How to Use DSM-5 In the Transition to ICD-10

Abstract
On October 1, all HIPAA-covered entities must transition from using ICD-9 codes to
using ICD-10 codes. The following information and guidelines will help you transition to
ICD-10 using DSM-5.

Figure 1 (To enlarge, click here.)

What is the relationship between the codes in my DSM and ICD codes?

Since 1980, every code that has been listed in DSM has been an ICD-9 code.
However, DSM-5, unlike previous versions of DSM, contains both ICD-9 and ICD-10
codes. For most behavioral health providers, if you have a DSM-5, you are ready for the
transition to ICD-10 on October 1.

Where do I find the ICD-10 codes in DSM-5?

Figure 1 is an illustration taken from DSM-5. The code on the left is an ICD-9 code. The
code on the right is an ICD-10 code. Beginning October 1, you will need to use the code
on the right.

Since ICD-10 has more codes than ICD-9, how do I code disorders that now have
multiple coding options?
Figure 2 (To enlarge, click here.)

Part of the reason the U.S. is upgrading to a newer version of ICD is because it allows
providers to be more specific in their diagnoses. For example, there is only one ICD-9
code you can use to diagnose anorexia nervosa. The code is 307.1. ICD-10 provides a
unique code for the two types of anorexia nervosa—the binge-eating/purging type and a
separate code for the restricting type. With ICD-10, you can now be more specific by
assigning a different code to each type.

Figure 2 is an excerpt from a page of DSM-5 to show what these more specific codes look
like in the classification:

Figure 3 is an excerpt from the Feeding and Eating Disorders chapter of DSM-5 to show
what these look like in the text:

If I have DSM-5, do I need to purchase an ICD-10 to identify correct billing codes?

Figure 3 (To enlarge, click here.)

No. If you are a behavioral health provider, DSM-5 should remain your primary resource.
It is a tool that provides you with diagnostic criteria and corresponding ICD-10 codes.

Do I need DSM-5 to practice, or can I just use the ICD-10 book?

Providers should continue to use DSM-5 to determine the correct diagnosis of a mental
disorder. ICD-10 does not contain information to help guide diagnosis; it is simply a
listing of disease names and their corresponding codes. There is a diagnostic book, The
ICD-10 Classification of Mental and Behavioural Disorders (referred to as the “Blue
Book”), which contains diagnostic criteria and non-U.S. ICD-10 codes. However, this
book was last updated in 1992 and is not in line with contemporary thinking about mental
illness in the same way as DSM-5.

Does the U.S. officially recognize DSM-5 for use in identifying ICD-10 codes?

Yes. The National Center for Health Statistics and the Centers for Medicare and Medicaid
Services (CMS) oversee the official implementation of ICD-10 in the U.S. CMS has
posted the following on its website:

“DSM-5 contains the standard criteria and definitions of mental disorders now approved
by the American Psychiatric Association (APA), and it also contains both ICD-9-CM and
ICD-10-CM codes (in parentheses) selected by APA. Since DSM-IV only contains ICD-9-
CM codes, it will cease to be recognized for criteria or coding for services with dates of
service of October 1, 2015 or later. Updates for DSM-5 criteria and their associated ICD-
10-CM codes (identified by APA) will be found on the DSM-5 website. ■

For additional help on using DSM-5 to transition to ICD-10, view APA’s free webinar
tutorial. If you do not yet have DSM-5, you can order it at a discount. You can also
download the Brief Guide to Using DSM-5 in the Transition to ICD-10 here.

PSYC 2030U Case Study Assignment:

Diagnosing DSM 5 Criteria
PSYC 2030U – Abnormal Psychology Case Study Assignment

PSYC 2030U Case Study Assignment – The specific learning objectives of this case
study assignment are:

1. to provide you the exposure to real-world clinical cases, and

 2. to allow you the opportunity to learn clinical diagnostic techniques by evaluating
one of the case studies in an in-depth manner.

To meet this objective, you will be required to choose one of the four provided case
studies (see end of this document), and author a case report that includes each of the
following sections:

 Presenting symptoms
 Background info / Personal history
 Assigned Diagnosis
 Rationale for Diagnosis
 Potential Differential Diagnoses
 Treatment recommendations
 Prognosis

Please do use these headings, and ensure that you have fully covered the material within
each heading in a manner that matches the grading criteria (provided below). For most
sections, one complete paragraph should be sufficient. If you dedicate 1 paragraph to each
section, the final paper should be between 3-4 double-spaced pages. Please do not exceed
5 double-spaced pages.

