Dorothy is a 66-year-old female who entered counseling at an agency because of overwhelming anxiety. She had experienced a number of episodes of not being able to leave her apartment for periods of a few days to several weeks. She describes her anxiety as feeling like she's having a "heart attack," with shortness of breath, rapid heart rate, dizziness, sweating, and feeling "doomed." She has gone to the emergency room several times, and each time, been told that she is healthy and that her symptoms are due to anxiety. Dorothy describes herself as being "a worrywart." She reported that she has worried about things for as long as she can remember. As a child, she worried about her mother dying and went through periods of not wanting to attend school in order to make sure that her mother was all right. At the time, the family lived in a neighborhood that had some problems with crime, but by the time Dorothy was 12, the family had relocated to an area that was quite safe, and Dorothy continued to worry. Dorothy went through a period in ninth grade during which she had to receive home tutoring because her anxiety became so bad that she was unable to leave the family's house. She saw counselors and a psychiatrist during this period and, with a combination of medication and counseling, was able to return and complete high school. Dorothy went on to college but had to leave school in the middle of the first semester because of a "nervous breakdown." When questioned further about this during the interview, Dorothy stated that she became very depressed because she thought everyone was talking about her in her classes, saying that she was "stupid." Dorothy was hospitalized for 4 weeks as a result and placed on a regimen of the antidepressant and antipsychotic medications that were used at the time. A few weeks after her release, she stopped taking the medications because of the unpleasant side effects, specifically, because she "felt like a zombie." After that hospitalization, Dorothy became obsessive about living a healthy lifestyle. She started running and was very careful about eating healthy foods that are low in fat and sugar. She believed that many common foods "poisoned her life force," so restricted her food intake to just a few low-calorie foods. During this time, she began reading the Bible, opening it up to pages randomly and thinking that "God was talking to her directly." She reported that she experienced several visions in which she was told that she was a sinner and needed to eat certain foods to cleanse her soul. By the time she was 24 years old, her weight had dropped to 78 pounds (she is 5'6" tall), she became deeply depressed once again, and was hospitalized "to treat an eating disorder." She remained in the hospital for nearly two years. She finally was released when her weight stabilized at 115 pounds and had conformed to a regimen of antidepressants and antipsychotic medications for 8 months. Dorothy lived with her parents off and on for the next 20 years. During this time, she was hospitalized again for "an eating disorder," after she would only eat the sacramental bread in church "to maintain her purity" and refused all other food because it contained "soul poison." She was married for a less than a year after her release from the hospital to a male patient who she met in the hospital. She was re-hospitalized when she became deeply depressed because her husband had "poisoned her purity," which led to her arrest for breaking into a church to obtain sacramental bread to "re-purify" herself. This hospitalization lasted for approximately one year and included electro-convulsive therapy (ECT) treatments, when Dorothy became deeply depressed to a point where antidepressants were not effective.

Dorothy stabilized and was released at age 29. She continued to live with her parents until she was 45, supporting herself with disability payments. While she did not have another eating disorder type episode, she continued to obsess about religious beliefs, her sinfulness, and would occasionally report experiencing "visions" and hearing spoken messages from God, to her mother. Three years ago, Dorothy experienced four devastating losses: her mother and father died within a three-month period from heart disease. Less than a year later, her grandmother, who was in her late 80's, passed away from a stroke. Six months after that, Dorothy's brother suffered a fatal heart attack at work. Shortly after his funeral, Dorothy stopped leaving the house altogether because she feared dying when she was still "not pure enough to go to heaven". She began restricting her diet once again and exercising compulsively for hours each day on a treadmill. She hears messages from the devil telling her she's not doing enough to purify herself and that he will be coming for her if she fails to do more. Dorothy stated that, while she is seeking counseling for anxiety, she has become increasingly discouraged and depressed because she is "impure" and fears "eternal damnation." She disclosed that she has not been sleeping well, waking up in the middle of the night and not being able to sleep. As stated above, she is eating minimally. When she entered the interview, she presented as unkempt, with poor personal hygiene. When asked about this, she reported that she is afraid to take a shower because the tap water "hasn't been blessed." When pressed, she stated that she feels that her beliefs are the same as "any other God fearing person." She was taking medication up to the time of her mother's death but stopped because Dorothy believed that the medications were sinful, and that "God struck my mother down to punish me."

Directions: Read the attached case study and use the information provided to produce a narrative report using the Intake Report template distributed in class. Be sure to include the following sections: Diagnostic Impression (DSM 5) with the Diagnostic Formulation Treatment Recommendations General Treatment Goals Develop a treatment plan with at least two treatment goals, each having one to three