Clinical Comp Exam Flashcards
When taking the California clinical comp exam, what are the four areas of priority to consider before answering the question?
1) Safety
2) ethics
3) culture
4) intervention
The three clinical core concepts are:
(1) therapy emphasizes _______ over content
(2) therapy creates/facilitates a _____________
(3) therapy must have client _______ specificity
process
corrective emotional experience
response
a symptom or problem that is offered by a client or a patient as the reason for seeking treatment. In psychotherapy, for example, a client may present with depression, anxiety, panic, anger, chronic pain, or family or marital problems; such symptoms may become the focus of treatment or may represent a different, underlying problem that is not recognized or regarded by the client as requiring help
Presenting Problem
The ___________ isn’t just the person - even if only a single person is interviewed - it is the set of relationships in which the person is embedded
unit of treatment
Five stages of change are:
1) Pre-contemplation
2) Contemplation
3) Preparation
4) Action
5) Maintenance
Stage of Change - client denies the problem, therefore no need for change [raise client’s awareness towards the urgency of the issues and the pain/fear that issue may cause, suggest change could be possible]
1) Pre-contemplation
Stage of Change - client displays ambivalence and experiences the pros and cons about making the change, they are aware of the problem but not ready for change [explore both sides of ambivalence, validate and help client identify the barriers to change and the strengths that will make change possible]
2) Contemplation
Stage of Change - client is gathering information and preparing for action, not quite ready to take action yet, learning about what might need to happen if change were to occur, taking small steps related to change and thinking about possible goals [goal setting]
(3) preparation
Stage of Change - client is making change already, may move into stage while in therapy, able to make changes without seeking help [support client gains and help with setbacks]
(4) action
Stage of Change - client has achieved goal and is ready to move out of therapy [plan for ways to cope with temptations to fall back into old patterns, relapse preparation, planning for ways to reward success]
(5) maintenance
All factors of assessment (intake, psychosocial stressors, DSM criteria, developmental stages), _______________, and impact on the therapeutic process.
cultural and spiritual diversity
SCAGSO → Cultural Diversity acronym
Socioeconomic status
Culture (ethnicity and race)
Age
Gender (sex roles and orientation)
Spiritual values
Other (profession, psychological profile)
___________ refers to all identities that make up an individual (Race, Sex, Gender, Ethnicity, Sexual Orientation, Religious/Spiritual Views, etc.).
Cultural competency
Erikson Stage 1
Trust vs mistrust → 0 - 1 ½
Is the world a safe place? Can I trust?
Leads to virtue of HOPE
Erikson Stage 2
autonomy vs shame → 1 ½ - 3
Is it ok to be me? Self control without loss of self-esteem
Leads to virtue of WILL
Erikson Stage 3
initiative vs guilt → 3 - 5
Is it okay for me to do, move, act? Children assert themselves more frequently, interact with other children, plan activities, make up games, initiate activities involving others
Virtue of PURPOSE
Erikson Stage 4
industry vs inferiority → 5 - 12
Can I make it in this world? Capable of completing increasingly complex tasks, seeks more approval for accomplishments
Leads to virtue of COMPETENCE
Erikson Stage 5
identity vs role confusion → 12 - 18 (adolescence)
Who am I? Ability to relate to others and form genuine relationships, learn roles they will occupy as an adult, sexual and occupational identities, goal is reintegrated sense of self and identity
Leads to virtue of FIDELITY
Erikson Stage 6
Intimacy vs isolation → 18 - 40 (adulthood)
Will I be loved or alone? Romantic relationships, companionship, marriage, starting a family, isolation means avoiding commitment, intimacy or fearing relationships
Leads to virtue of LOVE
Erikson Stage 7
generativity vs stagnation → 40 - 65
We give back to society, raising children, being productive at work, becoming involved in community, by failing - we feel stagnant and unproductive
Leads to virtue of CARE
Erikson Stage 8
ego integrity vs despair → 65 +
Ego integrity - feeling of being whole, not scattered, comfortable with oneself, development of wisdom and integrity, success and satisfaction, despair - aspects of the present that cause unremitting pain and inescapable death
