sample case vignette

Case Vignette Slides and Sample Cases

Through the use of case vignettes, students can engage in conversations and discussions of clinical and ethical considerations that come up in practice as well as discussions on various substance use treatment modalities and what treatment planning may look like.

These slides and sample case vignettes provide discussion prompts for faculty to use in small group sessions or can be used as part of a written assignment.

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Oct 29, 2021

Clinical Vignettes 101

• Alfred Burger, MD, FACP, FHM; 
• Chad S. Miller, MD, FACP, FHM; 
• Elizabeth A. Paesch, MD

Best in Class Check out winners of the HM13 Research, Innovation, and Clinical Vignette competition at www.hospitalmedicine2013.org/riv/vignettes.php. The site includes poster PDFs and presentations from the winners, as well as poster PDFs for all finalists.

Physicians are exposed to a wide variety of cases that pique our interest. Cases that make you go home and read just a little bit more. Cases that prompt you to seek out your classmates and colleagues for further discussion, or trigger a call to someone from your past. Residents and students often ask, “Should I write this case up?” Our answer is, “Yes!”

Why do we recommend that you write the case up? Much of medical education is a clinical- or case-based exercise. Clinical cases provide context for the principles being taught. We use real cases to point out the nuance in a presentation of a particular illness or the management of a disease.

In clinical conferences, such as morning report or clinical-pathologic conferences (CPCs), we highlight the choices we make as physicians to provide the best care. Respected physicians and master clinicians at our own institutions often lead these discussions, which form the building blocks for how many of us will practice in our careers.

At grand rounds, the best speakers start with a case. These vignettes grab our attention, making us realize the importance of what the speaker teaches us.

Writing up a vignette will give you a skill set you need. You learn how to select a case, create a “teachable moment,” or hone a series of teaching points. You develop your skills in searching and critically appraising the literature. You become a content expert among your peers. This activity helps you to develop and master the academic skills that will drive your career and will be pivotal in your success.

Follow these eight steps to produce successful clinical vignette submissions:

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Be a good doctor and make the correct diagnosis: Interesting cases will come to you. Don’t chase a zebra on every cough. Don’t send autoimmune panels for every rash. Read about each patient’s case that you see. Use the time to build your clinical acumen and develop your own illness scripts. Through the process of being a thoughtful student of medicine, you will come to distinguish the fascinoma from the merely fleeting infatuation with a diagnosis.

Recognize the good case: The best way to recognize a good case is appreciate when it excites people locally. If you present it at morning report or CPC, are you inundated with requests to speak more after the conference has finished? Did it stump your colleagues (usually a pretty bright group)? Do you find that the consultants ask for others in their division to come and see the case? Clinically, did it take the team a while to come to the end diagnosis? If any of these are true, then you should move forward.

Perform a literature search: How often does a similar situation arise? Is it 1 in 10,000, 1 in a million, or less? Even a case of 1 in 10,000 can be impactful to read about when you consider how long it may take a physician to see that many patients.

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Presenting a Clinical Vignette: Deciding What to Present

If you are scheduled to make a presentation of a clinical vignette, reading this article will improve your performance. We describe a set of practical, proven steps that will guide your preparation of the presentation. The process of putting together a stellar presentation takes time and effort, and we assume that you will be willing to put forth the effort to make your presentation successful. This and subsequent articles will focus on planning, preparation, creating visual aids (slides), and presentation skills. The intent of this series of articles is to help you make a favorable impression and reap the rewards, personal and professional, of a job well done.

The process begins with the creation of an outline of the topics that might be presented at the meeting. Your outline should follow the typical format and sequence for this type of communication: history, physical examination, investigations, patient course, and discussion. This format is chosen because your audience understands it and uses it every day. If you have already prepared a paper for publication, it can be a rich source of content for the topic outline.

To get you started, we have prepared a generic outline to serve as an example. Look over the generic outline to get a sense of what might be addressed in your presentation. We realize that the generic outline will not precisely fit all of the types of cases; nevertheless, think about the larger principle and ask yourself, "How can I adapt this to my situation?" In order to help you visualize the type of content you might include in the outline, an example of a topic outline for a clinical vignette is presented.

Introduction

The main purpose of the introduction is to place the case in a clinical context and explain the importance or relevance of the case. Some case reports begin immediately with the description of the case, and this is perfectly acceptable.

1. Describing the clinical context and relevance

i. Ergotism is characterized by intense, generalized vasoconstriction of small and large blood vessels. ii. Ergotism is rare and therefore difficult to diagnose. iii. Failure to diagnose can lead to significant morbidity.

Case Presentation

The case report should be chronological and detail the history, physical findings, and investigations followed by the patient's course. At this point, you may wish to include more details than you might have time to present, prioritizing the content later.

i. A 34-year-old female smoker has chronic headaches, dyspnea, and burning leg pain. ii. Clinical diagnosis of mitral valve stenosis is made. iii. She returns in one week because of burning pain in the legs. iv. One month after presentation, cardiac catheterization demonstrates severe mitral valve stenosis. v. Elective mitral valve commisurotomy is scheduled, but the patient is admitted to hospital early because of increased burning pain in her feet and a painful right leg.

2. Physical Examination

i. Normal vital signs. ii. No skin findings. iii. Typical findings of mitral stenosis, no evidence of heart failure. iv. Cool, pulseless right leg. v. Normal neurological examination.

3. Investigations

i. Normal laboratory studies. ii. ECG shows left atrial enlargement. iii. Arteriogram of right femoral artery shows subtotal stenosis, collateral filling of the popliteal artery, and pseudoaneurysm formation.

4. Hospital Course

i. Mitral valve commisurotomy is performed, as well as femoral artery thombectomy, balloon dilation, and a patch graft repair. ii. On the fifth postoperative day, the patient experienced a return of burning pain in the right leg. The leg was pale, cool, mottled, and pulseless. iii. The arteriogram of femoral arteries showed smooth segmental narrowing and bilateral vasospasm suggesting large-vessel arteritis complicated by thrombosis. iv. Treatment was initiated with corticosteroids, anticoagulants, antiplatelet drugs, and oral vasodilators. v. The patient continued to deteriorate with both legs becoming cool and pulseless. vi. Additional history revealed that the patient abused ergotamine preparations for years (headaches). She used 12 tables daily for the past year and continued to receive ergotamine in hospital on days 2, 6, and 7. vii. Ergotamine preparations were stopped, intravenous nitroprusside was begun, and she showed clinical improvement within 2 hours. Nitroprusside was stopped after 24 hours, and the symptoms did not return. viii. The remainder of hospitalization was uneventful.

The main purpose of the discussion section is to articulate the lessons learned from the case. It should describe how a similar case should be approached in the future. It is sometimes appropriate to provide background information to understand the pathophysiological mechanisms associated with the patient's presentation, findings, investigations, course, or therapy.

1. Discussion

i. The most common cause of ergotism is chronic poisoning found in young females with chronic headaches. ii. Manifestations can include neurological, gastrointestinal, and vascular (list each in a table). iii. Ergotamine poisoning induces intense vasospasm, and venous thrombosis may occur from direct damage to the endothelium. iv. Vasospasm is due primarily to the direct vasoconstrictor effects on the vascular smooth muscle. v. Habitual use of ergotamine can lead to withdrawal headaches leading to a cycle of greater levels of ingestion. vi. In addition to stopping ergotamine, a direct vasodilator is usually prescribed. vii. Lesson 1: Physicians should be alert to the potential of ergotamine toxicity in young women with chronic headaches that present with neurological, gastrointestinal, or ischemic symptoms. viii. Lesson 2: The value of a complete history and checking the medication list.

Creating a topic outline will provide a list of all the topics you might possibly present at the meeting. Since you will have only ten minutes, you will prioritize the topics to determine what to keep and what to cut.

How do you decide what to cut? First, identify the basic information in the three major categories that you simply must present. This represents the "must-say" category. If you have done your job well, the content you have retained will answer the following questions:

What happened to the patient? What was the time course of these events? Why did management follow the lines that it did? What was learned?

After you have identified the "must-say" content, identify information that will help the audience better understand the case. Call this the "elaboration" category. Finally, identify the content that you think the audience would like to know, provided there is enough time, and identify this as the "nice-to-know" category.

Preparing a presentation is an iterative process. As you begin to "fit" your talk into the allotted time, certain content you originally thought of as "elaboration" may be dropped to the "nice-to-know" category due to time constraints. Use the following organizational scheme to efficiently prioritize your outline.

Prioritizing Topics in the Topic Outline

1. Use your completed topic outline.

2. Next to each entry in your outline, prioritize the importance of content.

3. Use the following code system to track your prioritization decisions:

A = Must-Say B = Elaboration C = Nice-to-Know

4. Remember, this is an iterative process; your decisions are not final.

5. Review the outline with your mentor or interested colleagues, and listen to their decisions.

Use the Preparing the Clinical Vignette Presentation Checklist to assist you in preparing the topic outline.

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Case Vignette

A promising complement to clinical case presentations in teaching.

Kathiresan, Jeyashree 1 ; Patro, Binod K. 2,

1 Senior Resident, School of Public Health, PGIMER, Chandigarh, India

2 Associate Professor, Department of Community Medicine & Family Medicine, AIIMS, Bhubaneswar, India

Address for correspondence: Dr. Binod Patro, Associate Professor, Department of Community Medicine & Family Medicine, AIIMS, Bhubaneswar - 751019, India. E-mail: [email protected]

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

Introduction: 

Case studies are widely used in medical education. They help students recognise and interpret important data coming from the patient's problem thereby enabling students to arrive at a correct diagnosis and best treatment course. We have used the case vignette method, a variant of the case study method, for teaching family medicine residents, and here we assess their perceptions of its advantages and limitations.

Methods: 

In the case vignette method, residents studied a particular case of interest from the community. Before presenting it to peers, they prepared and circulated a brief case vignette outlining the salient features of the case, the preferred line of management and suggested discussion probes. Structured notes were taken by programme faculty during the presentations, and feedback was obtained from residents.

Results: 

Major advantages perceived by residents were that the case vignette method demanded their active participation in the preparation and presentation of the case. The need to prepare a vignette helped them better organise their thinking and experience peer teaching. However, some felt that the exercise was time consuming and the discussion sometimes wandered from the intended course.

Conclusions: 

The case vignette method helps meet specific learning objectives in teaching sessions. Residents feel that it improves their skills as physicians and teachers. This study finds that case vignettes are a promising complement to existing methods of teaching medicine. Further research is required to more firmly establish this method's value.

Introduction

Case studies have been widely used as a teaching tool in various disciplines especially medicine, engineering and law. When students engage with cases, learning takes place: they analyse, synthesise and apply knowledge. The case study method allows for multiple viewpoints, encourages discussion and fosters greater understanding. [ 1 ] There are many models of case-based teaching described for teaching clinical medicine, including case-bedside, case-lecture and case-iterative teaching. [ 2 ] It has been found that these methods help solidify students' understanding as they have to find the solutions to their cases rather than relying passively on the instructor to provide the answers. [ 3 ]

Beyond teaching, case studies can be used to evaluate a learner's ability to recognise and interpret important data to support their decision making pertaining to the case's management. Case studies also allow faculty to evaluate learner's ability to organise and communicate their ideas. [ 4 ] They are also used as a method for measuring the competence of physicians and the quality of their actual practice. [ 5 ]

However, case-based methods, like all methods of teaching clinical medicine, have shortcomings. They are perceived as lengthy and time consuming, allowing little student participation and are sometimes repetitive. [ 6 ] There is a need for additional teaching methods that enable medical students and residents to make appropriate use of what they have studied for improving the quality of patient care. [ 7 , 8 ] In teaching family medicine residents, we have used a new variant of the case-based study method called the case vignette method. This study aims to document the strengths and limitations of the case vignette method of teaching medicine.

The study was conducted among Doctor of Medicine (MD) Community Medicine resident physicians of the Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India. Family medicine is one of the major concentrations of the curriculum of the MD Community medicine course under which resident doctors are trained as family physicians. One of the training methods used in our family medicine training programme is case presentations. Every week one case identified in the community/hospital is presented by a resident physician at a departmental education session moderated by the faculty in charge. The patient is not typically present during the session.

A new method of conducting these sessions was conceived [ Table 1 ]. The residents were instructed to prepare in writing a vignette on the case that they propose to present for discussion, and they were first briefed on how to do this. [ 9 ] They were instructed to have the vignette describe briefly the major features of the case including history and examination findings, and they were asked to suggest a line of management at the primary, secondary and tertiary levels of health care delivery. The residents were instructed to raise probes at the end of the vignette to focus the discussion on the points they find most important for the group. The complete case vignette including the probes/discussion points were not to be more than 400 words long.

Case vignettes were to be communicated to all residents and the faculty-in-charge 3 days prior to the case discussion to allow time for adequate preparation to promote a meaningful discussion. During the session, a brief presentation of the case history and examination findings was followed by a discussion along the lines of the probes/questions prepared by the resident. Structured notes were taken during the session tabulating the major probes that the resident had proposed for the session against the discussion that actually took place in the session. Schmidt [ 10 ] proposes a framework for evaluating problem-based learning methods. The teaching method should be able to use the students' prior knowledge of the subject optimally, provide a context of learning similar to that for application of knowledge and allow opportunities to elaborate on the knowledge gained. We evaluated the case vignette method against these criteria.

Semi structured feedback was obtained from the residents regarding their experience in preparing vignettes of their cases and framing probes for discussion. Feedback was obtained via email to encourage critical views. A moderated focus group discussion was also held with the resident physicians to understand their perceptions of the advantages and shortcomings of the case vignette method of teaching. Structured notes were taken during the focus group discussion. Textual analysis of the feedback was performed to arrive at an organised list of residents' suggestions and comments. The study was conducted in compliance with the ethical regulations for research on human subjects and approved by the peer review committee of the department.