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PSYC 2030U Case Study Assignment

Below I provide more information on what I expect in each section.

Presenting symptoms: Describe the key symptoms that the patient presents with at the
clinic. (ie. a succinct description of why the patient has come in for treatment). This
information will by and large be included within the case study. Please paraphrase the
symptoms; do not copy/paste.

Background info / Personal history: Provide patient demographics including age,

gender, race, ethnicity, marital status, education and work history; and detail any relevant
personal history. This information will largely come from the case study itself. Please
paraphrase; do not copy/paste. Examples of relevant personal history may include, but is
not limited to: trauma, abuse, isolation, shyness, divorce, poverty, physical health
concerns, previous psychiatric diagnoses, winning the lottery, etc. Where relevant,
provide a short explanation of why these personal history items are of relevance to the
patient’s symptoms/presentation/prognosis.
Assigning a diagnosis: You will be asked to provide an official DSM-V diagnosis. For
this you will need to read the textbook, consider the included DSM criteria, and come to
your best guess re appropriate diagnosis.

Rationale for diagnosis: Explain how and why you arrived at the DSM-V diagnosis that
you did. Do not just re-describe the patient’s symptoms. Rather, explain what about their
symptoms matches with the DSM-V diagnostic criteria for the disorder that you have
chosen.

Differential diagnoses: When you go to the doctor with a pain in your side, the doctor
devises a variety of hypotheses of what might be wrong with you, and works to rule them
out. Each possible illness is a differential diagnosis. In this section, write a paragraph
identifying and explaining at least one other diagnosis that the client might have. As with
your primary diagnosis, back up your statements by referring back to the DSM-V criteria
in your text.

Treatment recommendations. Write a final paragraph describing which form of treatment

(psychotherapy, medication, etc) you would suggest given your diagnosis of the case. Be
specific in what type (e.g. cognitive-behavioral therapy, systematic desensitization or
antidepressants, not “drug therapy” or “psychotherapy”). Explain why you have chosen
the treatment that you have. Feel free to recommend a back-up treatment option, if one is
available. You may use the text, the lectures, and/or outside sources to back up your
choices.

Prognosis: Describe the patient’s likelihood of controlling their symptoms, improving or

degrading or recovering completely. You may use the text, the lectures, and/or outside
sources to back up your claims.

PSYC 2030U Case Study Assignment Grading Rubric

The PSYC 2030U Case Study Assignment will be graded out of a total of 100 marks,
broken down as follows:

80% Content

 Presenting symptoms   5%
 Background info / Personal history                                                             10%
 Assigned Diagnosis                                                             10%
 Rationale for Diagnosis 15%
 Potential Differential Diagnoses 15%
 Treatment recommendations 15%
 Prognosis                                                             10%
20% Style

 Clarity, thoroughness, organization of writing and ideas 15%

 APA reference format (reference the DSM-V, your text, any external sources) 5%

PSYC 2030U Case Study Assignment APA format

Please utilize APA format for citing your references and for your reference page. I’m less
concerned about APA format for title pages, page numbers, etc – so you’re not going to
get docked for something like having page numbers in the top right corner instead of the
bottom left. But please do use APA for your citations and references – it’s good practice
to get used to that format, and it makes my (and Kristina’s/Rangina’s) job much easier
because it’s the format we’re used to reading the fastest.

PSYC 2030U Case Study Assignment Due Date

The Research Paper is due on Nov. 20th on line by 5:00pm, hard copy in class.

EARLY: Submissions will be awarded 1% for each day that they are early, including
weekends, up to a maximum of 10%. Once a paper has been submitted, it cannot be
returned until it has been graded (i.e., students cannot re-submit a paper even if the due
date has not passed). Please double check that the version you submit is the final version
of your assignment.

PSYC 2030U Case Study Assignment Assignment Submission

You should submit your paper electronically, via Blackboard, and bring a hard copy to
class. Given that you have the remainder of the semester to complete the assignment, little
leniency will be granted for late assignments.

If the paper is submitted even one minute after 5:00 pm on Tuesday, November 20th (so at

5:01 pm), it will be logged as late by Blackboard.

Papers registered as being submitted after 5:00pm on Tuesday, November 20 th will

be late and docked 10%.

