Download index for handouts

CSD 5980
DIAGNOSING AND
TREATMENT PLANNING
Dr. Gloria Leitschuh
Department of Counseling
and Student Development
Eastern Illinois University
Fall, 2007
1
INDEX FOR HANDOUTS
GENERAL
PAGE
Helpful Hints for Making a Diagnosis…………………………………………………… 3
Multiaxial Evaluation Report Form……………………………………………………… 4
Global Assessment of Functioning Scale…………………………………………………5
Examples of How to Record Results of a DSM IV Multiaxial Evaluation……………… 6
Criteria for Substance Dependence………………………………………………………. 7
Criteria for Substance Abuse……………………………………………………………...8
Criteria for Substance Intoxication/Withdrawl……………………………………………9
Michigan Alcoholism Screening Test (MAST)………………………………………….10
Treatment Modalities – Substance Abuse………………………………………………..11
Common Types of Delusions…………………………………………………………….12
Criteria for Schizophrenia……………………………………………………………13-15
Treatment of Chronic Schizophrenia…………………………………………………….16
Treatment & Therapy for Schizophrenia……………………………………………….. 17
Criteria Sets – Mood Disorders………………………………………………………18-21
Treatment of Depression and Medications Used……………………………………..22-25
Suicide Risk Assessment………………………………………………………………...26
Counselor’s Role with Suicidal Clients………………………………………………… 27
Criteria for Anxiety Disorders – Panic & Agoraphobia…………………………………28
Treatment – Panic Disorder & Agoraphobia…………………………………………….29
Criteria for Anxiety Disorders – Specific Phobia………………………………………. 30
Treatment for Phobias……………………………………………………………………31
Criteria for Social Phobia………………………………………………………………...32
Treatment for Social Phobias…………………………………………………………….33
Criteria Set for Anxiety – OCD………………………………………………………….33
Treatment for OCD………………………………………………………………………35
Criteria for Anxiety Disorder – Acute Stress/PTSD/GAD…………………………...36-38
Treatment for PTSD……………………………………………………………………...39
Treatment for GAD………………………………………………………………………40
Criteria for Somatoform Disorders………………………………………………….. 41-44
Criteria for Personality Disorders…………………………………………………… 45-55
Criteria for Dissociative Disorders…………………………………………………...56-58
Treatment for Dissociative Disorders……………………………………………………59
Criteria for Sexual & Gender Identity Disorders……………………………………..60-65
Warning Signs of Eating Disorders…………………………………………………..66-67
Eating Attitudes Test…………………………………………………………………….68
Criteria for Inpatient Treatment for Eating Disorders…………………………………...69
Normal Eating……………………………………………………………………………70
Criteria for Sleep Disorders…………………………………………………………..71-72
Medication for Sleep Disorders………………………………………………………….73
Criteria – V Codes……………………………………………………………………….74
Criteria – Mental Retardation……………………………………………………………75
Criteria – Adjustment Disorders…………………………………………………………76
2
Criteria – ADHD……………………………………………………………………..77-78
Treatment for ADHD……………………………………………………………………79
Criteria – Conduct Disorder & Oppositional Defiant Disorder…………………………80
Mental Status Exam………………………………………………………………….81-82
Mini-Mental State Examination……………………………………………………..83-84
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HELPFUL HINTS FOR MAKING A DIAGNOSIS
1. Disorders due to general medical conditions, or cognitive disorders, pre-empt all
other diagnoses that could produce the same symptoms.
Many general medical conditions produce mental symptoms and require urgent
evaluation and treatment to prevent serious medical complications. For example, a
patient's depression and lethargy could be due to a mood disorder, but is a hypothyroid
condition remotely possible? If so, it should be listed first, because hypothyroidism can
progress to coma and death.
2. Try to explain all the symptoms with the fewest diagnoses possible. It is best to
look for a single illness that explains all of the symptoms. This is called the rule of
parsimony.
3. Consider first, the patient's history of other disorders, since they may be related.
If a woman with longstanding Alcohol Dependence becomes depressed, this may indicate
that she has Alcohol-Induced Mood Disorder with Depressive Features, rather than two
independent disorders.
4. Use family history as a guide. Mental disorders run in families. Whether the mode
of transmission is environmental or hereditary, the presence of a relative with disorder X
suggests that your client may need to be assessed for similar disorders.
5. Try first to identify one or two general categories that the signs and symptoms
match. Each major diagnostic area begins with a description of the essential features
which must be present in order for that diagnosis to be made. If the symptoms do not
match the essential features, you must look elsewhere.
6. Some mental health professionals benefit from use of the decisional trees for
differential diagnosis (Appendix A). These are most helpful when there is a medical
problem, substance use, mood disorder, anxiety or somatoform disorder. The problem
with using the decision tree is that the individual criteria sets must still be used with more
than one diagnosis may apply.
7. Collateral information augments history from the patient. Informants often have
information or a point of view that can support or contradict information from the client.
Adapted from: Morrison, J., (1995) DSM IV made easy. Guilford Press, NY.
4
Multiaxial Evaluation Report Form
The following form is offered as one possibility for reporting multiaxial evaluations. In
some settings, this form may be used exactly as is; in other settings, the form may be
adapted to satisfy special needs.
AXIS I:
Clinical Disorders
Other Conditions That May Be a Focus of Clinical Attention
Diagnostic code
__ __ __ __ __
__ __ __ __ __
__ __ __ __ __
AXIS II:
Personality Disorders
Mental Retardation
Diagnostic code
__ __ __ __ __
__ __ __ __ __
AXIS III:
DSM-IV name
______________________________________________________
______________________________________________________
General Medical Conditions
ICD-9-CM code
__ __ __ __ __
__ __ __ __ __
__ __ __ __ __
AXIS IV:
DSM-IV name
______________________________________________________
______________________________________________________
______________________________________________________
ICD-9-CM name
______________________________________________________
______________________________________________________
______________________________________________________
Psychosocial and Environmental Problems
Check:
□ Problems with primary support group Specify:_____________________________
□ Problems related to the social environment Specify:_________________________
□ Educational problems Specify:___________________________________________
□ Occupational problems Specify:__________________________________________
□ Housing problems Specify:______________________________________________
□ Economic problems Specify:_____________________________________________
□ Problems with access to health care services Specify:________________________
□ Problems related to interaction with the legal system/crime Specify:____________
□ Other psychological and environmental problems Specify:____________________
AXIS V:
Global Assessment of Functioning Scale
Score: __ __ __
Time Frame: ________
5
Global Assessment of Functioning (GAF) Scale
Consider psychological, social, and occupational functioning on a hypothetical continuum of
mental health-illness. Do not include impairment in functioning due to physical (or
environmental) limitations.
Code
100
|
91
(Note: Use intermediate codes when appropriate, e.g., 45, 68, 72.)
Superior functioning in a wide range of activities, life’s problems never seem
to get out of hand, is sought out by others because of his or her many positive
qualities. No symptoms.
90
|
81
Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in
all areas, interested and involved in a side range of activities, socially effective,
generally satisfied with life, no more than everyday problems or concerns (e.g., an
occasional argument with family members).
80
|
71
If symptoms are present, they are transient and expectable reactions to
psychological stressors (e.g., difficulty concentrating after family argument); no more
than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in
schoolwork).
70
|
61
Some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in
social, occupational, or school functioning (e.g., occasional truancy, or theft within the
household), but generally functioning pretty well, has some meaningful interpersonal
relationships.
60
|
51
Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic
attacks) OR moderate difficulty in social, occupational or school functioning (e.g.,
few friends, conflicts with peers or co-workers).
50
|
41
Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent
shoplifting) OR any serious impairment in social, occupational, or school functioning
(e.g., no friends, unable to keep a job).
40
|
31
Some impairment in reality testing or communication (e.g., speech is at times
illogical, obscure, or irrelevant) OR major impairment in several areas, such as work
or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids
friends, neglects family, and is unable to work; child frequently beats up younger
children, is defiant at home, and is failing at school).
30
|
21
Behavior is considerably influenced by delusions or hallucinations OR serious
impairment in communication or judgment (e.g., sometimes incoherent, acts grossly
inappropriately, suicidal preoccupation) OR inability to function in almost all areas
(e.g., stays in bed all day; no job, home, or friends).
20
|
11
Some danger of hurting self or others (e.g., suicide attempts without clear expectation
of death; frequently violent; manic excitement) OR occasionally fails to maintain
minimal personal hygiene (e.g., smears feces) OR gross impairment in
communication (e.g., largely incoherent or mute).
10
|
1
Persistent danger of severely hurting self or others (e.g., recurrent violence) OR
persistent inability to maintain minimal personal hygiene OR serious suicidal act
with clear expectation of death.
0
Inadequate information
The rating of overall psychological functioning on a scale of 0-100 was operationalized by Luborsky in the HealthSickness Rating Scale (Luborsky L: “Clinicians; Judgments of Mental Health.” Archives of General Psychiatry 7:407417,1962). Spitzer and colleagues developed a revision of the Health-Sickness Rating Scale called the Global
Assessment Scale (GAS) (Endicott J, Spitzer RL, Fleiss JL, Cohen J: “The Global Assessment Scale: A Procedure for
Measuring Overall Severity of Psychiatric Disturbance.” Archives of General Psychiatry 33:766-771, 1976). A
modified version of the GAS was included in DSM-III-R as the Global Assessment of Functioning (GAF) Scale
6
Examples of How to Record
Results of a DSM-IV Multiaxial Evaluation
Example 1:
Axis I 296.23
Axis II
Axis III
Axis IV
Axis V
Major Depressive Disorder, Single Episode, Severe Without
Psychotic Features
305.00
Alcohol Abuse
301.6
Dependent Personality Disorder
Frequent use of denial
None
Threat of job loss
GAF=35 (current)
Example 2:
Axis I 300.4
315.00
Axis II V71.09
Axis III 382.9
Axis IV
Axis V GAF=53
Dysthymic Disorder
Reading Disorder
No diagnosis
Otitis media, recurrent
Victim of child neglect
(current)
Example 3:
Axis I 293.83
Axis II V71.09
Axis III 244.9
365.23
Axis IV
Axis V GAF=45
GAF=65
Mood Disorder Due to Hypothyroidism, With Depressive Features
No diagnosis, histrionic personality features
Hypothyroidism
Chronic angle-closure glaucoma
None
(on admission)
(at discharge)
Example 4:
Axis I V61.1
Axis II V71.09
Axis III
Axis IV
Axis V GAF=83
Partner Relational Problem
No diagnosis
None
Unemployment
(highest level past year)
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CRITERIA FOR SUBSTANCE DEPENDENCE
THREE OR MORE OF THE FOLLOWING IN THE SAME 12 MONTH PERIOD
1) TOLERANCE
2)
WITHDRAWAL
COMPULSIVE USE DEMONSTRATED BY THE FOLLOWING
3)
LARGER AMOUNTS OF DRUG OR LONGER PERIOD OF TIME
4)
UNSUCCESSFUL AT CONTROLLING USE
5) TIME SPENT
6) ACTIVITIES GIVEN UP
7)
CONTINUED USE DESPITE PROBLEMS
SPECIFY IF
* WITH PHYSIOLOGICAL DEPENDENCE
* WITHOUT PHYSIOLOGICAL DEPENDENCE
COURSE SPECIFIERS
* EARLY FULL REMISSION
* SUSTAINED FULL REMISSION
* EARLY PARTIAL REMISSION
* SUSTAINED PARTIAL REMISSION
* ON AGONIST THERAPY
* IN A CONTROLLED ENVIRONMENT
8
CRITERIA FOR SUBSTANCE ABUSE
A – ONE OR MORE OF THE FOLLOWING WITHIN A 12 MONTH PERIOD
1) CONTINUED USE RESULTS IN FAILURE TO FULFILL MAJOR ROLE OBLIGATIONS
2) RECURRENT USE OF SUBSTANCE IN HAZARDOUS SITUATIONS
3) RECURRENT USE RESULTING IN LEGAL PROBLEMS
4) CONTINUED USE DESPITE INTERPERSONAL PROBLEMS
B – THE PERSON HAS NEVER MET THE CRITERIA FOR SUBSTANCE DEPENDENCE
9
CRITERIA FOR SUBSTANCE INTOXICATION
A.
