Assessment and Intervention for High Prevalence Disorders

Question 1

What are some findings from the 2007 National Survey of Mental Health and Wellbeing?

Answer 1

• 45% of Australians aged 16 to 85 years will experience a mental disorder at some time in their life.
• 1.9 million Australians had accessed services for mental health problems in the 12 months prior to the survey.
• 20% had experienced a common mental disorder in the last year.

1. Anxiety disorders were most prevalent (14% );
   
   • The most common anxiety disorders were PTSD (6%)
   • Social phobia (5%).
2. Affective disorders (6%);
   
   • Depression most common (4%),
3. Substance use disorders (5%)
   
   • Harmful use of alcohol was most common (3%).

Question 2

What is the difference between the DSM and ICD?

Answer 2

Question 3

What is the ICD?

Answer 3

• The International Classification of Diseases (published by the world health organisation
• Generic to all diseases not just psychological
• Published in two parts;
  
  • Clinical; Descriptions and diagnostic guidelines, separated into categories like the DSM. Doesn’t include number of symptoms for diagnosis
  • Research; diagnostic criteria for researching disorders
• Most government research and grants refers to the ICD not the DSM (eg Australian NSMHWB)

Question 4

What are the six goals in a clinical interview for a depression diagnosis?

Answer 4

1. Identify the presenting problem/s (in terms of duration, frequency and intensity as well as other possible symptoms),
2. Take a history of past clinical concerns or episodes,
3. Gather any context for the presenting problem/s (e.g., consider the biopsychosocial factors),
4. Gather additional information from informants if permitted to do so by the client (e.g., family members, caregiver, teachers, school counsellor, GP, social workers, nurses and other health care providers),
5. Identify the client’s strengths and weaknesses
6. Conduct a Mental State Exam (MSE).

Question 5

What are the typical MSE symptoms for Depression?

Answer 5

• Appearance: Unkempt, poor self-care, stooped posturing, depressed facial expression with down-turned corners of mouth.
• Behaviour: Psychomotor retardation, limited or poor eye contact, reduced spontaneous movement, sometimes tearful.
• Mood: Low, depressed, irritable, often with disturbed sleep and appetite.
• Affect: Sad, teary, may be of restricted range, not responding to positives.
• Speech:Poverty, reduced rate, volume and tone, hesitant, lack of spontaneity but coherent.
• Thought: Pessimistic, worthlessness, hopelessness, helplessness, themes of guilt, low self-esteem, suicidal ideation
• Perception: Reduced intensity of normal perceptions
• Cognition: Impaired or poor concentration, indecisive, forgetful
• Insight: Intact, aware of problems and difficulties, preserved insight

Question 6

What is the reccomended method of diagnosis for depression?

Answer 6

• The gold standard method of assessment is the structured clinical interview
  
  • Conversationally seek information from the client about mood, behaviour, cognition, and functional impairment
• SCID-5
  
  • A semi-structured, licensed assessment tool
• The clinical interview can furthermore incorporate either performance-based or self-report personality testing
  
  • Enriches the symptom understanding and fosters a relationship

Question 7

What are some symptomatic differences between depression and grief?

Answer 7

• Mood/affect:
  
  • Grief = loss, emptiness with occasional positive feelings
  • Depression = pervasive anhedonia
• Time/Course
  
  • Grief = occurs in waves, lessens over time
  • Depression = more steady and persistent
• Cognition
  
  • Grief = focused on thoughts of loved one
  • Depression = Non-specific, self critical, pessimistic rumination
• Self Esteem
  
  • Grief = Generally perseved, regret based ‘should have visited more’
  • Depression = worthlessness, self-loathing
• Thoughts of Death/Suicide
  
  • Grief = joining loved one
  • Depression = worthlessness, incapable of going on

Question 8

What are some similar affective diagnosis to Major Depressive Disorder?

Answer 8

• Persistent Depressive Disorder (Dysthymia): 3+ symptoms for 2+ years
• Premenstral Dysphoric Disorder: Within final week before period, ends quickly after period
• Depression due to substance, medical, differential diagnosis
• Berevement:
  
  • In DSM4; exlusion criteria for depression within 2 months of death of loved one. This was removed in DSM5
  • Debate: Arbitrary time frame for exclusion, no real differences except trigger, however grief induced is less indicative of psychopathology
  • DSM5 emphasises differentiation of Grief and Depression

Question 9

What areas and considerations are typically addressed in a risk assessment?

Answer 9

1. Current Mental State: Suicidal ideation, suicidal behaviour, lack of judgement/insight, recent changes, presence of depression, mania, drugs etc
2. Current circumstances and adverse events; Lack of social support and isolated etc, Significant losses, Significant conflict and arguments, Significant shame and guilt
3. History of suicidality/homicidality; Lethality/seriousness of past attempts, means used, Context? Alcohol/drugs involved – dependency?
4. Future; Are contributing factors likely to persist? Are they changeable? What is the degree of hopelessness? What has kept them alive in the past? What is keeping them alive now?
5. Listening and understanding the clients perspective; The paradox: natural instinct is to live, yet living is painful, Look out for opportunities for intervention, What’s painful? What’s holding back the wish to live?