At the end of 3 months, 7 out of our 10 residents had completed at least one case vignette preparation and discussion. One of the model case vignettes presented by a resident is shown in Table 2 . The major advantages as perceived by the residents were that the method demanded that they actively engage in the preparation and presentation of the case, which fostered a thorough understanding of the case. The need to prepare a vignette helped them organise their thinking better. They were also able to place themselves in the teacher's position thus helping them practice and experience peer teaching. The probes helped them design and moderate a discussion about the case to meet specific learning objectives. The disadvantages they perceived were that compared with the earlier method, where they had to only present the case from their notes, the new method was more time consuming, as it required the preparation of a vignette and discussion probes. The residents also found that sometimes, the probes did not generate the expected discussion when residents did not understand the intended meaning of the probe, and the planned learning objectives consequently suffered.

The extent to which the case vignette method fulfils Schmidt's criteria for an effective Problem Based Learning (PBL) tool is presented in Table 3 . The method enables the student to apply his clinical reasoning skills in real life contexts in the community. It also motivates self learning and communication of the knowledge gained.

Case-based discussion and teaching that follows the presentation of the details of a case is a commonly used method of teaching in medicine. We discuss a variant of the case-based study method for use in family medicine teaching - the case vignette method. Here, the resident doctor was required to study in depth a particular case of interest from the community and prepare a brief case vignette listing the salient features of the case and a proposed line of management, and suggesting probes for discussion.

Most literature on case vignettes addresses the use of hypothetical case studies that are designed to pursue a particular learning objective. In contrast, our method requires study of real cases from the community, and the discussion centres on the diagnosis and comprehensive management. Another modification of our method was that the resident assumes the role of the teacher. The faculty instructor restricts himself/herself to only moderating the discussion and contributing specific points when necessary. Hence, our approach is more of a peer teaching style, which encourages more active discussion than traditional didactic teaching. Irby [ 2 ] points out that a good clinical teacher should be able to relate to three cognitive connections at the same time, namely the students' knowledge base, the case specific details and the general principles of medicine. The teacher should also be able to convey a few selected learning points for a discussion in an inductive manner through questions and discussions. Our method allows the teacher to be flexible in deciding his/her extent of involvement in the case vignette discussion.

Many studies in the medical and non-medical literature have highlighted the need for teaching methods to raise new information for learners and enable them to practice applying it appropriately. The effectiveness of an instructional method can be assessed by analysing what students are able to do with the information they receive. The case vignette method, as we have used it, was found to satisfy all the three of Schmidt's criteria.

One disadvantage perceived by the residents was that the discussion of the vignette sometimes takes a different course from that planned by the resident. However, appropriate moderation by both the resident presenting the case and the teacher can help keep the conversation on the planned course. We have not yet assessed how case vignettes affect the resident doctor's actual health care practice. [ 5 ] However, it is expected to both directly and indirectly improve the quality of care residents provide: directly for the particular case that is discussed, as the best line of management of the case is decided upon based on the suggestions and guidance of peers and the teacher, and indirectly by the overall effect on the resident's skills as a physician. Thus with many desirable features, the case vignette method seems a promising complement to the existing methods of teaching medicine.

Source of Support:

Conflict of interest:.

None declared.

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Case Vignettes

Start with:

• McGraw-Hill Case Files: Basic Sciences Covering anatomy, biochemistry, microbiology, neuroscience, pathology, pharmacology, and physiology.
• McGraw-Hill Case Files: Clinical Medicine Covering anesthesiology, emergency medicine, family medicine, internal medicine, neurology, obstetrics & gynecology, pediatrics, psychiatry, and surgery.
• Symptom Media Symptom Media is a film library of 180 clinical training vignettes that serves as an integral educational tool for "symptom recognition." All films are produced with an experienced multi-disciplinary behavioral health team working in concert with professional scriptwriters, filmmakers and highly trained actors, facilitating a synergistic realism and clinical accuracy during the entire filmmaking process. Videos range in length from 30 seconds to 15 minutes.

Then try any of the following:

Basic sciences.

• Clinical Neuroanatomy
• MSU Neuropathology Navigator
• Pathophysiology of Disease Cases
• UPMC Anatomic Pathology Cases of the Month
• University of Michigan Medical School BlueLink
• Yale University School of Medicine Anatomy Clinic

Family Medicine Cases

• Family Medicine Board Review

Geriatrics Cases

• Age-Friendly Care and Education Collection

Internal Medicine Cases

• Acid-Base Disturbances
• Harrison's Fluid/Electrolyte & Acid-Base Cases
• Kumar and Clark's Cases in Clinical Medicine
• Medicine: A Competency-Based Companion
• Resident Readiness: Internal Medicine
• Vanderbilt Internal Medicine and Pediatrics Curriculum

Neurological Cases

• Baylor College of Medicine Medical Center Dept of Neurology Case of the Month
• University of Utah NeuroLogical Cases

OB/GYN Cases

• McGraw-Hill Case Files: Obstetrics & Gynecology
• Obstetrics and Gynecology: A Competency-Based Companion

Pediatric Cases

• Pediatrics: A Competency-Based Companion

Surgery Cases

• Surgery : a Case Based Clinical Review
• Clinical Cases and OSCEs in Surgery
• Toronto Video Atlas of Surgery

Also check out:

• Aquifer Free Interdisciplinary Cases Aquifer is a non-profit organization dedicated to delivering evidence-based, peer-reviewed virtual learning to support best practices in clinical teaching and learning. Most content is available to subscribers only, but there are some interdisciplinary cases available for free.
• MedEdPortal A peer-reviewed, open-access journal that promotes educational scholarship and dissemination of teaching and assessment resources in the health professions. MedEdPORTAL publications are stand-alone, complete teaching or learning modules that have been implemented and evaluated with medical or dental trainees or practitioners.
• Virtual Interactive Case System Covers anesthesia, obstetrics, and rheumatology. Also has content specific to nurse practitioner and pharmacy programs.

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• June 01, 2024 | VOL. 75, NO. 6 CURRENT ISSUE pp.513-612
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Best Practices: Using Case Vignettes to Train Clinicians and Utilization Reviewers to Make Level-of-Care Decisions

• Peter B. Rosenquist , M.D. ,
• Christopher C. Colenda , M.D., M.P.H. ,
• Judy Briggs , R.N. ,
• Stephen I. Kramer , M.D. , and
• Michael Lancaster , M.D.

Search for more papers by this author

Note from the column editor: Dr. Rosenquist and his colleagues describe how their academically based health maintenance organization joined in training for level-of-care decision making with the external managed behavioral health organization that was providing utilization review and case management decisions. The academic department later took over its own utilization review and in so doing internalized the utilization review function.This development, which is beginning to occur in several states, is an important solution to the "assault" that many providers of care have experienced as a result of the utilization review process. Having taken this step to deal with the realities of 21st-century health care, the authors then seize the opportunity to use their own data to improve decision making within the clinic. This process is how we get to best practices.

Medical necessity has emerged as the de facto standard for decisions about payment for behavioral health services, despite criticisms leveled from theoretical ( 1 , 2 ) and practical ( 3 ) perspectives. Moreover, it has been difficult to define best practices within the current framework of medical necessity, largely because of the many sources of variation in decisions about appropriate levels of care.

In practice, when clinicians and clinical case managers—that is, utilization reviewers—communicate information about a patient, usually by telephone, they use a narrative case presentation. Discussion is focused on assessment of necessity criteria, such as symptom severity, dangerousness, social support, and resource availability, that would support a higher level of care, such as inpatient hospitalization. Unfortunately, the dialogue may break down without resolution of differences, and with considerable residual ill will between parties ( 4 ).

In this column we report on our use of case vignettes as a training device to help clinicians and clinical case managers make consistent decisions about appropriate levels of care and to develop best practices.

Development and use of case vignettes

Partly because of their research and teaching missions, academic centers have been slow to react to changes in health care financing and have a reputation of inefficiency and overuse of intensive levels of care ( 5 ). In 1995 Wake Forest University established a health maintenance organization with about 50,000 enrollees. In the first year of operation, the university contracted with an outside, for-profit managed behavioral health organization to provide behavioral health utilization review and case management. Eventually the department was able to establish its own internal managed behavioral health care organization ( 6 ).

Initially, however, the department struggled to meet the demands of managed care, working with the outside organization. To promote greater uniformity in decision making, we designed four case vignettes and used them in joint training with our clinicians and the clinical case managers from the outside organization.

Case vignettes have been used previously to compare decision-making strategies of different groups ( 7 ). Because use of vignettes limits variation in how people perceive a case by providing all persons with the same information, vignettes offer training advantages over real-life patients. Case vignettes are ideal when the primary objective is to identify conflicts in judgment ( 8 ).

Each vignette developed by the department is a typical narrative case presentation and includes details about the patient's history and mental status. Each patient has a different diagnosis—delirium, comorbid depression and substance abuse, chronic depression, and schizophrenia. In two vignettes, the patient presents as an outpatient. In another, the setting is an emergency room. In the fourth case, the patient has been referred for a consultation to an inpatient general medical setting. The vignettes do not convey any expectations about case disposition or information about insurance status.

Thirty-one persons participated in the training—seven attending physicians, 16 house officers (psychiatric residents), and eight clinical case managers. After reading each vignette, respondents were prompted to choose the most appropriate treatment setting—inpatient care, partial hospitalization, or outpatient care. They provided up to five of their own reasons for each decision. In a translational process paralleling the interaction between clinician and reviewer, the reasons were examined to determine whether they referred to either of two common medical-necessity criteria: the patient's level of dangerousness and the patient's support system. These reasons were tallied separately and compared by group using Fisher's exact tests.

Results are summarized in Table 1 . All the respondents recommended that the patient with delirium receive inpatient care. Similarly, for the patient with comorbid depression and substance abuse, 94 percent recommended inpatient care, and only 6 percent recommended partial hospitalization.

For the patient with schizophrenia who was experiencing negative symptoms, 52 percent of respondents recommended outpatient services, 36 percent recommended partial hospitalization, and 13 percent recommended inpatient care. For the patient with chronic depression, 39 percent recommended outpatient services, 26 percent recommended partial hospitalization, and 36 percent recommended inpatient care.

No significant differences were found between attending physicians and clinical case managers on any of the four level-of-care decisions. Only house officers selected inpatient treatment for the patient with schizophrenia. Compared with attending physicians and case managers, house officers selected higher levels of care for this patient; however, the difference was not significant.

Compared with attending physicians and case managers, house officers were significantly less likely to take into account the patient's support system as a factor in decision making in two cases—the patient with schizophrenia (Fisher's exact test, p=.09) and the patient with chronic depression (p=.09). Attending physicians were less likely than house officers and case managers to take into account the patient's level of dangerousness in their decision about the patient with chronic depression (Fisher's exact test, p=.06).

Our study failed to demonstrate significant differences between groups of clinicians and utilization reviewers in level-of-care decisions for any of four common psychiatric presentations. Similarly, we identified very few differences between groups in their use of particular criteria as a rationale for their decisions.

Both the clinicians and the utilization reviewers in our setting have expressed surprise at these findings, because they run counter to the expectation that level-of-care decisions and decision rules used by each group would be quite different. In a study of implementation of a managed care plan during the course of which use of inpatient services markedly declined, it was shown that over time clinical case managers rated fewer patients as severely disturbed while ratings by clinicians remained unchanged ( 8 ).

Use of the vignettes has effectively demystified the process of utilization review for clinicians in our department. Two vignettes engendered strong agreement by all respondents. The others revealed more variation in decisions about the most appropriate level of care, both across all respondents and within respondent groups. This finding raises the question of how we can increase the level of agreement for more equivocal cases. Level-of-care decisions must be reliable—that is, care managers must make similar decisions in similar cases across time. Without some degree of reliability, a meaningful best practice is unlikely to emerge.

First, we must develop meaningful and reliable criteria. Some progress has been made. In one study, when clinicians were presented with a broad and unstructured list of variables, they were unable to achieve an acceptable level of agreement about indicators for hospitalization ( 9 ). On the other hand, expert panels using modified Delphi techniques have achieved high levels of agreement in decisions about levels of care for both hypothetical and actual cases, and in the process they have identified and developed anchored ratings for a number of key variables ( 10 , 11 ).

Second, level-of-care decision criteria must not remain the sole province of health services researchers and clinical case managers. Instead, they should be widely disseminated to the network of providers. At our facility, the outside managed behavioral health care organization shared its criteria with clinicians from the outset. When the department took over care management, this practice was continued. Also, medical-necessity criteria have been incorporated into the admission forms, admitting orders, and computerized treatment planning documentation of the inpatient and partial hospital unit ( 12 ).

Experience and training would seem to be likely sources of variation in decision making in clinical and managed care settings. Although our study was limited by its small sample size, the results suggest that house officers may differ from more experienced psychiatrists and clinical case managers in their decisions and approach. By ensuring that the house officers encounter the decision criteria in the course of their daily work and by providing them with training material on managed care principles, we hope to create a working model of best practices against which they can compare their decisions. Senior residents may also participate in an elective rotation in managed care during which they can review cases and make interpretations of medical necessity.

Criterion-based admission policies and procedures clearly narrow the range of variables used in level-of-care decisions. However, we will continue to encounter equivocal cases. One approach to improving the reliability of decisions would be to conduct field tests to systematically identify sources of variation in decision making. Once we know the sources, we may more clearly define what constitutes best practice. In a study using videotaped interviews conducted in an emergency room, agreement between raters was low for recommended disposition, psychopathology, impulse control problems, ability to care for self, and danger to self ( 13 ). A somewhat higher level of agreement was reached for psychosis and substance abuse.