RECENT INGESTION AND EXPERIENCE OF RESULTING SYMPTOMS
DEPENDING ON THE DRUG
B.
PSYCHOLOGICAL OR BEHAVIORAL CHANGES
C.
NOT ANOTHER MEDICAL CONDITION OR MENTAL DISORDER
CRITERIA FOR SUBSTANCE WITHDRAWAL
A.
CESSATION OR REDUCTION OF DRUG USE AFTER HEAVY AND
PROLONGED USE
B.
IMPAIRMENT IN JOB OR SOCIAL SITUATIONS
C.
NOT ANOTHER MEDICAL CONDITION OR MENTAL DISORDER
10
MICHIGAN ALCOHOLISM SCREENING TEST (MAST)
YES
Do you enjoy a drink now and then?
NO
POINTS
____ ____
_______
1. Do you feel you are a normal drinker? (By normal we mean do you drink less
or as much as most other people).
____ ____
2. Have you ever awakened the morning after some drinking the night before and
found that you could not remember a part of the evening?
____ ____
3. Does your wife, husband, a parent or other near relative ever worry or complain
about your drinking?
____ ____
4. Can you stop drinking without a struggle after one or two drinks?
____ ____
5. Do you ever feel guilty about your drinking?
____ ____
6. Do friends or relatives think you are a normal drinker?
____ ____
7. Are you able to stop drinking when you want to?
____ ____
8. Have you ever attended a meeting at Alcoholics Anonymous (AA)? ____ ____
9. Have you gotten into physical fights when drinking?
____ ____
10. Has your drinking ever created problems between you and your wife, husband
a parent, or other relative?
____ ____
11. Has your wife, husband (or other family members) ever gone to anyone for
help about your drinking?
____ ____
12. Have you ever lost a friend because of your drinking?
____ ____
13. Have you ever gotten into work or school because of your drinking? ____ ____
14. Have you ever lost a job because of drinking?
____ ____
15. Have you ever neglected your obligations, your family, or your work for two
or more days in a row because you were drinking?
____ ____
16. Do you drink before noon fairly often?
____ ____
17. Have you ever been told you have liver trouble? Cirrhosis?
____ ____
18. After heavy drinking have you ever had Delirium Tremens (D.T.’s) or severe
shaking, or heard voices or seen things that really weren’t there?
____ ____
19. Have you ever gone to anyone for help about your drinking?
____ ____
20. Have you ever been in a hospital because of drinking?
____ ____
21. Have you ever been a patient in a psychiatric hospital or on a psychiatric ward
of a general hospital where drinking was a part of the problem that
resulted in hospitalization?
____ ____
22. Have you ever been seen at a psychiatric or mental health clinical or gone to
any doctor, social worker, or clergyman for help with any emotional
problem, where drinking was part of the problem?
____ ____
23. Have you ever been arrested for drunk driving, driving while intoxicated, or
driving under the influence of alcoholic beverages? (If YES, how many
times? _____)
____ ____
24. Have you ever been arrested, or taken into custody, even for a few hours
because of other drunk behavior? (If YES, how many times? _____) ____ ____
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
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TREATMENT MODALITIES – SUBSTANCE ABUSE
Individual Therapy- Can include the initial assessment, treatment planning, ongoing therapy and
aftercare. Treatment modalities range from humanistic, rational emotive therapy, behavioral
interventions, and education.
Group Therapy- Provides opportunities for modeling, feedback, and behavioral rehearsal.
Couples or Family Therapy- Appropriate if a stable relationship exists and the partner is willing
to participate. Exclude if domestic violence is a factor.
Self-Help Groups- Alcoholics Anonymous (AA)- Includes abstinence and the use of the 12
steps. A spiritual emphasis and a relationship with an AA sponsor are central to recovery.
Narcotics Anonymous (NA) is available for people in recovery from use of other drugs. AlanonFor family or friends of the individual seeking treatment. Offers guidance for allowing
consequences to the use of substances, and support for dealing with recovery issues. Also
Alateen and Alatot.
Rational Recovery- Based on Rational-emotive therapy and no spiritual emphasis.
Intensive Treatment Programs- May include residential treatment, group therapy, individual
therapy, education, and self-help. They generally incorporate behavioral change programs, social
skills training, relaxation training, and relapse prevention techniques.
Medications- Antabuse (disulfiram) for relapse prevention.
LEVELS OF CARE- (See also American Society of Addictive Medicine (ASAM) criteria).
Medical Hospitalization- Necessary if seizures, delirium, or acute medical problems exist.
Inpatient Treatment- Necessary if outpatient has failed, or 24 hour support system is needed.
Can be medical facility or social setting unit.
Outpatient- Used if client has social support and no physical problems exist.
Partial hospitalization or day treatment- Includes use of group and individual treatment to
accommodate client’s schedule, usually on a daily basis. Usually less expensive than total
hospitalization. Useful if patient has social support and needs to continue working.
Outpatient- Usually includes some combination of group or individual treatment but is less
intensive than day treatment. Useful if client has good social support and motivated to change.
Halfway House- Allows client to live in a supportive environment while continuing to work or
attend school. Generally after completion of inpatient treatment is complete.
Adapted from: Barlow, D. H., (Eds.). (1993). Clinical Handbook of Psychological Disorders (2nd
Ed.). New York: Guilford Press.
File: dsmsatrt
12
COMMON TYPES OF DELUSIONS
* BIZARRE
* DELUSIONAL JEALOUSY
* EROTOMANIC
* GRANDIOSE
* OF BEING CONTROLLED
* DELUSION OF REFERENCE
* IDEAS OF REFERENCE
* PERSECUTORY
* SOMATIC
* THOUGHT BROADCASTING
* THOUGHT INSERTION
13
CRITERIA FOR SCHIZOPHRENIA
A. CHARACTERISTIC SYMPTOMS – 2 OR
MORE
POSITIVE SYMPTOMS – EXCESS
1)
2)
3)
4)
DELUSIONS
HALLUCINATIONS
DISORGANIZED SPEECH
DISORGANIZED BEHAVIOR OR
CATATONIC
NEGATIVE SYMPTOMS – LOSS
5) * FLATTENED AFFECT
* ALOGIA
* AVOLITION
B. SOCIAL/OCCUPATIONAL DYSFUNCTION
C. DURATION – AT LEAST 6 MONTHS + 1
MONTH FROM A.
D, E, & F. RULE OUT MOOD AND SUBSTANCE
DISORDER, MEDICAL CONDITION ETC.
14
SCHIZOPHRENIA (295.) SUBTYPES (4TH DIGIT)
RULE OUT IN ORDER
295.20
CATATONIC TYPE
1) IMMOBILITY
2) PURPOSELESS MOTOR ACTIVITY
3) RIGID POSTURE
4) BIZARRE POSTURE
5) ECHOLALIA
295.10
DISORGANIZED TYPE (SCHIZO + ALL)
1) DISORGANIZED SPEECH
2) DISORGANIZED BEHAVIOR
3) FLAT OR INAPPROPRIATE AFFECT
295.30
PARANOID TYPE (SCHIZO +)
* DELUSIONS OR AUDITORY
HALLUCINATIONS
295.90
UNDIFFERENTIATED TYPE
* SYMPTOMS FROM VARIOUS SUBTYPES
295.60
RESIDUAL TYPE
* LACK OF PROMINENT POSITIVE
SYMPTOMS
* NEGATIVE SYMPTOMS EXIST (LACK OF
AFFECT, POVERTY OF SPEECH,
AVOLITION
15
OTHER SCHIZOPHRENIA DIAGNOSES
295.40
SCHIZOPHRENIFORM DISORDER
* SCHIZOPHRENIA BUT < 6 MONTHS
295.70
SCHIZOAFFECTIVE DISORDER
* SCHIZOPHRENIA + MOOD DISORDER
(SPECIFY TYPE)
297.1
DELUSIONAL DISORDER
* NOT SCHIZOPHRENIC, BUT
DELUSIONAL
(SPECIFY TYPE OF DELUSION)
298.8
BRIEF PSYCHOTIC DISORDER
* ONE SYMPTOM (FROM 1 DAY TO 1 MO.)
* Hallucinations, Delusions, Disorganized speech
or behavior, Catatonic
297.3
SHARED PSYCHOTIC DISORDER – RARE
293.XX PSYCHOTIC DISORDER DUE TO GMC
293.81 WITH DELUSIONS
293.82 WITH HALLUCINATIONS
___________(SUBSTANCE) INDUCED PSYCHOTIC DIS.
WITH HALLUCINATIONS
WITH DELUSIONS
DRUGS ALCOHOL
292.11
291.5
292.12
291.3
16
TREATMENT OF CHRONIC SCHIZOPHRENIA
PROBLEMS * Past research has involved the use of cooperative patients since they have to be
cooperative enough to consent to participate in the study.
* Many patients do not tolerate drugs and/or are noncompliant.
* Relapse rates average 40 percent for those who take medications for the
first year after hospitalization. Clozapine, an atypical antipsychotic drug
has shown promising results, but may have limitations and side effects.
* No single model is universally effective.
THERAPY GUIDELINES – Medication, Family Interventions, and Rehabilitation.
1. Even though Schizophrenia can be a lifelong illness, there are periods of exacerbation and
remission. The treatment of the disease requires a long term commitment to the patient.
2. Reserve the right to hospitalize for safety reasons. Most exacerbations can be handled in the
outpatient setting.
3. Teach patients how to understand and name psychotic experiences so they can achieve some
distance from them and recognize them for what they are.
4. Don’t pressure the patient since this may exacerbate symptoms. Let the patient guide you in
setting the pace of his/her treatment.
5. Do not view patients as responsible for their illness. They are however responsible for
limiting its impact on their lives. Frame it this way.
6. If they refuse to take medications, find out what the resistance is about rather than forcing
them to take it. Explore whether it stems from the medication’s side effects, the psychotic state
itself, or from the patient’s personality apart from his psychosis.
7. Show a willingness to compromise and negotiate. Don’t engage in struggles over issues that
might produce short-term results but could do harm in the long run. (In other words if you make
them take their meds today, and they don’t return, treatment is terminated).