**Submissions will be docked 10% for each day that they are late, including
weekends, even if it is only 1 minute late.** Papers submitted over 10 days late will
receive a grade of 0, but will still be marked to provide feedback.
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PSYC 2030U Case Study Assignment- Case Summary #1 

Robin Henderson is a 30-year-old married Caucasian woman with no children who lives
in a middle-class urban area with her husband. Robin was referred to a clinical
psychologist by her psychiatrist. The psychiatrist has been treating Robin for more than
18 months with primarily anti-depressant medication. During this time, Robin has been
hospitalized at least 10 times (one hospitalization lasted 6 months) for treatment of
suicidal ideation (and one near lethal attempt) and numerous instances of suicidal
gestures, including at least 10 instances of drinking Clorox bleach and self-inflicting
multiple cuts and burns.PSYC 2030U Case Study Assignment

Robin was accompanied by her husband to the first meeting with the clinical
psychologist. Her husband stated that both he and the patient’s family considered Robin
“too dangerous” to be outside a hospital setting. Consequently, he and her family were
seriously discussing the possibility of long-term inpatient care. However, Robin
expressed a strong preference for outpatient treatment, although no therapist had agreed to
accept Robin as an outpatient client. The clinical psychologist agreed to accept Robin into
therapy, as long as she was committed to working toward behavioral change and stay in
treatment for at least 1 year. This agreement also included Robin contracting for safety –
agreeing she would not attempt suicide.

Clinical History 

Robin was raised as an only child. Both her father (who worked as a salesman) and her
mother had a history of alcohol abuse and depression.  Robin disclosed in therapy that she
had experienced severe physical abuse by her mother throughout childhood. When Robin
was 5, her father began sexually abusing her. Although the sexual abuse had been non-
violent for the first several years, her father’s sexual advances became physically abusive
when Robin was about 12 years-old. This abuse continued through Robin’s first years of
high school.

Beginning at age 14, Robin began having difficulties with alcohol abuse and bulimia
nervosa. In fact, Robin met her husband at an A.A (Alcoholics Anonymous) meeting
while she was attending college. Robin continued to display binge-drinking behavior at an
intermittent frequency and often engaged in restricted food intake with consequent eating
binges. Despite these behaviors, Robin was able to function well in work and school
settings, until the age of 27.
She had earned her college degree and completed 2 years of medical school. However,
during her second year of medical school, a classmate that Robin barely knew committed
suicide. Robin reported that when she heard of the suicide, she decided to kill herself as
well. Robin displayed very little insight as to why the situation had provoked her
inclination to kill herself. Within weeks, Robin dropped out of medical school and
became severely depressed and actively suicidal.PSYC 2030U Case Study Assignment

A certain chain of events seemed to precede Robin’s suicidal behavior. This chain began
with an interpersonal encounter, usually with her husband, which caused Robin to feel
threatened, criticized or unloved (usually with no clear or objective basis for this
perception. These feelings were followed by urges to either self-mutilate or kill herself. 
Robin’s decision to self-mutilate or attempt suicide were often done out of spite-
accompanied by the thought, “I’ll show you.” Robin’s self-injurious behaviors appeared
to be attention-seeking. Once Robin burned her leg very deeply and filled the area with
dirt to convince the doctor that she needed medical attention- she required reconstructive
surgery.

Although she had been able to function competently in school and at work, Robin’s
interpersonal behavior was erratic and unstable; she would quickly and without reason,
fluctuate from one extreme to the other. Robin’s behavior was very inconsistent- she
would behave appropriately at times, well mannered and reasonable and at other times
she seemed irrational and enraged, often verbally berating her friends. Afterwards she
would become worried that she had permanently alienated them.  Robin would frantically
do something kind for her friends in an attempt to bring them emotionally closer to her.
When friends or family tried to distance themselves from her, Robin would threaten
suicide to keep them from leaving her.

During the course of treatment, Robin’s husband reported that he could not take her
suicidal and erratic behavior any longer. Robin’s husband filed for divorce shortly after
her treatment began. Robin began binge drinking and taking illegal pain medication.
Robin reported suicidal ideation and feeling of worthlessness. Robin displayed signs of
improvement during therapy, but this ended in her 14 month of treatment when she
committed suicide by consuming an overdose of prescription medication and alcohol.

