Pam is an attractive 27-year-old woman. She complained about feeling "down" and concerns about dirt and cleanliness. Pam has many intrusive thoughts about cleanliness and dirt. She also engages in a wide range of cleansing-related behaviours, particularly when she touches her genital or anal area, uses the toilet, has sexual fantasies, or encounters possible “contamination in public places”. For example, Pam first removes all of her clothing in a pre- established sequence. She lays out each article of clothing at specific spots on her bed and examines each one for any indications of “contamination”. She then thoroughly scrubs her body, starting at her feet and working meticulously up to the top of her head, using certain washcloths for certain areas of her body. Any articles of clothing that appear to have been “contaminated” are thrown into the laundry. Clean clothing is put in the spots that are vacant. She then dresses herself in the opposite order from which she took the clothes off. If there are any deviations from this order, or if Pam begins to wonder if she might have missed some contamination, she goes through the entire sequence again. She does this four or five times in a row on certain evenings.
Her focus on cleaning has interfered with her ability to carry out her work. She is aware of the absurdity of these behaviours, but at the same time feels compelled to go through with them and does not constantly question them. She reported feeling weepy most of the time and often cries when alone.
She lives by herself in a well-kept apartment. She has few friends, and social activities play a small role in her life. Most evenings she works rather late and then comes home, fixes her own dinner, and reads or watches television until she gets ready to fall asleep.
Frequently she needs alcohol and a sleeping pill to get to sleep.
Pam is an only child; her parents were divorced when she was 10 years old. She was primarily raised by her demanding mother, having had only sporadic contact with her father. Pam is a successful accountant for a large manufacturing firm and spends a lot of time at her work. She is perfectionistic, and pays much attention to detail.
Pam’s mother often expressed her love for her and spent a great deal of time with her. At times it was as if she had no other activities in her world that could give her a sense of meaning. Yet Pam does not recall the time with her mother as filled with warmth or fun. Rather, her mother focused on activities in which Pam could “improve herself”. She was constantly setting up lessons for Pam to take, and they would usually fight over whether or not Pam was really trying hard enough at these lessons. When home, her mother consistently emphasised the virtues of cleanliness and neatness. They struggled over these issues. Her mother would constantly nag her for not having the things in her room “in order”. Her mother sure that Pam washed her hands thoroughly each time Pam went to the bathroom or for any reason touched herself in the genital area. Her mother was repulsed by the smell of the bathroom and had a variety of deodorants and incense candles available to counteract the odours.
Like most individuals, Pam had times as a child when she felt unhappy. When she expressed these feelings to her mother, she would immediately try to talk Pam out of the feelings. Her major point seemed to be “I love you so much, and spend so much time with
you, so how can you be unhappy”? If Pam further expressed her unhappiness, it would quite clearly upset her mother.
Pam enjoyed visiting her father, who lived in a nearby city. He was more relaxed about the world, although he had not been very successful and had moved through a series of jobs. He was generally a happy person and attended to Pam when she was there, although he seldom kept in contact when she was absent. Her mother was never happy when Pam went to see her father and subverted this contact whenever possible. She never failed to take the chance to point out to Pam how her father’s “laziness” had brought him nothing from the world and implied that he did not support them the way he should.
Pam worked very hard and was meticulous in her preparation of school assignments. Because she was higher than average intellectually, she consistently succeeded in school. At the same time, she was seen as a “do-gooder” and was not popular with her peers. She did not get involved in class activities and spent most of her time preparing her lessons and then doing chores around the house.
She was quite active in the Methodist church, in which her mother raised her. This was generally a positive experience for her, although there were occasions when she became very upset about whether she had been “saved” or whether she was a “sinner”. The upset usually passed quickly as Pam pushed herself further into her school work or into any activity prescribed by her church for dealing with these concerns. As Pam moved into late adolescence, she became more and more beset by erotic fantasies. She was never totally sure whether this was against the rules of her church, but she supposed it was. Pam tried to control these fantasies by getting involved in repetitive tasks or other kinds of activities that distracted her attention. She particularly became a fan of crossword and jigsaw puzzles. These would occupy her for hours, and her mother was happy to buy her the most complex puzzles available. But occasionally the erotic fantasies arose at a time when Pam had few distractions available, and she would then engage in orgiastic bouts of masturbating.
Pam had surprisingly little difficulty interacting with males on a friendship basis.
Yet she seldom dated anyone for any length of time. She did become enamoured of a boy at a nearby school when she was a senior in high school. He constantly pressed her for sex, and she refused. However, one night she gave in when they had had too much to drink at a party. They then had sex virtually every day for a couple of weeks, at which time Pam began to fear pregnancy. It turned out her fears were well founded, to the horror of her mother when she was told. The mother immediately arranged an abortion. After the abortion, she took Pam on a trip to Europe, during which time she strictly chaperoned her. When they returned, the boyfriend had found another lover.
Pam slipped into the role of “top student,” received many honours, and then easily moved into the consequent role of “up-and-coming young career woman”. Her job absorbed most of her time, and it was clear that she was a rising star in the firm she worked for. Pam continued to have vague anxieties about dating, marriage, having a family, and other related issues. At the same time, however, she became preoccupied with cleanliness.
Gradually she began to engage in more and more cleansing-related behaviours, which were often triggered by her touching her genital or anal area. As time passed, she developed a variety of other cleansing-related behaviours and thoughts, usually related to such things as using the toilet. She gradually engaged in more and more cleansing-related behaviours.
CASE STUDY QUESTIONS AND REQUIREMENTS
1. Describe your clinical decision making process, assessment and diagnosis of this case (10 marks):
(A) List in point format all of the client’s presenting problems or behaviours that may constitute symptoms. (1 mark)
(B) Choose the three most likely mental disorders that the client may suffer from. Present a table for each disorder including the DSM-5 criteria, indicating which symptoms the client presents with and whether the criteria are met. (3 marks)
(C) Identify the client's primary diagnosis and justify why it is the primary diagnosis. Explain how you ruled out differential diagnoses. Are there any secondary diagnoses and or medical conditions that need considering, justify your clinical reasoning. (4 marks)
(D) What other information would you require in order to clarify the diagnosis and your understanding of the problems presented by this case? (2 marks)
2. Take the most likely principal diagnosis and discuss how the cognitive-behaviour model assists us in understanding the aetiology of the disorder by drawing on relevant theoretical and empirical research (15 marks).
3. Discuss the client’s predisposition, precipitants, perpetuating and protective factors associated with the primary disorder from the cognitive-behavioural perspective (10 marks).
4. Provide a brief overview of a treatment plan, prioritising problems and treatment goals.