Question 10

Outline the four areas that contribute to anxiety as a full body response

Answer 10

• Physical
  
  • Cardiovascular: flushing, palpitations, chest pain, etc
  • Respiratory: fast, shallow breathing, out of breath, hyperventilation, etc.
  • Gastrointestinal: nausea, cramps, gagging, etc.
  • Muscular: aches and pains, muscle tension, tremor, shaking
  • Neurological: sweating, tingling, ligh-headedness, dizziness, or numbness
• Cognitive
  
  • Racing thoughts, worries, preoccupations, often future oriented
  • Short attention span, confused, difficulty remembering
• Emotional
  
  • Fear, scared, anxious, distressed etc
• Behavioural
  
  • Safety behaviours (e.g., avoid feared situation)

Question 11

What common themes should psychologists note when assessing anxiety?

Answer 11

• Physical Symptoms: can vary from person to person
  
  • Helpful to identify for intervention purposes (breathing exercises)
• Preoccupation and patterns of thinking:
  
  • Focused preoccupation, Black-and-white, catastrophizing, etc
  • Can be a direct target for intervention
• Personality, general beliefs & cognitive schema
  
  • Perfectionism, unrelenting standards, vulnerability schemas
• Avoidance and safety behaviours;
  
  • can perpetuate anxiety via reinforcing that the fear or anxiety is real, reducing self-efficacy, perpetuating false beliefs that can interfere with treatment, perpetuating false beliefs that can interfere with life in general.
  • Assess and understand avoidance behaviour to facilitate intervention,
    
    • what is avoided, how often, and under what circumstances.
    • Elicit concrete examples.

Question 12

What is the purpose of cross-cutting system measures?

Answer 12

• 50% MDD diagnoses have cormorbid anxiety
  
  • Correlations strong even when controlling for overlapping systems
• Tripartite Model; MDD and anxiety share NA but differ on PA and PH
  
  • NA = negative affect
  • PA = positive affect (low in D)
  • PH = physical hyperarousal (high in A)
• Measures that assess multiple systems allow for dimensional diagnosis (DSM5)
  
  • some symptoms are important for treatment but don’t fit into diagnostic criteria
  • designed to be brief, sensitive to change
• Level 1; Symptom detecting for further query
  
  • Assesses broad range of symptoms (13 domains for adults) over the last 2 weeks
  • Used as a threshold basis for Level 2 assessment (with some exceptions for domains such as suicidal ideation)

Question 13

What are ‘culture bound syndromes’? Give some examples

Answer 13

• Culture bound syndromes are idioms that cause distress and are considered mental illnesses in only some non-Western cultures.
  
  • DSM-5 added the Cultural Framework Formulation and Interview
  • The DSM and ICD have different lists
• Examples
  
  • Dhat Syndrome (India); in both
  • Windego (Indigenous North America; ICD
  • Shenjing shuairuo (Chinese); DSM

Question 14

What are the steps in developing a case formulation in CBT?

Answer 14

• Creation of a problem list; list of psychological, financial, social and occupational problems
  
  • Prioritise, consider inter-relatedness, intervention requirements
• Building a “here and now” understanding of the problems
  
  • Analyse the ABCs of the problems
  • Identify associated thoughts/ behaviours/ emotions etc
• Understand the cognitions underlying the problem
  
  • 3 Levels of cognition; 1. Core Beliefs, 2. Intermediate Beliefs 3. Automatic thoughts
• Making a plan/Goal setting: Collaboratively make goals that are
  
  • Achievable
  • Attainable
  • Behaviourally specific
  • Focused on the client (not others)

Question 15

What are the nine steps when conducting a suicide risk interview?

Answer 15

1. Initial Inquiry; if idea is accepted by client continue on
2. Death Wish; When have you thought this
3. Ideation; rumination, control over thoughts
4. Affects and behaviours; hopelessness, impulsiveness and context
5. Motivation; why are you feeling this way, under what conditions, what effects would this have
6. Deterents/Demotivators; What reasons to continue on, negative outcomes
7. Threats/Gestures/Attempts; Past attempts and context, consequences
8. Preparations; have you written a will etc
9. Plans/Means/method; practicality, lethality and opportunity

Question 16

According to Jones what 13 factors should be addressed in an unstructured clinical interview?

Answer 16

1. Identifying Information (age, sex) = Clues to diagnosis
2. Presenting Problem/Chief Complaint
3. History of Presenting Problem; Onset severity and stressors
4. Family History;
5. Relationship History; interpersonal functioning and level of current support
6. Developmental History; psychosocial risk factors
7. Educational History; problems linked to illness
8. Work History; Level of dysfunction
9. Medical History; potential cause of symptoms
10. Substance Use; causal or coping
11. Legal History; aggression, mania, addiction
12. Previous Counselling; current application
13. MSE