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PSYC 2030U Case Study Assignment- Case Summary #2 

At the time of his admission to the psychiatric hospital, Carl Landau was a 19-year-old
single African American male. Carl was a college freshman majoring in philosophy who
had withdrawn from school because of his incapacitating symptoms and behaviors. He
had an 8-year history of emotional and behavioral problems that had become increasingly
severe, including excessive washing and showering; ceremonial rituals for dressing and
studying; compulsive placement of any objects he handled; grotesque hissing, coughing,
and head tossing while eating; and shuffling and wiping his feet while walking.PSYC
2030U Case Study Assignment

These behaviors interfered with every aspect of his daily functioning. Carl had steadily
deteriorated over the past 2 years. He had isolated himself from his friends and family,
refused meals, and neglected his personal appearance. His hair was very long, as he had
refused to have it cut in 5 years. He had never shaved or trimmed his beard. When Carl
walked, he shuffled and took small steps on his toes while continually looking back,
checking and rechecking. On occasion, he would run in place. Carl had withdrawn his left
arm completely from his shirt sleeve, as if it was injured and his shirt was a sling.

Seven weeks prior to his admission to the hospital, Carl’s behaviors had become so time-
consuming and debilitating that he refused to engage in any personal hygiene for fear that
grooming and cleaning would interfere with his studying. Although Carl had previously
showered almost continuously, at this time he did not shower at all. He stopped washing
his hair, brushing his teeth and changing his clothes. He left his bedroom infrequently,
and he had begun defecating on paper towels and urinating in paper cups while in his
bedroom, he would store the waste in the corner of his closet. His eating habits
degenerated from eating with the family, to eating in the adjacent room, to eating in his
room. In the 2 months prior to his admission, Carl had lost 20 pounds and would only eat
late at night, when others were asleep. He felt eating was “barbaric” and his eating rituals
consisted of hissing noises, coughs and hacks, and severe head tossing. His food intake
had been narrowed to peanut butter, or a combination of ice cream, sugar, cocoa and
mayonnaise. Carl did not eat several foods (e.g., cola, beef, and butter) because he felt
they contained diseases and germs that were poisonous. In addition, he was preoccupied
with the placement of objects. Excessive time was spent ensuring that wastebaskets and
curtains were in the proper places. These preoccupations had progressed to tilting of
wastebaskets and twisting of curtains, which Carl periodically checked throughout the
day.  These behaviors were associated with distressing thoughts that he could not get out
of his mind, unless he engaged in these actions.

Carl reported that some of his rituals while eating were attempts to reduce the probability
of being contaminated or poisoned. For example, the loud hissing sounds and coughing
before he out the food in his mouth were part of his attempts to exhale all of the air from
his system, thereby allowing the food that he swallowed to enter an air-free and sterile
environment (his stomach) Carl realized that this was not rational, but was strongly driven
by the idea of reducing any chance of contamination. This belief also motivated Carl to
stop showering and using the bathroom. Carl feared that he may nick himself while
shaving, which would allow contaminants (that might kill him) to enter his body.

The placements of objects in a certain way (waste basket, curtains, shirt sleeve) were all
methods to protect him and his family from some future catastrophe such as contracting
AIDS. The more Carl tried to dismiss these thoughts or resist engaging in a problem
behavior, the more distressing his thoughts became.

Clinical History 

Carl was raised in a very caring family consisting of himself, a younger brother, his
mother, and his father who was a minister at a local church. Carl was quiet and withdrawn
and only had a few friends. Nevertheless, he did very well in school and was functioning
reasonably well until the seventh grade, when he became the object of jokes and ridicule
by a group of students in his class. Under their constant harassment, Carl began
experiencing emotional distress, and many of his problem behaviors emerged. Although
he performed very well academically throughout high school, Carl began to deteriorate to
the point that he often missed school and went from having few friends to no friends.
Increasingly, Carl started withdrawing to his bedroom to engage in problem behaviors
described previously. This marked deterioration in Carl’s behavior prompted his parents
to bring him into treatment.

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PSYC 2030U Case Study Assignment- Case Summary #3

Hank Allen is a 32 year-old married Caucasian male who was brought to this screening
center for psychiatric evaluation following his arrest for the murder and sexual assault of
ten women. His wife, Jody, who eventually testified against him, had worked as his
partner, luring victims to their deaths.

Wanting to further her husband’s fantasy of finding the “perfect lover,” Jody had
accompanied him to shopping centers or county fairs and talked young girls into climbing
into their customized van. Once inside, the victims were confronted by her husband, who
held a handgun and bound them with adhesive tape. Most were teenagers, though two of
the final victims were adults; the youngest was 13. The oldest victim, age 34, was a
bartender who closed up late one night, went out to her car, then rolled down her window
to talk to the couple, who had been inside drinking and who now approached her. The
Allen’s kidnapped her and drove her back to their own residence. While Jody sat inside
watching an old movie on television, Hank assaulted his victim in the back of the van,
scripting her to play the role of his teenage daughter. When he was through, Jody rejoined
him and drove away in the early morning hours, the radio blaring to drown out the sounds
of her husband in the back of the van, strangling his victim to death. That evening they
celebrated Hank’s birthday at a restaurant.