8. Educate the family even if they are ambivalent.
9. Be cautiously optimistic. Encourage the patient to share your belief that the illness isn’t
hopeless.
MEDICATIONS
Antipsychotics – Older drugs (Neuroleptics) NEWER DRUGS (LOW RISK FOR T.D.)
Haldol
Clozaril
Risperdal
Thorazine
Zyprexa
Seroquel
Mellaril
17
TREATMENT AND THERAPY FOR SCHIZOPHRENIA
1. Develop a bond of trust, but be aware that this is not the cure. They need acceptance and
understanding, not agreement or disagreement.
2. Listen and accept. Do not try to change the patient’s mind.
A statement such as “My mind and body are being drained by a ray gun from Pluto,” only
requires appreciation of the patient’s feeling that she/he is unable to control parts of his own body
that such control is in the hands of external forces.
3. Educate patients. Show them that their symptoms are part of an identifiable mental process
in words they can understand. Show them that their thoughts are neither unique nor useful.
4. Teach them to communicate in more acceptable ways. Actions of disrobing, becoming
sexually disinhibited, verbally abusive, or threatening violence, all contain a message that can be
understood by the patient and counselor.
5. Help them to identify warning signs and stages. Identify their own baseline and know when
they have returned to their usual level of functioning. “The voices you hear are called
hallucinations. They sound very real to you, yet only your mind can hear them. I’ve had many
other people come to me with similar symptoms, and when they take medications it helps them
hear only things people can hear just like before you started having these symptoms.” (This
establishes expertise and simultaneously educates the patient).
6. Don’t get involved in their control drama. Be aware of your need to control or cure, which
when not realized, promotes angry and defensive termination of treatment with the therapist’s
rationalization that the “patient is untreatable.”
7. Work with their denial and projection. These two defenses predominate psychotic patients.
“I won’t take medication” is resistance and this is what needs to be addressed first. Move in
directions where the client is willing to go.
8. Teach the patient to use the nonpsychotic portion of his/her mind to gain a perspective on
the illness. “Yes, those seem to be intrusive ideas that are caused by stressful situations and are a
part of your illness.” Help them to regain control.
9. Allow for brief consultation, if possible. They may just need to have you help them reframe
what is happening to them. “You attempted something new and had a good practice.” Do not
frame it as failure.
10. Use group and classroom settings to educate. This will help to alleviate a direct challenge
with the patient’s psychotic belief system.
Adapted from: Sarti, P. & Cournos, F. (1990). Medication and psychotherapy in the treatment
of chronic schizophrenia. Psychiatric Clinics of North America 13, 215-227.
18
MOOD DISORDERS
4 CRITERIA SETS……………..
* MAJOR DEPRESSIVE EPISODE
* MANIC EPISODE
* MIXED EPISODE
* HYPOMANIC EPISODE
USED FOR MAKING THESE DIAGNOSES:
* MAJOR DEPRESSIVE DIS., SINGLE
EPISODE
* MAJOR DEPRESSIVE DIS., RECURRENT
* DYSTHYMIC DISORDER
* BIOPOLAR I DISORDER
* BIOPOLAR II DISORDER
* CYCLOTHYMIC DISORDER
19
AFFECTIVE EPISODES
I.
MAJOR DEPRESSIVE EPISODE
A. AT LEAST 2 WEEKS OF DEPRESSION OR
ANHEDONIA (CHILDREN- Irritable)
AND AT LEAST 4 OF THE FOLLOWING
1.
2.
3.
4.
5.
6.
7.
8.
9.
Depressed mood most days
Diminished pleasure in activities
Weight loss or gain – Change in appetite
Insomnia or Hypersomnia
Restlessness – Psychomotor agitation
Fatigue or loss of energy
Feelings of worthlessness or inappropriate guilt
Inability to concentrate or make decisions
Recurrent thoughts of death or suicidal ideation
C. IMPAIRMENT IN SOCIAL, OCCUP. ETC.
B.D. & E. RULE OUT MIXED EPISODE, SUBSTANCE
ABUSE, MEDICAL PROBLEMS OR
BEREAVEMENT – use V code for symptoms less
than 2 months, if symptoms persist longer than 2
months or are severe use Major Depression
20
AFFECTIVE EPISODE
II. MANIC EPISODE (A manic or mixed episode
means a diagnosis of Bipolar I Disorder and not
Bipolar II)
A. AT LEAST 1 WEEK OF EUPHORIC OR
IRRATABLE MOOD OR ALTERNATION
B. +3 OR MORE OF THE FOLLOWING
+4 IF IRRITABLE MOOD
1. Grandiosity
2. Decrease in sleep
3. Talkative, Abrupt changes in topic
4. Racing thoughts or ideas
5. Easily distracted
6. Increased activity – Over involved
7. Pleasure seeking with painful
consequences
(Overspending, affairs, etc.)
D. IMPAIRMENT IN JOB, SOCIAL, ETC.
C. & E. RULE OUT MIXED EPISODE,
SUBSTANCE OR MEDICAL PROBLEM
21
AFFECTIVE EPISODE
II. MIXED EPISODE
A. BOTH MAJOR DEPRESSION AND MANIC
(Nearly every day during at least 1 week)
B. CAUSES IMPAIRMENT IN JOB, SOCIAL
ETC. AND MAY NEED HOSPITALIZATION
C.
RULE OUT SUBSTANCE AND MED. COND.
IV. HYPOMANIC EPISODE (Identical to Manic
Episode EXCEPT no marked impairment)
A.
EUPHORIC MOOD FOR FOUR DAYS +
B.
SAME AS MANIC
C. & D. CHANGE IN FUNCTIONING
UNCHARACTERISTIC OF THE PERSON
E. DOES NOT CAUSE IMPAIRMENT IN
FUNCTIONING NECESSARY FOR HOSP.
F. RULE OUT SUBSTANCE & MED. COND.
*If episode turns into Manic Episode change diagnosis
22
Depression – Treatment
By Alan Brandis, Ph. D.
Depression is something that most people experience at some time in their life. It can be part of a normal,
natural reaction to loss, a major life change or a tragedy, in which case it is classified as a “Reactive
Depression.” As the grieving process proceeds, over the next few weeks or months the depressed feelings
should fade and life should go on, with less and less time spent thinking about the loss and feeling sad
about it. Although situation-specific counseling may be helpful in getting through such a period of
depression, and while there may be a brief (days or weeks) period of grieving in which normal daily
activities are suspended, most reactive depressions resolve themselves within 1 to 3 months and normal
functioning returns.
In cases where the reactive depression does not resolve “naturally” and within a reasonable period of time,
the depression is said to be “chronic” and becomes a cause for concern. Chronic depressed conditions are
sometimes associated with certain chemical changes in the brain, specifically with low levels or low
sensitivity to certain chemicals, called neurotransmitters, used to transmit nerve impulses. It is a “chicken
and egg” problem as to whether the depressed feelings “cause” the chemical changes, or vice versa, and it
really does not matter because once a person has chronic depression, the depressed feelings and the
chemical changes can both be present.
Depression can also be present in the absence of a triggering event, in which case it is called an
“Endogenous Depression” because it evolves from within the individual rather than from an external event.
Both Reactive and Endogenous Depressions have been successfully treated with several types of
interventions. A Psychologist or therapist can best help you determine which of the intervention
approaches might benefit you the most.
Cognitive-Behavioral Therapy: This approach starts with the assumption that you are depressed because of
the way you perceive and think about things, so it retrains you to think and react to events differently. It
uses techniques such as thought-stopping, thought substitution, skill building such as assertiveness training,
problem-solving and so on. This approach attacks the depression as a set of symptoms and treats the
problem at the symptom level. For many people, it is effective and long-lasting. However, it requires
concentration and discipline since it is a structured technique, and some depressed people are not able to
follow through on the assignments or in the application of the techniques.
Dynamic Psychotherapy: This approach looks for the roots of depression in early childhood experiences
such as emotional, verbal, physical or sexual abuse, or in the young child’s interpretation and adoption of
the parents’ wishes, expectations and values. Through exploring and examining your perceptions of events
and relationships from different stages of your life, the therapist helps you to understand how and why you
came to perceive things the way you did, and to change your view of yourself and your life. This is what
most people think of when they talk about being “in therapy.”
Pharmacological Therapy: Medications for depression are abundant and offer the hope that taking a pill
will “cure” the depression. Our experience has been that, for a significant number of depressed people,
medication can relieve the most severe symptoms of depression, but it rarely does the whole job. Because
many people we see have been depressed for a long time, and they have avoided close contact with others,
there are a variety of skills (especially interpersonal skills) they may not have learned, and they often need
help in sorting out what things mean in their relationships with people at work and in their families. We
usually recommend that medication be used while one of the other interventions is in progress.
23
Family Therapy: In cases, the triggering factor in depression is related to the patient’s ongoing
relationships within their family or love relationship with a partner. So, to go right to the source and
attempt to resolve the interpersonal conflict makes sense. A power struggle between parent and child,
alcoholism or drug abuse by a family member, infidelity, rage or anger resulting in abuse, and other
behavioral problems can cause and sustain a depressive reaction. By bringing these (often hidden) conflicts
out, and developing a strategy to resolve them, the source of the depression can often be eliminated.
A study was done in which rats were mildly shocked for several short periods during the day. Some of the
rats had levers they could push to shut off the current, and some did not. The rats who could push the
levers and shut off the current were essentially normal. The rats who had no levers, but had to endure the
shock, developed odd behavior including failure to mate, failure to play in the wheel, reduced food and
water consumption, altered waking/sleeping cycles, failure to make nests – in other words they became
depressed. We believe that this demonstrates a truism of human depression: Depression is not caused by
being in a bad situation – it is caused by being in a bad situation and believing that there is nothing you can
do about it! Successful interventions for depression create the belief that, and provide methods whereby,
something can be done to positively affect one’s life.
Signs and Symptoms of Depression
In chronic depression, day-to-day functioning is impaired to a greater or lesser extent:
1) The individual loses interest in formerly important people and/or activities (“anhedonia”) from contact
with loved ones or friends;
2) He may obsess or ruminate (have recurring, repetitive thoughts) about loss or about other things;
3) He may experience a sleep disorder which could be characterized by insomnia (difficulty falling asleep),
hypersomnia (sleeping much or all of the time), early awakening (waking up during the night and being
unable to fall asleep again) or constant fatigue;
4) He may have thoughts of self-harm or of suicide. Suicidality is sometimes assessed by the presence or
absence of a specific plan – if a plan has been made, the danger is increased.
5) There may be memory or concentration problems which affect his ability to work or function in school.
6) Depressed individuals are more likely to abuse alcohol or drugs, due to their temporary anti-depressant
effects.
7) He may express negative thoughts, feel discouraged, be “grumpy” or irritable, or express the feeling that
“things” or people are against him and are keeping him from doing well or achieving his goals.
If you or a loved one has some or all of those symptoms, it is important that a professional evaluation for
depression be scheduled, as soon as possible. If you are in the Atlanta area, we would be glad to help. If
you are not, please contact your family physician, insurance company, or local mental health center for a
referral.
Copyright 1996, Alan Brandis, Ph.D. All Rights Reserved.
