DSM-5 Diagnoses, Compassion Fatigue, and Social Work Ethics

DSM-5 Diagnosis: Panic Disorder vs. Normal Anxiety

The anxiety experienced by Mary Anne was abnormal, and the most likely DSM-5 diagnosis is panic disorder. Mary Anne presents with four of the symptoms required for a diagnosis of panic disorder: racing heart, shortness of breath (gasping), nausea, and trembling (American Psychiatric Association, 2013). The attack has been followed by a behavioral change in which she no longer wants to visit the mall, despite previously enjoying it. The symptoms are not associated with any side effects of substances she might be taking — such as drug abuse or medications — and there is no other identified medical condition (American Psychiatric Association, 2013). No other mental disorder can explain the symptoms she experiences. We can confidently say that Mary Anne was not in a fearful situation, so the panic attack was not a fear response. Mary Anne loved shopping at the mall, and her panic attack could not be a response to a traumatic trigger, since she would have experienced that reaction from the time she first began visiting the mall.

The diagnostic criteria for panic disorder require that a person present with at least four of the symptoms listed in the DSM-5 for criteria A (American Psychiatric Association, 2013). For criteria B, the panic attacks must be accompanied by one month or more of behavioral change related to the attack (Hilt & Nussbaum, 2015). Criteria C posits that the attacks should not be attributable to another physiological effect of a substance or medical condition. Finally, the attacks should not be better explained by another mental disorder. Mary Anne meets all of these diagnostic criteria based on her symptoms and the behavioral modification that followed her attack. She has no medical conditions, and her attacks cannot be attributed to medications or a substance abuse problem (Park & Kim, 2020). Her decision not to visit the mall again is a response to her fear of suffering another panic attack — she changed her behavior specifically to avoid a recurrence.

Bert's anxiety is normal because he simply does not like speaking in front of a class. It is normal to feel anxious when asked to do something one is uncomfortable with or dislikes. Bert does not present with any symptoms of a DSM-5 mental disorder, and we cannot place his anxiety on a public speaking disorder because he does not meet the criteria for that diagnosis (American Psychiatric Association, 2013). According to the information presented in the case, Bert dislikes speaking in front of the class — but he does not exhibit symptoms of an anxiety disorder or public speaking disorder. The anxiety he experienced when assigned a presentation was normal human behavior that cannot be attributed to a mental disorder. For Bert to be diagnosed with a mental disorder, he would need to display psychological symptoms such as intense worry and nervousness, intrusive thoughts about speaking in public, significant stress, fear, panic, and feelings of dread (American Psychiatric Association, 2013).

Rehearsing a presentation repeatedly is what most people do when they have to speak publicly. Singers and performers rehearse their material extensively before a show to be prepared — this does not indicate a public speaking disorder. While Bert used the opportunity to work through his anxiety, he did so to ensure he was ready for the challenge ahead, which is a common and healthy response. The discomfort Bert experiences is normal because it involves only slight nervousness. If he had experienced paralyzing fear and panic, his dislike of public speaking might be classified as abnormal. Notably, Bert delivered his presentation successfully and did not experience shaking hands or a quavering voice during it. We can therefore be confident that his anxiety is normal, as he managed to overcome it through practice alone.

Compassion Fatigue in Social Workers: Effects and Interventions

Compassion fatigue negatively impacts social workers, making it difficult to focus on daily professional activities. Some of its effects are persistent feelings of guilt, sadness, anger, numbness, or helplessness — these are referred to as the emotional symptoms of compassion fatigue (Cuartero & Campos-Vidal, 2019). Cognitive symptoms include difficulty concentrating, apathy, obsession, and perfectionism. Behavioral symptoms include social withdrawal, changes in appetite, difficulty sleeping, and hypervigilance (Ostadhashemi et al., 2019). Physical symptoms include an increased heart rate, muscle and joint pain, difficulty breathing, and an impaired immune system.

In many cases, the social worker will begin by experiencing self-contempt or irritability when clients are unresponsive to treatment. It can be deeply discouraging when a social worker strives to assist a client who appears to be deteriorating. Often, the social worker will blame themselves for failing to help and develop negative feelings that lead to difficulty sleeping or persistent fatigue. When compassion fatigue becomes severe, the social worker may experience the onset of depression (Ostadhashemi et al., 2019). Reaching this point can lead to burnout, as job satisfaction disappears entirely.

