Clinical Practice Flashcards
What does clinical practice seek to do?
Alleviate the internalized negative effects of environmental factors such as stress from health, vocational, family, and interpersonal problems
What is the workers role in clinical practice?
Helps individuals, couples, and families to modify attitudes, feelings, and coping behaviors that interfere with optimal social functioning
Where is clinical practice done?
Agencies or Private Practice Settings
What is assessment for in clinical practice?
Focused on the person-in-environment, with the goal of enhancing social functioning
What theoretical approaches are used in clinical practice?
Psychosocial
Problem-Solving
Behavior Modification
Cognitive Therapy
Crisis Intervention
Family Therapy
Group Therapy
Narrative Therapy
Ecological or Life Model
Task-Centered
Psychosocial
focuses on intrapsychic and interpersonal change; based on psychoanalytic theory, ego psychology, role, and systems theory
Problem-Solving
to solve discrete problems, based on psychosocial and functional approaches
Behavior Modification
for symptom reduction of problem behaviors and learning alternative positive behaviors
Cognitive Therapy
for symptom reduction of negative thoughts, distorted thinking, and dysfunctional beliefs
Crisis Intervention
Brief treatment of reactions to crisis situations to reestablish the client’s equilibrium
Family Therapy
treats the whole family system and sees the individual symptom bearer as indicative of a problem in the family as a whole
Group Therapy
a practice model in which group members can help and be helped by others with similar problems, get validation for their own experiences, and test new social identities and roles
Narrative Therapy
Uses the stories that people tell about their lives to reveal how they structure perceptions of their experiences; therapist co-constructs alternative, more affirming stories with the client
Ecological or Life Model
Focuses on life transitions, environmental pressures, and the maladaptive fit between individual and family or the larger environment; focuses on the interaction and interdependence of people and environments
Task-Centered
Focuses on accomplishing tasks to reinforce self-esteem and reestablish usual capacity for coping
What’re the assumptions and knowledge base used in clinical practice?
Individual growth, development, and behavior result from complex interaction of psychological and environmental factors
Theories of personality development
Systems Theory
DSM-5
Sociocultural factors are a significant influence, including ethnicity, immigration status, occupation, race, gender, sexual orientation, and socioeconomic class
What does the Ongoing Clinical Process Include?
Problem Assessment
Planning for Change
Determining the Intervention Locus
Evaluating Change
Problem Assessment
Identify forces that contribute to or maintain the problem
What is included in Problem Assessment?
Stresses that may impair functioning can originate in the individual, the individual’s system, or the system’s environment
DSM-5
Done to evaluate client’s strengths, to appraise the client-system’s strengths and weaknesses, and to identify supports or constraints that may influence change possibilites
What’s included in Planning for Change?
Criteria for Intervention Strategies
What is the criteria for Intervention Strategies?
Should be consistent with objectives
Should be evidence that strategy is effective
Must be consistent with professional values
What is included in Determining the Intervention Locus?
Behavioral: modify actions
Affective: modify feelings
Cognitive: modify thoughts or thought patterns
What is included in evaluating change?
Assess progress in achieving treatment goals
Assess effectiveness of treatment interventions
Determine areas still needing work
What’re the stages of clinical practice?
Beginning Stage
Middle Stage
Ending Stage
What is included in the beginning stages of clinical practice?
Assessment
Establishing a positive therapeutic relationship
Contracting or goal setting
Connecting with resistance clients
What is included during the assessment at the beginning stages of clinical practice?
Presenting problem
Match between presenting problem and available services
Understanding of the client’s problems and how that largely depends on data collected in early interviews that is expanded as treatment progresses
Worker’s Role
Other Sources of Data
Clinical Diagnosing
Beginning Stage: Presenting problem
What are the client’s concerns and problems?
How does the client describe the problems?
Can the client clearly articulate what is disturbing?
What factors contribute to the client’s problem?
What strengths does the client show in relation to the presenting problem?
Is the client’s affect appropriate and his expectations realistic?
What does the client hope to achieve?
Beginning Stage: Match Between Presenting Problem and Available Services
Does the agency or private practice setting offer the appropriate services and have the needed skills to address the client’s presenting problem effectively?
Should the client remain with this worker or agency, or be referred elsewhere?