Leads to virtue of WISDOM
Piaget Developmental Stages - simple reflexes, reflexive movements, primary circular reactions, secondary circular reactions, coordination of secondary reactions, tertiary circular reactions, internalization of schemas
Sensorimotor (birth - 2 years)
Piaget Developmental Stages - symbolic function, egocentric thinking diminishes, precausal reasoning, magical thinking, irreversibility, inability to conserve, animism centration
Preoperational (2 - 7 years)
Piaget Developmental Stages - ability to reason logically about direct experiences and perceptions, can solve concrete problems, understand relationships such as size, cognizant of others viewpoints “stop and think before you ask”, skills (seriation, classification, decentering, reversibility, achieving conservation)
Concrete operational (7 - 11 years)
Piaget Developmental Stages - concrete operations are carried out on things where formal operations are carried out on ideas, use rational and critical thinking not so concrete, less reliance on concrete and can work things out in own mind, third eye problem
Formal operational (12 - 18 years)
Family Life Cycle Stages:
Single adult
Marriage
Family with young children
Family with adolescent children
Launching children
Later life
Family Life Cycle Stage - Financial resources, Separation/individuation (mode of communicating with family-of-origin, Autonomy/responsibility, Skills/life goals, Gender identity/rules concerning privacy, Health issues (substance use, nutrition, AIDS, etc), Family history (abuse, substance use, separation from their families, etc.), Unresolved past issues affecting current relationships
Between families (single person – late teen – early 20’s)
Family Life Cycle Stage - Goals/values (financial, educational, social, children, etc.), Communication skills/conflict resolution (general/sexual), Cross-cultural differences, Role/gender issues; areas of responsibility, Development of family rituals/traditions, Family of origin issues, Unfinished business with other relationships, Negotiation – what is couple vs. individual domain; appropriate boundaries, Scheduling couple time/recreation, Chemical abuse
Marriage (young couple)
Family Life Cycle Stage - Balancing of child care/work responsibilities, Parenting responsibilities/values/expectations, Discipline/abuse, Communication/conflict resolution/stress management, Appropriate/inappropriate expectations (marital, children, work, etc.), Family of origin issues/role of grandparents/closeness or distance, Development of children (generic/idiosyncratic – special needs child), Child as carrier of family symptoms?, Scheduling – family time, couple time, alone time, vacations
Family with Young Children
Family Life Cycle Stage - Sibling interactions, Roles taken by different children in family (how evolved/how dealt with), Diversity of skills/interests/values – how does family handle?, Parental expectations re: kids’ increasing responsibilities, Parental responsibility for their aging parents, Parental values re: education; appropriate expectations for children, School problems – appropriate level/school/assignments?, Behavior problems (symptomatic of family distress?), Health issues (family nutrition, eating patterns, substance use), Abuse/molestation, Parental role modeling (same and opposite sex)
Family with Adolescents
Family Life Cycle Stage - Family in transition (school, work, members at home, etc.), Meeting financial demands (college, care for elderly or ill family member), Mother may start new career, Mid-life issues (job/family accomplishment, health, menopause, etc.), Sexuality issues for parents/teens, Return to “couple status” – may be positive or difficult change, Grief issues/losses (grandparents, job, power, idealism, children leaving), Dealing with stress/conflict (substance use)
Launching children
Family Life Cycle Stage - Later-life issues (menopause, loss of hopes/dreams, futility, declining health, dying/death of parents, decreased income, etc.) Empty next (children gone); stuffed nest (adult children returning), Planning for retirement (need for new friends, activities, interests), Vocational/avocational/ grandparenting issues, Decline in sexual ability; increase in divorce, Need to move to smaller housing; disposing of personal belongings, Planning for eventual death of spouse/self (writing will, etc.)
Family in Later Life
Bronfenbrenner’s Ecological Systems Theory - What are the 5 systems in the wheel?
