Case Study
Patient Demographic: Initial Intake: Age: 31 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Widowed Counseling Setting: Private Practice Type of Counseling: Individual
Mental Status Exam: The client appears her stated age, dressed appropriately for the circumstances. Her mood is identified as sad and frustrated and her affect is restricted and flat. Her primary emotion in the session is anger, though it is expressed in a tempered manner. She demonstrates limited insight, and appropriate judgment, memory, and orientation. She reports having considered suicide when she was in high school but made no attempt and would now never consider harming herself or anyone else.
Presenting Problem: You are a counselor in a private practice setting.  Your client is a 31 year-old female who reports that she is very impatient and feels angry all the time, and is taking it out on her children and others with angry outbursts. She says that her children are good but they don’t pick up when she tells them to and often, they put their toys away in the wrong places. The client states that her husband died while the family was on a vacation. She tells you that they had stopped for a break and her husband was hit by a car.  She says that it happened in front of her and the children, who are now 6 and 7 years old. She endorses feeling angry, restless, and having trouble making decisions. She tells you that she is having trouble falling asleep, is anxious and overwhelmed. The client tells you that her husband was a good man and “very much my opposite.” She has high expectations for neatness and being on time, he was often messy and ran late. She tells you that sometimes she felt like the whole activity they were doing was “ruined” because he made them late or the kids didn’t follow the rules. She states that she was the “controller” in their relationship, which worked well for both of them, except when she got angry with him for not doing what she wanted, when she wanted, or how she wanted it. She acknowledges that she was often angry and frustrated with his casual way of going through life but now regrets it because he’s gone. She states that her goals for counseling are to be more patient and decrease her anger.
Other Contexts: Family History:
The client reports a significant family history with her mother diagnosed with schizophrenia, with catatonia and was not medicated. She describes her mother as a “zombie” who loved her children but never told them because she was “absent.” The client describes her father as verbally abusive and involved with drugs and alcohol, often yelling, screaming, and throwing things. She states he often told the client that any mistakes she made were the reason that their life was so bad. She has no siblings but her husband has two sisters, with whom the client does not engage. She states one of his sisters is living with her boyfriend and the other asked to borrow money from her and her husband, which made the client angry. She identifies her support system as her church and a group of couples whom she and her husband were friends with prior to his death, most of whom attended the client and her husband’s high school and college. The client says she tends to be drawn to overly controlling people and her church, though fundamentalist and legalistic, became like family to her in high school.  She tells you that the couple’s closest friends are her husband’s best friend, whom the client dated in high school, and his wife. She says that while dating, her then boyfriend was very attentive, “almost smothering,” but also very demanding by leaving her notes with things or work he wanted her to do for him. She states they dated for several years and then she met and married his best friend, who was her husband. She tells you that their best friend’s wife is her best friend, although “she irritates me all the time, and I don’t really like her that much.” She says her friend has a strong personality, is controlling, and wants to make all the decisions and plans in their relationship.

Question: Based on the information provided, which of the following diagnoses should the counselor suspect for this client?
(A): Obsessive Compulsive Personality Disorder (OCPD)
(B): Major Depressive Disorder (MDD)
(C): General Anxiety Disorder (GAD)
(D): Adjustment Disorder (AD)

Correct Answer: Obsessive Compulsive Personality Disorder (OCPD)
Explanation: The client is not only angry and irritated with her friend, who asserts control in their relationship, but she is also easily angered when her children don't put toys away in the right places or when her sister-in-law does not meet her moral expectations. Additionally, she described her husband, who was her opposite, as messy and not always on time, which led to problems and arguments. These factors suggest the client meets criteria for OCPD, which are: preoccupations with rules, order, and organization such that the point of the activity is lost; perfectionism that interferes with activities; scrupulous about matters of morality; and miserly toward others as evidenced by anger at being asked to borrow money. The client may be experiencing an adjustment due to the death of her husband, but the characteristics she relates were present before his death. The client relates some symptoms of depression and anxiety, but does not meet criteria for either. Therefore, the correct answer is (A)
Competency: intake, assessment, and diagnosis