Summary
A woman with a pitiful posture and facial expression stood on the same street corner every summer day for years holding a ‘will work for food sign.’
Diagnosis
The woman’s expressive behavior and physical appearance seem unusual. Her repetitive actions and nonverbal gestures are also unusual. Since objective data based on clinical assessment is not available, determining whether a psychological problem is present based on the DSM-5 criteria would involve an evaluation of overt behavior. Based on the subjective data illustrated the woman could be suffering from obsessive-compulsive disorder (OCD), DSM-5 300.3. The two major OCD symptoms defined under the DSM-5 criteria include obsessions and compulsions manifested as recurrent thoughts and repetitive behaviors, respectively. The diagnosis is based on manifested symptoms, including compulsion that is seen in the woman’s repetitive behavior or overt ritual. The ritual, i.e., the street corner, may be a response to an obsessional theme or a way to lower an underlying anxiety. Her recurrent posture – bowed head and pitiful stance and facial expression – may be an indication of chronic compulsions.
The woman’s expressive behavior fits the DSM-5 definitions of obsessions and compulsions. Obsessions manifest as pervasive thoughts or mental images characterized by elevated anxiety not related to a real world stressor. One strange aspect of the woman’s behavior is her standing on the same street corner every summer day for years, holding a ‘will work for food’ sign. To an observer, her actions seem senseless unless they are meant to suppress her obsessions. Under the DSM-5, compulsions are described as repetitive behaviors that are a reaction to the obsession. The woman is always seen bearing a pitiful posture and facial expression and standing motionless at the same spot. It appears that she has to engage in the ritualistic behaviors to suppress her anxiety.
Treatment/Intervention Strategy
I would recommend cognitive-behavioral therapy as an intervention for the woman’s OCD. In particular, an exposure and ritual prevention (ERP) program would help redirect her compulsive thoughts. The approach involves gradual exposure of the client to harmless situations to help her overcome the obsessions. The woman could be engaged through biweekly jobs that could earn her an income. Alternatively, she could be introduced to better streets or locations within Philadelphia twice a week to prevent her from engaging in the rituals, i.e., standing on the particular street corner and bearing a pitiful posture.
OCD is attributed to stressful life events that cause intrusive thoughts or impulses. Therefore, the woman’s behavioral rituals result from recurrent thoughts caused by stress. As a result, obsessional fear is a negatively reinforced as a way of avoiding the stress. In this case, ERP is important to achieve response prevention through ‘reality testing’. Through this approach, the woman would learn that failure to stand on the street corner or assume a pitiful posture and facial expression does not result in harm. Additionally, she would learn that her situation is not dependent on the street corner or overt behavior.
The woman should be kept in the ERP program until the compulsive response subsides. Early withdrawal may lead to a relapse to compulsive rituals. The ERP intervention should begin with an assessment of the factors underlying the obsessions. It should also contain an educational component to train the woman on response prevention strategies. Therefore, working collaboratively with the client would help build self-efficacy to manage the fears that trigger compulsive behavior. The exposure exercises could initial exposure to moderate stimuli to evoke minimal distress. For example, the woman could be made to stand on a different street for an hour or take up a paid task lasting a few hours to reduce the compulsive rituals or behavior.