Macrosystem
Exosystem
Mesosystem
Microsystem
Individual (center)
Adverse Childhood Experiences Study (ACES) is used to assess:
Trauma
Trauma Informed Care (TIC) includes:
Realizing the _________ of trauma
Recognizing the _________
Responding through policies, procedures, and practices
Resisting re-traumatization
impact
signs and symptoms
The ________ impact of trauma can be: Denial, Anger, Fear, Sadness, Shame, Confusion, Anxiety, Depression, Numbness, Guilt, Hopelessness, Irritability, Difficulty Concentrating
Emotional/Psychological
The ________ impact of trauma can be: headaches. digestive symptoms. Fatigue, racing heart, sweating, feeling jumpy, hyperarousal
Physical
The five stages of grief are:
denial, anger, depression, bargaining, and acceptance (not linear)
_____________ → a future oriented mood state in which one is ready or prepared to attempt to cope with upcoming negative events
Anxiety Disorders
Anxiety Disorder: (A) consistent failure to speak in social situations where there is an expectation for speaking (like school), despite speaking in other situations (B) disturbance interferes with educational or occupational achievement or with social communication (C) duration: least 1 month (D) high anxiety (E) uncommon (F) childhood (2-4 years old)
Selective mutism (F94.0) (child only)
Anxiety Disorder: developmentally inappropriate and excessive fear or anxiety concerning separation from person(s) their attached to // child or adult // recurrent excessive distress in anticipating or experiencing separation // persistent and excessive worry about losing them or serious harm or illness // worry about experiencing untoward event // reluctance or refusal to go out // 4 weeks in children 6 months in adults
Separation anxiety disorder (F93.0)
Anxiety Disorder: (A) persistent fear of object or situation (B) exposure to phobic situation evokes immediate anxiety response (C) Avoid situations or endure through anxiety and distress (D) fear or anxiety out of proportion to actual threat (E) 6 months or more // Many types → animal type, natural environmental type, blood/injections type, situational type, other type
Specific phobia (F40.0)
Anxiety Disorder: (A) persistent fear of social or performance situations in which person possibly exposed to scrutiny (B) individual fears they will be embarrassing or humiliating (C) exposure to feared situation almost always provokes fear and anxiety
Social anxiety disorder (F40.10)
Anxiety Disorder: (A) recurrent unexpected panic attacks (palpitations, accelerated heart rate, sweating, trembling shaking, shortness of breath, smothering, feeling of choking, chest pain or discomfort, nausea or abdominal distress, feeling dizzy, unsteady, lightheaded, chills or heat sensation, paresthesia (tingling or numbness), derealization or depersonalization, fear of losing control or going crazy, fear of dying) (B) at least one attack has been followed by a month of 1 or both → persistent concern about having additional attacks or its consequences // a significant maladaptive change in behavior related to the attacks (C) not due to substance or medication (D) not accounted for by another mental disorder [important to consider concurrent mood disorder]
Panic disorder (F41.0)
Anxiety Disorder: (A) anxiety of fear about 2 of the 5 ( 1 using public transportation 2 being in open spaces 3 being in enclosed spaces 4 standing in line or being crowded 5 being outside of the home alone ) (B) situations almost always provoke fear and anxiety (C) situations are actively avoided (D) fear or anxiety disproportionate to danger (E) fear escaping would be difficult or help wouldn’t be available (F) persistent for 6 months or more
Agoraphobia (F40.0)
Anxiety Disorder: (A) excessive anxiety or worry, occurring more days than not for 6 months or more about a number of events or activities (B) person finds it difficult to control the worry (C) anxiety and worry is associated with 3 or more of the following ( 1 restless of feeling keyed up or on edge 2 being easily fatigued 3 difficulty concentrating or mind going blank 4 irritability 5 muscle tension 6 sleep disturbance ) (D) the anxiety, worry, or physical symptoms are causing clinically significant distress or impairment in functioning (E) disturbance not due to substance or medication
Generalized anxiety disorder (F41.1)
Anxiety Disorder: common substances: marijuana, amphetamines, caffeine // evidence from history, physical examination, or laboratory findings (1) symptoms developed during or soon after substance intoxication or withdrawal or after exposure to medication (2) involved substance/medication is capable of producing symptoms
Substance/medication-induced anxiety disorder
Anxiety Disorder: examples: hyperthyroidism, hypothyroidism, seizure disorders, cardiopulmonary conditions // evidence from history, physical examination, or laboratory findings that disturbance is the direct pathophysiological consequence of another medical condition
Due to another medical condition
_________________ → emotion (affect) gives richness and meaning to our world and depth and scope of the human experience. When affect becomes inappropriately extreme, it can become a source of overwhelming psychological distress
Mood Disorders (BPD & MDD)
Mood Disorders: manic episode criteria: (A) distinct period of abnormally and persistently elevated, expansive, or irritable mood (at least 1 week or any duration of hospitalization occurs) (B) during the period of mood disturbance 3 of the following symptoms have persisted (4 if only irritable mood) → inflated self-esteem or grandiosity, decreased need for sleep, more talkative than usual or pressure to keep talking, flight of ideas or racing thoughts, distractibility, increase in goal-directed activity or psychomotor agitation, excessive involvement in pleasurable activities that have potential for painful consequences // people w/ bipolar depression often stayed depressed longer, relapse more frequently, display more depressive symptoms, show more severe symptoms, have more delusions, hallucinations, commit more suicides, require more hospitalizations.
