Académique Documents
Professionnel Documents
Culture Documents
Case
The client is a 48 year old man who came to therapy for a fear of flying. Although he states that he
recognizes that his fear of flying is irrational, excessive and unreasonable, just the thought of being in an
airport provokes intense anxiety. According to the man, he is a geologist who is expected to fly to
various conferences. In the past, he has been able to avoid taking trips that would require him to fly;
however, recently his supervisor has been pressuring him to attend these conferences and this has been
causing him considerable distress. In other aspects of the job his work is adequate and he has received
acceptable yearly evaluations. Interpersonally, he has always been passive and shy. He reported that he
frequently looks to others for guidance and has difficulty making decisions on his own due to a lack of
confidence. He lives with his girlfriend and relies on her to provide support and reassurance. He will
frequently call her from work to seek her opinion or just to get approval for his decisions. As a result, he
often subordinates his needs to those of others and volunteers to do unpleasant tasks to get people to
like him. He reported that he would do anything for his girlfriend and that he is frequently concerned
that she might leave him. Although he has never been married, he has never been alone and quickly
enters a new relationship as soon as a previous relationship has ended. The thought of being on his own
is extremely anxiety-provoking to him, and he worries that he would not be able to function. He
reported that it is the feeling of terror when he thinks of getting into an airplane and the possibility that
it might crash that brought him in for treatment. He denied a history of drug or alcohol use and stated
that he is generally healthy, with the exception of mitral valve prolapse (i.e., mild heart condition).
300.29
DSM-5
Specific Phobia,
Situational Type
300.29
Specific Phobia,
Situational
Axis II 301.6
Dependent Personality
Disorder
301.6
Dependent Personality
Disorder
924.0
Axis IV
work difficulties
299.80
314.01
315.31
Axis II
Axis III
Axis IV
none
none
Axis V
GAF = 65
Pervasive Developmental
Disorder- Not
Otherwise Specified
Attention Deficit/
Hyperactivity
Disorder, Combined
Type (Provisional)
Expressive Language
Disorder (Provisional)
interpersonal
difficulties
DSV-5
315.39
Social (Pragmatic)
Communication Disorder
314.01
Attention Deficit/Hyperactivity
Disorder, Combined
(Provisional)
299.80
Aspergers Disorder
Axis II
none
Axis III
none
Axis IV
Axis V
GAF = 65
DSM-5
299.00 Autism Spectrum Disorder,
Level 1, without language
impairment
DSM-5
Axis I
295.30
Schizophrenia, Paranoid
Type
295.90
Schizophrenia
Axis II
301.20
Schizoid Personality
Disorder (premorbid)
301.20
Axis III
None reported
Axis IV
Unemployment,
inadequate social support
Axis V
GAF = 30 (current)
295.90
Schizophrenia
301.20
Hallucinations
Disorganized speech
Abnormal psychomotor behaviors
Negative symptoms
0
1
2
3
4
SCALE: 0 - 4
Not present
Equivocal
Present, but mild
Present and moderate
Present and severe
296.33
300.4
Axis II V71.09
No diagnosis
Axis III
None reported
Axis IV
Unemployment, limited
social support
DSM-5
296.33 Major Depressive Disorder,
Recurrent episode, Severe
DSM-5
Axis I
309.81
Posttraumatic Stress
Disorder, Acute, With
Delayed Onset
309.9
Axis II
301.7
Antisocial Personality
Disorder
301.7
Antisocial Personality
Disorder
Axis III
401.9
Hypertension, essential
(medical records)
401.9
Hypertension, essential
(medical records)
History of combat,
unemployment, lack of
stable home or social
support
Axis IV
Axis V
GAF = 40
(current)
DSM-5
A: stressor: need 1 of 4:
1) Direct exposure; 2) Witnessing,; 3) Indirectly, by
learning a close relative or close friend was exposed;
4) Repeated/extreme indirect exposure in the course
of professional job (not through media).
B: intrusion symptoms: need 1 of 5:
1) Recurrent, intrusive memories; 2) Traumatic
nightmares; 3) flashbacks; 4) Intense/prolonged
distress after exposure; 5) physiologic reactivity upon
exposure to cues
C: persistent effortful avoidance of distressing
trauma-related stimuli: need 1 of 2:
1) Trauma-related thoughts /feelings; 2) Traumarelated external reminders
D: negative cognitions/ mood: need 2 of 7:
1) Inability to recall key features of the trauma; 2)
negative beliefs about oneself, the world; 3) distorted
blame of self, others; 4) Persistent negative traumarelated emotions; 5) diminished interest; 6) Feeling
alienated, detachment/estrangement; 7) Constricted
affect
E: alterations in arousal and reactivity: need 2 of 6:
1) Irritable or aggressive behavior; 2) Self-destructive/
reckless behavior; 3) Hypervigilance; 4) Exaggerated
startle response; 5) Problems in concentration;
6) Sleep disturbance.
300.01
305.00
354.0
Axis II
V71.09
No diagnosis
Axis III
354.0
Axis IV
Axis V
DSM-5
Notes. He sought treatment for his anxiety symptoms so it should be listed if you considered the
alcohol problem primary, you could list it first but you would have to put (reason for visit) next to the
Panic Disorder. You could also list the V code: (V62.29 Other Problem Related to Employment) for the
work related problems, especially in DSM-5 since there is no axis IV.
DSM-5
799.59
Unspecified Neurocognitive
Disorder
Axis II 301.4
Obsessive Compulsive
Personality Disorder
(provisional)
301.4
Obsessive Compulsive
Personality Disorder
(provisional)
Hypertension, Essential
(medical records)
401.9
Hypertension, Essential
(medical records)
Axis IV
Axis I
294.8