24
PSYCHIATRIC MEDICATIONS
Brand names are on the right
Medications Used to treat Depression (4 Classes of Antidepressants)
1. Cycylic anitdepressants
Imipramine – Tofranil
Desipramine – Norpramine
Amitriptyline – Elavil
Nortriptyline – Pamelor
Clomipramine – Anafranil
Doxepin – Senequan
Protriptyline – Vivactil
Trimipramine – Surmontil
2. Monamine Oxidase Inhibitors (MAO)
Phenelzine – Nardil
Tranycypromine – Parnate
Isocarboxazid – Marplan
3. Newer antidepressants – (SSRI’s & SRI’s)
Fluoxetine – Prozac (SSRI)
Sertraline – Zoloft (SSRI)
Paroxetine – Paxil (SSRI)
Fluvoxamine – Luvox (SSRI)
Citalopram – Celexa (SSRI)
Venlafaxine – Effexor (SRI)
Nefazodone – Serzone (SRI)
Others Trazodone – Desyrel
4. Stimulant antidepressant Drugs
Amphetamines – Dexedrine
Methylphenidate – Ritalin
Pemoline - Cylert
Bupropion – Wellbutrin
25
Medications used to treat Manic Depression
Lithium – Lithonate
Divalproex Sodium – Depakote
Carbamazepine – Tegretol
Other Possibilities – Klonopin (Clonazepam) Clonidine (Catapres), Verapamil
(Calan)
26
SUICIDE RISK ASSESSMENT
1. What is the history of previous suicidal attempts?
2. What is the frequency of the suicidal ideation?
3. What is the nature of the suicidal ideation?
4. What is the typical duration of the ideation?
5. How strong is the person’s ego?
6. Is there as social network which the person perceives as caring?
7. What is the individual’s assessment of his/her likelihood of committing suicide?
8. Is there a plan?
9. Is the plan specific?
10. Are the means readily available?
11. How lethal is the plan?
12. How likely is rescue?
13. What has been the person’s coping style in similar situations?
14. What is the person’s perception of the effects of suicide on others?
15. What diagnostic category comes closest to describing the person?
16. Is the person psychotic?
17. Are there behavioral suggestions of suicide?
18. To what degree are helplessness, hopelessness, and exhaustion present? Is the client
able to verbalize their needs?
19. Can the client identify any reasons why she or he wants to live?
20. Is there family history of depression and/or suicide?
ADAPTED FROM: Pipes, R.B. & Davenport, D.S. (1990) Introduction to Psychotherapy:
Common Clinical Wisdom. New Jersey: Prentice Hall, by Dr. Gloria A. Leitschuh (WP:
27
COUNSELOR’S ROLE WITH SUICIDAL CLIENTS
1. Make an assessment of the risk.
2. Avoid power struggles.
3. Offer involvement.
4. Take all threats seriously and tell the client
5. Make suicide seem real.
6. Find out what they hope to accomplish by committing suicide
7. Share responsibility: Consult with supervisor or peers.
8. Watch for countertransference.
9. Help the client be aware of the ambivalence.
10. Utilize a contract.
11. Make sure someone is committed to staying with them until the thoughts subside.
12. Attempt with the client’s assistance to remove means to carry out any expressed
plan.
13. Offer hospitalizations if threat seems likely.
ADAPTED FROM: Pipes, R.B. & Davenport, D.S. (1990). Introduction to Psychotherapy:
Common Clinical Wisdom. New Jersey: Prentice Hall, by Dr. Gloria A. Leitschuh (WP: Suicide
28
ANXIETY DISORDERS
PANIC DISORDER
300.01 WITHOUT AGORAPHOBIA, 300.21 WITH
A. 1 & 2 UNEXPECTED PANIC ATTACKS
(REFER BACK TO PANIC ATTACK CRITERIA)
1+ MO. OF WORRY ABOUT ATTACK
B. DO THEY MEET THE CRITERIA FOR
AGORAPHOBIA? (REFER BACK TO CRITERIA)
C & D. RULE OUT SUBSTANCE ABUSE,(Caffeine
Intoxication), MEDICAL DISORDERS AND
SEPARATION ANXIETY
300.22 AGORAPHOBIA WITHOUT HISTORY OF P.D.
A. THIS DIAGNOSIS IS AGRAPHOBIA
(REFER BACK TO AGORAPHOBIA CRITERIA)
B. DIFFERENT FROM P.D. WITH AGOR. SINCE NO
HISTORY OF UNEXPECTED PANIC ATTACKS
C & D. RULE OUT P.D., SUBSTANCE, AND M.C.
29
TREATMENT – PANIC DISORDER AND AGORAPHOBIA
Assessment/Treatment
1. Functional Behavioral Analysis Antecedent
Behavior
Consequence
2. Medical evaluation
3. Self- Monitoring – Record panic attack frequency, duration, context, and symptoms.
Treatment Components – The aim of treatment is to influence the cognitivemisinterpretation of the panic attacks and anxiety, the hyperventilation response,
conditioned reactions to physical cues and fear and avoidance of situations.
1. Cognitive Restructuring (REBT, See Ellis, or Meichenbaum)
Overestimation – Can you think of events that you felt sure were going to happen
when you were feeling anxious, only to find out that they did not happen at all?
2. Breathing Retraining – Education about the physiological aspects of fear and anxiety
(how it can be protective as in fight or flight response). Practice diaphragmatic
breathing at least 2 times a day, at least 10 minutes each time.
3. Progressive Muscle Relaxation (PMR) and Anxiety Hierarchy – Teach PMR, develop
a hierarchy of situations, and begin exposure practice.
4. In Vivo (live) Situational Exposure – repeated confrontation with the feared situation
or object Live or Imaginary, exposure practice.
5. Distraction – Use specific distraction tasks during in vivo exposure (word rhymes and
spelling) and distracting self- statements to interrupt focus on bodily sensations.
6. Medications- SRI’s (Prozac, Paxil, Zoloft, and Luvox)
See also The Anxiety Disorders Interview Schedule-Revised (ADIS-R), DiNardo &
Barlow, 1988.
Adapted from: Barlow, D.H. (Ed.). (1993). Clinical Handbook of Psychological Disorders (Rev.ed.). New
York: Guilford Press.
30
ANXIETY DISORDERS
300.29 SPECIFIC PHOBIA (SIMPLE PHOBIA)
A. FEAR ASSOCIATED WITH SPECIFIC OBJECT
OR SITUATION (flying, height, animals)
B. CONTACT CAUSES RESPONSE, CAN BE
SITUATIONALLY BOUND OR PREDISPOSED
C. PERSON KNOWS IT IS EXCESSIVE
D. AVOIDS SITUATION OR ENDURES IT
E. THE DISTRESS OR AVOIDANCE CAUSES
PROBLEMS WITH JOB, RELATIONSHIPS
ETC.
F. UNDER 18 AT LEAST 6 MONTHS
G. RULE OUT OTHER DISORDERS
SPECIFY TYPE: (CAN BE MORE THAN ONE)
ANIMAL
NATURAL ENVIRONMENT
BLOOD INJECTION INJURY
SITUATIONAL
OTHER
31
TREATMENT – PHOBIAS
How are phobias treated?
The treatment of phobias usually has a behavior therapy
focus. In the safety of the therapeutic situation, people
with phobias are gradually introduced into the very situation
that normally causes them anxiety. They learn that they can
control their anxiety while gaining greater and greater
exposure to their phobic situation. Cognitive or behavior
therapy can be very effective when used in conjunction with
relaxation training.
Medication is sometimes prescribed for people with phobias
to help them control their anxiety. Some people do well on
medications such as monoamine, oxidase inhibitors
(MAOIs) or imipramine. Also, mild tranquilizers, like
benzodiazepines, can be effective in helping people control
the anxiety caused by their phobia.
What happens to someone with a phobia?
The course of a phobia may be quite varied. Some people
have mild phobias which can be easily treated and which last
only a short time. Others have severe anxieties, and they
suffer from their phobias for many years. Chronic phobias
can cause major disruptions in school, at work, and/or with
personal relationships.
What can people do if they need help?
If you, a friend, or a family member would like more
information and you have a therapist or a physician, please
discuss your concerns with that person.
Developed by John L. Miller, M.D., P.S.
Reviewed 7/2000
32
ANXIETY DISORDERS
300.23 SOCIAL PHOBIA (SOCIAL ANXIETY
DIS)
A. FEAR OF SOCIAL SITUATIONS (OR
PERFORM) (In children, must have history of ability
to develop relationships)
B. THE FEARED SITUATION PROVOKES
ANXIETY (Can be situationally bound or
predisposed)
C. PERSON KNOWS IT IS EXCESSIVE
D. SITUATIONS ARE ENDURED OR AVOIDED
E. INTERFERES WITH RELATIONSHIPS, JOB, ECT.
F. IF UNDER 18, DURATION IS AT LEAST 6 MO
F. RULE OUT SUBSTANCE, M.C. ETC.
SPECIFY:
GENERALIZED: if it happens in most social
situations.
33
TREATMENT - SOCIAL PHOBIAS
What Treatments Are Available for Social Phobia?
Research supported by NIMH and by industry has shown that there
are two effective forms of treatment available for social phobia:
certain medications and a specific form of short-term psychotherapy
called cognitive-behavioral therapy. Medications include
antidepressants such as selective serotonin reuptake inhibitors
(SSRIs) and monoamine oxidase inhibitors (MAOIs), as well as
drugs known as high-potency benzodiazepenes. Some people with
a form of social phobia called performance phobia have been helped
by beta-blockers, which are more commonly used to control high
blood pressure.
Cognitive-behavior therapy is also very useful in treating social
phobia. The central component of this treatment is exposure
therapy, which involves helping patients gradually become more
comfortable with situations that frighten them. The exposure
process often involves three stages. The first involves introducing
people to the feared situation. The second level is to increase the
risk of disapproval in that situation so people build confidence that
they can handle rejection or criticism. The third stage involves
teaching people techniques to cope with disapproval. In this stage,
people imagine their worst fear and are encouraged to develop
constructive responses to their fear and perceived disapproval.
Cognitive-behavior therapy for social phobia also includes anxiety
management training - for example, teaching people techniques
such as deep breathing to control their levels of anxiety. Another
important aspect of treatment is called cognitive restructuring,
which involves helping individuals identify their misjudgments and
develop more realistic expectations of the likelihood of danger in
social situations.
Supportive therapy such as group therapy, or couples or family
therapy to educate significant others about the disorder, is also
helpful. Sometimes people with social phobia also benefit from
social skills training.
What Other Illnesses Co-Occur With Social Phobia?
Social phobia can cause lowered self-esteem and depression. To try
to reduce their anxiety and alleviate depression, people with social
phobia may use alcohol or other drugs, which can lead to addiction.
Some people with social phobia may also have other anxiety
disorders, such as panic disorder and obsessive-compulsive
disorder.