Beginning Stage: Worker’s Role
Ask leading questions
Ask the client to elaborate and describe the situation in detail; the worker also observes the client’s behavior and affect in the treatment situation; worker organizes data to formulate a meaningful, dynamic psychosocial or diganostic assessment
Beginning Stage: Other Sources of Data
Interviewing Other Family Members
Home Visits
Collateral Contacts with Teachers
Clergy
Doctors
Social Agencies
Friends
Beginning Stage: Establishing a Positive Therapeutic Relationship
Characteristic of the Worker
Needs of the Client
Establishing a Therapeutic Relationship: Characteristics of the Worker
Nonpossessive warmth and concern
Genuineness
Appropriate empathy
Nonjudgemental Acceptance
Optimism about the Possibilities for Change
Objectivity Regarding the Client and the Client’s Situation
Professional Knowledge and Competence
Capacity to Communicate with the Client
Self-Awareness
Establishing a Positive Therapeutic Relationship: Needs of the Client
Hope and courage to engage in the change process
Motivation to change
Trust in the worker’s interest and skill to help
Be dealt with as an individual rather than a case
Personality type
To express self
To be accepted as a person of worth
Make one’s choices
Change one’s own pace
Contracting or Goal Setting: The Contract in Theory
Compatible with various models of social work practice; not limited to an initial working agreement, but part of the total social work process
Helpful in facilitating client’s activity in problem solving, maintaining a focus, and continuing in therapy
Contracting or Goal Setting
an explicit agreement between the worker and client regarding target problems, goals, and strategies of social work intervention, and differentiating the roles and tasks of the client and worker
Contracting or Goal Setting: Mutual Agreement
Determined in a reciprocal process between client and worker
Must be stablished at the beginning and monitored throughout to avoid hidden agendas
Contracting or Goal Setting: Differentiated Participation
Worker is responsible for delineating unique aspects of his/her participation at each phase of the process
Contracting or Goal Setting: Reciprocal Accountability
The client and the worker are each accountable to the other for fulfilling upon work toward agreed upon goals
Contracting or Goal Setting: Explicitness
Work is specific, clear, and open
No implicit or covert contracts, or discrepant client-worker expectations
Contracting or Goal Setting: Realistic Agreement
Within the capacities of client and worker
Contracting or Goal Setting: Flexibility
To guard against rigidity, includes provisions for renegotiation by mutual consent
Beginning Stage: Contracting with Resistant Clients
The worker recognizes, accepts, and addresses his/her own resistance if present
The worker recognizes and accepts client’s resistance, whether due to negative experiences with professionals, fear of worker’s authority, or fear of change
Client resistance may be expressed passively or through open hostility
The worker clarifies role and purpose
The worker explores client reactions (resistance) and strategizes on how to work with them
Limitations
Contracting with Resistant Clients: Limitations
Difficult to contract with involuntary clients who do not acknowledge or recognize problems, or who see the worker as marginal or unhelpful, and with very severely distrubed or mentally retarded clients
Acknowledge openly the difficulty for both worker and client inherent in mandatory treatment and to negotiate a contract within those realities
Middle Stage: Worker Interventions Definition
Continue the work of the beginning stage with more emphasis on helping the client resolve problems and make changes in feelings, behavior, or ways of thinking
Middle Stage: Worker Interventions
Supporting or Sustaining
Direct Influence
Exploration
Worker encourages the client’s reflections and responds to enhance the client’s insight; focus on current and recent experiences
Encourages the client’s reflection on pattern-dynamics and underlying personality dynamics adversely affecting current adaptation; focus on conscious and preconscious, rather than unconscious material
Confrontation
Clarification
Interpretation
Partilization
Universalization
Ventilation
Catharsis
Worker Interventions: Supporting or Sustaining
Reduce the client’s feelings of anxiety, poor self-esteem, and low self confidence, the worker expresses confidence in or esteem for the client, interest in and acceptance of the client, and a desire to help
Expressed through interest, sympathetic listening, acceptance of client, honest reassurance, and encouragement
Worker Interventions: Direct Influence
Worker gives advice or suggestions to influence client
Worker Interventions: Exploration
Workers continued effort to understand the client’s view of self and his/her situation
Worker Interventions: Confrontation
The worker finds ways to challenge the client to think about discrepancies in what s/he says or does, other maladaptive behavior behavior, or about resistance to treatment or to change
Worker Interventions: Clarification
Accomplished through questions, and repeating or rephrasing material the client brings up
Requires sensitivity to the client’s defensiveness
Worker Interventions: Interpretation
Used with clients who are not emotionally fragile
Worker suggest psychodynamic meaning of the client’s thoughts, feelings and fantasises, especially about the origins or problem behaviors
Aims at enhancing the client’s insight and working through conflictual material by deepening and extending the client’s conscious understanding
What may interpretation involve?