Clinical case managers and medical directors continue to oversee care management in our system through traditional review processes. Every three months appeals are presented for discussion and comment before a quality improvement committee composed of a rotating group of network clinicians. Level-of-care criteria are reviewed and amended annually. This body recently voted to begin using the Criteria for Short-Term Treatment of Acute Psychiatric Illness, jointly published by the American Academy of Child and Adolescent Psychiatry and the American Psychiatric Association ( 15 ).

As practice guidelines become more detailed, and more reflective of best practices, we anticipate an eventual eclipse of more generic level-of-care criteria. For example, the use of the Clinical Institute Withdrawal Assessment protocol ( 16 ) in our facility has supplanted the need for concurrent review of necessity and intensity of service for alcohol detoxification because such a review is part of the protocol. The measure of our success will be how well we work collectively to meet the needs of patients as we develop our mental maps, whether they are vignettes, criteria, practice guidelines, or protocols.

Dr. Rosenquist is assistant professor and Dr. Kramer is associate professor in the department of psychiatry and behavioral medicine at Wake Forest University School of Medicine in Winston-Salem, North Carolina. Ms. Briggs is chief executive officer of Carolina Behavioral Health Alliance in Winston-Salem. Dr. Colenda is professor in the department of psychiatry at Michigan State University in East Lansing. Dr. Lancaster is regional medical director of Value Options in Raleigh, North Carolina. Send correspondence to Dr. Rosenquist at the Department of Psychiatry and Behavioral Medicine, Medical Center Boulevard, Winston-Salem, North Carolina 27157-1087 (e-mail, [email protected] ). William M. Glazer, M.D., is editor of this column.

Table 1. Level-of-care decisions made by seven attending physicians, 16 house officers, and eight case managers about patients described in four case vignettes

Table 1. Level-of-care decisions made by seven attending physicians, 16 house officers, and eight case managers about patients described in four case vignettes

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Often Undiagnosed but Treatable: Case Vignettes and Clinical Considerations for Assessing Anxiety Disorders in Youth with Autism Spectrum Disorder and Intellectual Disability

Breanna winder-patel.

1 The MIND Institute, Sacramento, CA

2 Department of Pediatrics, University of California, Davis, Davis, CA

Megan E. Tudor

Connor m. kerns.

4 Department of Psychology, University of British Columbia, Vancouver, BC, Canada

Konnor Davis

3 Department of Psychiatry and Behavioral Sciences, University of California Davis, Davis, CA, USA

Christine Wu Nordahl

David g. amaral, marjorie solomon, anxiety, autism, and intellectual disability.

Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder characterized by social communication deficits and restricted and repetitive behaviors ( American Psychiatric Association [APA], 2013 ). The United States prevalence rate of ASD in 2016 was 2.76% ( Zablotsky et al., 2017 ). It was previously believed that the majority of individuals with ASD also have intellectual disability (ID), ( Thurm et al., 2019 ), which is diagnosed when individuals shows deficits in both intellectual functioning (IQ<70) and adaptive behavior ( APA, 2013 ). However, more recent reports estimate that only 40% of those with ASD have concurrent ID ( Baio et al., 2014 ). This shift in reported rates for those with ASD and ID is thought to be fueled by changes in the diagnostic criteria of ASD as well as a greater prevalence of those being diagnosed with autism having average or above average IQ ( Baio et al., 2014 ).

Importantly, individuals with both ASD and ID are at high risk for multiple co-occurring conditions, such as attention deficit hyperactivity disorder (ADHD), sleep and gastrointestinal problems, and seizures ( Mannion & Leader, 2013 ). In addition, children with both disorders experience mental health conditions such as anxiety and mood disorders ( Matson & Nebel-Schwalm, 2007 ). Diagnosing any co-occurring condition in individuals with ASD and ID is challenged by limitations of language and cognition in reporting symptoms, resulting in varying ranges in the literature ( Mannion & Leader, 2013 ). Furthermore, variation in study methodology and design, measurement, and type of sample (e.g., community vs. clinical) also contributes to the prevalence discrepancies. For anxiety specifically, some studies suggest that children with ASD and ID experience less anxiety ( Mayes et al., 2011 ; Mingins et al., 2020 ; Sukhodolsky et al., 2008 ), some studies suggest that the risk is equal ( Kerns et al., 2020 ), and one meta-analysis suggested a heightened rate of anxiety in autistic individuals with ID ( van Steensel et al., 2011 ). Despite the potential clinical significance of anxiety for this population, it can be challenging to diagnose, and is often overlooked.

The Challenge of Diagnosing Anxiety Disorders in Autistic Individuals

As described in the most recent 5 th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013 ), there are 6 major forms of anxiety disorder including: Separation Anxiety Disorder, Specific Phobia, Social Anxiety Disorder, Generalized Anxiety Disorder, Panic Disorder, and Agoraphobia (see Table 1 ). This study did not include Panic Disorder or Agoraphobia, which are low prevalence conditions in childhood (1% or lower; Beesdo et al., 2009 ). All of these forms of anxiety can significantly interfere with social skill development, daily functioning, and level of independence in both autistic and non-autistic children ( Grondhuis & Aman, 2012 ; Swan & Kendall, 2016 ; Vasa et al., 2016 ).

DSM-IV and Distinct Anxiety Included in this Study, Descriptions, and Examples

In addition to the DSM-5, there is a diagnostic manual for areas of mental health in those with intellectual disability, called the Diagnostic Manual – Intellectual Disability (DM-ID-2; Fletcher et al., 2018 ). The DM-ID-2 separately specifies whether adaptations should be made when applying DSM criteria to those with Mild ID, Moderate ID, and Severe to Profound ID. For the four anxiety disorders assessed in this study, there were typically no adaptations suggested for those with Mild or Moderate ID. However, for Severe to Profound ID, the adaptations typically include: “fear can be observed rather than subjectively described.” In addition, there are some specific examples depending on the anxiety disorder. For example, Specific Phobia includes “fear or anxiety may be expressed by crying, tantrums, freezing, or clinging.”

Notably, fears that do not align with these traditional categories have also been observed in children with ASD. These variations in the expression of anxiety, which are referred to as “distinct anxiety,” align closely with hallmark features of ASD, but are also characterized by fear and avoidance consistent with an anxiety disorder ( Kerns et al., 2016 ; Vasa et al., 2016 ). Distinct expressions of anxiety are responses to unusual and specific stimuli that would not be expected to the same degree in those without autism. Table 1 includes examples of the distinct anxiety areas referred to as uncommon phobia, special interest fear, fears of change, and other social fear ( Kerns et al., 2014 ). If impairing distinct anxiety is present, the DSM diagnosis of Other Specified Anxiety Disorder may be considered ( Kerns et al., 2016 ) in order to denote cases that may require an anxiety-focused treatment that might otherwise be overlooked or left unmanaged.

Along with identifying distinct anxiety, symptom overlap is common in autism and anxiety, contributing to the difficulty of detecting anxiety. For example, avoidance of social situations is a common feature both in individuals with ASD and in people with social anxiety ( Lecavalier et al., 2013 ). In youth with autism, obsessive thoughts are often reasonably construed as symptoms aligning with the child’s primary diagnosis of ASD, but in reality, these can be clinical indicators of a co-occurring anxiety disorder when they are accompanied by fear and avoidance ( Helverschou & Martinsen, 2011 ). In these situations, “diagnostic overshadowing” or the failure to recognize mental health symptoms in the presence of a salient disorder ( Mason & Scior, 2004 ), is one reason why the diagnosis of anxiety is challenging. Another reason why anxiety in ASD and ID might go undetected includes a belief that individuals with ASD and ID lack the cognitive capacity to worry about future events and, therein, experience anxiety. Furthermore, individuals with ASD and ID are less likely to describe their symptoms verbally due to language impairments and/or reduced emotional awareness and, when they do, the anxiety might be expressed in unconventional ways (e.g., repetitive requests to see their schedule) or about unconventional content (e.g., fear of leaves).

In response to observing idiosyncratic triggers of anxiety (i.e., distinct anxiety), Kerns and colleagues created an Autism Spectrum Addendum (ASA; Kerns et al., 2014 , 2016 , 2017 ) to be added to the gold standard Anxiety Disorders Interview Schedule for DSM-IV (ADIS-P; Albano & Silverman, 1996 ) to assess both clinically significant traditional anxiety according to DSM criteria, as well as distinct anxiety in youth with ASD. Both of these measures are more thoroughly described below.

In a first study ( Kerns et al., 2014 ; IQ range=67-158, M=104.69), similar proportions of children presented with DSM anxiety disorders (48%) and distinct anxieties (46%) overall, with 31% presenting with both DSM and distinct fears, 17% with only traditional anxiety and 15% with only distinct presentations. Recently, Kerns et al. (2020) examined anxiety in 75 children (aged 9-13) with ASD (36 also with ID; IQ range≤25-170, M=77.39) using the ADIS-P and ASA. This was a longitudinal study of ASD that began when the children were toddlers and, therefore, not recruited based on anxiety symptoms. Similar to Kerns et al. (2014) , 69% of children met criteria for at least one anxiety diagnosis. When comparing those with ASD and those with ASD and ID, the rates of anxiety disorders did not differ. Similar findings were observed in both groups with DSM-anxiety disorders (56% ASD vs. 47% ASD/ID) and distinct anxiety (49% ASD vs. 47% ASD/ID) ( Kerns et al., 2020 ). However, DSM anxiety disorders in the ASD and ID group were comprised solely of specific phobias and separation anxiety disorder. This is consistent with other studies of anxiety in youth with ASD, which find that specific phobias are often the most common type of traditional anxiety ( Kerns et al., 2014 ; Kerns et al., 2020 ; van Steensel et al., 2011 ).

Screening/Assessment Factors in Understanding Rates of Anxiety in Youth with ASD/ID

Within ASD research, estimates of elevated levels of co-occurring anxiety in youth range widely between 11-84% ( van Steensel et al., 2011 ). Imprecise detection of anxiety disorders in children with ASD and relatively lower cognitive and verbal functioning likely contributes to this broad range. Self- and parent-report measures are often used to assess anxiety. Endorsing symptoms of anxiety in self-report questionnaires and asking parents to infer about anxiety in their children in parent-report questionnaires both require that the child have a sufficient level of expressive language and the ability to convey internal states. For example, prompts that begin with “my child worries about” or “when my child is frightened, he feels” are difficult to answer with certainty for a child with autism or ID, who may not state emotions verbally or exhibit emotions in an atypical manner. Self-report measures may be impossible to administer to children with minimal verbal abilities. In sum, many of these relatively easy to administer measures rely on the verbal abilities of typically developing children, for which the measures are designed and standardized ( Lecavalier et al., 2013 ).

Consistent with these concerns, emerging research also suggests that parent-report questionnaires have reduced validity and precision in ASD samples, particularly those with individuals with co-occurring ID ( Dovgan et al., 2019 ; Kerns et al., 2015 , 2020 ; White et al., 2015 ). For example, the Multidimensional Anxiety Scale for Children, Parent Report (MASC-P; March et al., 1997 ), The Child Behavior Checklist/6–18 years, Parent Report (CBCL; Achenbach & Ruffle, 2000 ), and Screen for Child Anxiety and Related Emotional Disorders, Parent Report (SCARED-P; Birmaher et al., 1999 ) demonstrated weak sensitivity for detecting any clinically significant anxiety (MASC-P at 0.0, CBCL at 13.0, and SCARED at 9.1) when compared to a semi-structured interview like the ADIS-P, in a sample of youth with ASD and ID ( Kerns et al., 2020 ). Notably, greater language ability has been associated with increased endorsement of DSM-consistent anxiety ( Davis et al., 2011 ; Kerns et al., 2014 ; Rodas et al., 2017 ). Moreover, parents of children with ASD and ID may, like clinicians, find it challenging to differentiate anxiety from other problem behaviors in their children ( Tarver et al., 2020 ), but have little opportunity to discuss or clarify their responses when using a questionnaire format. Notably, studies using semi-structured interviews, which allow clinicians to follow up and query ambiguous responses, tend to result in a tighter range of problematic anxiety in youth with ASD than those using questionnaires, potentially because they allow clinicians greater latitude to address these diagnostic challenges ( Kerns & Kendall, 2012 ).

However, it must be noted that there certainly are limitations to conducting semi-structured interviews in clinical settings including accessing the training, the cost of the interview, and having the time to conduct the interview. In this case, gaining the knowledge to differentiate anxiety from ASD and to detect potential distinct areas of anxiety would be recommended to address the goal of more accurate assessment of anxiety in those with ASD/ID.

Observing Fear Responses

When attempting to diagnose anxiety in autistic individuals with ID, it can be useful to consider the Defense Cascade or the 6 Fs: Freeze, Flight, Fight, Fright, Flag, and Faint ( Lang et al., 2016 ; Schauer & Elbert, 2010 ) as a theoretical model applicable to understanding and behaviorally observing anxiety and fear. This model suggests that Freeze is an orienting response for the person to stop and attend to the concern of threat. Flight and Fight are “uproar reactions” and particularly regulated by sympathetic activation while this arousal reaches its height at Fright (intense fear combined with tonic immobility), followed by a “shut down” or parasympathetic activation with Flag and Faint. Flight, Fight, and Freeze, the three most commonly discussed behavioral variations of the Defense Cascade, are often observable, but can be confused with other behaviors typically seen in children with ASD and ID ( Bradley et al., 2014 ). Fright can be observed as well when a child is in intense fear and appears as though they can’t move. Flag and Faint reactions may also be highly informative when present; however, fainting is a severe, but less common symptom and flag reactions or signs of fatigue may be difficult to associate with anxiety, particularly in children.