Bipolar and Related Disorders
Mood Disorder: Diagnostic Criteria: (A) the presence of a manic episode currently or most recently (B) manic episode is not better accounted for by schizoaffective disorder (patient may or may not have history of a MDE or Hypomanic episode)
Bipolar I disorder
Mood Disorder: Diagnostic criteria: (A) presence or history of one or more MDE’s (B) presence or history of at least one hypomanic episode (C) there has never been a manic or mixed episode (D) mood symptoms not accounted for in schizoaffective, schizophrenia, or another psychotic disorder (E) symptoms cause clinically significant distress or impairment // major genetic components for inheriting BPD // onset occurs averagely in mid 20s, women experience more depressive episodes than man which leads to BPD II diagnosis
Bipolar II disorder
Mood Disorder: (A) for at least 2 years (1 year for child/adolescents) have experienced numerous periods with hypomanic symptoms that do not meet criteria for hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for MDE (B) during 2 year period the hypomanic and depressive periods have been present for at least half the time and the individual has not been without symptoms for more than 2 months at a time (C) criteria for major depressive, manic, or hypomanic episode have never been met (D) symptoms in A are not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified psychotic disorder (E) symptoms not due to effects of substance or other medical condition (F) symptoms cause clinically significant distress or impairment in important areas of functioning.
Cyclothymic disorder (F34.0)
Mood Disorder: evidence from history, physical examination, or laboratory findings (1) symptoms developed during or soon after substance intoxication or withdrawal or after exposure to medication (2) involved substance/medication is capable of producing symptoms
Due to substance-induced or another medical condition
Mood Disorder: evidence from history, physical examination, or laboratory findings that disturbance is the direct pathophysiological consequence of another medical condition
Unspecified bipolar and related disorder
Depressive Disorders: depressed mood or anhedonia (inability to feel pleasure) // biological or vegetative signs or symptoms (appetite loss, unintentional weight gain or loss, sleep disturbance, change in energy, psychomotor retardation or agitation, diminished libido) (diurnal mood variation: person feels worse in the morning and a little better at night) // they see the world through gray-tinted lenses // ruminates over personal failures (real or imagined) // the happiness of everyday life comes and goes but the dysphoria of MDD never leaves // Diagnostic criteria (A) presence of a major depressive episode (B) episode not better accounted by schizoaffective, schizophrenia or any other mental disorder (C) never been manic, mixed or hypomanic episode // genetic and environmental or learned components // greater association with family history of depression or mood disorders // leading cause of disability in US // early onset before age 20 // increases risk of heart attack, and complicating factor for stroke, diabetes, and cancer // pathways to depression → learned helplessness, loss and separation, stress, cognitive distortions, interpersonal PT of depression,
Major depressive disorder
Depressive Disorders: (A) severe recurrent temper outbursts verbally and/or behaviorally that are out of proportion of intensity or duration to the situation (B) temper outbursts inconsistent with age (C) occur, on average 3x per week (D) mood between outbursts is irritable or angry most of the day nearly everyday and is noticeable by others (E) Criteria A-D have been present for 12 months, during time person has not been without symptoms for more than 3 months at a time (F) the criteria are present in at least 2 of 3 (home, school, with peers) and are severe in at least 1 (G) diagnosis should not be made for the first time before age 6 or after age 18 (H) by history or observation onset of symptoms is before age 10
Disruptive mood dysregulation disorder (F34.8)
Depressive Disorders: 5 or more of the following symptoms present during the same 2 week period and is different than previous functioning: at least 1 symptom is either depressed mood or loss of interest or pleasure ( 1 depressed mood most of the day 2 marked diminished interest or pleasure in almost all activities most of the day 3 significant weight loss or gain or decrease or increase in appetite 4 insomnia or hypersomnia 5 psychomotor agitation or retardation 6 fatigue or loss of energy 7 feelings of worthlessness or excessive or inappropriate guilt 8 diminished ability to think or concentrate or indecisiveness 9 recurrent thought of death or suicidal ideation )