Uncovering repressed (unconscious process) or suppressed (conscious process) material
Connecting the present to the past so the client can see present distortions more clearly
Integrating material from various sources so the client gains a more realistic perspective on his/her situation
Worker Interventions: Partialization
To facilitate the client feeling less overwhelmed and more empowered to problem solve and break down problems or goals into smaller, more manageable components
Prioritize the components into a hierarchy of importance to the client or those that are more manageable to address first
Worker Interventions: Ventilation
The client airs feelings associated with the data presented about oneself and the situation
The release of emotions may help reduce the intensity of the client’s feelings, the feeling that they are unspeakable or that the client must be alone with them
Worker may need to distinguish between times when ventilation is useful to reduce the intensity and when it “feeds the fire”
Worker Interventions: Catharsis
Reliving and consciously examining repressed, early life, or traumatic experiences in treatment to achieve abreaction, the release of tension or anxiety that was caused by the conflict and its repression
Middle Stage: Special Considerations in Treatment
Resistance
Transference
Countertransference
Special Considerations in Treatment: Resistance
In psychodynamic terms, resistance is an unconscious defense against painful or repressed material
It can be expressed through silence, evasiveness, balking at the worker’s suggestions, or a premature desire to end treatment
The worker should recognize and understand resistance as an opportunity to learn more about the client and then work empathically with the client to face resistance and understand when and how to use it effectively
Special Considerations in Treatment: Transference
Client’s unconscious attempts to recapitulate with the worker the conflicts attached to a relationship experienced with significant persons in the past
The worker needs to help the client understand dynamics of transference, how it related to past relationships, and how it contributes to present relationship difficulties
The worker must be aware of self, reality of clinical situation and relationship, and of the client’s conflicts that are revealed through transference
Special Considerations in Treatment: Countertransference
The therapist’s unconscious distorted perceptions and responses to the client based on emotional conflicts regarding a significant person from the social worker’s past
Worker needs to understand countertransference reactions, be aware of their presence and consequences, and use supervisory help or therapy to understand them and not impose them on the client
Stages of Clinical Practice: Ending Stage
Used the termination phase of treatment
Ending Stage: Opportunities of Termination of Treatment
Rework old, unfinished issues or work on presenting problems that reemerge at time of termination
Growth opportunity for coping constructively with loss and anger, sadness, success, disappointment, abandonment
Offers a chance to evaluate treatment and the treatment relationship
Ending Stage: Factors Affecting the Client’s Ending
Degree of client’s involvement in treatment
Degree of success and satisfaction
Client’s earlier losses
Mastery of early life separation-individuation stage of development
Reason for Ending
Timing
Transfer Plan
Ending Stage: The Client’s Resistance to Ending
Clinging to therapy and to the worker to protect self from anxious and angry feelings
Resisting reworking old problems and symptoms if they recur during termination
Introducing new problems to avoid ending
Finding new relationships as an escape from dealing with pain of ending with the worker
Defensive reactions
Ending Stage: The Worker’s Role
Plan adequate time for termination
Inform the client if ending prematurely
Be aware of countertransference attitudes and behaviors about ending
Remain sensitive, observant, empathic, and responsive to the client’s response to ending
Encourage the client to deal with experience of ending, and to confront the client on inappropriate, dysfunctional coping with ending
Encourage the client’s belief in ability to take care of self and to direct his/her own life
Present the possibility of future contact at time of difficulty
How much time is required for long term treatment termination?
4-8 sessions
Clinical Practice: DSM-5
Classification system with periodic revisions
Comprehensive description of the symptoms and manifestations of mental health disorders and associated information
DSM-5: Cultural Assessment
Evaluation of the impact of cultural context, cultural belief systems, and cultural differences between client and interviewer in assessing illness behavior
DSM-5: Defensive Functioning Scale
An assessment of the client’s defense or coping patterns at the time of the evaluation and the period just preceding it
What is special about the fifth edition of the DSM?
underscores how they can continue to manifest at different stages of life and may be impacted by the developmental continuum that influences many disorders
recognizes age-related aspects of disorders by arranging each diagnostic chapter in chronological fashion, with diagnoses most applicable to infancy and childhood listed first, followed by diagnoses more common to adolescence and early adulthood, and ending with those relevant to adulthood and later years
Individual disorders, diagnostic criteria were revised to better serve young people (working with parents, defining a diagnostic home, developing more precise criteria
DSM-5: Parents’ Integral Role
Parents provided a particularly valuable perspective on framing of the DSM-5
Why do parent’s play an integral role when diagnosing a child?
criteria require that symptoms be observed by them or individuals who interact regularly with the child
What two disorders were added to the DSM-5?