More specifically, in terms of the common behavioral responses, “Flight” can appear like eloping, a term used to describe children with ASD who wander or run away from an environment possibly due to seeking out something preferred or avoiding a non-preferred situation/demand. For example, a child who runs out of the classroom due to fear of the Columbia pictures trailer before a movie shown in class, indicating an uncommon phobia. “Fight” appears similar to aggressive behavior towards others or self-injurious behavior and may be interpreted as a difficulty with frustration tolerance, when it could also be a manifestation of anxiety. For example, a child who is anxious in social situations and displays aggression towards the teaching staff when prompted to enter a room full of peers. “Freeze” may appear as if the child is simply not responding to a prompt or request, which occurs regularly in some children with ASD and ID for reasons that are often related to cognitive, language, or executive functioning impairments, but may also be a sign of significant fear. An example is a child who freezes and stares straight ahead or puts their head down when a worksheet is passed out due to worry about their performance. In sum, flight, fight, or freeze behavior might be interpreted as relating to other forms of problem behavior with potential anxiety being overlooked. Therefore, a careful consideration of whether anxiety is the function behind behaviors like eloping, aggression to self or others, and freeze behavior may lead to a more accurate diagnosis and, ultimately, necessary treatment recommendations.

Towards Best Practices for the Assessment of Anxiety in those with ASD and ID

Together, significant mental health needs and obstacles to assessment reveal a need for cohesive clinical considerations for assessing anxiety in youth with ASD and ID that are drawn from the literature, ongoing programs of research, and clinical experience. Recommendations regarding diagnosis of anxiety and co-occurring behavioral conditions, such as ASD, from MacNeil et al. (2009) include advocating for utilizing clinical interviews with various informants and, if possible, obtaining direct observation of patients in differing contexts. Vasa and colleagues (2016) recommend a careful evaluation of physical and behavioral symptoms suggestive of anxiety such as elevated heart rate, gastrointestinal and sleep problems, nail biting, skin picking, flat affect, and increased (or decreased) verbalizations while keeping in mind that these behaviors could also have overlap with ASD predilections such as seeking sensory stimulation. Lastly, the creation of questionnaires with a behavioral focus, that are validated for use specifically in those with ASD, is recommended ( MacNeil et al., 2009 ) and is a growing area of psychometric research. For example, Scahill and colleagues (2019) recently created, validated, and published a 25-item measure focusing purely on behavioral symptoms called the Parent-Rated Anxiety Scale for Youth with Autism Spectrum Disorder (PRAS-ASD). In addition, Mazefsky et al. (2018) have created and validated a short and precise survey titled the Emotion Dysregulation Inventory. Both of these measures have psychometric data available in those with a wide range of functioning and cognitive ability.

Below, we include three case vignettes of traditional and distinct presentations of anxiety in children with ASD and ID, including moderate-severe ID, where participants’ language is very limited. We then provide clinical considerations for assessment of anxiety in individuals with ASD and ID that derive from the literature, our ongoing programs of research, and clinical experience working with these and other children. The overarching goal of the following case illustrations and clinical considerations is to improve the detection of anxiety in youth within this population of children, thereby leading to the provision of necessary mental health services to these individuals. To this end, we conclude the manuscript with a discussion of treatment options.

Overview of Participants in the Research Study

The three cases described below and subsequent clinical considerations are drawn from work in a larger longitudinal research cohort of intellectually diverse children with ASD and typically developing individuals that were first seen at the UC Davis MIND Institute at ages 2-3 ½ years as part of the Autism Phenome Project with follow-up assessments in early childhood (ages 5-8 years) using a comprehensive battery including autism diagnostic, cognitive, language, and neuroimaging measures. The participants were recently followed up again at the 8-12-year middle childhood timepoint with a focus on the study of anxiety. In this phase of the Autism Phenome Project, anxiety was assessed with semi-structured parent interviews (ADIS-P/ASA) in a large sample of children with ASD and a broad range of intellectual functioning (IQ range≤25-170; M=77.39). The ADIS-P/ASA was administered and scored by licensed clinical psychologists, with established research reliability in the ADIS-P/ASA. Diagnosis was confirmed via scores on the semi-structured interview (ADIS-P criteria and clinical severity ratings) and the consensus of two independent experts in the assessment of mental health in children with ASD and ID, to whom the cases were presented. Participants reported a range of socioeconomic and racial and ethnic backgrounds with participants primarily reporting Caucasian and non-Hispanic (over 70%; see Kerns et al., 2020 for full demographic characteristics). This research was approved by the UC Davis Institutional Review Board and all participants gave informed consent or assent.

To summarize, in the overall study sample, participants with ASD and intellectual impairment (defined as IQ<70), specific phobias were diagnosed in 42% and separation anxiety in 6% ( Kerns et al., 2020 ). These were the only traditional DSM-IV anxiety disorders diagnosed in the 36 participants with intellectual impairment. Kerns and others (2020) note that these are the anxiety disorders that present earliest in development ( Beesdo et al., 2009 ), which is consistent with the developmental status of these participants. For distinct anxieties, 19% were identified as having interfering fears of change, 14% with uncommon phobias, 7% with other social fears, and 3% with special interest fears.

An alarming statistic was that, of the 40 overall participants in the study with ASD and ID, only three (7.5%) had been diagnosed with anxiety disorders before the current study evaluation. However, when they were carefully assessed using the clinical interviews ADIS-P/ASA with expert consensus diagnosis, an additional 24 were identified with at least one clinically significant DSM or distinct anxiety problem bringing the total to 27 (67.5%). It is likely that the challenges in diagnosing anxiety in individuals with ASD and ID, including distinct expressions of anxiety, the difficulty of determining if anxiety is present from behavior alone rather than verbal report, the lack of sensitivity in traditional anxiety screening questionnaires, and potential diagnostic overshadowing, among others, played a central role in these rates considering that the majority did not have a prior diagnosis.

Case Selection and Assessments

Case study participants described in the vignettes were selected because they had a range of clinically significant traditional and distinct anxiety manifestations determined from a modified parent interview approach using the ADIS-P/ASA and expert consensus, illustrated some of the more complex diagnostic presentations including unique and distinct areas of anxiety, met criteria for ASD, had reduced language ability or were nonverbal, and cognitive functioning in the range commensurate with moderate-severe intellectual disability. Table 3 includes data regarding the IQ scores, ADOS-2 Calibrated Severity Scores (CSS; Gotham et al., 2008 ), and anxiety parent questionnaires of the three cases. Through these case illustrations, it is our goal to (a) illustrate approaches for conducting a more developmentally sensitive parent interview for anxiety in children with ASD and ID and (b) shine light on how accurate diagnosis of anxiety is the first major steppingstone to providing appropriate and effective evidence-based treatment for those with anxiety, ASD, and ID. Names of the children in the case vignettes were changed to protect anonymity.

Case Study Descriptives

VIQ = Verbal IQ; NVIQ = Nonverbal IQ ( Elliot, 2007 ).

Cognitive Ability

Participants were administered the Differential Abilities Scale, Second Edition (DAS-II; Elliott, 2007 ), to measure intellectual functioning level. The General Conceptual Ability (GCA) composite was reported as a measure of full-scale IQ. The Verbal and Nonverbal Ability Composites are reported in Table 3 due to the large discrepancy between those scores in most participants. If a participant could not complete the age-appropriate School Age version of the DAS-II, we used the Early Years version.

Autism Spectrum Disorder

ASD diagnostic status and severity was evaluated with a gold standard autism diagnostic assessment including the Autism Diagnostic Observation Schedule – Second Edition (ADOS-2; Lord et al., 2012 ), the DSM-5 diagnostic criteria, and expert clinical judgment. Table 3 includes a CSS for the three case examples, which provides a level of ASD severity across the range of functioning for those with ASD ( Gotham et al., 2008 ).

Semi-structured Interviews

The ADIS-P ( Albano & Silverman, 1996 ) is an established, semi-structured interview developed for typically developing children ( Lyneham et al., 2007 ; Silverman et al., 2001 ). Research-reliable clinical psychologists assigned a clinical severity rating (CSR) for each anxiety disorder assessed. CSRs range from 0 to 8, with a score ≥4 suggesting clinically significant interference and the threshold for diagnosis if the other criteria are met. The ADIS-P modules administered in this study were separation anxiety disorder, social anxiety disorder, generalized anxiety disorder, specific phobia, and obsessive-compulsive disorder. The generalized anxiety disorder module was not included if the child had not ever verbally expressed thoughts or feelings to their parent. Considering that these participants were either non-verbal or had reduced language ability, we adjusted the wording of the prompts if they were verbally mediated by saying, “Has he/she indicated…,” rather than, for example, “Has he/she told you…” We relied heavily on deriving solid behavioral examples of anxiety ( Table 2 ) with a focus on determining whether anticipatory anxiety was indicated by the child in any way. For example, a child looking distressed/anxious, pacing around, and checking many times to see if her mother’s handbag is still in the house in anticipation of her mother leaving for work. In addition, the child’s estimated developmental level was taken into consideration when evaluating whether the extent to which their fears and behavior should be considered excessive or atypical. For example, the inability to complete a sleepover at a friend’s home was not considered problematic for a child with severe developmental delays/the developmental level of a 3-year-old, whereas an inability to stay with a trusted family member or other familiar adult due to high distress in anticipation of separation and lack of reduction of distress following separation was considered problematic.

Behavioral Examples of Anxiety in Children with ASD and ID

The ASA ( Kerns et al., 2017 ) includes a number of prompts and guidelines that are added to the ADIS-P to facilitate differential diagnosis between symptoms of anxiety and those of ASD. It also captures “distinct” presentations of anxiety ( Table 1 ) with CSRs provided for each distinct area. Furthermore, the ASA includes considerations for differential diagnosis such as assigning a rating for the child’s functioning in the following areas: friendships, social motivation, bullying, theory of mind, hypersensitivity, and perseverative thinking. These items are coded on a Likert scale of 0 to 3, where 0 representing no impairment and 3 severe impairment in each domain. These scores are used to help the clinician parse out potentially overlapping ASD and anxiety features (e.g., sensitivity v. phobia of loud sounds).

Parent-report Questionnaires

Three parent-report questionnaires were administered to determine whether clinically significant anxiety in these participants was detected by these screening measures. The results of these measures were viewed after anxiety diagnoses were determined through the clinical interview with the ADIS-P/ASA and are reported in Table 3 . The CBCL ( Achenbach & Ruffle, 2000 ) is a widely used measure of a range of problematic behaviors. We chose to specifically focus on the DSM Anxiety Scale due to our goal of determining whether the participants met criteria for DSM clinically significant anxiety. Clinically significant elevations are indicated by a T-Score of ≥70. The MASC ( March et al., 1997 ) includes items of harm avoidance, physical symptoms, social, and separation anxiety. A MASC Total score is derived from the 39 items with a T-Score of ≥65 suggesting clinically significant anxiety. The SCARED ( Birmaher et al., 1999 ) includes items of somatic symptoms, school phobia, and generalized, separation, and social anxiety. A total score is derived from the 41 items with a total of ≥25 indicating clinically significant anxiety.

Case Vignettes

Kylo was a 12-year-old Caucasian (Non-Hispanic) and Asian male diagnosed with ASD at age 2 with a current verbal IQ of 31 and adaptive skills ranging from those of a four-month-old (socialization) to a four-year-old (daily living skills). At the time of the assessment, he spoke some words and used an iPad for communication training. Clinical interviewing revealed that when Kylo approached social situations, he would look anxious and uncomfortable and would cling to his parents and not leave their side. He did not engage with others in public and would actively avoid people by putting his hand up if people tried to speak to him or by putting on headphones and covering his head with a blanket when he had to be around new people. This was in contrast to his behavior around familiar individuals, illustrating that it was not general avoidance of people. When Kylo was around people, he would talk repetitively to his parents in a pressured way about his favorite food, which was French fries, even if he had just eaten. He appeared comforted by thinking about this preferred food like another child might be comforted by a favorite object, such as a blanket. In addition, this behavior only occurred when he was around other people. When he was attending mainstream classes, he displayed aggression towards teachers, staff, and peers and also engaged in self-injurious behavior. It was difficult to determine the source of his stress in the school situation at first; however, the behavior decreased once he was moved to a specialized classroom with fewer and more similar peers. This behavior was not always present for Kylo; his parents noticed an increase in this distress around people starting about a year prior. The family tried various medications to target this aggressive behavior and only noticed a decrease once they began tetrahydrocannabinol (THC)/cannabidiol (CBD), which has been thought to ameliorate anxiety; however, while CBD has been studied in adults with anxiety (e.g., Crippa et al., 2011 ), there are no known controlled trials that have specifically evaluated anxiety reduction in children with ASD and ID.

Likely given Kylo’s low level of cognitive functioning, most viewed his behavior as lack of social interest related to ASD or sensory sensitivity, rather than symptoms of anxiety. This case is a good illustration of why it is necessary to consider an anxiety diagnosis. Supportive of the fact that Kylo’s behaviors were not just problem behaviors or symptoms of his autism, he exhibited anticipatory anxiety (with an anxious facial expression and clinginess towards parents upon approaching social situations) and avoidance, two hallmarks of an anxiety disorder when in social situations. Furthermore, Kylo had this response even in quiet social situations when unfamiliar people were close to him, indicating it could not be solely accounted for by a sensory sensitivity to noise.

