. She maintained that they were still apart
but that she would consider getting back with him if he made some changes, such as managing
his frustration and acting maturely, with the help of counseling. She described Wayne as “like
a child.” She said it was part of his appeal when she first met him; he seemed so innocent and
cute and just blurted out his thoughts. She said her initial attraction to him had been physical.
She had been unemployed for a short period and lived in the apartment complex where he was
working at the time. She had a lot of work done on her apartment, and he agreed to get her
marijuana. After “partying” together, they became sexually involved. She said she was no longer
smoking, because she had taken a job at a company that does random drug testing.

She said Wayne would lose his temper over anything, even “stuff that hadn’t happened.”
She described one incident in which she went out with her coworkers for a good-bye dinner
for an executive in her company. With the speeches and the various courses, the dinner went
on longer than she had expected. By the time she got home, there were 10 messages on her
answering machine from Wayne. On the final message, he broke up with her. She said it took an
hour to convince him that she had been at the work dinner the whole time. Wendy said another
problem was his driving. She refused to let him drive with her anymore, because he would drive
too fast, switch in and out of lanes, and yell at other drivers. Wayne said he “hates traffic” and
feels unbearable frustration when he is stuck behind other drivers.

Wendy realized she had her own “issues” and is working on them in her own therapy. She
said that she didn’t foresee marrying Wayne. He said that was fine because he never wanted to
get married, but he would eventually like to live with her. He also said he never wanted children,

Part Two: Neurodevelopmental Disorders50

and Wendy revealed that he had physically abused his previous girlfriend’s child. He said, “I feel
bad about that. He didn’t deserve it. I know I’m too much of a kid myself to have kids.”

Wendy said she had met Wayne’s mother and was surprised she was so nice. Wayne’s
mother was sympathetic to Wendy’s difficulties with him, commenting that, “He’s always been
like that.” She said that he was an exhausting child, and from the time he could walk she ran
after him constantly. Wayne didn’t mind her, not so much because he was contrary but because
he was so distracted; he went with whatever caught his fancy at the moment. Wendy said his
mother had told her that Wayne had had some problems after his birth and had to stay in the
hospital for a week. Wendy didn’t know more specifics than that. She said Wayne’s mother has
never smoked cigarettes or used drugs and drinks alcohol minimally, although Wayne’s father
reportedly had a problem with alcohol. In the session, Wayne announced that he was thirsty and
got up and left the office to use the drinking fountain down the hall. Wendy commented that
this was a good example of how he was; if he felt a sensation or had a thought, he would act on
it immediately, rather than delaying gratification or thinking things through.

Wayne graduated from high school but got poor grades throughout school. He denied
being in any specialized classes (“I’m not a retard.” Then he laughed. “At least I don’t think I
am.”). He said he wasn’t diagnosed with any learning disorders that he knew of or anything
else as a child. He joined the army after high school, served for four years, and was honorably
discharged. He said that he was in the army during peacetime, so he saw no combat.

After that he worked as a maintenance man for apartment complexes. He liked the work—
moving around all day and figuring out how to fix things rather than being “stuck in an office.”
He also got a free apartment as part of his job. But he said the pay was “crap” and he didn’t
have health insurance. He admitted to having a hard time keeping a job for more than a year.
It wasn’t so much because he would forget instructions that were given to him; his work was
usually good enough for management to overlook that. But he would usually end up talking
back to management because he wouldn’t “take any shit.” He said that he had walked away
from one job in the past for something that made him mad.

Wayne said he generally got along well with his coworkers and enjoyed talking to people
who lived at the apartment complex. He said he had some good friends from the military that
he still sees occasionally, although they don’t live in the same town.

Wayne said he did not have a history of trouble with the law, except for traffic and speeding
tickets, for which he was jailed once. Then he added that he had been arrested on one occasion
for family violence charges against his previous girlfriend (the one before Wendy). He pointed
out that in all his other serious relationships (four in all), he had behaved violently only with
that one person and said that she was “stupid,” “a bitch,” and “knew how to get me.” He said
that his previous girlfriend was also violent with him, and the charges were eventually reduced
to a Class C misdemeanor for both of them. He said his previous girlfriend also had a drinking
problem and would steal his belongings and pawn them in order to buy beer. She eventually left
him after two years for another man.

Wayne said he liked to drink and occasionally smoked marijuana, but not like his past
girlfriend and other friends who “couldn’t stop.” He said that he tended to lose interest after
a few beers, and he never missed drinking if he didn’t have money to buy beer. He denied
any other drug use, said he “hated coke” because of the way people acted when on it, and
commented that he was too “hyper” to take something like that.

As for Wayne’s childhood, he didn’t remember much. He didn’t know his father at all.
According to his mother, his father physically abused her, but she didn’t leave him until he
started physically abusing Wayne and his younger (by two years) brother. Wayne repeated that
he did poorly in school and would run around the classroom when he was young. He said he
still considered himself a slow reader.

Neurodevelopmental Disorders 51

Wayne was seeing the counselor as one of the agency’s sliding-scale clients and said that
as a result of having to pay the $5 fee, he would be eating macaroni and cheese, potatoes, and
peanut butter and jelly sandwiches until the end of the month (a week away) when he got his
check. He attributed this problem to the fact that he didn’t get paid much, but also admitted to
mismanaging his money. He would spend money on something that caught his eye and later
not have money for food or bills.

Please go to the Additional Case Workbook for directions to this case.

references

52

Schizophrenia

CASE 1: Emmanuel

Anna Yannucci is a 26-year-old single Caucasian female who was referred to the outpatient mental
health facility following a two-week stay at a psychiatric unit of a local hospital. A report from the
hospital indicated that her father, Thomas Yannucci, took Anna to the hospital from an apartment
where she had been staying for two weeks with a 45-year-old man. Her father believed that this man
was a drug user and barely knew his daughter. Mr. Yannucci had learned where Anna was staying
when she called him one day to ask for money. He came to the apartment immediately and found
that his daughter was apparently not eating well, not changing or washing her clothes, not going
outside, and not communicating coherently. When her father arrived, Anna was sitting still and
remained quiet, watching television absently. When spoken to, she replied in polite but short phrases
and did not initiate conversation. She seemed “lost in her own little world.” Mr. Yannucci brought
Anna home from the apartment and later that day drove her to the emergency services unit of the
hospital. Mr. Yannucci stated that his daughter “behaves like this much of the time” but he thought
that she had lately become even more difficult to communicate with. He added that she always “sat
around, spaced out” when she was in her own apartment.

S
chizophrenia is a mental disorder characterized by a person’s abnormal patterns of
thought and perception. It is a psychotic disorder, that is, a mental state in which
the person’s thoughts and perceptions are severely impaired. Schizophrenia includes

two types of symptoms (American Psychiatric Association [APA], 2013). Positive symp-
toms represent exaggerations of normal behavior and include hallucinations, delusions,
disorganized thinking, and tendencies toward agitation. Negative symptoms represent the
absence of what would be considered normal behavior and include flat affect (the absence
of expression), social withdrawal, noncommunication, passivity, and ambivalence in deci-
sion making. In DSM-IV, five subtypes of schizophrenia were listed, based on its particular
symptom presentation, but these have been eliminated from DSM-5 because of their low
validity and reliability (APA, 2013).

Prevalence and comorbidity

Schizophrenia has a worldwide prevalence of approximately 1% (Murray, Jones, & Susser,
2003). Data from the National Institute of Mental Health–sponsored Epidemiological
Catchment Area research project noted the lifetime prevalence of schizophrenia to be
1.3% in the United States (Kessler, Berglund et al., 2005). Schizophrenia tends to be di-
agnosed among African-American persons more frequently than among Caucasians.
This imbalance may result because practitioners attribute and weigh particular symptoms

c h a p t e r 5

Schizophrenia 53

differently for clients of different races (Luhrmann, 2010). Clinicians of Caucasian origin
tend to interpret the suspicious attitudes of African Americans as symptomatic of schizo-
phrenia, representing delusions or negative symptoms, when these attitudes may in fact be
protective in situations of perceived discrimination.

Persons with schizophrenia have a high rate of comorbidity for other DSM disorders.
The national comorbidity study noted earlier found that 79.4% of persons with lifetime
nonaffective psychosis (most often schizophrenia) meet the criteria for one or more other
disorders (Kessler, Berglund et al., 2005). These include a mood disorder (most often
major depression) (52.6%), anxiety and trauma-related disorders (especially the phobias,
posttraumatic stress disorder, and panic disorder) (62.9%), and substance-related disor-
ders (26.8%). A recent meta-analysis found that persons with schizophrenia who abuse
substances experience fewer negative symptoms than those who are abstinent (Potvin,
Sepehry, & Strip, 2006). This suggests either that substance abuse relieves negative symp-
toms or that persons with fewer negative symptoms are more prone to substance use. Along
these same lines, several studies have found that nicotine use helps alleviate psychotic
symptoms in some persons with schizophrenia (Punnoose & Belgamwar, 2006). Finally,
schizophrenia is often comorbid with the schizotypal, schizoid, and paranoid personality
disorders (Newton-Howes, Tyrer, North, & Yang, 2008).

assessment

The assessment of schizophrenia is done through client interviews, interviews with signifi-
cant others, and history gathering. There are no tests currently available that conclusively
determine when schizophrenia is present. See Box 5.1 for assessment guidelines.

adults

• Criterion A for schizophrenia requires two of
the following symptoms, including at least one
of the first three: delusions, hallucinations,
disorganized speech, grossly disorganized or
catatonic behavior, and negative symptoms for a
period of one month.

• Assess for the duration of active symptoms, which
may rule out brief psychotic disorder or schizo-
phreniform disorder.

• Refer the client for a medical evaluation to rule out
any medical conditions that may be contributing to
symptom development.

• Assess whether the client abuses substances or is
currently under the influence of a drug that may
be causing symptoms.

• Assess for psychosocial stressors that may be con-
tributing to symptom development.

• Assess for psychotic or mood disorders among
relatives.

• Assess the family system for the possibility of stresses
that may precipitate an onset of psychotic symptoms.

• Assess for mood swings at present or in the cli-
ent’s history that may indicate a schizoaffective,
major depressive, or bipolar disorder.

• Assess for premorbid functioning to determine the
presence of a possible schizotypal, schizoid, or
paranoid personality disorder.

• Rule out the possibility of neurocognitive, perva-
sive developmental, obsessive-compulsive, and
substance use disorders.

childhood

• In cases of childhood psychosis, rule out the pres-
ence or influence of developmental, anxiety, and
mood disorders.

• Visual hallucinations and disorganized speech
may be more common than delusions and halluci-
nations.

Adapted from Volk et al., 2008.

box 5.1 assessment of schizophrenia

Part Three: Schizophrenia Spectrum and Other Psychotic Disorders54

The admission report stated that Anna had been living with her younger sister in a
condominium owned by her father for the past six months. Anna met the man with whom
she was most recently staying at a fast-food restaurant. He had bought her lunch and then
invited her to his apartment, where he lived alone. Mr. Yannucci did not know why Anna
would accept the invitation, but he added that “she does crazy things sometimes.” He
thought that the man wanted to take advantage of his daughter financially.

Doctors at the hospital ordered a variety of neurological tests to rule out physical
causes of Anna’s symptoms. A toxicology screen found no traces of drugs in her sys-
tem. While at the hospital Anna was cooperative, except that she refused to consider
taking medications. When asked for her reasons, she replied simply, “I just don’t want
to.” Staff efforts to help the client elaborate on any of her thoughts and feelings were
not successful. In fact, Anna seemed to become mildly irritable when asked questions,
always saying, rather politely but in a monotone, “I just don’t have a lot to talk about
right now.” She rarely made direct eye contact with staff but tended to stare blankly.
Anna did seem to enjoy walking about the unit, and the nursing staff reported that
she often appeared to be talking to herself. Her mood was quite consistent, but as one
nurse wrote, “the patient doesn’t seem to be feeling anything.”

Anna’s condominium was located one mile from the mental health agency. She
walked to her first appointment alone, arriving on time and with the card in her
hand. Her father met her there, coming from his job at a baker y. Anna was dressed
appropriately but appeared not to have changed her clothes or bathed in the recent
past. She exuded such a strong, disagreeable odor that support staff at the agency
complained to the director about her presence in the waiting room. Anna seemed
oblivious to this condition. Upon questioning, she denied hearing voices but
seemed highly distracted at times, as if her attention were focused on somewhere
far away. She minimized the issues of her personal hygiene, saying that she eats
“something good ever yday” and bathes “when I need to.” Her answers to all ques-
tions were brief. She seemed preoccupied but not upset about being at the agency.

Anna stated that she spent most of her time at home but added, “I like to take
walks for exercise.” When asked to elaborate, she said that she took walks everyday to
nearby fast-food restaurants or the bank to deposit and withdraw money. She did not
have a job, did not attend school, and was not involved in any recreational activities.
When asked about her goals in these areas, she said, “I’d like to have a job someday
when I’m ready.” When asked about any friends, she said, “I’d like to have friends some-
day,” but about the present, she said, “People can’t be trusted.” Anna stated that she
got along with her sister, but that “we don’t really talk much.” Thirty minutes into the
interview Anna said, “It’s nice meeting you, but I should go now.” The social worker
asked if she would mind waiting in the room or outside on the porch while he talked
with her father. She agreed, and walked outside. Throughout this interview Anna had
maintained the same blank look on her face, revealing no affect.

Mr. Yannucci remained for another half hour and provided background information.
He is a 50-year-old Italian American who came to the United States when he was 10 years
old. He has worked successfully in the restaurant business for the past 30 years, always
maintaining strong ties to the Italian community in his city. The welfare of his family is par-
amount to him. He clearly does not understand what might be “wrong” with his daughter,
and he tends to see her behavior as “willful misbehaving.” Yet he tried hard to understand
her as he told the story of her background.

“I have to be responsible for my daughter. It is a father’s responsibility to care for
his family. But I do not understand why she does not try harder. Anna’s mother and I
never got along. I was the breadwinner and she was the mother, and she became very

Schizophrenia 55

strange not long after we married. She stayed home all the time and sometimes did not
come out of her room. She cried often for no good reason and did not do enough to
take care of Anna, her sister, and me. She talked about crazy things and never made
sense. Sometimes she walked away from home and did not return for days. Sometimes
the hospital would call me—or the police would. She was always wandering around
looking for Lord knows what, finally getting into trouble when she stole food and ob-
jects out of people’s yards. I did my best to help her get more rest and get outside more
with good people, but it did not work. Her behavior became worse as the years went
on. Finally, she left me for good. I don’t know where she is, but she lives here in town.
A few times she comes to get money from me, but that’s all.”

“Anna was a good girl growing up. She wanted to be a nurse, and she got good grades
in school. Everyday she came home from school and went to her room and studied. But
she was not a sociable girl. She never had a boyfriend. That was good, because I didn’t want
her with dangerous boys. She stayed home and studied and helped take care of me and her
sister Beth. She never talked much, but she behaved well and was respectful.”

When asked for details about Anna’s functioning as a child and adolescent,
Mr. Yannucci stated, “She did not ever seem to be happy, but that’s only because she was
serious, which is a good thing. She didn’t have friends, but that was fine, too, because she
was busy at home. She never wanted to go out and play in the neighborhood, even as a
young girl. Like I said, she kept to herself and studied. She didn’t need much help from her
mother or me. She was independent.”

“I didn’t want her going to college, but Anna was determined. She lived at home and
went to the university, but she did not do well. She stopped going to school and started stay-
ing in her room more. She was still helping out around the house, but not as much, and it
got worse. After about a year she started to loaf all the time and sat in the television room
alone. She started having bad dreams, because I could hear her screaming many nights in
her bedroom. Many times I would notice her talking to herself, but when I asked what she
was doing she got quiet and said, ‘Nothing.’ ”

“Two years ago I met my current wife, Margaret, and she did not care for Anna’s be-
havior at all. Margaret thought that Anna was ‘crazy,’ which is a terrible thing to say about
someone. She thought that Anna should be forced to move away or go to school again, and
leave us to our new life. But my wife is a good person. She thought that I was babying Anna,
and that I should make her live on her own. But I can’t do that. So as a compromise I got a
condominium for Anna and her sister. Margaret told me that she would not marry me un-
less I did that. I go and see them everyday! I plead with Anna to get a job and to get busy,
but she will not do it. She stays home and does nothing. She is a nice girl, so why would
she not want to be busy and have friends? I don’t understand her. And lately she has started
wandering off, just like her mother.”

At this point, the interview ended. Anna returned to the room for a few minutes and
politely declined an offer to see a physician for a medication evaluation. She did agree to
come back to the agency in two days to meet with the social worker again. “It wouldn’t hurt
anything” was her response to the invitation.

Directions Part I, Diagnosis Given the case information, prepare the following:
a diagnosis, the rationale for the diagnosis, and additional information you would
have wanted to know in order to make a more accurate diagnosis.

Part Three: Schizophrenia Spectrum and Other Psychotic Disorders56

bioPsychosocial risk
and resilience influences

onset

The specific causes of schizophrenia are not known. Its onset and course are likely
due to a mix of biological, psychological, and perhaps some social influences (Cardno
& Murray, 2003). Many persons who develop schizophrenia display what is called pre-
morbid or “early warning” signs. These include social withdrawal, a loss of interest in
life activities, deterioration in self-care, and a variety of “odd” behaviors. The signs can
exist for many years, but even when present they do not guarantee the eventual onset of
schizophrenia. The stress/diathesis theory holds that schizophrenia results from a mix of
heritability and biological influences (perhaps 70%) and environmental and stress factors
(approximately 30%) (Cardno & Murray, 2003), which may include insults to the brain,
threatening physical environments, emotionally intrusive or demanding experiences,
and emotional deprivation.

See Box 5.2 for a summary of issues related to the diagnosis of schizophrenia in special
populations.

biological influences

Biological theories of schizophrenia implicate the brain’s limbic system (center of emotional
activity), frontal cortex (governing personality, emotion, and reasoning), and basal ganglia
(regulating muscle and skeletal movement) as primary sites of malfunction (Conklin &

children

• Schizophrenia is rare prior to adolescence, with
only 10% of persons experiencing its onset by
that time.

Women

• Men have an earlier onset (ages 18 to 26) com-
pared with women (26 to 40 years).

• Women tend to have higher levels of premorbid
(prepsychotic) functioning and more “positive”
symptoms than do men; women also have a better
prognosis with regard to their social functioning
potential and response to intervention.

minorities

• African Americans are more frequently diagnosed
with schizophrenia than are Caucasians, possibly
due to clinician interpretation of culturally ap-
propriate suspicion within the African-American
community as a negative symptom, rather than a
learned attitude.

low ses

• The prevalence of schizophrenia is twice as high in
lower than in higher socioeconomic classes for the
following three reasons: increased stressors due
to living in low SES may contribute to the onset of
schizophrenia; persons who develop schizophrenia
lose occupational and social skills and fall into the
lower classes; and others never develop skills to es-
tablish themselves in stable social roles.

older adults

• Older adults have not been studied as extensively
with regard to antipsychotic medications effects,
so at present there is little data to guide decisions
about which medications to prescribe for them.

• There is no clear evidence that any particular psychoso-
cial interventions are suited to older adult clients.

Drawn from Fonagy, Target, Cottrell, Phillips, & Kurtz, 2002;
Marriott, Neil, & Waddingham, 2006; Mulvany, O’Callaghan, Takei,
Byrne, & Fearon, 2001; Seeman, 2003; Trierweiler et al., 2000; Van
Citters, Pratt, Bartels, & Jeste, 2005.

box 5.2 schizophrenia in vulnerable and oppressed Populations

Schizophrenia 57

Iacono, 2003). People with schizophrenia are believed to have a relatively high concentra-
tion of the neurotransmitter dopamine in nerve cell pathways extending into the cortex
and limbic system. Dopamine levels are not considered causal for the disorder, however,
and other neurotransmitters, including serotonin and norepinephrine, have also been pro-
posed as risk influences (van Os, Rutten, Bart, & Poulton, 2008). Whether symptoms result
from abnormal development or deterioration of function is not clear.

Some researchers are beginning to study the influences of certain chromosomes on
molecular pathways in the brain as causal mechanisms for schizophrenia (Detera- Wadleigh
& McMahon, 2006), but this work remains speculative. Still, its genetic transmission is
supported by the higher-than-average risk mechanisms among family members of persons
with the disorder (Ivleva, Thaker, & Tamminga, 2008). An identical twin of a person with
schizophrenia has a 47% chance of developing the disorder. A nonidentical twin has only
a 12% likelihood, which is the same probability as for a child with one parent who has
schizophrenia. Other risk factors include a maternal history of schizophrenia and affec-
tive disorder (Byrne, Agerbo, & Mortensen, 2002). The age of onset for a child tends to be
earlier when the mother has schizophrenia. Further, negative symptoms are frequently seen
among nonpsychotic first-degree relatives of people with schizophrenia.

It has also been hypothesized that a variety of neurodevelopmental phenomena ac-
count for the onset of schizophrenia (Fatjó-Vilas et al., 2008). These include central ner-
vous system development, the quality of nerve cell connections, the manner in which
nerve cell activity influences the formation of circuits underlying brain functions, and
the development of the dopamine system. The brain volumes of persons with schizophre-
nia appear to be lesser than those of persons without the disorder. A recent literature
review found that the whole-brain and hippocampus volumes of most study participants
were reduced, while ventricular volume was increased (Steen, Mull, McClure, Hamer, &
Lieberman, 2006). In genetically predisposed subjects, the change from vulnerability to
developing psychosis may be marked by a reduced size and impaired function of the tem-
poral lobe (Crow, Honea, Passingham, & Mackay, 2005), although some researchers do
not agree that a reduction in size of the temporal lobe or amygdala is inevitable (Vita,
Silenzi, & Dieci, 2006). Traumatic brain injury, often cited as a contributing cause of the
disorder, increases the chances of schizophrenia in families, but only when there is already
a genetic loading (Kim, 2008).

Brain trauma from birth complications has been postulated as one of the pathways
to the disorder (Prasad, Shirts, Yolken, Keshavan, & Nimgaonkar, 2007), and obstetrical
complications are related to earlier age of onset (Mittal, Ellman, & Cannon, 2008). Post-
mortem studies show brain abnormalities indicative of developmental problems in the
second or third trimester of pregnancy, such as altered cell migration in the hippocampus
and prefrontal cortex. Other postulated (but debated) causes of these abnormalities are re-
lated to the higher-than-expected frequencies of prenatal exposure to influenza viruses and
infections (urinary and respiratory) in persons who later develop schizophrenia (Keshavan,
Gilbert, & Diwadkar, 2006). People with schizophrenia tend to be born in winter or early
spring, which means that their mothers were pregnant during a time of year when viruses
are more prevalent (Reid & Zborowski, 2006). Also, older men are more likely than younger
men to father sons with schizophrenia (Torrey et al., 2009). Although the risk influence
is not clear, it could be due to a mild biological degeneration in the father’s reproductive
system.

Biological characteristics that are protective of a person’s developing schizophrenia in-
clude the absence of a family history of the disorder, normal prenatal development, and a
normally developed central nervous system. Protective environmental influences include
being born during the late spring, summer, or fall and an absence of physically traumatic
events during childhood and adolescence (Geanellos, 2005; Jobe & Harrow, 2005).

Part Three: Schizophrenia Spectrum and Other Psychotic Disorders58

Psychosocial Influences
There are no known psychological influences of specific stress events, on the development
of schizophrenia, although many years ago they were considered the likely dominant causes
(Phillips, Francey, Edwards, & McMurray, 2007). There are, however, some possible social
risk influences for schizophrenia. These include living in an urban versus a rural environ-
ment, being born into a relatively low socioeconomic status (SES), and having migrated into
a new culture (Selten, Cantor-Graae, & Kahn, 2007). Conversely, living in a rural environ-
ment, being of middle- or upper-class SES, and geographic stability would be protective.

course and recovery

Schizophrenia tends to be a chronic disorder and complete remission is uncommon (Perkins,
Miller-Anderson, & Lieberman, 2006). Its course, however, is variable. Suicide is unfortu-
nately the leading cause of premature death in schizophrenia, as 20 to 40% of persons at-
tempt suicide at some point in their lives and 9 to 13% succeed (Pinikahana, Happell, & Keks,
2003). Persons most at risk for suicidal ideation during the early stages of the disorder are
young white males who are depressed, unmarried, unemployed, socially isolated, function-
ally impaired, and lacking external support (Pinikahana et al., 2003). The average life span
of persons with schizophrenia is approximately 15 years less than the national average in the
United States, although this reduced life expectancy is largely due to lifestyle factors such as
high rates of smoking, medication use, side effects of medication, substance use, diet, poor
access to health care, and other risks related to poverty (Wildgust, Hodgson, & Beary, 2010).

Although the causes of schizophrenia are uncertain, clues are available to differentiate
a better or worse prognosis. These are listed in Table 5.1.

Risk mechanisms Protective mechanisms

Biological Biological

Gradual symptom onset
Prominence of negative symptoms
Repeated relapses of active symptoms
Medication absence or noncompliance

Later age of onset
Brief duration of active phases
Good interepisode functioning (with minimal residual
symptoms)
Absence of brain structure abnormalities
Family history of mood disorder

Psychological Psychological

Poor insight into the disorder
Delay in intervention

Insight into the disorder
Early and ongoing intervention

Social Social

Significant family expressed emotion
Poor social adjustment prior to the onset of
schizophrenia
Noncompliance with, or absence of, psychosocial
interventions
Absence of a support system
Living in an urban area

Development of social skills prior to onset of the
disorder
Family participation in intervention
Interest in independent living
Participation in a range of psychosocial interventions
Presence of support systems
Living in a nonurban area

Sources: Andreasen et al., 2005; Lenoir, Dingemans, Schene, Hart, & Linszen, 2002; Pharoah, Rathbone, Mari, & Streiner, 2003;
Zammit, Lewis, Dalman, & Allebeck, 2010.

Risk and Resilience Assessment
Table
5.1

Schizophrenia 59

intervention

Although empirical research support for many interventions is limited, there is a consen-
sus that the treatment of schizophrenia should be multimodal and include interventions
targeted at specific symptoms as well as the social and educational needs of the client and
family (Spaulding & Nolting, 2006). In this section we will review medication, individual
therapy, group intervention, family intervention, assertive community treatment (ACT),
case management, hospitalization, vocational rehabilitation, and early intervention. One
literature review established that client satisfaction with interventions for schizophrenia
and other psychotic disorders is influenced by multiple factors, including an absence of
significant drug side effects, participation in treatment planning and decision making, and
involving family members in the intervention plan (Chue, 2006).

medications

Medication is the primary intervention modality for persons with schizophrenia. It cannot
“cure” a person of the disorder but can be effective in eliminating or reducing some of the
symptoms. The first-generation antipsychotic drugs, most popular from the 1950s through
the 1980s, act primarily by binding to dopamine receptors and blocking their transmission
(Leonard, 2003). These medications act on all dopamine sites in the brain, although only
those in the forebrain contribute to the symptoms of schizophrenia. A reduction in dopa-
mine in other areas (extending from the midbrain to basal ganglia) causes adverse effects
of akathisia (restlessness and agitation), dystonia (muscle spasms), parkinsonism (muscle
stiffness and tremor), and tardive dyskinesia (involuntary muscle movements of the face and
limbs). Anticholinergic medications are often prescribed to combat these effects, although
they in turn have their own adverse effects of blurred vision, dry mouth, and constipation.

The “second-generation” antipsychotic medications, available in the United States
since the late 1980s, act differently from those developed earlier. Clozapine, the first of
these, acts selectively on dopamine receptors (Faron-Gorecka et al., 2008). Their sites of
action are the limbic forebrain and the frontal cortex, and thus they do not carry the risk
of adverse effects for the muscular system. The fact that they block receptors for serotonin
suggests that this neurotransmitter also has a role in the production of symptoms. Ris-
peridone, introduced in 1994, has fewer adverse effects than the first-generation drugs and
is at present the most widely prescribed antipsychotic drug (Yu et al., 2006). Olanzapine,
sertindole, ziprasidone, quetiapine, aripiprazole, and amisulpride are other newer medica-
tions on the market (Schatzberg & Nemeroff, 2001). Their somewhat greater alleviation of
negative symptoms suggests that serotonin antagonist activity is significant in this regard.

Both the first- and second-generation medications continue to be used to treat
persons with schizophrenia. Prescribing practices depend on the physician’s preferences
and the client’s family history and financial status (the older medications are less expen-
sive). The effects of antipsychotic medications on older adults have not been studied as
extensively, so at present there is little data to guide decisions about which medications to
prescribe for them (Marriott, Neil, & Waddingham, 2006). There is some evidence that
the newer atypical antipsychotic medications are more effective for older adults than the
first- generation drugs (Van Citters, Pratt, Bartels, & Jeste, 2005).

Directions Part II, Biopsychosocial Risk and Resilience Assessment Formulate
a risk and resilience assessment, both for the onset of the disorder and for the course
of the disorder, including the strengths that you see for this individual.

Part Three: Schizophrenia Spectrum and Other Psychotic Disorders60

Although almost all physicians recommend antipsychotic medication for persons with
schizophrenia, their relative risks and benefits with regard to the patient’s physical and emo-
tional well-being are subject to debate (Cohen, 2002). Studies of drug effectiveness for schizo-
phrenia symptoms consistently show that many clients discontinue their medication for a
variety of reasons, such as perceived ineffectiveness and adverse side effects. One large-scale
study found that the first-generation medications were as effective as the newer medications,
but discontinuation rates over an 18-month period for all medications were alarmingly high,
at 74% (Lieberman et al., 2005). Up until this study, it was assumed that the lesser adverse side
effects of the newer medications would be associated with increased compliance.

Nonadherence is best predicted by recent illicit drug or alcohol use and medication-
related cognitive impairment (Ascher-Svanum et al., 2006). Fortunately, clinical practices
such as counseling, written information, and occasional phone calls can increase medica-
tion adherence, at least in the short term (Hanes et al., 2005). Despite the issues of adverse
effects and limited effectiveness, medication nonadherence is significantly associated with
poorer outcomes in schizophrenia. A multisite study of 1,900 consumers found that client
nonadherence was associated with greater risks of hospitalization, use of emergency ser-
vices, arrests, violence, victimization, poorer mental functioning, greater substance abuse,
and alcohol-related problems (Ascher-Svanum et al., 2006).

Other types of medication are occasionally prescribed for persons who have
schizophrenia, usually along with the antipsychotic drugs. These include antidepres-
sants, benzodiazepines, and mood stabilizers (Wolff-Menzler, Hasan, Malchow, Falki, &
Wobrock, 2010). There is no clear evidence that these medications help alleviate symptoms
of depression or control psychotic symptoms, however.

Electroconvulsive therapy (the induction of a seizure by administering an electrical
shock to the scalp) is an intervention that has been used for more than 50 years with persons
who have schizophrenia. Although controversial, several dozen studies have shown that it
can be an effective short-term option for alleviating symptoms, especially when the client
has not responded to medication or rapid improvement is sought (Tharyan & Adams, 2005).

Psychosocial interventions

Individual psychotherapy
Research on psychodynamic intervention with schizophrenia has limited empirical support.
Malmberg and Fenton (2005) concluded that individual psychodynamic treatment is not
effective in symptom reduction, reduced hospitalizations, and improved community adjust-
ment. One positive aspect of this type of intervention, however, is that it alerts the practi-
tioner to the importance of the worker–client relationship. Persons with schizophrenia are
often initially distrustful of service providers, so no matter what type of intervention is pro-
vided, the practitioner must take care to develop a positive working alliance with the client
over time.

Cognitive-behavioral therapy (CBT) is increasingly being used to treat persons with
schizophrenia (Kuipers, Garety, & Fowler, 2006). This is based on the premise that current
beliefs and attitudes mediate much of the person’s affect and behavior. CBT focuses first
on a review of the client’s core beliefs regarding self-worth, the ability to create changes in
his or her life, and realistic short- and long-term goals. If the client appears to be thinking
“irrationally” in any of these core areas (i.e., drawing conclusions that are insufficiently
based on external evidence), the social worker can work toward the client’s acquisition of
more “rational” thinking. Clients are helped to (1) modify their assumptions about the self,
the world, and the future; (2) improve coping responses to stressful events and life chal-
lenges; (3) relabel some psychotic experiences as symptoms rather than external reality;
and (4) improve their social skills. It is important to emphasize that although clients with

Schizophrenia 61

schizophrenia engage in psychotic thinking about some or many issues in their lives, some
aspects of their thinking are either “rational” or amenable to change.

A meta-analysis of research on the efficacy of CBT for schizophrenia indicates that it is
an effective adjunct to medication (Pfammatter, Junghan, & Brenner, 2006). Despite these
encouraging findings, it is not yet clear what the specific ingredients of effective psychoso-
cial intervention are or which interventions are most effective in particular settings. Fur-
ther, CBT does not affect social behavior and overall cognitive functioning (Rathod, Phiri,
& Kingdon, 2010). Another group of researchers reviewed clinical trials and concluded that
although CBT showed promise, more research was needed to demonstrate its effectiveness
relative to “supportive” therapies (Jones, Cormac, da Mota Neto, & Campbell, 2004).

Social skills training (SST) is a type of CBT that addresses deficits in interpersonal
relations, which are common among persons with schizophrenia. SST promotes the client’s
acquisition of social skills and leads to short-term improvements in cognitive and social
functioning (Pfammatter et al., 2006). In a meta-analysis of 22 randomized, control group
studies, Kurtz and Mueser (2008) concluded that such training was effective, with certain
caveats. Clients perform best on tests of the content of the training interventions but less
well on their transfer of that training to activities of daily living. SST also seems to have a
mild positive effect on general measures of pathology.

Group interventions
Group interventions include insight-oriented, supportive, and behavioral modalities.
They are often used in conjunction with other interventions such as medication and CBT.
There are few controlled studies of group therapy. In his review of the descriptive literature
on both inpatient and outpatient groups, Kanas (2005) concluded that for persons with
schizophrenia, groups focused on increased social interaction and managing symptoms
were often effective. Group interventions are widely used in inpatient settings, but there
is little evidence of their effectiveness in helping stabilize persons who are recently highly
symptomatic. A systematic review of five controlled trials of group CBT for schizophrenia
indicated, however, that benefits were evident with regard to some symptoms, most promi-
nently anxiety and depression (Lawrence, Bradshaw, & Mairs, 2006).

Family interventions
Family participation in the client’s intervention is a protective influence (Pharoah, Mari,
Rathbone, & Wong, 2010). When a person has schizophrenia, a chronic emotional burden
develops, which is shared by all family members. Their common reactions include stress,
anxiety, resentment of the impaired member, grief, and depression (McFarlane, 2002). The
concept of family (or caregiver) expressed emotion (EE) has been prominent in the schizo-
phrenia literature for the past 30 years (Kymalainen & Weisman de Mamani, 2008). EE can
be defined as the negative behaviors of close relatives toward a family member with schizo-
phrenia, including emotional overinvolvement and expressions of criticism and hostility. The
concept is not used to blame family members for the course of a relative’s illness, but to affirm
that families need support in coping with it. In a meta-analysis of 27 studies by Butzlaff and
Hooley (1998), EE was consistently shown to correlate with symptom relapse, especially for
clients with a more chronic disorder. Family environments with low EE are associated with
fewer symptom relapses and rehospitalizations than those with high EE environments.

Family interventions in schizophrenia usually focus in part on producing a more posi-
tive atmosphere for all members, which in turn contributes to the ill relative’s adjustment.
Pilling et al. (2002) conducted a meta-analysis of all randomized clinical studies done on
single- and multiple-family intervention (conducted in groups) and found that these inter-
ventions were more effective at 12 months than the comparison conditions, which usually
included some form of “standard care” (e.g., medication alone). Single-family interventions

Part Three: Schizophrenia Spectrum and Other Psychotic Disorders62

reduced readmission rates in the first year. After two years, all 18 family interventions low-
ered the relapse and readmission rates of the ill relative and increased medication compli-
ance. Another review of the literature on EE showed that family interventions designed to
reduce expressed levels of criticism, hostility, or overinvolvement tend to decrease relapse
and increase medication compliance, although families are still left with a significant bur-
den (Pharoah, et al., 2010).

Family psychoeducation refers to interventions that are focused on educating
participants about the ill relative’s schizophrenia, helping them develop resource supports
in managing the disorder, and developing coping skills to deal with related challenges
(Griffiths, 2006). A review of 40 randomized controlled studies indicated that (1) education
improved members’ knowledge of mental illness, (2) behavioral instruction helped mem-
bers ensure that their ill relative take medications as prescribed, (3) relapse prevention skills
development reduced the ill relative’s relapses and rehospitalizations, and (4) new coping
skills development reduced the distress associated with caregiving (Mueser et al., 2002).

Assertive community treatment and case management interventions
Case management is a term used to describe a variety of community-based intervention
modalities designed to help clients receive a full range of support and rehabilitation services
in a timely, appropriate fashion (Northway, 2005). Case management interventions are usu-
ally carried out in the context of large, community-based programs. The most famous of
these, ACT, was developed by Stein and Test (1980) in Wisconsin and has since been rep-
licated in many other sites around the world. By 1996 there were 397 such programs in
the United States (Mueser, Bond, Drake, & Resnick, 1998). The core characteristics of the
ACT model of service delivery are assertive engagement, service delivery in the client’s
natural environment, a multidisciplinary team approach, staff continuity over time, low
staff-to-client ratios, and frequent client contacts. Services are provided in the client’s home
or wherever the client feels comfortable and focus on everyday needs. Frequency of contact
is variable, depending on assessed client need. Other kinds of case management programs
share some, but not all, characteristics of the ACT model.

A number of comprehensive reviews of ACT have been conducted. A recent system-
atic literature review of 38 studies by Dieterich, Irving, Park, and Marshall (2010) concluded
that clients receiving ACT services were significantly more likely to remain in treatment,
experience improved general functioning, find employment, not be homeless, and experi-
ence shorter hospital stays. There was also a suggestion that such clients had a lesser risk of
death and suicide. In an earlier review of 75 studies, Marshall and Lockwood (2003) found
that both ACT and case management were more effective than other forms of intervention
in helping clients stay in contact with services, spend fewer days in the hospital, secure
employment, and experience life satisfaction. There were no clear differences, however,
in measures of mental status and social functioning. ACT was superior to case manage-
ment in client use of hospitalization, but differences on the other measures were not clear.
Although ACT does promote greater client acceptance of interventions (Tyrer, 1999), an-
other comprehensive review indicated that the programs vary considerably with regard to
staffing, types of clients, and resources; comparisons are thus difficult to make (Mueser
et al., 1998). Further, efforts to make interventions compulsory are not effective in engaging
clients (Kisely & Campbell, 2007). That being said, the reviewers found that client gains
persist only as long as comprehensive services are continued.

Hospitalization
It is widely believed that inpatient hospitalization is an expensive, ineffective, and socially un-
desirable treatment setting for persons with schizophrenia. Hospitalization is primarily used
now to stabilize persons who are a danger to themselves and others, rather than providing

Schizophrenia 63

active and ongoing interventions. Five randomized controlled trials showed that a planned
short-term stay does not encourage a revolving door pattern of admission for people with seri-
ous mental illnesses (Johnstone & Zolese, 2005). Still, the use of clubhouses and other partial
or day hospitalization programs is effective in reducing inpatient admission and improving
outcomes (Marshall et al., 2006). Partial or day hospital programs are staff-run, structured,
psychosocial rehabilitation programs for persons with schizophrenia who have the capacity to
live in the community. Clubhouses are vocational rehabilitation programs in which members
work side by side with staff to complete the work of the facility (e.g., cooking lunch, keeping
records, managing a member bank, and answering phones). Members are not paid for their
participation, but an employment specialist helps place members in community jobs.

Vocational rehabilitation
Vocational rehabilitation is work-related activity that provides clients with pay and the ex-
perience of participating in productive social activity. The goals of vocational programs
may be full-time competitive employment, any paid or volunteer job, the development of
job-related skills, and job satisfaction. Twamley, Jeste, and Lehman (2003) conducted a
meta-analysis of randomized controlled trials of vocational rehabilitation that focused on
both client placement and support (with training, placement, and occasional contact) or
supported employment (more intensive participation by the case manager in the client’s job
functions). These programs have a positive influence on promoting work-related activities
such as paid employment, job starts, duration of employment, and earnings. Supportive
employment programs tend to be more effective than prevocational training (Zito, Greig,
Wexler, & Bell, 2007). Unfortunately, a diagnosis of schizophrenia is negatively related to
the attainment and maintenance of employment when compared with other diagnoses.

Bond (2004) conducted another meta-analysis of the effectiveness of supported em-
ployment for people with severe mental illness. He found that in 13 studies, 40 to 60%
of clients obtain competitive employment, versus 20% of those not enrolled. Interestingly,
although clients who hold jobs for an extended period of time show benefits such as im-
proved self-esteem and symptom control, their employment does not correlate with out-
comes such as prevention of hospitalization and quality of life. Another recent systematic
review suggests that ACT intervention models produce vocational outcomes that are supe-
rior to usual treatment (Kirsh & Cockburn, 2007). The authors emphasize that ACT teams
who designated a vocational specialist were most successful in this regard.

Early intervention
Early intervention refers to efforts to detect schizophrenia in its early stages (possibly ap-
pearing as brief psychotic or schizophreniform disorder) and then provide those persons
with phase-specific treatment. Several such programs have been initiated in the United
States, Europe, and Australia (Marshall & Rathbone, 2006). Data regarding the risks and
benefits of early detection and intervention remain sparse, and the evidence is not suf-
ficient to justify preonset treatment as a standard practice (McGlashan, Miller, & Woods,
2001). There are also ethical issues involved in primary prevention efforts, including clini-
cal priorities, screening ethics, stigma, confidentiality, and informed consent.

Directions Part III, Goal Setting and Treatment Planning Given your risk and
protective factors assessments of the individual, your knowledge of the disorder, and
evidence-based practice guidelines, formulate goals and a possible treatment plan for
this individual.

Part Three: Schizophrenia Spectrum and Other Psychotic Disorders64

critical PersPective

Schizophrenia remains an enigma. Although it is among the most disabling of all mental
disorders, researchers and clinical practitioners are not able to describe exactly what it is,
how it is caused, or how it can be effectively prevented or treated. There is a consensus,
however, that its primary causes are biological or hereditary (although the extent of those
influences is debated), and that family and social environments are more significant to its
course than to its onset. There is also a general worldwide agreement on its basic symptom
profile. Schizophrenia thus appears to be recognized as a valid mental disorder. Some theo-
rists debate, however, whether the symptoms of schizophrenia represent a single or several
disorders, and refer to the schizophrenia spectrum disorders as also including schizoaffec-
tive disorder and the paranoid, schizoid, and schizotypal personality disorders (Keefe &
Fenton, 2007).

A major problem with the diagnosis of schizophrenia is that its causal influences are
inferred from the hypothesized actions of antipsychotic medications (Conklin & Iacono,
2003). As more information about the condition’s neurobiology is developed, professionals
may become able to articulate its core features. As described earlier, the limited effective-
ness of these medications casts some doubt on the validity of the presumed “nature” of
schizophrenia. Still, because the pharmaceutical industry and psychiatric profession are so
heavily invested in drug marketing (Moncrieff, Hopker, & Thomas, 2005), relatively little
research currently focuses on the psychosocial influences on the disorder.

Directions Part IV, Critical Perspective Formulate a critique of the diagnosis as it
relates to this case example. Questions to consider include the following: Does this
diagnosis represent a valid mental disorder from the social work perspective? Is this
diagnosis significantly different from other possible diagnoses? Your critique should
be based on the values of the social work profession (which are incongruent in some
way with the medical model) and the validity of the specific diagnostic criteria ap-
plied to this case.

CASE 2: The Reluctant Day Treatment Member

Donald is a 23-year-old Caucasian male who presents as quiet and polite, with a flat affect. At
age 20, he was in church with his family when he started spinning his body around, feeling
that something was pushing him. After returning home, he felt restless and randomly moved
items and furniture around the house. Over a short period of time, his parents noticed that his
speech was becoming disorganized and his behavior more erratic. He would sit outside in cold
weather with light clothing, sleep in the backyard, and live in his car. At one point, Donald felt
he was possessed by demons and needed to purify his body by not eating. He thought that if
he lost weight, the demons would have to leave. From the initial onset of his symptoms until
six months ago, Donald was hospitalized 14 times as a result of aggressive behavior toward his
family. His aggression was usually characterized by shouting and shoving his parents. Once he
punched his father in the face. At times, Donald is bothered by his aggressive thoughts and has
sufficient insight to recognize that his illness impacts his life.

Donald is currently receiving treatment from a county mental health agency as an
outpatient. He is seen regularly by a social worker and by a psychiatrist who monitors Donald’s
medication and coordinates treatment with his primary care physician. Donald is also attempting
to become more involved with a day treatment program, but is finding it difficult. Initially,

Schizophrenia 65

he liked the idea of participating in group activities and having the chance to develop social
relationships. Over time it became stressful for him, and at one point he said he felt the program
was “evil” so he stopped attending. He is trying to attend again, but initially he would go out
on the grounds and stay behind the trees. Donald has progressed to being able to come out
from behind the trees and sometimes enter the building, but he is still not able to engage in any
kind of social interaction. He has been known to wear earplugs during his entire time at the day
program to protect himself from perceived ridicule.

When at home, Donald spends the majority of his time in his room. He no longer watches
television or listens to music, activities he previously enjoyed doing. His parents encourage
Donald to eat dinner with the family several times a week to foster the social interaction he
otherwise lacks. He is notably distracted by his internal stimuli and often talks and laughs to
himself. He paces, goes in and out of the house, and picks up and examines items that are not
there. His speech is often tangential.

Donald is currently obsessed with children and their safety. He mistrusts his father and
fathers in general, although abuse by his father has been ruled out. He mistrusts the Catholic
church because of reports of child abuse by priests. He often misinterprets parental behavior as
child abuse. On a recent visit to a fast-food restaurant, Donald saw a father holding a fussy child.
He thought the child was crying because the father was holding the child “in a perverted way,”
and he demanded that the father put the child down.

At his intake for the day treatment program, Donald told the doctor that his parents and
siblings had murdered his friend. In truth, the friend had died of a heroin overdose. He also
reported that he hears a voice that is “nasty” in tone. He stated that the voices “do cruel jokes”
on him, and he laughs or talks back to them. He tries to control the voices by praying. Donald
also talks about “a presence touching me.” He described it as a sharp jolt of terror, as if someone
was in the room with him, touching him. This presence comes and goes, and Donald thinks it
may be Satan. He also thinks that people are reading his mind and making fun of him.

Recently, Donald has had problems sleeping and is becoming increasingly agitated over
the need to organize protests against abortion. His father contacted Donald’s social worker and
requested that both the social worker and the doctor see Donald to reevaluate his medication.
When Donald was informed of this appointment, he became extremely annoyed and threatened
to cut the doctor’s throat. He left the house on foot, returning several hours later at 2:00 a.m.,
cold, tired, and wet from the rain. He agreed to be hospitalized the next day.

Over the course of his illness Donald has continued to experience periods of depression.
During these periods, which last for several weeks, he will sleep at least 12 to 14 hours a day
and has a great deal of difficulty waking. By his parents’ report, he eats less, is more withdrawn,
more isolated, and less active than at other times. His depressed moods are noted by his mother,
his social worker, and the psychiatrist. He has described other moods in which he feels like
“doing a lot of things,” but these episodes were short lived and do not meet the criteria for
manic or hypomanic states. According to both Donald and his family members, he does not
smoke or use drugs or alcohol.

Despite his psychotic and depressive symptoms, there are times (at most a few days at a
time) when he is oriented to reality and does exhibit some insight regarding his illness. Still, he
continues to experience “voices” (although understanding that they are not real) and flat affect
and withdrawal during these periods.

Donald is the youngest of three children. His mother reported that she had a normal
pregnancy and delivery with Donald. He was born in February. Donald’s older brother is 34 and
his sister is 26. His mother works as a nurse, and his father is an engineer. There is a family history
of mental and mood disorders. Donald’s mother is taking antidepressants, and her brother has
bipolar disorder with manic episodes marked by psychosis and a substance use disorder. There is
also a history of attempted suicides in Donald’s mother’s family, and a paternal great-uncle had
“a breakdown.”

Part Three: Schizophrenia Spectrum and Other Psychotic Disorders66

Donald’s parents describe him as a shy child who did well in school. He was diagnosed
with depression at age 13 and took antidepressants until he was 20. At age 15, he had his first
suicidal ideation but made no attempt to take his life. He also reported thoughts of suicide when
he was 19 and 20, but never made any attempts. Donald graduated from high school with
a 3.6 GPA. He attended college for three semesters, earning a 3.1 GPA in his studies. During
high school and college Donald held several jobs. He worked in a veterinarian’s office for nine
months. He was also employed in retail and as a waiter in several eating establishments, but was
unable to stay employed at any of these places more than a few weeks.

The medications Donald currently takes are a cause for concern. His illness has not responded
well to medications, even though he is taking many of them. These include Depakote, Zyprexa,
Abilify, Geodon, and Risperdal. He experiences several undesirable side effects, most notably
tremors of his hands, arms, and feet. The health care providers treating Donald would like to
have him try clozapine, described by his social worker as a drug of last resort. This is an unlikely
possibility, however, as transitioning medications requires a person to be hospitalized. The
patient is then monitored twice weekly during the first six months and weekly for the following
six months. Donald has not been particularly compliant with medication and treatment but is
especially reluctant to be hospitalized, feeling that hospitals are “evil.”

Please go to the Additional Case Workbook for directions to this case.

CASE 3: Emma’s Private World

Emma is a 59-year-old African-American woman, born in July, who presents with a well-groomed
appearance but flat affect. Her medical chart shows that her weight is in the normal range for
her height, and she has a medical diagnosis of hypertension. Emma is an inpatient resident at a
mental health facility, where she has resided since her admission one year ago.

Emma believes that she still owns a house in another city, in spite of having been shown the
deed of sale from 13 years ago. She says her son has been replaced by an impostor who came
from a seedpod. Emma also states that she was shot while at work but went home because she
didn’t bleed. She denies that she has siblings, saying they were just people who were put in her
parents’ house to be raised. She doesn’t want contact with them, and they don’t attempt to
contact her. When questioned about some of these beliefs, Emma states that she was instructed
by a secret group, of which she is part, not to give out further information. When staff challenge
her beliefs, she says it hurts her feelings and responds to them in anger.

Emma has been observed responding to internal stimuli. She also reported that while in
her room, she heard her psychiatrist’s voice telling her she was released. Emma does not believe
herself to have a mental illness or hypertension and states that she takes her medication only
because the nurses give it to her. She is currently being treated with Haldol (a first-generation
antipsychotic), the dosage of which was recently increased due to persistent delusions. A
previous medication, Zyprexa (a second-generation antipsychotic), was recently discontinued
due to lack of efficacy.

This is Emma’s third admission to an inpatient mental health facility. Emma is pleasant
when approached. She attends scheduled treatment groups independently. Her records show
her to be Protestant, but she does not attend any spiritual services at this time. She participates
in occasional outings if prompted.

Prior to admission, Emma was living with her son in a large urban area where she was
noncompliant with medication and reportedly caused problems at home. She was originally
placed with her son 14 years ago after becoming unable to care for herself in her home, which
was located in another city where she had lived for 10 years. At the time she was removed,

Schizophrenia 67

she had no electricity or running water. Her son was appointed legal guardian and payee at
that time. At his house, her son stated that Emma would sit in front of the television with no
sound and get up only to go outside to smoke. She was reported as being aggressive toward
her grandchild and attempted to return to the home she no longer owns. On one occasion
she had to be removed from her son’s house by the police for aggressive behavior toward him.
On another occasion she had to be removed by the police from a bank, where she erroneously
insisted that she had an account. Emma is now estranged from her son. He says he is “worn out
from dealing with her.”

Emma has a history of noncompliance with outpatient treatment. She has no history of
drug or alcohol abuse but does smoke about half a pack of cigarettes per day. Neither does
she have a history of depressive or manic episodes. Her son said there was no family history of
schizophrenia that he knew of, and he didn’t think that his mother had suffered from traumatic
events as a child. He said that his mother’s parents were strict and would give out “whippings”
for misbehavior. Emma came from a poor background, and when she married, the family could
have been classified as “working poor.”

When Emma was going through a divorce in her 40s, she told her son that she’d bought
him a car and that he should go to the dealer and pick it up. When he spoke with the car dealer,
he discovered that his mother had had a number of confused conversations with the dealer,
telling him the bank would provide the necessary money. She had not, in fact, bought a car.
He soon found out that his mother had also not paid his college tuition bill, which she denied.

Emma was recently evaluated by the occupational therapy department using the Kohlman
Evaluation of Living Skills (KELS) and the Allen Cognitive Level Screen (ACLS). She was reported
to be friendly and cooperative during this 90-minute evaluation. Emma’s KELS score showed
her as able to accomplish some tasks independently but having poor judgment in other areas.
She was unable to identify her current source of income but stated that the bank gives money
to people who need it. She has not been employed for over 20 years but states that after her
release from the mental health facility, her prior employer will find her and send her to France
to a government school. Emma’s ACLS results showed weakness in the areas of problem solving,
insight, and judgment. Overall, her scores, KELS/fair and ACLS/4.4, demonstrate her need to live
in a 24-hour supervised environment.

Please go to the Additional Case Workbook for directions to this case.

references

68

Bipolar and Related Disorders

Catherine is a 38-year-old married Mexican-American female with no children who lives in a
rural county. She was court-ordered to attend an outpatient mental health clinic for individual
and group anger management services. Two months ago, her husband charged her with assault
after she stabbed him in the shoulder with a steak knife during an argument at a local restaurant.
Catherine is also awaiting incarceration for an arrest in which she was recklessly driving a
vehicle without a license. She has in fact been jailed on five occasions for offenses ranging from
disturbing the peace to assault. The social worker met with Catherine on four occasions over five
weeks. Catherine is separated from her husband but is open to possibly reuniting with him after
she receives professional help.

Catherine is in generally good physical health and reports that she is in regular contact
with her family physician. She broke her arm two years ago in a saloon fight, however, and has
diminished strength in that arm. She also reports having ankle pain due to possible arthritis,
which moderately decreases her mobility. Still, Catherine has kept a full-time job at the post
office for the last 15 years, working primarily as a mail sorter and occasionally as a deliverer.

Catherine reports that she has had irritable and “up and down” moods for most of her
adult life. She describes extended periods of time when she becomes “hyperactive” and easily
annoyed by people around her. Catherine says she has “incredible energy” at those times and
“gets a lot done.” At those times she likes delivering the mail, working out at the local recreation
center, eating out in restaurants, and going to bars. She rests primarily with “short naps” during
her energy bursts. Catherine drinks alcohol (only beer) regularly and makes no apologies for
it. “It’s fun. Who says girls can’t hold their liquor like the guys?” Upon further questioning,
she admits that she drinks only “enough to get drunk” when she is in a “high-energy” phase.
Otherwise she limits herself to a few beers on the weekends.

Catherine admits that she “wears herself out” after about a month of this hyperactivity,
becoming “shaky” and “disoriented” from the lack of sleep. When in a manic episode, she is
apt to lose her temper and argue with “almost anyone” who gets in the way of her activities.
She gets into physical fights frequently, often with strangers, but sees this as acceptable
behavior. “I was raised to take care of myself. No one is going to push me around.” Despite
her erratic behaviors, Catherine is “accepted for who I am” in her small community. The culture
of her Mexican-American family of origin features high levels of emotional expressiveness and
Catherine is comfortable behaving this way. She is usually released from jail a few days after her
arrests to the custody of her husband, with the charges dropped.