For more information about social phobia and other
disorders, write:
The Anxiety Disorders Education Program, National Institute of
Mental Health
6001 Executive Blvd.
Room 8184, MSC 9663 Bethesda, MD 20892-9663
34
ANXIETY DISORDERS
300.3 OBSESSIVE-COMPULSIVE DISORDER
A. EITHER OBSESSIONS OF COMPULSIONS
OBSESSIONS- 1,2,3, AND 4
1. INTRUSIVE PERSISTENT THOUGHTS
2. NOT TYPICAL OF REAL LIFE WORRIES
3. PERSON TRIES TO IGNORE THEM
4. PERSON RECOGNIZES THEY ARE NOT
THOUGHT INSERTION
COMPULSIONS - 1 AND 2
1. REPETITIVE BEHAVIORS (hand washing,
ordering, checking) or MENTAL ACTS
(praying,counting, repeating words silently)
THAT THE PERSON FEELS DRIVEN TO
PERFORM
2. PERFORMING THE BEHAVIOR IS
AIMED AT PREVENTING THE DISTRESS
B. TIME CONSUMING (1 + hr. A day) and
INTERFERES WITH NORMAL FUNCTIONS
C. NOT PART OF ANOTHER DISORDER
SPECIFY IF: WITH POOR INSIGHT
35
TREATMENT - OBSESSIVE COMPULSIVE DISORDER (OCD)
Assessment/Treatment
External Fear Cues - Gather specific information about cues that elicit distress to get to
basic source of fear.
Internal Fear Cues - Gather specific information about images, impulses, or abstract
thoughts that the individual finds disturbing, shameful, or disgusting.
Feared Consequences - Identify fears about something terrible happening if they fail to
perform their ritual.
Strength of Belief - Insight: Do they know the obsession is irrational?
Treatment
1. In Vivo or imaginal exposure - gradual presentation of stimuli.
2. Response prevention - Be specific with rules for response prevention
For Example - Washing
1. Do not exceed one 10 minute shower daily.
2. Do not exceed 5 hand washings per day, 30 seconds each.
3. Restrict hand washing to when hands are visibly dirty and sticky.
4. Expose yourself deliberately to object that illicit the response 2x a week.
3. Cognitive Restructuring - See Ellis, or Meichenbaum
4. Medications - SRI's (Luvox)
See also: The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) (Goodman et al.,
1989) The Compulsive Activity Checklist (CAC) (Philpott, 1975)
Adapted from: Barlow, D.H. (Ed.). (1993). Clinical Handbook of Psychological
Disorders (Rev.ed.). New York: Guilford Press.
36
ANXIETY DISORDERS - 308.3 ACUTE STRESS DIS.
* Similar to PTSD: Use A.S.D. for symptoms that occur
within 1 mo. of stressor
* PTSD Requires more than 1 month
* If A.S.D. is diagnosed and symptoms persist for more
than 1 month, may consider PTSD
A. EXPOSURE TO TRAUMA + 1 AND 2 (= PTSD)
1. EXPERIENCED OR WITNESSED EVENT
2. INTENSE FEAR RESULTS
B. 3+ DISSOCIATIVE SYMPTOMS
1. NUMBING, DETACHMENT
2. IN A DAZE - UNAWARE OF SURROUNDING
3. DEREALIZATION
4. DEPRESONALIZATION
5. DISSOCIATIVE AMNESIA
C. REEXPERIENCED THROUGH DREAMS,
ILLUSIONS, FLASHBACKS OR RELIVING
D. AVOID PLACES ASSOCIATED WITH TRAUMA
E. ANXIETY
F. IMPAIRS FUNCTIONING
G. LASTS 2 DAYS TO 4 WKS. AND OCCURS WITHIN
1 MO. OF TRAUMA (NOT PTSD)
H. NOT SUBSTANCE, M.C. OR PSYCHOTIC DIS
37
ANXIETY DISORDERS – 309.81 P.T.S.D
A. EXPOSURE TO TRAUMA + 1 AND 2
1. PERSON EXPERIENCED OR SAW LIFE
THREATENING EVENT OR PHY. INJURY
2. FEEL FEARFUL OR HELPLESS
B. REEXPERIENCED IN AT LEAST 1 WAY
1. THOUGHTS OR IMAGES ABOUT EVENT
2. DREAMS
3. SENSES OF RELIVING EXPERIENCE
(Hallucinations, flashbacks, upon waking)
4. DISTRESS WHEN EXPOSED TO CUES
5. PHYSIOLOGICAL RESPONSE TO CUES
ARE THE ORIGINAL TRAUMA
C. AVOIDANCE OF CUES AND NUMBING 3+
1.
2.
3.
4.
5.
6.
7.
AVOID THOUGHTS & CONVERSATIONS
AVOID ACTIVITIES ASSOCIATED WITH IT
UNABLE TO REMEMBER THE EVENT
LOW PARTICIPATION IN GENERAL
FEELING DETACHED FROM OTHERS
RESTRICTED RANGE OF AFFECT
SUSPECTS SHORT LIFE SPAN
38
D. TWO OR MORE…
1. SLEEP DIFFICULTIES
2. IRRITABLITY OR ANGER OUTBURST
3. DIFFICULTY CONCENTRATING
4. HYPERVIGILANCE
5. EXAGGERATED STARTLE RESPONSE
E. MORE THAN ONE MONTH
F. IMPAIRMENT OF FUNCTIONING
SPECIFY IF ACUTE OR CHRONIC
300.02 GENERALIZED ANXIETY DISORDER
A. ANXIETY OR WORRY- most days for 6 months
B. PERSON CAN’T CONTROL IT
C. 3+ FOR 6 MONTHS (1 FOR CHILD)
6. RESTLESSNESS
7. EASILY FATIGUED
8. DIFFICULTY CONCENTRATING
9. IRRITABILITY
10.MUSCLE TENSION
C. & F. RULE OUT SUBSTANCE, M. AND P.D.
D. CAUSES IMPAIRMENT
39
TREATMENT – POST-TRAUMATIC STRESS DISORDER
Individual reactions to the trauma are more important than the type of trauma.
57% of women who had been raped developed PTSD at some point in their life (Kilpatrick 1987).
31% of rape victims developed PSTD compared to 5% of nonvictims (Kilpatrick, et al, 1992).
Treatment
1. Stress Inoculation Training- Identify at least 2 coping skills, demonstrate, practice
in session, apply to situation, evaluate effectiveness.
Muscle Relaxation – Jacobsonian tension-relaxation method is used for most
frequently. Relax all major muscle groups in session and provide tape for home
practice.
Breath Control – Diaphragmatic breathing
Covert Modeling – Visualize fear and imagine successful confrontation of fear.
Role Play – Client and therapist act out successful assertiveness skills
1. Prolonged Exposure – (Specific to rape-related PTSD) Incorporates new
information that is incompatible with the current fear structure, so that new
memories are formed. Recall and talk about assault in detail until it is no longer
intensely painful. (May tape it and listen at home, Desensitization) This is
combined with exposure to feared but safe stimuli.
2. Cognitive Processing Therapy (CPT) – combines exposure based therapies that
are most likely to have been disrupted as a result of trauma. Recall and think
about the event in detail, may write about it including sensory memories. May
read in session, help label feelings, and identify stuck points. Provide new
information that is incompatible with the current fear structure in order for new
memory to be provided.
3. Rational Emotive Behavioral Therapy (See Ellis & Meichenbaum)
4. Group Therapy – Clients with severe PTSD should be in individual therapy
simultaneously with group treatment. Always screen for appropriate placement.
See also The Impact of Events Scale (IES) (Horowitz, Wilner, Alvarez, 1979)
Derogatis Symptom Checklist 90-R (SCL-90-R) (Derogatis, 1979)
The Ways of Coping Questionnaire (Folkman & Lazarus, 1988)
Adapted From: Barlow, D.H. (Ed.). (1993). Clinical Handbook of Psychological Disorders (Rev. ed.). New
York: Gilford Press.
40
TREATMENT – GENERALIZED ANXIETY DISORDER (GAD) Worry may serve
to hinder attention to or processing of more disturbing thoughts or images.
1.
Physiological – Progressive Muscle Relaxation (PMR) training. Incorporate into any
type of treatment method utilized.
2.
Cognitive Restructuring – Help client identify specific faulty interpretations/predictions
that they are making and help challenge these cognitions. Use a cognitive monitoring format.
EventAutomatic ThoughtAnxiety level- Likert scale of 0-8
Unrealistic probability that it will happen: 0-100%
Counter and Alternative thoughtsRealistic probability that it will happen: 0-100%
Anxiety level- Likert scale of 0-8
3.
Behavioral
Worry prevention – Engage in competing response. For example listen to music on radio
rather than weather reports if fear of storms exists. Compare predictions to actual
outcomes.
Time Management – To deal with perfectionist attitudes
Delegating responsibility –
Assertiveness Training – Role Playing
Adhering to agendas – daily goal setting so that important activities are
completed.
Problem Solving – Teach client to conceptualize problems in specific terms and to break
the problem into smaller, more manageable segments. Brainstorm possible solutions to
gether.
4.
Self Monitoring – Keep a daily record of anxiety or depression levels.
5.
Medications – Buspar – Takes up to 4 weeks to work
Benzodiazepines – Long Acting – Valium, Librium, Centrax, Klonopin, Tranxene
Benzodiazepines – Short Acting – Ativan, Serax, Xanax (worse
withdrawl)
See also: Penn State Worry Questionnaire (PSWQ)
Anxiety Disorders Interview Schedule- Revised (ADIS-R) (DiNardo & Barlow, 1988).
Beck Anxiety Inventory
Adapted From: Barlow, D.H. (Ed.). (1993). Clinical Handbook of Psychological Disorders (Rev. ed.).
New York: Gilford Press.
41
SOMATOFORM DISORDERS
300.81 SOMATIZATION DISORDER
A. History of many physical complaints before age 30
for several years and causes impairment.
B. All of the following:
1. 4 different pain symptoms & sites (sites,
abdomen, back, joints, etc.)
2. 2 Gastrointestinal systems (nausea, bloating)
3. 1 Sex symptom (erectile, libido, menses)
4. 1 Pseudoneurological symptom (impaired
coord., localized weakness, aphonia, loss of
sensation, double vision, blindness, deafness,
seizures, etc.)
C. Either 1 or 2
1. Can’t be explained by general m.c. or substance
2. If there is a m.c. complaints are in excess
D. Not intentionally produced or faked
300.82 UNDIFFERENTIATED SOMATOFORM DIS.
* Not the multiplicity of symptoms & not as long
* Or if many symptoms, they exist for less than 6 months
42
SOMATOFORM DISORDERS
300.11 CONVERSION DISORDER – Neurological funct.
1+ symptoms that affect motor or sensory functioning
Stress seems to make it worse
D. & F. Not intentional or faked, rule out m.c., substance
and pain or sexual dysfunction.
E. Causes impairment in functioning
SPECIFY TYPE:
With Motor symptom or deficit – (balance, paralysis)
With Sensory symptom or deficit – (touch, vision, deaf)
With Seizures or Convulsions –
With Mixed Presentation – More than 1 of above
*Although symptoms are not intentional, person may
derive secondary gain, like not having to work
43
SOMATOFORM DISORDERS
PAIN DISORDERS (CODE BASED ON SUBTYPE)
A. Pain exists
B. Pain causes distress or impairment in functioning
C. Psychological factors seem to play a role
D. Not faked
E. Rule out Mood, Anxiety, or Psychotic disorder
307.80 PAIN DIS. ASSOC. WITH PSYCH. FACTORS
* If psychological onset
SPECIFY IF: ACUTE- duration less than 6 mo
CHRONIC- duration 6 mo or more
307.89 PAIN DISORDER ASSOC. WITH BOTH
PSYCHOLOGICAL FACTORS AND G.M.C.