Furthermore, it is possible that Kylo’s aggression towards others and himself were examples of “fight mode” reaction with underlying anxiety to propel this behavior rather than aggressive behavior due to other reasons, such as lack of preference of social situations or sensory irritation. As is typical in those with ASD and ID, Kylo was not able to verbally indicate any fear of negative evaluation, the primary characteristic of social anxiety disorder. In addition, he scored a 3 on the theory of mind section of the ASA (most severe score indicating very poor to no awareness of the thoughts/opinions of others), suggesting that his awareness of others’ thoughts and opinions was limited, and that people were potentially confusing or unpredictable to him in a manner that made him anxious. Though Kylo’s fears were considered to be both severe and functionally impairing, they fell short of the criteria for social anxiety disorder, given that a fear of negative evaluation (criterion A) could not be established. As such, Kylo’s significant and functionally impairing fears (ADIS/ASA CSR=6) were considered to be most consistent with a diagnosis of Other Specified Anxiety Disorder: “Other Social Fears.”

As shown in Table 3 , his CBCL DSM Anxiety, MASC-P and SCARED Totals were all well below the cut-offs for clinically significant anxiety, indicating the low sensitivity of these measures in this population, likely due to their reliance on verbally mediated symptoms, rather than a lack of anxiety.

Everly was an 11-year-old Caucasian (Non-Hispanic) female with a verbal IQ of 32 and diagnosed with ASD when she was 16 months old. She was speaking at a level that included single words at the present evaluation and had adaptive skills ranging from those of a one-year-old (socialization) to a five-year-old (fine motor skills). Everly and her family had lived in several different homes. After a period of several weeks coming and going without issue, Everly would begin to express high levels of distress in response to driving up to each house, including looking scared, crying, covering her ears, screaming, covering someone’s mouth if they tried to talk to her, and refusing to get out of the car. If they did get her out of the car, she would try to run away. We queried her parents in depth in order to obtain these behavioral examples and to accumulate evidence of anticipatory anxiety/fearful avoidance (e.g., looking scared and avoiding the house) and defense cascade behavior (e.g., attempting to run away aligning with “flight”) to determine whether they were associated with anxiety. To further confirm that their function was related to anxiety and not something simply to avoid activities that were non-preferred, we considered whether she preferred outings but did not want them to end. However, she did not seem distressed upon leaving activities or outings and it was only when she approached the house that she became highly anxious. Also, she would not enter the house calmly even if there were highly preferred objects or activities inside. Everly could not indicate to her family what was causing her great distress but, once it started, it would occur every time they pulled up to their house and the process to get her to enter the house often took over 30 minutes. This caused great interference for the family since they became worried about taking her out of the house for fear of what would happen when they had to come home, and if she might injure herself. The family attempted to determine the cause by walking with her to see what she was focusing on or if she could gesture to indicate the problem; however, this was not successful. Each time the family eventually explained to her that they were going to move (they waited 6 weeks before moving the first time) and took her to look at new houses. She was fine with going into new houses and the family picked a new house based on her display of positive emotion in the house. The positivity would not persist following the move, and eventually the problem behaviors would start again. The family had moved five times by the time of this evaluation at 11 years of age. It is unclear what the trigger was for her high levels of distress. Some untestable possibilities discussed with her parent were whether she saw a spider or shadow in her room that scared her, or if she had an uncomfortable sensory experience that developed into a fear. Since anticipatory anxiety, fearful avoidance, possible fight and flight mode, and high interference were present, but the topic of her anxiety/fear was uncertain, Everly’s symptoms were deemed most consistent with a diagnosis of Other Specified Anxiety Disorder: Fears related to the home (coded as “Other Distinct Anxiety” on the ADIS/ASA; CSR=7). Her CBCL DSM Anxiety, MASC-P and SCARED totals were the lowest scores of all of the participants highlighted here, indicating that the type of anxiety/fear she experienced was not captured by these brief-screening questionnaires. Furthermore, anxiety as a trigger for these symptoms and behaviors had never been mentioned to the family by any professional. So, pharmacological or anxiety cognitive-behavioral/behavioral interventions had not been previously recommended.

Everly also had a fear of people singing in person or on the radio. This was singing at a regular or even low volume rather than extremely loud volume, indicating that it was not just a sensory aversion to loud sounds. This began 2-3 years prior to this evaluation. If her family tried to take her into a store or restaurant that potentially played music, she would start looking distressed in the car before entering the place, indicating anticipatory anxiety. If they were able to get her out of the car, she would then pause before walking through the door and listen. If she heard the music, she would look scared, then scream, and shake her head no. If she wasn’t permitted to avoid going in, she would cover her ears, scream, attempt to run, and hit people to get away if they were in her way. This indicated the pattern of fearful avoidance with “fight” and “flight” mode if she was not able to avoid. This occurred as well if she heard singing on the radio. The family had stopped taking her to any public places that they knew played music due to her high levels of distress that affected her safety at times. It is important to note that the ASA has a section to assess for the level of sensory sensitivity in order to assist with differential diagnosis. Everly scored a 1 on the sensory sensitivity section (score of 3 indicates the most interference). She was not sensitive to most loud sounds or other sensory experiences other than some taste sensitivity with food, so it is just these specific sounds that she experienced with such distress. It is possible that she could be sensitive to the sound of singing regardless of volume. However, by obtaining clear behavioral examples, there was an indication of not only an aversion to singing, but also of anticipatory anxiety (e.g., checking for music in stores before going in), avoidance, and fight and flight behavior. Considering idiosyncratic or uncommon areas of anxiety were relevant with Everly since she was not scared of all loud sounds but sounds that were much more specific. Therefore, these symptoms and behavior were deemed most consistent with a diagnosis of Specific Phobia: Other Type (coded as “Uncommon Phobia” on the ADIS/ASA; CSR=6).

Amelie was a 12-year-old Caucasian (Hispanic) female with a verbal IQ of <25 on the DAS II Early Years Protocol ( Elliott, 2007 ) and adaptive skills ranging from those of a four-month-old (socialization) to a three-year-old (daily living skills). She was diagnosed with ASD when she was 2 years old. She had previously been diagnosed with cerebral palsy, spastic hemiplegia, and tethered cord (neuromigrational). As of the current evaluation, she had also been diagnosed with cyclic vomiting syndrome, abdominal migraines, seizures, and tic disorder. She did not display spoken language and used an Augmentative and Alternative Communication (AAC) program on her iPad. Amelie appeared anxious and fearful in situations involving separation from her family members (mom, dad, and brother). If she thought her mother was leaving (e.g., noticed her mom putting on her shoes and getting her purse), she went to her mother, held her hand, cried, stomped her feet, and asked for “mommy” on her communication device. This all occurred before her family member actually left and there were clear behavioral examples indicating anticipatory anxiety. At home, she followed her mother around and sat at the dining room table where she could see most areas of the house and looked for her family members. If a family member left, she would become distressed, start sweating, cry, bite her hand, wring her hands, and ask for them repetitively on her communication device. Amelie’s behavior of biting her hand is a sign of self-injurious behavior and can be considered to be a part of “fight” mode, although it is to herself rather than someone else. This could last up to an hour or until someone could redirect her to an activity of interest. Amelie previously slept with her mother every night but transitioned to sleeping with her service dog once she joined the family. In addition, Amelie regularly (ranging from several times throughout the day to continuously for at least an hour or more) checked that all of her family members were there by doing a head count and also looked to see that her mother’s car was in the garage, and her mother’s purse was in the house. These seemed to be ways Amelie attempted to cope with her anxiety, by looking for reassurance that her family was home, rather than compulsive checking related to obsessive-compulsive disorder. This information was derived from exploring how Amelie was currently coping as it can give clues into the anxiety a child is experiencing. If the entire family of four would go to the grocery store, Amelie would want everyone to stay together in the store. If they were in line and they forgot something, she became distressed if one person tried to leave to go retrieve it so the entire family would get out of line to go. Amelie’s mother reported that the family had eventually organized their whole life around this area of anxiety and worked to run all of her errands or do anything she needed to do while Amelie was in school. When Amelie was around other children, she wanted her mother to stay by her side and do everything the kids were doing. Amelie had a history of vomiting and stomachaches resulting in medical diagnoses of cyclic vomiting syndrome and abdominal headaches. Considering that these exact physical symptoms are in the DSM-5 diagnostic criteria for separation anxiety, it is possible that these symptoms were directly related to her anxiety and her mother wondered this as well. This was possible since Amelie appeared to be worrying about separation often throughout the day, even if separation was not imminent; however, also difficult to parse out since her anxiety did not depend on specific triggers for separation to be present. Therefore, these symptoms and behavior that significantly interfered with Amelie’s life were deemed most consistent with Separation Anxiety Disorder (ADIS/ASA CSR=7). Amelie’s CBCL DSM Anxiety, MASC-P and SCARED Totals were, again, all within the average range. A psychiatrist had recently informed Amelie’s family that she had anxiety and Zoloft had been prescribed.

Amelie also had a fear of garland or other overhead hanging decorations. The family attempted to take Amelie to go see the holiday decorations in their town. When she saw the garland, she attempted to run away and appeared scared, indicating “flight” mode and fearful avoidance. They could not convince her to go towards the decorations and her fear remained sufficiently intense that they eventually left without participating in the event. Her immediate and extended family refrained from decorating for the holidays in this way due to this fear and related interference. When Amelie’s mother decorated the playroom in their house with hanging decorations, outside of the holiday season, she refused to enter. She invariably looked away, showed a fearful facial expression, trembled, and pointed to the items as if to request to remove them. Her mother moved the hanging decorations to her brother’s room, at which point she refused to enter until they were removed. Amelie’s mother was asked specific questions to obtain the behavioral examples to confirm the presence of anticipatory anxiety, fearful avoidance, flight behavior, and an idiosyncratic fear of decorations hanging overhead. Therefore, these symptoms and behaviors were deemed most consistent with Specific Phobia: Other Type (coded as “Uncommon Phobia” on the ADIS/ASA; CSR=4).

Clinical Considerations for Assessing Anxiety in ASD and ID

1) keep anxiety on the radar..

Always carefully consider whether a child with ASD and ID might have a significant anxiety problem that has gone undetected. Some behavioral manifestations of anxiety in this population can be easily confused with autism symptoms or problem behaviors.

2) Behavioral examples.

Use semi-structured interviews (as recommended by MacNeil et al., 2009 ), particularly those that are designed and validated for use in children with ASD (e.g., ADIS-P/ASA) as a guide with a central focus on obtaining behavioral examples, as suggested by the DM-ID-2. Also, while the DM-ID-2 specifies focusing more on behavioral observations of anxiety for children with severe or profound ID, we also applied this approach to all children with autism, with or without ID, since some children do not express their emotions verbally even if their overall language and cognitive level is sufficient to do so. Table 2 includes a list of behavioral examples ( Vasa et al., 2016 ) with a potential underlying function of anxiety that can be queried as part of the interview process. It may be necessary to adjust the wording of interview probes to make them more appropriate for the child’s language level (e.g., “Has he/she indicated…,” rather than, for example, “Has he/she told you…”).

3) The Defense Cascade or 6Fs.

While the 6Fs are not specifically outlined in the DSM-5, the behaviors are mentioned in the DM-ID-2 (e.g., freezing). They are also inherent in clinically significant anxiety and fear and can often be observed directly. Notably, the behaviors in the case vignettes of aggression, self-injurious behavior, eloping, and freeze behavior do not always indicate anxiety; however, identifying when these symptoms co-occur with hallmarks of anxiety disorders (e.g., avoidance, and anticipatory anxiety) may lead to more accurate examination of anxiety disorders.

4) Physical symptoms.

As recommended by Vasa et al. (2016) , consider gastrointestinal symptoms such as vomiting and stomachaches, as well as headaches, as these symptoms are often associated with anxiety. Physical symptoms of anxiety can be difficult to determine if a child cannot express them verbally. However, if there is evidence that pain or other somatic patterns are present, considering anxiety as the culprit is encouraged. Physical symptoms may prompt extensive medical workups that can be highly distressing to children with ASD and ID. Some examples we have observed, with a function eventually determined to be anxiety, include feeding tube placement due to nausea, vomiting, and reduced desire to eat, and asthma diagnosis and extensive medicine due to difficulty breathing. Therefore, while a medical workup should always occur first if physical symptoms are present, we encourage a consideration of anxiety as well if no clear medical cause is found.

5) Anticipatory anxiety/fearful avoidance.

Differentiate anticipatory anxiety/fearful avoidance from behaviors not associated with anxiety/fear (e.g., core ASD symptoms, non-preferred tasks/situations, or distress with a different underlying emotion such as frustration, anger, or sadness). Anticipatory anxiety occurs when an individual experiences increased anxiety about what they think might happen in the future (e.g., my parent might leave and not come back). Fearful avoidance is when one avoids situations/experiences that could lead to the fear (e.g., avoid separating from parent). These are two hallmarks of an anxiety disorder and can be difficult to determine if a child is not able to verbally describe these symptoms. To evaluate this, the clinician might ask the parent to describe how they can tell when the child is afraid v. angry or afraid v. disinterested and also to describe why they think the child is afraid in the particular scenario being discussed. In this way, the clinician can combine their expertise about varied signs and behavioral patterns that may reflect anxiety with the parent’s expertise regarding the unique way their child expresses their emotions. Asking the parent to differentiate emotions in this way may be critical to ensure that not all moments of distress or challenging behavior are reframed as anxiety. In reality, a child may engage in repetitive behaviors both when they are excited and upset. Anticipatory anxiety or fearful avoidance is a key component to determining whether clinically significant anxiety is present. In conducting these interviews, parents often report, “My child does not like that,” when asked about whether they are fearful of something or exhibit anxiety. It is the role of the interviewer to ask further questions to determine if there is anything that is evident in a fearful or anticipatory way.

6) Idiosyncratic coping/repetitive behaviors.