Most of Hank’s victims were petite blonds like Jody and Hank’s own daughter. All were
sexually abused, then shot or strangled to death; several were buried in shallow graves.
One, a pregnant 21-year-old hitchhiker (Jody was also pregnant at the time), was raped,
strangled, and buried alive in sand.

Hank rated the sexual performance of each of his victims and always made sure that Jody
knew she was never number one. Jody tried to redeem herself in the eyes of her difficult
husband by submitting to his every demand. Even when she finally separated from him,
she was unable to say no. They had been apart for several months when Hank called her,
asking that they get together one more time. She agreed, and that day they claimed their
ninth and tenth victims.

Clinical History 

Hank’s violence was a legacy from his father. When he was born, his 19-year-old father
was serving a prison sentence for auto theft and passing bad checks. A later conviction
earned him a term for second-degree robbery, but he escaped. In an ensuing saga of
recapture, escape, recapture, and escape, he killed a police officer and a prison guard,
blinding the latter by tossing acid into his face before beating him to death. Often told that
he was going to be just like his father when he grew up, Hank was 16 when he learned
that his father had been captured and executed in a gas chamber after his mother betrayed
his hiding place. Hank later confessed to the police: “Sometimes I [think] about blowing
her head off. . . . Sometimes I wanna put a shotgun in her mouth and blow the back of her
head off. . . . ”

In a forensic psychiatric evaluation, Hank revealed that his mother was the object of his
most intense sexual fantasy:

“I was gonna string her up by her feet, strip her, hang her up by her feet, spin her, take a
razor blade, make little cuts, just little ones, watch the blood run out, just drip off her
head. Hang her up in the closet, put airplane glue on her, light her up. Tattoo “bitch” on
her forehead. . . “

Hank’s mother had beaten and mocked her son, a bed wetter until age 13, calling him
“pissy pants” in front of guests. One of her husbands punished him mercilessly, forcing
him to drink urine and burning a cigar coal into his wrist. When his mother tried to
intervene, his stepfather smashed her head into a plaster wall. From that point on, she
joined in the active abuse of her children. As far back as he could remember, Hank had
nightmares of being smothered by nylon stocking material and being strapped to a chair
in a gas chamber as green gas floated into the room.

Hank began to burglarize with an older brother at 7, and at 12 was put on probation. A
year later he was sent to the California Youth Authority for committing “lewd and
lascivious acts” with a 6-year-old girl. As a teenager he faced charges of armed robbery
and auto theft. A habitual truant, he was suspended from high school at 17 with F’s in five
academic subjects and F’s in five categories of “citizenship.” That same year he married
for the first time.  Often knocked unconscious in fights, he was comatose twice, briefly at
16 and for over a week at 20. A computed tomography brain scan revealed “abnormally
enlarged sulci and slightly enlarged ventricles.” A neuropsychological battery showed
“damage to the right frontal lobe.”  Hank married seven times. He beat each of his wives,
sometimes badly. Most of the marriages lasted no more than a few months. One wife
described him as “dominant” and said “he’s got to be in control.” Another, who had had
clumps of hair yanked from her head, called him “a Jekyll and Hyde.” Yet another said he
was “vicious.” When she told him she wanted out, he took revenge by beating her
parents. His first marriage ended when he beat his wife with a hammer. When she left
him, she replaced his mother in his central fantasy. They had married 5 days after the
birth of a baby daughter and a custody battle ensued. In spite of his lengthy record of
assaults, thefts, and parole violations, Hank won.

When he was 23, Hank went on a crime spree that eventually covered five states. Stealing
license plates and cars, holding up bars and drugstores, he eluded capture until caught and
convicted for the armed robbery of a motel. Sent to prison for 5 years to life, he molested
his 6-year-old daughter for the first time during a conjugal visit.  He was 30, and his
divorce from his fifth wife had not been finalized when he moved in with Jody. By the
time they met, Hank had been arrested on 23 separate occasions. The following summer
Hank was fired from his job as a driver. He had been fired often, and it was an event that
usually left him sexually impotent.

