Case Vignette

Lisa is a 32-year-old Caucasian bank teller. She has been married for five years and has a 3-year-old daughter. Lisa’s job requires her to interact with customers on a daily basis. Her work involves processing routine bank transactions including cashing checks and depositing and exchanging money.

Lisa is constantly fearful of coming into contact with anything that might be contaminated. Concerned about bacteria and viruses from the money she handles, Lisa hurries to the bathroom to wash her hands after each teller transaction. She is convinced the bacteria on her hands will cause an illness, serious or fatal, eventually leading to her inability to take care of her family. Lisa spends up to ten minutes each time in the bathroom. This has caused delays in getting her work done. Despite spending a significant part of her day washing and using hand sanitizer, Lisa constantly doubts her cleanliness. If she accidently touches something she believes is dirty, she immediately washes her hands. This has resulted in bleeding and skin abrasions.

Lisa showers twice daily and systematically washes each body part starting with her head and working down to her feet. This often takes her one hour each time. After showering, Lisa “drip dries” so that her bath towel does not spread germs. To avoid spreading germs at home, she excessively uses Lysol on household objects, sanitizes dishes using several wash cycles, and even uses her elbow to flip light switches. Lisa’s husband often assists with the daily cleaning to reassure her that the house is clean.

Based on your reading of the vignette, discuss the possible diagnoses you considered when thinking about the client’s presenting issues.

1. What diagnosis would you make?
2. What is your rationale for how the client meets all of the specific DSM-5 diagnostic criteria for the mental disorder you have selected?
3. What other information would you need if your client does not meet all of the criteria?
4. What are some examples of current medications being used to treat this diagnosis?
   • What are the benefits the client might receive from taking medication, and what are the potential side effects?
   • What other issues or concerns would you want to address when considering the use of medication with this client?
5. How is the impact of the larger social system (family, school, work, and community) important to consider when assessing and diagnosing the client?