Consider whether the child does anything idiosyncratic to attempt to cope with anxiety (e.g., repetitively ask for favorite food item, check schedule often to see when parent is returning). These behaviors may serve as coping mechanisms, and in many cases, anxiety may be identified by observing how the child attempts to cope when anxious. Further, repetitive behaviors sometimes increase when the child is anxious (e.g., pacing) and other children talk more frequently about their special interest when anxious. More specifically, Spiker et al. (2011) found that symbolic enactment of restricted interests (RI; i.e., a child repetitively enacting or mimicking characters or scenes related to a RI) was significantly associated with increased anxiety.

7) Distinct anxiety.

Using the ASA ( Kerns et al., 2017 ) as a guide, consider whether distinct areas of anxiety are present (e.g., uncommon phobia, fears of social interaction despite limited fears of negative evaluation). Since the specialized training on the ASA might not be possible for all clinicians, even becoming familiar with distinct areas of anxiety can help detect anxiety that might otherwise go overlooked.

8) Clinician training.

We recognize that some of these considerations, such as full semi-structured interviews, might not be as feasible in a fast-paced clinical setting. It is still possible to obtain knowledge through training that would lead to more accurate detection of anxiety. It is suggested that clinicians responsible for the mental health in those with ASD/ID have in-depth knowledge of the differentiation between ASD and anxiety including where there is symptom overlap; have awareness of how to obtain clear behavioral examples of anticipatory anxiety and fearful avoidance, especially in those with Severe ID, as suggested by the DM-ID-2; consider how the Defense Cascade manifests behaviorally and ways to ask about these symptoms; consider screening questionnaires carefully due to the reduced sensitivity in this population; and consider whether distinct areas of anxiety are present and need clinical attention.

Additional strategies suggested for a multi-method assessment

Other methods/approaches ideally integrated into a multi-method assessment include using newer anxiety parent questionnaires that have been specifically designed for individuals with ASD and have prompts that are more behaviorally oriented than verbally mediated (e.g., PRAS-ASD; Scahill et al., 2019 ); including self-report when possible either through interview or drawing; and direct observation of the child, especially in contexts that might induce anxiety (e.g., while greeting unknown people). Moskowitz, Rosen, et al. (2017) discussed using the Behavioral Avoidance Test (BAT; Hagopian & Jennett, 2008 ), as one type of direct observation, to systematically expose the child to the feared object/situation while assessing the child’s various displays of anxiety and avoidance. The PRAS-ASD was not yet available for the present study so results of the parent-report screening questionnaires (MASC, CBCL, SCARED) used were discussed.

Assessment as a Means to Effective Treatment

Accurate assessment of anxiety disorders ultimately has one clear aim: to guide appropriate treatment. The evidence base for cognitive-behavioral therapy (CBT) for youth with anxiety disorders is both long-standing and robust ( Higa-McMillan et al., 2015 ). CBT for youth with anxiety targets impairing symptoms through several key components, including psychoeducation, cognitive restructuring, and exposure ( Gosch et al., 2006 ). Exposure consists of interrupting the fear-relief cycle that occurs when youth avoid the stimuli or situations (real or imagined) of which they are afraid. CBT, fortunately, is not reserved for typically developing populations and CBT for youth with autism and anxiety is supported by a growing body of research ( Kester & Lucyshyn, 2018 ). To date, less research has focused on CBT for youth with ID though evidence shows promising results with appropriate modifications ( Blakeley-Smith et al., 2021 ; Hronis et al., 2017 ). Recent studies have investigated treatments for anxiety in ASD and ID that bear resemblance to CBT, specifically an array of behavioral interventions, which de-emphasize the cognitive component of CBT and adapt the intervention(s) to the child’s functioning level ( Moskowitz, Walsh, et al., 2017 ; Rosen et al., 2016 ).

The case participants presented here did not receive treatment as part of this study, yet exposure-based strategies could clearly be applied to target their anxious symptoms. For Amelie, prescribed exposures would likely consist of gradually spending increased amounts of time without her family immediately nearby (e.g., across the room, in an adjacent room, upstairs, and so on), consistent with traditional separation anxiety exposures. Her fear of garland, which is an uncommon fear, would similarly be targeted via exposures to the feared stimuli (e.g., pictures of garland, garland being inside a bag in the room, touching garland for one second and so on). Importantly, exposure could decrease avoidant behavior, not simply as a form of compliance and habituation, but also a sense of mastery and reduction of the fear response. Indeed, reaching this aim may require particular modifications to achieve treatment goals, such as including concrete visual materials, idiosyncratic rating scales (e.g., feelings thermometer), tangible reinforcement programs, and enhanced parental involvement as compared to traditional CBT ( Moree & Davis, 2010 ; Walters et al., 2016 ). In virtually all cases the integration of children’s special interests is key to building motivation and engagement. Lastly, special attention must be paid to the co-occurring attention, language, and memory deficits that may present in youth with ID ( Hronis et al., 2017 ). Together, a high level of flexibility, creativity, and individual tailoring is necessitated.

For instance, Everly might benefit from visual materials that illustrate her fear and avoidance in a concrete manner, such as cartoons showing her tantrumming about music on the radio and her bravely listening to a song. Her mantras may consist of one word, such as “Okay!” or “Listen!” or even a preferred character (e.g., “Mickey!”) while participating in initial music exposures. Similarly, Kylo’s presentation would warrant rapid rewards, such as watching a Star Wars video intermittently during exposures. Kylo may also benefit from inclusion of comfort items during initial exposures (e.g., Yoda stuffed animal, blanket), which could be faded out gradually over time. Further, he may engage most from modeling in the form of showing two Star Wars characters talking. Such forms of treatment may significantly and positively impact these children’s lives, but identification of anxiety must occur in order for appropriate mental health referrals to be made.

Limitations

The data presented here was limited to case studies of youth with anxiety, ASD, and ID. They are uniquely useful for illustrating detailed information regarding the idiosyncratic presentation of anxiety; however, they may not be representative of anxiety in those with ASD and ID overall. In addition, our parent-report questionnaires of anxiety were not sensitive enough to detect anxiety in any of the three cases. While this highlights the discrepancy between the utility of brief screening questionnaires versus semi-structured interviews in this population, newer measures have recently been developed to help address this concern, such as the PRAS-ASD ( Scahill et al., 2019 ). Furthermore, while we provided clinical considerations related to a thorough parent-interview process, a multi-method approach is recommended for clinical determinations.

An imperative future direction for our field, both within neurodevelopmental and mental health specialties, is to enhance clinicians’ ability to assess for anxiety amongst youth with ASD and ID. We have outlined a parent interviewing approach with case vignettes and clinical considerations with a focus on behavioral examples, anticipatory anxiety, and fearful avoidance, to more accurately detect anxiety that might otherwise be easily overlooked in this complex population. To this end, more training on the topics presented is needed at both the graduate training program and professional level. These children experience anxiety that can be treated but first it must be identified. Therefore, thoughtful assessment of potential anxiety is paramount to enhancing the mental health of this population of children and their families.

Acknowledgements:

We would like to thank and acknowledge the participants and their families who have taught us so much about the various presentations of anxiety. We are so grateful for you. During this work, Drs. Winder-Patel, Tudor, Solomon, Nordahl, and Amaral were supported by Autism Center of Excellence grant awarded by the NICHD (P50 HD093079, PI: Amaral). Additional support to Dr. Solomon was provided by R01 MH106518 and R01 MH103284; to Dr. Amaral by R01 MH103371. The project was also supported by the MIND Institute Intellectual and Developmental Disabilities Research Center (P50HD103526).

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DSM-5 Clinical Cases

• Rachel A. Davis , M.D.

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DSM-5 Clinical Cases makes the rather overwhelming DSM-5 much more accessible to mental health clinicians by using clinical examples—the way many clinicians learn best—to illustrate the changes in diagnostic criteria from DSM-IV-TR to DSM-5. More than 100 authors contributed to the 103 case vignettes and discussions in this book. Each case is concise but not oversimplified. The cases range from straightforward and typical to complicated and unusual, providing a nice repertoire of clinical material. The cases are realistic in that many portray scenarios that are complicated by confounding factors or in which not all information needed to make a diagnosis is available. The authors are candid in their discussions of difficulties arriving at the correct diagnoses, and they acknowledge the limitations of DSM-5 when appropriate.

The book is conveniently organized in a manner similar to DSM-5. The 19 chapters in DSM-5 Clinical Cases correspond to the first 19 chapters in section 2 of DSM-5. As in DSM-5, DSM-5 Clinical Cases begins with diagnoses that tend to manifest earlier in life and advances to diagnoses that usually occur later in life. Each chapter begins with a discussion of changes from DSM-IV. These changes are further explored in the cases that follow.

Each case vignette is titled with the presenting problem. The cases are formatted similarly throughout and include history of present illness, collateral information, past psychiatric history, social history, examination, any laboratory findings, any neurocognitive testing, and family history. This is followed by the diagnosis or diagnoses and the case discussion. In the discussions, the authors highlight the key symptoms relevant to DSM-5 criteria. They explore the differential diagnosis and explain their rational for arriving at their selected diagnoses versus others they considered as well. In addition, they discuss complicating factors that make the diagnoses less clear and often mention what additional information they would like to have. Each case is followed by a list of suggested readings.

As an example, case 6.1 is titled Depression. This case describes a 52-year-old man, “Mr. King,” presenting with the chief complaint of depressive symptoms for years, with minimal response to medication trials. The case goes on to describe that Mr. King had many anxieties with related compulsions. For example, he worried about contracting diseases such as HIV and would wash his hands repeatedly with bleach. He was able to function at work as a janitor by using gloves but otherwise lived a mostly isolative life. Examination was positive for a strong odor of bleach, an anxious, constricted affect, and insight that his fears and behaviors were “kinda crazy.” No laboratory findings or neurocognitive testing is mentioned.

The diagnoses given for this case are “OCD, with good or fair insight,” and “major depressive disorder.” The discussants acknowledge that evaluation for OCD can be difficult because most patients are not so forthcoming with their symptoms. DSM-5 definitions of obsessions and compulsions are reviewed, and the changes to the description of obsessions are highlighted: the term urge is used instead of impulse so as to minimize confusion with impulse-control disorders; the term unwanted instead of inappropriate is used; and obsessions are noted to generally (rather than always) cause marked anxiety or distress to reflect the research that not all obsessions result in marked anxiety or distress. The authors review the remaining DSM-5 criteria, that OCD symptoms must cause distress or impairment and must not be attributable to a substance use disorder, a medical condition, or another mental disorder. They discuss the two specifiers: degree of insight and current or past history of a tic disorder. They briefly explore the differential diagnosis, noting the importance of considering anxiety disorders and distinguishing the obsessions of OCD from the ruminations of major depressive disorder. They also point out the importance of looking for comorbid diagnoses, for example, body dysmorphic disorder and hoarding disorder.

This brief case, presented and discussed in less than three pages, leaves the reader with an overall understanding of the diagnostic criteria for OCD, as well as a good sense of the changes in DSM-5.

DSM-5 Clinical Cases is easy to read, interesting, and clinically relevant. It will improve the reader’s ability to apply the DSM-5 diagnostic classification system to real-life practice and highlights many nuances to DSM-5 that one might otherwise miss. This book will serve as a valuable supplementary manual for clinicians across many different stages and settings of practice. It may well be a more practical and efficient way to learn the DSM changes than the DSM-5 itself.

The author reports no financial relationships with commercial interests.

• Cited by None

Case Examples

Examples of recommended interventions in the treatment of depression across the lifespan.

Children/Adolescents

A 15-year-old Puerto Rican female

The adolescent was previously diagnosed with major depressive disorder and treated intermittently with supportive psychotherapy and antidepressants. Her more recent episodes related to her parents’ marital problems and her academic/social difficulties at school. She was treated using cognitive-behavioral therapy (CBT).

Chafey, M.I.J., Bernal, G., & Rossello, J. (2009). Clinical Case Study: CBT for Depression in A Puerto Rican Adolescent. Challenges and Variability in Treatment Response. Depression and Anxiety , 26, 98-103.  https://doi.org/10.1002/da.20457

Sam, a 15-year-old adolescent

Sam was team captain of his soccer team, but an unexpected fight with another teammate prompted his parents to meet with a clinical psychologist. Sam was diagnosed with major depressive disorder after showing an increase in symptoms over the previous three months. Several recent challenges in his family and romantic life led the therapist to recommend interpersonal psychotherapy for adolescents (IPT-A).

Hall, E.B., & Mufson, L. (2009). Interpersonal Psychotherapy for Depressed Adolescents (IPT-A): A Case Illustration. Journal of Clinical Child & Adolescent Psychology, 38 (4), 582-593. https://doi.org/10.1080/15374410902976338

© Society of Clinical Child and Adolescent Psychology (Div. 53) APA, https://sccap53.org/, reprinted by permission of Taylor & Francis Ltd, http://www.tandfonline.com on behalf of the Society of Clinical Child and Adolescent Psychology (Div. 53) APA.

General Adults

Mark, a 43-year-old male

Mark had a history of depression and sought treatment after his second marriage ended. His depression was characterized as being “controlled by a pattern of interpersonal avoidance.” The behavior/activation therapist asked Mark to complete an activity record to help steer the treatment sessions.

Dimidjian, S., Martell, C.R., Addis, M.E., & Herman-Dunn, R. (2008). Chapter 8: Behavioral activation for depression. In D.H. Barlow (Ed.) Clinical handbook of psychological disorders: A step-by-step treatment manual (4th ed., pp. 343-362). New York: Guilford Press.

Reprinted with permission from Guilford Press.