Bipolar disorder is a mood disorder in which a person experiences one or more manic
episodes that usually alternate with episodes of major depression (American Psychiatric
Association [APA], 2013). Depressive episodes are described in chapter 7. A manic episode
is a period in which a person’s mood is elevated and expansive to such a degree that he or
she experiences serious functional impairment in all areas of life. Manic episodes may be
characterized by unrealistically inflated self-esteem, a decreased need for sleep, pressured speech,

C h a p t e r 6

Bipolar and Related Disorders 69

racing thoughts, distractibility, an increase in unrealistic goal-directed activity, and involvement
in activities with a high potential for negative consequences. Manic episodes develop rapidly
and may persist for a few days or up to several months. The average duration of bipolar I mood
episodes is 13 weeks (Solomon et al., 2010).

Another feature associated with bipolar disorder is the hypomanic episode (APA, 2000), a
gradual escalation over a period of days or weeks from a stable mood to a manic state. In this
mild form of mania, the person experiences higher self-esteem, a decreased need for sleep,
a higher energy level, an increase in overall productivity, and more intensive involvement in
pleasurable activities. Its related behaviors may be socially acceptable, but the danger is that
the bipolar person’s decreased insight may lead him or her to believe that the disorder has
permanently remitted and that there is no need for ongoing interventions. In fact, poor insight is
a prominent characteristic of the active phases of bipolar disorder (Grant, Stinson, et al., 2005).

There are two types of bipolar disorder (APA, 2013): Bipolar I disorder is characterized by
one or more manic episodes, usually accompanied by a major depressive episode. Bipolar II
disorder is characterized by one or more major depressive episodes accompanied by at least one
hypomanic episode. Although generally “milder” than bipolar I disorder, bipolar II disorder is
characterized by a higher incidence of comorbidity, suicidal ideation, and rapid cycling (Vieta &
Suppes, 2008). For both types of the disorder, the duration between episodes tends to decrease
as further cycles occur (Geller, Tillman, Bolhofner, & Zimmerman, 2008).

PrevalenCe and Comorbidity

Prevalence estimates of bipolar disorder have increased in recent years and range from 0.5
to 5% (Matza, Rajagopalan, Thompson, & Lissovoy, 2005). The estimated prevalence in the
most recent National Comorbidity Survey was 2.1% (Merikangas et al., 2007).

The lifetime prevalence of bipolar I disorder is equal in men and women (close to 1%),
although bipolar II disorder is more common in women (up to 5%) (Barnes & Mitchell,
2005). In men the number of manic episodes equals or exceeds the number of depressive
episodes, whereas in women depressive episodes predominate. Between 1994 and 2003
there was a 40-fold increase in child and adolescent diagnoses of the disorder, which may
be due to changing diagnostic criteria (perhaps informally) or greater practitioner sensitiv-
ity to its symptoms (Moreno, et al., 2007). This may diminish with the inclusion of a new
diagnosis for children and adolescents, disruptive mood dysregulation disorder, which fea-
tures some symptoms similar to those of bipolar disorder.

Bipolar I disorder is often comorbid with other disorders. Its highest rates of comorbid-
ity are 71% for anxiety and trauma-related disorders, 56% for substance use disorders, 49% for
alcohol abuse, 47% for social phobia, and 36% for a personality disorder (Marangell, Kupfer,
Sachs, & Swann, 2006). One study of 500 clients in a bipolar disorder treatment program noted
an earlier age of onset (15.6 versus 19.4 years) and an increased presence of suicidal ideation
in persons with comorbid anxiety and trauma-related disorders (Simon et al., 2004). Another
study concluded that bipolar disorder is more often accompanied by the antisocial, borderline,
narcissistic, and histrionic personality disorders than by major depressive disorder (Mantere
et al., 2006). Further, a one-year prospective study of 539 outpatients revealed that persons with
rapid-cycling bipolar disorder have higher rates of lifetime substance abuse (45.4 versus 36.4%)
and anxiety disorders (50.2 versus 30.7%) (Kupka, Luckenbaugh, & Post, 2005). Bipolar disorder
is also modestly associated with medical illnesses in adulthood, such as cardiovascular, cerebro-
vascular, and respiratory diseases (Krishnan, 2005).

Bipolar women are 2.7 times more likely than men to have a comorbid disorder.
Women with bipolar disorder have a premature mortality rate, which may be related
to metabolic changes that increase their risk of diabetes and vascular disease (Taylor &

Part Four: Bipolar and Related Disorders70

MacQueen, 2006). Women are also at greater risk for anxiety and trauma-related disorders
and thyroid problems. Women have an increased risk of developing episodes of bipolar I
disorder in the postpartum period. Bipolar men have a greater prevalence of alcoholism
than women do (Barnes & Mitchell, 2005).

Given this information about comorbid disorders, it is important to note that sub-
stance abuse and the presence of another comorbid disorder are two major risk influences
for suicidal ideation and behavior among persons with bipolar disorder (Hawton, Sutton,
Haw, Sinclair, & Harris, 2005). Other risk influences identified in this meta-analysis in-
clude a family history of suicide, an early onset of bipolar disorder, high levels of depres-
sion, severity of the affective episodes, the “mixed features” type of the disorder, and the
presence of rapid cycling.

Catherine says that she doesn’t know why her energy bursts come and go. “I don’t know,
it’s all about biorhythms, isn’t it?” She admits to getting “dark, really dark” for extended periods
of time as well, sometimes for several months. She is barely able to get her work done when
depressed and admits that her boss complains about her “laziness.” When she is not in a “hyper”
or “down” mood, Catherine’s moods tend to change throughout any given day. She reports the
following symptoms at those times: forgetfulness, shifting ideas, distractibility, cycling between
not sleeping at all and sleeping too much, bursts of energy, feelings of elation, decreased interest
in most of her daily activities, fatigue, feelings of sadness, and impulsivity.

When asked whether it has ever been suggested that she has a mental problem,
Catherine sighs. “My doctor thinks I should take medicine for my moods, but I don’t want
to do that. I’m not a doper. I like to drink, but I’m not a doper.” When pressed on this point,
Catherine adds, “I’m usually pretty calm when I see my doctor. I don’t go to him when I’m
hyper.” Surprisingly, Catherine does not recall that many people in her community have
suggested professional intervention to her. “I can take care of myself. All of us had to learn
to do that where I came from.” Regarding her drinking, Catherine does not exhibit signs of
tolerance or withdrawal. She experiences no physical symptoms when she does not drink
for weeks at a time, and she has not increased her overall alcohol intake over the years.

Catherine was born and raised in the Midwest and moved to the mid-Atlantic region
when she was six years old. Her mother was a homemaker who was considered “odd” by
her siblings. “She stayed home most of the time and seemed sad. She never had any fun. She
was pretty, though, but I think Dad married her because he got her pregnant.” Catherine
says her mother was nice but not very active and that she drank too much. Her father, a
military veteran, was a “great man” whom she loved very much. He “worked all the time”
but played with Catherine and her younger brother, to whom she has never been close.

When Catherine was 16 years old, her father died. She says her father was the most
important person in her life and remembers becoming “out of control” at about that time.
Her mother died of breast cancer when she was 29 years old, though she reports that her
mother’s passing was more manageable for her.

Catherine has been married for 15 years to a seemingly supportive husband. “We met
at community college. He’s a good man, a calm man, and he taught me to get more focused
about my life.” Carl, a manager at a local manufacturing plant, reports that he loves his wife
and states, “She is my heart and my life.” Catherine and her husband report having frequent
financial difficulties, requiring her husband to work long hours and leaving Catherine at
home alone many evenings.

Catherine says she has some friends but inconsistent contact with the people in the
community. “I’m friendly with everyone, but nobody in particular.” She stated that she is
eager for her mandated treatment to end so that she can resume her work routines without
interruption. When asked about her possible sentencing to more time in jail, she shrugged.
“I’m sorry for acting up like I do. I hope the judge knows that. My husband is OK with me
now. I’m a good person.”

Bipolar and Related Disorders 71

assessment of biPolar disorder

Because of its presumed biological influences, social workers need to participate in a multidis-
ciplinary assessment of persons with possible bipolar disorder. A meta-analysis of 17 studies
revealed that most persons with bipolar disorder were able to identify symptoms in advance of
their first episode, the most common of which is sleep disturbance (77% median prevalence)
(Jackson, Cavanaugh, & Scott, 2003). Adults with bipolar disorder are sometimes misdiagnosed
with borderline personality disorder, and as noted earlier, the two disorders are sometimes co-
morbid (Zanarini, Frankenburg, Hennen, Reich, & Silk, 2004). There is much symptom overlap
between them, as both types of clients may experience mood swings, alternating periods of
depression and elation, and transient psychotic symptoms. With the personality disorder, how-
ever, the mood changes are related to environmental influences and chronic feelings of insecu-
rity, whereas bipolar disorder features more biologically patterned mood changes (Stone, 2006).
Further, the client with bipolar disorder may function very well when stable, whereas the client
with a personality disorder tends to be continuously labile. Other general assessment guidelines
are summarized in Box 6.1.

Social workers must be extremely cautious in their diagnoses of children, because
there is controversy about appropriate criteria with that population (Stone, 2006). Most
researchers agree that bipolar disorder can occur in childhood and adolescence, but that
it presents differently in those age groups (Birmaher et al., 2006). Symptoms that are most
specific to childhood bipolar disorder include elevated mood, pressured speech, racing
thoughts, and hypersensitivity (Youngstrom, Findling, Youngstrom, & Calabrese, 2005).
The child typically engages in reckless behavior, but this must be distinguished from either
normal behavior or that which may also be associated with other disorders. In fact, a recent
longitudinal study found that among children aged 6 to 12 who exhibited symptoms of
mania only 11% had bipolar disorder (Findling et al., 2010). As noted earlier, it is anticipated
that in the new DSM-5 diagnosis, disruptive mood dysregulation disorder may be given to
many children previously diagnosed with bipolar disorder. Valid diagnoses of bipolar dis-
order in children can be enhanced with the use of a screening instrument such as the Child
Behavior Checklist (Youngstrom et al., 2005).

• Assess family history for the presence of bipolar
disorder, other mood disorders, or substance use
disorders.

• Assess the client’s social history for evidence of
significant mood problems.

• Facilitate a medical examination to rule out any
medical conditions that may be responsible for the
symptoms.

• Make sure the symptoms are not the result of the
direct physiological effects of substance abuse.

• Rule out major depression, which would be the
diagnosis in the absence of any manic or hypo-
manic episodes.

• Rule out cyclothymic disorder, which is character-
ized by the presence of hypomanic episodes and
episodes of depression that do not meet criteria
for bipolar disorder.

• Rule out psychotic disorders, which are character-
ized by psychotic symptoms in the absence of a
mood disorder.

• Assess for suicidal ideation.

• Assess the quality of the client’s social supports.

• Evaluate the client’s insight into the disorder.

Source: First, Frances & Pincus, 2002.

box 6.1 assessment Guidelines for bipolar disorder

Part Four: Bipolar and Related Disorders72

Directions Part I, Diagnosis Given the case information, prepare the following:
a diagnosis, the rationale for the diagnosis, and additional information you would
have wanted to know in order to make a more accurate diagnosis.

bioPsyChosoCial risk and
resilienCe influenCes

onset

The etiology of bipolar disorder is primarily biological, although certain psychological and
social stresses may contribute to the first episode of mania or depression (Leahy, 2007).
Table 6.1 summarizes the risk and protective influences for the onset of bipolar disorder.

Risk Influences Protective Influences

Biological Biological

First-degree relative with bipolar disorder Absence of mood disorders among first-degree
relatives

Endocrine system imbalances Asian race

Neurotransmitter imbalances

Irregular circadian rhythms

Obstetrical complications

Postpartum hormone changes

Psychological Psychological

Poor sleep hygiene Effective communication and problem-solving skills

Irregular daily living routines Structured daily living routines

Traumatic experiences during childhood Sense of self-direction, internal rewards

Hypersensitivity

Self-criticism, low self-esteem Positive self-esteem

Exaggerated use of denial

Substance abuse disorders Absence of substance abuse

Mood lability

Transient psychotic episodes

Social Social

Ongoing conflict with family members Positive family relationships

Sources: Berk et al., 2007; Ryan, et al., 2006; Newman, 2006; Scott, McNeil, & Cavanaugh, 2006; Swann, 2006; Youngstrom
et al., 2005.

Risk and Protective Influences for the Onset of Bipolar Disorder
Table
6.1

Bipolar and Related Disorders 73

Genetic and biological influences
Family history studies indicate a higher-than-average aggregation of bipolar disorder in
families. Children with a bipolar parent are at an increased risk for mental disorders in gen-
eral (Birmaher et al., 2009), and their chances of developing bipolar disorder are between
2 and 10% (Youngstrom et al., 2005). Persons who have a first-degree relative with a mood
disorder are more likely to have an earlier age of onset than persons without a familial pat-
tern. Twin studies further support the heritability of the disorder. A study of identical and
fraternal twins in which one member of the pair had bipolar disorder showed a concor-
dance rate of 85% (McGuffin et al., 2003).

Researchers once speculated that the potential for bipolar disorder emanated from
a single gene, but studies are now focusing on polygenic models of transmission (Ryan,
Lockstone, & Huffaker, 2006). Although genetic research remains promising, the “core”
of bipolar disorder remains elusive, because no brain-imaging techniques exist that might
provide details about its causes. The limbic system and its associated regions in the brain
are thought to serve as the primary site of dysfunction for all the mood disorders. Four
areas under study include the role of neurotransmitters, the endocrine system, physical
biorhythms, and physical complications during the mother’s pregnancy and childbirth
(Swann, 2006). The amounts and activity of norepinephrine, serotonin, gamma-aminobu-
tyric acid, and perhaps other nerve tract messengers are abnormal in persons with bipolar
disorder, although the causes of these imbalances are unknown (Miklowitz, 2007). Some
theories focus on the actions of the thyroid and other endocrine glands to account for ner-
vous system changes that contribute to manic and depressive episodes. Biorhythms, or the
body’s natural sleep and wake cycles, are erratic in some bipolar persons and may account
for, or result from, chemical imbalances that trigger manic episodes. Finally, a few stud-
ies have associated obstetrical complications with early-onset and severe bipolar disorder
(Scott, McNeil, & Cavanaugh, 2006).

Psychosocial influences
Stressful life events may play an activating role in early episodes of bipolar disorder, with
subsequent episodes arising more in the absence of clear external precipitants (Newman,
2006). Many of these life events are associated with social rhythm disturbances (sleep,
wake, and activity cycles) (Berk et al., 2007). Persons with bipolar disorder who have a
history of extreme early-life adversity (e.g., as physical or sexual abuse) show an earlier
age of onset, faster and more frequent cycling, increased suicidality, and more comorbid
conditions, including substance abuse (Post, Leverich, King, & Weiss, 2001). Most clients
can recognize that a depressive or manic episode is coming two to three weeks in advance
(Marangell et al., 2006). Such symptoms include changes in motivation, sleep cycle distur-
bances, impulsive behavior (for mania), and changing interpersonal behavior. Although
such insight may be fleeting, the client may avoid a full manic or depressive episode if he or
she receives intervention during this time.

Course and recovery

Bipolar I disorder is highly recurrent, with 90% of persons who have a manic episode de-
veloping future episodes (Sierra, Livianos, Arques, Castello, & Rojo, 2007). The number
of episodes tends to average four in 10 years (APA, 2000). Approximately 50% of persons
with bipolar disorder move through alternating manic and depressed cycles (Tyrer, 2006).
About 10% experience rapid cycling (APA, 2000), which implies a poorer long-term out-
come, because such persons are at a higher risk for both relapse and suicidal ideation (75%
have contemplated suicide) (Mackinnon, Potash, McMahon, & Simpson, 2005). The prob-
ability of recovery is also decreased for persons with severe onset and greater cumulative

Part Four: Bipolar and Related Disorders74

comorbidity (Solomon et al., 2010). It is estimated that 40% have a “mixed features” type
of the disorder, in which a prolonged depressive episode features short bursts of mania.
Women are at risk for an episode of bipolar disorder in the postpartum stage, and they
experience rapid cycling more than men do, possibly because of hormonal differences and
natural changes in thyroid function (Barnes & Mitchell, 2005). A majority of those affected
(70 to 90%) return to a stable mood and functioning capacity between episodes. Between
5 and 15% of persons with bipolar II disorder develop a manic episode within five years,
which means that their diagnosis must be changed to bipolar I disorder (APA, 2000). Stud-
ies of the natural course of the disorder over one decade indicate that persons with bipolar
I  disorder experience depression for 30.6% of weeks, compared with 9.8% of weeks for
hypomanic or manic symptoms (Michalak, Murray, Young, & Lam, 2008).

A recent meta-analysis of the literature has summarized the predictors of relapse in
bipolar disorder (Altman, Haeri, & Cohen, 2006). Major predictors include the number of
previous manic or depressive episodes, a history of anxiety, a persistence of affective symp-
toms even when the mood is relatively stable, and the occurrence of stressful life events.
Other predictors include poor occupational functioning, a lack of social support, high

Risk Influences Protective Influences

Biological Biological

Childhood onset Adolescent or adult onset

Antidepressant drugs (for bipolar I type)

Number of previous episodes

Persistence of affective symptoms Absence of interepisode mood symptoms and medication
adherence

Substance use

Psychological Psychological

Irregular social rhythms Regular social rhythms, sleep cycle

Introversion/obsessiveness

History of anxiety Knowledge about the disorder

Exaggerated use of denial Willingness to assume responsibility for the disorder

Social Social

Low levels of social support Identification and use of social and community resources

Participation in support groups

Absence of professional intervention Ongoing positive alliance with family, mental health
professionals

Marital conflicts

Work-related difficulties

High family expressed emotion

Sources: Miklowitz, 2007; Schenkel, West, Harral, Patel, & Pavuluri, 2008; Tyrer, 2006.

Risk and Protective Influences for the Course of Bipolar Disorder
Table
6.2

Bipolar and Related Disorders 75

levels of expressed emotion in the family, and the personality characteristics of introversion
and obsessive thinking. We will elaborate on many of these predictors later.

Persons with bipolar disorder tend to experience serious occupational and social prob-
lems (Marangell et al., 2006). One study indicated a stable working capacity in only 45% of
clients, and 28% experienced a steady decline in job status and performance (Hirschfeld,
Lewis, & Vornik, 2003). Missed work, poor work quality, and conflicts with coworkers all
contribute to the downward trend for clients who cannot maintain mood stability. From
30 to 60% fail to regain full function between episodes with regard to vocational and so-
cial performance. A systematic review by Burdick, Braga, Goldberg, and Malhotra (2007)
suggests that although general intellectual function is preserved in persons with bipolar
disorder who have stabilized, there may be some negative effects related to verbal memory
and attention capacity.

An adolescent who develops bipolar disorder may experience an arrest in psycho-
logical development, thus developing self-efficacy and dependency problems that endure
into adulthood (Floersch, 2003). A study of 263 children and adolescents with the disorder
highlighted some issues related to course (Birmaher et al., 2006). Approximately 70% of the
subjects recovered from their first episodes and 50% showed at least one recurrence, most
often with a depressive episode. Table 6.2 summarizes the risk and protective factors for the
course of the disorder, and Box 6.2 lists other risk influences for bipolar disorder among
members of vulnerable populations.

Clients who experience high levels of life stress after the onset of bipolar disorder are
four times more likely to have a relapse than clients with low levels of life stress (Tyrer,
2006). Events that can cause these episodes include disruptions in social and family sup-
ports and changes in daily routines or sleep–wake cycles, such as air travel and changes in
work schedules.

females

• Women are at greater risk of developing bipolar II
disorder, which is characterized by symptoms of
major depression.1

• Women have an increased risk of developing sub-
sequent episodes of bipolar I disorder during the
postpartum period.2

• Women are more likely to experience a first epi-
sode of depression in bipolar I disorder.

• Rapid-cycling bipolar disorder is more common.3

• Women with bipolar disorder are more likely than
men to have a comorbid disorder.

• Women with bipolar disorder are more likely to die
earlier than women without the disorder.

• Women are more at risk for anxiety disorders and
thyroid problems.

youths

• Extreme early-life adversity may place one at more
risk of developing bipolar disorder. This experience
may also predetermine an earlier age of onset,
faster and more frequent cycling, increased sui-
cidality, and more comorbid conditions (including
substance abuse).4

race

• Prevalence of bipolar disorder is less among
persons of Asian background, but similar among
Caucasians, Latinos, and African Americans.

Sources: Ingram & Smith, 2008; Michalak, Murray, Young, & Lam,
2008; Muroff, Edelsohn, Joe, & Ford, 2008; Taylor & MacQueen, 2006.

1Hilty, Brady, & Hales, 1999.
2Hilty et al., 1999.
3Hilty et al., 1999.
4Post, Leverich, King, & Weiss, 2001.

box 6.2 bipolar disorder in vulnerable and oppressed Populations

Part Four: Bipolar and Related Disorders76

One study found that relapse risk was related to both the lingering presence of
symptoms of mania and harsh comments from relatives (Schenkel, West, Harral, Patel, &
Pavuluri, 2008). Clients from families that are high in expressed emotion (critical com-
ments) were likely to suffer a relapse during a nine-month follow-up period. Another study
of 360 persons with bipolar disorder indicated that family interactions had impact on the
one-year course of the disorder (Miklowitz, Wisniewski, Otto, & Sachs, 2005). Clients who
were more distressed by their relatives’ criticisms had more severe depressive and manic
symptoms than persons who were less distressed.

intervention

The National Comorbidity Study indicates that 80.1% of all persons with bipolar disorder
have received some type of intervention (Merikangas et al., 2007). In another study, more
than half (53.9%) of those who sought treatment attended a mental health facility, although
38.3% received services from general medical providers and 20.9% received treatment from
non–health care providers (percentages are overlapping) (Wang, Berglund, et al., 2005).
These statistics are significant, in that medication is always recommended as a primary
intervention for bipolar disorder, so clients will likely benefit from seeing psychiatrists.
Psychosocial interventions can be helpful for controlling the course of the disorder. A re-
cent literature review found that service providers prefer first to stabilize the client’s mental
status and then introduce psychosocial interventions (Fava, Ruini, & Rafanelli, 2005).

medications

The Food and Drug Administration (FDA) has approved a number of medications for the treat-
ment of bipolar disorder (Ketter & Wang, 2010). These are summarized in Table 6.3. Most phy-
sicians recommend that clients take medication even after their moods stabilize to reduce the
risk of recurrence of another mood episode. Generally a single mood-stabilizing drug is not
effective indefinitely, and a combination of medications is more often used (Hamrin & Pachler,
2007). It must be emphasized that although older adults may benefit from the same medications
as younger populations, they are more susceptible to adverse effects (Young, 2005). Lithium,

D i r e c t i o n s P a r t I I , B i o p s y c h o s o c i a l R i s k a n d P r o t e c t i v e F a c t o r s
Assessment Using the directions in the appendix, formulate a risk and protective
factors assessment, both for the onset of the disorder and for the course of the disor-
der, including the strengths that you see for this individual. What techniques could
you use to elicit additional strengths in this client?

Symptoms Medication

For acute mania

For maintenance of stable mood following an
acute phase
For long-term treatment of bipolar disorder
For acute bipolar depression

Lithium, carbamazepine, divalproex, risperidone, olanzapine,
quetiapine, ziprasidone, and aripiprazole
Lithium, olanzapine, lamotrigine, and aripiprazole

Lithium, lamotrigine, and olanzapine
The combination of olanzapine and fluoxetine

FDA-Approved Medications Used to Treat Bipolar Disorder
Table
6.3

Bipolar and Related Disorders 77

carbamazepine, valproate, and lamotrigine are all used with children who have bipolar disorder,
although none has been subjected to randomized, controlled trials (Findling, 2009).

Lithium is the best studied of the mood-stabilizing drugs. It is effective for stabilizing
both manic and depressive episodes in bipolar disorder, although it takes several weeks to
take effect and is more effective for treating manic than mixed or rapid-cycling episodes
(Huang, Lei, & El-Malach, 2007). As a maintenance drug, lithium has been shown in a
meta-analysis to be effective in preventing all types of relapses, but it is most effective with
manic relapses (Geddes, Burgess, Hawton, Jamison, & Goodwin, 2004). Lithium also has a
positive effect on clients’ suicidal ideation. A meta-analysis documented an 80% decrease
in such episodes for consumers who have used the drug for 18 months (Baldessarini et al.,
2006). Another meta-analysis demonstrated that lithium, compared to both placebo and
other medications, is effective in the prevention of deliberate self-harm (with 80% fewer
episodes) and death from all causes (55% fewer episodes) in persons with mood disorders
(Cipriani, Pretty, Hawton, & Geddes, 2005). Still, lithium is less effective at preventing re-
lapses after about five years of use (Scott, Colom, & Vieta, 2007).

The difference between therapeutic and toxic levels of lithium is not great, so
monitoring blood levels is important. Most of the common side effects of lithium are tran-
sient and benign, but diarrhea, dizziness, nausea and fatigue, slurred speech, and spastic
muscle movements characterize lithium toxicity. Lithium should not be prescribed for
women during pregnancy, as it is associated with fetal heart problems (Bowden, 2000),
and breast-feeding women should not use it because it is excreted in breast milk. Lithium
seems to have an antiaggression effect on children and adolescents (Carlson, 2002). It is
not advised for children under age eight, as its effects on them have not been adequately
studied. Adolescents appear to tolerate long-term lithium use well, but there are concerns
about its accumulation in bone tissue and effects on thyroid and kidney function. The
decreased kidney clearance rates of older adults put them at a higher risk for toxic blood
levels (Schatzberg & Nemeroff, 2001).

Another class of medications, the anticonvulsants, is also effective for the treatment
of bipolar disorder, although like lithium they are not effective in treating mania in its ear-
liest stages. Three of these are FDA-approved: valproate, carbamazepine, and lamotrigine
(Melvin et al., 2008). These medications offer an advantage over lithium in that they usu-
ally begin to stabilize a person’s mood in two to five days. A recent systematic review, how-
ever, concluded that these drugs are not more effective than lithium overall in preventing
relapses (Hirschowitz, Kolevzon, & Garakani, 2010).

Valproate is the most thoroughly tested of the anticonvulsants. Carbamazepine is an
alternative to lithium and valproate, but its side effects tend to be more discomfiting than
those of the other drugs, and only about 50% of clients who use the medication were still
taking it one year later (Nemeroff, 2000). A third anticonvulsant drug, lamotrigine, is used
less often to treat manic episodes, but according to a large randomized trial, it is the only
drug that is effective for bipolar depression (Bowden, 2005).

The anticonvulsant drugs are all used in the treatment of children with bipolar disorder,
but few studies have been done to establish long-term safety (McIntosh & Trotter, 2006). The
same qualifications that apply to lithium for pregnant women, children, and older adults also
apply to the anticonvulsant medications. Carbamazepine is used more cautiously with chil-
dren, as it can precipitate aggression (Ginsberg, 2006), and it has also been associated with
developmental and cranial defects in newborns (Swann & Ginsberg, 2004).

Antidepressant medications (usually the selective serotonin reuptake inhibitors) are not
generally used for the treatment of bipolar I disorder. They have been shown to induce mania
in as many as one third of all clients, and one fourth of consumers experience the activation of
a rapid-cycling course (Vieta & Suppes, 2008). In bipolar II disorder, however, the antidepres-
sants may be used along with an antimania drug for mood stabilization (Cipriani et al., 2006).
After a first episode of bipolar depression, antidepressant therapy should be tapered in two to
six months to minimize the possibility of the development of a manic episode.

Part Four: Bipolar and Related Disorders78

Many clients are prescribed antipsychotic medications on a short-term basis to control the
agitation and psychotic symptoms that may accompany their mood episodes. Approximately
one third of persons with bipolar disorder use small doses of these drugs during the mainte-
nance phase of treatment as well, because they tend to experience periods of intense agitation
(Faravelli, Rosi, & Scarpato, 2006). Among the newer antipsychotic medications, aripriprazole,
olanzapine, risperidone, quetiapine, and ziprasidone have been tested as treatment adjuncts.
In a meta-analysis of 18 studies, all of these drugs were superior to placebo in treating bipolar
mania, with no significant differences among them (Perlis, Welge, Vornik, Hirschfeld, & Keck,
2006). These medications may be effective for acute bipolar depression as well.

Two alternative methods of mood stabilization are available for persons with bipolar
disorder who do not respond positively to medication. One is electroconvulsive therapy
(ECT), in which electrical shocks are given to the client, usually in a series over several
weeks. Although this form of treatment seems overly invasive to some professionals, it is
a demonstrated safe and effective method of stabilizing a client’s mood (Rush, Sackeim, &
Marangell, 2005). Vagus nerve stimulation, provided far less often than ECT, relies on an
implanted stimulator that sends electrical impulses to the left vagus nerve in the neck. Even
more invasive than ECT, it has been shown to be effective in people who experience severe
depression with bipolar disorder (Fink, 2006).

Psychosocial interventions

There is no evidence that psychotherapy without medication can eliminate the risk of bi-
polar disorder in persons with other predisposing factors. However, psychosocial interven-
tions have an important role in educating the client about the illness and its repercussions
so that it can be controlled (Miklowitz, Otto, & Frank, 2007). Teaching clients to identify
early warning signs of a manic or depressive episode can significantly reduce their fre-
quency of recurrence (Altman, Haeri, & Cohen, 2006). Clients’ feelings and beliefs about
their illness greatly affect their medication adherence. In addition, many people with bi-
polar disorder continue to have problems in their work and social environments despite
medication use, and psychosocial intervention can help improve functioning in these areas
(Miklowitz & Otto, 2006). Further, psychosocial treatment can help people with bipolar
disorder to develop a structured schedule for their daily living activities (sleep, meals, ex-
ercise, and work) to prevent disrupted rhythms or stressful life events from triggering a
bipolar episode.

Although studies have been few, one review has indicated empirical support for four
types of interventions incorporating these elements (Miklowitz & Otto, 2006):

• Interpersonal and social rhythm therapy is based on the assumption that interper-
sonal conflicts are a major source of depression for clients, including those with bi-
polar disorder (Frank, 2007). It also targets the person’s regular scheduling of daily
activities. Two large studies have supported the efficacy of interpersonal therapy in
combination with medication compliance to other forms of intensive case manage-
ment, which focus only on symptom management (Miklowitz & Otto, 2006).

• Cognitive-behavioral therapy (CBT) interventions challenge a client’s cognitions
that may activate episodes of mania or depression (such as “I have no control over
my moods”), and they can also target cognitions related to medication compliance
(Basco & Rush, 2005). CBT further incorporates client education (to help the client
overcome cognitive deficits) and systematic problem-solving strategies for clients
(Zaretsky, Lancee, Miller, Harris, & Parikh, 2008). A recent systematic review con-
cluded that CBT interventions have a moderately positive effect on symptoms and
functioning, although these effects may diminish after several months (Szentagotai
& David, 2010).

Bipolar and Related Disorders 79

• Family-focused therapy trains family members in communication and problem-
solving skills. As discussed earlier, there is much evidence that expressed emotion
is associated with poorer outcomes in bipolar disorder, and these therapies address
those issues, among others (Miklowitz et al., 2005). A recent systematic review
found mixed results for these interventions, but the authors noted that they need to
be studied more carefully (Justo, Soares, & Calil, 2009).

• Group psychoeducation may be a more cost-effective modality of treatment.

CritiCal PersPeCtive

The onset of bipolar disorder appears to result from a complex set of genetic, biological,
and psychosocial factors. Research overwhelmingly suggests that biological factors are pre-
dominant, whereas other factors may account more for the timing and course of the dis-
order. For this reason, bipolar disorder has legitimacy within the social work value system
as a mental disorder. Still, there are several controversial aspects to the diagnosis of bipolar
disorder. First, the disorder has been diagnosed more often in children and adolescents in
the past 20 years, and there is much disagreement about the appropriate symptom profile
in this age group, raising concerns about its validity. In fact, the DSM criteria for diagnos-
ing bipolar disorder are essentially abandoned when diagnosing children (Birmaher, et al.,
2006). Among young people there is much symptom overlap with the disruptive behavior
disorders. The new DSM-5 diagnosis of disruptive mood dysregulation disorder may affect
the prevalence of bipolar disorder diagnoses in childhood, but this remains to be seen.

Another issue related to diagnostic validity is the relationship among bipolar I disor-
der, bipolar II disorder, and major depression. Questions have been raised about whether
the disorders are truly distinct from one another. One pair of researchers studied whether
the mood disorders might exist on a continuum, based on the observation that manic-
type symptoms are present to a variable degree in all mood disorders (Serretti & Olgiati,
2005). They found that when compared with bipolar II disorder, persons with bipolar I
disorder had a higher prevalence of reckless activity, distractibility, psychomotor agitation,
irritable mood, and increased self-esteem. Still, one or two manic symptoms were observed
in more than 30% of persons with a major depressive disorder, with psychomotor agitation
being the most frequent. Given that excitatory manic signs and symptoms are present to a
decreasing degree in bipolar I, bipolar II, and major depressive disorders, the authors con-
cluded that they can be proposed to lie along a dimensional model.

Directions Part III, Goal Setting and Treatment Planning Given your risk and
protective factors assessments of the individual, your knowledge of the disorder, and
evidence-based practice guidelines, formulate goals and a possible treatment plan for
this individual.

Directions Part IV, Critical Perspective Formulate a critique of the diagnosis as it
relates to this case example. Questions to consider include the following: Does this
diagnosis represent a valid mental disorder from the social work perspective? Is this
diagnosis significantly different from other possible diagnoses? Your critique should
be based on the values of the social work profession (which are incongruent in some
ways with the medical model) and the validity of the specific diagnostic criteria ap-
plied to this case.

Part Four: Bipolar and Related Disorders80

CAse 2: The Pediatrician

Ms. Daniels is a 76-year-old Caucasian woman who has been residing in a publicly run assisted
living facility (ALF) for the last seven months. For three years prior to moving into this facility
she was a resident in another ALF. While there, Ms. Daniels suffered a myocardial infarction that
required hospitalization. She subsequently lost her bed and was forced to find a new residence,
bringing her to the new ALF. While at the previous facility Ms. Daniels was deemed incompetent
to care for her financial affairs for reasons of mental illness and was granted a guardian, a former
friend. Prior to her stay at the first ALF, she had lived alone in a rented townhouse for 18 years.

Ms. Daniels is a retired pediatrician, has never been married, and has no children. She
says that during college, she would have periods in which she thought she could accomplish
anything and that everybody loved her. But then she would slide into a depression for several
months at a time when a “blackness” would be upon her. Despite these mood swings, she
functioned with some success and graduated with honors.

She next went to a prestigious university to undertake her premed coursework and attend
medical school. Throughout these years Ms. Daniels felt at times, usually when depressed,
that the “authorities” were watching her closely for instability. She kept herself in “close
check” because they were always looking for reasons to throw her out. During medical school
Ms. Daniels sought psychiatric help but was considered to be a “diagnostic puzzle” (in her words).
She recalls being given medication for her “anxieties,” but she does not recall what these were.

Ms. Daniels’s depression and mood swings continued into her medical residency,
immediately following which she took $5,000 from her father’s savings account without
permission and traveled to Europe, where she met “the most interesting people” of her life.
Ms. Daniels remembers being “very talkative” at this time and sleeping little, usually on the
beach or the street. She had sexual relations with a man the day after they met, and they became
engaged two days later. During that time, she wrote a 200-page treatise on how to cure cancer.
During her three-week stay she spent all the money before receiving a medical escort home at
her father’s expense. Ms. Daniels was briefly hospitalized upon her return. She was stabilized
with antianxiety medication and shortly thereafter began her career in pediatric public health.

Her mood swings, which were primarily characterized by depressive episodes, continued
until about 10 years ago. Her depressive episodes lasted between two weeks and six months.
She states that her illness features impulsive and reckless acts, but she can give no examples of
these. Ms. Daniels denies that she was ever hospitalized again, yet over the next 20 years she
held 15 different medical positions, and she attributes the volatility of her career to her mental
illness. She retired from medical practice about 15 years ago and complains about the lack of
money she had accumulated at retirement.

It was not until 10 years ago that Ms. Daniels started receiving psychotropic medication
(lithium) that helped control her symptoms. The social worker asked Ms. Daniels what that
was like and she said, “It was as if the blinders had been taken off, the shades had been lifted,
and my eyes had been dusted. Everything seemed so bright it hurt to look around. I felt a huge
weight had been lifted from my back that I had been carrying for a long time and I could walk
upright with a spring in my step. Even my chest felt clearer and I could take deep breaths again.
I didn’t know what to do with myself. I had spent so much of my time depressed; I no longer
knew how to be happy.” When asked how often she experienced these feelings, Ms. Daniels
said, tearfully, “only a few times.”

For the last three months Ms. Daniels has felt useless and that she is not accomplishing
anything. She lacks the ability to concentrate, often thinks “black thoughts,” and is unsure she
wants to continue living. Ms. Daniels feels she cannot safely eat or sleep during her “dark”
periods, because she wonders if she is “being watched.”

Ms. Daniels’s medical diagnoses include glaucoma, peripheral vascular disease,
hypertension, osteoporosis, hypothyroidism, allergic rhinitis, gastroesophageal reflux disease,

Bipolar and Related Disorders 81

and osteoarthritis. Although these conditions are serious, they are being controlled with medical
care and do not incapacitate her. Ms. Daniels ambulates throughout the ALF with the aid of a
walker. Her sleep is within normal limits.

Although Ms. Daniels has no difficulty making friends currently, keeping them is more of a
challenge to her. After a few weeks of friendship, Ms. Daniels suggests that her new friend has
some incurable disease and needs a nursing home or hospice care. The same scenarios play
out with her ALF roommates, and three of them have asked for transfers. Ms. Daniels has two
outside friends. One is 45 years old, on dialysis, and calls Ms. Daniels every night. This friend has
told the nursing staff that she is in acute renal failure and is not expected to live more than a
couple of months. The second friend is 62 years old and in good health, and she seems to take
Ms. Daniels’s pronouncements in stride. When Ms. Daniels was asked how she could predict the
ends of people’s lives, she responded that it was because she is a doctor.

Ms. Daniels reports that she had a distant relationship with her parents because she was a
girl and had older, high-achieving brothers. Her father died when she was 39, and her mother
died when she was 50. Neither death triggered a worsening of her symptoms. Her two brothers,
aged 86 and 82, both live in the vicinity but are frail and have infrequent contact with her.
When asked about her relationships with her brothers, Ms. Daniels stated, “They would be great
if their money-grubbing wives would just die.”

Four mini-mental status exams have been performed since Ms. Daniels has been at this ALF,
and she has scored well on each of them. Prior to her latest depressive episode, she participated
in activities at the ALF, including a book club, arts and crafts, walks, resident council, a political
discussion group, and recreational outings. She now participates in only a few activities. At the
end of the interview, she said, “I think there’ll be a time when I’m going to feel desperate. I
don’t think I’m going to kill myself, but I just feel trapped. I don’t have enough money to live
anywhere else, and I don’t want to live here. There’s not enough for me here. I’m not being
challenged or stimulated, and I don’t know what to do.”

Regarding strengths, Ms. Daniels is intelligent, well educated, and capable of interacting
coherently with others; she maintains a high activity level some of the time, has several friends,
does not have life-threatening health problems, can verbalize her needs, and adheres to her
medication regimen.

Please go to the Additional Case Workbook for directions to this case.

CAse 3: The Postman

Gregory Jackson has just recently been released from an inpatient facility after a one-week
stay. He is a 46-year-old, bisexual, African-American veteran with asymptomatic HIV infection
and asthma. Mr. Jackson has been employed at a post office since 1985. He was hospitalized
recently after going to the hospital and reporting that he had been placed on administrative
leave from his job after threatening bodily harm to a coworker. Mr. Jackson indicated that he
felt as though he was going to “murder someone” unless he was seen by a psychiatrist and put
back on psychotropic medication. He cannot stop talking, but can be understood. Mr. Jackson
states, “I just need my cocaine and I need my medication. I’m going to New York City to get
cocaine because they step on it too much in D.C.” Throughout the hospital’s initial assessment,
Mr. Jackson did not stop talking for even a moment. He admits that he takes his psychotropic
medications only when he is having problems like this at work, and that he last took medication
about one year ago.

His partner indicates that Mr. Jackson was involved in an incident five years ago at the post
office, where he became agitated and a security guard had to physically remove him from the

Part Four: Bipolar and Related Disorders82

building. While involved in an altercation with the security guard, Mr. Jackson fell down the
stairs. Since this time he has felt great hostility toward the security guard and has mentioned
several times that he plans on hurting or killing him. His partner indicates that since being
placed on administrative leave two weeks ago, Mr. Jackson has been calling the post office and
threatening to blow up the building. One day earlier, he paced in front of the post office yelling
obscenities and threatening to sue. Mr. Jackson also demonstrated disruptive and threatening
behavior toward the staff at the leasing office of his Section 8 apartment building, which
resulted in the staff filing for a restraining order against him. When his partner had expressed
concern to the client about his behavior, Mr. Jackson has threatened to kill his partner or his
partner’s brother if he were to ever leave him. His partner feels the client may follow through on
his threats toward the post office, because Mr. Jackson mentioned to him yesterday that he has a
friend who will sell him a gun for $300. His partner indicates that Mr. Jackson becomes agitated
and restless, with a decreased need for sleep (taking only one short nap per day), every year
around this time. He began to notice the client’s mood shift approximately three weeks ago.

After agreeing to be admitted into the hospital, Mr. Jackson became angry when he learned
of the hospital’s no smoking policy. At this point Mr. Jackson insisted on being discharged while
pacing up and down the hall with his backpack slung over his shoulder. He then lit a cigarette
in the middle of the inpatient hallway while stating that he would slit his wrists and “bathe his
blood” along the unit unless he is allowed to leave. When Mr. Jackson is able to calm himself
slightly, he indicates to the social worker that he does not have a psychiatric condition that
requires medication or hospitalization. When asked why he believes he was committed to the
hospital, Mr. Jackson says that it is because he intimidates people. When asked to talk more
quietly he states, “I am a New Yorker and we talk loud. I’m fine. This is the way I am.” Mr. Jackson
occasionally shifts from anger to fear, stating that he often feels afraid that others might come
after him because he is “suing the post office for 10.5 million dollars for throwing an HIV nigger
down the stairs.” At these times Mr. Jackson admits to feeling grateful for being in the hospital
because he feels safe there. At one point during his stay he asked the social worker and other
patients if they were “black Greeks,” recounting all the black Greeks he had slept with. Mr. Jackson
went on to tell the social worker that all the patients were asking for sexual favors from him.
The next day, however, he indicated that he wanted to go home and be in a “homosexual
environment” because he was tired of the other patients asking him disrespectful questions
about his sexuality. Mr. Jackson denies experiencing hallucinations, although in the past he has
admitted to “feeling” voices and said that he feels as if he has “four brothers” inside of him and
fears what may happen if he becomes angry enough.

Mr. Jackson has been seen at the hospital on several occasions over the past 10 years. At one
point he responded very well to medication and complied with treatment for six months, which
is the longest that he has been compliant with treatment. During those six months, Mr. Jackson
appeared calm and had insight into his disability, stating that “I have mental issues and I am here
to control my mind.” He appeared less agitated and anxious and was able to remain focused and
state his needs clearly. When asked about depression, Mr. Jackson stated that he currently felt as
if he was beginning to be in a “low” mood and indicated feeling this way several times in the
past, though he denies suicidal ideation at any point. When asked about how he felt during these
“lows” in the past, Mr. Jackson indicated that he usually stays home in his apartment and watches
TV all day or sleeps. He says that he feels tired and doesn’t feel as if it is “worth it” to do anything
else. He indicates that he eats more during these times and frequently notices an increase in his
weight that bothers him at times. Mr. Jackson is generally fit, but notices his physique changing
occasionally, which is alarming to him, yet he feels as if there is nothing he is able to do about it.
He occasionally misses work when he feels like this, because he is “tired and lazy.” Eventually, he
will shift out of this mood and will gain more energy and motivation.

Mr. Jackson was raised by his parents in Brooklyn, New York. His parents report that as a
child he frequently banged his head on objects and shook his crib. In high school, Mr. Jackson

Bipolar and Related Disorders 83

experienced racism as the civil rights movement was taking place during this time. He has two
older sisters and an older brother. Mr. Jackson completed high school before entering the military
at the age of 19 where he served on active duty for three years. Immediately after his release,
Mr. Jackson was hired at the post office where he has been employed ever since with the exception
of a three-year period when he was called into active duty in order to serve as a sergeant in
Desert Storm. Mr. Jackson indicates that he has been placed on administrative leave from the
post office for angry and threatening behavior seven times. He makes approximately $4,000 per
month at this job. Mr. Jackson was married for six years after his release from active duty in the
military, during which time he had two daughters with whom he recently resumed contact. He
is currently divorced and pays child support. Prior to the divorce, Mr. Jackson went through a
nasty custody battle during which his wife refused to let him see his children. He states that he is
a “founding father” of a brotherhood organization in New York with 50 members that preaches
against racial violence. When describing his current lifestyle, Mr. Jackson admits that he rents a
new car every weekend and spends a lot of money for his New York trips, saying “every weekend
I go to the best clubs in New York City. . . . Shirley Chisholm used to listen to me speak  . . . I’m a
leader in the African-American community. I want to live each day as if it is my last.”

Mr. Jackson reports that he grew up in a “ghetto” and witnessed several murders in his
neighborhood as a child. His father, who passed away two years ago, was an alcoholic whose
interactions with his children were characterized by violence. His mother, who passed away
seven years ago due to complications from AIDS, had untreated bipolar disorder. Mr. Jackson
states that at times his mother was supportive and caring and that she usually fulfilled his
basic needs. As a child, Mr. Jackson watched his grandfather almost kill his father, and his
mother would often beat his father in front of the children. Additionally, Mr. Jackson’s father
knocked the client unconscious when he was six or seven years old after the father came home
intoxicated and became angry that his wife was not home. Mr. Jackson indicates that he was
regularly beaten with a cord or tied to the bed when he misbehaved. In addition to his physical
abuse, Mr. Jackson says he was sexually abused at the age of nine by his father, brother, sister,
and several older men. He had several imaginary friends as a child and “could become anyone
he wanted.”

In addition to his father’s alcoholism, Mr. Jackson admits that most of his family (siblings,
aunts, uncles, cousins) abuse alcohol. His brother is addicted to crack and is currently in prison.
His two sisters live in low-income housing in New York and Tidewater, Virginia. Mr. Jackson
drinks approximately a 12-pack of malt liquor four to five times per week, both socially and
when he is alone. He admits to using powdered cocaine and crack cocaine “when I have the
money.” He states that he spends approximately $300 a weekend on cocaine but denies having
used anything for approximately three weeks, due to not having any money. Mr. Jackson denies
experiencing any symptoms of withdrawal, including shakes, seizures, and delirium tremens,
when he stops using. His partner indicates that he has only infrequently known Mr. Jackson to
use cocaine when he is not manic. When admitted to the hospital, Mr. Jackson tested negative
for all substances. Mr. Jackson indicates that he began drinking when he was nine years old and
started experimenting with various substances when he was 14 years old. His use has elevated
since that time. He does not believe he has an alcohol problem and does not plan on stopping,
although he admits that he should control his drinking in order not to further complicate his
HIV infection. He was arrested for a DUI approximately 20 years ago. When he was 17, he was
arrested for disorderly conduct and spent one night in jail.

Unfortunately, Mr. Jackson has been noncompliant with his HIV medications. Although he
is able to receive his medications free of charge from the VA hospital, he has been inconsistent
in doing so. His immune cell count is very low, although he has remained asymptomatic. While
in the hospital, Mr. Jackson indicates that he does not feel he needs medication because he “is
protected, because I walk with God and Jesus Christ.” He offers his low CD4 count as proof that
God is protecting him.

Part Four: Bipolar and Related Disorders84

Mr. Jackson is a Baptist, and although he does not actively practice his religion, he feels as
though he is a “semi-good” religious man. When he is not hostile or upset, Mr. Jackson presents
as an intelligent, funny, charming individual who is sometimes able to laugh at himself when
confronted with his past behavior. When asked about his strengths, he indicates that he is a
“good comedian, a good politician, a strong leader, and a good father.” Mr. Jackson has worked
as a DJ in the past and enjoys doing this. He believes that he has an excellent support system
in his friends and family. At times, he has insight into his illnesses, stating that he “should stay
on my HIV medication, reduce my alcohol consumption, and be nicer to people, especially my
lover-boy.” Although Mr. Jackson presents as having many problems with the post office, he
generally enjoys his job and fears that one day he will be “kicked out for good.”

Please go to the Additional Case Workbook for directions to this case.

references

85

Depressive Disorders

Tammy is a 44-year-old African-American female who was diagnosed with multiple sclerosis
(MS), a degenerative autoimmune disease, nearly 15 years ago. The disease has progressed
to the point where she walks with two canes, one in each hand, when she leaves her house,
although she is able to use only one cane around the house. Tammy is unable to hold a job
because of her disability and receives about $500 in Supplemental Security Income each month.
In addition, she receives food stamps and Medicaid.

Tammy first sought assistance from the social work department a month ago because of her
housing situation. She has lived with a friend in her basement bedroom for the past 18 months.
The friend’s grown son, who does not live with them, owns the house. The friend also has two
other sons living in the house. Tammy pays them $200 in rent each month and uses her food
stamps to buy food for the entire household. The situation is causing her great stress, as the two
young men make her feel unwanted. They are loud and harass her (they “get on me”) and make
it difficult to sleep. She is unable to use the shower because it is not big enough for her safety
seat, and she has fallen a few times while using it. She takes sponge baths in her room instead.

The stress of her living situation is upsetting her, and she is afraid that she’ll have another
attack of MS and require hospitalization. She has been hospitalized once since moving in with
this friend. In addition, she has checked herself into a psychiatric hospital twice since living
with her friend. Now, for the past several weeks, she has found herself crying every day, feeling
hopeless, and wanting to hurt herself. She has never actually attempted self-harm, however. She
stays in her bed, either sleeping or watching television most days, except for the times she has
her physical therapy appointments. She describes feeling “incredibly tired” and also says that
she wants to stay out of the way of her roommates so that they won’t bother her.

Prevalence and comorbidity of dePression

Of all disorders that may be experienced in one’s lifetime, depression is the most common.
Indeed, 16.6% of people in the United States will experience a major depressive disorder in
their lifetime (Kessler, Berglund et al., 2005). A major depression is a period of two weeks
or longer during which a person experiences a depressed mood or loss of interest in nearly
all life activities. Persistent depressive disorder represents a general personality style featur-
ing ongoing symptoms that are similar to, but less intense than, those of major depression.
In a given year, 1.5% of the adult population will suffer from persistent depressive disorder
( Kessler, Chiu, Demler, & Walters, 2005). The prevalence rates for youth depression are 2.8%
in children and 5.7% in adolescents (Costello, Erkanli, & Angold, 2006). The rate of past year
major depressive disorder was lower among persons aged 50 or older (5.8%) than among
younger adults (Substance Abuse and Mental Health Services Administration, 2009).

c h a p t e r 7

Part Five: Depressive Disorders86

The lifetime rate of comorbidity for adults with major depressive disorder is nearly
three-fourths (72.1%) (Kessler, Berglund et al., 2005). The most common comorbid dis-
orders by far are the anxiety, obsessive-compulsive, and trauma-related disorders (59.2%),
followed by impulse control and substance use disorders. In the Treatment for Adolescents
with Depression Study (TADS) (TADS, 2006, 2007), the most common concurrent diag-
noses were anxiety disorders, attention-deficit hyperactivity disorder, oppositional defiant
disorder, and persistent depressive disorder.

assessment

General practitioners are often responsible for diagnosing depression because many people
initially seek help from the medical system. Unfortunately, general practitioners are able to
detect the presence of depression less than 50% of the time (Mitchell, Rao, & Vaze, 2010).
This is partly because the majority of physicians fail to use Diagnostic and Statistical Manual
of Mental Disorders (DSM) criteria to diagnose depression (Zimmerman & Galione, 2010).
Box 7.1 provides general assessment guidelines for clients who may have depression, and
Box 7.2 lists risks for depression among vulnerable and oppressed populations.

• Assess the recent occurrence of any stressors
that may account for the client’s symptoms
of depression, to consider the possibility of a
stressor-related disorder.

• Determine whether the client is under the
influence of any substances that may account
for the depressive symptoms.

• Assess the client for symptoms of mania, to rule
out bipolar disorder.

• With children and adolescents, seek collateral
reports from parents and teachers, given many
adolescents’ reluctance to disclose their feelings.
When they do communicate, adolescents tend
to be accurate reporters of their emotions. Count
a symptom as present if either the parent or the
child reports it.

• Older adults do not typically complain of sadness,
anxiety, or hopelessness but speak instead of
physical (weight loss, insomnia, and fatigue) and
cognitive (such as memory and concentration
impairment) signs of depression.

• For all clients, especially older adults, symptoms of
depression are common to many medical condi-
tions and can be brought on by medications taken
for physical disorders.

• For resources on standardized assessment instru-
ments for depression, see Joiner, Walker, Pettit,
Perez, and Cukrowicz (2005) for adults and Klein,
Dougherty, and Olino (2005) for children and ado-
lescents.

Sources: Alexopoulos et al., 2001; Bird & Parslow, 2002; Kotlyar,
Dysken, & Adson, 2005; Waslick, Kandel, & Kakouros, 2002.

box 7.1 assessment Guidelines for depression

youths

• Teens, especially girls, are at increased vulnerability
for depression,1 which may place them at risk for
future episodes and other mental disorders into
adulthood. (Fergusson, Horwood, & Lynskey, 1996;
Kovacs, 2001) Adolescence is a period of risk
because it is the time when people develop formal
operational thinking; they can reflect upon causality
for events in their lives and assume a future

orientation in which they may experience hopeless-
ness about the future. (Abela, Brozina, & Haigh, 2002)

older adults

• Many people, particularly older adults, do not see
depression as a health problem that can be treated
but rather as a character weakness or a sign of
being “crazy” (Laidlow, 2003). Other older adults
view depression as a normal event in older age.

box 7.2 depression and social diversity

(Continued)

Depressive Disorders 87

• Depressive symptoms can be precipitated by com-
mon ailments at this stage of life, such as neu-
rocognitive disorders, heart disease, cancer, and
arthritis; the accumulation of negative life events
may also contribute to depression (Alexopoulos
et al., 2001; Shanmugham, Karp, Drayer, Reynolds, &
Alexopoulos, 2005; Cole, 2005).

• Older adults who live in low-SES neighborhoods
and receive treatment for depression tend to
respond less well to treatment than their counter-
parts residing in middle-income neighborhoods
(Cohen et al., 2006).

• Older adults may not participate in psychotherapy
because of out-of-pocket payments required, lack
of referrals from health care providers, or the lack
of availability of local psychotherapy providers
(Wei, Sambamoorthi, Olfson, Walkup, & Crystal,
2005).