SPECIFY IF: ACUTE- duration less than 6 mo.
CHRONIC- duration 6 mo or more
44
SOMATOFORM DISORDERS (CONT)
300.7 HYPOCHONDRIASIS
A. Fears that one has a serious disease based on
misinterpretation of bodily symptoms.
* Preoccupied with physical symptoms such as
sweating, heart rate, sore throat ect.
B. Belief persists despite medical evaluation
C & F. Rule out Delusional, Somatic, OCD, Panic ect.
D. Causes impairment
E. Duration of at least 6 months
FACTITIOUS DISORDER
A. Intentional faking of physical or psych symptoms
(Presented with dramatic flair)
B. Motivation is to assume the sick role.
C. Not external incentives like Malingering, (V-code)
CODE ACCORDING TO SUBTYPE:
300.16 WITH PREDOMINANTLY PSYCH SIGNS
300.19 WITH PREDOMINANTLY PHYSICAL SIGNS
300.19 WITH COMBINED PSYCH & PHYSICAL
45
GENERAL PERSONALITY DISORDER CRITERIA
A. Pattern of Behavior Manifested in 2 +
1. Cognition: Interpretation of events is off base.
2. Affectivity: Emotional response is off base.
3. Interpersonal Functioning
4. Impulse Control
B. Pattern persists over time and situations
C. Impairment or distress
D. Begins in adolescence or early childhood
E & F. Not another mental disorder, S.D. or G.M.C.
46
301.0 PARANOID PERSONALITY DISORDER
A. Distrust others, suspicious of their motives, 4 +
1. Believes others are out to harm or deceive him/her
2. Doubts loyalty or trust of friends or associates
3. Reluctant to confide in others
4. Reads hidden meanings into benign remarks
5. Bears a grudge and is unforgiving
6. Thinks others are attacking his/her character
7. Suspicious of partners’ fidelity
B. Not during schizophrenia, Mood Disorder, Psychosis or
G.M.C.
ASSOCIATED FEATURES
* ARGUMENTATIVE, GUARDED, SECRETIVE
* MAY TRY TO CONTROL OR BLAME OTHERS
47
301.20 SCHIZOID PERSONALITY DISORDER
A. Lack of Social Relationships, Restricted
Emotions, begins by early adulthood, 4 +
1. Does not enjoy or desire close relationships
2. Prefers solitary activities, including job
3. Little interest in sexual activity
4. Few activities are pleasurable
5. Lacks close friends other than close relatives
6. Seems indifferent to praise or criticism
7. Seems emotionally cold or detached
B. Rule out Schizophrenia, Mood Dis., Psychosis,
GMC
ASSOCIATED FEATURES
* Life may seem aimless, drifting, passive
* Often do not marry
48
301.22 SCHIZOTYPAL PERSONALITY DISORDER
A. * Lack of social skills & close relationships
* Distortions in perceptions & eccentric behavior
* Begins in early adulthood & 5 +
1. Ideas of reference (external events have a
specific meaning to that person)
2. Odd beliefs or magical thinking
3. Unusual experiences (leaves = voices)
4. Odd thinking & speech (Make up words)
5. Suspicious or Paranoid
6. Inappropriate or constricted affect
7. Odd, eccentric or peculiar appearance or beh.
8. Lack of close friends
9. Excessive social anxiety
B. Rule out Schizophrenia, Mood Dis., Psychosis,
etc.
49
301.7 ANTISOCIAL PERSONALITY DISORDER
A. * Disregard for and violation of others’ rights
* Occurring since age 15
3+
1. No respect for social norms and laws
2. Lying or conning for profit or fun
3. Impulsive (No regard for consequences)
4. Aggressive Behavior
5. Disregard for safety of self or others
6. Irresponsible with work, financial, etc.
7. Lack of remorse, rationalize behavior
B. At least age 18 before diagnosis can be made
C. Evidence of Conduct disorder before age 15
* Aggression to people or animals
* Destruction of property * Deceitfulness or theft
* Serious violations of rules
E. Rule out Schizophrenia, Mania ect.
50
301.83 BORDERLINE PERSONALITY DISORDER
A. * Unstable relationships, self-image, & affect
* Impulsive * Begins by early adulthood, 5 +
1. Becomes frantic with threat of abandonment
2. Intense relationships (Idealize or Devalue)
3. Identity disturbance (External orientation)
4. 2 + self damaging behaviors
* Spending *Sex
*Substances
* Reckless driving *Binge eating
5. Suicidal behavior or threats of self-mutilation
6. Unstable Mood – (dysphoria, irritable)
7. Feelings of boredom or emptiness
8. Difficulty controlling anger (Sarcastic)
9. Stress related Paranoia or dissociative
* Suicide 8-10%
* Self mutilation may occur during dissociative state
51
301.50 HISTRIONIC PERSONALITY DISORDER
A. * Emotions are excessive * Seeks attention
* Begins by early childhood
*5+
1. Center of attention (May bring you gifts)
2. Sexually seductive, flirtatious, charming
3. Rapid shift of emotions or seem faked
4. Physical appearance to get attention or impress
5. Speech is impressionistic
6. Highly theatrical & dramatic
7. Easily influenced by others
8. Considers relationships to be more intimate than
they are (Romantic Fantasy is Common)
ASSOCIATED FEATURES
* Emotional Manipulation to Control Others
* High rates of Somatization, Conversion etc.
52
301.81 NARCISSISTIC PERSONALITY DISORDER
A. * Grandiose thoughts, behavior * Needs
admiration * Lacks empathy *Begins by early
adult *5+
1. Grandiose self-importance, Boastful
2. Fantasies of success, power, beauty ect.
3. Believes they are special and unique
* Needs to associate with special people
4. Requires excessive admiration
5. Sense of entitlement (expects special trt)
6. Takes advantage of others
7. Lack of empathy (Impatience with others)
8. Envious of others & believes other are
envious of them
9. Seems arrogant & patronizing
53
301.82 AVOIDANT PERSONALITY DISORDER
A. * Social Inhibition * Feels inadequate
* Hypersensitive * Begins by adult * 4 +
1. Avoids occupational activities involving
people
2. Avoids people unless certain of being liked
3. Avoids intimate relationships out of fear
4. Fears being criticized or rejected
5. Feels inadequate in new situations
6. Views self as inferior to others
7. Avoids new activities and personal risks
ASSOCIATED FEATURES
* Needs support and nurturing
* Seems tense which elicits negative reactions
* May overlap with Social Phobia & Dependent P.D.
54
301.6 DEPENDENT PERSONALITY DISORDER
A. * Needs to be taken care of * Submissive * Clinging
* Fears separation * Begins by adulthood * 5 +
1. Needs advice before making decisions
2. Needs others to be responsible for their life
3. Can’t disagree - fears loss of support
4. Lacks self-confidence, can’t initiate activity
5. Obtains nurturance by volunteering
6. Feels helpless when alone
7. Urgently seek a new relationship when 1 ends
8. Preoccupied by fear of being left alone to take
care of themselves.
ASSOCIATED FEATURES
* Don’t diagnose if fears are realistic – abusive spouse
* May co-occur with Borderline, Avoidant, Histrionic
55
301.4 OBSESSIVE-COMPULSIVE PER. DIS.
A. * Preoccupation with orderliness, perfectionism.
* Efficient and lacks flexibility * 4 +
1. Misses enjoyment due to list making & org
2. May not finish something due to
perfectionism
3. Workaholic (Takes work on vacation)
4. Inflexible about morality, ethics, or values
5. Can’t discard worthless objects (pack rats)
6. Can’t delegate since others aren’t perfect
7. Miserly (May live below level of
affordability)
8. Rigid and Stubborn
ASSOCIATED FEATURES
* Excessive deference to authority they respect
* Excessive resistance to authority they do not respect
*Type A Personality- Hostile, time urgency
56
DISSOCIATIVE DISORDERS
DISRUPTS FUNCTIONING * CONSCIOUSNESS
* MEMORY
* IDENTITY
* PERCEPTION
300.12 DISSOCIATIVE AMNESIA
A. Unable to remember personal info * Trauma that happened in the past
* Amnesia during self-mutilation or suicide attempt
B. Rule out GMC, Substance, P.T.S.D., Acute Stress dis.
C. Causes distress or impairment
DIFFERENTIATE:
AMNESTIC DISORDER DUE TO BRAIN INJURY:
* Memory Loss is usually for time just prior to head
trauma (Retrograde). And there is a head trauma.
DISSOCIATIVE AMNESIA:
* Memory Loss is usually for things that happen after
the trauma (Anterograde).
57
300.13 DISSOCIATIVE FUGUE
A. Sudden unexpected travel away from home and
can’t recall what happened.
* Can be for hours, days, weeks, or months.
* Does not appear abnormal in other ways.
* Not usually a new identity but can be.
B. Confusion about who they are.
C. Rule out GMC, substances
D. Causes distress or impairment
* Onset is usually related to stress or trauma
300.6 DEPERSONALIZATION DISORDER
A.
Feel like an outside observer of one’s body –
detached
* Feels like being on automation
* May lack control of body, or lack emotion.
B. Reality testing remains intact.
C. Causes distress or impairment
D. Rule out GMC, substance
58
300.14 DISSOCIATIVE IDENTITY DIS. (M.P.D.)
A.
2 + Personalities
* May have own history, self-image, handwriting
* May have one primary identity – passive
* Other identities may be opposite - hostile
B. At least 2 personalities that take control of person.
C. Has trouble remembering important personal info.
D. Rule out GMC, Substance Dis. (In children not
imaginary playmates or fantasy play)
ASSOCIATED FEATURES:
* May have history of abuse as a child
* Certain personalities may have other disorders
* May be physical differences between disorders
* Glasses * Allergies * Glucose levels
* More prevalent in U.S. culture than in others
* May persist for 6-7 yrs before diagnosed
59
How are the various dissociative disorders treated?
The treatment for dissociative amnesia is therapy aimed at helping the
client/patient restore lost memories as soon as possible. If a person is not
able to recall the memories, hypnosis or a medication called Pentothal
(thiopental) can sometimes help to restore the memories. Psychotherapy
can help an individual deal with the trauma associated with the recalled
memories.
Hypnosis is often used in the treatment of dissociative fugue. Hypnosis can
help the client/patient recall his/her true identity and remember the events
of the past. Psychotherapy is helpful for the person who has traumatic,
past events to resolve.
Treatment for dissociative identity disorder involves long-term
psychotherapy that helps the person merge his/her multiple personalities
into one. The trauma of the past has to be explored and resolved with
proper emotional expression. Hospitalization may be required if behavior
becomes bizarre or destructive.
Treatment for depersonalization disorder is very difficult. However, the
condition can improve with a thorough therapeutic exploration of the
trauma in the individual’s past and the expression of the emotions
associated with that trauma.
What happens to people with dissociative disorders?
Dissociative amnesia: The length of an event of dissociative amnesia may
be as short as a few minutes or as long as several years. If the episode is
associated with a traumatic event, the amnesia may clear when the
individual is removed from the traumatic situation.