Denise, a 59-year-old widow

Denise is described as having “nonchronic depression” which appeared most recently at the onset of her husband’s diagnosis with brain cancer. Her symptoms were loneliness, difficulty coping with daily life, and sadness. Treatment included filling out a weekly activity log and identifying/reconstructing automatic thoughts.

Young, J.E., Rygh, J.L., Weinberger, A.D., & Beck, A.T. (2008). Chapter 6: Cognitive therapy for depression. In D.H. Barlow (Ed.) Clinical handbook of psychological disorders: A step-by-step treatment manual (4th ed., pp. 278-287). New York, NY: Guilford Press.

Nancy, a 25-year-old single, white female

Nancy described herself as being “trapped by her relationships.” Her intake interview confirmed symptoms of major depressive disorder and the clinician recommended cognitive-behavioral therapy. 

Persons, J.B., Davidson, J. & Tompkins, M.A. (2001). A Case Example: Nancy. In Essential Components of Cognitive-Behavior Therapy For Depression (pp. 205-242). Washington, D.C.: American Psychological Association. http://dx.doi.org/10.1037/10389-007

While APA owns the rights to this text, some exhibits are property of the San Francisco Bay Area Center for Cognitive Therapy, which has granted the APA permission for use.

Luke, a 34-year-old male graduate student

Luke is described as having treatment-resistant depression and while not suicidal, hoped that a fatal illness would take his life or that he would just disappear. His treatment involved mindfulness-based cognitive therapy, which helps participants become aware of and recharacterize their overwhelming negative thoughts. It involves regular practice of mindfulness techniques and exercises as one component of therapy.

Sipe, W.E.B., & Eisendrath, S.J. (2014). Chapter 3 — Mindfulness-Based Cognitive Therapy For Treatment-Resistant Depression. In R.A. Baer (Ed.), Mindfulness-Based Treatment Approaches (2nd ed., pp. 66-70). San Diego: Academic Press.

Reprinted with permission from Elsevier.

Sara, a 35-year-old married female

Sara was referred to treatment after having a stillbirth. Sara showed symptoms of grief, or complicated bereavement, and was diagnosed with major depression, recurrent. The clinician recommended interpersonal psychotherapy (IPT) for a duration of 12 weeks.

Bleiberg, K.L., & Markowitz, J.C. (2008). Chapter 7: Interpersonal psychotherapy for depression. In D.H. Barlow (Ed.) Clinical handbook of psychological disorders: a treatment manual (4th ed., pp. 315-323). New York, NY: Guilford Press.

Peggy, a 52-year-old white, Italian-American widow

Peggy had a history of chronic depression, which flared during her husband’s illness and ultimate death. Guilt was a driving factor of her depressive symptoms, which lasted six months after his death. The clinician treated Peggy with psychodynamic therapy over a period of two years.

Bishop, J., & Lane , R.C. (2003). Psychodynamic Treatment of a Case of Grief Superimposed On Melancholia. Clinical Case Studies , 2(1), 3-19. https://doi.org/10.1177/1534650102239085

Several case examples of supportive therapy

Winston, A., Rosenthal, R.N., & Pinsker, H. (2004). Introduction to Supportive Psychotherapy . Arlington, VA : American Psychiatric Publishing.

Older Adults

Several case examples of interpersonal psychotherapy & pharmacotherapy

Miller, M. D., Wolfson, L., Frank, E., Cornes, C., Silberman, R., Ehrenpreis, L.…Reynolds, C. F., III. (1998). Using Interpersonal Psychotherapy (IPT) in a Combined Psychotherapy/Medication Research Protocol with Depressed Elders: A Descriptive Report With Case Vignettes. Journal of Psychotherapy Practice and Research , 7(1), 47-55.

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Suicide Risk: Case Studies and Vignettes

Identifying warning signs case study.

Taken from Patterson, C. W. (1981). Suicide. In Basic Psychopathology: A Programmed Text.

Instructions: Underline all words and phrases in the following case history that are related to INCREASED suicidal risk. Then answer the questions at the end of the exercise.

History of Present Illness

The client is a 65-year-old white male, divorced, living alone, admitted to the hospital in a near comatose condition yesterday because of an overdose of approximately thirty tablets of Valium, 5 mgm, combined with alcoholic intoxication. The client was given supportive care and is alert at the present time.

A heavy drinker, he has been unemployed from his janitorial job for the past three months because of his drinking. He acknowledges feeling increasingly depressed since being fired, and for the past two weeks has had insomnia, anorexia, and a ten pound weight loss. He indicates he wanted to die, had been thinking of suicide for the past week, planned the overdose, but had to “get drunk” because “I didn’t have the guts” [to kill myself]. He is unhappy that the attempt failed, states that, “nobody can help me” and he sees no way to help himself. He denies having any close relationships or caring how others would feel if he committed suicide (“who is there who cares?”). He views death as a “relief.” His use of alcohol has increased considerably in the past month. He denies having any hobbies or activities, “just drinking.”

Past Psychiatric History

Hospitalized in 1985 at Pleasantview Psychiatric Hospital for three months following a suicide attempt after his fourth wife left him. Treated with ECT, he did “pretty good, but only for about two years” thereafter.

Social History

An only child, his parents are deceased (father died by suicide when client was eight years old; mother died of “old age” two years ago). Raised in Boston, he moved to Los Angeles at twenty-one and has lived here since. Completed eighth grade (without any repeat) but quit to go to work (family needed money). Has never held a job longer than two years, usually quitting or being fired because of “my temper.” Usually worked as a laborer. Denies any physical problems other than feeling “tired all the time.” Currently living on Social Security income, he has no other financial resources. He received a bad conduct discharge from the army after three months for “disobeying an order and punching the officer.” He has had no legal problems other than several arrests in the past two years for public intoxication. Married and divorced four times, he has no children or close friends.

Mental Status Examination

65 y.o. W/M, short, thin, grey-haired, unkempt, with 2-3 day-old beard, lying passively in bed and avoiding eye contact. His speech was slow and he did not spontaneously offer information. Passively cooperative. Little movement of his extremities. His facial expression was sad and immobile.

Thought processes were logical and coherent, and no delusions or hallucinations were noted. Theme of talk centered around how hopeless the future was and his wishes to be dead. There were no thoughts about wishing to harm others.

Mood was one of depression. He was oriented to person, place, and time, and recent and remote memory was intact. He could perform simple calculations and his general fund of knowledge was fair. His intelligence was judged average.

Diagnostic Impression

• drug overdose (Valium and alcohol)
• Dysthymic Disorder (depression)
• Substance Use Disorder (alcohol)

Questions for Exercise

You have interviewed the client, obtained the above history, and now have to make some decisions about the client. He wants to leave the hospital.

• Is he a significant risk for suicide?
• discharging him as he wishes and with your concurrence?
• discharging him against medical advice (A.M.A.)?
• discharging him if he promises to see a therapist at a nearby mental health center within the next few days?
• holding him for purposes of getting his psychiatric in-client care even though he objects?
• Discuss briefly why you would not have chosen the other alternatives in question #2.

Identifying Warning Signs Case Study: Feedback/Answers

The client is a  65-year-old   white male ,  divorced ,  living alone , admitted to the hospital in a near comatose condition yesterday because of an overdose of approximately thirty tablets of Valium, 5 mgm, combined with alcoholic intoxication. The client was given supportive care and is alert at the present time. A  heavy drinker , he has been  unemployed  from his janitorial job for the past three months because of his drinking. He acknowledges feeling increasingly depressed since being fired, and for the past two weeks has had  insomnia  and a  ten pound weight loss . He indicates he wanted to die, had been thinking of suicide for the past week, planned the overdose, but had to “get drunk” because “I didn’t have the guts” [to kill myself]. He is  unhappy that the attempt failed , states that, “ nobody can help me ” and he sees no way to help himself. He  denies having any close relationships  or caring how others would feel if he committed suicide (“who is there who cares?”). He  views death as a “relief.”  His  use of alcohol has increased  considerably in the past month.  He denies having any hobbies or activities , “just drinking.”

Hospitalized in 1985 at Pleasantview Psychiatric Hospital for three months following a suicide attempt  after his  fourth wife left him . Treated with ECT, he did “pretty good, but only for about two years” thereafter.

An only child, his  parents are deceased  ( father died by suicide  when client was eight years old; mother died of “old age” two years ago). Raised in Boston, he moved to Los Angeles at twenty-one and has lived here since. Completed eighth grade (without any repeat) but quit to go to work (family needed money).  Has never held a job longer than two years , usually quitting or being fired because of “ my temper .” Usually worked as a laborer. Denies any physical problems other than feeling “tired all the time.” Currently living on Social Security income, he has  no other financial resources . He received a  bad conduct discharge from the army  after three months for “disobeying an order and punching the officer.” He has had no legal problems other than several arrests in the past two years for public intoxication.  Married and divorced four times , he  has no children or close friends .

65 y.o. W/M, short, thin, grey-haired, unkempt, with 2-3 day-old beard, lying passively in bed and avoiding eye contact.  His speech was slow and he did not spontaneously offer information . Passively cooperative. Little movement of his extremities. His facial expression was sad and immobile. Thought processes were logical and coherent, and no delusions or hallucinations were noted. Theme of talk centered around how  hopeless the future was and his wishes to be dead . There were no thoughts about wishing to harm others. Mood was one of depression . He was oriented to person, place, and time, and recent and remote memory was intact. He could perform simple calculations and his general fund of knowledge was fair. His intelligence was judged average.

• Is he a significant risk for suicide?  Yes. The client presents a considerable suicidal risk, with respect to demographic characteristics, psychiatric diagnosis and mental status findings.
• Discuss briefly why you would not have chosen the other alternatives in question #2.  The client appears to be actively suicidal at the present time,and may act upon his feelings. Nothing about his life has changed because of his attempt. He still is lonely, with limited social resources. He feels no remorse for his suicidal behavior and his future remains unaltered. He must be hospitalized until some therapeutic progress can be made.

Short-Term Suicide Risk Vignettes

*Case study vignettes taken from Maris, R. W., Berman, A. L., Maltsberger, J. T., & Yufit, R. I. (Eds), (1992). Assessment and prediction of suicide. New York: Guilford. And originally cited in Stelmachers, Z. T., & Sherman, R. E. (1990). Use of case vignettes in suicide  risk assessment. Suicide and Life-Threatening Behavior, 20, 65-84.

The assessment of suicide risk is a complicated process. The following vignettes are provided to promote discussion of suicide risk factors, assessment procedures, and intervention strategies. The “answers” are not provided, rather students are encouraged to discuss cases with each other and faculty. Two examples of how discussions may be facilitated are provided.

37-year-old white female, self-referred. Stated plan is to drive her car off a bridge. Precipitant seems to be verbal abuse by her boss; after talking to her nightly for hours, he suddenly refused to talk to her. As a result, patient feels angry and hurt, threatened to kill herself. She is also angry at her mother, who will not let patient smoke or bring men to their home. Current alcohol level is .15; patient is confused, repetitive, and ataxic. History reveals a previous suicide attempt (overdose) 7 years ago, which resulted in hospitalization. After spending the night at CIC and sobering, patient denies further suicidal intent.

16-year-old Native American female, self-referred following an overdose of 12 aspirins. Precipitant: could not tolerate rumors at school that she and another girl are sharing the same boyfriend. Denies being suicidal at this time (“I won’t do it again; I learned my lesson”). Reports that she has always had difficulty expressing her feelings. In the interview, is quiet, guarded, and initially quite reluctant to talk. Diagnostic impression: adjustment disorder.

49-year-old white female brought by police on a transportation hold following threats to overdose on aspirin (initially telephoned CIC and was willing to give her address). Patient feels trapped and abused, can’t cope at home with her schizophrenic sister. Wants to be in the hospital and continues to feel like killing herself. Husband indicates that the patient has been threatening to shoot him and her daughter but probably has no gun. Recent arrest for disorderly conduct (threatened police with a butcher knife). History of aspirin overdose 3 years ago. In the interview, patient is cooperative; appears depressed, anxious, helpless, and hopeless. Appetite and sleep are down, and so is her self-esteem. Is described as “anhedonic.” Alcohol level: .12.

23-year-od white male, self-referred. Patient bought a gun 2 months ago to kill himself and claims to have the gun and four shells in his car (police found the gun but no shells). Patient reports having planned time and place for suicide several times in the past. States that he cannot live any more with his “emotional pain” since his wife left him3 years ago. This pain has increased during the last week, but the patient cannot pinpoint any precipitant. Patient has a history of chemical dependency, but has been sober for 20 months and currently goes to AA.

22-year-old black male referred to CIC from the Emergency Room on a transportation hold. He referred himself to the Emergency Room after making fairly deep cuts on his wrists requiring nine stitches. Current stress is recent breakup with his girlfriend and loss of job. Has developed depressive symptoms for the last 2 months, including social withdrawal, insomnia, anhedonia, and decreased appetite. Blames his sister for the breakup with girlfriend. Makes threats to sister (“I will slice up that bitch, she is dead when I get out”). Patient is an alcoholic who just completed court-ordered chemical dependency treatment lasting 3 weeks. He is also on parole for attempted rape. There is a history of previous suicide attempts and assaultive behavior, which led to the patient being jailed. In the interview, patient is vague regarding recent events and history. He denies intent to kill himself but admits to still being quite ambivalent about it. Diagnostic impression: antisocial personality.

19-year-old white male found by roommate in a “sluggish” state following the ingestion of 10 sleeping pills (Sominex) and one bottle of whiskey. Recently has been giving away his possessions and has written a suicide note. After being brought to the Emergency Room, declares that he will do it again. Blood alcohol level: .23. For the last 3 or 4 weeks there has been sleep and appetite disturbance, with a 15-pound weight loss and subjective feelings of depression. Diagnostic impression: adjustment disorder with depressed mood versus major depressive episode. Patient refused hospitalization.