Women

• Rates of depression for women are twice that of
men, beginning by age 14 and persisting through
the life span (Kessler, 2003; Kovacs, 2001). A
number of reasons may account for the disparity:
female hormonal changes, rumination as a coping
strategy, higher rates of sexual abuse, greater
interpersonal stress, lower appreciation and pay
for women’s work, and role overload (Bolen &
Scannapieco, 1999; Desai & Jann, 2000; Girgus &
Nolen-Hoeksema, 2006; Le, Munoz, Ippen, &
Stoddard, 2003; Nolen-Hoeksema, 2002).

• For teenage girls, interpersonal stress may con-
tribute to the onset of depression as they typically
invest more than boys in relationships (Girgus &
Nolen-Hoeksema,2006; Hammen, Brennan, &
Keenan-Miller, 2008; Rudolph, 2002).

People with disabilities

• Medical conditions and disabilities increase the
risk of depression and its continuance (Ciesla &
Roberts, 2001; Karasu, Gelenberg, Merriam, &
Wang, 2002; Huijbregts et al., 2010).

ethnic minorities

• The prevalence of major depression in adults
is equivalent among different ethnic groups

(Caucasians, Mexican Americans, Puerto Ricans,
Caribbean Blacks, and African Americans).
Although ethnic disparities in the diagnosis and
treatment of depression have been reduced in
the psychiatric care system in the last 10 years,
these gains are not reflected in the primary care
system, where many people from ethnic minority
groups are served for their mental health needs
(Stockdale, Lagomasino, Siddique, McGuire, &
Miranda, 2008).

• Mexican American teens have a significantly
higher rate of mood disorders than Caucasians or
African Americans (Merikangas et al., 2010).

• Latino teens may not receive adequate mental
health care compared to Caucasians, but having
Medicaid or State Children’s Health Insurance
increases the odds of receiving appropriate inter-
vention (Alexandre, Martins, & Richard, 2009).

• African-American women have the lowest rates of
suicide (Tondo, Albert, & Baldessarini, 2006).

• American Indian and Alaskan Natives have the high-
est rate of suicide among those aged 15 to
24 (Centers for Disease Control and Prevention,
2004).

• Labor migrants have a 20% prevalence rate for
depression.

• Refugees have a 44% prevalence rate (Lindert,
von Ehrenstein, Priebe, Mielck, & Brähler, 2009).

• Hispanics have a higher risk of discontinuing
prescribed medication prematurely compared to
people from other ethnic groups (Olfson, Marcus,
Tedeschi, & Wan, 2006).

low ses

• A significant proportion (17.4%) of single women
facing the termination of welfare benefits suffered
from depression in the last 12 months, which is
more than twice the rate of women in the general

population (Cook et al., 2009).

• Individuals who are of low SES are at particular
risk for stopping the use of medication prematurely
(Olfson et al., 2006).

box 7.2 depression and social diversity (Continued)

Part Five: Depressive Disorders88

Tammy has been a patient at the rehabilitation hospital for most of the course of her
disease. She sometimes has what she calls “attacks” in which her MS symptoms worsen and
she needs to be hospitalized. She recognizes that this usually happens when she is under
great stress. Currently she is seen in the outpatient clinic and attends physical therapy twice
a week. She hopes to become strong enough to need only one cane while out in public, and
none at home. Her therapist believes that she is making good progress and that her goal
is attainable.

Tammy’s family situation is marked by conflict and estrangement. Tammy is divorced
and has two daughters and a son, all grown. Her son is in jail. Her younger daughter is
pregnant, and her older daughter just moved into a subsidized apartment. She says her rela-
tionship with her older daughter is strained, but they do speak. Her ex-husband died a few
years ago while in prison. She has a sister who lives in a shelter in a neighboring county, but
they also are not on speaking terms. Tammy says this is because while she was still married,
her sister had an affair with her ex-husband. All her brothers are in jail, and she is not close
to any other relatives.

Tammy is not eligible for public housing. She used to live in a Section 8 apartment, but
was evicted. Her children were responsible for paying her bills, and she did not realize that
they were not paying her rent until she learned that she owed over $2,000. She is ineligible
to get back on the public housing list until she has paid this money. She has worked with the
Center for Independent Living to try to find alternatives, but the cheapest apartments they
have found have rents higher than her monthly income.

Tammy says she does not take beta interferon, a medication used to treat MS symp-
toms that has a suspected connection to the development of depression (Arnett &
Randolph, 2006). On her most recent admission, eight months ago, the psychiatrist pre-
scribed an antidepressant medication and recommended psychotherapy when she left the
hospital. Tammy said she went to only one therapy appointment and stopped taking the
antidepressants when she began feeling better. She now reports that she is starting to won-
der if she should go back to the psychiatric hospital, but she is afraid that if she leaves her
friend’s house this time, the friend will not let her move back in. She would rather work on
easing the stress in her life.

One method Tammy uses to cope with her feelings is smoking marijuana. She started
smoking it to relieve the symptoms of her MS, but in the past few months, she admits she
has been using it more to cope with psychological stresses. She said she smokes approxi-
mately every other day and gets marijuana from the young men with whom she lives.

Tammy does not have many outside social activities. She used to belong to a church,
but when she was evicted and moved in with her friend it was too far to walk, so she stopped
attending. She does have a strong faith in God and believes that despite all the troubles she
is having, things could be much worse. She is grateful that she has housing for the moment
and is able to receive her medical care.

Tammy has a tenth-grade education. She said she used to smoke crack cocaine in
her “younger days,” but after her then husband went to prison for drugs 20 years ago, she
stopped. She said that it wasn’t that difficult when she “made up her mind to do it.” She said
that both her parents drank too much and fought with each other verbally and physically
when she was growing up. She said both her parents died when she was a young adult—her
father from emphysema and her mother from cancer.

Directions Part I, Diagnosis Given the case information, prepare the following:
a diagnosis, the rationale for the diagnosis, and additional information you would
have wanted to know in order to make a more accurate diagnosis.

Depressive Disorders 89

bioPsychosocial risk and
resilience influences

onset

Biological influences
The fact that major depression tends to run in families partially supports the notion of
genetic transmission. The extent of variance that heritability explains for major depression
ranges from 31 to 42% (Sullivan, Neale, & Kendler, 2000). Many types of depression are
thought to be associated with deficiencies of certain neurotransmitters in the limbic area
of the brain, which controls emotions. Although no genes linked to depression have been
found to have more than small effects (Ebmeier, Donaghey, & Steele, 2006), studies have
centered on the serotonin transporter gene (Kumsta et al., 2010) and its interaction with
stressful life events, such as childhood maltreatment (Caspi et al., 2003). Other biological
processes implicated in depression include the secretion of the cortical enzyme in response
to stress (Sher, 2003) and impairment in the hypothlamic–pituitary–adrenal axis of the
brain (Vreeburg et al., 2009).

More recently, cigarette smoking, obesity, and sleep problems demonstrate risk for
depression. When tracked over a 10-year period, smoking doubled the odds of women
developing major depression (Pasco et al., 2008). Although this study seems to indicate
that smoking increases risk for depression, a bidirectional relationship appears to exist
between depression and obesity. People with obesity had a 55% increased risk of developing
depression over time. Additionally, people with depression had a 58% likelihood of becom-
ing obese (Luppino et al., 2010). Certain mechanisms have been proposed to account for
this association. Because thinness is considered a beauty ideal in both the United States
and Europe, being overweight may contribute to body dissatisfaction and low self-esteem,
placing individuals at risk for depression. Additionally, depression may increase weight
over time through interference with the endocrine system. A self-medication basis may
also operate, in that people may eat in order to improve mood.

Sleep also seems to play a critical role in depression. For example, teenagers reporting
five or fewer hours per night were 71% more likely to suffer from depression and 48% more
likely to think about committing suicide than those who reported getting eight hours of
nightly sleep (Gangwisch et al., 2010).

Finally, a major contributor to depression is poor physical health. Medical conditions
such as heart attack, cancer, stroke, MS, HIV, and diabetes increase one’s risk of depression
(Ciesla & Roberts, 2001; Karasu, Gelenberg, Merriam, & Wang, 2002; Shanmugham, Karp,
Drayer, Reynolds, & Alexopoulos, 2005). People who were unhappy with their health had
high rates of past year major depressive disorder (14.2%) compared to those who stated their
health as excellent (4.3%) (Substance Abuse and Mental Health Services Administration,
2009). Further, depression can be detrimental to physical health, involving activity restriction,
illnesses, increased health care use, and mortality (Rugulies, 2002; Shanmugham et al., 2005).

Psychological influences
At the psychological level, depression is related to distorted and rigid beliefs and thoughts.
These typically involve the “cognitive triad” of depression (thoughts about the self as worth-
less, the world as unfair, and the future as hopeless) (Beck, Rush, Shaw, & Emery, 1979).
Coping style is another psychological variable associated with the onset of depression.
Coping methods that are more active in nature, such as problem solving, have the potential
to ward off depression. However, avoidant coping styles, such as evading situations and
indulging in ruminative thinking (the tendency to focus on the symptoms of a distressed
mood in an incessant and passive way) (Nolen-Hoeksema, 2002), present risk.

Part Five: Depressive Disorders90

Social influences
Family factors can influence the development and maintenance of depression in youth.
Hostility and a lack of parental warmth and availability have been particularly associated
with depression (McLeod, Weisz, & Wood, 2007; Sander & McCarty, 2005). Depression
in mothers is a particular risk mechanism for depression and other disorders ( Hammen,
Brennan, & Keenan-Miller, 2008; Pilowsky et al., 2006; Weissman et al., 2006). The associa-
tion of parental depression with increased rates of depression in children may be accounted
for by genetics, biological impairment in utero transmitted from mother to developing
fetus, dysfunctional parenting, modeling, and the link of depression with parental marital
problems (Goodman, 2007).

A number of studies have indicated a significant relationship between depression and
childhood physical abuse and sexual abuse (Penza, Heim, & Nemeroff, 2006). Of all types
of maltreatment, sexual abuse poses the greatest risk for depression and suicide attempts
(Fergusson, Boden, & Horwood, 2008). Adults who reported being maltreated as children
appear to have an elevated inflammatory response to stress compared to adults who lacked
child mistreatment in their histories; thus childhood maltreatment may create a possible
biological vulnerability to depression (Carpenter et al., 2010).

Other family relationships may influence the development of depression. For adults,
those who were divorced or separated were more likely to experience major depressive dis-
order in the past year (13.1%) than people in other relationship status categories (Substance
Abuse and Mental Health Services Administration, 2009). Conversely, sibling affection and
support may play a protective role (Padilla-Walker, Harper, & Jensen, 2010).

In general, social support may mitigate harsh early family circumstances and the
stressful life events that people with depression are prone to experience (De Beurs et al.,
2001; Kraaij, Arensman, & Spinhoven, 2002). Friends can provide support and enable peo-
ple to self-disclose in a safe setting. Having positive peers is associated with less depression
in adolescence (Gutman & Sameroff, 2004), whereas bullying (being either a perpetrator
or a victim) was associated with depression, with higher frequencies of bullying (physical,
verbal, or relational) having a linear relationship to levels of depression (Wang, Nansel, &
Iannotti, 2011). For girls, relational victimization, when paired with genetic vulnerability, is
also predictive of depression (Benjet, Thompson, & Gotib, 2010).

In terms of the wider social environment, neighborhood cohesiveness acts as a
protective influence for adolescent females, whereas neighborhood problems pose risk
( Gutman & Sameroff, 2004). Finally, socioeconomic status (SES), and its link to depres-
sion for youths aged 10 to 15 years, was studied in a systematic review (Lemstra et al., 2008)
establishing a negative association between the two variables. That is, the lower the SES, the
higher the rate of depression.

course and recovery

Depressive disorders are associated with high rates of relapse (Brodaty, Luscombe, Peisah,
Anstey, & Andrews, 2001; Klein, Shankman, & Rose, 2006). About 50% of people with
one episode of major depressive disorder go on to experience another (Hammen et al.,
2008). However, the course of depression is variable, depending on the balance of risk
and protective influences. Several studies have identified risk and protective factors that
influence outcomes (Friedman et al., 2009; Klein, Shankman & Rose, 2006; Korczak &
Goldstein, 2009; McGrath et al., 2008). At the biological level, a familial loading for chronic
depression seems to carry risk, as well as a childhood onset (Crum et al., 2008). As with
onset, medical problems continue to pose risk for relapse.

At the psychological level, personality disorders can confer risk and their very absence
is protective (Korczak & Goldstein, 2009). Drug abuse and other comorbid Axis I  disorders,

Depressive Disorders 91

including posttraumatic stress disorder, anxiety disorders, and somatic symptom disorder,
are also risk influences. Melancholic depression (characterized by the inability to find plea-
sure in positive things, weight loss, psychomotor agitation or retardation, insomnia with
early morning awakenings, feelings of guilt, and a worsening of symptoms in the morning
with improvement at night) is also a pernicious influence on major depression.

Family risk influences include a poor relationship with the mother in childhood and
a sexual abuse history, the latter of which is also a contributor to the onset of depression.
People who have less than a college education also tend to have poorer outcomes, likely
owing to their lack of resources to obtain effective treatment.

intervention

Almost two-thirds (64.5%) of adults who experienced past year major depressive disorder
received treatment (Substance Abuse and Mental Health Services Administration, 2009),
which seems to represent a substantial increase compared to previous estimates of this type
(Wang, Berglund et al., 2005). However, many people seek help from the general health
care system and as a result, only about 19% of this group receives appropriate care, defined
as using medication or counseling in ways that are consistent with empirically validated
treatment guidelines (Young, Klap, Sherbourne, & Wells, 2001). Not surprisingly, there is
a greater reliance on medication than psychotherapy in the health care system (Olfson &
Marcus, 2009).

The initial stage of intervention for persons who are depressed is to assess for suicidal
risk, which is associated with the following factors (Borges et al., 2006; Fawcett, 2006):

• Presence of suicidal or homicidal ideation, with intent or plans
• History and seriousness of previous attempts (a key factor)
• Access to lethal means for suicide
• Presence of psychotic symptoms
• Presence of severe anxiety
• Presence of substance use
• Presence of conduct problems
• Family history of, or recent exposure to, suicide

Some social factors involved with suicide attempts include young age, low SES, divorce
(Borges et al., 2006), and cultural and religious beliefs that promote suicide—for instance,
that suicide is a noble way to handle difficulties (U.S. Department of Health and Human
Services, 2001).

The social worker can also ask a number of strengths-based questions when doing a
suicide risk assessment, such as the following (Bertolino & O’Hanlon, 2002):

• Have you had thoughts about hurting yourself in the past? What did you do to get
past that point?

• Things sounded really hard then. How did you manage? How did you stop things
from getting even worse?

• What needs to happen now so that you feel a bit better? What will that look like?

Directions Part II, Risk and Resilience Assessment Formulate a risk and protec-
tive mechanisms assessment both for the onset of the disorder and for the course
of the disorder, including the techniques that you would use to elicit additional
strengths in this client.

Part Five: Depressive Disorders92

If the practitioner concludes that the risk of suicidal behavior is considerable, inpatient
treatment should be considered. Inpatient intervention is especially indicated if the client
is psychotic, severely hopeless, demonstrates suicidal or homicidal ideation with significant
substance abuse, has strong impulses or plans to act on these ideas, has inadequate social
supports for effective outpatient treatment, and has a complicating psychiatric or medical
condition that makes outpatient medication treatment unsafe (Fawcett, 2006). Outpatient
intervention is indicated if the client is free of psychosis, not abusing substances, and main-
taining control over suicidal thoughts.

If a client with suicidal ideation is seen on an outpatient basis, the social worker should
take certain precautions (Fawcett, 2006). He or she should provide education about the
symptoms of depression and the effectiveness of treatment; develop a “no harm” contract;
advise abstinence from substances, as these may increase symptoms and impulsive behav-
iors; see the client at least weekly to monitor suicidal ideation, hopelessness, and substance
abuse; explain to family members how to respond to suicidal ideas; and remove any fire-
arms from the house.

After suicide risk has been assessed, interventions for persons with depression may
include psychotherapy and medication. A more recent trend has been for people to re-
ceive the latter more so than the former (Olfson & Marcus, 2009). Although medication
is considered to act on the biological mechanisms of depression, it must be recognized
that psychotherapy may also enact biological change. For example, Koch et al. (2009)
describe the way in which psychotherapy for major depression alters the plasticity of
the brain.

Psychotherapy

The benefits of psychotherapy are that many clients prefer it to medication; it is ap-
propriate for clients who have mild, moderate, or chronic depression; and the person
learns to cope with or avoid factors that precipitate the depressive episodes (Karasu
et al., 2002). (We should note that no information is available about the “new” depressive
disorder included in DSM-5, disruptive mood dysregulation disorder, which is specific to
children and adolescents.) Psychotherapy is particularly indicated when the person’s life
is characterized by psychosocial stress, difficulty coping, and interpersonal problems.
Sometimes psychotherapy is not indicated, however, at least not by itself—for example,
if the person is at risk of not completing the course of treatment. Further, sessions
may be time consuming, and it may not be easy to find high-quality treatment and
practitioners.

Psychotherapies with a lot of research attention include cognitive-behavioral ther-
apy (CBT) and interpersonal therapy (IPT). CBT involves behavioral models that focus
on the development of coping skills, especially in the domains of social skills and pleas-
ant daily activities, so that the person receives more reinforcement from his or her en-
vironment. Cognitive models include assessing and changing the distorted thinking that
people with depression exhibit. Although typically delivered as a package of interven-
tions, some of the techniques have been used as stand-alone treatment. These include
behavioral activation treatment, which centers on activity scheduling and increasing
pleasant activities, and problem-solving therapy, which focuses on behaviorally defining
specific problems, brainstorming ideas to solve them, and deciding upon and imple-
menting solutions.

IPT is a relatively brief psychodynamic intervention (approximately 12 sessions) focus-
ing on how current interpersonal relationships have contributed to the person’s depres-
sion. This perspective considers interpersonal conflicts to be a major source of depression.

Depressive Disorders 93

The social worker’s goal is to help the client repair these conflicts (Weissman, Markowitz,
& Klerman, 2000). Intervention focuses on significant role transitions, grief processes,
and interpersonal disputes or deficits; it has also been adapted for use with adolescents
(Mufson, Dorta, Moreau, & Weissman, 2005).

Various psychotherapies for depression in adults were compared in a meta-analysis
(Cuijpers, van Straten, Andersson, & van Oppen, 2008). These included IPT, psychody-
namic therapy, nondirective supportive treatment (any unstructured therapy without
specific techniques such as offering empathy and helping people to ventilate their experi-
ences and emotions), CBT, behavioral activation treatment, and problem-solving therapy.
The authors found that none of the treatments were appreciably more efficacious than
others, except for IPT (which was superior to others at a small effect size) and nondirective,
supportive therapy (which was less effective than the others at a very small effect). One
limitation of this meta-analysis is that effect sizes calculated were nonindependent, which
means that comparison groups were sometimes counted more than once. This may render
the results less valid.

Although most older adults in the United States have basic health coverage through
Medicare, fee-for-service reimbursements currently cover only 50% of mental health care
costs (Wei, Sambamoorthi, Olfson, Walkup, & Crystal, 2005). Depressed older adults are
often unwilling to seek treatment when they have to pay out of pocket. Further, primary
care physicians may not refer older adults to psychotherapy because of a lack of awareness
of its possible clinical efficacy. A national survey of community-dwelling Medicare benefi-
ciaries aged 65 and older found that the use of psychotherapy was associated with relatively
younger age, a college education, and the availability of psychotherapists (Wei et al., 2005).
Even when psychotherapy was used, a minority (33%) included clients who remained in
consistent treatment, defined as extending for at least two-thirds of the episode of depres-
sion. The availability of local providers correlated positively with consistent psychotherapy
use. One implication of this study is that for older adults with less formal education, social
workers may need to provide education on how psychotherapy works and respond to an
individual’s concerns about therapy.

In addition to CBT, discussed earlier, reminiscence and life review therapies may be
effective for older adults, according to a study of old-age well-being in long-term care
facilities (Bishop, Martin, MacDonald, & Poon, 2010), a meta-analysis of 24 studies
(Bohlmeijer, Smit, & Cuijpers, 2003), and another study of old-age well-being (Bishop
et al., 2010). A strong effect was shown for these interventions, especially for persons with
severe depression. Most of the studies were conducted in noninstitutionalized settings,
however, so the results may not generalize to the older adults in nursing home and
extended care facilities.

medication

The use of antidepressants has increased drastically in recent years from 5.84% in 1996
to 10.12% in the United States in 2005 (Olfson & Marcus, 2009). Medication has also in-
creased in relation to psychotherapy as a primary means of treating depression (Olfson
et al., 2002). At the same time, the use of antipsychotic drugs to treat depression has
increased for both adults (Olfson & Marcus, 2009) and children (Olfson, Blanco, Liu,
Moreno, & Laje, 2006). The latter is a concern because there are no controlled stud-
ies on the use of antipsychotic drugs for the treatment of depression in youth. General
practitioners, rather than psychiatrists, prescribe most medications, and majority of gen-
eral physicians fail to use DSM criteria to diagnose depression (Zimmerman & Galione,
2010). Because of these recent patterns, social workers should be prepared to educate

Part Five: Depressive Disorders94

clients and their families about the benefits and limitations of medication. The prescrib-
ing physician should see clients often (every one to two weeks) in the initial treatment
phase. Close monitoring produces greater treatment adherence and more opportunities
for education, and also enables clinicians (including social workers) to assess clients for
potential worsening of symptoms, the emergence of suicidal thinking, and other compli-
cating factors.

Youths
Concerns have been raised about the use of medication with youngsters. For children, car-
diac problems may be associated with the tricyclic medications (Silva, Gabbay, & Minami,
2005). Indeed, these older antidepressants are not recommended for children, given the
lack of evidence to support their use (Hazell, O’Connell, Heathcote, & Henry, 2003).
Newer antidepressants (developed since the late 1980s) are characterized by their actions
on serotonin. The selective serotonin reuptake inhibitor (SSRI) drugs block the reuptake
of serotonin. An even newer class of medication, the dual serotonin and norepinephrine
reuptake inhibitors (SNRIs), does not interfere with other chemicals that are affected by the
cyclic antidepressants to cause adverse effects.

In this country SSRIs are used with adolescents and have shown greater therapeu-
tic effectiveness and fewer adverse effects than the tricyclic drugs. A systematic review
of SSRIs with youths aged 5 to 18 found that only fluoxetine (Prozac) showed favorable
risk-to- benefit profiles (Whittington et al., 2004). A more recent meta-analysis indicated
that Prozac, as well as other antidepressants, although having only a modest effect on de-
pression, has benefits greater than the risks from suicidal ideation or attempts in teenagers
(Bridge et al., 2007). Further, only Prozac outperformed placebo in children younger than 12.
Therefore, social workers should be aware that other SSRIs are not indicated for the treat-
ment of depression in children.

The Treatment of Adolescent Depression Study (TADS), a large-scale, multisite study,
looked at combining medication and CBT, and comparing it to antidepressants and psy-
chotherapy alone (TADS, 2006, 2007). The researchers found that a combined approach,
offering both medication (in the study Prozac was given) and CBT over six to nine months,
was the ideal treatment for adolescents who are moderately to severely depressed (March &
Vitiello, 2009). CBT may protect against the suicidality that might develop with the use of
medication. Brief treatment may therefore not be sufficient.

Adults
There is a common perception that the newer SSRIs are more effective than the older
tricyclic antidepressants, but a meta-analysis of 102 randomized controlled trials found
no overall difference in efficacy between the two classes of drugs (Anderson, 2000).
The SSRI drugs are better tolerated, however, with significantly lower rates of treat-
ment discontinuation. Further, studies have shown that the effects of antidepressants
are not substantially greater than placebo effects, the latter of which may account for
68% of the improvement for depression (Rief et al., 2009). It seems that the major
influence of antidepressants may often be due to placebo or people’s expectation that
they will get better.

Indeed, a meta-analysis examining the severity of depression and response to medica-
tion showed that the benefit of antidepressant medication compared with placebo increases
with severity of depression symptoms. In other words, medication benefits may be minimal
or nonexistent, on average, in people with mild or moderate symptoms (Fournier, Hunter, &
Kupfer, 2010). For people with severe depression, improvement due to antidepressants over
placebo may be substantial.

Depressive Disorders 95

The largest study on “real-life” community clients with depression showed that an ini-
tial trial of antidepressant medication produced remission rates (defined as the absence of
symptoms) of 28% and response rates (a reduction of about half in symptom levels) of 47%
(Trivedi, Rush, Wisniewski et al., 2006). As discussed in the risk and protective influences,
remission is a desirable outcome because residual symptoms after treatment put people at
risk for relapse. The study by Trivedi, Rush, Wisniewski et al. (2006) demonstrates that a
majority of people (over 70%) do not meet the desired goal of medication, and fewer than
half show a response.

A common practice following the lack of response to one antidepressant is to try an-
other. For instance, in a continuation of the study described earlier, remission rates were
examined for those who initially lacked response to Celexa when another SSRI or SNRI
was tried (Rush et al., 2006). Apparently, there was little difference in performance be-
tween the various SSRIs or SNRIs, with remission rates ranging between 17.6 and 24.8%.
Another practice following the lack of response to one medication is to augment it with
another antidepressant. Referring again to the earlier study, Trivedi, Fava, Wisniewski
et al. (2006) found that adding bupropion (Wellbutrin) to Celexa resulted in remission
rates of nearly 30%.

As with younger adults, about 50% of older people will experience treatment response,
defined as a reduction of half their symptoms, from a course of antidepressants. Because of
physiological changes in older adults, clinicians should increase doses more slowly than in
younger clients and monitor them closely for side effects and medication interactions, to
which older adults tend to be more sensitive (Alexopoulos et al., 2001).

Many people fail to comply with prescribed medication. A nationally representative
sample indicated that a significant proportion of clients (40%) discontinue taking medica-
tion during the first 30 days of treatment (Olfson, Marcus, Tedeschi, & Wan, 2006). Side ef-
fects are common and are generally underreported to medical doctors (Zimmerman et al.,
2010). Clients treated with SSRIs or SNRIs were more likely to continue medication than
those treated with the older medications. The use of psychotherapy was positively related to
drug adherence in this review.

To summarize, the use of medication to treat depression has both indications and
contraindications (Agency for Health Care Policy and Research, 1993; Karasu et al., 2002).
Medications may be indicated if the client has severe depression, prefers the option of med-
ication, has a personal or a first-degree relative history of prior positive response, is likely
to adhere to a medication regime, and can work with an experienced physician. Medica-
tion may also be indicated when psychotherapy alone has not been successful (Antonuccio,
Thomas, & Danton, 1997). Medication may not be indicated if there are cost considerations
or if the client has a medical illness or takes other medications that make its use risky. The
benefits of medication are that it is easily administered and can produce a relatively rapid
response (four to six weeks). Its limitations are the need for monitoring, the possibility of
adverse effects, potential use in suicide attempts, and the possibility of nonadherence. Fur-
ther, it is difficult to predict how a certain person will react to a particular medication. The
process of finding a medication and appropriate dosage that helps improve mood is one of
trial and error (Healy, 2002).

Directions Part III, Goal Setting and Treatment Planning Given your risk and
protective factors assessments of the individual, your knowledge of the disorder, and
evidence-based practice guidelines, formulate goals and a possible treatment plan for
this individual.

Part Five: Depressive Disorders96

critical PersPective

As major depressive disorder criteria stemmed from clinical consensus, Zimmerman,
McGlinchey, Young, and Chelminski (2006) conducted an empirical analysis and found
that the weight change and indecisiveness criteria could be eliminated from the diagnosis.
This modification would result in more streamlined criteria and would include subthres-
hold cases (those that currently do not meet all the necessary criteria) in which there is
often significant impairment.

It must also be acknowledged that the criteria for depression, focusing on affective and
cognitive symptoms, comprise a view that is particular to industrialized, Western nations
(Maracek, 2006). Other cultures describe different ways of understanding depressive suf-
fering. For example, in many Asian cultures, somatic complaints are foremost. The DSM
criteria fail to capture these culture-bound experiences.

The chief limitation of the psychiatric view of depression is the assumption underlying
the diagnosis, namely, that it is due to internal dysfunction. This assumption can be seen in
the widespread acceptability of biological theories of depression and the use of medication
as treatment. The focus on medication, which furthers the interest of the pharmaceutical
companies, has also been criticized as a method aimed at providing only symptom relief
rather than targeting broader social changes (Maracek, 2006).

Directions Part IV, Critical Perspective Formulate a critique of the diagnosis
as it relates to this case example. Question to consider include the following: Does
this diagnosis represent a valid mental disorder from the social work perspective?
Is this diagnosis significantly different from other possible diagnoses? Your critique
should be based on the values of the social work profession (which are incongruent
in some ways with the medical model) and the validity of the specific diagnostic cri-
teria applied to this case.

Case 2: The Lonely Group Home Resident

Note: Although the following clinical illustration is intended to focus on a mood disorder, the
client in this case also experiences intellectual disability, a disorder that is not covered in this
book. This is a developmental disability, presumed to be lifelong. It is characterized by mild,
moderate, or severe cognitive impairments that create significant impairments in two or more of
the following areas: self-care, communication, home living, social and interpersonal skills, use of
community resources, self-direction, functional academic skills, work, leisure, health, and safety.

Indira is a 23-year-old female who, after a long waiting period, was accepted to live in a
group home for people with intellectual disability. Twelve people live in the group home, which
is located in a middle-class neighborhood. The home is split up into three apartments, with four
residents each.

Prior to her move to the group home, which occurred four months ago, Indira lived with
her parents and younger brother in a private home. Her parents came to the United States from
India before Indira and her brother were born. Her father is a computer analyst, and her mother
has never worked outside the home. Indira was the first child; she was born prematurely and
with the umbilical cord wrapped around her neck. According to Indira’s mother, the doctors
did not believe that Indira would survive, and she spent many months in the hospital before her
parents were allowed to take her home.

Depressive Disorders 97

During her childhood Indira was tested and found to have an IQ of about 15; she is also
blind and suffers from a seizure disorder. Indira cannot walk more than a few steps and only
when she can hold onto someone with both hands. She is wheelchair-bound and overweight.
Indira cannot communicate verbally but understands the English language. She conveys “yes”
and “no” by nodding or shaking her head. She can follow simple commands. Indira can’t
complete any activities of daily living by herself. For example, she is incontinent. She can feed
herself with a spoon, but only messily, and she has to wear a bib. She can drink with a straw but
cannot lift a cup. She can rattle toys and put them in her mouth.

When she was a child, Indira attended a school for children with severe disabilities,
autism spectrum disorder, and intellectual disability. After graduating from this school, Indira
participated in a day program for adults with mental handicaps. At the day program, participants
typically watch television, do puzzles, and color.

According to Indira’s mother, there is no history of mental illness in either her or her
husband’s family, and she has never suffered from depression, although she is very sad about
Indira’s current plight. She denies that Indira has ever suffered from depression.

The relationship between her parents appears to be a loving one. Indira’s brother enjoyed
a healthy childhood and is now a senior in high school. Indira’s primary caregiver has always
been her mother. However, after 23 years of caring for her handicapped and overweight child,
her mother started to experience health problems, especially backaches. The family decided that
they could no longer adequately care for Indira and asked a social worker for help in finding a
suitable placement.

After several visits to the group home, Indira was accepted and she was moved in. She had
one staff member assigned to her in the morning and a different one in the evening, and she
appeared to connect well with both of them. She smiled and responded to games and outings
that were initiated by staff. Two weeks after Indira moved into the group home, however,
management changed and several permanent staff quit their job. The result was that Indira
now had relief staff caring for her, meaning different voices on a daily basis. Especially during
the weekends, Indira did not have much to do. She got up late and then spent most of her
day in the living room, where the television was on. Outings were rare due to the unstable
staff situation, and relief staff did not want to take the responsibility of taking residents into the
community.

Indira started to become less active; she did not smile anymore and was easily annoyed,
making her feelings known through nonverbal sounds and body position. She refused to eat
most meals except for desserts and started losing weight. Indira’s refusal to eat might have been
caused by the different food. Her mother usually cooked Indian food, with lots of rice, spiced
vegetables, and fruits. Because the cow is sacred for Hindus, Indira had never eaten beef before.
The cook in the group home was not able to reproduce these foods and prepared standard
American meals, such as hamburgers, macaroni and cheese, and tuna helpers.

At night staff would often hear her crying for a long time until she fell asleep. Indira then
had a difficult time getting up in the mornings. She used to be cooperative and help staff by
moving her body into the right position for washing and dressing but refused to do so after a
while. She appeared to become more withdrawn and closed her eyes more often during the
day. When staff tried to engage her in an activity, Indira would bury her face in her hands and
rock herself back and forth as if to comfort herself, while making noises that sounded as if she
was crying—even though no tears streamed down her face.

Indira’s parents became very concerned for their daughter; they visited her two to three
times a week, but Indira did not change her behavior when they were around. She rejected the
hands of her mother and did not hug her as she used to do.

Indira’s behavior changed gradually at first and became more severe after several weeks. In
the meantime, the staff situation in the group home did not stabilize; Indira continued to have
different caregivers. She exhibited the same behavior in her day placement, and her counselor

Part Five: Depressive Disorders98

consistently reported that Indira was not eating her lunch and was not participating in group
activities as she used to. The nurse at the group home eventually became concerned enough to
schedule a complete physical exam and visit with the psychiatrist for Indira, even though when
her doctors saw her just prior to her move into the group home, everything had seemed fine.

Please go to the additional Case Workbook for directions to this case.

Case 3: an Unsettling Transition

Mrs. Elizabeth Cuthbert is an 81-year-old Caucasian woman. She has been diagnosed with
syncope (fainting spells), hypertension, and chronic obstructive pulmonary disease. For the
last four months she has resided in a nursing facility and receives skilled nursing services.
Mrs. Cuthbert’s move to the facility occurred as a result of repeated syncope and falls. Her
condition has been exacerbated by the recent development of a foot drop, a weakening of the
structures in her ankle that allows the foot to dangle when walking. This ailment has increased
her risk of falling. Mrs. Cuthbert has been fitted with an ankle foot orthosis (AFO) and provided
with a walker, but she claims these aids make her feel “weak.” Mrs. Cuthbert receives physical
therapy for her balance and occupational therapy for her tasks of daily living. Her discharge
plan involves placement in an assisted living apartment once she has developed the safety and
ambulation skills that will allow her to live without constant monitoring.

Mrs. Cuthbert’s medications for the last six months include therapeutic aspirin, blood
pressure medication, and Tylenol for pain relief from her fall and osteoarthritis. She is compliant
with her medications.

Mrs. Cuthbert was widowed 20 years ago and has lived alone in her home of 35 years since
that time. Her immediate family includes two adult children, who live in the area, and three
grandchildren, who visit and send her letters. Family members visit frequently, at least twice a week.

Mrs. Cuthbert expresses a negative attitude toward the aged in comments during unrelated
discussions. For instance, when the social work intern first met her, she cast aspersions on an
“old dog” who lived in the unit, and then went on to make negative comments about her own
appearance, saying she looked like “an old hag.” She received the social worker’s supportive
comments positively, but the change in attitude appears transitory.

The results of a mini-mental status examination conducted on Mrs. Cuthbert indicated that
she was aware of person, time, and place. Mrs. Cuthbert was also evaluated using a mood scale
to determine her risk for depression. She scored 7 out of 15 (a score higher than 5 is indicative
of depression). Her response to the mood-scale questions revealed feelings of worthlessness, low
energy, insomnia, and diminished interest in pleasurable activities. Mrs. Cuthbert evidences no
symptoms of mania.

Mrs. Cuthbert is undergoing significant change in her social support system as a result
of her recent move to the nursing facility. She no longer has the neighbors whom she visited
each day as she went about retrieving her newspaper, checking on her garden, and watering
her outdoor plants. She has lost the use of her car and feels that she should give up driving
permanently to prevent possible accidents. She also no longer has the option of walking to her
place of worship because of her current condition.

An additional problem for Mrs. Cuthbert is her reluctance to make safety changes that will
allow her to move to an assisted living apartment in a nearby community where several lifelong
friends reside. She has been very reluctant to adopt the walker or the AFO and has been refusing
the majority of her physical and occupational therapy treatments because she is “tired.”

During her care plan meeting, Mrs. Cuthbert expressed surprise that the entire
interdisciplinary team had gathered to discuss her case with her and her family. She asked,

Depressive Disorders 99

“Why are all of you interested in me?” She stated that she wanted to move to assisted living
because she would be able to visit with her friends there once she did so. When told that she
could not move until she addressed the safety and ambulation deficits she is experiencing,
she expressed interest in cooperating with the various therapists and counselors.

According to Mrs. Cuthbert’s daughter, Barbara, until her current health problems and
the move to the nursing facility, her mother was a relatively contented person. She crocheted,
enjoyed crossword puzzles, called on friends, assisted two shut-ins whom she has known for
years, and had her grandchildren over for weekend visits. Since her admission to the nursing
home, it has become difficult for Mrs. Cuthbert to accomplish several of her old activities, and
simply not feasible to continue others. However, she has also discontinued the activities that
were appropriate for her while at the nursing home, except for doing crossword puzzles. Barbara
noted that her mother was not interested in going out for meals as she had been before her fall.
Her daughter speculated that her mother might not want to be seen in public with the AFO and
walker, but noted that she also refused take-out meals offered as well. When asked, Barbara was
unaware of any history of mood disorders or other mental illness in her mother’s background,
but said that her mother wouldn’t typically speak of such things anyway.

Mrs. Cuthbert’s financial situation is sound. She owns her own house and collects pensions
from both her own employment as a secretary and her husband’s work.

Please go to the additional Case Workbook for directions to this case.

references

100

The Anxiety, Obsessive-Compulsive,
and Trauma and Stressor-Related

Disorders

Andrew is a 15-year-old Argentinian male currently enrolled in the ninth grade. His mother
contacted an outpatient mental health agency because of her son’s extreme fears of going to
school and stated that he has not been able to attend a single day of class since the academic
year started two months ago. At intake, Andrew said he was nervous and was also sweating
profusely, but he came across as friendly and mature. He smiled a lot, even when discussing
painful subjects. He sustained minimal eye contact, however, and focused instead on the floor.

Andrew explained that he tried to go to school at the beginning of the year but could not
get out of his mother’s car because he was “so scared.” Specifically, he feared “the larger class sizes
in high school” and “the large crowds of people looking at me and laughing.” He realized that
“people are probably not saying anything,” but he couldn’t stop worrying about it. He described
physical symptoms such as sweating and a racing heart. He said that he does not have friends at this
school and does not know which students from his middle school are now in his high school classes.
Andrew mentioned that he does have a small social network outside school. These friends are three
years older and primarily his brother’s friends. Andrew describes these individuals as “part of the
Argentinian community,” and “people who have known me for a long time.”

Andrew also reported difficulty in other areas such as sleeping and eating. He stated that he
tries to go to sleep before midnight but sometimes cannot fall asleep until 3:00 a.m. Sometimes
he will lie in bed and “just wait to sleep”; at other times he will go to the kitchen and consume
large quantities of food because “I’m so hungry.” He reported that he does not eat for the rest of
the day because he does not feel hungry then. He maintained that his weight has not changed;
he does not feel guilty or bad about his eating habits but does think they are “strange.”

T
he DSM-IV devoted one chapter to the anxiety disorders, but DSM-5 has spread them
among three chapters in accordance with their supposedly shared features. They now
fall into the categories of anxiety disorders (nine major types), obsessive-compulsive

and related disorders (six major types), and trauma and stressor-related disorders (five major
types, including the adjustment disorders). For simplicity’s sake we will refer to all of these as
“anxiety disorders” in this chapter, because most of them have until now been considered a
single category for research and intervention. All of them are characterized by intense, almost
unbearable fears that disrupt a person’s capacity for social functioning. Brief descriptions of
many of the anxiety (and related) disorders, differentiated by the nature of the anxious re-
sponse or feared stimulus, are offered in Table 8.1, along with their prevalence and recurrence
rates (when available). This chapter discusses anxiety disorders in general terms, although at

C h a p t e r 8

The Anxiety, Obsessive-Compulsive, and Trauma and Stressor-Related Disorders 101

Disorder and Description Prevalence Course (if available)

Anxiety Disorders

Separation anxiety disorder describes excessive
anxiety about separating from a major attach-
ment figure.

Lifetime prevalence in children is
4.1% and is 6.6% higher in children
living in single-parent and low-
income households.

One third (36%) of childhood
cases persist into adulthood.

Panic disorders involve unpredictable anxiety
attacks.
In panic disorder with agoraphobia, the panic
attacks arise from anxiety about being in places or
circumstances where escape might be difficult or
embarrassing.

Adult lifetime prevalence is 1.1%. Panic disorder without
agoraphobia has an 82%
probability of recovery and a
56% recurrence rate. Panic
disorder with agoraphobia
has a 48% recovery rate and
a 58% recurrence rate.

In panic disorder without agoraphobia, attacks are
not associated with particular situations but are
characterized by fears of losing self-control.

Adult lifetime prevalence is 3.7%.

In agoraphobia without panic disorder, panic
symptoms are experienced in places or situations
from which escape might be difficult.

Adult lifetime prevalence is 0.8%.

Phobia is anxiety triggered by a specific object or
situation and impedes the person’s functioning or
results in considerable distress.

Lifetime prevalence rates range from
10 to 11.3%. Twelve-month preva-
lence is 8%. The majority of those
diagnosed are female.

Social phobia is anxiety related to social situa-
tions. Fear of negative evaluation from others is
the overwhelming worry.

Both 12-month and lifetime preva-
lence are 5% in the United States.
Risk influences include being Native
American and having low income.

The probability of recovery is
37%; mean duration is 16.3
years.

Generalized anxiety disorder is persistent, exces-
sive worry that lasts for at least six months, occur-
ring more days than not, and accompanied by at
least three of the following symptoms: restless-
ness, fatigue, difficulty concentrating, irritability,
muscle tension, and disturbed sleep.

A lifetime prevalence of 4.1%. The recovery rate is 58% with
the probability of recurrence
45%.

Obsessive-Compulsive and Related Disorders

Obsessive-compulsive disorder (OCD) describes
recurring thoughts that cause marked anxiety,
and compulsive behaviors that temporarily serve
to neutralize the anxiety.

Lifetime prevalence rates are approxi-
mately 2.5% in the community over-
all, and 1 to 3.6% for adolescents.
Childhood rates are about 1%.

Trauma and Stressor-Related Disorders

PTSD is characterized by symptoms of anxiety
that follow exposure to a traumatic stressor.
Four major symptom categories include
re- experiencing the trauma, avoidance and
numbing, persistent changes in cognition and
mood, and increased arousal.

1 to 14%, lifetime prevalence rate of
6.8%, of youths exposed to traumatic
events, 36% have PTSD.

Symptoms in 90% of indivi-
duals with PTSD persisted for
more than three months; for
over 70%, the disorder lasted
for more than a year; more
than one third of people
never fully recovered.

Sources: American Psychiatric Association, 2000; Bruce et al., 2005; Cronk, Slutske, Madden, Bucholz, & Heath, 2004; Fletcher, 1996; Gorman
et al., 2002; Grant, Hasin, Blanco, et al., 2005; Kessler, Berglund, et al., 2005; Kessler, Chiu, et al., 2006; Schnurr, Friedman, & Bernardy, 2002.

Anxiety, Obsessive-Compulsive, and Trauma Disorders and Their Prevalence
Table
8.1

Part Six: The Anxiety, Obsessive-Compulsive, and Trauma and Stressor-Related Disorders102

times it will focus on specific disorders, most notably posttraumatic stress disorder (PTSD).
Information about anxiety disorders among socially diverse populations is included in Box 8.1.

PrevalenCe and Comorbidity

Anxiety disorders are the most common mental health disorders in the United States, with
a lifetime prevalence of 28.8% (Kessler, Berglund, et al., 2005). Their prevalence among chil-
dren and adolescents varies considerably among studies (Cartwright-Hatton, McNicol, &
Doubleday, 2006; Velting et al., 2004), but in a recent national study, 8% of youths reported
being severely impaired by at least one type of anxiety disorder (Merikangas et al., 2010b).

Anxiety disorders are often comorbid with one another and with depression. Sub-
stance use disorders are also highly comorbid with anxiety disorders (Kolodziej, Griffin, &
Najavits, 2005). Comorbid disorders are common with childhood anxiety and are often
associated with less positive outcomes (Storch et al., 2008). Personality disorders afflict
about 50% of people with panic disorder, the most common being the avoidant, dependent,
and obsessive-compulsive types (Gorman et al., 2002). Along with psychiatric comorbidity,
poor physical health is associated with the anxiety disorders, although the direction of cau-
sality is unknown (Sareen, Cox, Clara, & Asmundson, 2005). Medical problems may also
be a consequence of trauma (Schnurr et al., 2002), even for children and adolescents (Seng,
Graham-Bermann, Clark, McCarthy, & Ronis, 2005).

assessment of the anxiety disorders

The clinical assessment of anxiety should include a variety of focus areas (Bernstein &
Shaw, 1997; Gorman et al., 2002). Box 8.2 provides a summary of these.

Women

• Girls present with more fears than boys and gener-
ally have higher rates of these disorders, starting
during adolescence and continuing through the
life span; whether the gender difference is due to
biological factors, social factors (such as increased
rates of sexual abuse), or a combination of the two
is unknown (Hagopian & Ollendick, 1997; Ozer,
Best, Lipsey, & Weiss, 2003).

older adults

• Clinical trials that track the effectiveness of stan-
dard medications or psychosocial treatments in
older adults are lacking (Gorman et al., 2002).

• Prevalence rates for PTSD are unknown, although
rates for anxiety disorders in general range from
3.5 to 10.2% (Wetherell, Lenze, & Stanley, 2005).

ethnicity

• Although African Americans have lower rates
of anxiety disorders than Caucasians, (Breslau,
Kendler, Su, Gaxiola-Aguilar, & Kessler, 2005)

their anxiety disorders are more likely to persist
(Breslau et al., 2005).

• African Americans are more likely to report so-
matic symptoms and to seek medical attention
rather than mental health care, which may result
in misdiagnosis. (Gorman et al., 2002).

• High rates of PTSD have been found among Asian
Americans and Hispanic Americans who have
been exposed to trauma prior to immigration. (U.S.
Department of Health and Human Services, 1999).

• Narrative exposure therapy, a method by which
the survivor is asked to detail the trauma, but
also put it into the larger context of social justice
and political considerations, was found to have
the best evidence for the treatment of PTSD
in refugees and asylum seekers (Crumlish &
O’Rourke, 2010).

• Labor migrants have a 21% prevalence rate for
an anxiety disorder (including PTSD) (Lindert, von
Ehrenstein, Priebe, Mielck, & Brähler, 2009).

• Refugees have a 40% prevalence rate (Lindert
et al., 2009).

box 8.1 anxiety, obsessive-Compulsive, and trauma disorders and social diversity

The Anxiety, Obsessive-Compulsive, and Trauma and Stressor-Related Disorders 103

When the client is a child, separate interviews with parents and child are recom-
mended (Velting et al., 2004). Children frequently report fewer symptoms than their
parents and tend to be less reliable than parents in reporting details about the onset and
duration of anxiety symptoms. For standardized assessment instruments for anxiety disor-
ders, see Martin, Orsillo, and Roemer (2001) for adults, and for children and adolescents,
see Fonseca and Perrin (2001).

assessment Concerns specific to Ptsd

Although parent reporting is critical for diagnosing PTSD in children, parents often have a
tendency to minimize symptoms (Cohen, 1998; Scheeringa, Zeanah, Drell, & Larrieu, 1995).
On the other hand, when parents have experienced trauma, they may be biased toward
seeing more symptoms in their children. Of course, children whose parents have been
traumatized may experience impairments in their own adjustment to trauma (Scheeringa,
Peebles, Cook, & Zeanah, 2001). Also with children, the social worker must make a careful
distinction between attention-deficit hyperactivity disorder (ADHD) and PTSD (Perrin,
Smith, & Yule, 2000; Weinstein, Staffelbach, & Biaggo, 2000). Trauma may attenuate
already existing ADHD symptoms. Further, chronic hyperarousal and other symptoms of
trauma can look like hyperactivity and poor impulse control, and intrusive thoughts can
interfere with attention and concentration.

Other differential diagnoses to consider when assessing for PTSD in children or adults
include the following (Perrin et al., 2000):

• Acute stress disorder, which resolves within four weeks of the traumatic event.
• Adjustment disorder with anxiety, in which the number of symptoms is not suffi-

cient for PTSD.
• Psychotic disorders, in which the illusions, hallucinations, and other perceptual

disturbances are unrelated to exposure to an extreme stressor. When psychotic
symptoms accompany PTSD, however, the disorder can be characterized as severe
(Sareen, Cox, Goodwin, & Admundson, 2005).

• Bereavement, which involves the anticipated death of a loved one and is character-
ized by negative feelings and recollections of the loved one.

• Other diagnoses, such as a mood disorder or another anxiety disorder, should be
considered if the trauma did not precede the PTSD symptoms (Cohen, 1998).

Andrew mentioned that he has felt sad and lonely for a long time. He described in-
termittent suicidal ideation, but has no intention or plan of hurting himself. He said that
he does not talk to anyone about these feelings but occasionally cries and “stays under

• History of the onset, development, frequency, and
nature of the symptoms.

• Family history of anxiety.

• Any coexisting psychiatric disorders, including
substance abuse.

• A general medical history and review of a person’s
medications, including a physical examination to
search for a possible physical basis for the anxiety.
This is especially critical for older adults. If there is
a physical basis for the symptoms, the appropriate

diagnosis is anxiety disorder due to a general
medical condition. For medication-or substance-
induced anxiety, the appropriate diagnosis is
substance-induced anxiety disorder.

• The client’s response to life transitions, major life
events, and stressors.

• Social, school, and occupational history.

• An investigation of times when the anxiety symp-
toms are not present or are more manageable,
and what is different about those times.

box 8.2 areas of assessment for the anxiety, obsessive-Compulsive, and trauma disorders

Part Six: The Anxiety, Obsessive-Compulsive, and Trauma and Stressor-Related Disorders104

the covers.” He added that his friends “don’t even know the truth about why I don’t go
to school—they just think I’m being a slacker.” When asked what he does during the day
while he is not in school, Andrew said that he “does nothing except watch Argentinian soap
operas on the dish and do homework,” which a family friend brings to the home regularly.

Andrew’s inability to attend school is a great concern for both him and his mother.
Andrew wants to become an architect, so he knows it’s important to keep up with his
schoolwork. Andrew and his mother, along with the family friend, have had numerous
meetings with the school regarding this difficulty. The school has tried to make Andrew
feel comfortable by showing him around the campus after school hours and introducing
him to teachers. However, Andrew reported that he did not find this helpful. Currently, his
family is looking for the county to provide him with home tutoring until he can return to
class. Andrew maintains that his fear of school and other social situations began the previ-
ous year while he was in middle school. He denied any negative experiences at school or
with his peers and could not identify possible causes of this change. He reported that he
missed approximately two to three days per week for about seven months during eighth
grade because he was so nervous about going to school. At that time he also began to avoid
answering the door and the telephone because he worried about “saying something stupid
or wrong.” Additionally, he began to avoid social situations, such as going to the mall, going
to concerts, and taking public transportation, because he didn’t like people looking at him.
He stated that he sometimes wishes that he were invisible.

Andrew said he believed that if people looked at him it was because of something
negative, but described himself as “normal looking.” He explained that he will occasionally
go to small parties where he knows the people, but only after he asks the host to list every-
one who is expected to attend. If he does not know the people, he will not go. Even when
he knows the people, Andrew still feels “nervous” and drinks two to three beers to make
himself feel better. He reported that he drinks only in social situations and denied ever
using drugs or smoking.

Andrew’s mother believes that her son started to change following her divorce from
Andrew’s father three years ago. The mother, who speaks Spanish, explained in broken
English and through Andrew’s translation that her son became more withdrawn after his
father left the house. Andrew stated that he and his brother have infrequent contact with
his father, who currently resides out of state with a girlfriend. Andrew didn’t think his
father could be helpful or supportive with his current struggles.

Andrew expressed anger with his father for moving the family to the United States
and then “dumping us” to be with another woman. Andrew’s mother explained that the
family had moved to the United States five years ago to improve their economic situa-
tion. Currently, Andrew resides with his older brother and his mother in a rented house.
Andrew stated that his older brother works at a shop and that his mother “is in business.”
When asked to describe the type of business, Andrew turned bright red, looked down,
and answered, “She cleans houses.” Andrew mentioned that his mother is currently dat-
ing someone but could not remember his name. He said that the family was better off
financially when their father was around. He said that his father paints houses for a living
and doesn’t give his mother money now that they are divorced. The family does not have
health insurance.

Andrew’s mother indicated that she did not know a lot about her family’s mental health
history but stated that she cried a lot when she was pregnant with Andrew. She reported a
normal family medical history. She mentioned that Andrew developed normally and has
been fairly healthy except for strep throat approximately six months ago. Andrew’s goals
for therapy include going back to school and feeling like “the happy kid I used to be when I
lived in Argentina.” When asked to be more specific, Andrew said he used to enjoy drawing
and going out with friends.

The Anxiety, Obsessive-Compulsive, and Trauma and Stressor-Related Disorders 105

bioPsyChosoCial risk and
resilienCe influenCes

onset

Genetic and biological influences
A predisposition to anxiety is genetically based but modestly so, accounting for 30 to 40%
of the variance of the etiology (Hettema, Neale, & Kendler, 2001). Genetic influences may
account for the majority of variation in anxiety in young children, but as children grow
older environmental influences assume a greater role (Boomsma, van Beijsterveldt, &
Hudziak, 2005). For PTSD, having a shorter version of the serotonin transporter gene
appears to increase one’s risk for depression, as well as PTSD after exposure to extremely
stressful situations (Bryant et al., 2010); this has been demonstrated in both Caucasian and
African-American samples (Xie et al., 2009). This same gene variant increases the activa-
tion of an emotion control center in the brain known as the amygdala (Bryant et al., 2010).

Other biological processes have been associated with the occurrence of PTSD, in par-
ticular (Knapp, 2006). People with PTSD tend to have abnormal levels of some key hor-
mones that are involved in their response to stress. Their cortisol levels are lower than
normal, and their norepinephrine and epinephrine levels are higher than average. Scientists
have also found that people with PTSD experience alterations in the function of the thyroid
gland and in neurotransmitter activity involving serotonin and the opiates (Yehuda, 2006).
When people are in danger, they naturally produce high levels of opiates, which temporar-
ily mask emotional pain, but people with PTSD continue to produce those higher levels
even after the danger has passed. This may lead to the blunted emotions associated with
the condition.

Brain-imaging studies show that the hippocampus (a part of the brain critical
to emotion-laden memories) appears to be smaller in persons with PTSD (Jatzko,
Rothenhofer, & Schmitt, 2006). Changes in the hippocampus are thought to be responsible
for the intrusive memories and flashbacks that occur in people with the disorder, and sci-
entists are investigating whether this symptom is related to short-term memory problems.
The extent to which these processes are risk influences for PTSD or result from the person’s
experiencing certain types of traumatic events is unknown.