Social Communication Disorder
Disruptive Mood Dysregulation Disorder
DSM-5: Social Communication Disorder
persistent difficulty with verbal and nonverbal communication that cannot be explained by low cognitive ability
DSM-5: Disruptive Mood Dysregulation Disorder
characterized by severe and recurrent outbursts that are grossly out of proportion to the situation in intensity or duration
occurs, on average, three or more times each week for a year or more
What disorders had slight changes in the DSM-5?
Autism Spectrum Disorder
Attention Deficit Hyperactivity Disorder
Posttraumatic Stress Disorder
Specific Learning Disorder
Eating Disorders
DSM-5: Autism Spectrum Disorder
incorporates four disorders from the previous manual : ASD, Aspergers disorder, childhood disintegrative disorder, and the catch-all diagonsis of pervasive developmental disorder not otherwise specified
People diagnosed with one of the separate DSM-IV disorders should still meet the criteria for autism spectrum disorder or a different DSM-5 diagnosis
DSM-5: Attention deficit/hyperactivity disorder (ADHD)
prior to age 12, compared to 7 as the age of onset in DSM-IV
No clinical difference between children with earlier versus later symptom onset in terms of their disorder course, severity, outcome, or treatment response
DSM-5: Posttraumatic Stress Disorder (PTSD)
new subtype for children younger than 6
new research details what diagnosis looks like in younger children, which will help clinicians tailor treatment to younger children
DSM-5: Specific Learning Disorder
No longer limits learning disorders to reading, mathematics and written expression
Dyslexia is included in the descriptive text
DSM-5: Eating Disorders
Previously listed among Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence are now listed in the Feeding and Eating Disorders chapter
What disorders are included in the Feeding and Eating Disorders chapter in the DSM-5?
PICA, rumination and avoidant/restrictive food intake disorder
DSM-5: Characteristics of Childhood Disorders
primarily disorders of abnormal development and maturation
common for children to have more than one diagnosis
eating disorders and gender identity disorders were moved from the child section
learning disorders for reading and mathematics, or written expression are determined through the use of individually administered standardized testing
Intellectual Developmental Disorders
Abnormal Development and Maturation
the inability to attain certain normal developmental skills
DSM-5: Disorders Usually Diagnosed in Infancy, Childhood, or Adolescence
Motor Skill Disorder and Developmental Coordination Disorder
Communication Disorders
Pervasive Developmental Disorders
Attention-Deficit and disruptive behavior disorders
Feeding and Eating Disorders of Infancy or Early Childhood
Tic Disorders
Elimination Disorders
DSM-5: Intellectual Development Disorder
Below average intellectual functioning; an IQ (intelligence quotient) of 70 (+/-5) or below for an individually administered IQ test
Concurrent deficits or impairments in adaptive functioning
Degrees of severity range from mild, moderate, severe and profound
DSM-5: Motor Skills Disorder and Developmental coordination Disorder
motor coordination is substantially below or markedly delayed for the child’s age and measured intelligence
DSM-5: Communication Disorders
Expressive or receptive language disorders
Phonological (articulation) or stuttering disorders
DSM-5: Pervasive Developmental Disorders
spectrum of disorders characterized by qualitative impairment in communication skills; and stereotyped behavior, interests, and activities
DSM-5: Criteria for Childhood Disintegrative Disorder
at least two years of normal development, followed by deterioration of language skills and social interaction, and onset of stereotyped behaviors and interests
DSM-5: Criteria for Aspergers Disorder
social impairment and restricted behaviors and interests, but with normal language and cognitive development
DSM-5: Criteria for ADHD
Inattentive and/or hyperactive, impulse types
symptoms persist for at least six months and include difficulty staying focused, being easily distracted, fidgeting, acting “driven”
symptoms are not motivated by anger or the wish to displease or spite others
treatment by medication and/or behavior modification
DSM-5: Criteria for Conduct Disorder
persistent pattern of behavior in which others’ rights and property are violated, and significant age-appropriate rules or societal norms are ignored