Major depressive EPISODE disorder
Depressive Disorders: (A) depressed mood for most of the day, for most days, as indicated by self or observation of others for 2 years (B) Presence of 2 or more: poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, feelings of hopelessness (C) during 2 years (1 year for children) individual has never been without symptoms in A and B for more than 2 months (D) diagnosis of MDD present for more than 2 years (E) never been manic or hypomanic episode (F) no schizophrenia (G) no substance or medication (H) symptoms cause clinically significant distress or impairment in important areas of functioning
Persistent depressive disorder (dysthymia) (F34.1)
Depressive Disorders: (A) in majority of menstrual cycles at least 5 symptoms have been present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in week postmenses (B) 1 or more must be present: 1 marked affective lability (mood swings, feeling suddenly sad or tearful, increased sensitivity to rejection); 2 marked irritability or anger or increased interpersonal conflicts; 3 marked depressed mood, feelings of hopelessness, self-deprecating thoughts; 4 marked anxiety, tension, feelings of being keyed up or on edge (C) 1 or more of the following symptoms must be present to reach a total of 5 symptoms between criteria B and C: 1 decreased interest in usual activities; 2 subjective difficulty in concentration; 3 lethargy, easy fatigability; 4 change in appetite, overeating or specific food cravings; 5 hypersomnia or insomnia; 6 sense of being overwhelmed or out of control; 7 breast tenderness or swelling, joint or muscle pain, bloating, weight gain, physical symptoms [criteria must be met for most menstrual cycles] (D) causes clinically significant distress
Premenstrual dysphoric disorder (N94.3)
Depressive Disorders: evidence from history, physical examination, or laboratory findings (1) symptoms developed during or soon after substance intoxication or withdrawal or after exposure to medication (2) involved substance/medication is capable of producing symptoms
Substance/Medication-induced depressive disorder
Depressive Disorders: evidence from history, physical examination, or laboratory findings that disturbance is the direct pathophysiological consequence of another medical condition
Mood disorder due to another medical condition
__________: extreme reduction of intake, extreme overeating, extreme distress or concern about body weight or shape, significantly impairs physical health or psychosocial functioning
Eating Disorders
Eating Disorders: eating non nutritive, nonfood substances > 1 month, eating behavior inappropriate to developmental level of individual // in adults it can be an underlying medical condition (ex zinc or iron deficiency) // comorbid w/ autism and intellectual disability // different terms for different preferences
Pica
Eating Disorders: repeated regurgitation of food at least 1 month, food may be rechewed, re-swallowed or spit out // repeated regurgitation not due to GI or other medical condition // generally at least several times per week often daily // more common among those with intellectual disabilities // con occur across lifespan
Rumination Disorder (F98.21)
Eating Disorders: eating disturbance (ex lack of interest in food) manifested in persistent failure to meet nutritional or energy needs, as seen by 1 or more; weight loss or failure to achieve expected weight gain in children, significant nutritional deficiency, dependence on external feeding or nutritional supplements, marked interference with psychosocial functioning (inability to participate in normal school activities) // commonly develops in infancy or childhood, but may persist into adulthood
Avoidant/Restrictive Food Intake Disorder (F50.8)
Eating Disorders: Diagnostic criteria: 85% or less of expected body weight dropped, significantly low weight, less than energy needs, intense fear of gaining weight, even though underweight, disturbance in how body/weight is experienced, undue influence on self-evaluation, amenorrhea (absence of 3 menstrual cycles but controversial and criteria dropped) // specifiers of extremity and remission // long-term habit leads to thinning of the bones, brittle hair or nails, dry and yellowish skin, growth of fine hair over body // other symptoms; mild anemia, muscle weakness and loss, severe constipation, low blood pressure, slowed breathing and pulse, drop in internal body temperature, causing a person to feel cold all the time, lethargy