Another biological risk factor involves physical illness. Chronic illness may contribute
to the development of anxiety in adolescence (Hayward et al., 2008), as well as anxiety
being related to the onset of problematic physical health. Although most people who expe-
rience severe trauma exhibit a normal stress response, the stress response system becomes
deregulated and chronically overactive in PTSD, causing compromised immune function-
ing. PTSD has long been linked to increased risk of numerous physical health problems,
including diabetes and cardiovascular disease. The reason why PTSD is so strongly associ-
ated with physical health problems is that exposure causes epigenetic changes in immune
system genes and thus compromises immune functioning (Uddin et al., 2010).

Finally, the development of anxiety may be associated with temperamental style,
which, as discussed in chapter 2, might have a biological basis. Risk influences related to
one’s temperament involve anxiety sensitivity (the tendency to respond fearfully to anxiety

Directions Part I, Diagnosis Given the case information, prepare the following: a
diagnosis, the rationale for the diagnosis, and additional information you would have
wanted to know in order to make a more accurate and comprehensive diagnosis.

Part Six: The Anxiety, Obsessive-Compulsive, and Trauma and Stressor-Related Disorders106

symptoms), temperamental sensitivity (including a range of emotional reactions toward
negativity, such as fear, sadness, self-dissatisfaction, hostility, and worry), and behavioral
inhibition (timidity, shyness, emotional restraint, and withdrawal from unfamiliar situa-
tions) (Bosquet & Egeland, 2006; Essex, Klein, Slattery Goldsmith, & Kalin, 2010). Con-
versely, an extroverted temperament exerts a protective influence (Bosquet & Egeland,
2006).

Psychological influences
Psychological theories about the development of anxiety are dominated by the concept of
conditioning, which is the process of developing patterns of behavior through responses to
certain environmental stimuli or behavioral consequences (Kazdin, 2001). An initially neu-
tral stimulus comes to produce a conditioned response after being paired repeatedly with
a conditioned stimulus. For example, surviving a traffic accident may evoke overwhelming
anxiety when the person passes by an intersection similar to the one where the accident
occurred. Although a client’s initial symptoms may be directly caused by the trauma, ongo-
ing symptoms may result from avoiding contact with a feared situation (e.g., avoidance of
driving), which paradoxically may reinforce the occurrence of the anxiety through negative
reinforcement (Foa, Keane, & Friedman, 2000).

Along with avoidance as a poor coping method, the coping method of dissociation
after a trauma puts a person at risk for the development of PTSD (Ozer, Best, Lipsey, &
Weiss, 2003). In general, proactive problem-solving coping methods are protective against
anxiety disorders (Hino, Takeuchi, & Yamanouchi, 2002).

Certain mental disorders put a person at risk for the development of anxiety disor-
ders in adulthood. For example, a history of separation anxiety disorder could predispose
a child to later anxiety problems (Hayward, Wilson, Lagle, Killen, & Taylor, 2004). In ad-
dition, major depression often precedes an anxiety disorder, and comorbid depression fur-
ther increases the risk of the chronicity of anxiety disorders (Bruce et al., 2005). Substance
use disorders are also a risk influence for the development of problems with anxiety.

An association between intelligence (IQ) and PTSD has also been postulated. On the
protective side for intelligence, Storr, Ialongo, Anthony, and Breslau (2007) followed chil-
dren prospectively from first grade to young adulthood. Those in the lowest quartile on
reading scores were more likely to be exposed to trauma and therefore to develop PTSD. If
causal, it may be that children of lower intelligence are unable to cognitively process trauma
or do not have the coping methods to deal with the event and their symptoms (Silva &
Kessler, 2004). Alternatively, IQ could be a confounded variable, occurring with other
events, such as brain damage and maternal deprivation, which could result in both lower
IQ and a higher propensity toward PTSD (Silva & Kessler, 2004).

Finally, prior mental health problems, particularly internalizing problems, appear to
place children at risk for developing PTSD. In the Storr et al. (2007) prospective study, chil-
dren who were more anxious and depressed in first grade were more likely to suffer from
PTSD when later exposed to trauma. Preexisting anxiety was also a risk factor in another
study of trauma response (Copeland, Miller-Johnson, Keeler, & Angold, 2007).

Social influences
Two meta-analyses conducted to determine predictors for the onset of PTSD found that
social influences, involving trauma severity and lack of social support, posed the largest
risks (Brewin, Andrews, & Valentine, 2000; Ozer et al., 2003). In addition to severity, other
features of the traumatic experience linked to PTSD involve the degree of exposure to the
trauma (intensity, duration, and frequency) and the person’s subjective sense of danger
(Ford, Stockton, & Kaltman, 2006). Certain types of traumatic events may also predispose
to PTSD; these include war-related events (including refugee and immigration status),

The Anxiety, Obsessive-Compulsive, and Trauma and Stressor-Related Disorders 107

criminal victimization, and exposure to natural disasters (Mineka & Zinbarg, 2006).
Additional social stressors after the traumatic experience, such as homelessness, may lead
to PTSD (Creamer, McFarlane, & Burgess, 2005).

Family-related influences for the onset of anxiety disorders include stressful, negative,
or traumatic life events, including disruptions of relationships (Bandelow et al., 2002;
Phillips, Hammen, Brennan, Najman, & Bor, 2005). Anxious attachment patterns in chil-
dren are another family-related risk factor. Anxious attachment is characterized by an
infant’s becoming distressed and frantically seeking comfort from the attachment figure
through clinging and crying when faced with something the child fears (Hanklin, Kassel, &
Abela, 2005). Subsequent contact with the caregiver, however, does not seem to help the
child experience a sense of security or reduce the anxiety. In a study that tracked children
from infancy to adolescence, youths with an anxious attachment pattern were more likely
to suffer from an anxiety disorder as teenagers than those who were securely attached or
showed avoidant attachment (Warren, Huston, Egeland, & Sroufe, 1997). The means by
which insecure attachment history exerts its influence on adolescent anxiety appeared
to be related to the negative internalized representations of the relationship in childhood
( Bosquet & Egeland, 2006).

A number of other interpersonal patterns are seen in families of children with anxiety
disorders, particularly parental overcontrol (McLeod, Weisz, & Wood, 2007), but also over-
protection and criticism (Donovan & Spence, 2000). As well as having a genetic risk, chil-
dren of anxious parents may be more likely to observe anxiety in their parents and to have
fearful behavior reinforced by their parents (Bandelow et al., 2002; Hagopian & Ollendick,
1997). Despite the number of possible family factors involved, family factors explain only a
modest amount (4%) of the variance in anxiety (McLeod et al., 2007).

Finally, socioeconomic status (SES) and its link to anxiety for youths aged 10 to 15
years was studied in a systematic review that revealed a negative association (Lemstra
et al., 2008). That is, the lower the SES, the higher the rate of anxiety.

Course and recovery

The specific anxiety disorders have different prognoses, but most moderate to severe cases
are not likely to remit spontaneously. Indeed, the anxiety disorders tend to be chronic, with
low rates of full recovery and high probabilities of recurrence (Bruce et al., 2005). For ex-
ample, the mean duration of social anxiety is 15.1 years (Grant, Hasin, Blanco, et al., 2005).
When OCD in youths was followed up nine years later, it had continued in 41% of cases
(Micali et al., 2010).

Anxiety disorders also increase the risk of suicidality. Having one anxiety disorder in-
creases the odds of suicidal ideation by 7.96 times and the rate of attempts by 5.85 times
(Boden, Fergusson, & Horwood, 2007). Risk unfortunately increases with the number of
anxiety disorders present. The authors of this longitudinal study suggest that addressing
anxiety disorders is an important part of suicide prevention.

As for risk and protective influences for recovery, genetic factors may play a role in re-
sponse to treatment. In a recent study, people with PTSD who carried the short allele of the
serotonin transporter gene promoter responded less well to cognitive-behavioral treatment
than other individuals with PTSD (Bryant et al., 2010).

At the psychological level, the presence of residual symptoms has been identified
as placing a person at risk for relapse or the development of another anxiety disorder
(Connolly & Bernstein, 2007). This information should be shared with clients to motivate
them to continue treatment until no symptoms remain. Increased severity of the anxiety
disorder (Micali et al., 2010) and comorbidity are also implicated with poor outcome
(Connolly & Bernstein, 2007).

Part Six: The Anxiety, Obsessive-Compulsive, and Trauma and Stressor-Related Disorders108

As for social influences, family factors are associated with recovery. Parental anxiety
is a risk factor for the child’s recovery from an anxiety disorder. If a parent is anxiety free,
the child may have more positive outcomes from treatment (Kendall, Hudson, Gosch,
Flannery-Schroeder, & Suveg, 2008). For OCD, family dysfunction and accommodation
to the disorder were predictors of poor outcome to CBT (Ginsburg, Kingery, Drake, &
Grados, 2008; Keeley, Storch, Merlo, & Geffken, 2008).

Intervention is discussed in the next section, but it may be said here that seeking help
from the general health system is associated with less effective care (Wang, Lane, et al.,
2005). Another group of researchers found that lack of appropriate care for anxiety was
associated with being male, African American, uneducated, younger than 30, or older than
59 (Young, Klap, Sherbourne, & Wells, 2001).

intervention

Psychosocial interventions

People with anxiety disorders tend to delay seeking treatment, sometimes for up to 23 years
after onset (Wang, Berglund, et al., 2005), and they tend to seek help from the health system
rather than the mental health system (Young et al., 2001). Perhaps as a result, only about one-
fourth of clients received appropriate medication, and few (8.5%) received referrals for inter-
vention that fit the empirically validated treatment models described here (Stein et al., 2004).

CBT
The evidence-based approach to treating anxiety disorders is cognitive-behavioral treat-
ment (CBT) featuring exposure, for both children (James, Solar, & Weatherall, 2005) and
adults (Hoffman & Smits, 2008) (see Box 8.3). Brief (i.e., 12-session) protocols have been
described with individual, group, and family (for children) formats equally effective (James
et al., 2005). Therapist competence in delivering cognitive therapy may be important for
recovery (Strunk, Brotman, DeRubeis, & Hollon, 2010), especially with child anxiety treat-
ment (Connolly & Bernstein, 2007).

For PTSD, interventions with a direct focus on the trauma are most effective (Bisson &
Andrew, 2005). Imaginal exposure, a process in which clients confront their memories of
the traumatic event, is often used for treating PTSD (Johnson & Lubin, 2006). For example,
an initial exposure exercise might consist of the client’s writing a detailed account of the
trauma and reading it in a therapy session and also at home.

Children who suffer from PTSD are encouraged through desensitization procedures
to describe the traumatic event and its aftermath in a manner that diminishes arousal and
distressing emotions (Cohen, 2005). Stress management techniques—for example, progres-
sive muscle relaxation, thought stopping, positive imagery, and deep breathing—should be
taught to the child prior to detailed discussions of the trauma. The social worker should be
aware that intervention for children with PTSD involves direct exploration of the trauma.
Although nondirective play therapy is a popular treatment approach (Cohen, Mannarino, &
Rogal, 2001), it has not stood up well to CBT in studies (Cohen & Mannarino, 1996).

Directions Part II, Strengths-Based Assessment Formulate a risk and protective
influences assessment, both for the onset of the disorder and the course of the disor-
der, including the strengths that you see for this individual. What techniques could
you use to elicit additional strengths in this client?

The Anxiety, Obsessive-Compulsive, and Trauma and Stressor-Related Disorders 109

Combat-related PTSD appears to fare least well in treatment. This may be due to the greater
severity of pathology of veterans who seek treatment at Veterans Administration hospitals, their
tendency to limit disclosure upon returning home (which limits opportunities for both expo-
sure and social support), and the potential for secondary gain (disability-based income may
depend on remaining symptomatic) (Bradley, Greene, Russ, Dutra, & Westen, 2005).

Eye movement desensitization and reprocessing
Eye movement desensitization and reprocessing (EMDR) may be as effective as CBT (Bisson &
Andrew, 2007; Davidson & Parker, 2001). Shapiro (1995) has outlined the method and created
a training program for clinicians. Some consider EMDR a form of exposure treatment, because
clients are asked to keep a traumatic memory in their minds as the clinician elicits the eye
movements. However, a meta-analysis found no evidence that the eye movements were neces-
sary (Davidson & Parker, 2001). Further, there were no significant differences between studies
in which the clinicians had participated in approved training and those in which they had not.

Self-help manuals
Some general practitioners encourage client use of self-help treatment manuals (Jorm &
Griffiths, 2006). One review of self-help manuals administered in general practitioner set-
tings was conducted, and the approach proved promising; the more time a facilitator spent
on guidance in the use of materials, the more helpful the intervention (van Boeijen et al.,
2005). Social workers should be aware that self-help manuals might be a useful interven-
tion for those who are motivated or do not have other resources.

Crisis debriefing
Social workers and other mental health professionals often utilize crisis debriefing to fore-
stall the development of PTSD when people have undergone trauma. This involves meet-
ing with people individually but most often in groups, educating them about the nature
of trauma and its reactions, and encouraging their exploration of feelings. Unfortunately
there is no empirical evidence as of yet that crisis debriefing is helpful for either children
or adults, and it may cause additional distress (Rose, Bisson, Churchill, & Wessely, 2002;
Wethington et al., 2008).

Psychoeducation: providing information about the
nature of anxiety and how it can be controlled.

Monitoring symptoms: their frequency, duration, and
triggers.

Cognitive restructuring: identifying, challenging,
and replacing maladaptive belief systems that
contribute to anxiety.

Breathing retraining: to distract clients from symp-
toms and provide a sense of control over them.

Progressive muscle relaxation: to reduce tension in
anxiety-provoking situations by alternately tighten-
ing and relaxing certain muscle groups.

Problem solving: for generating a variety of practical
solutions to life challenges, and exposure.

Exposure: a process in which the client learns to face
the feared object until the anxiety dissipates. Typi-
cally conducted in a graduated fashion, the prac-
titioner helps the client construct a hierarchy of
situations from least to most feared and then work
through these in order, conquering smaller fears
before going on to bigger ones. There are several
variants of exposure: symbolic (through the use of
pictures or props), simulated (through role play-
ing), imaginal (the client imagines the feared situ-
ation), and in vivo, the preferred method (contact
with the real situation/stimulus).

Sources: Gorman et al., 2002; Velting, Setzer, & Albano, 2004.

box 8.3 Components of Cbt for anxiety, obsessive-Compulsive, and trauma disorders

Part Six: The Anxiety, Obsessive-Compulsive, and Trauma and Stressor-Related Disorders110

medication

The advantages of medications include their ready availability and the fact that less effort
is required of the client (Gorman et al., 2002). Of course, side effects are a potential disad-
vantage of medication. For many years the benzodiazepines were the first-line treatment
for anxiety, but they are no longer the drugs of choice because of the risk of physical addic-
tion with continuous use (DeVane, Chiao, Franklin, & Kru, 2005). Benzodiazepines may be
used preferentially in situations where rapid symptom control is critical (e.g., the client is
about to quit school or lose a job) (Gorman et al., 2002).

The past 10 years have seen an increased use of medications initially developed as an-
tidepressants to treat anxiety disorders. In a meta-analysis of 43 studies, the selective sero-
tonin reuptake inhibitors (SSRIs) and tricyclics (TCAs) were found to be equally effective
in reducing symptoms of panic, agoraphobic avoidance, depression, and general anxiety
(Bakker, van Balkom, & Spinhoven, 2002). The number of dropouts, however, was signifi-
cantly lower in the clients treated with SSRIs (18 versus 31%), which suggests that these are
tolerated better with regard to adverse effects. The side effects of TCAs include dry mouth,
constipation, and blurred vision. With PTSD in adults, several controlled trials have shown
that SSRIs produce positive effects (Stein, Zungu-Dirwayi, Van der Linden, & Seedat, 2003).

If a medication has been used effectively, a trial of discontinuation may be attempted
after 12 to 18 months. Many clients (between 30 and 45%) partially or fully relapse when
medication is discontinued (Gorman et al., 2002). Clients who show no improvement within
six to eight weeks with a particular medication should be reevaluated with regard to the need
for either a different medication or a combined drug and psychosocial treatment approach.

Because of the physical and psychological dangers of prescribing any psychotropic
drugs for children and adolescents, psychosocial interventions should always be used
in conjunction with medication, with the exception of obsessive-compulsive disorder
(Bernstein & Shaw, 1997). There is a dearth of studies evaluating the effectiveness of
psychotropic medications for treating PTSD in children, although physicians prescribe a
variety of medications for the disorder (Cohen, 2005).

Few clinical trials have documented the effectiveness of standard medications or
psychosocial treatments for older adults (Gorman et al., 2002), although the available
evidence suggests the value of pharmacological treatment (Wetherell, Lenze, & Stanley,
2005). If medication is used, the required dose is generally lower than that for younger
persons, and any increases should be more gradual than with younger adults.

CritiCal PersPeCtive

Some have argued that the expanded classification of disorders in the DSM over the years
has furthered the purposes of pharmaceutical companies (Angell, 2004). The current
edition of the DSM has, as noted, expanded the (former) anxiety disorders into three
major categories (or chapters). As more constellations of behaviors are considered mental
disorders, they become reimbursable and treatable through medication. As one example,
Kutchins and Kirk (1997) discuss social phobia as an example of what could be considered a

Directions Part III, Goal Setting and Treatment Planning Given your risk and
protective factors assessments of the individual, your knowledge of the disorder, and
evidence-based practice guidelines, formulate goals and a possible treatment plan for
this individual.

The Anxiety, Obsessive-Compulsive, and Trauma and Stressor-Related Disorders 111

normal behavior (shyness) but is construed as a mental disorder. The National Comorbidity
Survey Replication indicates that 12.1% of the U.S. population suffers from social phobia in
their lifetime (Kessler, Berglund, et al., 2005), and it is the second highest disorder reported
in the last 12 months (Kessler, Chiu, Demler, & Walters, 2005). Paxil, one of the SSRI drugs,
is now marketed specifically for the treatment of social phobia, even though its actions are
no different from other antidepressants of its class.

Several other critiques pertain to PTSD specifically. PTSD is one of the DSM disor-
ders that is conceptualized in terms of problematic functioning in the person–environment
system because a traumatic event has occurred (Bradshaw & Thomlison, 1996). However,
PTSD is not a unique outcome of trauma; depression is as common a response as other
anxiety disorders, substance use disorders, and eating disorders (Romano, 2004). In addi-
tion, in a majority of cases PTSD is accompanied by another disorder. Symptom overlap
among diagnostic categories helps explain the high likelihood of lifetime comorbid disor-
ders seen in PTSD. These facts indicate that diagnostic clarity is lacking for the disorder.
In addition, the validity of PTSD in children can be questioned, although DSM-5 features
new criteria that are specific to children. Still, the diagnostic criteria permit a great deal of
latitude in determining whether a particular stressor is “extreme” (Perrin, Smith, & Yule,
2000), and whether a liberal or strict threshold is used to define “persistent” symptoms
(McHugo, Mooney, Racusin, Ford, & Fleischer, 2000).

Directions Part IV, Critical Perspective Formulate a critique of the diagnosis as it
relates to this case example. Questions to consider include the following: Does this
diagnosis represent a valid mental disorder from the social work perspective? Is this
diagnosis significantly different from other possible diagnoses? Your critique should
be based on the values of the social work profession (which are incongruent in some
ways with the medical model) and the validity of the specific diagnostic criteria ap-
plied to this case.

CASE 2 After the Hurricane

Tracy Lo is a 30-year-old married Asian American woman with two young children. Her parents
were born in China but moved to the United States before Tracy was born. She was raised
largely with Chinese cultural traditions but married a Caucasian man when she was 22 years old.
She was very happy, although her parents were disappointed that she married a “Westerner.”
Tracy’s family situation is stable and her parents, to whom she remained close, have lived nearby
since she got married. Tracy and her family lived in apartments until two years ago, when they
were finally able to afford their first house in the suburban neighborhood of their large city.
Tracy works part-time at a nearby bank, and her husband is a chemist at a plant that develops
petroleum products. Their two children are in primary school.

One September the remnants of a hurricane passed through her city. This storm had been
predicted as dangerous, and Tracy and her husband took every reasonable precaution to prepare
for it. However, a large tree from their backyard was blown over into the house and cut a large
hole in the roof. The damage would take several months to repair, and many other homes in the
area were also damaged.

Tracy and her family were forced to move temporarily into her parents’ three-bedroom
apartment. The extended family did its best to accommodate the situation, but space was
cramped. It was the first time the extended family had lived together, and the situation was one
that understandably resulted in a lack of privacy, frequent shortages of food and clean clothes,

Part Six: The Anxiety, Obsessive-Compulsive, and Trauma and Stressor-Related Disorders112

and some disagreements about parenting responsibilities. Tracy left her children in the care
of her parents, who tended to be stricter than Tracy and her husband had been. Her parents
complained that Tracy’s husband was not providing the children with strong traditional values.

From the time of the storm, Tracy began to feel increasingly stressed with regard to the
tasks of working, caring for her husband, mediating household conflicts, raising her children, and
managing the home repair process. She became anxious (experiencing heart palpitations and
feelings of unease in her abdomen), began to be irritable with her children, and showed some
signs of depression (inability to sleep and concentrate on her work, feelings of overwhelming
sadness). Tracy had not experienced symptoms of this type in the past, and in fact she had always
functioned effectively and assertively. Her new feelings of helplessness were unfamiliar, and they
frightened her. At the suggestion of a coworker, Tracy came to the emergency services unit of a
nearby mental health center to ask for help, so that she would not “lose her mind.” She did not
tell her husband or children about this visit, because she did not want to appear “weak” in their
eyes. Her parents in particular would not have approved of her going outside the family for help.

Please go to the Additional Case Workbook for directions to this case.

CASE 3 In the Hospital

Jay is an 18-year-old African-American male who has been treated since birth for hemoglobin SS,
a form of sickle cell disease. Over the course of Jay’s life, he has been hospitalized multiple
times with pain crises and acute chest syndrome, both common ailments of those with sickle
cell disease. Jay presents upon this hospital admission this time with both of those conditions.
The attending hematologist consulted the social work intern after Jay threatened to commit
suicide if the doctor entered the room. Upon arrival, Jay allowed this social work intern into the
room, where he continued to appear distressed, revealing that he felt as though he was “having
trouble breathing.”

Jay lives with his mother and 10-year-old half brother in a poor, urban area. His biological
father was murdered when he was four. His mother was recently diagnosed with breast cancer.
She is currently single and employed as an administrative assistant at a federal government
agency. Jay is enrolled in the 11th grade at a charter school for those who excel in the arts. He
is actively involved in the dance team and expresses a desire to become either a professional
dancer or a fashion designer after graduation. His recurrent hospitalizations have forced him to
repeat one grade and are currently affecting his ability to finish coursework to graduate on time.
His health insurance is covered through Medicaid, which provides him with a case manager who
is actively involved in coordinating all of his services.

When asked by the social work intern if he was having thoughts of suicide, Jay denied
actually wanting to act upon his thoughts, but knew that it would “get the doctor out of the
room.” Jay reports that over the past eight months he has been having episodes where he feels
like he is “out of control” and these affect his breathing, heart rate, and cause him to have
diarrhea. He reports that he “does not like” the doctor on service who entered the room when
he was actively having an episode and that he “said the first thing that [he] thought would
make him leave.” He says that he feels like he is going to go crazy if he cannot get himself
“under control.” He reports he has these episodes up to two times a week and is always on edge
because of fear of having another one.

Jay reports that over the past eight months he has started consuming a larger amount of
opioids to control his pain and anxiety. He says he wants a different doctor to see him, because
the current physician will not increase the amount of medicine he needs to get his pain under

The Anxiety, Obsessive-Compulsive, and Trauma and Stressor-Related Disorders 113

control and stop the anxiety. In a family meeting, his mother stated that she has recently started
keeping his pain medication in a lock box to keep Jay from consuming more than he should.
Despite her best efforts, she reports that he sometimes finds a way to break into the lock box
and obtain the pain medication.

During this admission, Jay told the social work intern that he is bisexual and has been in
a relationship with a male student at his school for the past several months. He reports that he
wants to reveal his sexuality to his mother, but fears she will have a negative reaction. He also
reports that he has anxiety over his mother’s recent cancer diagnosis and has been cutting his
arms with a kitchen knife when his emotions become “too strong.” The intern did not observe
any visible signs of the reported cutting.

Jay reports a strong relationship with his maternal grandmother who provides some
financial support to his family. He attends church weekly and often has the hospital chaplain
come to pray with him during admissions. He reports having a strong social support network at
school and says that he has a good relationship with his dance coach, who is trying to help him
get into a training program after graduation. Several of his classmates have visited him during
this admission, which he reports cheers him up.

He states that he is not currently sexually active with his boyfriend and is aware of safe
sexual practices. He reports that recently, he has started smoking marijuana occasionally with
his boyfriend and other friends at school, although he denies regular usage. He says he has
a good relationship with his mother, but blames her for his sickle cell disease because it is a
genetic disorder, and he inherited it from her side of the family. His mother reports that he often
becomes very angry and yells at her when he does not get his way, saying that she is responsible
for giving him anything that he wants because she gave him “this disease.” She dismisses Jay’s
current symptoms of anxiety and says that he was a nervous child who has always been sick.

Jay admits being comfortable with the social work intern, but often says he does not want
to become too close because “you will leave me just like everyone else ever has.” Jay believes
that he is not responsible for most of his problems and associates much of his distress with his
lifelong medical condition. He believes that his recent episodes of extreme anxiety are related
to worrying too much about his mother’s cancer diagnosis and the possibility of revealing his
sexuality to his mother.

Jay believes if he is able to come out to his mother, much of his anxiety will be relieved
and some of his symptoms will subside. He knows that his fear of “going crazy” is sometimes
irrational, but he feels like he loses all control when the symptoms begin, which causes
him to spiral further out of control. He says he is open to receiving treatment, but prefers
pharmacological agents to control the symptoms because these have helped calm him down in
the past. His mother is also committed to being actively involved in improving Jay’s condition
and hopes that treatment will improve his overall mental status.

Please go to the Additional Case Workbook for directions to this case.

references

114

Eating Disorders

Nikki, an 18-year-old Caucasian female, came to the university counseling center at the behest
of her dormitory floor’s residential adviser, who was concerned about Nikki’s weight loss. Nikki
admitted that she was “not happy” about coming to the center, but she liked the residential
adviser and didn’t want to “alienate” her. When she came to her initial session, Nikki appeared
visibly emaciated and was wearing a long, oversized sweater and baggy sweatpants. At the
beginning of the interview, she was guarded and answered questions with only a few words. But
when she realized that the social worker “was not going to tell me I needed to gain weight like
everyone else,” she began to open up, although she spoke in a flat, matter-of-fact tone, even
about painful subjects.

Nikki said she had begun to lose weight the summer of her senior year of high school,
though her concerns about her weight had begun at age 13. Before that time she had been a
“skinny kid,” and that’s how she wanted to stay. She admitted that she didn’t want to grow up
and thought that staying thin was a way to achieve this. She said she admired little girls’ bodies
(even girls as young as three and four) and thought they looked great.

During that summer, Nikki said that she was bored because there were no jobs for high
school students in the midsized city where she lived. Losing weight gave her “something to do.”
Every day, she ate only two meals and jumped rope for 30 minutes. If she didn’t exercise daily,
she felt “fat” and “disgusted” with herself. Nikki said that before the summer, she didn’t have
the discipline to cut back on her food intake. At the same time, she said she had exercised and
weighed herself almost every day since she was 14 years old. At five feet, four inches, she has
never weighed more than 105 pounds.

Nikki admitted with embarrassment that she lost control of her eating on occasion, usually
with sweet food (ice cream, brownies, cake) but more recently with peanut butter; she could
eat an entire jar at one sitting. She said that this happened “maybe once a month” and that she
would atone for it by eating even less afterward. She denied using any methods of purging.

When asked how she was feeling during the summer after she finished high school, other
than “bored” at the prospect of leaving for college, she seemed surprised by the question and
answered, “How did I feel? I didn’t feel anything.”

Since entering college three and a half months ago, Nikki has eaten only two meals a day,
subsisting on salad, yogurt, popcorn, and Diet Coke, and has lost an additional 10 pounds (she
now weighs 85 pounds). She said that she doesn’t feel hungry and that the weight loss has been
easy. She has also stopped exercising.

Nikki admitted she hadn’t menstruated in seven months and was losing her hair. She didn’t
mind the lack of menstruation because she had always hated her period, a clear marker that
she was a woman. Her hair loss bothered her, however, and she showered only every other
day because too much hair fell out when she washed it. She said that occasionally she felt her
heart rate “slow down and then speed up.” On one hand, this scared her; on the other hand,

C h a p t e r 9

Eating Disorders 115

she would sometimes think, “Maybe I’ll just die of a heart attack, and all this will be over.”
Despite these physical concerns, she had not been to a doctor.

Nikki said that in one sense she knew she was too thin and wore baggy clothes to disguise
the fact, but she still felt “fat inside,” recognizing that no amount of weight loss would help
her feel different. Yet she didn’t know anymore what normal eating was and became panicky
when people pressured her about gaining weight. She denied having anorexia to anyone
who pushed her about it, saying that she had read the criteria and she hadn’t lost 15% of her
body weight; therefore, she couldn’t have it. If she ever got fat, she said, she would be totally
worthless.

F
eeding and eating disorders are characterized by disturbances in a person’s eating
behaviors and usually perceptions of body weight and shape (American Psychiatric
Association, 2013). Pathological fears of becoming overweight lead those with eating

disorders to enact extreme, potentially damaging behaviors to lose weight and keep it off.
Anorexia nervosa (AN) and bulimia nervosa (BN), two primary eating disorders, are the
focus of this chapter, although a new DSM diagnosis, binge eating disorder, characterized
by chronic, episodic overeating, is the most often diagnosed eating disorder (Eddy, Doyle,
Hoste, Herzog, & Le Grange, 2008). (It was included in DSM-IV among the eating disorders
not otherwise specified.)

PrevalenCe and Comorbidity

In the National Comorbidity Survey Replication, bulimia nervosa (termed “bulimia” from
this point) was found among 1.5% of the U.S. female population and 0.5% of the male popu-
lation (Hudson, Hiripi, Pope, & Kessler, 2006). The lifetime prevalence of bulimia is 1% of
the population. The prevalence of anorexia nervosa (termed “anorexia” from this point) is
0.9% of females and 0.3% of men. The lifetime prevalence is 0.6% of the U.S. population.
Bulimia in particular has increased during the second half of the 20th century (Hudson
et al., 2006).

Most people with eating disorders, especially those with bulimia, have another psy-
chiatric disorder. Indeed, three or more diagnoses are the most common comorbidity
pattern among both anorexic (33.8%) and bulimic (64.4%) clients (Hudson et al., 2006).
The most common comorbid diagnoses are (in order of occurrence) anxiety and
obsessive-compulsive disorders; disruptive, impulse control, and conduct disorders
(oppositional defiant disorder, conduct disorder, attention-deficit hyperactivity disorder,
intermittent explosive disorder); and substance use disorders (Franko et al., 2005; Hudson
et al., 2006). Depression is also common, but may be a consequence of malnutrition
among those with anorexia (Godart et al., 2007). Personality disorders are often present
with eating disorders, with perhaps as many as 58% of eating disorder cases (Cassin & von
Ranson, 2005). People with bulimia typically suffer from borderline personality disor-
der, whereas the avoidant and obsessive-compulsive personality disorders are associated
with anorexia.

General health complications, as well as mental health problems, also occur among
those with eating disorders (Rome & Ammerman, 2003). Specific to bulimia are enlarged
salivary glands, the erosion of dental enamel, and electrolyte imbalances, which in turn
increase the likelihood of cardiac arrhythmia and renal failure. Anorexia is associated with
starvation and malnutrition, amenorrhea, metabolic abnormalities, electrolyte imbalances,
irregular heart rate, low body temperature, low blood pressure, heart failure, anemia, and
the growth of hair over the body.

Part Seven: Feeding and Eating Disorders116

assessment

People with eating disorders tend to be underdiagnosed and undertreated. This is especially
true for minority (Mexican-American and African-American) women (Cachelin &
Striegel-Moore, 2006; Fairburn, Agras, Walsh, Wilson, & Stice, 2004; Goeree, Ham, & Iorio,
2011). Screening for the possibility of an eating disorder should routinely be done during
the medical assessment of teenage girls and in situations where individuals, particularly
adolescent females, have already been diagnosed with another disorder (Lewinsohn,
Streigel-Moore, & Seeley, 2000), as both health (Johnston, Fornae, Cabrini, & Kendrick,
2007) and mental health professionals (Hudson et al., 2006) often overlook eating
disorders. Assessment guidelines are delineated in Box 9.1.

Nikki readily admitted to “feeling depressed” since she started high school. She said
she sometimes wished she wasn’t alive but wouldn’t kill herself because of what it would do
to her mother. She said she still felt depressed most days and that everything tended to look
dark, “like the color is sucked out of everything. The dorm, all the old buildings around
campus, everything looks dreary and grey.”

She studied constantly, even though she found it sheer drudgery, because she wanted
to get all A’s and felt guilty when she didn’t study. If she didn’t get all A’s she would be worth-
less. Despite all her studying, Nikki had no career plans and was undecided about a major.
Therefore, all this studying “lacked meaning.” She said she couldn’t see a future for herself
and didn’t want to be married or have children.

Nikki also didn’t have any other activities that she enjoyed, except for meeting boys.
She was surprised that boys seemed attracted to her because she didn’t think she looked

The assessment of a suspected eating disorder optimally involves the following components
(Mizes & Palermo, 1997):

1. Clinical interview.

2. Medical evaluation that, in addition to a routine
checkup, assesses for problems due to weight
loss and amenorrhea, tests for electrolyte imbal-
ance, and refers individuals with bulimia to a
dentist for the examination of problems due to
enamel erosion.

3. Questionnaire measures of eating disorders,
body image, and related problems (see
Corcoran & Walsh, 2006).

4. Assessment of concurrent psychiatric disorders.

5. Risk and resilience assessment.

6. Emphasis on times when an individual feels bet-
ter about herself/her body, and times when eat-
ing disorder symptoms have not been present or
are lessened.

7. Motivation to overcome the disorder.

Goals (Yager et al., 2002):

1. Restore healthy weight.

2. Reduce or eliminate binge-eating and purging
behaviors.

3. Provide education on nutrition and healthy eating
and exercise patterns.

4. Treat physical complications.

5. Correct core maladaptive thoughts, attitudes,
and feelings related to the eating disorder.

6. Treat comorbid disorders.

7. Build coping skills and problem-solving abilities.

8. Address themes that may underlie eating disorder
behaviors (developmental conflicts, identity forma-
tion, body-image concerns, self-esteem, sexual
and aggressive difficulties, mood regulation, gen-
der role expectations, and family dysfunction).

9. Enlist family support and provide family therapy
where appropriate.

10. Improve interpersonal and social functioning.

11. Prevent relapse.

box 9.1 assessment of eating disorders

Eating Disorders 117

sexually appealing at her current weight. She was asked out on a lot of dates and accepted
these invitations, but didn’t feel serious about anyone.

Nikki said her concentration was good, although she incessantly thought about food
and not eating. She never went to sleep before 2:00 a.m., because that was when her dorm
hall finally quieted down. She would wake up naturally at 7:00 a.m. She denied feeling
tired, although she slept only five hours a night.

When asked about other symptoms of depression before the present time, Nikki
said she had had chronic insomnia since becoming a teenager. She had difficulty fall-
ing asleep some nights and often woke up at 5:00 a.m. She said that beginning in her
teenage years her appetite increased, and one of her few pleasures was food and eating.
That was why she had become concerned about her weight; she wanted to eat so much
because it made her feel better. Another thing that had made her feel better about her-
self in high school was male attention. When a boy she liked didn’t return the feeling or
something went wrong in a relationship, she felt suicidal, although she never acted on
those feelings. Nikki couldn’t remember a time since she was 14 when these symptoms
had lifted for more than a few days. She said she had never been referred for treatment,
and because she followed the rules and got good grades, no one really noticed anything
unusual about her.

One of Nikki’s roommates in the dorm was a friend, Alice, whom she had known in
high school. Her other roommate, Megan, was a “total partier,” who drank a 12-pack when
she went out drinking and hung around a coke dealer, “So that must mean she’s doing coke,
right?” According to Nikki, Megan had some kind of eating disorder. She was thin and
would eat only salad and drink alcohol. Nikki said it was hard having Megan as a roommate
because she stayed up all night and would come in and go out of the room at all hours, dis-
rupting Nikki’s sleep. She didn’t clean up after herself and constantly left the door unlocked,
even though both Nikki and Alice had talked to her numerous times about this.

Nikki said that her parents didn’t seem to love or even like each other, and that her
mother was always afraid of her father leaving and not providing for them. He would
retreat into distant silence if she challenged him, sometimes for days, until she begged
forgiveness. When he was mad at her mother, he would take his anger out on the whole
family and speak to no one. He typically worked 12-hour days and also went to work on
Saturdays.

Nikki’s mother, who was slightly overweight and was always talking about how fat
and ugly she was, didn’t work outside the home. Nikki said she thought her mother was
depressed, although her mother never said so. Nikki said, “I could just feel it in the at-
mosphere at home.” Nikki said she knew her mother loved her, but she was “insane” and
“paranoid.” When asked what this meant, she said her mother thought people, such as
their neighbors, were “out to get her” and wouldn’t answer the phone or the door. She also
“would get lost in her own world, and even if we jumped up and down and shouted her
name, we couldn’t get her attention.”

Ever since Nikki was a child, her mother would sometimes tell Nikki she was the “best
girl in the world,” but at other times she would say that Nikki was “bad,” “cold-blooded,”
“a user of people,” and “selfish,” and was critical of Nikki’s schoolwork, even though Nikki
received all A’s. Nikki feared that her mother was right about her. When asked, Nikki said
her mother displayed this pattern toward other people as well. She would “feel deeply about
other people’s pain,” but if they did something wrong in her mother’s eyes, she would “write
them off completely.” She had cut herself off from her own family of origin as a young adult
and had not had contact with them for 20 years.

Nikki had two sisters, both still in high school. The older one was a junior, and she
and Nikki were close, but her other sister, a sophomore, was “spoiled” and “impossible for
anyone to get along with.” Nikki said that due to her father’s corporate job, the family had

Part Seven: Feeding and Eating Disorders118

moved around a lot so that he could “move up the ladder.” The last move was in the middle
of her junior year of high school.

Nikki said she had been brought up going to (Episcopalian) church every Sunday and
still went to church by herself now that she was in college. She didn’t get much out of going
to services but did so because she was “supposed to.” She reported that her parents had
never considered that she go to counseling because “they didn’t believe in it and thought
that people should solve their own problems.” She said her mother would also say “only
your family can help, not anyone on the outside.”

Nikki said she hadn’t made any new friends since starting college. She had moved
around so much that she didn’t feel like making the effort, and no one interested her.
Despite this attitude, she went to all the dorm parties on the weekends because “it was
something to do.” She sometimes drank alcohol and felt the effects easily because of her low
weight. She said she had started drinking during her junior year in high school, at times
to the point of blacking out. She denied any drug use. Several of her paternal relatives (an
uncle and a great-uncle) were known to the family as alcoholics.

bioPsyChosoCial risk and resilienCe
influenCes

onset

For the purposes of examining the risk and protective mechanisms for the onset of eat-
ing disorders, anorexia and bulimia will be considered together, as they share overlapping
risk factors, symptoms, and causes (White, 2000). However, influences on each disorder’s
course will be explored separately, as sufficient evidence has been gathered on each one.
Box 9.2 further describes the eating disorders in various socially diverse populations.

Directions Part I, Diagnosis Given the case information and your responses to
the following questions, prepare the following: a diagnosis and a rationale, as well
as additional information you would have wanted to know in order to make a more
accurate diagnosis.

females

• Although eating disorders are more prevalent in
females, about 25% of cases are represented by
males (Hudson et al., 2006).

Gay and lesbian

• Homosexual males may be at risk for eating disor-
ders (Muise, Stein, & Arbess, 2003).

ethnic minorities

• In Western countries, Asians have a similar risk to
Caucasians, if not higher (Wildes & Emery, 2001).

• Although Caucasian women in Western countries
do not have higher rates of diagnosable eating
disorders than do non-Caucasian women, they do
have higher rates of body dissatisfaction and eat-
ing disturbance (Wildes & Emery, 2001).

• Lack of existing research on eating disorders
as they pertain to Hispanic, Native-American,
East-Indian, and eastern European women
(O’Neill, 2003).

• Mexican-American and African-American women
are underdiagnosed and undertreated (Cachelin &
Striegel-Moore, 2006; Fairburn et al., 2004; Goeree,
Ham, & Iorio, 2011; Keel & Brown, 2010).

box 9.2 eating disorders and social diversity

Eating Disorders 119

Biology
Biological influences on eating disorders include heritability, obstetrical complications,
early puberty, early eating patterns, obesity, and dieting. Anorexia is moderately heritable
(Bulik et al., 2006), and more so than bulimia (Fonagy, Target, Cottrell, Phillips, & Kurtz,
2002), although family members of individuals with eating disorders have an increased
vulnerability for both disorders (Bulik et al., 2006).

Preterm birth and pregnancy complications are associated with eating disorders.
A study conducted in Italy found that certain obstetrical complications, such as maternal
anemia, diabetes, and preeclampsia (a hypertensive disorder), were associated with the
development of anorexia, whereas others, such as placental infarction, early eating dif-
ficulties, and low birth weight for gestational age, were associated with bulimia (Favaro,
Tenconi, & Santonastaso, 2006). The total number of obstetrical complications was pre-
dictive of the development of anorexia. The authors concluded that neurodevelopmental
impairments could be associated with the etiology of eating disorders.

Adolescence is clearly a developmental stage that makes females vulnerable to eating
disorders. The mean age of onset is 18.9 years for anorexia and 19.7 for bulimia (Hudson et al.,
2006). Anorexia tends to have an earlier age of onset than bulimia (Lewinsohn et al., 2000). The
tension between the cultural ideal of female beauty and the physical reality of the female body
after puberty is magnified by female gender role expectations. That is, female identity is defined
in relational terms, and beauty is a core aspect of female identity (Striegel-Moore, 1993).

Early onset of puberty (prior to age 11) confers particular risk for the development
of eating disorders; conversely, later-onset menarche (age 14 and over) is protective.
Interestingly, one review indicated that earlier maturation is related to increased life stress
in childhood (DeRose, Wright, & Brooks-Gunn, 2006), although the mechanisms by
which this happens are not well understood. Early-maturing females tend to be shorter
and heavier; therefore, their body type strays further from the current body ideal (Mizes
& Palmero, 1997; Striegel-Moore, 1993). In fact, a lean body build presents protection from
eating disorders because this body type matches the contemporary standard. People often
tease early-maturing girls for their development; they may also be exposed to experiences
for which they are not psychologically prepared, such as dating and sexual pressure.

Certain food patterns, some with early onset, present risks for eating disorders. For
instance, picky eating in childhood is a risk influence for thin body preoccupation and pos-
sibly anorexia (Agras, Bryson, Lawrence, Hammer, & Kraemer, 2007). Childhood obesity
poses a risk for bulimia (Stice, 2002), perhaps because of its damaging effect on body image
(Striegel-Moore & Cachelin, 1999). Dieting is also a risk (Lowe & Timko, 2004). “Unrealis-
tically rigid standards of dietary restraint coupled with a sense of deprivation may leave
dieters vulnerable to loss of control after perceived or actual transgression of their diet.
A lapse leads to an ‘all-or-nothing’ cognitive reaction. . . . Dieting can also be associated
with different conditioning processes that may predispose a person to binge eating. For
example, it may increase the appeal of ‘forbidden’ or ‘binge’ foods (typically those high in
fat and sugar)” (Lowe, 2002, pp. 96–97). At the same time, dieting by itself will not cause an
eating disorder, as dieting is fairly normative among adolescent and adult women. Among
dieters, more disturbed eating habits and attitudes are associated with the development of
eating disorders (Fairburn, Cooper, Doll, & Davies, 2005).

Psychology
Body dissatisfaction and distortion, negative affect, perfectionism, impulsivity, and sub-
stance use are risk factors for eating disorders (Stice, 2002). As discussed in the section
Prevalence and Comorbidity, having a mental disorder puts one at risk for the develop-
ment of an eating disorder. Protective factors in the psychological domain include high
self-esteem, a strong sense of identity, well-developed social and coping skills, and a posi-
tive temperament (Striegel-Moore & Cachelin, 1999).

Part Seven: Feeding and Eating Disorders120

Social influences
Family influences on eating disorders have been noted, but whether the link is due to ge-
netic mechanisms, childhood experiences, family concerns about weight, family psycho-
pathology, or transaction patterns is unknown (Cooper, 1995; Wilson, Heffernan, & Black,
1996). In addition, specific patterns have not been delineated, but families in which eating
disorders develop tend to be dysfunctional in various ways (Mizes & Palermo, 1997). A
small significant relationship exists between sexual abuse, which often occurs within the
context of the family, and eating disorders (Smolak & Murnen, 2002). On the protective
side, families that foster parent-child attachment and have effective discipline skills, healthy
cohesion, and positive communication help buffer their children against eating disorders
(Striegel-Moore & Cachelin, 1999).

Another family process involves the extent to which parents transmit societal values
having to do with weight and appearance (Striegel-Moore & Cachelin, 1999). When parents
focus excessively on their own or their children’s shape and size, children may feel pressure
to lose weight (Kotler, Cohen, Davies, Pine, & Walsh, 2001; Mizes & Palermo, 1997). Teasing
by family members about a child’s weight is particularly detrimental.

Of note, families tend to experience a high level of burden in terms of feeling depressed
and anxious when a child in the family has an eating disorder (Zabala, Macdonald, &
Treasure, 2009). Parents also experience a high degree of expressed emotion, especially when
their daughters have been ill for a long time. The Academy for Eating Disorders has recently
issued a position paper on families, taking the stance that families should not receive blame
for their children’s eating disorders (Le Grange, Lock, Loeb, & Nicholls, 2010). The rationale
stems from the difficulty of specifying family mechanisms through which eating disorders
develop, and it also avoids alienating families from treatment and invites their collaboration.

Aside from family influences, other social mechanisms include social support, extra-
curricular activities, certain societal values, and socioeconomic status (Striegel-Moore &
Cachelin, 1999). A poor social support system may evolve from social isolation, social
anxiety, and public self-consciousness and increased risk of eating disorders. Conversely,
protective mechanisms include social skills, social connections, and social support
(Stice, 2002). A recent five-year longitudinal study showed that teens are influenced by
their friends’ extreme weight control behaviors (Eisenberg & Nuemark-Sztainer, 2010).
Adolescents (both male and female) showed more extreme control behaviors themselves at
five-year follow-up if their friends performed such behaviors in adolescence.

Involvement in certain extracurricular activities that emphasize very low body fat,
such as certain sports and dance, places an individual at risk for eating disorders (Striegel-
Moore & Cachelin, 1999). Activities that emphasize health and fitness protect against the
development of eating disorders, as well as activities that presumably involve other aspects
of the individual aside from appearance and weight.

Societal overemphasis on thinness for females has resulted in widespread dissatisfac-
tion among females concerning their body image (Mizes & Palmero, 1997). Exposure to im-
ages in the media of extremely thin women is associated with this dissatisfaction (Groesz,
Levine, & Murnen, 2002). Finally, products involving weight and appearance targeted at
females are big business, creating strong incentives for corporations to boost markets for
products that address females’ supposed flaws.

Unlike many other mental disorders, high socioeconomic status (SES) does not confer
protection against the development of eating disorders (Striegel-Moore & Cachelin, 1999).
Females of middle and upper SES may indeed be more vulnerable due to increased demands
in terms of social compliance and perfectionism. However, Goeree et al. (2009) recently ex-
amined data from the National Heart Lung Blood Institute’s Growth and Health survey and
found that, contrary to expectations, African Americans and girls from low-income homes
had higher rates of bulimic behavior than did Caucasians and mid- to upper-income girls.

Eating Disorders 121

The authors’ contention is that the widespread belief that mid- to upper-income Caucasian girls
suffer from higher rates of eating disorders is because they are more likely to come to the atten-
tion of treatment providers. In contrast, low-income girls have not been identified and treated.

Course and recovery

Studies that follow clients over time reveal wide variations in the course of eating disor-
ders. Less positive outcomes typically pertain to anorexia compared to bulimia (Keel &
Brown, 2010). Eating disorder symptoms, whether low level (fasting, dieting, using weight
loss drink or powder, skipping meals, smoking more cigarettes) or high level (diet pill
usage, vomiting, laxative use), are associated with suicidal behavior in adolescents (Crow,
Eisenberg, Story, & Neumark-Sztainer, 2008) and physical and mental health problems in
adulthood (see Wilson, Grilo, & Vitousek, 2007, for a review). A U.K. study of almost 2,000
people who had been admitted to an eating disorder treatment facility found that those
with anorexia had a 10-fold increased risk of early death. Very low body mass index and
alcohol misuse emerged as predictors of mortality (Button, Chadalavada, & Palmer, 2010).

Risk and Resilience Factors Influencing the Course of AN

Sources: Bell, 2003; Berkman, Lohr, & Bulik, 2007; Gowers & Bryant-Waugh, 2004; Keel, Dorer, Franko, Jackson, &
Herzog, 2005; Yager et al., 2002.

Risk Protective

Features of the disorder

Initially lower minimum weight Shorter duration of illness before treatment

Eating disorder severity

Long duration of eating disorder

Developmental stage

Adults Adolescent (with younger adolescents having
better outcome than older adolescents)

Psychological

Greater body-image disturbance

Comorbid psychological disorders, such as anxiety disorders,
obsessive-compulsive disorder, depression, and substance
abuse

Resistance and denial

Sexual problems

Impulsivity

Social

Disturbed family relationships before onset of the disorder Support and empathic relationships, whether
professional or nonprofessional

Impaired social functioning

Treatment factors

Failure to respond to previous treatment

Table
9.1

Part Seven: Feeding and Eating Disorders122

Risk and Resilience Factors Influencing the Course of Bulimia Nervosa

Suicide is the major cause of death for people with anorexia (Berkman, Lohr, & Bulik,
2007), and suicide rates for those with anorexia are greater than in the normal population
(Pompili, Mancinelli, Girardi, Ruberto, & Tatarelli, 2004). Suicide attempts are also com-
mon among those with bulimia (25 to 35%) (Franko & Keel, 2006).

Another finding is that the “crossover” rate between anorexia and bulimia is high.
Among persons with an initial diagnosis of restricting-type anorexia, 36% developed buli-
mia, whereas 27% of those with an initial diagnosis of bulimia developed anorexia (Tozzi
et al., 2005). A typical such pattern for anorexia is for people to start out with the restricting
type (Peat, Mitchell, Hoek, & Wonderlich, 2009). Because a high level of restriction from
food is difficult to maintain, they may then experience a loss of control and binge, and thus
present as having the binge-purge subtype. From there, many people go on to gain weight
and meet diagnostic criteria for bulimia.

Following the onset of an eating disorder, a similar combination of risk and protective
mechanisms is thought to maintain the condition, determine whether a person recovers, or
predict responses to particular interventions (Gowers & Bryant-Waugh, 2004). Tables 9.1
and 9.2 provide the risk and resilience factors influencing the course of anorexia and
bulimia, respectively.

Risk Protective

Features of the disorder

High baseline frequencies of bingeing and vomiting Milder symptoms

Preoccupation and ritualization of eating Shorter duration of illness

Long duration of symptoms

Psychological

Substance use disorder

Depression

Personality disorder

Impulsivity

Greater body-image disturbance

Lower motivation for change

High initial perfectionism

Social

Interpersonal problems Support and empathic relationships, whether profes-
sional or nonprofessional

Treatment factors

Short abstinence period Early change in purging frequency

Only reduction in bulimic behaviors at end of
treatment

Complete abstinence at end of treatment

Sources: Bell, 2003; Berkman, Lohr, & Bulik, 2007; Fonagy, Target, Cottrell, Phillips, & Kurtz, 2002; Gowers & Bryant-Waugh,
2004; Hartmann, Zeeck, & Barrett, 2009; Keel, Dorer, Franko, Jackson, & Herzog, 2005; Keel & Mitchell, 1997; Wilson et al.,
1999; Yager et al., 2002.

Table
9.2

Eating Disorders 123

intervention

The intervention research for eating disorders has suffered from certain limitations. Evi-
dence for how to treat anorexia, in particular, has not been strong. Further, studies usually
do not focus on adolescents, which is unfortunate for a condition that commonly arises in
adolescence (Gowers & Bryan-Waugh, 2004). The goals of intervention with clients who
have eating disorders should focus, of course, on aspects of their weight and eating behav-
iors. However, interventions that attend to weight alone are associated with client dissatis-
faction (Bell, 2003), and dietary advice as the only intervention seems particularly onerous
to women (Hay, Bacaltchuk, Claudino, Ben-Tovim, & Yong, 2003).

treatment settings

Although outcome studies of inpatient treatment of bulimia are lacking, in the vast majority
of cases (95%) outpatient treatment is sufficient (Fonagy et al., 2002). Inpatient treatment
usually involves multidisciplinary services comprising psychiatry, psychology, nursing,
dietetics, occupational therapy, physical therapy, social services, and general medical ser-
vices (Foreyt, Poston, Winebarger, & McGavin, 1998). Inpatient treatment for anorexia is
indicated with the following risk factors (Foreyt et al., 1998; Golden et al., 2003): (1) seri-
ous physical complications (malnutrition, dehydration, electrolyte disturbances, cardiac
dysrhythmia, arrested growth); (2) extremely low body weight; (3) suicide risk; (4) lack of
response to outpatient treatment; (5) lack of available outpatient treatment; (6) comorbid
disorders that interfere with outpatient treatment (i.e., severe depression, OCD); and (7) a
need to be separated from the current living situation.

Hospital stays have shortened in recent years due to changes imposed by managed care.
Shorter stays make it harder for the client to achieve optimal weight, as weight should be re-
stored at a rate of only one to three pounds per week. If the client is released before reaching
optimal weight,1 he or she may be unable to maintain the weight, which might necessitate re-
hospitalization (Mizes & Palmero, 1997). In addition, individuals benefit from having some
control over the process and pace of intervention (Bell, 2003). Those who are resistant to
weight gain may need to gain weight more slowly and have a period of weight maintenance,
thus requiring a longer hospital stay (Willer, Thuras, & Crow, 2005). Still, due to patterns
of insurance reimbursement, the outpatient care of anorexia will increasingly be the norm.

Psychosocial interventions

For bulimia, two major psychosocial interventions, both delivered in a brief format (e.g.,
16 sessions) have received empirical validation: cognitive-behavioral therapy (CBT) and
interpersonal therapy (IPT). A review of psychotherapy studies showed that about 40% of
those who complete treatment recover (this percentage is reduced to 32.6 when including
dropouts from treatment) (Thompson-Brenner, Glass, & Westen, 2003).

Directions Part II, Biopsychosocial Risk and Protective Factors Assess-
ment Formulate a risk and protective factors assessment, both for the onset of the
disorder and the course of the disorder, including the strengths that you see for this
individual.

1Ninety percent of normal weight, so that menstruation can resume.

Part Seven: Feeding and Eating Disorders124

CBT includes a “package” of strategies, among them self-monitoring, social skills
training, assertiveness training, problem solving, and cognitive restructuring. A review of
studies found that about one-half of women with bulimia recover with a course of CBT
(Hay & Bacaltchuk, 2003), which generally achieves a superior effect to medication
(Whittal, Agras, & Gould, 1999).

