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Annie is a 13-year-old Indian-American girl presenting to therapy with complaints of fear and anxiety. It has been reported that Annie has been raised in the United States, but frequently travels to India for weeks at a time to visit her family. Although she often visits with her family, she does not speak her family’s dialect but does understand a few phrases. Per Annie and family’s report, Annie avoids interacting with new people or large crowds. Annie also experiences symptoms of anxiety when taking a test at school and is concerned about making mistakes in her schoolwork. Annie is also reportedly afraid of the dark and requires someone in the room to fall asleep. Per the family, Annie requires reassurance, which has become “burdensome.”
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The case of Annie will be analyzed using the three key models of psychopathology, biological, psychological, and sociocultural to determine how each model views her behaviors. Each model has its own method of explaining Annie’s presenting behaviors as well as treating them. There are cultural questions due to Annie’s familial background, and as such, a Cultural Formulation Interview will be explored. Additionally, more information will be gathered from Annie’s parents using the Parent/Guardian-Rated DSM-5 Level 1 Cross Cutting Symptom Measure. Because Annie has presented to treatment with her family, it is vital to take a systemic approach and consider any applicable Z Codes.
Part 1: Examining Models of Psychopathology
From a biological standpoint, there are questions in regards to Annie’s health. While it is reported that Annie is currently in good health, it was noted that Annie was previously hospitalized for three weeks, at the age of five, due to a serious illness. While the nature of the illness is unknown, it has been reported that since Annie’s hospitalization, she has struggled with fears and anxiety. Annie may be treated with anti-anxiety medications, offering her relief of her anxiety symptoms, as well as lessening the distress for her and her family, which have found her symptoms “burdensome” (National Institute of Mental Health, n.d.).
From a psychological model, we should a behavioral approach in Annie’s case. Behavioral approaches focus, in part, on reinforcing behaviors (Nolen-Hoeksema & Marroquin, 2017). Annie’s family has reinforced her behaviors when they have fulfilled Annie’s requests of not sleeping alone and accommodating her reassurance seeking behaviors. Per behavioral therapy, systematic desensitization therapy would be a gradual way to eliminate anxiety reactions to stimuli (Nolen-Hoeksema & Marroquin, 2017). This process deliberately teaches the person relaxation techniques first, as a means to cope, and then expose them to stimuli in a hierarchical manner with the goal of desensitization to the feared stimuli (Nolen-Hoeksema & Marroquin, 2017). Combining systematic desensitization therapy with cognitive behavioral therapy (CBT) can be considered, as cognitive behavioral therapy would allow Annie to test her hypotheses (cognitions) when facing her feared stimuli and systematic desensitization therapy would encourage her to use her coping skills to manage her anxiety. Annie would also be encouraged to face her worst fears and use a journal to recognize how she’s been able to cope (Nolen-Hoeksema & Marroquin, 2017).
From a sociocultural perspective, we’ll need to consider if Annie comes from a collectivistic culture, in which case Annie would be identified as being a part of a group rather than an individual (Nolen-Hoeksema & Marroquin, 2017). Additionally, depending on Annie’s cultural norms, being emotionally expressive may not be considered acceptable (Nolen-Hoeksema & Marroquin, 2017). All aspects of Annie’s culture will have to be considered in order to determine the best course of therapeutic action and what would be effective for her. Some research has even suggested some cultures benefit more from more structured psychotherapy approaches (Nolen-Hoeksema & Marroquin, 2017).
From a biological standpoint, there may be a medical reason to explain Annie’s behaviors, but ultimately, they can be treated with anti-anxiety medications (National Institute of Mental Health, n.d.). From a psychological perspective, using cognitive behavioral therapy and systematic desensitization, it can be said that Annie’s behaviors have been reinforced each time her family has accommodated to her requests of reassurance and sleeping with her at night. From a sociocultural standpoint, it’s important to note that it appears Annie has a blended cultural identity. Annie was raised in the United States of America; however, she spends weeks at a time in India. The cultural difference and her level of assimilation must be taken into account to explain her behaviors. It is difficult to explain her behaviors and make a responsible assessment without knowing more about how Annie self-identifies. Research shows that contemporary immigrants are able to adapt better to the United States customs while still having the ability to retain some aspects of their distinct Indian identities (Mathur, Guiry, & Tikoo, (2008).