Anorexia Nervosa
Anorexia Nervosa __________: during current episode, has not regularly engaged in binge-eating or purging (dieting, fasting, exercising)
Restricting type (F50.01)
Anorexia Nervosa __________: person has regularly engaged in binge-eating/purging (ex self-induced vomiting, misuse of laxatives, diuretics, or enemas)
Binge eating/purging type (F50.02)
Eating Disorders: binge eating + compensatory behaviors, recurrent episodes of binge eating (larger amounts of food or sense of lack of self control), recurrent inappropriate compensatory behavior to prevent weight grain (self-induced vomiting, misuse of laxatives, diuretics, enemas, fasting, exercising), at least once a week for 3 months, self-evaluation unduly influenced by body weight and shape // other symptoms; chronically inflamed sore throat, swollen glands in neck and below jaw, worn tooth enamel and increasingly sensitive and decaying teeth due to stomach acids, gastroesophageal reflux disorder, intestinal distress and irritation from laxative abuse, kidney problems from diuretic abuse, severe dehydration from purging of fluids
Bulimia Nervosa (F50.2)
Eating Disorders: recurrent episodes of binge eating, definition of binge eating, marked distress over binge eating, binge-eating occurs at least once a week for 3 months, no use of compensatory behaviors (purging or nonpurging) as a result of binging // need 3 of the following; (1) eating much more rapidly than usual (2) eating until feeling uncomfortably full (3) eating large amounts of food when not feeling physically hungry (4) eating alone because of being embarrassed (5) feeling disgusted, depressed, or guilty for overeating
Binge-Eating Disorder (F50.8)
______________: (A) persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development by inattention and/or hyperactivity-impulsivity // 6 or more of following symptoms have persisted for 6 months that is inconsistent with developmental level and that negatively impacts directly on social and academic-occupational activities // older adolescents or adults are 5 or more required
Attention Deficit Hyperactivity Disorder
Attention Deficit Hyperactivity Disorder - 1) Symptoms of __________ → often fails to give close attention to detail or makes mistakes, has difficulty sustaining attention in tasks or activities, does not seem to listen when spoken to directly, does not follow through on instructions and fails to finish schoolwork or workplace duties, has difficulty organizing tasks and activities, avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort, loses things necessary for tasks and activities, easily distracted by extraneous stimuli, forgetful in daily activities
inattention
Attention Deficit Hyperactivity Disorder - 2) Symptoms of ____________ → fidgets with or taps hands and feet, or squirms in seat, leaves seat in situations when remaining in seat is expected, runs and climbs in situations when it is inappropriate (adolescents or adults may feel restlessness), unable to play or engage in leisure activities quietly, “on the go” acting as if “driven by a motor”, talks excessively, blurts out answers before question has completed, difficulty waiting their turn, interrupts or intrudes on others
hyperactivity
____________: (B) several inattentive or hyperactive-impulsive symptoms were present prior to age 12 (C) several symptoms present in 2 or more settings (home, school, work, with friends or relatives, other activities) (D) clear evidence that symptoms interfere with or reduce quality of social, academic, or occupational functioning (E) symptoms not due to another mental disorder or substance induced
Attention Deficit Hyperactivity Disorder
Disruptive, Impulse Control, and Conduct Disorders - _________________: (A) pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting least 6 months, exhibited by least 4 symptoms and during interaction with least 1 individual who is not a sibling: (angry/irritable mood) 1 often loses temper, 2 often touchy or easily annoyed, 3 often angry and resentful; (argumentative/defiant behavior) 4 argues with authority, or for adolescents with adults, 5 actively defies or refuses to comply with requests from authority or rules, 6 deliberately annoys others, 7 blames others for their mistakes or behaviors; (vindictiveness) 8 been spiteful or vindictive at least 2x in last month (under 5 - almost everyday for 6 months) (over 5 - at least 1x week for 6 months) (B) behaviors associated with distress in individual or others (C) behaviors do not occur exclusively during course of a psychotic, substance use, depressive or bipolar disorder
Oppositional Defiant Disorder (F91.3)