Individual therapy seems more effective than group modalities (Thompson-Brenner
et al., 2003). In addition, a self-help format is a promising approach (Hay & Bacaltchuk,
2003). These intervention procedures have been clearly outlined in treatment manuals
(Fonagy et al., 2002). (See Fairburn, Marcus, & Wilson, 1993, for an example of a treat-
ment manual.) Despite these advantages, many experienced clinicians do not find CBT as
useful as described by researchers (Yager et al., 2002). This disparity may be due to lack
of training, discomfort with the methods, or differences between clients seen in the com-
munity and those who participate as research subjects. In randomized controlled trials (the
gold standard of intervention research), individuals with substance use disorders, bipolar
disorder, or suicidality are screened out from research (Thompson-Brenner et al., 2003).
Therefore, the results of such trials may not generalize to clients who are seen in clinical
settings for bulimia.

Individual IPT is another empirically validated approach for bulimia (Fairburn et al.,
1991, 1995), which has been adapted from the treatment of depression (see chapter 7). CBT
and IPT compare favorably with each other, although IPT may take longer to achieve its
desired outcomes.

Unfortunately, these empirically validated interventions have not typically been tested
with adolescents. It seems that developmentally appropriate modifications, including a de-
gree of parental involvement and addressing age-related motivational issues, would be nec-
essary (Gowers & Bryant-Waugh, 2004).

A great deal of ambivalence about staying thin and getting better is typically present
with eating disorders, and motivational interviewing may be necessary to engage people in
treatment and to restore healthy eating patterns. Motivational interviewing, which origi-
nated in response to substance use disorders (see chapter 11), has been adapted for eating
disorders (Killick & Allen, 1997; Tantillo, Bitter, & Adams, 2001; Treasure & Ward, 1997).
Preliminary evidence suggests that motivational interviewing compares favorably with
CBT for reducing bulimic symptoms (Treasure et al., 1999).

Empirical support for psychosocial treatment of anorexia is lacking. Long-term psy-
chodynamic therapy is most often used for the outpatient treatment of anorexia, although
results have not typically been examined empirically (Mizes & Palermo, 1997). A Cochrane
Collaboration systematic review of outpatient psychotherapies for anorexia found only
seven studies, with little evidence to support any particular intervention (Hay, Bacaltchuk, &
Stefano, 2004).

As discussed, certain risk influences involve the family. Although there is consensus
among practitioners that family involvement should be part of the treatment plan, at least
for younger adolescents with anorexia (Crisp et al., 1991; Robin, Siegel, & Moye, 1995; Robin
et al., 1999), methodologically strong studies have been few. More recently, a systematic
review of randomized, controlled trials of family therapy for anorexia was conducted
(Fisher, Hetrick, & Rushford, 2010). Based on 13 studies, there was some evidence that
family therapy may be more effective than treatment as usual but not other psychothera-
pies for remission from anorexia, where there were no differences found in relapse rates,
symptom scores, weight measures, or the number of dropouts (Fisher et al., 2010).

Despite these findings, much attention in the literature has centered on the Maudsley
model, a family intervention that has been used mainly with adolescents. Influenced by
Minuchin’s family systems therapy (Minuchin, Rosman, & Baker, 1978), the Maudsley
model was developed by Dare and Eisler at London’s Maudsley Hospital in the 1980s with

Eating Disorders 125

the main aim of getting the parents to unite to stand up to an externalized illness and re-
feed their adolescent until a healthy weight is resumed (Lock, Le Grange, Agras, & Dare,
2001). Family treatment may include therapeutic techniques from traditional family ther-
apy or other schools of psychotherapy and in this way depart from family systems therapy.

medication

Although psychotropic medications should not stand as the primary treatment of eating
disorders (Bacaltchuk, Hay, & Trefiglio, 2001; Gowers & Bryant-Waugh, 2004; Nakash-
Eisikovitz, Dierberger, & Westen, 2002), selective serotonin reuptake inhibitors (SSRIs),
particularly fluoxetine (Prozac), have been used to treat bulimia. Bacaltchuk and Hay
(2003) examined antidepressants compared to placebo in 19 trials and found that the likeli-
hood of short-term remission from binge episodes was increased with the use of antide-
pressants (70% reduction of binges) compared to placebo (50% reduction).

Bacaltchuk et al. (2001) focused on medication compared to psychotherapy and medi-
cation in combination with psychotherapy. When medication was compared to psycho-
therapy, remission rates from eating disorder symptoms were higher for psychotherapy,
and dropout rates were much higher for medication. However, there were no statistically
significant differences between mean binge frequency and depression between people tak-
ing antidepressants and attending psychotherapy. Results of their studies lead the authors
to conclude that combining medication and psychotherapy produces few consistent gains
over psychotherapy alone when considering other outcomes, including depression and
binge frequency.

Of note is that medication does not seem to have much impact on anorexia (Claudino
et al., 2006; Gowers & Bryant-Waugh, 2004). When medications are used, it is usually be-
cause of comorbid depression or anxiety. People being treated for eating disorders, espe-
cially those with anorexia, report psychological interventions as being more helpful than
medication (Bell, 2003).

CritiCal PersPeCtive

A major critique of the diagnosis of eating disorders that is central to the social work per-
spective is that it focuses on the internal deficits of those with the diagnoses, rather than
emphasizing social and cultural attitudes (Pratt & Woolfenden, 2003). Both anorexia and
bulimia have increased throughout recent decades due to cultural standards of thinness
(Keel & Klump. 2003). One of the challenges faced by those involved in prevention efforts
is the difficulty of changing the dieting and weight preoccupations that are so culturally
pervasive (Mizes & Palmero, 1997).

For bulimia, one problem with the criteria is the term excessive exercise for inappropri-
ate compensating behavior. Excessive implies a large amount of time dedicated to exercise, yet
it is not the quantity of physical activity that is salient, but its compulsive quality ( Adkins &
Keel, 2005). It has been suggested that the word compulsive be substituted for excessive.
Another way to define the criterion as excessive is to ask the client if the postponement

Directions Part III, Goal Setting and Treatment Planning Given your risk and
protective factors assessments of the individual, your knowledge of the disorder, and
evidence-based practice guidelines, formulate goals and a possible treatment plan for
this individual.

Part Seven: Feeding and Eating Disorders126

of exercise results in intense guilt or if it is undertaken solely to influence weight or shape
(Mond, Hay, Rodgers, & Owen, 2006).

Other critiques concerning the diagnosis for bulimia involve the duration of binges, the
amount of food consumed during binges, and the frequency criterion for bulimia. Although
the criterion requires that the binge eating happen “in a discrete period of time,” no evidence
indicates that discrete binges offer any more clinical utility than episodes that occur over
an extended period of time (Franko, Wonderlich, Little, & Herzog, 2004). The binge is re-
quired to be “an amount that is definitely larger than what most people would eat.” However,
many women report subjective binge episodes and then feel compelled to purge but perhaps
would not meet the criterion because their binges are not sufficiently large (Franko et al.,
2004). Better indicators of a binge episode might be the level of mood disturbance involved
or the sense of loss of control (Herzog & Delinsky, 2001, as cited in Franko et al., 2004).
Finally, the current DSM requires that the bingeing and purging episodes occur only once
per week for a three-month period, while the previous edition required a frequency of twice
per week. Such behavior may involve a clinically significant problem (Franko et al., 2004;
Wilson & Sysko, 2009) but is also harder to distinguish from nonproblematic bingeing.

A final critique involves the subtyping of anorexia (whether binge eating and purging
or restricting) and bulimia (purging or nonpurging). Questions have been generated as
to the utility and validity of these subtypes (Franko et al., 2004; Peat, Mitchell, Hoek, &
Wonderlich, 2009; van Hoeken, Veling, Sinke, Mitchell, & Hoek, 2009). For example,
anorexia binge eating-purging type may be more like bulimia than restricting anorexia,
which may represent a discrete type of eating disorder. Additionally, the bulimia subtypes
may not involve a true distinction.

A final critique has been presented by Goeree et al. (2009), economists who created
mathematical models of bulimic behaviors from a national survey. They determined that
bulimic behavior could be conceptualized as an addiction because the best predictor of
a continued eating disorder was current status with an eating disorder. Although eating
disorder researchers have discounted an addiction hypothesis (Wilson, 1999), Goeree and
colleagues argue that an addiction model would help increase insurance coverage for the
treatment of eating disorders, which are not as frequently or as generously covered as the
substance use disorders.

CAse 2: Off to the Races

Kelly is a 28-year-old married white female whose chief complaint is, “I can’t stop eating.” She
loves foods rich in carbohydrates, such as sugar and flour, and claims that once she starts eating
refined foods, she cannot stop (i.e., she loses the ability to control the size of her food portions).
Her belief is that once she takes a bite of something that is sugary, “the bite takes me and I’m
off to the races.” She admits to eating when she is not hungry and reports that she eats quickly,
“stuffing it into my face.”

Directions Part IV, Critical Perspective Formulate a critique of the diagnosis as it
relates to this case example. Questions to consider include the following: Does this
diagnosis represent a valid mental disorder from the social work perspective? Is this
diagnosis significantly different from other possible diagnoses? Your critique should
be based on the values of the social work profession (which are incongruent in some
ways with the medical model) and the validity of the specific diagnostic criteria ap-
plied to this case.

Eating Disorders 127

Kelly has struggled with food since she was nine years old. Kelly was always “overweight
as a child”; she is presently 5 feet 6 inches tall and weighs 200 pounds. She constantly obsesses
about food, planning each day what she will eat and where she will obtain food. Often (at least
four days a week) she will buy large quantities of ice cream and cake from the store, binge, and
then sleep. When she wakes up, she feels depressed, guilty, and full of self-loathing. She often
has crying jags because she feels so bad. When questioned, she denied any regular purging, but
said that she resorted to laxatives “about once every two weeks.”

In the past Kelly has attempted to lose weight. For example, when she was 10 years old
she joined a recreational track team and was moderately successful in losing weight. However,
although her weight began to normalize according to body mass index figures, Kelly would still
binge on certain foods, such as pizza, pasta, and desserts. This pattern of behavior continued
later during cross-country and cheerleading seasons. She recalls that despite the binge episodes,
she would maintain a normal weight and sometimes would even weigh less than what was
considered healthy for her height and frame, although she never met the criteria for anorexia.
During off-seasons, when she was not participating in sports activities, however, her binge
eating would result in significant weight gains.

Since her teenage years, Kelly has made multiple attempts to deal with her eating disorder.
These include a “healthy” diet devised by a nutritionist; behavioral modifications designed to
moderate and control her intake of carbohydrate-rich foods; psychodynamic psychotherapy
to explore the causes that led to her binge eating; and CBT to examine her faulty thinking
concerning food, body shape, and size. In her mid-20s she also admitted herself to a residential
program that specialized in women and empowerment, and attended Overeaters Anonymous
(OA), a 12-step support group for compulsive eaters.

There is a strong history of addiction-related disorders in Kelly’s family, including alcoholism
on the paternal side, and eating disorders, primarily binge eating, on the maternal side. Kelly’s
mother is a first-generation Italian immigrant who believes that food can be an “emotional
comfort.” Further, Kelly’s mother suffered from bulimia herself; she exercised for weight
compensation, even running marathons. An uncle also sexually abused Kelly’s mother when she
was a child.

Kelly has two sisters and three brothers, all of whom are obese. She is close to her sisters
and less close to her brothers. All of the brothers exhibit alcoholism to varying degrees, as
does her father. Additionally, some of the males in the extended paternal side of the family are
described as “gutter” alcoholics.

Kelly’s parents had an antagonistic relationship with each other during Kelly’s formative
years, in which Kelly’s father physically and sexually abused Kelly’s mother; Kelly witnessed this
abuse. Kelly’s father works for the post office, while Kelly’s mother is a school bus driver, placing
the family as lower middle class. They are Catholic and attend mass regularly.

Upon graduating from high school, Kelly attended college, but after the first year, she
switched to a community college in order to live at home. She told her family about her eating
disorder and was able to derive some emotional support from her sisters and mother. She also
attended OA meetings with her mother. Because she had to move to another state to attend
graduate school, Kelly was lonely and would use both food and men to fill her emotional void.
She also stopped going to OA.

As a result of meeting a man through a personal ad, she married within the year. She
admitted that she didn’t know him well because they had lived in different areas and had not
spent much time together. After the wedding, Kelly discovered that her husband was controlling
and verbally abusive. He ordered her around, wanted her to cater to his needs, and called her
“fat” and “lazy with no willpower.” Although Kelly admits that her husband “pushed and shoved
her around” physically, when asked about physical abuse, Kelly became silent and repeatedly
avoided talking about the subject.

Part Seven: Feeding and Eating Disorders128

Kelly recently learned that she was six weeks pregnant. In an attempt to abort the baby in
utero, she repeatedly punched herself in the stomach (this was not successful) and used ipecac
(an over-the-counter emetic often used by bulimic individuals) to purge after binge eating. She
also felt suicidal. One day, she wrote a suicide note; placed the note beside her on the car seat in
the garage, which was closed; and started the engine in an attempt to commit suicide through
carbon monoxide poisoning. However, she then called one of her sisters, who was able to talk
her out of the attempt.

Kelly is adamant about wanting a divorce but is concerned about her financial status.
Although she has successfully completed graduate school, she has been unable to find a job.
She admits that she feels too disgusted with herself even to try. “Who’s going to want me when
I look like this?” She feels incredibly ashamed of her appearance and her unsuccessful marriage.

Kelly made no friends at graduate school, and the phone contact she maintains with
her family members is inadequate to meet her needs for social and emotional support. Kelly
presents as a tearful, poorly groomed individual (her hair is not brushed, and she attended initial
therapy sessions in baggy pants and an inside-out sweatshirt), with suicidal ideation because of
her binge eating and deteriorating marital situation.

Please go to the Additional Case Workbook for directions to this case.

CAse 3: The Perfectionist

Tina, a 14-year-old biracial Asian American girl, was brought to outpatient therapy after her
discharge from a two-week stay in an inpatient eating disorders unit. Six months previously, she
had begun to restrict sweets and fats and drastically increased her exercise regimen (running
an hour a day on average). In total, Tina lost 15 pounds from her unusually small 4-feet,
11-inch frame, bringing her weight down to 82 pounds. She had stopped menstruating for
three months and had a low heart rate before her hospitalization, during which she was placed
on a feeding tube and treated with an SSRI. During her hospital stay she gained 10 pounds.

Other symptoms that had developed prior to and after her hospitalization were a
preoccupation with her hygiene and morning routine; she took an average of 90 minutes
each morning to get ready, constantly redoing her hair and makeup. She denied that this
preoccupation was due to a defect in her appearance; she just wanted to look “perfect.” She
didn’t view these behaviors as excessive and said that all the girls at school spent a lot of time
getting ready if they wanted to look good.

Additionally, if she didn’t get straight A’s, she felt like a failure, became angry with herself,
and withdrew into her room. She regularly stayed up until 2:00 a.m. doing her schoolwork until
it was “perfect” or memorizing for exams until she could recite the material back word for word.
She admitted that she told no one at school how much time she spent studying (six to seven
hours a night) and acknowledged that by anyone’s standards but her own and her father’s, it
was excessive.

Tina was still extremely preoccupied with her weight and shape after her hospitalization,
as evidenced by her continuing restricted eating, exercising, and constant self-criticism. She
often said to her mother, “I hate how I look. Do I look fat to you? Would you tell me if I did?”
Her mother did not know how to respond to this “barrage of questions,” and Tina remained
unconvinced by her attempts at reassurance. Tina denied bingeing or purging, and her mother
confirmed this report.

The above behaviors and ideas were not bothersome to Tina; in fact she didn’t understand
why her parents and psychiatrist were making such a fuss over them, as she had always been
this way. “My father is a perfectionist, too,” she said. Her parents were stymied by her behaviors

Eating Disorders 129

and especially angered by her monopolization of the bathroom in the morning. Yelling at her,
punishing her, reprimanding her—all came to naught. Tina was “stuck” in her behaviors despite
her stated desire to change them. She worried constantly that she was fat and had a great deal
of difficulty accepting the recommendation of continued weight gain.

Tina is the younger of two children and reports being close to her brother, three years her
senior. Her parents are of mixed ethnicity; her father is a second-generation Korean and her
mother is American. Both parents are intelligent and accomplished; her father is an academic
scientist and her mother a pianist who limits herself to teaching students privately, having given
up her career when the children were born. Tina’s relatives lived across the United States, and
she typically saw them only once a year. She said she doesn’t feel particularly close to anyone in
her extended family. Tina has never drunk alcohol or used drugs, and her parents report being
social drinkers, which they define as an occasional glass of wine.

Tina’s father is obsessed with being thin and in shape and gives her mixed messages about
food. He wants her to eat, but is not unhappy that she eliminated “fatty, junk food” and is
critical of “the American diet.” His wife is of healthy weight, although she gained weight after
having children. The household environment is conflicted, angry, and tense due to their marital
problems, mostly about parenting differences. Tina’s father is often critical of her mother for
being too “permissive” with the children and for letting herself go. He feels that children are
raised too loosely in the United States, whereas Tina’s mother feels that he is too hard on them,
often putting them down and calling them “lazy failures,” among other pejorative terms. She
also reported feeling very controlled by her husband’s criticisms and demands. “Nothing I do
is right.” She reported having thoughts about leaving him many times, and he, too, often feels
hopeless and resigned to a disappointing marriage. Tina’s mother has a history of depression,
which has been treated with medication in the past; her father has refused to consider the
possibility of any emotional difficulties in himself.

In the initial session Tina spoke flatly, showing little expression and eye contact as she
talked about what she had been through for the last six months. She gave minimal answers
to questions and displayed little response to empathic statements made by the therapist. She
said that art was an outlet for her and showed some energy when the therapist suggested
she draw a picture in the session to indicate how she felt. When she talked about her drawing, she
described feeling “trapped” and “frightened.” When questioned further about these feelings,
she said that she hated her family and felt no future for herself. Despite this statement, she said
she had never felt suicidal or depressed. She also denied having been sexually abused.

Tina described having only one friend, a second-generation Korean girl her age, and said
she wasn’t interested in having a boyfriend. She said, “What’s the point of a relationship? Look
at my parents and how their marriage turned out.” Tina liked participating in track and cross-
country at school for the exercise it provided; she said that she liked long-distance running,
although she never placed in races. She admitted that this made her feel like a “failure.”

Please go to the Additional Case Workbook for directions to this case.

references

130

Oppositional Defiant Disorder and
Conduct Disorder

Josie is a 19-year-old Romanian female currently placed at a specialized school for children
with developmental disabilities and emotional and behavioral problems. She has attended the
program for the past year. Her teacher reports that she often disrupts class, becomes verbally
aggressive, has attacked other students, and has difficulty transitioning from one activity to the
next. The trigger for these behaviors is typically frustration due to her inability to complete
or understand school assignments. She will make disparaging comments about herself (“I’m
stupid”) before erupting in anger.

Oppositional defiant disorder (ODD) and conduct disorder (CD), both categorized
as disruptive, impulse control, and conduct disorders, are discussed together in this chapter
because they both feature anger, defiance, rebellion, lying, and school problems (Loeber, Burke,
Lagey, Winters, & Zera, 2000). The major distinction between them is that youths with CD
also violate societal norms through aggression, theft or deceit, and/or destruction of property
(American Psychiatric Association [APA], 2013). A client can be diagnosed with both disorders
but clinicians usually select only one based on the preponderance of symptoms.

Prevalence and comorbidity

ODD is more common than CD, with a lifetime prevalence of 10.2% of the U.S. population
(Nock, Kazdin, Hiripi, & Kessler, 2006). The median age of onset of CD is 11.6 years. For pre-
schoolers, estimates for the rates of ODD range between 4 and 16.8%, and for CD between 0
and 4.6% (Egger & Angold, 2006). Males have a higher rate of CD than females (12 versus 7.1%)
(APA, 2013). CD increases the risk of many other mental, emotional, and behavioral disorders,
such as substance use and mood disorders (Nock et al., 2006). Attention-deficit hyperactivity
disorder (ADHD) is common in children with ODD and CD.

assessment of odd and cd

Social workers should always engage in a multifaceted approach to ODD and CD, using
many informants—the child, parents, and school personnel—to obtain reports, and dif-
ferent methods—interview, rating scales, and observations of the child—to formulate their
assessments (Alvarez & Ollendick, 2003; Fonagy & Kurtz, 2002; McMahon & Frick, 2005).
The Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria require behavior

c h a p t e r 1 0

Oppositional Defiant Disorder and Conduct Disorder 131

problems in more than one setting. Children also tend to downplay their own symptoms
(Loeber, Green, Lahey, Frick, & McBurnett, 2002). Symptom reports from parents and
teachers are preferable, although even these sources have their biases. Teachers are more
accurate than mothers at identifying a child’s ADHD symptoms, whereas parents are more
aware of their children’s oppositional behavior. For different assessment tools for conduct
problems, see McMahon and Frick (2005). Box 10.1 includes additional guidelines for mak-
ing DSM diagnoses.

Josie was born in Romania and placed in an orphanage at the age of six weeks, until an
American couple finally adopted her at the age of eight. Her half sister (one year younger)
was also adopted. Three years ago, Josie took the Wechsler Intelligence Scale for Children
and was shown to have a verbal IQ of 57, a performance IQ of 65, and an overall IQ of 57.
Severe deficits in expressive and receptive language were noted.

Results of the Vineland Adaptive Behavior Scales—Interview Edition indicated that
her overall functioning fell into the low, mild-deficit range—a level comparable to that of
an eight-year-old. Her communication skills fell at the 10.2 age equivalent, her daily living
skills were at a nine-year-old equivalent, and her socialization skills were at 7.11 age equiva-
lent. According to the Ekwall/Shanker Reading Inventory, she was reading at a first-grade
level. Overall, results of individually administered, standardized testing in math, reading,
and written expression placed her in the first percentile for her age, significantly lower than
was expected for her IQ.

During the time of testing, Josie was attending a specialized school for students with
learning disabilities, where she did well for a while but then began exhibiting aggressive
and threatening behaviors toward students and staff. She was then referred to another spe-
cialized school that offered self-contained classrooms and a more restrictive program with
a clinical team. Her behavior improved at this placement until her grandmother died two
years ago, at which time the school also moved to a different building. School reports in-
dicate that she was absent 23 days that year. In the file, school personnel remark on Josie’s
poor self-esteem, poor coping skills, difficulty transitioning to new environments and

• Transient oppositional behavior is common in chil-
dren and adolescents.

• Consider a less severe diagnosis, such as adjust-
ment disorder with disturbance of conduct (when
there is a recent stressful life event) or the V-code
“child or adolescent antisocial behavior.”

• Oppositional behaviors should be distinguished
from disruptive behaviors associated with ADHD,
which occur in response to frustrations associated
with inattention and hyperactivity.

• A diagnosis of ODD or CD should not be made
when the symptomatic behavior is protective for
a child (e.g., one living in an impoverished, high-
crime community).

• Symptoms should not occur only in the context of
a mood disturbance or symptoms of psychosis.

• Consider whether the oppositional and angry be-
haviors are part of a symptom pattern indicative of
PTSD; irritability and outbursts of anger are listed
as symptoms under the hyperarousal criterion for
PTSD.

• It is permissible to diagnose ODD and CD together.

• CD should be diagnosed in adults older than 18
only if the criteria for antisocial personality disor-
der are not met.

• See suggested modifications to the DSM criteria
for ODD and CD for preschoolers from the Re-
search Diagnostic Criteria-Preschool Age (Task
Force on Research Diagnostic Criteria: Infancy
and Preschool, 2003) http://www.ncbi.nlm.nih
.gov/pubmed/14627886.

Sources: APA, 2013; Carlson, Tamm, & Gaub, 1997.

box 10.1 Guidelines for assessing odd and cd

Part Eight: Disruptive, Impulse Control, and Conduct Disorders132

dealing with new people and experiences, tendency to be easily distracted, disruptiveness
in class, defiance toward staff, and attention-seeking behaviors. A year and a half ago, Josie
carried a pocketknife that was subsequently confiscated. She said she didn’t intend to use
it but only wanted to show it to her friends. From that point she had to be searched daily.

After that placement, Josie was transferred to her current school, where she continues
to display disruptive and angry behaviors, to the point of attacking other students on occa-
sion. The teacher completed an ADHD rating scale, but neither the score on this test nor
the teacher’s remarks indicated that Josie had the disorder. However, her reactions when
frustrated do tend to have an impulsive and explosive quality.

During the last semester Josie was absent 25 days, with six of those due to school sus-
pension. At that time she had been in detention 66 times for a total of 38 hours for various
reasons, including being out of location, throwing objects, disruption, and physical aggres-
sion toward staff. In addition to the pocketknife incident, Josie brought matches to the
school on two occasions. She again mentioned that she had no intention of hurting anyone;
she just wanted to show off. Staff have often had to restrain her while transporting her to
locked support. In the hallways, she yells profanities, tears down bulletin boards, pushes
other students, and runs away from staff.

In the school environment, Josie is said to have positive relationships with one of the
assistant teachers and a counselor. One teacher described Josie as helpful in the classroom
and showing pride in her accomplishments. Josie has a small group of friends and is par-
ticularly close to one other female student in the classroom. They spend a lot of time talk-
ing with each other, sometimes disrupting class with their chatter.

Her adoptive mother says that her relationship with Josie is good (which Josie con-
firms) and that Josie is able to confide in her. According to her mother, Josie also gets along
well with her sister. However, her mother reports that Josie has become verbally threaten-
ing and abusive to her, although not physically. She says that Josie’s temper rises when Josie
faces tasks or chores she doesn’t want to do. Josie’s mother says that she finds herself giving
in to Josie “more than I should” because she just wants to end the conflict.

The family lives in a middle socioeconomic neighborhood, where most of the resi-
dents know each other. Josie’s father works long hours and travels frequently for business.
He is not as involved with his children as his wife is and on weekends typically plays golf.
Most of the parenting responsibility falls on Josie’s mother, although she claims not to mind
this. “All I’ve ever wanted to do was be a mother.” Josie’s mother says that she has a circle of
friends that she relies on for support, although some of the parents are wary of Josie being
around their children. The family regularly attends a Protestant church, and many of her
own friends are from her church.

Josie’s mother says that when Josie was adopted, she made a good transition, but they
soon had her tested, not knowing if some of her difficulties in learning and delays in lan-
guage were due to cognitive deficits.

Josie denied feelings of depression or sadness at this time with the social work intern,
although she did say, “I’m stupid.” There has been no change in her eating or sleeping hab-
its. There is also no evidence of manic episodes.

Josie’s most recent physical examination was conducted two months ago. No abnormal
physical findings were noted. She had successful open-heart surgery while in Romania.

Directions Part I, Diagnosis Given the case information, prepare the following:
a diagnosis, the rationale for the diagnosis, and additional information you would
have wanted to know in order to make a more accurate diagnosis.

Oppositional Defiant Disorder and Conduct Disorder 133

bioPsychosocial risk and resilience
influences

onset

The current understanding of ODD and CD is that they arise from an interaction of genetic
risk and environmental adversity (Hicks, South, DiRago, Iacono, & McGue, 2009). The
biological, psychosocial, and social risk and protective influences—and how they interact
together—are discussed here. Additional risks in socially diverse populations are summa-
rized in Box 10.2.

Biological Influences
About 50% of the variance in the inheritance of CD may be accounted for by genetics
( Gelhorn et al., 2006). Children with a biological predisposition toward ODD or CD may
demonstrate as newborns a difficult temperament (defined as negative emotionality, intense
and reactive responses to stress and frustration, and inflexibility), which predicts conduct
problems (Nigg & Huang-Pollock, 2003). In contrast, an inhibited or approach-withdrawal
temperament is protective against antisocial behaviors (Burke, Loeber, & Birmaher, 2002;
Lahey & Waldman, 2003).

females

• The disorders are less prevalent in females than
males before puberty, but rates are more equal
after puberty, mainly due to girls’ involvement with
antisocial boyfriends (APA, 2013; Burke, Loeber,
& Birmaher, 2002; Moffit, Caspi, Rutter, & Silva,
2001).

• CD may go unrecognized in females because of
relational or indirect aggressiveness—for example,
exclusion of others; threats of withdrawal from
relationships; rumor spreading; and efforts to
alienate, ostracize, or defame others (Ledingham,
1999; Loeber, Burke, Lagey, Winters, & Zera,
2000).

• Inadequate information exists for treatment
for girls because of the lack of gender-specific
treatment research (Brestan & Eyberg, 1998;
Ehrensaft, 2005).

ethnicity

• Hispanics are at lower risk for ODD (Nock, Kazdin,
Hiripi, & Kessler, 2006).

• When controlling for SES and neighborhood influ-
ences, there is little difference in the prevalence of
most conduct problems among African-American,
Hispanic, and non-Hispanic white youths. Ethnic

minority youths, however, are more likely to join
gangs (Lahey & Waldman, 2003).

• Physical discipline may not be associated with
child aggression among African-American children
(Deater-Deckard, Dodge, & Sorbring, 2005).

• Insufficient data exist on effective interventions
for children who are from minority groups,
although minority youths benefit from juvenile
offender programs as well as Caucasian youths
(Brestan & Eyberg, 1998; Wilson, Lipsey, &
Soydan, 2003).

low ses

• Living in poor and disadvantaged communities
poses substantial risks for antisocial behavior in
children in terms of unemployment, community
disorganization, availability of drugs, the presence
of adults involved in crime, community violence,
and racial prejudice (Hill, 2002; Loeber, Burke,
Lagey, Winters, & Zera, 2000; McGee & Williams,
1999).

• Lead exposure elevates risk for conduct problems
(Marcus, Fulton, & Clarke, 2010).

• Other indirect influences are that parents living in
poverty are overwhelmed by stressors, hindering
their parenting ability.

box 10.2 oppositional defiant disorder and conduct disorder and social diversity

Part Eight: Disruptive, Impulse Control, and Conduct Disorders134

Children with a greater genetic predisposition to conduct problems are, unfortunately,
more likely to encounter environments that foster antisocial behavior (Loeber et al., 2002).
Children predisposed to CD are likely to be raised by ineffective (and sometimes abusive)
parents with histories of antisocial behavior, substance use problems, and other psycho-
pathology. With regard to mating, the likelihood of persons with particular characteris-
tics selectively partnering and producing children is substantial for antisocial behavior
(Ehrensaft, 2005).

Low IQ, especially verbal deficits, may give rise to the development of antisocial
behaviors (Hill, 2002; Nigg & Huang-Pollack, 2003; Wachs, 2000). Children who are un-
able to identify emotions in themselves and others and cannot reason well verbally may
react aggressively rather than by talking about their feelings, seeking comfort, or problem
solving.

Male gender is a risk influence for the development of conduct problems. Females
may demonstrate more empathy and distress over breaking rules and hurting others at
a younger age than boys do (Alvarez & Ollendick, 2003). Girls’ communication skills are
also more developed at a younger age, as are their social skills. Other reasons for differ-
ences in rates of conduct problems may include gender-specific hormone levels, especially
testosterone.

A large-scale British study of 16,000 children showed that among a variety of preg-
nancy and birth factors examined, only prenatal maternal smoking was highly associated
with conduct problems in youths (Murray, Irving, Farrington, Colman, & Bloxsom, 2010).

Psychological Influences
More severe and chronic conduct problems and poorer treatment outcomes are associated
with a number of personality traits, such as lack of guilt, empathy, emotional expression,
low harm avoidance, and a preference for novel, exciting, and dangerous activities. These
traits are found in about a third of treatment-referred children with early-onset conduct
problems (Frick, 2006). However, the dominant personality profile for this type of CD fea-
tures impulsivity, low verbal IQ, and a lack of emotional regulation, coupled with higher
rates of family problems. Problems with emotional regulation result in impulsive and reac-
tively aggressive behaviors.

Social Influences
Children who live in poor and disadvantaged communities experience a variety of risks.
These include poverty, unemployment, community disorganization, availability of drugs,
the presence of adults involved in crime, community violence, racial prejudice, overcrowd-
ing, poor and unresponsive schools, and lack of access to services—for example, day care,
after-school programs, and health and mental health services (Hankin, Abela, Auberbach,
McWhinnie, & Skitch, 2005; Hill, 2002; Loeber et al., 2000). These stressors may over-
whelm parenting abilities.

Any parental psychopathology, such as depression (Silberg, Maes, & Eaves, 2010), sub-
stance use problems, antisocial personality disorder, and criminal offending, are risk influ-
ences (Steinberg, 2000). Further, parental rejection of the child, lack of supervision, and
lack of involvement in the child’s activities are risk influences for the disruptive disorders.
Girls with conduct problems are more likely to come from homes characterized by intense
emotional conflict and unstable interpersonal relationships (Ehrensaft, 2005). Conversely,
family stability, stable parental relationships, and parental social support are protective.
Moreover, child physical abuse and sexual abuse, which often occur in the context of the
family, are associated with conduct problems but only in the presence of genetic risk (Jaffee,
Caspi, & Moffitt, 2005).

Oppositional Defiant Disorder and Conduct Disorder 135

Peer relationships can act as either a risk or a protective mechanism for the onset of
and recovery from conduct problems. In particular, deviant peer relationships are a major
pathway for adolescent-onset CD (Frick, 2006). Youths with conduct problems display
several distortions in the way they perceive and code their social experiences (Dodge,
2003; Kazdin, 2001). These distortions include an inability to produce a variety of strate-
gies to manage interpersonal problems, difficulty figuring out ways to achieve a particular
desired outcome, problems identifying the consequences of a particular action and its
effects on others, a tendency to attribute hostile motivations to the actions of others, and
failure to understand how others feel. The combination of perceived threat and limited
options for managing social situations makes antisocial youths more likely to respond
with aggression rather than with prosocial problem-solving strategies. In general, children
diagnosed with conduct problems often experience rejection by peers for their aggression
and lack of social skills (Miller-Johnson, Coie, Maumary-Gremaud, & Bierman, 2002).
As a result, delinquent youths often consort together, further reinforcing their conduct
problems.

course and recovery

Approximately 40% of youths with ODD later develop CD (Egger & Angold, 2006) while
antisocial personality disorder in adulthood is a possibility for 25% (Lemery & Doelger,
2005) of males who had conduct problems as youths, whereas borderline personality dis-
order may be a risk for girls with antisocial behavior (Ehrensaft, 2005). Of all the child
and adolescent mental disorders, ODD is singular in being associated with a wide vari-
ety of mental disorders manifesting in young adulthood (Copeland, Shanahan, Costello, &
Angold, 2009). Outcomes may partially result from the number of risk influences. In one
study, only 2% of youths who had no childhood risk influences showed persistent delin-
quency in adolescence, compared with 71% of youths who had risk influences in five differ-
ent areas of life (Frick, 2006).

Many of the risk and protective mechanisms for recovering from ODD or CD and
subsequent adjustment are the same as those involved with the onset of these disorders.
One other major factor relates to age of onset; compared with the adolescent-onset types,
the childhood-onset type results in more severe and chronic problems that may persist into
adulthood (Moffit, Caspi, Harrington, & Milne, 2002).

interventions for odd and cd

Psychosocial interventions

Individual treatment with the most research attention involves cognitive-behavioral
therapy (CBT) intervention, often provided in the school setting. Many of these interven-
tions focus on social information processing (Baker & Scarth, 2002), which is described in
Table 10.1. Although effective, CBT interventions for children with conduct problems tend
to show only small effect sizes over control conditions (Wilson & Lipsey, 2007).

Directions Part II, Strengths-Based Assessment Formulate a risk and resilience
assessment, both for the onset of the disorder and for the course of the disorder.
What additional techniques could you use to elicit strengths in this client and how
would you use them?

Part Eight: Disruptive, Impulse Control, and Conduct Disorders136

For adolescents, Lipsey, Landenberger, and Wilson (2007) conducted a review of 58
studies of adolescent and adult offenders who received treatment while they were on proba-
tion. They found a 25% reduction in reoffending as a result of treatment. They also looked at
commercial packages of CBT, such as aggression replacement training (Goldstein, Glick, &
Gibbs, 1998), which involves social skills training, feeling management, stress management,
learning alternatives to aggressions and how to plan ahead, anger control, and moral edu-
cation. There were no statistically significant benefits in using these types of commercial
packages, however. Instead, implementation of the program was a key moderator. When
programs were implemented as they had been designed, better outcomes were produced.
Crucial elements of CBT were also identified. Anger control and interpersonal prob-
lem solving were important elements, whereas victim impact and behavior modification
were not.

Family interventions have been tested for the treatment of conduct problems (Eyberg,
Nelson, & Boggs, 2008). Of these, the most extensively investigated and demonstra-
bly effective model is parent training (Table 10.1) (Dretzke et al., 2009; McCart, Priester,
Davies, & Azen, 2006). Other family interventions are described in Table 10.1. For more
information on the empirical evidence of these models, see Corcoran (2011).

medication

As discussed, many youths with ODD or CD will have comorbid ADHD. Stimulants are ef-
fective for reducing aggression with this population (Pappadopulos et al., 2006). In addition,
risperidone reduces aggression substantially in youths with CD and below average IQ. Other

Interventions for ODD/CD

Intervention Description
Empirically Validated Manuals/
Programs

Social information
processing

Involves the following steps:
(1) encoding and then interpreting

situational and internal cues
(2) setting goals
(3) determining possible responses
(4) role-playing responses

Anger control training (Lochman,
Barry, & Pardini, 2003).

Parent training Parents are taught to specify goals for behav-
ioral change; track target behaviors; positively
reinforce prosocial conduct through the use
of attention, praise, and point systems; and
employ alternative discipline methods.

Helping the Noncompliant Child
(ages 3–8) (Forehand & McMahon,
1981), Living with Children (ages
3–12) (Patterson & Gullion, 1968),
and the Incredible Years (ages 2–8)
(Webster-Stratton, 2001).

Multisystemic
therapy (MST)

A manualized, ecologically based family preser-
vation program targeted at juvenile offending.

Henggeler, Schoenwald, Borduin,
Rowland, and Cunningham (1998)
and Henggeler, Schoenwald,
Rowland, and Cunningham (2001).

Functional family
therapy (FFT)

A behavioral-systems family therapy targeted at
juvenile offending.

Alexander and Parsons (1982) and
Gordon, Arbuthnot, Gustafson, and
McGreen (1988).

Table
10.1

Oppositional Defiant Disorder and Conduct Disorder 137

classes of medication have either not been studied sufficiently or show little evidence of ef-
fectiveness. Aggression uncomplicated by ADHD should first be treated with a psychosocial
approach, and such an approach should continue even when medications are used.

critical PersPective

The DSM criteria for CD include overt aggression, and as a result of this focus, females
with this disorder may be underrecognized. The female presentation of CD tends to be
less noticeable, because it involved indirect or relational aggressive behaviors such as the
exclusion of others; threats of withdrawal from relationships; efforts to alienate, ostracize,
or defame others; and rumor spreading (Ledingham, 1999; Loeber et al., 2000). Some ex-
perts have suggested that the diagnostic criteria for CD should be modified for females to
include these variables (Loeber et al., 2000; Ohan & Johnston, 2005), although others have
argued that there are no gender differences in symptom patterns (Moffit, Caspi, Rutter, &
Silva, 2001).

In their critique of the DSM, Kutchins and Kirk (1997) emphasize the importance of
distinguishing between behavior as a dysfunction within a person and as a reaction to life
stressors. Although it is possible that a client’s behaviors signify internal dysfunction as
postulated by the DSM, it is possible that he or she is reacting negatively to environmen-
tal circumstances, or more likely, that a combination of these forces is working together.
Indeed, the literature on ODD and CD identifies coercive family factors and other social
environment variables as key to the development of these disorders. The DSM view of in-
ternal dysfunction is therefore not in line with what has been empirically validated as con-
tributing to these disorders.

Directions Part III, Goal Setting and Treatment Planning Given your risk
and resilience assessments of the individual, your knowledge of the disorder, and
evidence-based practice guidelines, formulate goals and a possible treatment plan for
this individual.

Directions Part IV, Critical Perspective Formulate a critique of the diagnosis as it
relates to this case example. Questions to consider include the following: Does this
diagnosis represent a valid mental disorder from the social work perspective? Is this
diagnosis significantly different from other possible diagnoses? Your critique should
be based on the values of the social work profession (which are incongruent in some
ways with the medical model) and the validity of the specific diagnostic criteria ap-
plied to this case.

Case 2: The Boy With No Restraint

Sam is a nine-year-old African-American male who is new to a school that offers educational
services for children who can no longer perform in an ordinary school setting. He came from
an elementary school where he attended a special education program. He was referred to the
specialized school because he continued to exhibit significant behavioral, social, emotional, and
academic difficulties.

Part Eight: Disruptive, Impulse Control, and Conduct Disorders138

The prior public elementary school’s psychological report stated that Sam spent a majority
of his time out of the classroom, either on suspension or in counseling sessions because of his
behavior. The report also stated that he required physical restraint on a number of occasions
and was recently so aggressive and dangerous that the school filed a complaint with the court
asserting that he was out of control both at home and in school. No further information was
available about the outcome of this referral to the courts, nor about the specifics of the behavior
that warranted such a referral.

Sam lives with his mother, his three-year-old brother, paternal great-grandmother, and
uncle in his great-grandmother’s home. The family recently moved from the home of Sam’s
grandmother after a heated argument between Sam’s mother and her own mother. This is the
third move and Sam’s fourth school in just three years. Sam’s father was shot to death a year
ago (his mother was no longer with him at the time), and he has no contact with his father’s
family except for his paternal great-grandmother. Sam did have a relationship with his paternal
grandmother, but she passed away six months ago.

Sam’s mother completed the 11th grade, is currently unemployed, and collects
Supplemental Security Income. It is unclear why Sam’s mother receives such assistance. Sam
also has a 12-year-old half brother and a 10-year-old half sister. All the children have the same
mother but different fathers, and the older children live with their paternal relatives.

Sam’s family had home-based services to assist with the difficulties they were experiencing,
but the services were terminated several months ago because the agency lost all contact with
Sam’s mother. The home-based worker stated her belief that Sam’s mother may have started a
new relationship, and that in the past she has allowed her relationships with men to take away
from her time with her children. The worker also stated that the unstable living situation and
Sam’s mother’s mental state (which she believes may be persistent depressive disorder) make it
difficult to work with the family on a consistent basis. Through the home-based services agency,
Sam was connected with mental health counseling, but his attendance and participation were
sporadic.

About a year ago, Sam took the Woodcock Johnson tests, which indicated that his reading,
writing, and math skills were significantly delayed for his age, IQ, and educational level. His
academic achievement is poor because of these delays. Because of his refusal to participate in a
number of the tests, his IQ score could not be accurately identified, but the examiner estimated
it to be in the range of 74 to 87.

Since the beginning of the school year Sam has continued to exhibit aggressive and
dangerous behaviors. In a meeting with the behavior staff director of the school, the social work
intern learned that Sam will have to be searched daily because of his many threats of bringing
a knife or gun to school to kill staff. Sam has had to be physically restrained by staff at least a
dozen times. The director stated that she would never restrain Sam alone and that it takes two
to three staff to do so safely. In this same meeting, the director stated that Sam has attempted to
stab staff with pencils and thumbtacks grabbed from hallway bulletin boards.

In locked restraint, Sam will kick the door and scream out obscenities. According to incident
reports, Sam has spit at, lunged at, and attacked staff and has even tried biting. He tends to
blame others for his behavior (“I’m in support because [staff member] said a bad word to me.”).
He neither shows remorse for his behavior nor empathy toward people he has been angry with.

Sam’s teacher reports that he often has difficulty transitioning from one location to another
or from one assignment to another. Sam refuses to complete his school assignments and will
not accept redirection from his teacher. He often becomes verbally disrespectful toward her, but
she reports he has not yet been physically aggressive. She does report that he often destroys
property (ripping papers, breaking pencils, turning over chairs and desks) when upset and is
known for tearing up his school worksheets when he does not want to work on them.

Sam currently spends a significant amount of time out of class because of his behaviors. He
is falling behind in class work because of his absence from lessons and his refusal to participate.

Oppositional Defiant Disorder and Conduct Disorder 139

Not surprisingly, Sam doesn’t have friends because other children are scared of his out-of-control
behaviors.

Sam’s mother is difficult to contact, and she doesn’t return telephone calls in a timely
manner. She is guarded about sharing personal information. She attended the most recent
individualized educational plan (IEP) meeting and reports that since Sam was a young child,
she has seen similar behaviors at home. When Sam gets frustrated, he becomes verbally and
physically abusive toward her.

Sam’s mother states that she has sought outside help to control Sam’s behavior. She
attempted mental health counseling, but discontinued services because he refused to speak.
Sam’s mother says that she is overwhelmed and has tried every punishment—spanking, sending
him to his room, taking away privileges—but that none of her efforts has been successful in
changing his behavior. She says that he does not seem depressed to her, just angry. Sam’s
mother states that she has also called Juvenile Court to relinquish Sam. She was told to come in
to complete the intake process but did not do so.

Sam presents as a well-dressed and well-groomed young boy. When he is not upset, he is
engaging and very polite. He states that he enjoys coming to the sessions with the social work
intern, and he plays games cooperatively, though with high energy, during these times. He shows
particular interest in sports, especially basketball. He doesn’t bring up his deceased father or other
aspects of his family life and shies away from questions about them, although he admits to feeling
“sad” about his father’s and his grandmother’s deaths. He denies, however, that he is sad in
general. He says he has not been sexually or physically abused, but says that in the past his mother
and a couple of her boyfriends have “whipped” him but not left marks. Sam’s most recent physical
examination, performed a year ago, confirms that he is in good health and particularly noted that
he has a good appetite.

Please go to the additional Case Workbook for directions to this case.

Case 3: Nell’s Family Conflicts

Nell is a 13-year-old Hispanic-Caucasian female. She is currently detained at the county juvenile
detention center for violating the conditions of probation by continuing to run away from home.

Nell previously resided with her mother, stepfather, 15-year-old brother, and 14-year-
old sister in a single-family rental in a suburban, working-class neighborhood. Nell also has
two older brothers who no longer live at home. The family just moved two months ago after
being evicted from their last residence. The landlord told them that the neighbors complained
about the police constantly being called to the house for family arguments and Nell’s runaway
behavior. Nell also admitted that she stole money from a neighbor’s home on several occasions.
The neighbors eventually confronted her, but the incident was not reported to the police.

Nell stated that she does not get along with her stepfather (he has been in her life for
two years) and has a conflicted relationship with her mother. She says that she has a close
relationship with her sister. Nell’s parents agree that her stepfather is strict and inflexible
about rules, whereas her mother gets in the middle of conflicts between her husband and her
daughters. Nell’s mother admits that her children take advantage of her. Nell’s mother and
stepfather claim that their relationship is “all right,” but that the arguments over discipline
and Nell’s behavior in particular exact a toll. Despite Nell’s negative behaviors, both her
mother and stepfather actively participate in meetings involving treatment planning, academic
issues, and court dates. They both stated that they love and care for Nell a great deal but are
unsure what they can do to help her.

Part Eight: Disruptive, Impulse Control, and Conduct Disorders140

The family’s socioeconomic status is low. Nell’s stepfather works in retail, and Nell’s mother
said that she quit her job as a secretary when she was diagnosed with breast cancer. Her mother
stated that she worries that her children do not always have the same clothing and “things” that
their peers have. The family does have health insurance.

Nell is in seventh grade and is currently being schooled through the county school system
at the juvenile detention center. She does enough, she says, “to get by.” According to her
parents, Nell was an honor roll student and a member of the safety patrol and the school choir
until her behavior changed drastically about a year ago.

In the past year Nell has refused to obey her parents’ rules and has run away from home
over a dozen times. She often stays out late at night and refuses to tell her parents where she is
going or with whom. She often misses school when on the run, and her grades have suffered
significantly. Nell has admitted to hanging out with males who are in their 20s, including known
gang members, but denies personal membership in any gang.

Nell’s parents report that any time she does not get her way, she throws temper tantrums
and threatens to run away. They state that she went from being a sweet, loving child to being
disrespectful and unmanageable. Nell’s acting out seemed to start when Nell’s older sister
disclosed to her mother that their biological father sexually molested her. Nell denies that
she witnessed the sexual abuse or that she was sexually abused herself. After the sexual abuse
disclosure, Nell’s mother was diagnosed with breast cancer. Nell has shared some concern about
this, stating, “I don’t want my mom to die.”

Nell admitted to engaging in sexual activity with at least ten male partners in the past
several months. On at least two occasions she had sex with male strangers in laundromats for
$5 because she was trying to save up enough money to move to another state. Nell stated that
she almost always initiates the sex and cannot seem to control this behavior. She thought she
was pregnant on more than one occasion, but stated that tests she took while in shelter care
confirmed that she was not pregnant and did not have any sexually transmitted diseases. Nell
has previously accused male staff at the shelter and the juvenile detention center of touching her
in a sexually inappropriate manner, but all cases have been investigated and deemed unfounded.

Nell stated that she started using various substances about a year ago. Marijuana is her
drug of choice, and at the height of her use (four months ago) she smoked every other day.
Nell reported last using marijuana one month ago. Additionally, around this time she smoked
marijuana laced with cocaine “once or twice” and reported snorting several lines of cocaine on
one occasion.

Nell reported that she has also used alcohol, and four months ago her use increased to
several times a week. She stated that she can consume five to seven 12-ounce beers before
she is intoxicated. Nell reported vomiting on several occasions and experiencing three or four
blackouts. She stated that she last consumed alcohol one month ago before she was admitted
to the juvenile county detention center.

Nell admitted to dextromethorphan (DXM) use beginning this past year. DXM, the
active ingredient found in many over-the-counter cough and cold medications, produces
hallucinogenic and stimulant effects in high doses. Seven months ago, because of her running
away and substance use, Nell was placed in a county shelter care residential facility. While there,
staff reportedly took her to the hospital after she ingested 10 tablets of DXM. She stated that she
last used DXM four months ago when she ingested 15 pills.

Nell denied experiencing withdrawal symptoms from any substance. She said that she
does not see anything wrong with “smoking a little weed and having a few drinks” and was
unable to articulate any negative consequences associated with substance use. She admitted
that her incidents of sexual activity have been when she is under the influence of one substance
or another, even when she has been with adult males unknown to her. She acknowledged that
it is illegal for her to drink alcohol and use drugs and knows that it upsets her mother, but she
has no intention of stopping. Nell reported that the majority of her friends also use alcohol

Oppositional Defiant Disorder and Conduct Disorder 141

and drugs. Access is no problem, she claims, because her friends are older and able to obtain
marijuana and alcohol.

Nell’s mother and stepfather state that they have witnessed her under the influence of
substances and believe that a problem exists. Nell’s mother says she herself rarely drinks, but
Nell’s stepfather says he has a “couple of beers” each night when he gets home from work.
Both parents deny that he has a problem with alcohol. However, Nell’s mother said that Nell’s
biological father was an alcoholic, and it was one of the reasons she left him, along with his
sporadic employment. Nell has not had contact with her father since the divorce three years
ago.

Nell has hypothyroidism, a medical condition in which the thyroid is underactive and does
not produce a sufficient amount of thyroid hormones. She reported no other health or medical
issues. Nell takes a thyroid hormone medication, Levothyroxine.

Nell ran away from shelter care but was returned there until five months ago, when she
used a paper clip to cut her nickname into her forearm. At that point Nell was referred to a
psychiatric hospital. Nell denied suicidality in the past or at present.

After her stay at the psychiatric hospital, Nell went home. Soon after, she had a fight with
her mother and drank kitchen cleaner. Nell insisted that she drank it to make her mother feel
bad and had no desire actually to harm herself. She was then placed in a nonprofit home for
at-risk adolescents but ran away on three occasions. She was put on probation for her runaway
behaviors.

When reporting on her current mood, Nell states that although at times she feels sad
and worried, she believes it is because of her circumstances—being locked up at the juvenile
detention center. She is convinced she will feel better once she returns home with her family.
While being interviewed, Nell showed little remorse for her actions and their effect on her family
or her personal well-being.

Nell has several strengths. She has an engaging personality, is smart, and has an excellent
singing voice. She used to be in the school choir, and her goal is to become a professional
singer. Nell believes that her problems will be solved when she and her sister are able to get
along with their mother and stepfather. Nell does not wish to return home until her relationship
with her parents improves and they no longer see the need to criticize her and yell at her.

Please go to the additional Case Workbook for directions to this case.

references

142

Substance-Related and Addictive
Disorders

Vlad is a 17-year-old Caucasian male court-mandated to attend a six-month residential treatment
program at a local juvenile detention center for breaking and entering and unauthorized
possession of a firearm. Vlad has unsuccessfully participated in several residential placements in
the past few years and has repeatedly had positive urine screens for marijuana use.

S
ubstance use is highly prevalent in American society. Social workers often work
with clients who have substance-related problems, regardless of their agency set-
tings. This situation arises partly because of the high comorbidity found between

substance- related and other disorders, as well as problems such as domestic violence and
child abuse. Social workers thus need to be able to assess for substance use disorders and
become familiar with their empirically validated treatments. Alcohol-related disorders in
adolescence and adulthood are the primary focus of this chapter, although other substances
will be incorporated into the presentation.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) provides general
criteria for substance-related disorders rather than separate criteria for each substance, of
which 10 categories are included (American Psychiatric Association [APA], 2013). (It should
be noted, too, that gambling disorder is included in this chapter of the DSM; the only non-
substance-related addictive disorder.) These include disorders of use, intoxication, with drawal,
substance or medication induced disorders, and unspecified substance induced disorders. The
disorders are characterized as mild, moderate, or severe, depending on the numbers of symp-
toms identified, which range from negative consequences of use to compulsive use despite
serious consequences, often accompanied by tolerance and withdrawal.

Prevalence and comorbidity

Substance use disorders are the fourth most diagnosed group of disorders in the United
States (Kessler, Chiu, Demler, & Walters, 2005). The National Epidemiologic Survey on
Alcohol and Related Conditions reported a 17.8% lifetime prevalence of alcohol abuse and
a 4.7% prevalence during the past year (Hasin, Stinson, Ogburn, & Grant, 2007). The life-
time prevalence for alcohol dependence was 12.5% and past year dependence was 3.8%.
The lifetime and 12-month prevalences of drug abuse were 1.4 and 7.7%, respectively, and
for drug dependence they were 0.6 and 2.6%, respectively (Compton, Thomas, Stinson, &
Grant, 2007).

c h a p t e r 11

Substance-Related and Addictive Disorders 143

In older adults, one-month prevalence rates for alcohol use disorders ranged from 0.9
to 2.2% (Office of the Surgeon General, 1999). According to the National Surveys on Drug
Use and Health, drug abuse in those over age 50 is very low (0.33%) (Blazer & Wu, 2009).
In 2004, the rate of substance abuse was 8.8% for youths aged 12 to 17 (Substance Abuse and
Mental Health Services Administration [SAMHSA], 2006).

There is a high degree of psychological comorbidity with substance use disorders
( Stinson et al., 2005). The National Comorbidity Survey reported that more than half
(51.4%) of adults with substance use disorders at some point in their lives also had another
mental disorder (Kessler, 2004). The co-occurrence of substance use and personality
disorders, for example, is 39% for those with alcohol dependence and 69% for those with
drug dependence (Jané-Llopis & Matytsina, 2006). Antisocial personality disorder is par-
ticularly common in men who abuse substances. Adolescent abusers have a 60% likeli-
hood of being diagnosed with another psychiatric disorder, most frequently the disruptive
disorders (conduct disorder [CD], oppositional defiant disorder [ODD], and attention-
deficit hyperactivity disorder [ADHD]), depression, and posttraumatic stress disorder
(PTSD) (Armstrong & Costello, 2002; Chung & Maisto, 2006). Not surprisingly, alcohol
and drug use disorders are highly comorbid with each other. Among individuals with an
alcohol use disorder, over half (55.17%) also had a drug use disorder (Stinson et al., 2005).