Shortly before his final arrest, Hank, a gun enthusiast, owned a semiautomatic assault
rifle, an automatic pistol, two revolvers, and a derringer. He was working as a bartender.
A co-worker described him as a ladies’ man and said that women called him at work at all
hours. After hanging up, he would rate them. For his crimes, he eventually received
multiple death sentences. Five years after his arrest, he now awaits execution.

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PSYC 2030U Case Study Assignment-Case Summary #4
At the time of his admission to a private psychiatric hospital, Sonny Ford was a 24-year-
old single Latino male who lived with his adoptive parents. Sonny had been referred for
hospital admission by his outpatient psychotherapist. Over the past 2 years, Sonny had
struggled with symptoms such as concentration difficulties, anxiety, and obsessional
thinking. More significantly, within the year prior to his admission, Sonny began to
experience paranoid and delusional thoughts that had become quite persistent. These
difficulties began after Sonny smoked marijuana. While experiencing the effects of
marijuana, Sonny believed that his mind had gone “numb.” From that time on, Sonny
believed that the marijuana had permanently “warped” his brain. He became increasingly
distressed and frustrated over his inability to get others to agree that marijuana had this
effect on him. More recently, Sonny had developed concerns that the police and FBI were
“out to get him.” In addition, he had begun to feel that certain television shows had
special importance to him and important information was embedded in these programs
directed specifically at him. Sonny believed that these messages coming to him through
the television were sent to remind him that he was at risk for some sort of plot by the
authorities.  Sonny also heard voices in his head. Although he could not make out what
they were saying, Sonny perceived the voices as “angry” and “critical.”

Over the past few months, Sonny’s symptoms had worsened to the point that they were
interfering substantially with his attendance at work as a state office janitor. Because of
these factors and the lack of improvement in outpatient counseling, Sonny was referred to
this inpatient hospital.  At the intake evaluation for his inpatient admission, Sonny’s
emotions were restricted. Although appearing tense and anxious, Sonny’s face was mostly
immobile for the duration of the interview. He engaged in very little eye contact with the
interviewer and his body movements were agitated and restless, as evidenced by rocking
movements of his legs and body. His speech was hesitant and deliberate, and he often
answered the interviewer’s questions with brief and empty replies. For example, when the
interviewer asked “what difficulties are you having that you would like help for?” Sonny
replied, “I think it was the marijuana.”

Case History

Sonny was adopted at birth, and no records were available about medical or psychiatric
history of his family origin. Sonny was raised in a household of four: in addition to his
parents, he had a sister 4 years older who had also been adopted. He could recall very few
memories from his early childhood. However, Sonny said that throughout his life he had
always been a loner who, to this day, never had any friends. Sonny’s parents, who were
present at the time of his admission to the hospital, confirmed that Sonny had always been
frustrated by social interactions and added that their son had always been hypertensive to
real or perceived criticism during his school years. Sonny was very attached to his father
and, for may years, experienced considerable distress and loneliness when he was
separated from the family’s home or his father for extended periods. Whereas Sonny
described his father as “a very accepting person” he claimed that his mother was
“excessively critical and not accepting of me as a person.” Sonny also claimed that his
mother was an alcoholic, a statement that was not supported by either of his parents.

When Sonny was 16, he realized that he was homosexual. Although his father had been
accepting Sonny reported that his mother had been very unaccepting of his homosexuality
and often referred to him with pejorative labels, such as “fag.”  While Sonny accepted his
sexual orientation, he said that being gay had caused him many troubles one of which was
loneliness. Many of Sonny’s persistent and obsessive thoughts focused on the possibility
of contracting the HIV virus from having unprotected sex on one occasion. Sonny’s fears
of having HIV had not been quieted by the fact that the person with whom he had sex
with was HIV negative or by the fact the all of his recent HIV tests were also negative.

Despite lifelong difficulties with social adjustment, Sonny had been able to meet most of
the demands and responsibilities of adolescence. Following his graduation from high
school (with a C+ average), sonny decided to attend a local college to take introductory
courses. This decision was strongly influenced by his apprehension of moving out of his
parent’s house to attend school away from his immediate community. However, it was
during his freshman year that Sonny had smoked the marijuana that he believed
permanently damaged his brain. Following the incident, Sonny dropped out of college
due to the worsening of behaviors. Sonny enrolled at a second college for only one
semester before dropping out again, because of his inability to cope with sitting in
crowded classrooms and completing assignments and tests on time. Sonny has held his
current position as a janitor for the last 18 months, in part because this position allows
him to work alone and does not require extensive social interaction.

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