Using the case study below, answer the following questions in a narrative form.

1. What would you diagnose the client with? Please provide justification and ensure you use proper specifiers if applicable.

2. Are there any differentials that you would consider? If so, what are they?

3. What would your treatment recommendations be? (is there a certain theory you'd use? Would you suggest individual, family, couples, etc? Would you suggest medication and if so what would you think a prescriber would prescribe?). Please ensure you explain why you chose the recommendations you did.

Terry Najarian, a 65-year-old salesman for a large corporation, presented for a psychiatric evaluation after his wife threatened to leave him. Although he said he was embarrassed to discuss his issues with a stranger, he described his sexual interest in women's undergarments in a quite matter-of-fact manner. This interest had surfaced several years earlier and had not been a problem until he was caught masturbating by his wife 6 weeks prior to the evaluation. Upon seeing him dressed in panties and a bra, she initially "went nuts," thinking he was having an affair. After he clarified that he was not seeing anyone else, she "shut him out" and hardly spoke to him. When they argued, she called him a "pervert" and made it clear that she was considering divorce unless he "got help."

Mr. Najarian's habit began in the setting of his wife's severe arthritis and likely depression, both of which significantly reduced her overall activity level and specifically her interest in sex. His "fetish" was the bright spot during his frequent and otherwise dreary business trips. He also masturbated at home but generally waited until his wife was out of the house. His specific pattern was to masturbate about twice weekly, using bras and panties that he had collected over several years. He said that intercourse with his wife had faded to "every month or two" but was mutually satisfying.

The patient had been married for over 30 years, and the couple had two grown children. Mr. Najarian had planned to retire comfortably later that year, but not if the two choices were either to "split the assets or to sit around the house and be called a pervert all day." He became visibly anxious when discussing his marital difficulties. He described some recent difficulty falling asleep and "worried constantly" about his marriage but denied other psychiatric problems. He had made a show of throwing away a half dozen pieces of underwear, which had seemed to reassure his wife, but he had saved his "favorites" and "could always buy more." He said he was of mixed mind. He did not want to end his marriage, but he saw nothing harmful in his new mode of masturbating. "I'm not unfaithful or doing anything bad," he said. "It just excites me, and my wife certainly doesn't want to be having sex a few times a week."

Mr. Najarian denied any difficulties related to sexual functioning, adding that he could maintain erections and achieve orgasm without women's undergarments. He recalled being aroused when he touched women's underwear as a teenager and had masturbated repeatedly to that experience. That fantasy had disappeared when he became sexually active with his wife. He denied any personal or family history of mental illness.