Various theories have been postulated to explain the high comorbidity between sub-
stance use and other mental disorders. Buckley (2006) suggests the following three:

1. People use substances to medicate symptoms of other mental disorders.
2. Substance use may precipitate mental illness.
3. There may be genetic vulnerability to both substance use and mental disorders

involving certain neurotransmitter systems.

Unfortunately, substance use by people with mental disorders may lead to destabili-
zation and exacerbation of mental illness symptoms, medication noncompliance, health
consequences, and risky behavior such as increased suicidal ideation (Buckley, 2006).

Substance use disorders also have significant medical consequences. Substance
dependence (excluding nicotine) in the United States annually accounts for 40% of all hos-
pital admissions and 25% of mortality rates (500,000 deaths) (SAMHSA, 2006). Medical
problems related to drinking include gastrointestinal (gastritis, ulcers, liver problems,
and pancreatitis) and cardiovascular (hypertension and cholesterol and subsequent heart
disease) conditions (Corrao, Bagnardi, Zambon, & Arico, 1999).

assessment

Social workers should routinely screen both their clients and clients’ family members for
alcohol and drug problems (McCrady, 2005). Box 11.1 summarizes assessment guidelines
for use with clients of all age groups.

Vlad is on probation for breaking and entering until his 18th birthday. He entered a
neighbor’s house through the window and stole money and electronics. Upon searching
his bedroom, police discovered a gun, which resulted in a second charge of unauthorized
possession of a firearm. Vlad states that after being threatened, he bought the gun from a
friend but had no intention of using it. After he was arrested and charged, his mother paid
his restitution. He has yet to repay her. He also underwent urine screens as a condition of
his probation, which were repeatedly positive for marijuana use.

Vlad has attended but failed to complete several residential placements in the past
several years, including a military school, a private alternative school, and a wilderness pro-
gram. His disregard of regulations has contributed to his termination from several previous

Part Nine: Substance-Related and Addictive Disorders144

placements. Despite reports of his prior disrespect toward authority figures, Vlad presents
as cooperative, bright, and approachable. His posture and eye contact are appropriate, but
he displays a somewhat flat affect. He expresses a desire to improve his relationship with his
family and to stay out of trouble. He says that the burglary occurred four months prior and
admits that until he was placed at the residential program he continued to flout the rules
his parents had set for him. He recognizes that once he turns 18, the legal repercussions for
any crimes he commits will become more severe.

Vlad was adopted at age seven from an orphanage in Russia. His biological parents
were alcohol abusers, and his father was physically abusive toward his mother. It is un-
known whether Vlad was abused, but his father literally threw him out on the street when
he was five years old. The Russian police discovered him as he wandered the streets with
frostbite due to the extreme cold. Parental custody was rescinded, and Vlad was placed in
an orphanage.

Vlad’s two younger biological brothers were adopted by a family in the United States.
When this family discovered that the two boys had an older brother still in Russia, a rela-
tive of this family adopted Vlad. Prior to his incarceration, Vlad lived with his adoptive
parents, Mr. and Mrs. Meyers, and two younger adopted sisters. Vlad also has three much
older stepbrothers from Mr. Meyers’s first marriage. Mr. and Mrs. Meyers are officers in
the U.S. military. Mr. Meyer is now retired and lives with the two girls; Mrs. Meyers is cur-
rently stationed overseas. Despite the physical distance between them, Mr. Meyers claims
that he and his wife are close. The family is well off financially, and the parents appear to
be invested in their children’s well being. Mr. Meyers says the family’s main support is their
extended family out of state.

Vlad states that his most important relationships are with his adoptive sisters and his
biological brothers, all of whom live out of state. However, Mrs. Meyers says that even when

1. Examine patterns of use, including onset, fre-
quency, quantity, drugs of choice, tolerance, or
withdrawal symptoms.

2. Examine “triggers” and contexts of use.

3. Review consequences of substance use in the
physical (might include physical examination),
psychological, legal, financial, occupational, and
educational realms.

4. Assess motivation for treatment, including the
perceived advantages and disadvantages of use.

5. Review major life events that may contribute to
substance use.

6. Assess the possible coexistence of other
disorders, including the relationship between
the onset and progression of the other symp-
toms and their relationship to substance use.
Optimally, the assessment of comorbid disorders
should take place about three to four weeks after
the person has stopped using substances.

7. Consider the client’s strengths and coping skills,
and inquire about periods of abstinence or re-
duced use.

8. Assess the client’s social support networks.

9. Assess for suicide risk (see chapter 7 for guide-
lines on how to conduct such an assessment).

For adolescents

Interview the adolescent and parent(s) separately.
The interview with the parent should be done to
gather information about the child but should also
address the extent of parental substance use, atti-
tudes toward their child’s use, the amount of monitor-
ing and supervision the youth receives, and the level
of cohesion in the family (Bukstein et al., 1997).

Sources: Bradizza, Stasiewicz, & Paas, 2006; Bukstein, Cornelius,
Trunzo, Kelly, & Wood, 2005; Graybeal, 2001; Miller & Rollnick,
2002; Riggs & Whitmore, 1999.

box 11.1 assessment of substance Use

Substance-Related and Addictive Disorders 145

given the opportunity to visit with his biological brothers, he has chosen to stay at home.
Vlad’s relationship with his adoptive father is beginning to improve, but he expresses an
immense amount of anger and resentment toward his adoptive mother. Both his adop-
tive mother and father state that Vlad does not have close attachments to other people.
According to his adoptive parents, Vlad has always preferred to be alone in his room and he
shies away from physical affection.

Of his early childhood in Russia, Vlad recalls little, unsure whether his memories are
“real or dreams.” Mr. Meyers attends the biweekly family therapy sessions and reports that
Vlad was a “wonderful, happy little boy.” Both Vlad and Mr. Meyers deny a history of sig-
nificant illnesses or injuries and state that Vlad is in excellent physical health. He does
have some residual sinus problems and is susceptible to allergies as a result of his early
childhood experience. It is unknown whether there is a history of mental illness in Vlad’s
biological family other than his parents’ alcoholism.

Vlad has a history of unsuccessfully treated mental health issues. He has received psy-
chological evaluations and counseling at most of his past placements. He says that at age 11,
he took Adderall to treat his ADHD, but he is not currently taking any medications. Vlad
adamantly denies a history of cruelty toward animals or fire setting. He states that he gets
into fights only when antagonized by others.

Vlad has a history of frequent and persistent alcohol and marijuana use beginning
at age 11 or 12. Vlad admits to smoking daily “as long as me or my friends had some.”
He reports evidence of tolerance to marijuana, both increasing the amount to achieve the
desired effect and reduced feelings of intoxication with continued use. Despite a history
of negative consequences—criminal involvement, academic problems, and interpersonal
conflicts—he has not been successful in controlling or limiting his marijuana use. He says
he experiences cravings for marijuana every day and admits that he would still be using
if he had access. He says that he used alcohol less frequently (“a few times a week, mostly
beer”), but more often when marijuana wasn’t available. He said he was able to control or
stop his alcohol consumption “when I tried, although I didn’t usually want to.” He said
he doesn’t miss alcohol as much as he does marijuana. He admits that he tried PCP on
two occasions but found the effects dysphoric and unpleasant. He denies using any other
substances.

Vlad does not display empathy for the victims of his crime nor express guilt for the
stress he has caused his family. He is aware, however, that the majority of his problems stem
from his substance use and involvement with undesirable peers. He admits that he has a
problem with substances and that he would probably be using if he had access to drugs and
alcohol.

Vlad has had two heterosexual relationships. He reports that he felt a strong attach-
ment to his first girlfriend but believes that his parents sabotaged the relationship. He
admits that on two occasions he hit his last girlfriend during arguments while he was under
the influence of alcohol and marijuana. He claims that she sustained no injuries as a result
of his abuse.

Beginning around age 11, Vlad began to associate with a group of undesirable peers.
Even after the family relocated to a new neighborhood at age 14, Vlad continued to select
unsuitable friends, and his behavior worsened. He repeatedly stayed out past his curfew and
on several occasions ran away overnight when his parents attempted to ground him. He
started skipping classes at school, and his academic performance began to suffer, although
he had received good grades before this time. He was also unable to play basketball, a sport
at which he excelled, given the school policy requiring a minimum grade point average to
play sports.

Vlad attended school at the detention center and was able to earn his GED with mini-
mal preparation. His father reports that Vlad has always been a talented artist. He initially

Part Nine: Substance-Related and Addictive Disorders146

had some difficulty processing his feelings verbally and was given the option of using a
therapeutic journal and mandala circle drawings as an outlet for his emotions. Vlad used
both outlets effectively and produced some creative works depicting both positive and neg-
ative feelings he experienced over the course of therapy. Vlad can be stubborn at times, but
because of this trait he tends to work hard at an assignment or project until it is satisfacto-
rily completed. For example, he was given an art assignment when he was first placed in the
detention center and spent a month working on the drawing. He created a beautiful final
product of which he was extremely proud.

Vlad expresses interest in attending a trade school or community college where he can
study to become a car mechanic or electrician, as he is “good at fixing things.” Mr. Meyers
says he will support Vlad in whatever educational and occupational decisions he makes.
Vlad is athletic and hopes to resume playing basketball in the future. The Meyers family
regularly attends a Catholic church, and Mr. Meyers has a close relationship with the priest.
Vlad identifies as Catholic and previously attended a church youth group.

While in the program, Vlad has been sharing living quarters with up to 14 other
adolescents and is well liked by his peers. His peers describe him as funny, athletic,
competitive, and helpful on the unit. Vlad denies any feelings of depression, sadness,
or suicidal intent. He also denies experiencing any manic symptoms or episodes when
these were described to him. He says the main feeling he struggles with is anger. He
admits that he has difficulty controlling himself when he is mad, and he typically yells
and throws things.

Vlad views his biggest problems as his negative relationship with his parents and his
marijuana use. He states that he would know his problems were solved when he could
communicate with his parents about any problems involving work, friends, or school. Vlad
would like to be able to ask his parents questions about his birth family and adoption and
hopes to feel close enough to them to have a conversation about his early life. Once he gets
out of the residential treatment program, he would like to start eating dinner with his fam-
ily on a regular basis and playing basketball with his dad and his sisters.

Vlad hopes that one day he will no longer feel the urge to get high and thinks this
will happen when he does not feel so angry all of the time. He recognizes that for his
situation to change he would have to stop feeling so angry toward his parents, become
more capable of effectively managing his anger, and feel more connected to his family
and peers. Rather than reacting to angry feelings by yelling or throwing something, Vlad
hopes to be able to walk away from a situation and address whatever made him angry
when he calms down. Vlad said that he would know his situation has changed for the
better when his parents stop criticizing him for his friends and choices. When asked what
he would be doing when his parents accept him, Vlad admitted that he would have to be
making better choices. Vlad says that if he is busy with school, work, and other positive
activities, he will no longer struggle with boredom, which he identified as a trigger for
his drug use.

When asked the miracle question (“What would you experience if you woke up one
day and your life was the way you want it to be?”), Vlad states that he would be enrolled in
college and getting good grades, working at a part-time job that pays well, have a girlfriend
who does not use drugs, and enjoy a close relationship with his family.

Directions Part I, Diagnosis Given the case information, prepare the following:
a diagnosis, the rationale for the diagnosis, and additional information you would
have wanted to know in order to make a more accurate diagnosis.

Substance-Related and Addictive Disorders 147

bioPsychosocial risk and resilience
inFlUences

onset

Substance use disorders usually begin in late adolescence or early adulthood, with a median
age of 20 years (Kessler et al., 2005). The various risk and protective processes for the onset
of adolescent substance use disorders are listed in Table 11.1. Note that although these are
listed separately, there are typically interactional effects among them. For example, family
stress and parental heavy substance use can amplify the negative influence of teen peers on
alcohol misuse (Ennett et al., 2008).

Genetic mechanisms have received much attention with regard to the onset of sub-
stance use disorders in adults, but one meta-analysis established that heritability is actually
quite low, though stronger for males (Walters, 2002). One factor that protects against the de-
velopment of substance use disorders is not having another mental disorder (Armstrong &
Costello, 2002). Disorders that often precede substance use are depression in females and
antisocial personality disorder in males (Lynch, Roth, & Carrol, 2002). Many females with
substance use problems have a history of physical or sexual abuse, both as children and as
adults (Orwin, Maranda, & Brady, 2001). At the social level, peers who use substances place
an individual at risk, whereas friends who do not support such use are protective against

Biopsychosocial Risk and Resilience Assessment for the Onset of Substance
Use Disorder

Risk influences Protective influences

Biological

Problem alcohol use seems to be moderately heritable1

Psychological

Early onset of drinking (defined as before age 14)2

Early externalizing problems3

Social

Child abuse and neglect4 Parental warnings about alcohol

Lack of parental monitoring5 Parents who were both warm and required that
their children were accountable

A parenting style which is either warm without holding
children accountable or strict without warmth6

Having abstinent friends

Alcohol availability in terms of alcohol retailers in the
neighborhood

1Young, Rhee, Stallings, Corley, & Hewitt, 2006
2Hingson, Hereen, & Winter, 2006
3Siebenbruner, Englund, Egeland, & Hudson, 2006
4Shin, Edwards, & Heeren, 2009
5Siebenbruner et al., 2006
6Bahr & Hoffmann, 2010

Table
11.1

Part Nine: Substance-Related and Addictive Disorders148

youths

• Children born to addicted mothers are at risk
for health problems, including fetal alcohol
syndrome, low birth weight, complications
of postnatal withdrawal, and HIV infection
(Finnegan & Kandall, 2008).

racial and ethnic minorities

• The rate of substance abuse is similar among
African Americans and Caucasians (9.5 and
9.3%, respectively) but lower for Latinos (Breslau,
Kendler, Su, Gaxiola-Aguilar, & Kessler, 2005).

• The rate of substance abuse is highest among
Native Americans and Alaska Natives (Huang
et al., 2006; Surgeon General, 1999).

• The second highest rate of substance abuse (13%)
is among biracial persons (Surgeon General, 1999).

• Being Asian offers protection against substance
use disorders—the annual prevalence rate among
Asians is 4.2%—possibly because of the negative
physiological response (“flushing”) found in many
Asian groups (Japanese, Chinese, and Koreans)
(Mirin et al., 2002).

• Ethnic minorities are less likely to have access to
services (Wells, Klap, Koike, & Sherbourne, 2001).

• While it is recommended that intervention should
integrate culturally relevant beliefs and healing
practices, such guidelines have tended to be
nonspecific and have not yet been subjected to
empirical testing (Castro, Proescholdbell, Abeita, &
Rodriquez, 1999).

socioeconomic status (ses)

• People with lower education and low SES are at
higher risk for drug use and dependence (Huang
et al., 2006; Stinson et al., 2005).

• People of low SES have limited access to
affordable treatment (SAMHSA, 2006).

Gay and lesbian Persons

• Homosexuals are at increased risk for substance use
disorders for the following possible reasons: limited
social venues where alcohol is not a feature of the
environment; limited access to societal institutions
that provide protection against substance use (i.e.,
marriage); lack of social support; coping with grief
over loss of gay peers through disease and death;
coping with discrimination (Beatty et al., 1999).

• Only (6%) substance use treatment facilities
surveyed across the nation offer special programs
for gay and lesbian clients (SAMHSA, 2007).

Women

• Males have a higher risk of having substance use
disorders, except for younger cohorts. In 2004,
males aged 12 or older were twice as likely as
females to be classified with substance depen-
dence or abuse problems (12.7 versus 6.2%),
but among youths aged 12 to 17, the rate of
substance dependence or abuse was similar (8.7
to 9.0%) (SAMHSA, 2006).

• Women are more susceptible than men to rapid
onset of addiction and health problems once they
begin drinking; this disparity may be partly due to
women’s higher fat and lower water ratios, which
may impair their ability to metabolize alcohol
(Brady & Back, 2008).

• In treatment, females have more health problems
than males, including respiratory, gynecological,
heart, and digestive conditions (Wechsberg,
Craddock, & Hubbard, 1998).

• Depression often precedes substance use in
females, so use seems to be a coping response.

• Many females with substance use problems have
a history of physical or sexual abuse (both as chil-
dren and as adults), and a history of victimization
is associated with a worse outcome (Orwin et al.,
2001).

• Financial barriers such as lack of money, health
insurance, child care, and transportation, as
well as the fear of social stigma associated with
substance use, may contribute to women’s
underrepresentation in treatment (Nelson-Zlupko,
Kauffman, & Dore, 1995).

• Women often develop substance use problems in
the context of relationships with substance-abusing
male partners (Ashley, Marsden, & Brady, 2003).

older adults

• Age bias among health care providers may
present obstacles to assessment of substance
use disorders in the elderly, as providers may not
believe that elders can benefit from intervention or
that their quality of life would improve as a result
( Vinton & Wambach, 2005).

box 11.2 substance Use disorders and social diversity

Substance-Related and Addictive Disorders 149

the development of alcohol and drug problems. Even for older adults, the social context
plays a role. Results of one study showed that older adults who have more money, engage in
more social activities, and whose friends approve of drinking are more likely to engage in
what is considered high-risk drinking, defined as more than three drinks per day or more
than 14 drinks per week (Holahan et al., 2010). Finally, the availability of drugs in a par-
ticular neighborhood confers risk for those residents. At a policy level, increasing the tax
on alcohol can also reduce drinking overall as well as heavy drinking and death rates from
alcohol-associated diseases (Maldonado-Molina & Wagenaar, 2010).

course and recovery

Despite the severe consequences to health and well-being, only a minority of those with
drug and alcohol disorders seeks treatment (Compton et al., 2007; Hasin et al., 2007). For
drug use disorders, lifetime help-seeking behavior is uncommon (8.1% for abuse and 37.9%
for dependence) (Compton et al., 2007). Only 24.1% of those with alcohol dependence ever
receive treatment (Hasin et al., 2007). For adolescents, only 10% of those with substance use
disorders receive treatment (Kraft, Schubert, Pond, & Augirre-Molina, 2006).

Several characteristics of clients, their substance use patterns, and their environments
influence the course of recovery (Bond, Kaskutas, & Weisner, 2003; Chung & Maisto, 2006;
Conner, Sorenson, & Leonard, 2005; Karageorge & Wisdom, 2001; McKay, 1999; Orwin
et al., 2001; SAMHSA, 2006) and many of these involve socially diverse groups (see Box 11.2).

Patterns of use that present risk include high levels of pretreatment use, substance
use during treatment, and substance use the year after treatment. Abstinence lasting two
years is a protective influence. Protective client characteristics include client motivation
and the absence of a comorbid mental health problem. PTSD may put a client at risk for
worse outcomes (Bradizza et al., 2006). For this reason, clients with PTSD should receive
treatment for this disorder soon after receiving substance use treatment. Social workers
should also be aware that people with depression may be slower to benefit from treatment
( Conner et al., 2005) and that depression may impede recovery (Kodl et al., 2008). For
adolescents, conduct problems, depression, and ADHD present risk for relapse (Chung &
Maisto, 2006). The coping strategy of avoidance rather than that of active problem solving
leads to more cravings when a user is confronted with stress (Cleveland & Harris, 2010).

Socially, a lack of family support for sobriety, substance-abusing family members, socializing
with substance-abusing peers (especially for teenagers), low socioeconomic status, and life
events featuring physical or sexual victimization are risk influences. Protective mechanisms
include family support for sobriety, nonsubstance-using peers, the ability to develop new rela-
tionships, Alcoholics Anonymous (AA) attendance, and culturally relevant interventions.

There are some gender differences in relapse propensity. In general, women tend to ben-
efit more than men in treatment for alcohol use disorders (though not necessarily for drug
disorders) despite greater pretreatment risks (Walitzer & Dearing, 2006). Negative mood
states and depression play a greater role for adults than teenagers, whose main risks typically
involve the social context (Chung & Maisto, 2006). Negative mood is a particular risk for
women, whereas positive mood is associated with relapse for men. Other gender differences
in relapse risk involve marital and interpersonal conflicts (for women) and being unmarried
or alone (for men) (Walitzer & Dearing, 2006). Being married may not be protective for
women because they are often partnered with men who have substance use problems.

For adolescents, among pretreatment, treatment, and posttreatment factors, it was the
third of these, including participation in aftercare and AA meetings, a lack of substance-
using peers, involvement in a variety of nonsubstance-related activities, use of coping
strategies learned in treatment, and motivation to continue sobriety, that had the most
influence on outcomes (Chung & Maisto, 2006).

Part Nine: Substance-Related and Addictive Disorders150

intervention

Intervention goals for clients who abuse substances are summarized in Box 11.3. Generally
speaking, permanent abstinence is the major goal. Whether adult clients can manage con-
trolled drinking is a controversial topic. Controlled drinking may also be an interim goal
for some people or may be appropriate in the early stages of alcohol use (Mirin et al., 2002).

About half of those with a substance use disorder will eventually make treatment contact
(Wang, Lane et al., 2005), although past-year treatment seeking is low: 6% for people with
alcohol use disorders, 16% for people with drug use disorders, and 22% for people with both
alcohol and drug use disorders (Stinson et al., 2005). Commonly available treatment set-
tings include (in order of usage) outpatient rehabilitation facilities, inpatient rehabilitation
facilities, inpatient hospitals, and outpatient mental health centers (SAMHSA, 2006). Some
programs are specifically designed for adolescents, pregnant or postpartum women, and
women with young children. Many people receive intervention from locations that are not
specialized for the treatment of these disorders, including self-help groups, private doctors’
offices, emergency rooms, and prisons or jails (SAMHSA, 2006). For further guidance on
appropriate placement, social workers should be aware of the Patient Placement Criteria
for the Treatment of Substance-Related Disorders of the American Society of Addiction
Medicine (Mee-Lee, Shulman, Fishman, Gastfriend, & Griffith, 2001).

Adolescents who access care for substance use concerns are often clients in other
intervention systems, such as child welfare, juvenile justice, and mental health. The needs
of each young person may consequently be managed by multiple agencies, and providing
quality treatment often requires the social worker’s navigation across these systems (Kraft
et al., 2006).

Directions Part II, Biopsychosocial Risk and Resilience Assessment Formulate
a risk and resilience assessment, both for the onset of the disorder and for the course
of the disorder, including the strengths that you see for this individual and the tech-
niques you would use to elicit them.

1. Reduce or eliminate substance use.

2. Improve psychological and social functioning
by mending disrupted relationships, reducing
impulsivity, building social and vocational skills,
and maintaining employment.

3. Prevent relapse by discussing the client’s ambiv-
alence about sobriety, identifying the emotional
and environmental triggers of craving, developing
coping strategies to deal with internal or external
stressors, exploring the chain of decisions lead-
ing to the resumption of substance use, and
learning from brief relapse episodes (slips) about
triggers leading to relapse so as to develop effec-
tive techniques for early intervention.

For adolescents

1. Improve family communication.

2. Help parents to develop skills for providing
proper guidance and limit setting for the youths.

3. Recognize and, if possible, treat addiction pat-
terns in the parents.

4. Help adolescents and their families to develop
alcohol- and drug-free lifestyles.

Sources: Bukstein et al., 2005; Larimer, Palmer, & Marlatt, 1999.

box 11.3 intervention Goals

Substance-Related and Addictive Disorders 151

Client characteristics that influence decision making about the most appropriate treat-
ment setting include the perceived potential harm of withdrawal, the severity of comorbid
health and mental health concerns, the level of previous treatment response, and the extent
of environmental support for the client’s sobriety (Mirin et al., 2002). These risks need to
be addressed in treatment with either a high degree of community support or temporary
removal from those circumstances through residential treatment. Regardless of the treatment
site or modalities utilized, positive outcomes are associated with the frequency, intensity, and
duration of treatment participation (Mirin et al., 2002; Prendergast, Podus, & Change, 2000).

Psychosocial treatments

Although AA models of recovery have tended to dominate the substance use treatment
field (Fuller & Hiller-Sturmhofel, 1999; Kelly, Myers, & Brown, 2002; Sheehan & Owen,
1999), social workers should be aware of alternatives for people who need help with sub-
stance use disorders. Here, we will talk about AA, alternative self-help groups, motivational
interviewing, cognitive-behavioral treatment, and family interventions. In AA self-help
groups, the participant reaches and maintains abstinence by moving through a series
of 12 steps with the assistance of a support group and sponsor. AA and NA ( Narcotics
Anonymous) self-help groups have been shown to increase abstinence, self-efficacy, and
social functioning for those who attend, especially when they engage in outside activities
with people they meet at AA (Humphreys et al., 2004). Attendance at AA meetings may
also stave off the depression that often accompanies heavy drinking (Kelly, Stout, Magill,
Tonigan, & Pagano, 2010). Still, self-help groups should probably not act as a substitute
for professional intervention, especially for those who are mandated to attend treatment,
as involuntary clients typically do not stop drinking when attending AA (Kownacki &
Shadish, 1999).

AA treatment models have also been developed as a treatment modality. In one large-
scale study called Project match, the AA model was as effective as other treatments, es-
pecially for those who initially showed severe dependence and for those whose social
networks supported drinking (Longabaugh, Wirtz, Zweben, & Stout, 1998; Project match
Research Group. 1997). The reader should be aware that, in addition to 12-step groups,
there are alternative self-help groups available to clients. These include Secular Organiza-
tion for Sobriety, SMART Recovery, Women for Sobriety, and Moderation Management
(Humphreys et al., 2004).

Of course, many people who present to treatment are not willing to change and main-
tain that they do not have a problem. One treatment approach, known as motivational
interviewing, has been designed for such involuntary clients (Miller & Rollnick, 2002) (see
Table 11.2). Another individually oriented approach that is typically used when the client
is more motivated to change is cognitive behavioral therapy. These interventions focus on
certain aspects of the substance use behavior and can be utilized in a variety of comprehen-
sive approaches (Kaminer & Waldron, 2006). Other cognitive-behavioral treatments that
are part of family intervention are described here.

Families have tremendous potential impact on either perpetuating or ameliorating the
substance use problems of a family member, including the abuser’s ability and willingness
to comply with intervention (Mirin et al., 2002). For the partners of people with addic-
tions, Al-Anon has been a widely used intervention approach. Al-Anon is a 12-step model
derived from AA and cultivates detachment from the person with the addiction and the
well-being of the family member. A lesser-known group of interventions called by various
names, such as CRAFT (Miller et al., 1999), essentially trains family members in behav-
ioral techniques to exert influence on the “drinker” so that he or she may develop motiva-
tion to change. Behavioral couples therapy is another research-focused approach for use

Part Nine: Substance-Related and Addictive Disorders152

Psychosocial Treatment for Substance Use Disorders

Theoretical orientation Description Indications and contraindications

Individual

Motivational
interviewing

A brief model (1–4 sessions) exploring
and resolving the ambivalence people
have about changing.

Can be effective with clients who
demonstrate high levels of anger1

Cognitive-behavioral Techniques include self-monitoring, the
avoidance of stimulus cues, changing
reinforcement patterns, and developing
coping skills to manage and resist urges
to use. Other skills that can be incorpo-
rated include substance refusal, commu-
nication, problem-solving, assertiveness,
relaxation training, anger management,
modifying cognitive distortions, and
relapse prevention.

The person should be motivated to
change his or her behaviors because
cognitive-behavioral therapy (CBT) is an
action-oriented approach.

Family

Behavioral training for
family member (i.e.,
CRAFT)2

The family member removes conditions
in the environment supportive of drink-
ing, reinforces appropriate behavior of
the addict, gives feedback about inappro-
priate behavior while drinking, and pro-
vides consequences if behavior exceeds
agreed-upon limits.

Although results are mixed for whether
adjustment improves for the family
member,3,4 the research shows that
these approaches have resulted in the
person with substance use entering
treatment at a significantly higher rate
and with reduced drinking than in the
comparison conditions.

Behavioral couples
therapy

A brief (10 to 15 sessions) CBT approach
delivered in either individual or couples’
group modalities that entails building
communication skills, planning family
activities, initiating caring behaviors, and
expressing feelings.

A meta-analysis found that couples
therapy was superior to individual
treatment at posttest on relationship
satisfaction, but not until the follow-up
period were substance use outcomes
superior to the control conditions.5
Most of the research has been done
with men, but recently women with
substance use disorders have been a
focus, and couples therapy especially
has been found helpful for women
with other disorders.6

1Longabaugh, Wirtz, Zweben, & Stout, 1998; Project MATCH Research Group, 1997.
2Miller, Meyers, & Tonigan, 1999.
3Miller et al., 1999
4Thomas & Corcoran, 2001
5Powers, Vedel, and Emmelkamp, 2008.
6 Fals-Stewart, Birchler, & Kelley, 2006; McCrady, Epstein, Cook, Jensen, & Hildebrandt, 2009; Winters, Fals-Stewart, O’Farrell,
Birchler, & Kelley, 2002

Table
11.2

Substance-Related and Addictive Disorders 153

when there is both a substance use problem (either alcohol or drug use) and a conflict issue
within the couple. The main objective of couples therapy is to alter patterns of interaction
that maintain chemical abuse and build a relationship that more effectively supports sobriety
(O’Farrell & Fals-Stewart, 2006).

Family therapy approaches have received the most research attention for adolescent
substance use disorders (Bukstein et al., 2005), along with CBT (Waldron & Turner, 2008).
Because of the multidimensional nature of substance use problems in adolescence, most
family therapy approaches integrate several theoretical frameworks. For instance, brief
strategic family therapy (Szapocznik & Williams, 2000) incorporates both structural
and strategic techniques. Functional family therapy possesses elements of structural and
strategic family systems approaches, as well as behavioral family therapy, with a particular
emphasis on the functions of symptoms (Alexander & Parsons, 1982). Both multidimen-
sional family therapy (Liddle, 1999) and multisystemic therapy (Henggeler, Schoenwald,
Borduin, Rowland, & Cunningham, 1998) are presented as “ecologically integrative
approaches” (Mirin et al., 2002), because they go beyond family therapy to modify multiple
domains of functioning affecting the youth’s behavior, including other key supports and
systems in the youth’s life.

As discussed, other mental health problems often coexist with substance use disorders.
Some guidelines have been developed for the treatment of people with co-occurring
psychiatric and substance use disorders (Petrakis, Gonzalez, Rosenheck, & Krystal, 2002),
and these are summarized in Box 11.4.

Pharmacologic interventions

Three types of medications are currently used in substance use treatment: (1) aversive
medications (such as Antabuse), designed to deter client drinking; (2) anticraving
medications (known as the antidipsotropics); and (3) substitution therapy. Details about
these medications are provided in Table 11.3. As aversive medications have lost popularity,
anticraving medications have become more widely used. Evidence indicates more support
for Naltrexone than Acamprosate (Anton et al., 2006). It has recently been found that a
prescription of Naltrexone for those with drinking problems substantially reduced health
care costs compared to those without a prescription (Kranzler, Montejano, Stephenson,
Wang, & Gastfriend, 2010). The use of Naltrexone may thus be a cost-effective method of
treatment.

1. Concrete needs, such as shelter and physical
health, must be a priority.

2. The mental disorder should first be stabilized.

3. Motivational interviewing may help people com-
ply with mental health treatment and substance
use treatment.

4. Confrontation, a common approach in many
substance use treatment settings, may not be ef-
fective for clients who are psychotic or potentially
suicidal, and a supportive approach is suggested
instead.

5. For clients with depression and anxiety, CBT can
address both the psychiatric and substance use
concerns.

6. The initial phase of substance use treatment
may be crucial to successful engagement and
retention, so developing interventions that focus
on improving early success in clients who are
depressed may be beneficial.

Sources: Conner et al., 2005; Martino, Carroll, Kostas, Perkins, &
Rounsaville, 2002; Petrakis et al., 2002; Rosenthal & Westreich,
1999.

box 11.4 Guidelines for the treatment of co-occurring mental health and substance Use disorders

Part Nine: Substance-Related and Addictive Disorders154

Substitution medications, such as methadone and buprenorphine, are used for heroin
dependence specifically. The goals of such medications are the prevention of withdrawal,
the elimination of cravings, and the blockage of euphoric effects obtained by illegal opiate
use (Bukstein & Cornelius, 2006). The addition of psychosocial intervention to methadone
or buprenorphine seems to produce benefits in terms of compliance with treatment,
reduced use of opiates, and abstinence from drugs at follow-up over medication alone
(Amato et al., 2009).

Pharmacological Treatment of Substance Use Disorders

Type Description Indications and contraindications

Aversive

Antabuse Inhibits the activity of aldehyde dehy-
drogenase, the enzyme that metabolizes
acetaldehyde, the first metabolic break-
down product of alcohol. In the presence
of disulfram, alcohol use results in an
accumulation of toxic levels of acetalde-
hyde, which is accompanied by a variety
of unpleasant and potentially dangerous
(but rarely lethal) symptoms1

Compliance with this medication is dif-
ficult and physicians may be reluctant to
prescribe because of common adverse
reactions2

Anticraving

Naltrexone An opioid receptor antagonist, a sub-
stance that blocks opioid receptors in
the brain, so that the individual fails to
experience positive effects from opiates or
alcohol.

Meta-analysis3: better at preventing a
“lapse” from becoming a relapse
COMBINE study4: performed as well as
behavioral treatment on drinking outcomes

Acamprosate May block glutamine receptors while acti-
vating gamma-aminobutyric acid

Meta-analysis5: better at preventing a
relapse
COMBINE study6: showed no evidence of
efficacy

Substitution (for
opioid addiction)

Methadone Works on opioid receptors Substitution medication for opioid (heroin)
addiction

Buprenorphine Works on opioid receptors Can be prescribed on an outpatient basis

Sources: Ross & Peselow, 2009
1Mirin et al., 2002
2McLellan, 2008
3Rosner, Leucht, Lehert, & Soyka, 2008
4Anton et al., 2006
5Rosner et al., 2008
6Anton et al., 2006

Table
11.3

Substance-Related and Addictive Disorders 155

critical PersPective

A difficulty with applying diagnostic criteria to substance use disorders is that so often
comorbid disorders are present—about 50% of such persons will have a co-occurring mental
health disorder. The symptoms of substance use, and the effects of certain substances and
withdrawal from substances, are often difficult to disentangle from symptoms of other mental
disorders, such as depression, anxiety, and ADHD. Substance use can be a stand-alone disor-
der or it may mask the presence of other disorders in which it is comorbid to those disorders.
A conservative position is to wait until after six weeks of sobriety to determine the presence of
comorbid disorders, although this practice is typically not implemented in treatment settings.

Another critique, regarding treatment services, is that many facilities are still oriented
around the “disease model of recovery.” Although this has been useful for many people,
our position is that substance use disorders, as well as other mental health problems, are a
biopsychosocial manifestation and that other research-based treatments should be readily
available and disseminated in addiction treatment settings. This is not so much a critique
of the validity of the disorder as much as the way in which addiction is perceived by the
substance use treatment field, and even among some social work professionals.

Directions Part III, Goal Setting and Treatment Planning Given your risk
and resilience assessments of the individual, your knowledge of the disorder, and
evidence-based practice guidelines, formulate goals and a possible treatment plan for
this individual.

Directions Part IV, Critical Perspective Formulate a critique of the diagnosis as it
relates to this case example. Questions to consider include the following: Does this
diagnosis represent a valid mental disorder from the social work perspective? Is this
diagnosis significantly different from other possible diagnoses? Your critique should
be based on the values of the social work profession (which are incongruent in some
ways with the medical model) and the validity of the specific diagnostic criteria ap-
plied to this case.

CASe 2: The Coffee Shop Waitress

Janelle is a 53-year-old widowed Caucasian female who began individual therapy three months
ago in a women’s outpatient substance use treatment program as a self-referral. She wants to
quit drinking once and for all and also get help for a deepening depression. She reports having
been “depressed” since the death of her second husband four years ago (of a heart attack), but
this has gotten worse in the past six months as she has tried to stop drinking. Janelle has abused
alcohol on and off since she was 15. She takes no other drugs. Janelle’s father and one of her
uncles were alcohol abusers, and her adult daughter (age 29) drinks heavily.

When Janelle began individual therapy, she reported having drunk approximately 10 beers
a day during a previous nine-month time span, which ended six months ago (after which her
depression began to worsen). During that time, she drank in larger and larger amounts to
achieve the desired effect, despite the fact that she was aware of the possible negative effects
on her health. Janelle states that her impulse to drink was strong whenever she tried to stop and
that she experienced spells of shaking when she went without alcohol. Janelle reports having
abused alcohol for many years before that, but not on a daily basis. She was more of a “binge
drinker,” drinking mixed drinks in bars and at home to the point of passing out, alone or with

Part Nine: Substance-Related and Addictive Disorders156

friends, once every week or two. Janelle currently reports having abstained from alcohol for
the past six months, except for two episodes of binge drinking since she began treatment one
month ago. These episodes were related to being alone and feeling lonely.

Janelle admits to feeling “terrible” about herself, because she drank so much at times.
“I must be a real weakling to have to rely on alcohol and not be able to quit. I’m certainly not
very attractive in that condition.” In addition to the issues related to her drinking, Janelle reports
intense feelings of loneliness that she attributes to a long-term sadness due to the loss of her
second husband.

Janelle also has a serious physical condition. She was diagnosed with type II diabetes eight
years ago and currently adheres to a special diet to control that illness. She reports several past
hospitalizations due to dehydration, which frequently occurs in persons with type II diabetes.
Janelle reports that she must be sure to drink enough liquids and watch out for symptoms such
as dizziness and feeling weak. Janelle has also experienced episodes of nausea and vomiting
since undergoing stomach surgery for an ulcer four months ago. Her doctor had told her to
expect periods of nausea related to her stomach condition. Janelle reports that she used to “love
food,” but since the stomach surgery she has experienced a decreased appetite and general lack
of interest in food. She finds this very frustrating and admits that “now and then” she “forgets”
about her diet and just eats what she wants, even though she may feel ill afterward. Physicians
have warned her that drinking alcohol is hard on her stomach, and although this serves as a
motivator for her to stop, she still can’t “just do it.” She sees her medical doctor regularly but
cannot sustain the treatment plans he initiates with her.

Janelle is currently working as a waitress at a coffee shop. She seems to have a strong work
ethic and has had a variety of jobs throughout her adolescent and adult life. They are all unskilled
jobs, as Janelle has only a high school diploma and never “sets out to work in one place for too
long, because my kids have always needed me.” Her three children are adults now, but she is highly
involved in the lives of her two grandchildren, often caring for them. Janelle misses work occasionally
due to oversleeping or being hung over, but she has never lost a job due to this behavior. She states
that she is considered to be “likable” and a “good worker.” She adds that “working has been
especially helpful since my husband died,” because it keeps her mind off her sadness. She admits
that if she doesn’t have to go to work in the morning, she tends to lie in bed alone for many hours,
feeling preoccupied with her sadness and crying about her lack of “purpose” in life.

Janelle currently lives alone in an apartment. She is in regular contact with her children.
Although her family relationships provide her with support, they are also sources of stress in Janelle’s
life. Her children make frequent and last-minute demands on her time for child care and financial
assistance. Janelle currently has a romantic partner, who is separated but still involved with his wife.
She views this relationship as shallow and temporary, and she wonders if she will ever again be close
to a man. In addition to still grieving the loss of her second husband, she is also mourning the recent
death of a good friend. Janelle currently has few friends, and although her church community is a
possible source of support, she is not currently very involved with it. Janelle does not have regular
transportation and must rely on friends and family in order to meet this need.

Despite her current stresses she enjoys some activities, most notably fishing and cooking.
She values her role as a grandmother. Janelle also maintains a sense of humor about her physical
health, her often stressful relationships with her children, and her overall life situation.

Janelle grew up in a rural community in the mountains of Virginia. She was raised and
continues to identify as Baptist. She considers herself a religious person, and she attended
church regularly in the past. Janelle’s household featured emotional and physical family violence.
Her father was alcohol-dependent and physically and emotionally abusive toward Janelle, her
two brothers, and her mother. Janelle identifies using alcohol as one way she learned to cope
with the trauma and stress of her family situation. Even adolescents easily obtained alcohol in
her community,, and Janelle states that she began to enjoy the “buzz” from whisky and wine
soon after she began drinking. She and her friends often drank in each other’s homes and in the
nearby woods and were rarely caught or confronted about their activity.

Substance-Related and Addictive Disorders 157

Shortly after graduating from high school, Janelle married a man she believed would be a
“good provider.” She states that her attraction to the man, whom she never knew “too well,”
abated after a year or so, but she stayed in that emotionally abusive marriage for 20 years, because
“I had kids then.” He berated her as a wife, parent, and person. Janelle worked a series of unskilled
part-time jobs during those years and says she was never happy. She saw her life as “all stress and
all work.” She was prone to spells of extreme hopelessness in which she stayed in bed, wished that
she could die, and wondered why there was nothing “pleasurable” in her life. Janelle reports that
in the past six months, and at several other times in her life, she experienced symptoms such as
low mood, fatigue, feelings of worthlessness, excessive guilt, and trouble falling asleep.

Please go to the Additional Case Workbook for directions to this case.

CASe 3: The Restless Realtor

Larry is a 27-year-old Caucasian male who lost his driver’s license six months ago after his third
DUI offense; he is required to complete a substance use treatment program in order to have the
license reinstated. He kept drinking on the first two occasions he was placed in the program and
refused to attend the required weekly AA meetings. This is the last opportunity the agency will
give him to comply with the program requirements before they close his case. Larry came to the
interview at the treatment facility well dressed and spoke articulately. He was somewhat fidgety,
constantly wringing his hands and shifting in his seat. He also had some difficulty keeping his
train of thought as he spoke about his situation, stating that he felt “distracted.”

Larry started using marijuana when he was 14 and drinking when he was 16. He was
arrested for several drug- and alcohol-related offenses in his youth and spent time in a juvenile
justice facility as a result. He was diagnosed with ADHD when he was in elementary school and
struggled with all academic subjects, especially math. He was on Ritalin for several years but is
no longer taking it. He dropped out of school during his senior year because he was making so
much money dealing drugs that he did not see the need to continue struggling in school. He
later completed his GED while serving a jail sentence for dealing.

Larry is now working as a realtor, but his business is suffering because he cannot drive. Although
he seems motivated to complete the program so that he can get his license back, he believes he has
learned to “control” his drinking and sees no problem with his regular marijuana use. When asked
what he means by controlling his drinking, he said that the three DUIs got his attention and he
doesn’t want to get into further legal trouble. He now drinks only “a couple of beers” on weekdays;
on weekends, he consumes a six-pack each night. He no longer drinks at bars because he can’t
drive and can’t afford to buy drinks. He says he is not seeing much of his friends lately because of his
transportation problems. Another reason he views his alcohol use as not being a problem is that his
friends tend to drink more than he does. In contrast, he sees himself as only a social drinker.

In sum, Larry does not think he should be in a substance use treatment program. He also
thinks he should be given credit for the few weeks he attended the program in the past, so that
his current requirements could be shortened. Larry is disgusted that he is required to attend AA,
stating that he is “not like those people” and asking, “How am I supposed to attend all these
meetings and groups if I can’t drive?”

Larry is the older of two boys. His parents divorced when he was 11, leaving his family to
struggle financially. He is close to his mother. Larry considers his mother his strongest support
and often turns to her for help. He says she is sympathetic to his driving prohibition, and she
sometimes takes him places he needs to go. She supports his need to seek treatment so that
he can get his license back, but according to Larry, “she doesn’t think I have a problem either.”
Larry has not kept in touch with his father, and his relationship with his brother is somewhat
strained. Larry claims that his brother is the source of much of his stress and that he has a lot of

Part Nine: Substance-Related and Addictive Disorders158

resentment toward him. It seems that Larry and his brother started a business together that is
not working out, and Larry feels his brother is to blame. Members of Larry’s paternal family (an
uncle and grandfather) have a history of alcohol use disorders.

Larry is currently living with his girlfriend of 18 months and their three-month-old daughter
in an apartment. His relationship with his girlfriend has been a major source of stress for the last
six months. They were engaged to be married but have broken the engagement, as Larry wants
to “move on.” Though they still live together, they are not getting along, and Larry is having a
hard time dealing with the tension. He says they argue about his inadequate earnings, his drinking
and marijuana use, and his children from a previous marriage. Larry admits he gets so frustrated
with the situation that he has been violent with his girlfriend, usually when drinking. She has called
the police, and Larry has been arrested twice for family violence. When questioned about these
episodes, Larry says, “I’ve never hit her.” He does, however, admit to once pinning her against the
wall and “getting in her face.” He also shoved her out of the way when she blocked his way out of
a room, which on at least one occasion resulted in her being knocked to the floor.

Larry has three children from a previous marriage whom he cares for every other weekend.
His relationship with his ex-wife is acrimonious, according to his description. His oldest child,
who is six, was diagnosed with leukemia three years ago. During that time, Larry was taking
antidepressants to help him deal with “that gut-wrenching situation.” The child’s cancer is now
in remission, and Larry is no longer taking the medication. When asked, he said that he did
not notice if his distractibility and fidgeting were any better on antidepressants as “I had other
things on my mind.” He says that he does not feel depressed currently but is “stressed out.”

Larry says he smokes marijuana to help him relax, and that it is the only thing that helps
him in this way. He has used it at least twice a week for several years in the evening. He finds
using marijuana preferable to being on medication. He does not report tolerance, saying that he
has always smoked one joint “to get high” and this amount has not changed in years.

Larry considers himself in excellent health and reports that “everything checked out fine” at
a physical examination about a year ago. He suffers from asthma, but keeps it under control by
using an inhaler before he exercises. He is not currently taking any other medications. He tries
to work out every day and notices that he is having an easier time working out since he quit
smoking last month.

Larry states that he has problems sleeping. It is not hard for him to fall asleep, but he
wakes frequently and has trouble getting back to sleep. He feels that he does not get enough
“deep sleep” to feel refreshed in the morning. Larry also complains that he feels anxious all the
time and cannot remember when he has not felt that way. He worries about his children, his
relationship with his girlfriend, his job, and his need to complete this program. He feels this
anxiety in his stomach and in his head and neck.

Given his visible symptoms of distractibility and hyperactivity and the fact that Larry
was diagnosed with ADHD as a child, the social work intern asked about other symptoms of
inattention, hyperactivity, and impulsivity. In regard to inattention, Larry admitted to avoiding
tasks that take a lot of mental energy and having difficulty keeping his attention on paperwork.
He says that he would probably make more money if he were better organized. He says that his
girlfriend complains about his forgetfulness and inattentiveness to her, even when she speaks to
him directly. With regard to hyperactivity, Larry fidgets, but he denies any of the other symptoms
when asked about them. However, he admits to “feeling restless” if he does not drink or smoke
marijuana in the evenings.

Please go to the Additional Case Workbook for directions to this case.

references

159

Alzheimer’s Disease

Mrs. Shirley Washington is an 89-year-old African-American female who was admitted to the
hospital with a diagnosis of lumbago (general lower back pain) and urinary retention (failure to
empty the bladder completely). Mrs. Washington appeared confused and disoriented when the
social work intern attempted to assess her. The social work intern then made an appointment
with Mrs. Washington’s son, who was listed in her chart as the emergency contact.

Mr. Washington appeared relieved when contacted by the social work intern. He reported
that he was the primary caretaker of his elderly mother, whom a physician had diagnosed
with a neurocognitive disorder about one year ago after performing a series of tests.
Mr. Washington said that the symptoms were initially not serious. Mrs. Washington would
occasionally forget things, but she was able to take care of herself. During the last three or
four months, however, his mother was becoming more forgetful. She would pick up various
personal items and then put them down, and become frustrated when she was unable to
find them. Mr. Washington reported that he kept finding these items in random places in
and around the house. In addition, Mr. Washington reported that his mother is no longer
able to perform certain activities, such as knitting, that she had done throughout her life. His
mother, he went on to say, often did not recognize her own children, relatives, and friends.
She became panicky at such times and would yell at people to leave her alone. These episodes
became worse around sunset.

N
eurocognitive disorders are characterized by deficits in a person’s thought pro-
cesses that are due to brain dysfunction and account for a significant decline
from the previous level of functioning (American Psychiatric Association [APA],

2013). The classifications of these disorders include delirium (a time-limited cognitive
disturbance), and the major and mild neurocognitive disorders (ranging in severity from
memory impairment as the only symptom to multiple cognitive deficits beyond mere
memory impairment). Cognitive deficits may develop in the areas of complex attention;
executive function; learning, and memory; language; perceptual/motor ability and social
cognition. This chapter focuses on neurocognitive disorder (NCD) due to Alzheimer’s
disease (hereafter noted as AD). (Note: Any disorder is diagnosable as either major or mild
based on symptom severity.) AD involves a progressive decline in the number of func-
tioning neurons in the person’s central nervous system (He et al., 2010). About 50 to 60%
of persons with NCD have AD, making it the most common form of NCD worldwide
(Dartingues, 2009). There are many other NCDs that, unlike AD, stem from identifiable
medical conditions; as one example, vascular neurocognitive disorder is produced by a
series of small strokes.

C h a p t e r 1 2

Part Ten: Neurocognitive Disorders160

PrevalenCe and Comorbidity

Old age is often falsely stereotyped as a stage of life that includes high rates of AD. Still,
the disease affects as many as 5 million Americans (Mosconi et al., 2010). More than half
of them receive care at home, whereas the others reside in health care institutions. The
prevalence of AD doubles for every age group five years beyond age 65. Some studies indi-
cate that nearly half of all people aged 85 and older have symptoms of AD (Boise, Neal, &
Kaye, 2004). Prevalence estimates range from 1.4 to 1.6% for persons aged 65 to 69 years,
rising to between 16 and 25% for persons over 85 years old. A study sponsored by the
National Institute on Aging indicated that the annual number of cases in the United States
is expected to double by the middle of the 21st century (Brookmeyer et al., 2011). The pro-
portion of new cases identified after age 85 will increase from 40% (in 1995) to 62% in 2050,
when the youngest baby boomers reach that age.

The most common observable symptoms of AD are apathy (found in 72% of per-
sons), agitation and aggression (60%), anxiety (48%), and depression (48%) (Waldemar
et al., 2007). It must be emphasized, however, that recent research has shown that persons
with AD retain more of their emotional responsiveness to external stimuli than was once
assumed (Henry, Rendell, Scicluna, Jackson, & Phillips, 2009). Ten to twenty percent of
such persons qualify for a diagnosis of major depressive disorder, which presents somewhat
differently than “typical” depression. In AD depression features the symptoms of poor mo-
tivation, delusions, anxiety, and agitation, but not suicidal ideation, guilt, or low self-esteem
(Rosenberg et al., 2005).

assessment Guidelines

Social workers who are involved with clients who have NCDs are likely to function as mem-
bers of interdisciplinary health care teams. They can provide comprehensive psychosocial
assessments of client and family functioning, but AD must be diagnosed by a physician. The
major symptoms of AD (listed in the order in which they develop) include loss of recent
memory, loss of judgment, problems with abstract thinking, loss of higher order functions
(planning), and personality changes (exaggerations of normal traits). There are no medical
tests that can positively identify the presence of the disorder; instead, it is diagnosed when
other possibilities are ruled out (Mungas et al., 2010). The following guidelines, however, can
help differentiate possible AD from other neurocognitive and mental disorders:

• AD is not diagnosed if the deficits occur exclusively during a period of delirium.
• Memory impairment alone is not sufficient to diagnose a major NCD (it may indi-

cate the presence of a minor form of the disorder).
• Some NCDs are due to identifiable medical causes such as strokes, anemia, brain

tumors, hypothyroidism, infections, and metabolic deficiencies.
• Cognitive impairments may occur due to the effects of substance intoxication or

withdrawal, so these possible etiologies must be ruled out.
• NCD differs from the cognitive disorder of schizophrenia, in that the latter diagno-

sis has an earlier age of onset, less severe cognitive impairment, and symptoms that
usually include hallucinations and delusions.

• Memory deficits may be present in major depression; these deficits tend to remit
with the depression.

• Most older adults experience age-related cognitive impairments, but these are not
as severe as the symptoms of NCD; still, it is often difficult to distinguish “normal”
cognitive decline from mild NCD.

Alzheimer’s Disease 161

Mr. Washington stated that he locked the house at night and took the key to his
bedroom because Mrs. Washington would sometimes wander through the house. On
several occasions when the key was in the lock, she wandered into the streets and got lost.
Fortunately, Mrs. Washington was never injured and was returned home by either neighbors
or the police. Mr. Washington mentioned that his mother took medication for NCD, but the
medication caused constipation. She ate prunes every morning and drank milk of magnesia.

When the social work intern asked Mr. Washington about his mother’s substance use,
he said that she used to smoke cigarettes. She didn’t smoke on a regular basis anymore, but
sometimes people would give her cigarettes that she would save and smoke later. Unfortu-
nately, she would often put a lit cigarette down and then forget about it, leading to several
small fires in the home. Mrs. Washington also used to drink two bottles of beer every night
with dinner until about two months ago, when Mr. Washington started to give his mother
nonalcoholic beer as recommended by her primary care physician.

Mr. Washington reported that his mother was still able to take care of most of her activi-
ties of daily living (ADLs), although she required help with washing and bathing. Because
she had difficulty getting in and out of the bathtub, Mr. Washington remodeled the bathroom
and installed a tub with a seat and a door on the side. When helping his mother undress for
the bath during the past few weeks, Mr. Washington noticed some occasional incontinence.

Mr. Washington reported that the house in which he and his mother live has two lev-
els, with 12 steps between levels. Mrs. Washington had no difficulty climbing the stairs
prior to her recent hospitalization. She also did not use a cane, wheelchair, or any other
durable medical equipment.

Mr. Washington stated that until recently one of his brothers lived in town and helped
with the care of his mother. This brother moved out of state several months ago for a
work-related reason. Mrs. Washington has two more sons, both of whom live out of state,
and grandchildren scattered throughout the country. Mrs. Washington also has an elderly
brother and sister who live in the area. In addition, Mr. Washington has many friends and
a few other relatives who live locally and occasionally help out with the care of his mother.

Mr. Washington mentioned that his mother’s neurocognitive symptoms have wors-
ened over the past few months, and it has become increasingly difficult for him to take care
of her. He expressed frustration that his mother had recently failed to recognize him on sev-
eral occasions and had started shouting, believing him to be an intruder. Mr. Washington
requested that the social work intern help him place his mother in long-term care because
of his inability to continue providing adequate care. At 70 years of age, he is becoming
an elderly person himself and is experiencing some health problems, including back pain,
which make it difficult to help with his mother’s ADLs such as washing and bathing. He has
never married and said he needs to concentrate on looking after himself.

As for Mrs. Washington’s previous life history, she received a high school diploma and
spent most of her adult years taking care of her children. She worked for the Census Bureau
for about 10 years.

Directions Part I, Diagnosis Given the case information prepare the following: a
diagnosis, the rationale for the diagnosis and additional information you would have
wanted to know in order to make a more accurate diagnosis.

Diagnosis
Rationale and Differential Diagnosis
Additional Information Needed

Part Ten: Neurocognitive Disorders162

Mr. Washington indicated that to his knowledge the family had no history of NCD or
any other mental health disorders. He admitted that Mrs. Washington followed a high-fat
diet for most of her life, eating a lot of fried foods.