30-year-old white male brought from his place of employment by a personnel representative. Patient has been thinking of suicide “all the time” because he “can’t cope.” Has a knot in his stomach; sleep and appetite are down (sleeps only 3 hours per night); and plans either to shoot himself, jump off a bridge, or drive recklessly. Precipitant: constant fighting with his wife leading to a recent breakup (there is a long history of mutual verbal/physical abuse). There is a history of a serious suicide attempt: patient jumped off a ledge and fractured both legs; the precipitant for that attempt was a previous divorce. There is a history of chemical dependency with two courses of treatment. There is no current problem with alcohol or drugs. Patient is tearful, shaking, frightened, feeling hopeless, and at high risk for impulsive acting out. He states that life isn’t worthwhile.

Vignette Discussion Examples

Vignette example 1.

Twenty-six year old white female phoned her counselor, stated that she might take pills, and then hung up and kept the phone off the hook. The counselor called the police and the patient was brought to the crisis intervention center on a transportation hold. Patient was angry, denied suicidal attempt, and refused evaluation; described as selectively mute, which means she wouldn’t answer any of the questions she didn’t like.

Facilitator: How high a risk is this person for committing suicide? Low, moderate or high? Student Answer 1: Maybe moderate because the person is warning somebody, basically a plea for help. Facilitator: Okay, so we have suicidal talk. That’s one of our red flags. What else? She said she might take pills, so we didn’t know if she does have the pills. So she has a plan. The plan would be to take pills, but we don’t know if we have means. Student Answer 2: High. She’s also angry. I don’t know if she’s angry often. Facilitator: A person in this situation who is really thinking about killing themselves tends not to deny it. They tend not to deny it. There are exceptions to everything, but most of the time, for some reason, this is one of the things where people tend to mostly tell you the truth. If you ask people, they tend to tell you the truth. It’s a very funny thing about suicide that way. That’s certainly not true about most things. If you ask people how much they drink…But, “Are you thinking about killing yourself?” “Well, yes.” If you ask a question, you tend to get a more or less accurate, straight answer. Student question: Is that because it doesn’t matter anymore? If they’re going to die anyway, who’s going to care about what anybody thinks or what happens? Facilitator: My hypothesis would be, when someone is at that point, they’re talking about real, true things. They’re not into play. This is where they are. If they’re really looking at it, then they’re just at that place. What’s to hide at that point? You don’t have anything to lose. It’s a state of mind. And then if you’re not in that place—it’s like, how close are you to the edge of that cliff? “I’m not there. I know where that is, and I’m not there.” “If you get there, will you tell me?” “Yeah, I’m not there.” So, people have a sense—if they’ve gotten that close, they know where that line is, and they know about where they stand in regard to it, because it’s a very hard-edged, true thing.

Twenty-three year old white male, self-referred. Patient bought a gun two months ago to kill himself and claims to have the gun and four shells in his car. Police found the gun but no shells. Patient reports having planned time and place for suicide several times in the past. States that he cannot live anymore with his emotional pain since his wife left him three years ago. This pain has increased during the last week, but the patient cannot pinpoint any precipitant. Patient has a history of chemical dependency but has been sober for 20 months and currently goes to AA.

Facilitator: How high a risk is this person for committing suicide? Low, moderate or high? On a scale from 0 to 7 (7 being very high). Student Answer 1: High. On a scale of 0 to 7? Student Answer: Six. Student Answer 2: I would say three. I think it would be lower because if he’s already bought the gun two months ago and he’s self-referring himself to get help, he wants to live. He has not made peace with whatever, and he’s more likely not give away his things, and he’s going to AA meetings. I think it’s lower than really an extreme…I would say a three or four. Student Answer 3: I would say a four or five, moderate. Student Answer 4: About a five..several times and hasn’t followed through, tells me he doesn’t really want to follow through with it. Facilitator: And there are no shells, right? So we can see some of the red flags are there, but some of them aren’t. He’s still sober… Student: He has a support group. Student: He’s not using, though he bought a gun—so that’s a concern. There is a lot there. Student: He may not have the shells so he doesn’t have the opportunity to. So does that make him more…? Student 2: Think I’ll change mine to a five. Facilitator: So the mean was 4.68, so 5 was the mode. If we’re saying this is a moderate risk, what things would we look for that would make this a high risk? Student: Take away AA. Student: If he falls off the wagon, he goes right to the top. Student: And if he finds the shells. Facilitator: Because it probably is not that hard to find shells. All these stores around here, you can get shells quicker than you can get a gun, so he’s only a five-minute purchase away from having lethal—in contrast to not having the gun. Student: Could there be a difference in the time? Let’s say his wife left him just four to six months ago rather than three years. Would that be something that would be more serious? Facilitator: Yes, or if his wife just left him. So, say his wife left him a month ago that would bump it up. So that’s unresolved. That’s taking a person that was worried and that’s pushing him higher. Student: It also raises the homicide rate. Facilitator: Yes, because these tend to be murder-suicides. How often have we seen that? Murder-suicide is a big deal. If she won’t be with me, she won’t be with anybody.

Social Work Today magazine

John Sommers-Flanagan

A short existential case example from counseling and psychotherapy theories . . ..

Each chapter in Counseling and Psychotherapy Theories in Context and Practice includes at least two case vignettes. These vignettes are brief, but designed to articulate how clinicians can use specific theories to formulate cases and engage in therapeutic interactions. The following case is excerpted from the Existential Theory and Therapy chapter.

This post is part of a series of free posts available to professors and students in counseling and psychology who are teaching and learning about theories of counseling and psychotherapy. It, as well as the recommended video clip at the end, can be used for discussion purposes and/or to supplement course content.

Vignette II: Using Confrontation and Visualization to Increase Personal Responsibility and Explore Deeper Feelings

In this case, a Native American counselor-in-training is working with an 18-year-old Latina female. The client has agreed to attend counseling to work on her anger and disruptive behaviors within a residential vocational training setting. Her behaviors are progressively costing her freedom at the residential setting and contributing to the possibility of her being sent home. The client says she would like to stay in the program and complete her training, but her behaviors seem to say otherwise.

Client: Yeah, I got in trouble again yesterday. I was just walking on the grass and some “ho” told me to get on the sidewalk so I flipped her off and staff saw. So I got a ticket. That’s so bogus.

Counselor: You sound like you’re not happy about getting in trouble, but you also think the ticket was stupid.

Client: It was stupid. I was just being who I am. All the women in my family are like this. We just don’t take shit.

Counselor: We’ve talked about this before. You just don’t take shit.

Client: Right.

Counselor: Can I be straight with you right now? Can I give you a little shit?

Client: Yeah, I guess. In here it’s different.

Counselor: On the one hand you tell me and everybody that you want to stay here and graduate. On the other hand, you’re not even willing to follow the rules and walk on the sidewalk instead of the grass. What do you make of that?

Client: Like I’ve been saying, I do my own thing and don’t follow anyone’s orders.

Counselor: But you want to finish your vocational training. What is it for you to walk on the sidewalk? That’s not taking any shit. All you’re doing is giving yourself trouble.

Client: I know I get myself trouble. That’s why I need help. I do want to stay here.

Counselor: What would it be like for you then . . . to just walk on the sidewalk and follow the rules?

Client: That’s weak brown-nosing bullshit.

Counselor: Then will you explore that with me? Are you strong enough to look very hard right now with me at what this being weak shit is all about?

Client: Yeah. I’m strong enough. What do you want me to do?

Counselor: Okay then. Let’s really get serious about this. Relax in your chair and imagine yourself walking on the grass and someone asks you to get on the sidewalk and then you just see yourself smiling and saying, “Oh yeah, sure.” And then you see yourself apologize. You say, “Sorry about that. My bad. You’re right. Thanks.” What does that bring up for you.

Client: Goddamn it! It just makes me feel like shit. Like I’m f-ing weak. I hate that.

In this counseling scenario the client is conceptualized as using expansive and angry behaviors to compensate for inner feelings of weakness and vulnerability. The counselor uses the client’s language to gently confront the discrepancy between what the client wants and her behaviors. As you can see from the preceding dialogue, this confrontation (and the counselor’s use of an interpersonal challenge) gets the client to look seriously at what her discrepant behavior is all about. This cooperation wouldn’t be possible without the earlier development of a therapy alliance . . . an alliance that seemed deepened by the fact that the client saw the counselor as another Brown Woman. After the confrontation and cooperation, the counselor shifts into a visualization activity designed to focus and vivify the client’s feelings. This process enabled the young Latina woman to begin understanding in greater depth why cooperating with rules triggered intense feelings of weakness. In addition, the client was able to begin articulating the meaning of feeling “weak” and how that meaning permeated and impacted her life.

To check out a 4+ minute existential counseling video clip go to: https://www.youtube.com/watch?v=jiirtIKcIeM

This clip is taken from our Counseling and Psychotherapy Theories 2 DVD set. The 2 DVD set is available through Psychotherapy.net: http://www.psychotherapy.net/video/counseling-psychotherapy-theories and Amazon: http://www.amazon.com/Counseling-Psychotherapy-Theories-Context-Practice/dp/1118402537/ref=asap_bc?ie=UTF8

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2 thoughts on “a short existential case example from counseling and psychotherapy theories . . .”.

Beautiful example of “process” work, staying with the client’s existential experience. Yes, it works.

Thanks Nadine! I hope all is well for you and your chickens:)

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The place to click if you want to learn about psychotherapy, counseling, or whatever john sf is thinking about..

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LCSW Study Help

California LCSW exam tips, insights and help for studying to pass the test. We also include links to tools and resources for study.

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Monday, august 16, 2010, sample case vignette: harrison's diagnosis, 10 comments:.

I believe it's D. Keep the questions coming!

What's the answer ? I think A

Here is how I score A. Element A1 Scores 1. Harrison does not show evidence of Obsessive Compulsive Personality Disorder. There is little evidence his symptoms are pervasive. This is almost a zero. Element A2 Scores 3. There is a strong suggestion that Harrison binges on food. The vignette also suggests that he may be engaging in excessive exercise. Finally, there are also parts of the element that suggest that he may be using pills as well as exercise to purge after binging. Element A3 Scores 0 There is no more Eating Disorder NOS in the DSM-V. If you are using DSM-IV this would score a three. We don't have enough evidence to clearly diagnose Bulimia. Eating D/O NOS is another strong possibility if the clinician finds that Harrison does not meet criteria for Bulimia. Element A4 Scores 0 We can be confident that Harrison is not anorexic. He appears to be a normal weight and there is no indication he fears becoming obese or has a distorted body image.

I believe the answer is C

Here is how I score C. Element C1 Scores 1. However, some raters may rank it just high enough to score a 2. Harrison's parents describe him as unhappy and the vignette alludes to irritability (although his anger appears contextual as opposed to habitual). Harrison's weight change and psycho motor agitation are clearly driven by a focus on athletics more than depressive symptoms. Element C2 Scores a 1. There is an absence of BPD symptoms in the vignette. Element C3 Scores a 3. There are strong indications that Harrison meets criteria for Binge Eating Disorder. BED is more common than anorexia nervosa or bulimia nervosa. Approximately 40 percent of those with binge eating disorder are male. Harrison's age puts him at additional risk and BED often begins in the late teens or early 20s. Element A4 Scores 1. Neither Harrison or his parents describe him as plagued by recurring, unwanted thoughts, ideas or sensations (obsessions) that make him feel driven to take an action like eating repetitively (compulsions).

i think its D

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Subsample table in pepr

Michal stolarczyk & nathan sheffield, learn sample subannotations in pepr.

This vignette will show you how and why to use the subsample table functionality of the pepr package.

basic information about the PEP concept visit the project website .

broader theoretical description in the subsample table documentation section .

Problem/Goal

This series of examples below demonstrates how and why to use sample subannoatation functionality in multiple cases to provide multiple input files of the same type for a single sample .

Example 1: basic sample subannotation table

This example demonstrates how the sample subannotation functionality is used. In this example, 2 samples have multiple input files that need merging ( frog_1 and frog_2 ), while 1 sample ( frog_3 ) does not. Therefore, frog_3 specifies its file in the sample_table.csv file, while the others leave that field blank and instead specify several files in the subsample_table.csv file.

This example is made up of these components:

• Project config file:

Let’s create the Project object and see if multiple files are present

And inspect the whole table in p1@samples slot

You can also access a single subsample if you call the getSubsample method with appropriate sample_name - subsample_name attribute combination. Note, that this is only possible if the subsample_name column is defined in the sub_annotation.csv file.

Example 2: subannotations and derived attributes

This example uses a subsample_table.csv file and a derived attributes to point to files. This is a rather complex example. Notice we must include the file_id column in the sample_table.csv file, and leave it blank; this is then populated by just some of the samples ( frog_1 and frog_2 ) in the subsample_table.csv , but is left empty for the samples that are not merged.

Let’s load the project config, create the Project object and see if multiple files are present

And inspect the whole table in p2@samples slot

Example 3: subannotations and expansion characters

This example gives the exact same results as Example 2, but in this case, uses a wildcard for frog_2 instead of including it in the subsample_table.csv file. Since we can’t use a wildcard and a subannotation for the same sample, this necessitates specifying a second data source class ( local_files_unmerged ) that uses an asterisk ( * ). The outcome is the same.

And inspect the whole table in p3@samples slot

Example 4: subannotations and multiple (separate-class) inputs

Merging is for same class inputs (like, multiple files for read1). Different-class inputs (like read1 vs read2) are handled by different attributes (or columns). This example shows you how to handle paired-end data, while also merging within each.

And inspect the whole table in p4@samples slot