To address compassion fatigue, the social worker should first reduce their stress by managing caseload size and connecting clients with additional resources, so that they are not the sole professional working with each client (Yi et al., 2018). Journaling has been shown to have a significant positive impact on social workers experiencing compassion fatigue. Writing down thoughts, frustrations, and emotions can help the individual manage negative feelings and refocus on the positive aspects of their work. Creating boundaries and making time for personal pursuits through self-care can also help individuals recover. The goal is to identify activities the individual enjoys — such as exercising, reading, or spending time with family and friends. Joining a support group to connect with others who have had similar experiences is another useful coping mechanism (Yi et al., 2018). Talking through feelings with people who understand firsthand can be genuinely therapeutic.

Addressing Compassion Fatigue as a Clinical Supervisor

When a supervisee shows signs of compassion fatigue — such as absenteeism, cynicism toward clients, or late submission of reports — the first step for the clinical supervisor is to recognize that these signs are consistent with compassion fatigue. The supervisor should approach the supervisee in the same thoughtful manner they would use with a client when raising a concern. The supervisee may be unaware of their own behavior and may be reacting in ways they do not fully recognize. Their actions could stem from burnout and loss of job satisfaction resulting from a sense that their strategies are not helping clients. The clinical supervisor should approach the supervisee with understanding and seek to identify the root cause of the behavior. If compassion fatigue is present, the supervisor should work to reduce the supervisee's job-related stress — for example, by reducing the number of clients they are managing (Kinman & Grant, 2020). It is also appropriate to inform the supervisee that they may be experiencing compassion fatigue so they can begin taking corrective action.

The clinical supervisor can explain the symptoms of compassion fatigue to the supervisee and outline the potential impact on both the supervisee and their clients if it is not properly addressed. The goal should be to help the supervisee recover by connecting them with appropriate treatment. As a clinical supervisor, it is appropriate to recommend — or if necessary, mandate — that the supervisee attend treatment, and to offer suggestions such as joining a support group, practicing self-care, and journaling (Kiley et al., 2018). These strategies have demonstrated effectiveness in treating compassion fatigue. Importantly, the supervisee should not be punished for their behavior toward clients or for late reports. Punitive action would worsen the situation and risk pushing the supervisee toward depression, given that their difficulties stem from deep empathetic engagement with client trauma. The supervisor's role is to offer constructive support and guide the supervisee through the recovery process.

References

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Barnett, J. E. (2020). Ethical and legal issues in the clinical use of technology. Routledge.

Cuartero, M. E., & Campos-Vidal, J. F. (2019). Self-care behaviours and their relationship with satisfaction and compassion fatigue levels among social workers. Social Work in Health Care, 58(3), 274–290.

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Illinois Department of Children & Family Services. (2010). DCFS code of ethics for child welfare professionals. State of Illinois.

Kiley, K. A., Sehgal, A. R., Neth, S., Dolata, J., Pike, E., Spilsbury, J. C., & Albert, J. M. (2018). The effectiveness of guided imagery in treating compassion fatigue and anxiety of mental health workers. Social Work Research, 42(1), 33–43.

Kinman, G., & Grant, L. (2020). Emotional demands, compassion and mental health in social workers. Occupational Medicine, 70(2), 89–94.

Ostadhashemi, L., Arshi, M., Khalvati, M., Eghlima, M., & Khankeh, H. R. (2019). Social workers' resilience: Preventing burnout and compassion fatigue in pediatric oncology. International Journal of Cancer Management, 12(7). https://doi.org/10.5812/ijcm.61376

Park, S.-C., & Kim, Y.-K. (2020). Anxiety disorders in the DSM-5: Changes, controversies, and future directions. Anxiety Disorders, 187–196.

Yi, J., Kim, M. A., Choi, K., Kim, S., & O'Connor, A. (2018). When does compassion fatigue hit social workers? Caring for oncology patients in Korea. Qualitative Social Work, 17(3), 337–354.