Mrs. Washington lacks financial assets; she has no savings and does not own a home.
Mr. Washington owns the house they are living in and has the financial means to take care
of her. Mrs. Washington has health care access through Medicare and a private insurance
company from her deceased husband’s employment.

bioPsyChosoCial risk and
resilienCe influenCes

onset

A minority of AD patients develop the disorder between the ages of 40 and 60, and an ear-
lier onset implies a more rapid course. This form of AD often runs in families (McMurtray,
Ringman, & Chao, 2006). In general, AD has a gradual onset (it will usually be diagnosed
as a minor neurocognitive disorder) and produces a slow, steady decline in the person’s cog-
nitive functioning. Risks for AD are heavily weighted toward biological mechanisms, but
there are also some psychological and social influences on its development.

Biological Risk Influences
The role of genetics and biology is universally accepted as critical in the etiology and course
of AD. An analysis of the Swedish Twin Registry reported a 58 to 79% biological heritabil-
ity for AD for both men and women (Gatz et al., 2006). Age of onset is significantly more
similar for monozygotic than for dizygotic twin pairs, indicating an important role for en-
vironmental influences.

In people with AD, brain cells in the cortex and hippocampus (areas that are responsi-
ble for learning, reasoning, and memory) die after they become clogged with two abnormal
structures: neurofibrillary tangles (twisted masses of protein fibers) and plaques (deposits of
a protein called amyloid) (Meeks, Ropacki, & Jeste, 2006). Symptoms begin with changes
to the amyloid, which is part of a larger molecule, the amyloid-precursor protein (APP),
which extends from a neuron’s outer membrane (Ziabreva, Perry, & Perry, 2006). Normally
APP is “chopped up” by other enzymes and dissolves after its use. In AD, however, a pair
of enzymes (beta and gamma secretase) cleaves APP in the wrong places, leaving behind
insoluble amyloid fragments, which then become prone to bind to each other and to other
proteins, forming fibrils that make them even less soluble and harder for the body to clear
(He et al., 2010). These fibrils in turn bind with one another to form plaques. When these
substances reach a certain threshold, the brain can no longer function efficiently. Brain
neurons slowly die and lower levels of essential neurotransmitters are produced, creating
signaling problems among cells.

Specific information about genetic processes in AD is lacking, but mutations in any
of four genes (located on chromosomes 1, 14, 19, and 21) are associated with its develop-
ment (Glodzik-Sobanska et al., 2009). The APOE-2 and APOE-3 proteins appear to protect
against AD by strengthening structures vital to nerve cell functioning.

For many years amyloid-beta plaques could be observed only in autopsied brains, but
methods have recently emerged that allow the plaques to be seen in living brains (Mosconi
et al., 2010). Researchers have discovered a greater number of protein clumps among the
healthy adult children of persons with AD, especially among those whose mothers had
been diagnosed, although the presence of these plaques does not necessarily mean that a
person will develop the disease.

Alzheimer’s Disease 163

Some biological risk influences for AD are associated with gender and race. There is a
gender difference in AD incidence, but it is not significant until the age of 90, after which it
is higher among women (Musicco, 2010). One study of thousands of persons with AD and
healthy volunteers revealed that the APOE-4 gene appears to increase the risk of AD for
persons in many ethnic groups, but perhaps more consistently for Caucasians (Bachman,
Green, Benke, Cupples, & Farrer, 2003). Persons with Down syndrome, which is related to
an extra copy of chromosome 21, have an increased risk of AD. Mothers who deliver such
children prior to age 35 also have an increased risk, because they may carry the marker gene.
It must be emphasized that AD is a genetically heterogeneous disorder, and advances in the
knowledge of the human genome may contribute to more accurate profiles of its develop-
ment and course (Papassotiropoulos, Fountoulakis, Dunckley, Stephan, & Reiman, 2006).

Several biological protective influences have been identified for AD (Jedrziewski,
Lee, & Trojanowski, 2005). These include regular exercise (Middleton, Barnes, Lui, & Yaffe,
2010), the maintenance of low cholesterol levels, the use of statins (medications that work
to lower cholesterol), and the absence of head trauma.

Psychological Risk Influences
There are no known psychological causes of AD. One meta-analysis has, however,
identified depression as a small but significant risk influence (Ownby, Crocco, Acevedo,
John, & Loewenstein, 2006). Another five-year study of older adults found that although a
history of depression did not predict an onset of AD, depressive symptoms are often early
indicators of the disease for some persons (Gatz, Tyas, St. John, & Montgomery, 2005).
Higher rates of depression are found among first- and second-degree relatives of persons
with AD, perhaps because the characteristic neurofibrillary tangles are higher in cerebral
areas where the pathogenesis of depression takes place, and thus the two disorders may
share a biological association (Saczynski et al., 2010). When people begin to experience
the symptoms of AD, however, depression and anxiety are common. People may exhibit
mood swings, become distrustful of others, and show increased stubbornness. Those emo-
tional states and behaviors may be in response to frustration and changes in self-image.

Social Risk Influences
Lifestyle factors may contribute to negative health conditions that put some people at
greater risk for AD, although the role of these influences is somewhat speculative (Steinberg
et al., 2006). The prevalence of possible contributing factors, such as infections, nutritional
deficiencies, brain injury, endocrine conditions, cerebrovascular diseases, seizure disorders,
substance abuse, and brain tumors, varies across cultural groups. Persons with higher risks of
these types may have relatively low educational backgrounds and occupational status. They
may consume high-fat foods, have low blood levels of folic acid and vitamin B-12, and have
elevated levels of homocysteine, an amino acid that has been linked to circulatory problems.
Their lifestyles may include poor exercise habits, cigarette smoking (Cataldo, Prochaska, &
Glantz, 2010), and the ingestion of environmental toxins such as water pollutants.

Protective influences for AD have been identified in one literature review as including
high educational level (Rolstad et al., 2010), continued employment, regular engagement
in activities that use cognitive functions, and the pursuit of leisure activities (Jedrziewski
et al., 2005).

Course and recovery

AD cannot be cured or stabilized indefinitely; its downward course is unfortunately
unremitting. The duration of its course is unpredictable, but 5 to 10 years is most common
(Steeman, de Casterle, Godderis, & Grypdonck, 2006). Some mechanisms can either hasten

Part Ten: Neurocognitive Disorders164

or slow the progression of the disease, as outlined in Table 12.1. this section centers on
family caregiving, as there are positive associations between caregiver coping and patient
survival time (McClendon, Smyth, & Neundorfer, 2004), and between dysfunctional cop-
ing strategies and caregiver depression and anxiety (Cooper, Katone, Orrell, & Livingston,
2004). Research consistently shows that there is a sensitive psychological balance between
patients with AD and their caregivers, and that the patient’s agitation is related to caregiver
behaviors and attitudes (Zarit & Femia, 2008).

Only one third of persons with NCDs in the United States live in nursing homes (Boise
et al., 2004), which means that families are the primary caregivers for the majority of these
individuals. Although the symptoms of AD are distressing for the affected person, the situ-
ation may be equally stressful for the caregivers (Phillipe, Lalloue, & Preux, 2006). Behavior
problems—perceptual disturbances, mood disturbances, wandering, agitation, sleep dis-
turbances, incontinence, and refusal to eat—are the leading reason family members seek
professional intervention on behalf of a person with apparent NCD (Lott & Klein, 2003).
Predictors of caregiver burden are the older adult’s behavioral disturbances (especially at
night) and the presence of hallucinations (Allegri et al., 2006).

The caregiver faces ongoing challenges in balancing his or her own limits on time,
energy, and patience. The stresses experienced by family caregivers may be heightened
by their fears of loss, guilt over not being an adequate caregiver, ambivalence about the
caregiver role, conflicts with each other, and fears about their own mortality. Caregivers
with preexisting symptoms of depression experience these stresses more severely (Lu &
Austrom, 2005). Support availability is significantly associated with less stress (Morano,
2003). Many caregivers also develop some degree of resentment toward the client because
of the relentless responsibilities associated with client care (Martin-Cook, Remakel-Davis,
Svetlick, Hynan, & Weiner, 2003).

There are some differences among caregivers of older adults (not limited to AD) from dif-
ferent ethnic groups with regard to stress, resource availability, and psychological outcomes.

Biopsychosocial Risk and Resilience Assessment for the Course
(or Quality of Life) of AD

Risk Influences Protective Influences

Biological

Early onset (before age 60)
Cerebrovascular disease
Poor diet (fatty foods, low blood levels of folic acid and
vitamin B-12)

Later onset (after age 60)
Good physical health
Low-fat diet, high in folic acid and vitamin B-12, high
fish diet

Psychological

High levels of stress
Depression

Lower levels of stress
Stable mood

Social

Later diagnosis
Lack of resource availability
Absence of psychosocial interventions

Early detection and intervention
Resource availability
Interpersonal supports
Psychosocial interventions

Table
12.1

Alzheimer’s Disease 165

A meta-analysis of empirical studies found that minority caregivers were younger, less
likely to be a spouse, and more likely to receive informal support (Pinquant & Sorensen,
2006). They provided more care than Caucasian caregivers and felt stronger obligations
to do so. Asian American caregivers used less formal support than Caucasian caregivers
and, like Hispanic caregivers, were more depressed than their Caucasian counterparts. One
focus group study found that in each of these cultures, families were slower to seek out pro-
fessional interventions than were their counterparts in Western cultures, being more likely
to rely on cultural traditions of family caregiving (Jones, Chow, & Getz, 2005).

intervention

Goals

Interventions for persons with AD are focused on promoting the client’s safety, comfort, and
productivity for as long as possible and helping the family or other caregivers be more com-
petent and capable of managing the stresses that accompany their role. Early assessment and
diagnosis can reveal the range of potential problems in need of intervention, help individuals
prepare for the future, align them with support groups and other community resources, pro-
vide financial and legal referrals for persons and their families (such as information about
disability benefits and power of attorney), and initiate ongoing counseling and monitoring.

Psychosocial interventions

A literature review of evidence-based psychosocial interventions for AD patients found
support for group activities, physical activities, activity planning based on an evaluation
of behavior patterns, and sensory interventions such as music (Vernooij-Dassen, Vasse,
Zuidema, Cohen-Mansfield, & Moyle, 2010). The psychosocial interventions described later
provide examples of these kinds of interventions and are widely accepted by professionals
as effective, but it should be kept in mind that there is not yet extensive evidence-based
research to support some of them.

Traditional “talk” psychotherapies are not helpful to persons with AD except for their
adjustment in the early (mild) stages of the disease, when cognitive functioning is largely
intact. Both interpersonal and cognitive therapies have been used with clients in the early
stages. In one study, brief psychodynamic or interpersonal therapy (six sessions) helped
clients to experience less subjective stress but had no effects on cognitive functions (Burns
et al., 2005). In another study, the use of cognitive interventions (focused on education and
problem solving) helped the client and family to become proactive in managing the disease
(Claire, Wilson, Carter, Roth, & Hodges, 2004). Cognitive rehabilitation and training,
however, are not effective for improving the client’s cognitive functioning (Clare, Woods,
Moniz-Cook, Orrel, & Spector, 2007).

Many studies suggest that psychosocial interventions are helpful in improving the
patient’s quality of life (feelings of well-being and comfort). In one study of 201 per-
sons with AD, perceived quality of life improved with regular cognitive stimulation

Directions Part II, Biopsychosocial Risk and Resilience Assessment Formulate
a risk and resilience assessment, both for the onset of the disorder and for the course
of the disorder, including the strengths that you see for this individual and the tech-
niques you would use to elicit them.

Part Ten: Neurocognitive Disorders166

(being encouraged to engage in regular physical activity and discussion), although this
did not affect the course of the disorder (Lu et al., 2006). Another study of residents in a
Florida nursing home found that when nursing staff were trained to communicate more
often and more substantively with residents, those residents’ self-reports of depression
diminished ( Bourgeois, Dijkstra, & Hickey, 2005). Further, staff gained a greater awareness
of the residents’ personal lives and cognitive abilities.

There is wide agreement among researchers and practitioners that behavioral interven-
tions can be modestly effective in reducing or abolishing certain problem behaviors of clients
with AD, including aggression, screaming, poor hygiene, and incontinence (Conn & Seitz,
2010). For behavioral interventions to be effective, the social worker needs first to clarify the
target behavior and break it down into steps. The social worker next identifies the relevant
antecedent and consequent reinforcers of the target behavior as clearly as possible, includ-
ing the roles of significant others, and then enlists the caregivers to develop environmental
conditions that will make the client more likely to exhibit the desired behavior.

Lichtenberg and his colleagues have developed a “well-being” intervention for persons
with NCDs residing in special care units in nursing homes (Lichtenberg, Kemp-Havican,
MacNeill, & Johnson, 2005). This intervention, which emphasizes the empirically validated
strategy of increasing clients’ activity levels, involves training nursing staff to implement a
well-being treatment for individual clients three times weekly for 20 to 30 minutes. Following
a brainstorming session with the resident’s primary caregivers, the staff implement a series of
structured pleasurable activities for the residents on the unit, such as bird watching, walking,
and small-group interactions. The staff member assesses the client’s mood and then engages
in the activity, which is followed by rating the client’s mood again. After a 13-week experi-
mental study involving 20 residents with NCD, members of the experimental group had sig-
nificantly fewer behavioral problems, even though their levels of depression were unchanged.

Three other types of cognitive and behavioral interventions are commonly associated
with older adults, including those with AD: reminiscence, validation, and reality orienta-
tion therapies. The reminiscence and validation therapies attempt to improve or maintain
the patient’s quality of life and self-esteem, and prevent depression, anxiety, and behavior
problems, by stimulating the client’s memory (Pot et al., 2010). There is evidence to support
the usefulness of reminiscence therapy, as some participants experience cognition and
mood improvement, and caregivers may experience lower strain. Validation therapy repre-
sents a similar intervention, except that the client’s erroneous statements and observations
are not challenged. The point of the intervention is to relieve the client’s negative moods by
facilitating emotional expression and conveying empathy (Zeltzer & Cohn, 2006). Reality
orientation, which is used to increase the client’s awareness of the present and ability to
focus on self-care, also seems to have modest benefits, although these tend not to persist
beyond the situation in which they are applied (O’Connell et al., 2007). These two interven-
tions include possible adverse effects, however, such as increased agitation and frustration
in clients and stress in caregivers who apply them.

Other therapies have been adapted for use with persons who have AD. The recreational
therapies provide stimulation and enrichment for persons with NCD, mobilizing their
cognitive processes. These interventions also seem to produce short-term improvements in
mood and decreases in behavioral problems (Fitzsimmons & Buettner, 2003; Heyn, 2003).
Art interventions focus on the patient’s self-expression through the visual arts, which may
help persons with AD tap into memories (Abraham, 2005). One study of persons with mild
NCD found that participants demonstrated significantly more interest, sustained pleasure,
attention, self-esteem, and normalcy during a creative arts program (Kinney & Rentz,
2005). Still, these persons showed no differences in negative affect. Studies of music therapy
as a means of diminishing behavior and cognitive problems, and improving social and
emotional functioning, are also inconclusive (Vink, Birks, Bruinsma, & Scholten, 2007).

Alzheimer’s Disease 167

nutritional interventions

Many persons with AD gradually lose their interest in eating, which contributes to their
health problems. Several studies have considered the effects of interventions on nutritional
outcomes. In one study, behavioral interventions by nursing staff were successful in keeping
residents with AD at their meal tables longer and eating more food (Beattie, Algase, &
Song, 2004). The use of nutritional supplements improved weight gain in another experi-
mental study of 91 patients, although their weight gain was not associated with changes in
mood or cognitive function (Lauque et al., 2004). Still, nutritional supplements are least
likely to enhance energy intake in persons with low body weight (Young, Greenwood, Van
Reekum, & Binns, 2004). Diets high in carbohydrates are more favored by persons in the
late stage of the disease and thus should be provided for those persons (Young et al., 2004).

medications

The ideal remedy for AD would slow the production of amyloid by disabling the enzymes
that fabricate it. Current drug research is focused on the development of beta secretase
(a type of enzyme that affects the speed of molecular processes in the body), because the
earlier gamma blockers (which moderate the activity of a certain brain neurotransmitter)
seemed to interfere with normal brain function (He et al., 2010). Other drugs are being
targeted to prevent the binding of amyloid fragments and to bolster the immune system to
ward off development of amyloid. New drugs under investigation may mimic the protec-
tive actions of APOE-2 or APOE-3, or block the effects of APP-4. Drug therapy may be able
to decrease blood levels of APOE-4 and  support growth factors that keep brains healthy
(Lavretsky, Nguyen, & Goldstein, 2006).

With this in mind, no known medical treatment exists at the present time to cure AD
or stop its progression. At present, drug interventions are limited to those that modify
its symptoms and slow its progression (López & Birks, 2007; McShane, Areosa-Sastre, &
Minakaran, 2007). The most prominent of these are the cholinesterase inhibitors. The
FDA has approved four such drugs since 1994: tactrine, donepezil, rivastigmine, and galan-
tamine. These medications work by inhibiting the breakdown of a key brain chemical, ace-
tylcholine. A meta-analysis reveals that these medications may improve cognitive function
and global level of functioning in persons with mild AD, but that no solid evidence for
drug therapy in severe dementia exists (Birks, Grimley-Evans, Iakovidou, & Tsolaki, 2007;
Olsen, Poulsen, & Lubline, 2005). Adverse effects are significant and account for high rates
of medication withdrawal. There is little evidence that any one of the specific drugs is supe-
rior to the others in producing these modest effects.

Several claims have been made that the cholinesterase inhibitors (donepezil in par-
ticular) can improve the person’s responsiveness to psychosocial interventions. One experi-
mental study found that the use of donepezil in combination with a cognitive stimulation
program (12 hours of participatory activities involving homework and life-story discus-
sions provided over eight weeks) had greater effects on conversational and functional abili-
ties than the medication alone (Zientz, Rackley, & Chapman, 2007). Another randomized,
controlled trial found that reality-orientation interventions by caregivers (engaging the
patient in reality-based communication for 30 minutes three times a week) enhanced the
effects of donepezil (Onder, Orazio, & Ezio, 2005).

Antipsychotic drugs are the only class of medications effective in reducing or eliminat-
ing symptoms of psychosis and agitation (Lonergan, Luxenberg, Colford, & Birks, 2007).
No differences in effectiveness have been found between the older (“conventional”) and
newer (“atypical”) medications. Still, because of the increased incidence of cerebrovascular
events in dementia patients treated with these medications, caution is advised in their use
(Ballard & Waite, 2006).

Part Ten: Neurocognitive Disorders168

Formal evaluations of the efficacy of antidepressants with NCD clients are lacking.
One meta-analysis of controlled studies found very weak support for the contention that
antidepressants are an effective intervention for persons with depression and NCD (Bains,
Birks, & Dening, 2005). Another review of double-blind, placebo-controlled, randomized
trials found that antidepressant drugs improved depression but did not reduce agitation
(Franco & Messinger-Rapport, 2005). The newer selective serotonin reuptake inhibitors,
which have not yet been studied for this purpose, are generally the first choice of physicians
because of their relatively mild side effects.

interventions for Caregivers

Interventions for caregivers should include both skill-building and coping components.
As summarized by Walsh (2010a), psychoeducational interventions have been found to
be effective for alleviating the stress of caregivers and improving their coping skills. Even
“lay” community consultants may be successfully trained to provide caregivers with sup-
port and education, to an extent that caregivers experience less depression, less sense
of burden, and diminished reactivity to client behavior (Teri, McCurry, Logsdon, &
Gibbons, 2005).

Media-based psychoeducational interventions show promise as well. Caregivers who
participated in a 12-month computer-mediated, voice-interactive intervention designed
to assist with responding to patient problem behaviors through counseling, access to
stress experts, and a voice-mail telephone support group resulted in significantly lower
anxiety, depression, and sense of bother about caregiving (Mahoney, Tarlow, & Jones,
2003). A related study demonstrated the utility of a telephone-based intervention for
rural caregivers providing information, education, and support on an as-needed basis
(Glueckauf et al., 2005).

CritiCal PersPeCtive

Research on neurocognitive disorder due to Alzheimer’s disease overwhelmingly con-
cludes that the disorder results from degenerative biological processes in the brain. There
appear to be no significant psychological or social factors that directly affect its onset,
although its course may be exacerbated or slowed in the context of certain emotional and
social factors. One point of controversy, however, is based on the possibility that some
older adults who experience normal cognitive decline may be diagnosed with mild NCD,
which is new to the DSM-5. Still, AD is universally accepted as a medical disorder. It
does not generate much debate within the social work profession about negative labeling,
stigma, subjectivity, and the effects of values on diagnosis. One may wonder why AD is
included in the DSM at all, although cognitive disorders related to aging, substance abuse,
and injury have been included in the manual since its first edition in 1952. In spite of these
points, the specific causes and range of biological characteristics of AD have not been
clearly identified, which points to the need for further research before its etiology, symp-
toms, and course can be specified.

Directions Part III, Goal Setting and Treatment Planning Given your risk and
resilience assessments of the individual, your knowledge of the disorder, and evi-
dence-based practice guidelines, formulate goals and a possible treatment plan for
this individual.

Alzheimer’s Disease 169

CAse 2: From the Group Home to the Nursing Facility

Paul is a 56-year-old Caucasian male. He was raised by both parents and has one brother, but
little is known about his early years or his family’s medical history. He was diagnosed with Down
syndrome and intellectual disability sometime during his youth. He attended a special education
program in the public school system until his 18th birthday. Afterward he remained at home
with his parents and did not participate in any day programs for his cognitive impairment.
When Paul was 20 years old, his mother died from complications due to diabetes. Paul took her
death very hard, secluding himself and rarely leaving his home. His father had a serious stroke
when Paul was 33, and they both moved to another state to live with his brother. Paul started
working in a sheltered workshop shortly after arriving there. He had a hard time coping with
these adjustments and began experiencing depressive symptoms as well as significant anxiety.
He also gained almost 50 pounds. He began seeing a therapist and was put on medication for
depression and anxiety. Three years later the family moved to yet another state; soon afterward,
Paul entered the County Residential Program for persons with intellectual disabilities and moved
into a group home.

Paul thrived in this program. Within two years he lost all of the weight he had gained after
his mother’s death and no longer needed psychotropic medication. Initially Paul was living in a
home with 24-hour supports, but he was so successful there that he was given the opportunity
to move into a more independent placement, a town home for four adult males. Daytime
supports were in place to help the residents with budgeting, shopping, home maintenance,
transportation to medical appointments, and medication administration. Paul was able to
perform most other daily living tasks on his own, including showering, dressing himself, cooking
simple meals, doing his laundry, and using public transportation. Paul also had no problems
communicating with others; he spoke clearly and had a fairly diverse vocabulary. He was never
able to read, but he was able to comprehend most of what was read to him and always asked
questions about things he didn’t understand.

For about the past 15 years, Paul worked in a variety of jobs for an employment company
that helps find jobs for people with cognitive disabilities. His most recent job was in a hotel,
where he worked in the kitchen polishing all of the dinner and banquet ware for the catering
department. He enjoyed this job and took pride in bringing home his paychecks. His supervisor
said he was an excellent employee, always on task and pleasant.

Paul is a friendly, helpful, and compassionate person. He is always open to new learning
experiences and enjoys spending time in the community. He particularly likes live music and
theater, dancing, bowling, and movies. He is well liked by all who know him.

After Paul’s father died 20 years ago, he and his brother eventually lost contact. Preceding
this, his brother would routinely cancel plans to spend time with him, usually without notice.
Paul also reported that his brother treated him poorly when they did spend time together,
calling him stupid, yelling at him, and pushing him around physically. As a result, Paul decided
that he no longer wanted to spend any time with his brother. They had no contact for over 10
years, until his brother wrote an e-mail to the County Mental Health and Mental Retardation

Directions Part IV, Critical Perspective Formulate a critique of the diagnosis as it
relates to this case example. Questions to consider include the following: Does this
diagnosis represent a valid mental disorder from the social work perspective? Is this
diagnosis significantly different from other possible diagnoses? Your critique should
be based on the values of the social work profession (which are incongruent in some
ways with the medical model) and the validity of the specific diagnostic criteria ap-
plied to this case.

Part Ten: Neurocognitive Disorders170

system earlier this year, inquiring about him. Paul received the message and wrote back, but
there was no response. His brother visited Paul once when he was in the hospital for 10 minutes,
but there has been no contact since.

Paul does have some close friends. He has a close bond with the three men with whom
he lived for 15 years, as well as with one housemate’s family whom he routinely visits. He also
befriended some of the program staff members, maintaining relationships with them long after
they worked with him. He often spent the holidays and weekends with these friends.

Over the years Paul has developed a number of health problems. He has alopecia, a disease
that caused him to lose all of the hair on his body, and he also has diverticulosis, a growth in
the intestinal wall. Until recently he exercised at the local gym several days a week and has been
eating healthy foods, so he has suffered few negative effects from these disorders.

About four years ago Paul’s residential program underwent some changes. The level of staff
support increased as the needs of Paul and his housemates also grew. They now had overnight
support to ensure that the men got up and went to work on time during the week. They also had
staff for extended hours on the weekends to help transport them to community and recreational
activities, as navigating public transportation became harder. Paul was able to communicate and
perform his daily living skills with little assistance until fairly recently.

Two years ago the staff at Paul’s group home began noticing changes in his behavior. He was
beginning to struggle with signing his name. He also began repeating questions multiple times,
for example, “What are we doing today?” When reminded, he would say, “Oh, that’s right.”
Over the next year the staff noticed additional changes, such as Paul’s increased apprehension
of the unknown and greater fearfulness of walking on grass or any unpaved surfaces due to
fear of falling. His repetition of questions also became more frequent. One year ago, due to the
emergence of these behaviors, and his Down syndrome, his neurologist put him on Aricept, a
medication designed to stabilize the symptoms of early cognitive deterioration.

Around this time Paul began having a harder time remembering the names of people he
knows, but with prompting he was able to recall them. He also began developing behavioral
problems, such as incontinence during the night and smearing feces in the bathroom. His
emotions became more intense, and he cried easily whether he was happy, sad, or upset.
During the past year Paul began to struggle with tasks such as cooking and laundry that he was
previously able to complete. He lost his desire to go outside the home as well. His “lifeline” also
appeared to be blurring. He had always talked fondly of his years growing up, but he began
talking as if those memories were recent, and to speak about his parents as if they were still
alive. He was taken off Aricept six months ago because of concern that it was exacerbating his
symptoms. While the smearing ceased, no other changes were noted.

Six months ago there was a marked decline in Paul’s appetite and an increase in lethargic
behavior. Initially, staff thought this was due to a virus but after two weeks he was unable to
overcome it. His doctor did some tests and determined that he was dehydrated. A few days later
his energy appeared to be returning, but he then had a seizure at home and was taken to the
hospital by ambulance. Because Paul had no history of seizure activity, doctors ordered a CAT
scan and an MRI. There was no evidence of stroke, but the doctor said that small strokes are
rarely evident in such tests, and he suspected that Paul had had several.

After Paul returned from the hospital, his condition deteriorated further. He was no longer
able to dress or shower without full assistance. He had frequent accidents with incontinence and
began wearing special undergarments. He was unable to complete his duties at work and had to
quit his job. After a few weeks he began to sit slumped over and was no longer able to eat solid
food, or even feed himself. His communication skills suffered, he had trouble focusing on what
people were saying, and he answered questions with only one word. Soon he could walk only
with support.

Because his decline during the past month had been so rapid, Paul was re-admitted to the
hospital. The doctors thought that some of his behaviors could be due to a too-strong dose of

Alzheimer’s Disease 171

antiseizure medications, so these were discontinued. After a few days Paul began to regain some
of his faculties. He was able to converse with others, sit up straight, eat on his own (although still
only pureed foods), and walk with support. He was introduced to a new antiseizure medication
while still in the hospital, and upon release was referred to a rehabilitation facility for physical
and occupational therapy.

Paul did well in his physical and occupational therapy sessions. He became strong enough
to walk on his own, and some remnants of his “old self” returned. Still, he was unable to return
to the group home, because he required more daily support than the facility was able to provide.
He applied for Medicaid and became a resident in another long-term nursing facility.

At the present time Paul’s condition fluctuates day by day. He is still able to walk but
sometimes has difficulty eating without assistance, often forgetting how to use utensils
properly. He recognizes his friends when they visit but is unable to recall their names. Paul is
still affectionate and enjoys company, but he generally speaks in one-word phrases, and his
responses to questions often seem nonsensical. He can often be found staring into space with a
blank expression or playing intently with a small object, such as a straw or piece of paper.

Paul has been hospitalized twice since moving into his present nursing facility. Once he was
found lying on the floor of his room with a dangerously low amount of oxygen in his system,
and the other time he had another seizure. A friend of his has been appointed his legal guardian
to make medical and monetary decisions for him. The guardian is currently trying to transfer
him into a group home that offers more intensive support, or to a different nursing home, due
to concerns that have arisen in his current placement. His current roommate has pretty much
taken control of all extra space and has been heard calling him “stupid” and other similar terms.
At this facility, Paul is also not generally encouraged to use the skills he does have. For example,
staff were transporting him everywhere in a wheelchair, unaware that he could still walk. A
similar scenario occurred in regard to his feeding himself.

Please go to the Additional Case Workbook for directions to this case.

CAse 3: The Former Volunteer

Mr. Grahm is an 88-year-old Caucasian widower and father of 11 children. After his wife died
21 years ago, he retired and moved into his daughter’s urban home. For 11 years following the
move, Mr. Grahm volunteered by coaching at a local high school, filing at one local hospital,
and transporting patients around the buildings at another hospital. In addition, he stayed active
by attending church on a daily basis, attending his grandchildren’s sports activities, and visiting
with family members whenever possible. Mr. Grahm also walked two miles every day to stay
healthy.

Beginning 10 years ago, Mr. Grahm’s daughter and family noticed that he frequently
misplaced his keys, hats, wallet, and other items. He also started to forget that he had eaten
less than an hour after he had had a meal. In addition, his volunteer supervisors reported that
Mr. Grahm was found wandering in the parking lot, confused about where he was. He made
filing errors and asked for assistance at least once a week regarding the filing system that he had
initially developed and with which he had been quite conversant. Eight years ago, Mr. Grahm
began getting lost driving to his volunteer jobs.

Over the next few years, Mr. Grahm cut back on his volunteer work because of increasing
trouble with the tasks, getting lost, and displaying general confusion. His confusion increased at
home as well. He lost items more regularly and frequently forgot his daily schedule, whether or
not he had eaten, and whether he had turned off the stove. These problems caused Mr. Grahm
to become frustrated, agitated, and confrontational with his daughter.

Part Ten: Neurocognitive Disorders172

Six years ago, Mr. Grahm suffered an atrial fibrillation, a heart rhythm disturbance that
caused him to experience a series of minor strokes. He was admitted to the hospital for several
days. Upon returning home, the family noticed a marked decline in his functioning. He could
not remember card games he had played his whole life. He called family members by the wrong
name. He occasionally forgot how to get to church and back.

Shortly after his hospital stay, Mr. Grahm retired from all volunteer activities because his
family members took his car away from him. He also began to worry about intruders at night.
He would get up to check the doors, the hallways, and the kitchen. He looked for robbers, and
he accused neighbors and family members of spying on him and stealing his money. He hid his
personal items and could not find them. Following this, Mr. Grahm could no longer balance his
checkbook, remember how to fill out a check, or pay bills.

As the years passed, Mr. Grahm’s mental functioning continued to deteriorate, and he
became more stubborn and agitated. The family reports that as of four months ago he rarely
remembered where his personal items were, people’s names, recent events, what he was doing,
or what day it was. He forgot people and would become upset or anxious because he did not
know who the people in the house were. Mr. Grahm accused family members of stealing from
him daily. He awoke at night wandering around. When asked, he could not remember where
he was. At night, Mr. Grahm often believed he was a college student or young husband again;
he would deny having children and would insist upon completing his homework or whatever
task he needed to complete. He would often think he was in one of his past houses. He slept
later into the morning and took naps during the day. He was unable to prepare toast in the
morning because he couldn’t remember what he was doing long enough to put the bread
in the toaster. Mr. Grahm’s memory of the past was starting to fade, with the most recent
memories vanishing first.

Several months ago, Mr. Grahm was found unconscious in his room and was taken to the
hospital, where he remained for one week. The social worker did not have access to the medical
reports from this hospital stay. Upon Mr. Grahm’s return to the home, he began having auditory
hallucinations and became delusional several times a day. He thought that bugs were attacking
him. He could not remember most people, even his caregivers, and was suspicious of everyone.
He also began to wet himself. He could no longer follow two-step instructions, because he could
not remember each step nor which one came first. Mr. Grahm remains in this state currently.

Regarding his developmental and social history, Mr. Grahm experienced a normal birth.
He had three older brothers, one younger brother, and an older sister, and reports having close
relationships with his parents and siblings. His younger brother is his only living relative, and
this brother suffers from AD. His sister was diagnosed with schizophrenia and lived her adult life
in supervised residential facilities. Two of his brothers had alcohol use problems. He denies any
substance abuse or having ever seen a psychologist or psychiatrist.

Mr. Grahm grew up on a farm and his family had lower-middle socioeconomic standing.
He completed two years of college and then worked two blue-collar jobs most of his adult life to
support his family. He retired at age 67.

Mr. Grahm had kidney stones removed at age 66. Since then he has undergone two hip
replacement surgeries and cataract surgery. He was diagnosed with diabetes mellitus, type 2, at
age 82, although he made only minor dietary changes to manage this. That same year he was
diagnosed with hypertension and severe rheumatoid arthritis in his neck, shoulder, hands, and
hips. He currently takes eight medications for his various health problems.

Mr. Grahm lives with his youngest and middle daughter and her husband. These three
family members provide him with his basic care. All family members work, so Mr. Grahm is left
alone during the day. Three of his other children visit him weekly, and all others visit him twice
a month and call him each week. Mr. Grahm reportedly had close relationships with his children
and grandchildren.

Alzheimer’s Disease 173

Mr. Grahm’s primary caregivers report being exhausted and on edge. Because of his nightly
wandering and hallucinations, at least one of the caregivers stays up with him each night. At the
same time, his agitation and suspicion cause him to reject their care, and he lashes out at them.
The family is concerned about his safety during the day and the caregivers’ ability to provide
him with proper care.

Mr. Grahm is a practicing Catholic and his faith is a strong support for him. Until this year
he attended Mass each morning and had a core group of friends from the church. He still
attends Mass and sees his friends on Sundays. He occasionally speaks with his former coworkers
and volunteers, and they have provided him with additional support and conversation when
needed.

The family reports that Mr. Grahm functions best at home during the day and when
there are a lot of people around. He suffers most at night after a long day of visitors. He enjoys
reminiscing and watching live sports outside. The middle daughter, with whom he lives, most
easily calms him. Mr. Grahm is also more alert when he eats regular meals that are low in sugar.
He denies suicidal thoughts, although he says that he is lonely and sleeps when he is alone.

Please go to the Additional Case Workbook for directions to this case.

references

174

Borderline Personality Disorder

Kenda Starnes is a 19-year-old single Caucasian female referred to the mental health center
by a housemate, a 42-year-old man named John. When John called the agency, he was told
that he could not make an appointment on behalf of a nonrelative. “But she’s threatening to
kill herself,” he pleaded. He added that Kenda had recently spent one week in a psychiatric
hospital and was refusing to take the antidepressant medications the doctor had prescribed.
“She won’t listen to the doctor. She won’t listen to me. She jerks everyone around, trying to get
her way.” John was about to arrange to have the discharge summary sent to this agency, but he
apparently persuaded Kenda to call on her own behalf, because she contacted the social worker
the next day.

Kenda came to her first appointment dressed casually and appeared her stated age. During
the meeting she seemed uncomfortable and suspicious. Her affect was grim, and she rarely
made eye contact. Kenda admitted to the social worker that she was in a lot of emotional pain.
“I feel so lonely sometimes. I don’t know if it will ever go away. I used to wish someone would
rescue me, but really I don’t think anyone understands me.” Kenda added that she tried to stay
active, to “keep my mind off myself,” spending most of her time with John, his six-year-old
daughter, and the two other young adult women who lived at the house. “All of us work as
volunteer emergency medical technicians (EMTs) for the Fire Department. That’s where we met.
John had just gotten divorced and was looking for housemates.”

Asked about her current relationships, Kenda said that she liked the other women in the
house “OK” but didn’t feel that she knew them very well. She was quick to say, “They’re not
trustworthy.” She added, “John is divorced. He’s just a friend to all of us.” About that relationship,
she said, “I don’t know what he wants from me, but it’s a place to stay. Actually, I think he wants
sex from me, but I don’t like him that way. He’s kind of creepy. But it’s nice to have people
around, even though they don’t care much about me. It’s terrible when I’m by myself.” When
asked to elaborate on that point, Kenda said, “I feel lonely all the time. I need people to be
with me. Sometimes I feel I’m disintegrating when I’m alone, like I’m just fading away. It’s scary.
It’s why I hate to go to bed at night. I have to lie there alone in the dark and think. I get more
and more afraid, because I’m so empty.” Kenda admitted that she feels tired almost all the time,
partly because of poor sleep but also because of “feeling frustrated so often.”

When asked about other friends, Kenda said, “People don’t like me. You can’t trust them
anyway. People are always letting me down. I don’t do anything to hurt them, but they’re
always abandoning me when I need them. I call them and they can’t talk, or I stop by their
apartments and they’re not home, even when they’ve said they would be. I don’t know why
people don’t treat me better. I’m a good person.”

Alarmingly, the hospital records, which arrived after the first visit, indicated that Kenda had
been hospitalized 10 times in the year since her high school graduation. These inpatient stays
were all precipitated by the onset of depression, fears of losing self-control, and the alarming

C h a p t e r 1 3

Borderline Personality Disorder 175

anxiety she experienced when alone. The episodes often occurred during her chronically
sleepless nights. The hospital report also indicated that Kenda was prone to strike her fist into
concrete walls when upset. She had broken bones in her hand at least five times by doing this.
When the social worker asked about this, Kenda responded, “When I get upset, I have to do
something. I’m afraid I’ll lose control or fall apart. Sometimes when I hit the wall it brings me
down to earth.” There was no history of any mental health intervention prior to her leaving her
family’s home.

P
ersonality is a difficult concept to define. One noted theorist defined it as a stable set
of tendencies and characteristics or thoughts, beliefs, and actions that have continu-
ity over time (Maddi, 2007). The Diagnostic and Statistical Manual of Mental Disor-

ders (DSM-5) category of personality disorders represents an attempt to identify persons
whose chronic problems in social functioning are related to ingrained patterns of thinking,
behaving, and feeling. The idea of a personality as disordered is controversial, however
(Millon & Grossman, 2006). Social workers should be concerned about using these diag-
noses because they appear to describe the total person, rather than a particular aspect of
the person or the result of person-in-environment processes. In this chapter, we consider
the concept of personality disorder and, more specifically, one that is often encountered by
clinical practitioners: the borderline type.

CharaCteristiCs of Personality DisorDers

According to the American Psychiatric Association (APA) (2013), all of the personality
disorders are characterized by enduring cognitions and behaviors that deviate from cul-
tural standards, are pervasive and rigid, are stable over time, have an onset in adolescence
or early adulthood, and lead to unhappiness and impairment. They must include maladap-
tive behavior in at least two of the following areas: affect (range and intensity of emotions),
cognition (how the self and others are perceived), impulse control, and interpersonal
functioning. The DSM-5 Personality Disorders Work Group considered a revised focus on
the “disturbance of self ” and “interpersonal” domains of personality (APA, 2013) but ulti-
mately chose not to make this change. This idea has been placed in a section of the manual
including disorders for further study.

It may be helpful to consider the personality disorders as including three general
types, based on shared characteristics. The paranoid, schizoid, and schizotypal disorders
are believed to have a genetic base and are more common in the biological relatives of
people with schizophrenia. The antisocial, borderline, histrionic, and narcissistic types
are characterized by dramatic, emotional, and erratic presentations. These disorders
may have a partial genetic base, in that they have associations with other DSM disorders
such as substance abuse, mood, and somatic disorders. The avoidant, dependent, and
obsessive-compulsive types feature anxious or fearful presentations and are associated
with the anxiety disorders. It is estimated that about 9.1% of the adult U.S. population
has a personality disorder (Lenzenweger, Lane, Loranger, & Kessler, 2007). The practi-
tioner must be cautious about diagnosing a specific personality disorder, because there
is much overlap among their symptoms (Skodol, 2005). If the social worker plans to
focus intervention on the personality disorder, the term principal diagnosis should be
included.

The diagnosing clinician must make judgments about personality functioning in the
context of the client’s ethnic, cultural, and social background. Some cultures, for example,
value interpersonal dependency more than others do. Disproportionately high rates

Part Eleven: Personality Disorders176

of personality disorders are diagnosed in African-American populations, but no such
differences are evident among the Caucasian, Asian, and Hispanic populations ( McGilloway,
Hall, Lee, & Bhui, 2010). Hispanic clients have more symptoms reflecting anger, affective
instability, and unstable relationships than Caucasians do. African Americans are more
likely than Caucasians or Hispanics to be diagnosed with the paranoid and schizotypal
personality disorders (Whaley, 2001).

Personality disorder diagnoses should rarely be applied to adolescents. Personality
patterns are not considered to reach a state of constancy until late adolescence or young
adulthood. Further, the diagnosis lacks validity in young people because many symp-
toms occur in the course of normal adolescence (Chabrol et al., 2004). To diagnose a
personality disorder in a client under age 18, the symptoms must have been present for
a full year.

BorDerline Personality DisorDer

With this introduction we now move into a discussion of borderline personality disorder
(BPD). Persons with this disorder are frequently encountered in clinical settings and are
often difficult to engage in an intervention process. However, many of the principles
of assessment and intervention described here are also relevant to clients with other
personality disorders. BPD is characterized by a pattern of instability in interpersonal
relationships and self-image and a capacity for frequent and intense negative emotions.
Although there is disagreement about the core features of the disorder, most observers
agree on the characteristics of highly variable mood and impulsive behavior (Hopwood &
Zanarini, 2010).

PrevalenCe anD ComorBiDity

BPD is a significant mental health problem present in many cultures around the world
(Freeman, Stone, & Martin, 2005). A national study found that it can be diagnosed in 5.9%
of adults, and it is the most common personality disorder found in clinical settings (Grant
et al., 2008). BPD is diagnosed predominantly in women; the estimated gender ratio is
3:1 (Freeman et al., 2005). Actual population rates are comparable in women and men
( Lenzenweger et al., 2007), but clinical samples include more women.

Many disorders are often comorbid with BPD. A majority (84.5%) of cases meet criteria
for at least one other disorder in the past year, and the mean number is 3.2 ( Lenzenweger
et al., 2007). The most commonly seen comorbid disorders include the mood, anxiety,
and substance use disorders, with 29.4%, 21.5%, and 14.1% one-year comorbidity rates,
respectively (Grant et al., 2008). There is overlap among the symptoms of the personality
disorders as well, and BPD most often co-occurs with additional symptoms of the antiso-
cial and avoidant types (Grilo, Sanislow, & McGlashan, 2002).

Up to 55% of inpatients with BPD have a history of suicide attempts, and the actual
suicide rate is between 5 and 10% (APA, 2000). Up to 80% have committed acts of
self-mutilation (such as cutting the forearms or face). Studies have shown that non-
suicidal acts of self-mutilation are intended to express anger, punish oneself, generate
normal feelings when experiencing depersonalization, or distract oneself from painful
feelings (Brown, Comtois, & Linehan, 2002). The risk of suicide appears to be highest
when clients are in their 20s. The presence of substance use has major implications
for treatment, because clients with BPD who abuse substances generally have a poor
outcome and are at higher risk for suicide and death or injury from accidents (Kolla,
Eisenberg, & Links, 2008).

Borderline Personality Disorder 177

assessment

Although general assessment guidelines for BPD are offered in Box 13.1, a particular
challenge for assessment is to determine whether symptoms of other disorders are
circumscribed enough to justify their diagnosis. When the practitioner combines another
disorder with BPD, intervention should focus on both disorders, because the presence of
BPD is a risk influence for recovery from many other disorders (Livesley, 2004). Depressive
disorders are strongly associated with BPD. Features of depression that are particularly
characteristic of BPD are emptiness, self-condemnation, abandonment fears, hopelessness,
self-destructiveness, and repeated suicidal gestures (Berrocal, Moreno, Rando, Benvenuti, &
Cassano, 2008). In this type of presentation, one would diagnose only BPD and not a
separate major depressive disorder.

• Do the client’s presenting problems result from
patterns of interaction with others?

• Are there recent stressors that may account for
the client’s symptom presentation? If so, is this an
isolated situation or part of a general pattern?

• Is the client under the influence of any substances
(alcohol, drugs, or medicine) that may account for
the symptoms of anxiety and depression?

• Has the client’s personality changed as a result
of the presence of a medical condition (in which
case the appropriate diagnosis would be a person-
ality change due to a general medical condition)?

• Is there evidence of a history of hypomanic or
manic episodes (which may suggest a diagnosis of
bipolar disorder)?

• Is the client experiencing a major depressive
episode? (Note that features of depression
particularly characteristic of BPD are emptiness,
self-condemnation, fears of abandonment,
sense of hopelessness, self-destructiveness, and
repeated suicidal gestures; these would not be
diagnosed as a separate major depressive disorder
but as indicative of BPD.)

• If the client is an older adolescent/young adult, are
the identity concerns related to a developmental
phase?

• If there are manipulative behaviors displayed by the
client, are they related to a desire for nurturance or
to a desire for power, profit, or personal gain?

Sources: Yen et al., 2004.

Box 13.1 assessment of BPD

Kenda volunteered that she was the fourth of eight children (five girls and three boys) born to a
Catholic couple, and the fourth girl. The family was lower middle class. Her father is a struggling
furniture salesman. Her parents had a rural background and moved to their present suburban
area when Kenda was a few years old. “My dad never felt accepted in the city, because we were
country people. He seemed to take his frustrations out on me.” Kenda added, “I was always the
black sheep. I didn’t do anything bad, but that’s what my folks always told me. I was always
getting yelled at for no reason. They used to get mad, saying I was a dangerous driver. I liked to
drive my car fast, but I only did that late at night, and I never had a serious accident. It was fun,
and I knew what I was doing. But no one in my family would ride with me. I used to like when
people rode with me, because I liked to scare them.” Kenda added that she was at best cordial
with her family and had little contact with her parents and siblings. She described her parents
as “mean.” When pressed about this, Kenda shared that “My parents were together all the time
and didn’t pay much attention to us. We all had to raise ourselves.” Kenda said that she moved
out of the house the day after her high school graduation. “I stayed away from home as much

Part Eleven: Personality Disorders178

as I could all through high school, and I couldn’t wait to get away.” Kenda stated again that she
was frequently singled out as the family scapegoat. Her father in particular always criticized her
and told the others that she was worthless. “He’s like a lot of people, who don’t want to give
credit to me when it’s due.”

During the second interview Kenda was more verbal and the social worker learned more
about her background. In high school Kenda showed remarkable athletic ability, starring on
her high school’s state championship softball team two years in a row. Another impressive
accomplishment was her work on the town’s volunteer rescue squad. Kenda developed an
early interest in nursing and intentionally sought out the EMT position. She hoped to become
a registered nurse one day. She admitted to being a bit of a daredevil as well, jumping off high
cliffs into reservoirs and sometimes starting fights with other young women she didn’t know
“just for the excitement of seeing what happens.”

Kenda smiled when she talked about her fights but downplayed her accomplishments,
saying that “I’m not really good at anything. I don’t have any skills. I’m kind of a nobody.” Yet,
beginning at the age of 18, Kenda had been making emergency squad runs, going to the sites of
heart attacks and car accidents and participating in dramatic rescues. Further, she seemed to be
very effective in that capacity. “I like to keep busy,” she said. “I don’t feel so good when I just sit
around.” Indeed, Kenda and her housemates worked long hours at the Fire Department, attended
parties, played sports, and took weekend trips together. When asked if she took pride or pleasure
in these activities, she replied, “No. I’m just filling time. If I stop doing things I feel empty.” Kenda
did say that she missed a lot of work due to her inability to concentrate on external events and
functioned poorly when she felt sad, frightened, or irritable. She usually missed several days of
work each week and thus had an unsteady income, which was a concern to her.

Kenda suggested that her parents could provide more accurate background information and
invited the social worker to meet with them, as long as she didn’t have to be present. The social
worker had one meeting with her parents and was struck by their defensiveness. Her father said,
“Whatever Kenda tells you, don’t believe it. I always provided very well for her. We always had
food on the table and clothes in the closet. I never cared that Kenda never appreciated anything.
She was an ungrateful girl.” Kenda’s mother agreed that she was not one to nurture or be soft
with her kids. She said, “Children cannot learn too early to stand on their own two feet, and I ran
my household accordingly. They had to learn early to take care of themselves.” The social worker
concluded that Kenda’s description of an emotionally cold household was accurate.

During the third assessment meeting, Kenda said again that she sometimes felt she deserved
to be lonely, because “I’m a bad person,” even though she was not able to elaborate on this
point. At other times, however, she felt she was “an OK person.” Kenda talked about a series of
short-term relationships with boys during her last two years of high school, but she insisted that
they were superficial. She never let her boyfriends get to know her well and was never physically
intimate with them. She said, “They were always smothering me, wanting to be with me all the
time, but who wants that? They all seemed nice at first, but then I realized I couldn’t count on
them for anything, and they eventually wanted sex. That’s probably all they ever wanted. So we
wound up having lots of arguments and I had to push them away.” Still, Kenda said that she
always had a new boyfriend within a few weeks of a breakup. She said, somewhat sarcastically,
“It was a way for me to pass the time.”

After this third visit, the social worker received a letter from Kenda detailing her history
of sexual abuse by her father that spanned the ages of 5 through 17. She had never discussed
these incidents with anyone. Kenda added that the incest was her own fault, proof that she was
a bad person. The social worker asked Kenda why she had finally decided to tell her about the
incest. Kenda said she had never trusted anyone and assumed that anyone who knew her secret
would reject her. She perceived that the social worker was genuinely interested in her, although
she admitted to feeling confused by his concern. “You’re the best therapist I’ve ever known, and
I’m really trusting you with something here. You’d better not let me down.”

Borderline Personality Disorder 179

During their fourth meeting Kenda was again experiencing thoughts of death and fears
of losing control. They began the process of writing up a treatment contract and plan, and the
social worker arranged for Kenda to be seen by the agency physician for a medication evaluation.
“I’ll see him,” Kenda said, but I’ve taken meds before and they never do anything for me.”

Directions Part I, Diagnosis Given the case information, prepare the following: a
full diagnosis, the rationale for the diagnosis, and additional information you would
have wanted to know in order to make a more accurate diagnosis.

BioPsyChosoCial risk anD resilienCe
influenCes

onset

Borderline personality disorder most likely results from a combination of biological and
environmental processes. It is approximately five times more common among first-degree
biological relatives of those with the disorder than in the general population (APA, 2000).
BPD also increases familial risk for substance abuse, antisocial personality, and mood dis-
orders. Still, these risks may be related to environmental conditions as well as personal
constitution. A recent large-scale study of the genetic and environmental risk influences
among twins found that BPD appears to be approximately 38% genetic and 63% environ-
mental (Kendler et al., 2008). Additional risks for people from oppressed and vulnerable
populations are listed in Box 13.2.

youths

• Childhood history of neglect, abuse, loss, or lack
of validation places youths at risk for development
of BPD.1

• Ongoing sexual abuse in childhood is a major pre-
dictor of the severity of BPD.2

females

• BPD is diagnosed more often in women,3 although
in a national study, rates were comparable for men
and women living in the same community.4

• Men with BPD are more likely to present with
comorbid substance abuse disorders, whereas
women are more likely to present with PTSD and
eating disorders.5

racial minorities

• Hispanic persons have a disproportionately higher
rate of BPD when compared with Caucasian and
African-American groups.6

low socioeconomic status (ses)

• A background of poverty places a person with
BPD at risk of lower success rates in the realms of
intimacy and work because of additional stresses
associated with low SES.7

• Of all the personality disorders, BPD puts people
at greatest risk for unemployment, which is associ-
ated with low SES.8

1Yen et al., 2004.
2Zanarini, Frankenburg, Reich, & Fitzmaurice, 2010.
3APA, 2013.
4Lenzenweger et al., 2007.
5Skodol et al., 2007, 2005.
6Skodol et al., 2007, 2005.
7Skodol et al., 2007, 2005.
8Lenzenweger et al., 2007.

Box 13.2 BPD in vulnerable and oppressed Populations

Part Eleven: Personality Disorders180

Biological influences
The biological causes of BPD are speculative. Some of its symptoms (impulsivity, irritability,
hypersensitivity, emotional lability, and intensity) are associated with a biological founda-
tion. Researchers have studied the link between BPD and two neurotransmitters: serotonin
(which is diminished) and norepinephrine (which is overactive) (Goodman, Triebwasser, &
New, 2008). Serotonin has been linked to both external and self-directed aggression.
As noted earlier, a relationship between the personality and affective disorders has long
been argued (Mackinnon & Pies, 2006). Persons with BPD are said to have mood swings
that resemble bipolar disorder (the interpersonal conflicts are a differentiating factor).
Biological contributors to this process may include elevations of the person’s catechol-
amines (neurotransmitters that mediate mood states and aggression) and dysfunctions in
the locus coeruleus (used for information processing and memory), the amygdala in the
limbic system (that manages fear and anxiety), and the hippocampus (a center of emotional
experience) (Skodol et al., 2002).

Psychological influences
Although there is limited evidence to support their validity, psychodynamic theorists
have produced a rich literature on persons with BPD (Clarkin, Yeomans, & Kernberg,
2006; Gabbard & Horowitz, 2009). These clients are said to have failed to negotiate suc-
cessfully the delicate task of separating from primary caregivers while maintaining an
internalized sense of being cared for. During infancy, they either were or felt themselves
to be abandoned. They feel that when a parent or other close attachment figure is not
physically present or immediately available, he or she may be gone forever. The person
often experiences intense separation anxiety as a result. For these reasons, the person
carries into new relationships the sense that abandonment by significant others is always
a real threat.

Social influences
Most empirical research shows a positive relationship between childhood trauma and
borderline symptoms (Holm & Severinsson, 2008). Such trauma includes loss, sexual
and physical violence, neglect, abuse, firsthand observation of domestic violence, and
parental substance abuse or criminality. In general, clients with BPD report significantly
more negative life events than do persons with other personality disorders or depression
(Skodol et al., 2005). Ongoing sexual abuse in childhood is a major predictor of the sever-
ity of borderline syndromes (Schulte-Herbrüggen et al., 2009). Dissociative symptoms are
positively associated with inconsistent treatment by a caregiver, sexual abuse by a caregiver,
firsthand observation of sexual violence as a child, and an adult rape history (Zanarini &
Jager- Hyman, 2009).

The role of childhood trauma as a risk mechanism also appears to be related to
the person’s biological sensitivity to environmental stimuli. This mechanism is thought
to act through the neurotransmitters described earlier during the person’s physical
development. In studies of predictor variables for the BPD diagnosis, interpersonal
sensitivity emerged as most significant (Gratz, Tull, & Gunderson, 2008). Sensitivity to
intense experiences of negative emotions may be a stronger predictor of the disorder
than childhood sexual abuse. When experiencing intense emotions, persons with this
disorder tend to lose their sensitivity to the feelings of others (Bland, Williams, Scharer,
& Manning, 2004). This may produce a situation in which the person uses impulsive
and self- destructive behavior to manage the stress related to his or her hypersensitive
reactions to negative stimuli.