Dissociative fugue: Once dissociative fugue is discovered and treated,
many people recover quickly. The problem may never occur again.
Dissociative identity disorder: The course of dissociative identity disorder
tends to recur over several years. It may become less of a problem,
however, after mid-life.
Depersonalization disorder: An episode of depersonalization disorder can
be as brief as a few seconds or continue for several years.
What can people do if they need help?
If you, a friend, or a family member would like more information and you
Have a therapist or a physician, please discuss your concerns with that
Person.
Developed by John L. Miller, M.D., P.S.
Reviewed 7/2000
60
SEXUAL & GENDER IDENTITY DISORDERS
SPECIFY FOR: OR SUBTYPES
1. NATURE OF ONSET
*Lifelong Type
*Acquired Type
2. IN WHAT CONTEXT
*Generalized Type *Situational Type
3. ETIOLOGY
*Due to Psychological Factors
*Due to Combined Factors
61
I. DISORDERS OF SEXUAL DESIRE
B. Cause distress or relationship problems
C. Rule out Depression, but can have both
302.71 HYPOACTIVE SEXUAL DESIRE DIS.
A. Absence of desire for sexual activity.
* Assess both partners
302.79 SEXUAL AVERSION DISORDER
A. Persistent aversion to & Avoidance of almost all
genital sexual contact with a partner.
* May include touching & kissing
* May report disgust with opportunity
* May go to bed early, neglect appearance
Use substances or activities to avoid
62
II. SEXUAL AROUSAL DISORDERS
302.72 FEMALE SEXUAL AROUSAL
DISORDER
(Don’t diagnose if due to lack of sexual stimulation)
A. Can’t maintain sexual excitement- Lack of
lubrication during excitement phase
*Diagnose Sexual Dysfunction Due to a GMC of
Menopausal, postmenopausal, diabetes, or lactation
302.72 MALE ERECTILE DISORDER
(Don’t diagnose if due to lack of sexual stimulation)
A. Can’t attain or maintain adequate erection
63
IV. SEXUAL PAIN DISORDERS
302.76 DYSPAREUNIA (NOT DUE TO GMC)
A. Genital pain during intercourse-Male or Female
B. Causes distress or relationship problems
C. Not Vaginismus, lack of lubrication, ect.
* Usually Chronic & seeks medical treatment.
* Diagnose due to GMC if infections, endometriosis,
lactation, or gas
306.51 VAGINISMUS (NOT GMC)
A. Spasms of the outer 3rd layer of muscles of vagina
That make intercourse difficult. (Usually prevents
coitus)
* More often in younger than older females
* History of sex abuse
64
302.2 PEDOPHILIA
A. Sexual activity with a child (Usually under 13)
B. Causes distress or impairment
C. The person is at least 16 years old & at least 5
years older than the child.
(Do not diagnose…….)
Specify if…
1.
Attracted to Males
Attracted to Females
Attracted to Both
2.
Limited to Incest
3.
Exclusively Type (only children, not adults)
Nonexclusive Type (may be attracted to adults too)
65
III. ORGASMIC DISORDERS
302.73 FEMALE ORGASMIC DISORDER
302.74 MALE ORGASMIC DISORDER
(Don’t diagnose for either if due to inadequate
stimulation)
FOR FEMALES:
* Ability to have orgasms increase with age.
* More prevalent in younger women.
* Uncommon to lose the ability once learned unless
to trauma, relationship problems or MC
due
FOR MALES:
* May obtain orgasm from manual or oral stimulation but
not intercourse.
* Males can usually reach orgasm even if after loss of
prostrate with cancer surgery.
* Orgasm can also occur even if there is no semen.
302.75 PREMATURE EJACULATION
A. Ejaculation with stimulation before the person wants it
to occur
* Most can delay during masturbation
* Can be with younger males, new partner, or decreased
frequency of sex activity.
66
Warning Signs of Eating Disorders
ANOREXIA NERVOSA
•
Significant weight loss in the absence of physical illness.
•
Significantly decreased easting and angry, evasive, or proud denials of hunger.
•
Unwillingness or inability to eat dominates family and peer interactions
•
Accompanying reports of dieting are new; increased reports of feeling strong, being in
control, and feeling pleasure in not eating.
•
Fears of being fat continue despite weight loss.
•
Unusual eating habits: food rituals, strange food combinations, eating in isolation.
•
Unusual oral habits: excessive gum chewing, counting amount of chewing for each bite,
excessive consumption of diet sodas and/or coffee.
•
Increased interest in food; cooking for others, insisting that others eat in their presence
while they do not eat.
•
Frequent fasting.
•
Excessively high activity levels.
•
Dressing inappropriately for warm weather with excessive layers of clothing.
•
Compulsive adherence to routines are often highly idiosyncratic.
BULIMIA NERVOSA
•
Indications of rapid and/or unusual amounts of food consumed: food disappearing more
rapidly from kitchen, large numbers of empty food wrappers or containers found hidden
in bedroom, large amounts of food purchased or shoplifted.
•
Evidence of self-induced vomiting: unusual bathroom messes and/or smells, unexplained
plumbing problems, purchase of emetics such as Syrup of Ipecac.
•
Unexplained calluses on knuckles (from inducing vomiting).
•
Makes excuses to go to bathroom after meals.
•
Habitual overeating in response to stress.
From: The Child Therapy News December, (1994).
67
•
Eating unprepared foods or foods that are meant to be eaten with other things such as
frozen dough, canned frosting, maple syrup, uncooked hot dogs, etc.
•
Dramatic mood swings.
•
Alternation of dieting and overeating.
•
Frequent, repetitive fantasies of success and happiness contingent on being thin.
•
Dramatic weigh fluctuations.
•
Impulsive behaviors in other domains: spending, drug and alcohol abuse, sexual activity.
Hospitalization or Immediate Medical Attention is Required When:
•
Weight is below 80 percent for height by age.
•
Child or adolescent is dehydrated.
•
Signs of cardiac arrhythmia: chest pains, tingling in fingers and/or toes, shortness of
breath, light-headed, fainting spells.
•
Signs of circulatory failure: low blood circulation.
•
Suicidal ideation and threats.
•
Self-destructive activities: self-mutilation, excessive drug/alcohol abuse.
•
Behaviors and emotions extremely out of control.
•
Severe abdominal pain.
•
Persistent vomiting and/or vomiting blood.
From: The Child Therapy News December, (1994).
68
EATING ATTITUDES TEST (EAT-26)
Name: ________________________________________ Date: ________________________________ Age: _______________
Present Weight: _____________________(lbs)
Height: _________________________
Highest Past Weight: ____________________
How Long Ago? __________________
Lowest past Adult Weight: ________________
How Long Ago? __________________
Sex: _________________
INSTRUCTIONS
NEVER
RARELY
SOMETIMES
OFTEN
USUALLY
ALWAYS
Please place an (x) under the column which applies best to each of the numbered statements. All of the results will be strictly
confidential. Most of the questions directly relate to food or eating, although other types of questions have been included. Please
answer each question carefully. Thank you.
1.
Am terrified about being overweight.
2.
Avoid eating when I am hungry.
3.
Find myself preoccupied with food.
4.
Have gone on eating binges where I feel that I may not be able to stop.
5.
Cut my food into small pieces.
6.
Aware of the calorie content of foods that I eat.
Particularly avoid foods with a high carbohydrate content
(e.g., bread, rice, potatoes, etc.).
Feel that others would prefer if I ate more.
7.
8.
9.
Vomit after I have eaten.
10.
Feel extremely guilty after eating.
11.
Am preoccupied with a desire to be thinner.
12.
Think about burning up calories when I exercise.
13.
Other people think that I am too thin.
14.
Am preoccupied with the thought of having fat on my body.
15.
Take longer than others to eat my meals.
16.
Avoid foods with sugar in them.
17.
Eat diet foods.
18.
Feel that food controls my life.
19.
Display self-control around food.
20.
Feel that others pressure me to eat.
21.
Give too much time and thought to food.
22.
Feel uncomfortable after eating sweets.
23.
Engage in dieting behavior.
24.
Like my stomach to be empty.
25.
Enjoy trying new rich foods.
26.
Have the impulse to vomit after eating.
EAT – D. M. Garner and P. E. Garfinkel (1979), Toronto General Hospital, Toronto, Canada.
Scoring Instructions: Sum the responses to each item to arrive at a total score. “Always” = 3; “Usually” = 2; “Often” = 1;
“Sometimes,” “Rarely,” and “Never” = 0 except for item 25 where the scoring is reversed. Items loading on Factor I (Dieting) are 1,
6, 7, 10, 11, 12, 14, 16, 17, 22, 23, 24, and 25. Items loading on Factor II (Bulimia and Food Preoccupation) are 3, 4, 9, 18, 21, and
26. Items loading on Factor III (Oral Control) are 2, 5, 8, 13, 15, and 20.
69
CRITERIA FOR INPATIENT TREATMENT FOR EATING DISORDERS
1.
Significant medical difficulties resulting from low body weight. DSM-IIIR
criteria for anorexia nervosa is weight loss of 15% less then expected body
weight. Anorexics who are hospitalized for the first time are on the average
25 – 30% below expected body weight.
Example:
Women of 18 y/o who are 5’5” and medium body frame desired weight is
approximately 130 pounds
>10%
>15%
>20%
>25%
>30%
117
110.5
104
97.5
91
2.
Significant medical difficulties from persistent self-induced vomiting, laxative use
or diuretic abuse.
3.
Significant suicidal risk or demonstrated inability to provide self-care.
4.
Inability of family or current living arrangements to provide an adequate
psychological environment for improvement to occur.
5.
Hospitalize to facilitate a complex differential diagnosis.
6.
The binge-purge cycle needs to be interrupted.
7.
Addiction to diet pills or laxatives and the person can not abstain from usage on
an outpatient basis.
8.
Individual reports feeling “out of control” or feels she is “going crazy” and wants
a safe, structured environment.
9.
Lack of improvement in outpatient treatment; therapeutic stalemate.
R.E. Simmons
SIU Counseling Center
6/27/89
70
NORMAL EATING
“I submit that the normal eating pattern for women is a different pattern. Consider the
following women, each of whose example contains a strategy for both denial of appetite
and manipulation of appearance.”
1) Susan keeps a list of every calorie she eats, and exercises every day. If she goes over
her allotted calories, she is unhappy and berates herself. She immediately worries about
how much weight she has gained from the one transgression, but never weighs herself.
Susan, in her mid-thirties and a professor at a major university, is in many ways
extremely competent and effective woman.
2) Jane has a different strategy. She eats nothing until 5:00 p.m. At that time, she allows
herself to eat a large meal. She maintains her average weight this way. Jane is a woman
in her mid-fifties who has raised a family, worked in a paraprofessional capacity, and has
now returned to school for an advanced degree. She is a talented artist.
3) Andrea has yet another strategy. She allows herself a different food each day,
something she is really craving. To maintain control, she eats only that one food for that
day. Sometimes she loses control and eats too much. Then she feels guilty. She also
feels too fat unless she is about ten pounds below her ideal healthy weight. She feels that
the extra weight, which settles on her hip and thigh areas, is like a burden that she carries
around and is not really part of her. She hates it and wishes it would go away, but often
does not have the will power to deny herself food.