Annie has been struggling with fears and anxiety that have been both distressing to Annie and her family. It has been noted that the family finds Annie’s need for reassurance “burdensome.” Additionally, Annie exhibits dysfunctional behaviors by reportedly avoiding being around new people and large groups, as well as being unable to sleep in her room alone. Deviant and dangerous behaviors have not been noted.
Part 2: Assessment Instruments to Aid in Diagnosis
The Parent/Guardian Level 1 Cross Cutting Symptom Measure consists of 25 questions assessing for 12 psychiatric domains (American Psychiatric Association, 2013). The measure is used to assess different mental health domains that would help identify particular areas that need further assessment to make a proper diagnosis. This will also help a clinician identify the appropriate course of treatment and prognosis (American Psychiatric Association, 2013). The parent/guardian version is intended for the use of parents/guardians with children between the ages of six and 17 (American Psychiatric Association, 2013). This measure will be administered during the initial visit and during each follow-up visit thereafter to track progress. It is important to note that the same parent must be the same one to complete the measure for each follow-up visit (American Psychiatric Association, 2013).
The Cultural Formulation Interview is a set of 16 questions that the clinician asks the client to assess for what the impact of their culture may have in the context of therapy. The categories that are assessed are cultural identity of the individual, cultural conceptualization of distress, psychosocial stressors and cultural features of vulnerability and resilience and cultural features of the relationship between the individual and the clinician. The clinician is then able to formulate an overall cultural assessment based on the interview (American Psychiatric Association, 2013). Items 1-19 are rated on a five-point scale with none or not at all = 0, and severe or nearly every day =4. The clinician needs to review each response to determine whether further assessment is required or indicated for that particular domain. For items 20-25, further assessment is determined by the response of the parent (American Psychiatric Association, 2013).
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The Cultural Formulation Interview can be used during an initial assessment with a client, which can be used partially or in its entirety (American Psychiatric Association, 2013). Supplementary modules have also been created to address specific populations, such as children, immigrants, and refugees (American Psychiatric Association, n.d.). This tool would be helpful when diagnosing is difficult due to significant cultural differences and uncertainty in cultural differences (American Psychiatric Association, 2013). The interview would also be a helpful tool to aide clinicians in identifying their own biases when working with a particular culture (Adeponle, Groleau, & Kirmayer, 2015).
In the case of Annie, the Cultural Formulation Interview would be helpful because although it appears that Annie was raised in the United States, there is still a significant cultural influence as she reportedly spends several weeks a year in India. As a clinician, we should not assume that because Annie was raised in the United States and does not speak her family’s dialect, her family in India does not have any particular cultural influence.
Part 3: Systemic Perspectives for Diagnosis
Given Annie’s case, I believe Academic or Educational Problem (Z55.9) and Acculturation Difficulty (Z60.3) apply (American Psychiatric Association, 2013). Annie has expressed experiencing anxiety when having to take exams, as well as being concerned she will make mistakes on her schoolwork. Annie and her family have described how Annie’s symptoms impair her ability to function symptom-free in an academic setting. Moreover, it could be said that Annie is having a difficult time acculturating. It was reported that Annie was raised in the United stated but spends weeks at a time every year in India. Annie does not speak her family’s dialect and only understand a few phrases. This could indicate that Annie has a difficult time understanding her cultural identity.
Z codes provide clinicians the opportunity to highlight psychosocial factors that are impacting the client, rather than just focusing on a diagnostic disorder (Walsh, 2016). Furthermore, Z codes can also be used to provide a different focus on therapy instead of concentrating on a particular DSM-5 diagnosis. I believe Z codes allow for a more systemic approach to therapy because they consider the client’s environmental factors, whereas, the DSM-5 and ICD-10 look to assign a disorder to an individual without taking into account other cultural elements.
Dissecting the three key models of psychopathology allowed for an in-depth biopsychosocial assessment of Annie. Additionally, when combining the models, this allowed us to determine where there was a need for further exploration. In conclusion, in Annie’s case, it will be imperative to collect more information about her symptoms using the Parent/Guardian Level 1 Cross Cutting Symptom Measure to make a more accurate diagnosis. It is also crucial that we learn more about Annie’s cultural self-identity, through the use of the Cultural Formulation Interview, to identify the most appropriate therapeutic approach to take while considering her cultural background.
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