Another risk influence for BPD is the familial structure of Western society, in which
the upbringing of most children is limited to one or two primary caregivers, without other

Borderline Personality Disorder 181

consistent parent figures to assist when these caregivers prove to be inadequate (Millon,
2010). This is in contrast to some cultural groups where extended family routinely provide
major parenting roles.

Course and recovery

Long-term studies of clients with BPD indicate that its course is variable (Zanarini et al.,
2010) (see Table 13.1). The person’s early adulthood is often characterized by instability,
episodes of affective and impulse control problems, and high usage of general health and
mental health resources. One study of young adults found that BPD predicted negative out-
comes in the areas of academic achievement and social maladjustment over the subsequent
two years, regardless of the presence of any other diagnoses (Bagge et al., 2004).

There is some evidence, however, that the course of BPD is more benign than formerly
believed, in part because of the availability of effective interventions (Fonagy & Bateman,
2006). Later in life, a majority of individuals with the disorder attain greater stability in
social and occupational functioning, even in the absence of intervention, in part because
their acting-out symptoms tend to decrease (Himelick & Walsh, 2002). It has also been
found that the symptoms of this disorder may wax and wane throughout its course. In
a longitudinal study of clients with a variety of personality disorders, affective instability

Risk and Resilience Influences for Course of the Disorder

Risk influences Resilience influences

Biological

Estimated 37% genetic heritability
Sensitive temperament
Elevated risk of mood disorders among first-degree
relatives

Healthy prenatal environment

Psychological

Attachment deficits
Abuse, neglect
Chaotic family environment
Presence of a comorbid disorder
Self-injury
Substance use
Major symptoms: higher levels of affective instability,
identity disturbance, and impulsivity

Resolution of attachment issues, childhood trauma,
and neglect
Absence of substance use
Efforts to avoid abandonment
Stable family environment

Social

Invalidating early environment
Lack of structure in daily life
Failure to establish relationships with others
Absence of enduring relationships
Poor academic achievement
Poor occupational functioning
Living in poverty

Structured lifestyle
Some stable relationships
High academic achievement
Stable occupational functioning
Absence of poverty conditions

Sources: Bagge et al., 2004; Fonagy & Bateman, 2006; Livesley, 2004; Paris, 2003; Skodol et al., 2005; Zanarini et al., 2010.

Table
13.1

Part Eleven: Personality Disorders182

and inappropriate anger were the most stable characteristics over a two-year span for per-
sons with BPD, whereas self-injury and efforts to avoid abandonment were the least stable
(Skodol et al., 2005).

Longitudinal studies also indicate that about one third of clients with BPD appear to
recover from the disorder within 10 years after initial diagnosis, solidifying their identi-
ties and replacing self-damaging acts with modulated behavior patterns (Zanarini et al.,
2010). After 10 years of intervention, 50% of clients no longer meet the full criteria for
the disorder. Studies of hospitalized clients with BPD indicate that even though they may
gradually attain functional roles 10 to 15 years after admission to psychiatric facilities,
only about 50% of the women and 25% of the men will have attained enduring success
in intimacy (as indicated by marriage or long-term partnership) (Paris, 2003). From 50
to 75% of clients will have achieved stable, full-time employment by that time. Clients
with the disorder from backgrounds of poverty may have substantially lower success
rates in the spheres of intimacy and work because of the additional stresses associated
with that condition. Clients with comorbid drug use disorders have a higher risk of sui-
cide attempts, as do those with affective instability, identity disturbance, and impulsivity
(Skodol et al., 2005).

Biopsychosocial Risk and Resilience Assessment for the Onset of the Disorder

Risk Influences Protective Influences

Biological

Psychological

Social

Biopsychosocial Risk and Resilience Assessment for the Course of the Disorder

Risk Influences Protective Influences

Biological

Psychological

Social

Directions Part II, Biopsychosocial Risk and Resilience Assessment. Using
Table 13.2 and 13.3 formulate a risk and resilience assessment, both for the onset of
the disorder and the course of the disorder, including the strengths that you see for
this individual. What techniques could you use to elicit additional strengths in this
client?

Table
13.2

Table
13.3

Borderline Personality Disorder 183

intervention

Clients with BPD show a greater lifetime use of most categories of medication, and most
types of psychotherapy, than clients with other personality disorders or major depressive
disorder (Zanarini, Frankenburg, Hennen, Reich, & Silk, 2004). According to the National
Comorbidity Replication Survey, 42.4% of those with BPD were in treatment during the
past year (Lenzenweger et al., 2007). Still, it is challenging for practitioners to engage them
in a sustained process of intervention. It is estimated that 40 to 60% of these clients drop
out of intervention prematurely (Marziali, 2002). Further, there is a dearth of empiri-
cally validated methods of intervention, although psychodynamic writers have theorized
extensively about clinical intervention (Levy & Ablon, 2009). Much of this literature is case
studies and small samples.

Between 1974 and 1998, 15 clinical studies that included pre- and posttreatment
effects were conducted (Perry, Banon, & Ianni, 1999). All of the studies were based on
psychodynamic, interpersonal, cognitive-behavioral, and supportive therapies and reported
positive outcomes. Four studies focused specifically on BPD, and although all of these had
limitations, their pooled results indicate a 25% recovery rate per year for clients receiving
intervention. This finding about the utility of a variety of interventions for persons with
BPD has been supported more recently for cognitive therapy (Wenzel, Chapman, Newman,
Back, & Brown, 2006) and interpersonal therapy (Markowitz, Bleiberg, Pessin, & Skodol,
2007). Psychodynamic approaches will be discussed later.

In standard interventions, the practitioner establishes and maintains a therapeutic al-
liance, responds to crises, monitors the client’s safety, provides education about the disor-
der, offers consistent supportive or insight-oriented therapy, and coordinates interventions
by other providers (Livesley, 2004). In one research study, clients and practitioners alike
emphasized the theme of trust as crucial for the establishment and maintenance of a thera-
peutic relationship (Langley & Klopper, 2005). In his review of outcome studies, Livesley
(2004) concluded that comprehensive intervention in BPD requires an array of interven-
tions from different therapeutic models, delivered in a coordinated way. The practitioner
must be able to build an effective alliance with the client and then treat both the core in-
terpersonal pathology and the various behavioral manifestations of the disorder. Group in-
terventions are often productive for persons with BPD (Marziali, 2002). They can provide
opportunities for identification with other members, more opportunities for learning and
experimenting with new patterns of behaviors, and opportunities to provide and receive
empathic feedback in a supportive environment.

Because of clients’ labile moods, changing motivation, and self-harm tendencies, many
practitioners establish an explicit “contract” agreement with the client about how the rela-
tionship will proceed (Levy, Hay, & Bennett, 2006). The contract should address the timing
and frequency of sessions; plans for crisis management; the practitioner’s after-hours avail-
ability (if any); and expectations about scheduling, attendance, and payment. Because of
the client’s potential for impulsive behavior, practitioners must be comfortable with setting
limits on self-destructive behaviors.

Psychosocial interventions

While validating clients’ suffering, practitioners must also help them take appropriate
responsibility for their actions. Effective intervention helps clients realize that although
they are not responsible for their past traumas, they are responsible for controlling self-
destructive patterns in the present and future (Ryle, 2004). Interpretations of here and now
behavior as it links to events in the past are useful for helping clients learn about their
repetitive and maladaptive behavior patterns. As previously noted, splitting is a major

Part Eleven: Personality Disorders184

defense mechanism of clients with BPD. Intervention must be geared toward helping the
client begin to experience the shades of gray between these extremes and integrate the posi-
tive and negative aspects of the self and others.

Some clients with BPD may need to be seen in protective environments, usually for short
periods of time until their mood symptoms stabilize. Indications for partial or brief hos-
pitalization include dangerous, impulsive behavior that cannot be managed in an outpatient
setting; nonadherence to outpatient intervention and a deteriorating clinical picture; complex
comorbidity that requires intensive assessment of response to intervention; symptoms that
significantly interfere with functioning and are unresponsive to outpatient intervention; and
transient psychotic episodes associated with a loss of impulse control or impaired judgment
(Friedman, 2008).

Psychodynamic intervention
Psychodynamic interventions involve careful attention to the therapist–client relationship
with thoughtfully timed interpretations of the client’s transference. They draw from the
theoretical perspectives of ego psychology, object relations, and self-psychology. Psycho-
dynamic intervention is usually conceptualized as operating on an exploratory-supportive
continuum of interventions (Berzoff, 2007). On the supportive end of the continuum,
goals involve the strengthening of defenses and self-esteem, validation of feelings, inter-
nalization of the therapeutic relationship, and development of a greater capacity to cope
with disturbing feelings. At the exploratory end of the continuum the goals are to make
unconscious patterns more consciously available, increase affect tolerance, build a capacity
to delay impulsive action, provide insight into relationship problems, and develop re-
flective functioning toward a greater appreciation of internal motivation in the self and
others. A meta-analysis of psychological therapies for BPD showed that psychodynamic
interventions lower levels of anxiety and depression and reduce use of medications (Binks
et al., 2006b).

A form of psychodynamic intervention known as mentalization-based treatment
(MBT) consists of 18 months of individual and group therapy provided by a supervised
team of professionals (Bateman & Fonagy, 2008). A primary theme of the program is that
client behavior must be understood in terms of underlying mental states, and the focus of
therapy is the client’s moment-to-moment state of mind. The client and practitioner col-
laboratively generate alternate perspectives on the client’s experience of himself or herself
and others by moving from validating and supportive interventions to exploring the prac-
tice relationship itself. MBT was found superior to “treatment as usual” in an eight-year,
randomized controlled study involving 41 clients. Participants were assessed at three times
following the completion of treatment on measures of suicidality, symptoms scales, BPD
rating scales, and global assessment of functioning, and significant differences were found
between the groups.

Dialectical behavior therapy
This intervention approach assumes that the client’s core difficulty is one of affec-
tive instability (Linehan, 1993; Robins & Chatman, 2002). Dialectical behavior therapy
(DBT) is based on cognitive-behavioral and learning theories and is an intensive, one-
year outpatient intervention that combines weekly individual sessions with skills-training
groups. The purposes of the groups are to teach adaptive coping skills in the areas of
emotional regulation, distress tolerance, interpersonal effectiveness, and identity confu-
sion, and to correct maladaptive cognitions. The individual interventions, provided by
the same practitioner, address maladaptive behaviors while strengthening and general-
izing coping skills. Some client–practitioner phone contact is permitted between sessions

Borderline Personality Disorder 185

for support and crisis intervention. An important component of DBT is the consultation
team, which can help the practitioner maintain objectivity during the often intensive in-
tervention process.

DBT can be considered a well-established intervention for a client with BPD as
evidenced by seven randomized clinical trials across four different research teams
(Lynch, Chapman, & Rosenthal, 2006). Another summary of studies that compared DBT
with other treatments indicated that DBT is more effective than less structured interven-
tions in reducing client suicidality, although overall outcome differences were modest
(Binks et al., 2006a). A more recent meta-analysis of 16 randomized studies concluded
as well that DBT had a moderate effect on reducing participants’ self-injurious and sui-
cidal behaviors (Kliem, Kröger, & Kosfelder, 2010). The same study found a 27% dropout
rate, however, across studies. Finally, a 12-week psychoeducational family intervention
program based on the DBT model has been developed for family members to assist
them with managing burden and grief, and increasing their coping skills. (Fruzzetti &
Boulanger, 2005).

medications

Many clients with BPD receive medications to help manage their symptoms of depression,
suicidal ideation, anger, and impulsive behavior. In fact, because of their problematic
behaviors and frequency of comorbid symptoms, clients with BPD are prescribed more
psychotropic medications than are other psychiatric outpatients (Sansone, Rytwinski, &
Gaither, 2003). Medications generally target cognitive symptoms, mood lability, and
impulsivity. Prescribing effective medications is difficult, however, because of the disor-
der’s symptom heterogeneity, diagnostic unreliability, presence of comorbid disorders, and
potential for self-destructiveness.

Only 40 to 50 studies have been done on the drug treatment of BPD, and drug effects
are modest (Soloff, 2005). In a recent meta-analysis of the effects of various medications
on the symptoms of anger and depression, however, it was found that the class of mood
stabilizers had a significant positive effect on both symptoms (Mercer, Douglass, & Links,
2009). Antidepressant and antipsychotic (especially aripiprazole) medications had positive
effects on anger, but not depression.

Several other meta-analyses of comparison group studies support the above points.
One such study found that selective serotonin reuptake inhibitors (SSRIs) (particularly
fluoxetine) appear to be helpful in reducing anger and hostility, but that haloperidol may
be a better choice for controlling hostility and psychotic symptoms (Binks et al., 2006b).
Another meta-analysis of 22 randomized, placebo-controlled clinical trials concluded
that antidepressant and mood-stabilizing drugs were mildly effective against affective
instability and anger but did not produce significant benefits in relation to impulsiv-
ity, aggression, unstable relationships, suicidal ideation, and global functioning (Nose,
Cipriani, Biancosino, Grassi, & Barbui, 2006). Antipsychotic drugs as a class had a posi-
tive effect in terms of impulsivity, aggression, interpersonal relationships, and global
functioning.

Directions Part III, Goal Setting and Treatment Planning. Given your risk and
resilience assessment of the individual, your knowledge of the disorder, and evi-
dence-based practice guidelines, formulate goals and a possible treatment plan for
this individual.

Part Eleven: Personality Disorders186

CritiCal PersPeCtive

BPD, like all of the personality disorders, is a highly problematic diagnostic category. First,
it is based on a concept (personality) that is itself difficult to capture. Second, a personality
disorder is supposed to represent an enduring pattern of experience and behavior.
However, the DSM does not specify how long the pattern needs to persist. Without stating
a time frame, clinicians may make a diagnosis without a history of interactions with the cli-
ent. Specifically, the BPD diagnosis lacks strong validity and reliability in research studies
(Skodol et al., 2005). Different clients with this diagnosis may have quite different symptom
clusters and as a result present very differently to practitioners. Indeed, considering the dif-
ferent symptoms, people can meet the criteria in 126 different ways (Asnaani, Chelminski,
Young, & Zimmerman, 2007). Further, because one’s personality is synonymous with the
person, the diagnosis seems to present practitioners with an ethical dilemma in reinforcing
a deficits perspective on human functioning.

Third, some researchers and theorists believe that personality disorders would be
more legitimately conceptualized as dimensional rather than categorical (Skodol et al.,
2005). That is, clients should be assessed with regard to the functionality of each one of a
stable set of common personality traits, rather than as having a disorder relating to all of
them. In other words, personality disorders could be redefined as sets of generally stable
personality traits with intermittent symptomatic behaviors tied to some of these traits.
Such a conceptual shift would also create a diagnostic practice that was less stigmatizing to
clients. It was noted in Chapter 1 that the The APA considered making these fundamen-
tal change in DSM-5 but decided that the process required additional study. Proposals for
dimensional assessment are included in Section 3 of the manual.

In spite of these concerns, clients with symptoms of BPD have very real, ongoing prob-
lems, and practitioners should remain committed to working with them so that they can
achieve their goals of improved relationships and social integration.

Directions Part IV, Critical Perspective. Formulate a critique of the diagnosis as
it relates to this case example. Questions to consider include the following: Does this
diagnosis represent a valid mental disorder from the social work perspective? Is this
diagnosis significantly different from other possible diagnoses? Your critique should
be based on the values of the social work profession (which are incongruent in some
ways with the medical model) and the validity of the specific diagnostic criteria ap-
plied to this case.

CAse 1: The Only Child

Marcy is a 36-year-old Caucasian woman who came to the women’s counseling center several
weeks ago reporting feelings of anger and “wanting an outlet to vent” about several of her
relationships. She has never seen a psychiatrist or counselor before coming to the counseling
center.

Marcy’s childhood years were riddled with stresses. Her mother, Gloria, was “beautiful,”
“high-spirited,” “highly dramatic,” and an alcohol abuser. Her father, Michael, was (and
remains, accordingly to Marcy) emotionally immature and ineffectual in his career, parenting,
and many of his relationships. He was emotionally bereft over the marriage’s dissolution,
which came about because of Gloria’s drinking. The couple divorced when Marcy was two
years old.

Borderline Personality Disorder 187

Marcy was an only child, and when her parents divorced she remained in her mother’s
custody. Gloria’s addiction caused a rapid deterioration in her physical and emotional state, to
the extent that when Michael’s mother (Marcy’s paternal grandmother) came to visit several
years later, she found Marcy emaciated with sores over much of her body. Marcy’s paternal
grandparents took temporary custody of her but made it clear to Gloria that they wanted her
“to get herself together” so that Marcy could eventually return to her mother. Her grandparents
described Marcy as a “difficult child,” in that she cried easily and was hard to soothe. Gloria’s
former in-laws ended up paying for Gloria’s two lengthy stays in a drug and alcohol rehabilitation
center; however, she was unable to stop drinking.

Within several years of Marcy’s arrival in their lives, her grandparents sought permanent
legal custody through the judicial system to facilitate certain decisions for Marcy, such as
schooling and medical care. They still hoped Gloria would “dry out” and “get herself together”
so that she and Marcy could be together again. These hopes were dashed when Gloria died in a
Las Vegas hotel room, “unintentionally drinking herself to death,” when Marcy was ten.

It is clear that from the time Marcy’s grandparents took custody of her, they were her
primary caregivers. She refers to them as Mom and Dad and refers to her biological father
(Michael) as “the big kid.” Michael, who also lived with his parents through much of the rest of
Marcy’s childhood, was always in the background of her life. He took no visible parenting role,
for which Marcy continues to hold him in contempt.

Three years ago Marcy married a man named Zach, six years her junior. Marcy has no
female friends and professes to dislike most women strongly. She rarely drinks alcohol and no
longer uses illicit substances, as she fears she may have inherited a propensity toward addiction
from her mother. She admitted to drinking “a great deal,” and doing her “fair share of drugs”
in college, but she now avoids drugs and (mostly) alcohol. She admits to impulsivity in “binge
shopping,” but the behavior does not appear to cause marital strife, presumably because her
grandmother continues to allow Marcy to use her credit cards at several fine department stores.

Marcy admits to a lengthy history of instability in her interpersonal relationships, dating
back to when she was in high school, until she married. Whenever she became convinced that
a boyfriend was going to leave her, she would “beg and humiliate herself.” If that didn’t work,
she said, she would “dump him before he could do it to me.” Her romantic relationships prior to
her marriage lasted for six months at the most. At some point in college, she reported “getting
really skinny. It was great! I would run a few miles a day, eat next to nothing, and drink my
dinner at bars every night.” She was not diagnosed or treated for an eating disorder, and the
behavior seemed to resolve itself after graduation.

Marcy acknowledges that she goes through periods of feeling profoundly depressed, empty,
and abandoned, no matter how much her husband Zach tries to console her. She fears that
“something,” by which she means death, will “happen to my husband.” In the session she
emphasized loudly, “I would kill myself if anything happened to my Zach. He’s my world. He fills
me up. Every day, I live for the moment he gets home from work. I get so lonely and depressed
whenever I am apart from him.” She then quickly asserted, “He knows better than to have an
affair. I would throw him out, scratch his eyes out, and literally cut the crotches of every pair of
pants he owns. He knows better than to fuck with me. I’d make him wish he’d never been born!”

Marcy claims she and her husband are very happy and do everything together. They have
no outside friends but feel that their family (of two dogs and a cat) is their world. When Marcy
mentioned that she had thrown a party for her husband recently on his birthday, the social
worker asked who was invited. Marcy retorted that it was only she and Zach and their animals.
“Why would I want to invite anyone else? Zach is my world.”

Early in Marcy’s counseling, she confided that until very recently, she was quite close to her
husband’s sister, Jessica, but that she had flown into a rage when Jessica apparently set personal
boundaries related to Marcy’s unsolicited and disparaging advice about Jessica’s new boyfriend,
whom Marcy had never met. Marcy felt disrespected, that Jessica was “treating me like a

Part Eleven: Personality Disorders188

neighbor, not like a sister. I hate her. I hate all of my husband’s family. Zach and I decided it’s just
us against the world, and I am fine with that. We don’t need anyone else.” Since then the two
women have “made up,” and Marcy has changed her perception of Jessica to one of adoration
and admiration. “I can’t live without my sister.” She also has fluctuated between adoration and
devaluation of her mother-in-law during her short tenure at the counseling center.

Marcy says that she made clear to her husband’s family when she and Zach became
engaged that once her grandparents were gone, she was completely alone and she expected
them to be her family. She forbade them to refer to her as an “in-law,” stated that she was their
daughter or sister, and declared that she wanted a family with whom she could be “naked and
vulnerable.”

Marcy readily acknowledges that her feelings about people are very “all or nothing,” that
she “is pretty honest,” that she “either loves you or hates you,” a quality she highly values in
herself.

Marcy has been fired from two jobs in the past two years. Marcy’s version of events is,
“They’re all a bunch of assholes anyway, who set me up to fail from the beginning.” She is not
receptive to seeing any other possible interpretation and denies the possibility that she may
have had any culpability in the outcomes.

Three months ago, Marcy secured a software training position that allows her to work from
home, which minimizes her interactions with supervisors and coworkers. This arrangement has
apparently worked out quite well for her. Some strife and friction occurred recently, however, in
her relationships with her employers and coworkers, with whom she deals primarily via e-mail,
telephone, and biweekly meetings. Concurrently, Marcy was under significantly increased stress
with a heavy travel and training schedule.

Marcy exhibits remarkably little insight into her behavior, and her husband appears to align
with Marcy’s interpretations in all instances, whether regarding her troubled career path or her
relationships with coworkers, former friends, or even his sister. Marcy acknowledges that early in
their relationship, she demanded that of him (as she did of her grandmother): “You are either
with me or you are against me. If I can’t count on him to side with me no matter what, who can
I count on?”

Please go to the Additional Case Workbook for directions to this case.

CAse 3: The “Passive” Waitress

Erica is a 23-year-old single Jewish Caucasian woman who says she’s “devastated” over her recent
breakup with her boyfriend and her sudden relocation to Virginia from Florida two months ago.
She is currently staying with her sister and her sister’s fiancé in a suburb of Washington, D.C.,
while she assesses her future. Their relationship is contentious; Erica feels “controlled by her
sister,” who she says “nags” her to “clean” around the house and “judges” her when she spends
money going clubbing with her new friends instead of on groceries for the household. Erica
admits that her sister feels she abuses her hospitality.

Erica graduated from college a year ago with a degree in criminal justice, which is a field
she claims to feel “passionate” about. After graduation, Erica spent June in Europe with her
father. Upon returning to the United States she began an intimate relationship with a man who
had recently been released from prison and needed a place to stay. She allowed him to move
into her apartment and paid for his room and board over the summer, using her father’s credit
card to pay for their expenses. In early September, upon realizing that the man was cheating
on her, she abruptly moved out and came to Virginia because she wanted “to show him that I
didn’t care” and because “I wanted to escape.” At the same time, her father cut off her access

Borderline Personality Disorder 189

to his credit card. Currently, her mother is helping her with basic expenses but is threatening to
stop supporting her as well. Her sister has given her a deadline of two months to move out on
her own.

Erica details a history of unstable relationships and making “unhealthy” choices in her
relationships, with men in particular. She had a boyfriend throughout high school, by whom
she became pregnant twice (she aborted in each case) and comments that he was similar in
character to her most recent boyfriend. She remained emotionally involved in that relationship
throughout college. She is puzzled by the men she dates, stating, “I don’t know why I always
like the guys that I know my father won’t approve of.” Erica remained sexually active in college,
“You know, getting drunk and sleeping with guys I didn’t even know,” but did not have a
monogamous relationship with anyone. She has been in “almost daily” phone contact with a
young African-American man who lives in New Jersey whom she met two years ago over spring
break. Despite admitting that this man “has some problems”—he still lives at home, is in debt,
is a heavy drinker, dropped out of college, and never comes to see her (she always drives to see
him)—she has strong feelings for him and is considering moving to New Jersey to be near him.

She now holds a part-time job waiting tables at an area bar, for which she receives no
health insurance. After one week at her new job, she began dating one of the waiters, a 27-year-
old African-American male who has a four-year-old daughter. Erica states that she wants to “take
it slow,” yet she is already intensely emotional about the course of the relationship and had sex
with him within their first week of dating. She says “she just knows” they are supposed to be
together. She worries about what her family will think of these relationships, because they want
her to marry a white Jewish man.

Erica grew up in Miami, Florida, the younger of two sisters. Her parents divorced when she
was six years old and shared custody of her. She denies any history of sexual or physical abuse.
Her father fought her mother over child support for many years, and money is a controlling
force in Erica’s relationship with her father. Erica has “many issues” with her father, and her
feelings about him tend to shift. When he is financing her lifestyle, he is a “good guy.” When
she does something he does not approve of, he cuts off contact with her and she views him as
“Castro.” She repeatedly asked the social worker if her father is to blame for her problems.

Erica chose to live with her father and his new wife and stepchildren through most of her high
school years, because his rules and supervision were much more lax than those of her mother. She
used marijuana heavily throughout high school and began using other drugs (alcohol, ecstasy,
cocaine, acid) extensively in college. In her junior year in college Erica started experiencing panic
attacks and was unable to attend classes. She was given paroxetine, which she took for six months,
and her symptoms alleviated. She said her doctor told her the panic attacks could have been
caused by her recreational drug use. She denies current drug use at this time and continues to
drink socially. She is no longer taking any psychoactive medications and stated a strong aversion to
taking any at this time. She declined to see the staff psychiatrist for a consultation.

Erica describes a close and supportive relationship with her mother. She says she has a
similar personality to her mother and that they are both “passive,” although she wasn’t able to
provide any details about what this meant. She believes her father resents her because she is so
much like her mother. Erica reports that her mother suffered from major depression for over two
years after breaking up with a long-term boyfriend and was finally helped through therapy. Her
mother is currently remarried and has stepchildren much younger than Erica.

Erica’s mother sent her to therapy numerous times when she was growing up, blaming
Erica’s problems on the divorce. Erica has little recollection of the therapy and usually stopped
attending after only a few visits. She reports several traumatic events in her life thus far: having
a driver on her street pull out a gun at her and her mother while at a stop sign when she
was in the fifth grade; allowing gang members to come to a party held at her mother’s house
(while her mother was away), which resulted in the house being robbed; and undergoing two
abortions while in high school.

Part Eleven: Personality Disorders190

Erica says she doesn’t think about these past events in more than fleeting ways, and she
doesn’t have bad dreams about them. She recounted the events in detail and did not, in session,
seem to be avoiding memories of them. Erica states that while she has thought about “what it
would be like if I was no longer here,” she has never had suicidal ideation with a plan or intent
to carry it out.

Erica is an intelligent young woman with an engaging and outgoing personality and a
good sense of humor. When asked how these traits were “passive,” as she had described herself
earlier, Erica wasn’t able to reconcile these aspects of herself. Erica admits to having very low
self-esteem and no sense of “who I am” beyond what others identify for her. Her values and
goals change from day to day depending on whom she is talking to. She describes herself as
“too generous and kind,” but has strong expectations about what she must get in return for her
nurturance of others.

Erica states that she has a group of close friends in Florida with whom she maintains
contact, but she is reluctant to move back to Florida because of their negative influence on her
life (excessive partying). Still, she is bored in Virginia and “just wants to go out and have fun.”
She says she goes clubbing with her coworkers most nights after work and likes the restaurant
trade for that reason; there is typically an instant social life attached to it. She says she feels
bored and empty when she stays home at night and then usually spends her time talking on
the phone to the young man in New Jersey or her friends in Florida. She says she feels restless,
tense, and “empty” when there is no one in the house and she is alone. Because she doesn’t
like feeling this way, she says that she avoids the feelings by being with other people as much as
possible and talks on the phone almost constantly when she is by herself. She states that one of
the reasons she moved to Virginia is that she didn’t want to live by herself in the apartment after
she broke up with her boyfriend.

Erica believes that money would answer all of her problems and yearns for life in college
when she could do whatever she wanted and her father paid her expenses. She has little insight
into her pattern of behaviors in relationships and seeks therapy hoping that the social worker
can advise her “what to do.” Erica identifies “figuring out what I want to do with my life” as
her major goal and is also interested in having a “healthy relationship.” Erica has committed to
only eight therapy sessions because of her financial situation, and since beginning therapy two
months ago she has either missed or rescheduled half her appointments, allegedly due to work
conflicts.

Erica completed a Beck’s Assessment for depression and scored a 19 out of 60, putting
her in the low-depression range. She denied insomnia, decreased or increased appetite, lack of
energy, an inability to concentrate, or recurrent thoughts of death. When asked about episodes
of major depression in the past, she said she has sometimes “felt depressed” but can “snap out
of it” if she talks to a boyfriend or meets someone new.

Please go to the Additional Case Workbook for directions to this case.

references

191

Please copy and use these workbook pages for the second and third cases in each chapter.

Directions Part I Diagnosis Given the case information, prepare the following:
a diagnosis, the rationale for the diagnosis, and additional information you would
have wanted to know in order to make a more accurate diagnosis.

Diagnosis:

Rationale:

Additional Information Needed:

Appendix: Hao

Directions Part II Biopsychosocial Risk and Resilience Assessment Using Tables
A.1 and A.2, formulate a risk and resilience assessment, both for the onset of the dis-
order and for the course of the disorder. What additional techniques could you use
to elicit strengths in this client?

192 Appendix

Directions Part IV, Critical Perspective Formulate a critique of the diagnosis as it
relates to this case example. Questions to consider include the following: Does this
diagnosis represent a valid mental disorder from the social work perspective? Is this
diagnosis significantly different from other possible diagnoses? Your critique should
be based on the values of the social work profession (which are incongruent in some
ways with the medical model) and the validity of the specific diagnostic criteria
applied to this case.

Biopsychosocial Risk and Resilience Assessment for the Onset of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.1

Biopsychosocial Risk and Resilience Assessment for the Course of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.2

Directions Part III Goal Setting and Treatment Planning Given your risk and
protective factors assessment of the individual, your knowledge of the disorder, and
evidence-based practice guidelines, formulate goals and a possible treatment plan for
this individual.

193

Please copy and use these workbook pages for the second and third cases in each chapter.

Directions Part I Diagnosis Given the case information, prepare the following:
a diagnosis, the rationale for the diagnosis, and additional information you would
have wanted to know in order to make a more accurate diagnosis.

Diagnosis:

Rationale:

Additional Information Needed:

Appendix: DeShon

Directions Part II Biopsychosocial Risk and Resilience Assessment Using Tables
A.1 and A.2, formulate a risk and resilience assessment, both for the onset of the dis-
order and for the course of the disorder. What additional techniques could you use
to elicit strengths in this client?

194 Appendix

Directions Part IV, Critical Perspective Formulate a critique of the diagnosis as it
relates to this case example. Questions to consider include the following: Does this
diagnosis represent a valid mental disorder from the social work perspective? Is this
diagnosis significantly different from other possible diagnoses? Your critique should
be based on the values of the social work profession (which are incongruent in some
ways with the medical model) and the validity of the specific diagnostic criteria
applied to this case.

Biopsychosocial Risk and Resilience Assessment for the Onset of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.1

Biopsychosocial Risk and Resilience Assessment for the Course of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.2

Directions Part III Goal Setting and Treatment Planning Given your risk and
protective factors assessment of the individual, your knowledge of the disorder, and
evidence-based practice guidelines, formulate goals and a possible treatment plan for
this individual.

195

Please copy and use these workbook pages for the second and third cases in each chapter.

Directions Part I Diagnosis Given the case information, prepare the following:
a diagnosis, the rationale for the diagnosis, and additional information you would
have wanted to know in order to make a more accurate diagnosis.

Diagnosis:

Rationale:

Additional Information Needed:

Appendix: Wayne

Directions Part II Biopsychosocial Risk and Resilience Assessment Using Tables
A.1 and A.2, formulate a risk and resilience assessment, both for the onset of the dis-
order and for the course of the disorder. What additional techniques could you use
to elicit strengths in this client?

196 Appendix

Directions Part IV, Critical Perspective Formulate a critique of the diagnosis as it
relates to this case example. Questions to consider include the following: Does this
diagnosis represent a valid mental disorder from the social work perspective? Is this
diagnosis significantly different from other possible diagnoses? Your critique should
be based on the values of the social work profession (which are incongruent in some
ways with the medical model) and the validity of the specific diagnostic criteria
applied to this case.

Biopsychosocial Risk and Resilience Assessment for the Onset of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.1

Biopsychosocial Risk and Resilience Assessment for the Course of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.2

Directions Part III Goal Setting and Treatment Planning Given your risk and
protective factors assessment of the individual, your knowledge of the disorder, and
evidence-based practice guidelines, formulate goals and a possible treatment plan for
this individual.

197

Please copy and use these workbook pages for the second and third cases in each chapter.

Directions Part I Diagnosis Given the case information, prepare the following:
a diagnosis, the rationale for the diagnosis, and additional information you would
have wanted to know in order to make a more accurate diagnosis.

Diagnosis:

Rationale:

Additional Information Needed:

Appendix: Donald

Directions Part II Biopsychosocial Risk and Resilience Assessment Using Tables
A.1 and A.2, formulate a risk and resilience assessment, both for the onset of the dis-
order and for the course of the disorder. What additional techniques could you use
to elicit strengths in this client?

198 Appendix

Directions Part IV, Critical Perspective Formulate a critique of the diagnosis as it
relates to this case example. Questions to consider include the following: Does this
diagnosis represent a valid mental disorder from the social work perspective? Is this
diagnosis significantly different from other possible diagnoses? Your critique should
be based on the values of the social work profession (which are incongruent in some
ways with the medical model) and the validity of the specific diagnostic criteria
applied to this case.

Biopsychosocial Risk and Resilience Assessment for the Onset of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.1

Biopsychosocial Risk and Resilience Assessment for the Course of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.2

Directions Part III Goal Setting and Treatment Planning Given your risk and
protective factors assessment of the individual, your knowledge of the disorder, and
evidence-based practice guidelines, formulate goals and a possible treatment plan for
this individual.

199

Please copy and use these workbook pages for the second and third cases in each chapter.

Directions Part I Diagnosis Given the case information, prepare the following:
a diagnosis, the rationale for the diagnosis, and additional information you would
have wanted to know in order to make a more accurate diagnosis.

Diagnosis:

Rationale:

Additional Information Needed:

Appendix: Emma

Directions Part II Biopsychosocial Risk and Resilience Assessment Using Tables
A.1 and A.2, formulate a risk and resilience assessment, both for the onset of the dis-
order and for the course of the disorder. What additional techniques could you use
to elicit strengths in this client?

200 Appendix

Directions Part IV, Critical Perspective Formulate a critique of the diagnosis as it
relates to this case example. Questions to consider include the following: Does this
diagnosis represent a valid mental disorder from the social work perspective? Is this
diagnosis significantly different from other possible diagnoses? Your critique should
be based on the values of the social work profession (which are incongruent in some
ways with the medical model) and the validity of the specific diagnostic criteria
applied to this case.

Biopsychosocial Risk and Resilience Assessment for the Onset of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.1

Biopsychosocial Risk and Resilience Assessment for the Course of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.2

Directions Part III Goal Setting and Treatment Planning Given your risk and
protective factors assessment of the individual, your knowledge of the disorder, and
evidence-based practice guidelines, formulate goals and a possible treatment plan for
this individual.

201

Please copy and use these workbook pages for the second and third cases in each chapter.

Directions Part I Diagnosis Given the case information, prepare the following:
a diagnosis, the rationale for the diagnosis, and additional information you would
have wanted to know in order to make a more accurate diagnosis.

Diagnosis:

Rationale:

Additional Information Needed:

Appendix: Ms. Daniels

Directions Part II Biopsychosocial Risk and Resilience Assessment Using Tables
A.1 and A.2, formulate a risk and resilience assessment, both for the onset of the dis-
order and for the course of the disorder. What additional techniques could you use
to elicit strengths in this client?

202 Appendix

Directions Part IV, Critical Perspective Formulate a critique of the diagnosis as it
relates to this case example. Questions to consider include the following: Does this
diagnosis represent a valid mental disorder from the social work perspective? Is this
diagnosis significantly different from other possible diagnoses? Your critique should
be based on the values of the social work profession (which are incongruent in some
ways with the medical model) and the validity of the specific diagnostic criteria
applied to this case.

Biopsychosocial Risk and Resilience Assessment for the Onset of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.1

Biopsychosocial Risk and Resilience Assessment for the Course of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.2

Directions Part III Goal Setting and Treatment Planning Given your risk and
protective factors assessment of the individual, your knowledge of the disorder, and
evidence-based practice guidelines, formulate goals and a possible treatment plan for
this individual.

203

Please copy and use these workbook pages for the second and third cases in each chapter.

Directions Part I Diagnosis Given the case information, prepare the following:
a diagnosis, the rationale for the diagnosis, and additional information you would
have wanted to know in order to make a more accurate diagnosis.

Diagnosis:

Rationale:

Additional Information Needed:

Appendix: Gregory

Directions Part II Biopsychosocial Risk and Resilience Assessment Using Tables
A.1 and A.2, formulate a risk and resilience assessment, both for the onset of the dis-
order and for the course of the disorder. What additional techniques could you use
to elicit strengths in this client?

204 Appendix

Directions Part IV, Critical Perspective Formulate a critique of the diagnosis as it
relates to this case example. Questions to consider include the following: Does this
diagnosis represent a valid mental disorder from the social work perspective? Is this
diagnosis significantly different from other possible diagnoses? Your critique should
be based on the values of the social work profession (which are incongruent in some
ways with the medical model) and the validity of the specific diagnostic criteria
applied to this case.

Biopsychosocial Risk and Resilience Assessment for the Onset of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.1

Biopsychosocial Risk and Resilience Assessment for the Course of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.2

Directions Part III Goal Setting and Treatment Planning Given your risk and
protective factors assessment of the individual, your knowledge of the disorder, and
evidence-based practice guidelines, formulate goals and a possible treatment plan for
this individual.

205

Please copy and use these workbook pages for the second and third cases in each chapter.

Directions Part I Diagnosis Given the case information, prepare the following:
a diagnosis, the rationale for the diagnosis, and additional information you would
have wanted to know in order to make a more accurate diagnosis.

Diagnosis:

Rationale:

Additional Information Needed:

Appendix: Indira

Directions Part II Biopsychosocial Risk and Resilience Assessment Using Tables
A.1 and A.2, formulate a risk and resilience assessment, both for the onset of the dis-
order and for the course of the disorder. What additional techniques could you use
to elicit strengths in this client?

206 Appendix

Directions Part IV, Critical Perspective Formulate a critique of the diagnosis as it
relates to this case example. Questions to consider include the following: Does this
diagnosis represent a valid mental disorder from the social work perspective? Is this
diagnosis significantly different from other possible diagnoses? Your critique should
be based on the values of the social work profession (which are incongruent in some
ways with the medical model) and the validity of the specific diagnostic criteria
applied to this case.

Biopsychosocial Risk and Resilience Assessment for the Onset of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.1

Biopsychosocial Risk and Resilience Assessment for the Course of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.2

Directions Part III Goal Setting and Treatment Planning Given your risk and
protective factors assessment of the individual, your knowledge of the disorder, and
evidence-based practice guidelines, formulate goals and a possible treatment plan for
this individual.

207

Please copy and use these workbook pages for the second and third cases in each chapter.

Directions Part I Diagnosis Given the case information, prepare the following:
a diagnosis, the rationale for the diagnosis, and additional information you would
have wanted to know in order to make a more accurate diagnosis.

Diagnosis:

Rationale:

Additional Information Needed:

Appendix: Tracy Lo

Directions Part II Biopsychosocial Risk and Resilience Assessment Using Tables
A.1 and A.2, formulate a risk and resilience assessment, both for the onset of the dis-
order and for the course of the disorder. What additional techniques could you use
to elicit strengths in this client?

208 Appendix

Directions Part IV, Critical Perspective Formulate a critique of the diagnosis as it
relates to this case example. Questions to consider include the following: Does this
diagnosis represent a valid mental disorder from the social work perspective? Is this
diagnosis significantly different from other possible diagnoses? Your critique should
be based on the values of the social work profession (which are incongruent in some
ways with the medical model) and the validity of the specific diagnostic criteria
applied to this case.

Biopsychosocial Risk and Resilience Assessment for the Onset of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.1

Biopsychosocial Risk and Resilience Assessment for the Course of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.2

Directions Part III Goal Setting and Treatment Planning Given your risk and
protective factors assessment of the individual, your knowledge of the disorder, and
evidence-based practice guidelines, formulate goals and a possible treatment plan for
this individual.

209

Please copy and use these workbook pages for the second and third cases in each chapter.

Directions Part I Diagnosis Given the case information, prepare the following:
a diagnosis, the rationale for the diagnosis, and additional information you would
have wanted to know in order to make a more accurate diagnosis.

Diagnosis:

Rationale:

Additional Information Needed:

Appendix: Jay

Directions Part II Biopsychosocial Risk and Resilience Assessment Using Tables
A.1 and A.2, formulate a risk and resilience assessment, both for the onset of the dis-
order and for the course of the disorder. What additional techniques could you use
to elicit strengths in this client?

210 Appendix

Directions Part IV, Critical Perspective Formulate a critique of the diagnosis as it
relates to this case example. Questions to consider include the following: Does this
diagnosis represent a valid mental disorder from the social work perspective? Is this
diagnosis significantly different from other possible diagnoses? Your critique should
be based on the values of the social work profession (which are incongruent in some
ways with the medical model) and the validity of the specific diagnostic criteria
applied to this case.

Biopsychosocial Risk and Resilience Assessment for the Onset of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.1

Biopsychosocial Risk and Resilience Assessment for the Course of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.2

Directions Part III Goal Setting and Treatment Planning Given your risk and
protective factors assessment of the individual, your knowledge of the disorder, and
evidence-based practice guidelines, formulate goals and a possible treatment plan for
this individual.

211

Please copy and use these workbook pages for the second and third cases in each chapter.

Directions Part I Diagnosis Given the case information, prepare the following:
a diagnosis, the rationale for the diagnosis, and additional information you would
have wanted to know in order to make a more accurate diagnosis.

Diagnosis:

Rationale:

Additional Information Needed:

Appendix: Kelly

Directions Part II Biopsychosocial Risk and Resilience Assessment Using Tables
A.1 and A.2, formulate a risk and resilience assessment, both for the onset of the dis-
order and for the course of the disorder. What additional techniques could you use
to elicit strengths in this client?

212 Appendix

Directions Part IV, Critical Perspective Formulate a critique of the diagnosis as it
relates to this case example. Questions to consider include the following: Does this
diagnosis represent a valid mental disorder from the social work perspective? Is this
diagnosis significantly different from other possible diagnoses? Your critique should
be based on the values of the social work profession (which are incongruent in some
ways with the medical model) and the validity of the specific diagnostic criteria
applied to this case.

Biopsychosocial Risk and Resilience Assessment for the Onset of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.1

Biopsychosocial Risk and Resilience Assessment for the Course of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.2

Directions Part III Goal Setting and Treatment Planning Given your risk and
protective factors assessment of the individual, your knowledge of the disorder, and
evidence-based practice guidelines, formulate goals and a possible treatment plan for
this individual.

213

Please copy and use these workbook pages for the second and third cases in each chapter.

Directions Part I Diagnosis Given the case information, prepare the following:
a diagnosis, the rationale for the diagnosis, and additional information you would
have wanted to know in order to make a more accurate diagnosis.

Diagnosis:

Rationale:

Additional Information Needed:

Appendix: Tina

Directions Part II Biopsychosocial Risk and Resilience Assessment Using Tables
A.1 and A.2, formulate a risk and resilience assessment, both for the onset of the dis-
order and for the course of the disorder. What additional techniques could you use
to elicit strengths in this client?

214 Appendix

Directions Part IV, Critical Perspective Formulate a critique of the diagnosis as it
relates to this case example. Questions to consider include the following: Does this
diagnosis represent a valid mental disorder from the social work perspective? Is this
diagnosis significantly different from other possible diagnoses? Your critique should
be based on the values of the social work profession (which are incongruent in some
ways with the medical model) and the validity of the specific diagnostic criteria
applied to this case.

Biopsychosocial Risk and Resilience Assessment for the Onset of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.1

Biopsychosocial Risk and Resilience Assessment for the Course of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.2

Directions Part III Goal Setting and Treatment Planning Given your risk and
protective factors assessment of the individual, your knowledge of the disorder, and
evidence-based practice guidelines, formulate goals and a possible treatment plan for
this individual.

215

Please copy and use these workbook pages for the second and third cases in each chapter.

Directions Part I Diagnosis Given the case information, prepare the following:
a diagnosis, the rationale for the diagnosis, and additional information you would
have wanted to know in order to make a more accurate diagnosis.

Diagnosis:

Rationale:

Additional Information Needed:

Appendix: Sam

Directions Part II Biopsychosocial Risk and Resilience Assessment Using Tables
A.1 and A.2, formulate a risk and resilience assessment, both for the onset of the dis-
order and for the course of the disorder. What additional techniques could you use
to elicit strengths in this client?

216 Appendix

Directions Part IV, Critical Perspective Formulate a critique of the diagnosis as it
relates to this case example. Questions to consider include the following: Does this
diagnosis represent a valid mental disorder from the social work perspective? Is this
diagnosis significantly different from other possible diagnoses? Your critique should
be based on the values of the social work profession (which are incongruent in some
ways with the medical model) and the validity of the specific diagnostic criteria
applied to this case.

Biopsychosocial Risk and Resilience Assessment for the Onset of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.1

Biopsychosocial Risk and Resilience Assessment for the Course of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.2

Directions Part III Goal Setting and Treatment Planning Given your risk and
protective factors assessment of the individual, your knowledge of the disorder, and
evidence-based practice guidelines, formulate goals and a possible treatment plan for
this individual.

217

Please copy and use these workbook pages for the second and third cases in each chapter.

Directions Part I Diagnosis Given the case information, prepare the following:
a diagnosis, the rationale for the diagnosis, and additional information you would
have wanted to know in order to make a more accurate diagnosis.

Diagnosis:

Rationale:

Additional Information Needed:

Appendix: Nell

Directions Part II Biopsychosocial Risk and Resilience Assessment Using Tables
A.1 and A.2, formulate a risk and resilience assessment, both for the onset of the dis-
order and for the course of the disorder. What additional techniques could you use
to elicit strengths in this client?

218 Appendix

Directions Part IV, Critical Perspective Formulate a critique of the diagnosis as it
relates to this case example. Questions to consider include the following: Does this
diagnosis represent a valid mental disorder from the social work perspective? Is this
diagnosis significantly different from other possible diagnoses? Your critique should
be based on the values of the social work profession (which are incongruent in some
ways with the medical model) and the validity of the specific diagnostic criteria
applied to this case.

Biopsychosocial Risk and Resilience Assessment for the Onset of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.1

Biopsychosocial Risk and Resilience Assessment for the Course of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.2

Directions Part III Goal Setting and Treatment Planning Given your risk and
protective factors assessment of the individual, your knowledge of the disorder, and
evidence-based practice guidelines, formulate goals and a possible treatment plan for
this individual.

219

Please copy and use these workbook pages for the second and third cases in each chapter.

Directions Part I Diagnosis Given the case information, prepare the following:
a diagnosis, the rationale for the diagnosis, and additional information you would
have wanted to know in order to make a more accurate diagnosis.

Diagnosis:

Rationale:

Additional Information Needed:

Appendix: Janelle

Directions Part II Biopsychosocial Risk and Resilience Assessment Using Tables
A.1 and A.2, formulate a risk and resilience assessment, both for the onset of the dis-
order and for the course of the disorder. What additional techniques could you use
to elicit strengths in this client?

220 Appendix

Directions Part IV, Critical Perspective Formulate a critique of the diagnosis as it
relates to this case example. Questions to consider include the following: Does this
diagnosis represent a valid mental disorder from the social work perspective? Is this
diagnosis significantly different from other possible diagnoses? Your critique should
be based on the values of the social work profession (which are incongruent in some
ways with the medical model) and the validity of the specific diagnostic criteria
applied to this case.

Biopsychosocial Risk and Resilience Assessment for the Onset of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.1

Biopsychosocial Risk and Resilience Assessment for the Course of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.2

Directions Part III Goal Setting and Treatment Planning Given your risk and
protective factors assessment of the individual, your knowledge of the disorder, and
evidence-based practice guidelines, formulate goals and a possible treatment plan for
this individual.

221

Please copy and use these workbook pages for the second and third cases in each chapter.

Directions Part I Diagnosis Given the case information, prepare the following:
a diagnosis, the rationale for the diagnosis, and additional information you would
have wanted to know in order to make a more accurate diagnosis.

Diagnosis:

Rationale:

Additional Information Needed:

Appendix: Larry

Directions Part II Biopsychosocial Risk and Resilience Assessment Using Tables
A.1 and A.2, formulate a risk and resilience assessment, both for the onset of the dis-
order and for the course of the disorder. What additional techniques could you use
to elicit strengths in this client?

222 Appendix

Directions Part IV, Critical Perspective Formulate a critique of the diagnosis as it
relates to this case example. Questions to consider include the following: Does this
diagnosis represent a valid mental disorder from the social work perspective? Is this
diagnosis significantly different from other possible diagnoses? Your critique should
be based on the values of the social work profession (which are incongruent in some
ways with the medical model) and the validity of the specific diagnostic criteria
applied to this case.

Biopsychosocial Risk and Resilience Assessment for the Onset of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.1

Biopsychosocial Risk and Resilience Assessment for the Course of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.2

Directions Part III Goal Setting and Treatment Planning Given your risk and
protective factors assessment of the individual, your knowledge of the disorder, and
evidence-based practice guidelines, formulate goals and a possible treatment plan for
this individual.

223

Please copy and use these workbook pages for the second and third cases in each chapter.

Directions Part I Diagnosis Given the case information, prepare the following:
a diagnosis, the rationale for the diagnosis, and additional information you would
have wanted to know in order to make a more accurate diagnosis.

Diagnosis:

Rationale:

Additional Information Needed:

Appendix: Paul

Directions Part II Biopsychosocial Risk and Resilience Assessment Using Tables
A.1 and A.2, formulate a risk and resilience assessment, both for the onset of the dis-
order and for the course of the disorder. What additional techniques could you use
to elicit strengths in this client?

224 Appendix

Directions Part IV, Critical Perspective Formulate a critique of the diagnosis as it
relates to this case example. Questions to consider include the following: Does this
diagnosis represent a valid mental disorder from the social work perspective? Is this
diagnosis significantly different from other possible diagnoses? Your critique should
be based on the values of the social work profession (which are incongruent in some
ways with the medical model) and the validity of the specific diagnostic criteria
applied to this case.

Biopsychosocial Risk and Resilience Assessment for the Onset of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.1

Biopsychosocial Risk and Resilience Assessment for the Course of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.2

Directions Part III Goal Setting and Treatment Planning Given your risk and
protective factors assessment of the individual, your knowledge of the disorder, and
evidence-based practice guidelines, formulate goals and a possible treatment plan for
this individual.

225

Please copy and use these workbook pages for the second and third cases in each chapter.

Directions Part I Diagnosis Given the case information, prepare the following:
a diagnosis, the rationale for the diagnosis, and additional information you would
have wanted to know in order to make a more accurate diagnosis.

Diagnosis:

Rationale:

Additional Information Needed:

Appendix: Mr. Grahm

Directions Part II Biopsychosocial Risk and Resilience Assessment Using Tables
A.1 and A.2, formulate a risk and resilience assessment, both for the onset of the dis-
order and for the course of the disorder. What additional techniques could you use
to elicit strengths in this client?

226 Appendix

Directions Part IV, Critical Perspective Formulate a critique of the diagnosis as it
relates to this case example. Questions to consider include the following: Does this
diagnosis represent a valid mental disorder from the social work perspective? Is this
diagnosis significantly different from other possible diagnoses? Your critique should
be based on the values of the social work profession (which are incongruent in some
ways with the medical model) and the validity of the specific diagnostic criteria
applied to this case.

Biopsychosocial Risk and Resilience Assessment for the Onset of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.1

Biopsychosocial Risk and Resilience Assessment for the Course of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.2

Directions Part III Goal Setting and Treatment Planning Given your risk and
protective factors assessment of the individual, your knowledge of the disorder, and
evidence-based practice guidelines, formulate goals and a possible treatment plan for
this individual.

227

Please copy and use these workbook pages for the second and third cases in each chapter.

Directions Part I Diagnosis Given the case information, prepare the following:
a diagnosis, the rationale for the diagnosis, and additional information you would
have wanted to know in order to make a more accurate diagnosis.

Diagnosis:

Rationale:

Additional Information Needed:

Appendix: The Only Child

Directions Part II Biopsychosocial Risk and Resilience Assessment Using Tables
A.1 and A.2, formulate a risk and resilience assessment, both for the onset of the dis-
order and for the course of the disorder. What additional techniques could you use
to elicit strengths in this client?

228 Appendix

Directions Part IV, Critical Perspective Formulate a critique of the diagnosis as it
relates to this case example. Questions to consider include the following: Does this
diagnosis represent a valid mental disorder from the social work perspective? Is this
diagnosis significantly different from other possible diagnoses? Your critique should
be based on the values of the social work profession (which are incongruent in some
ways with the medical model) and the validity of the specific diagnostic criteria
applied to this case.

Biopsychosocial Risk and Resilience Assessment for the Onset of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.1

Biopsychosocial Risk and Resilience Assessment for the Course of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.2

Directions Part III Goal Setting and Treatment Planning Given your risk and
protective factors assessment of the individual, your knowledge of the disorder, and
evidence-based practice guidelines, formulate goals and a possible treatment plan for
this individual.

229

Please copy and use these workbook pages for the second and third cases in each chapter.

Directions Part I Diagnosis Given the case information, prepare the following:
a diagnosis, the rationale for the diagnosis, and additional information you would
have wanted to know in order to make a more accurate diagnosis.

Diagnosis:

Rationale:

Additional Information Needed:

Appendix: The “Passive” Waitress

Directions Part II Biopsychosocial Risk and Resilience Assessment Using Tables
A.1 and A.2, formulate a risk and resilience assessment, both for the onset of the dis-
order and for the course of the disorder. What additional techniques could you use
to elicit strengths in this client?

230 Appendix

Directions Part IV, Critical Perspective Formulate a critique of the diagnosis as it
relates to this case example. Questions to consider include the following: Does this
diagnosis represent a valid mental disorder from the social work perspective? Is this
diagnosis significantly different from other possible diagnoses? Your critique should
be based on the values of the social work profession (which are incongruent in some
ways with the medical model) and the validity of the specific diagnostic criteria
applied to this case.

Biopsychosocial Risk and Resilience Assessment for the Onset of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.1

Biopsychosocial Risk and Resilience Assessment for the Course of the Disorder

Risk influences Protective influences

Biological

Psychological

Social

Table
A.2

Directions Part III Goal Setting and Treatment Planning Given your risk and
protective factors assessment of the individual, your knowledge of the disorder, and
evidence-based practice guidelines, formulate goals and a possible treatment plan for
this individual.

References for Chapter 1

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