4) Diane has recently completed a commercial diet program, in which she lost twenty
pounds. Her lover often complained of her excess weight in the stomach and hip areas
and let her know that he was attracted to slim, young women. After Diane lost the
weight, he left her for one of these women. Diane is in her late forties, as is her former
lover. His new partner is nineteen. Diane struggles to maintain her new weight, has
bought a new wardrobe of stylish clothes, and is actively dating. She feels much more
attractive and desirable than she did with the “extra” twenty pounds. She hopes to be
able to compete for men and find a new man.
5) Theresa, in her late twenties, has a thin and shapely figure that is often admired by
others. She wears form-fitting clothes and bikinis in the summer to show off. However,
she feel that her breasts sag and, although this is not apparent when she is clothed, it
bothers her enough that she is considering plastics surgery to “correct” the problem. Her
husband supports this plan, although he does not comment on her “defect”.
71
DYSSOMNIAS
307.42 PRIMARY INSOMNIA – Problems initiating or
maintaining sleep for at least 1 month.
307.44 PRIMARY HYPERSOMNIA – Excessive
sleepiness for at least 1 month.
347 NARCOLESPY – Attacks of sleep that occur every
day for at least 3 months + One or both of the following –
1. Cataplexy – loss of muscle tone
2. Intrusion of REM into the transition between sleep
and wakefulness.
780.59 BREATHING RELATED SLEEP DISORDER
- Disruption of sleep due to breathing problems
ie) sleep apnea or another medical condition
72
PARASOMNIAS – Abnormal behavioral or
physiological events related to sleep.
307.6 SLEEP TERROR DISORDER
A. Abrupt awakening from sleep (scream)
B. Intense fear
C. Difficult to comfort
D. Amnesia about episode
307.46 SLEEPWALKING DISORDER
A. Walks during sleep
B. Unresponsive
C. Amnesia about episode
73
Medications used to treat Sleep Disorders
Benzodiazepines
Flurazepam – Dalman
Temezepam – Restoril
Triazolam – Halcion
Estazolam – Prosom
Quazepam – Doral
Non-benzodiazepine
Zolpidem – Ambien
Zaleplon – Sonata
Adapted from: Gorman, J.M (1997). The Essential Guide to Psychiatric Drugs. St.
Martins Griffin: New York
74
V CODES
1. DOESN’T MEET CRITERIA FOR MENTAL
DISORDER
2. MAY HAVE UNRELATED MENTAL DIS.
3. MAY HAVE ADDITIONAL DIAGNOSIS
Psychological factors affecting medical condition.
Relational Problems
Problems related to abuse or neglect
Bereavement
Occupational
Identify
Acculturation
Noncompliance w/ trt.
Academic
Religious or Spiritual
Phase of life
Malingering
75
MENTAL RETARDATION – CODED ON AXIS II
CODE NUMBER: DEPENDS ON SEVERITY
A. IQ less than 70
B. At least 2 functioning areas affected
C. Before age 18
317 MILD MR – IQ: 50-55 TO 70
6th GRADE
318 MODERATE MR – IQ: 35-40 TO 50-55 2ND GR
318.1 SEVERE MR – IQ: 20-25 TO 35-40
318.2 PROFOUND MR – IQ: BELOW 20-25
319 MR – SEVERITY UNSPECIFIED – CAN’T TEST
CAUSES
GENETIC – 5%
EARLY PREGNANCY FACTORS – 30%
LATER PREGNANCY FACTORS – 10%
ACQUIRED CHILDHOOD PHYSICAL COND. – 5%
ENVIRONMENTAL INFLUENCES – 20%
UNKNOWN – 30%
76
ADJUSTMENT DISORDERS
A. Emotional response within 3 months of the stress.
B. Symptoms of either of the following
1) Distress
2) Impairment in social or job
C. Not part of another diagnosis
D. Not bereavement unless it is in excess of what
would be expected or prolonged.
E. Once the stressor is gone, the symptoms do not
Persist for more than an additional 6 months.
ACUTE: If the disturbance lasts less than 6 months.
CHRONIC: If the disturbance last 6 months +.
CODE BASED ON SUBTYPE:
309.0 WITH DEPRESSED MOOD
309.24 WITH ANXIETY
309.28 WITH MIXED ANXIETY AND
DEPRESSED
309.3 WITH DISTURBANCE OF CONDUCT
309.4 WITH MIXED DISTURBANCE OF
EMOTIONS AND CONDUCT
309.9 UNSPECIFIED
AXIS IV – List the stressors
77
ATTENTION-DEFICIT/HYPERACTIVITY DIS.
A. EITHER 1 OR 2
1) INATTENTION: 6+ FOR 6 MONTHS
a. Careless and inattention to detail
b. Difficulty paying attention in play
c. Does not seem to listen
d. Does not follow directions
e. Difficulty with organization
f. Avoids difficult tasks
g. Loses things
h. Easily distracted
i. Forgetful
2) HYPERACTIVITY-IMPULSIVITY-6+, 6
MO.
HYPERACTIVITY
a. Fidgets
b. Leaves seat in class
c. Runs and climbs excessively
d. Difficulty playing quietly
e. On the go
f. Talks excessively
IMPULSIVITYg. Blurts out answers before question
h. Difficulty waiting turn
i. Interrupts or intrudes on others conversations
78
ADHD (cont.)
B. Some symptoms present before age 7
C. 2 or more settings
D. Impairment in functioning
CODE BASED ON TYPE:
314.01 ADHD-COMBINED TYPE:
6+ Symptoms in each area:
1) Inattention & 2) Hyperactivity-Impulsivity
314.00 ADHD-PREDOMINANTLY
INATTENTION
Meets criteria for Inattention but not Hyp.Imp.
314.01 ADHD-PREDOMINANTLY
HYPER.IMPUL.
Meets criteria for Hyp.Imp. but not Inattention
* Difficult to diagnose before age 4 or 5.
* Symptoms may subside during engaging activities
and worsen during settings that require attention
* More frequent in Males than Females 4:1
79
How is attention-deficit/hyperactive disorder treated?
Behavior therapy and the use of medications have been shown to be
effective treatments for ADHD. The use of stimulant medications
such as Cylert (pemoline), Dexedrine (dextroamphetamine), or
Ritalin (methylphenidate) have become the treatment of choice
throughout much of the country.
If the person with ADHD is a child, behavior therapy involving the
child and his/her parents is frequently helpful. Behavior therapy can
be conducted alone or can be combined with medication therapy.
The therapist’s consultation with the child’s teacher(s) is a very
important element of the treatment.
What happens to someone with attention-deficit/hyperactive
disorder?
Children with ADHD often continue to show symptoms of
inattention and impulsivity into their adolescence and early adulthood. Children and adolescents with ADHD frequently struggle with
low self-esteem.
What can people do if they need help?
If you, a friend, or a family member would like more information and
you have a therapist or a physician, please discuss your concerns with
that person.
_____________________________________________________
Developed by John L. Miller, M.D., P.S.
Reviewed 7/2000
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312.8 CONDUCT DISORDER
A. Behavior where rights of others are violated.
+ 3 or more during last 12 mo. and 1 in last 6 mo.
* Aggression to people or animals
* Destruction of property
* Deceitfulness or theft
* Serious violations of rules
B. Causes Impairment
C. If over 18, consider Antisocial P.D. – Axis II
Specify Subtype –
Specify Severity –
Childhood – Onset – before age 10
Adol- Onset – Absence before 10
Mild – Few or minor symptoms
Moderate – Intermediate Number
Severe – Many symptoms – excess
313.81 OPPOSITIONAL DEFIANT DISORDER
A. Negative, hostile, defiant behavior – 6 mo + 4
* temper
* argues with adults
* defies rules
* deliberately annoys people
* blames others
* easily annoyed
* angry
* spiteful or vindictive
B. Impairment
C & D. Rule out Psychotic, Mood And Conduct Dis.
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THE MENTAL STATUS EXAMINATION IN PSYCHIATRY
I. General Description
A. Appearance
1.
Dress and grooming
2.
Physical characteristics
3.
Posture and gait
B. Attitude and interpersonal style
C. Behavior and psychomotor activity
D.
Speech and language
1.
Rate
2.
Clarity, pitch, volume, tone, quality
3.
Abnormalities
II. Emotions
A.
Mood
B.
Affect
C.
Neurovegetative signs of depression
III. Cognitive Functioning
A.
Orientation and level of consciousness
B.
Attention and concentration
C.
Memory
1.
Immediate registration, retention, and recall
(a minute or less)
2.
Recent memory (a minute to days or weeks)
3.
Remote memory (weeks to years)
D. Ability to abstract and generalize
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E.
Information and intelligence
1. Fund of knowledge
2. Estimate of intelligence
IV. Thought and perception
A.
Disordered perceptions
1. Illusions
2. Hallucinations
3. Depersonalization and derealization
B.
Thought content
1. Distortions
2. Delusions
3. Ideas of reference
4. Magical thinking
C.
Thought process
1. Flow of ideas
2. Quality of associations
D.
Preoccupations
1. Somatic
2. Obsessions and compulsions
3. Phobias
V. Suicidality, Homicidality, and Impulse Control
VI. Insight and Judgment
VII. Reliability
This is just one possible format which may be useful.
From: LaBruzza, A. L. & Mendez-Villarrubia, J. M. (1994).
Using DSM-IV: A clinician’s guide to psychiatric diagnosis.
Northvale, N. J: Jason Aronson Inc.
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THE MINI-MENTAL STATE EXAMINATION
Adapted from M.F. Folstein and colleagues (1975).
ORIENTATION
A. (5 points) What is the (year) (season) (date) (day of the week) (month)?
B. (5 points) Where are we (country) (state) (city or town) (hospital) (floor of the
building)?
REGISTRATION
C. (3 points) The examiner names three unrelated objects, taking one second to say
each. The client is asked to repeat all three objects after the examiner has
said them. Give one point for each correct answer. Repeat the objects
until the client learns all three. Record the number of trials.
ATTENTION AND CALCULATION
D. (5 points) Serials 7’s. One point for each correct answer. Stop after five answers.
Alternatively, have the patient spell the word “WORLD’ backwards,
giving one point for each correct letter.
RECALL
E. (3 points)
Ask the client to recall the three objects learned in item C.
LANGUAGE
F. (2 points)
The client is shown a pencil and a watch and is asked to name each one.
G. (1 point)
Ask the client to repeat, “No ifs, ands, or buts.” Listen for dysarthria.
(Difficulty in speech production related to anatomical or coordination
deficit).
H. (3 points) The client is handed a sheet of paper and given a three-stage command:
“Take this paper in your right hand, fold it in half, and put it on the floor.”
I. (1 point)
Show the client a sign which reads “Close your eyes,” and ask the client to
follow the command.
J. (1 point)
Ask the client to write a sentence.
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VISUAL-MOTOR INTEGRITY
K. (1 Point) The client is asked to copy a Bender-Gestalt figure.
INTERPRETATION: Scores range from 0 to 30. According to Folstein, a score of less
than or equal to 23 points in a person with at least nine years of education is evidence of
cognitive impairment. False positive results often occur in persons with fewer than nine
years of education.