Elijah, a 46-year-old, never married, male presented for treatment of depression at a community mental health center. Elijah told the psychologist that he had been struggling with symptoms of depression for years. Over the past couple of years, he has tried several medications and supportive therapy with only minor improvement. Elijah worked full time as a janitor but indicated that he was otherwise minimally engaged in activities. When describing his mood, he described it as low and that he hasn't been able to enjoy things as much as he used to. He stated that he feels this way every day, "almost all day." He reported laying down at night and feeling wide awake, with his thoughts keeping him up. He stated that he was probably only sleeping four hours per night when 9 hours is his baseline. Elijah also stated that he is having trouble thinking clearly, too. He added that he has trouble making decisions, such that he could stand in his closet for 20 minutes not being able to pick an outfit for the day. When asked about suicidal thoughts, Elijah strongly denied them, stating "I could never do that to my parents;" however, he stated that he often wonders if it would be easier if he wasn't here. In terms of alcohol, he reported drinking 1-2 beers every night. He reported recreational cocaine use in his early 20s while in college and graduate school. He denied using substances since then. When asked about anxiety, he noted concerns about being infected with HIV. When the psychologist noticed an unusually strong disinfectant smell, he asked Elijah if he had any particular cleaning behaviors related to the HIV concern. Elijah paused for a second and provided clarification that he generally won't touch anything outside of his home without gloves or using a disinfectant. Upon additional probing, Elijah stated that if he came close to things that he believed to be contaminated, that he would have to wash his hands with bleach. He noted that this takes up a considerable amount of time (up to 30 times per day of washing). He added, "I know this sounds delusional. Others have told me that I have delusions or schizophrenia or something, but I just know that I will become sick and I get so worried that I need to make sure I disinfect." He noted that physically touching unknown objects was most difficult, such as at grocery stores. He added that especially during the pandemic, he is even more scared. He described a significant difficulty with social relationships as well, as physical contact was challenging. In terms of other worries, he stated that he sometimes has images of hitting other people or yelling at them unprovoked. He stated that he hasn't ever done so, but he has these images in his head that make him feel crazy and that he just wants them to go away. He is able to counteract anxiety produced by these images and thoughts by constantly replaying prior conversations or keeping extensive journals to record what he said to people that day. His medical history was unremarkable. Upon mental status exam, he was observed to be a casually dressed man who had a strong cleaner odor. He appeared worried and his affect was constricted. He was interpersonally pleasant and engaged in the evaluation. His thought process was somewhat tangential but generally logical. He denied suicidality or homicidality currently. He was oriented X4 and cognitively intact. He recognized that his fears were "kind of crazy" but felt that he could not control the worry.

• Evaluate the diagnosis, etiology, and treatment plan presented by the group, then indicate your support or rejection using evidence from this module. Specifically, state evidence supporting or contradicting the group's diagnosis, etiology, and treatment plan.
• What other diagnoses would you consider?
• What other etiological factors would you consider?
• What other treatments are available for the diagnosis?