aggression and destruction of property are common
DSM-5: Criteria for Oppositional Defiance Disorder
pattern of negative, hostile, and defiant behavior with less serious violations of the basic rights of others that characterize conduct disorders
behavior is motivated by interpersonal reactivity or resentful power struggle with adults
DSM-5: Criteria for PICA
persistent eating of nonnutritive substances such as paint, hair, sand, cloth, pebbles, etc., without aversion to food
DSM-5: Criteria for Rumination Disorder
Regurgitation and rechewing of food
DSM-5: Criteria for Tic Disorders
Characterized by rapid, recurrent, stereotyped motor movements or vocalizations
DSM-5: Criteria for Tourette’s Disorder
multiple motor tics and one or more vocal tics
DSM-5: Criteria for Chronic Motor or Vocal Tic Disorder
either motor or vocal tics
DSM-5: Transient Tic Disorder
like Tourette’s but less severe, and symptoms and within 12 months
DSM-5: Elimination Disorders
Encopresis
Enuresis
DSM-5: Criteria of Encopresis
repeated passage of feces in inappropriate places
DSM-5: Criteria of Enuresis
repeated voiding of urine during day or night in bedding or clothes after continence would be expected
DSM-5: Other Disorders of Infancy, Childhood and Adolescence
Separation Anxiety Disorder
Reactive Attachment Disorder
Selective Mutism
Stereotype/Movement Disorder
DSM-5: Criteria of Separation Anxiety Disorder
Excessive distress when separated from major attachment figure(s)
sleep refusal unless near that person
DSM-5: Criteria for Reactive Attachment Disorder
a lack of attachment or indiscriminate, superficial attachments
DSM-5: Criteria for Selective Mutism
not speaking in specific social situations though having the ability to communicate
DSM-5: Criteria for Stereotype/Movement Disorder
repetitive, driven motor behavior, (e.g., hand waving, picking, head banging, rocking)
DSM-5: Delirium, Amnestic, and Other Cognitive Disorders
Delirium, dementia, amnestic disorder
DSM-5: Criteria for Delirium
Disturbance in consciousness or cognition that develops over a short period of time and is due to a medical condition or substance induced
DSM-5: Criteria for Dementia
memory impairment, multiple cognitive deficits
includes Alzeheimer’s (gradual onset with progressive deterioration), vascular dementia, dementia due to HPV, Parkinson’s or other medical conditions
DSM-5: Criteria for Amnestic Disorder
memory impairment without other cognitive impairments
may be substance induced
DSM-5: Mental Disorders Due to a General Medical Condition
Delirium, dementia or amnestic disorder
Psychosis
Mood Disorder
Sexual Dysfunction
Sleep Disorder
Personality Change due to medical condition
DSM-5: Substance Related Disorders
may be caused by abusing a drug, by side effects of a medication, or by toxin exposure
DSM-5: Substance Dependence Criteria
maladaptive pattern of drug use with increased tolerance, withdrawal symptoms, compulsive use, or behavior problems
DSM-5: Substance Abuse Criteria
social role, legal, or medical problems due to drug use
DSM-5: Substance Intoxication or Withdrawal
Behavioral, psychological, and physiological symptoms due to effects of the substance
will vary depending on type of substance
DSM-5: What symptoms can come with substance dependence?
Induced Delirium
Dementia
Psychosis
Mood Disorders
Anxiety Disorder
Sexual or Sleep Dysfunction
Should treatment of substance abuse come first or treatment of symptoms?
treatment of substance abuse
What treatment options are there for those going through substance abuse issues?
Outpatient or Inpatient
Residential or Day Care
Group
Individual
Family Counseling
Methadone Maintenance (for opiates)
Detoxification
Self-Help Groups
Combination of Therapies and Medication
DSM-5: Schizophrenic and Other Psychotic Disorders
characterized by psychotic symptoms during an active phase, deterioration from a previous level of functioning, and extended duration of symptoms
onset is often in adolescence or young adulthood
medical conditions or substances causing psychosis should be evaluated and diagnosed seperately
What psychotic symptoms can be present during an active phase?
Delusions
Hallucinations
Disorganized Speech
Thought disorder
Examples of thought disorder?
loose associations or poverty of content
Examples of negative symptoms for psychotic disorders?
flat affect
alogia
avolition
DSM-5: Duration for Psychotic Symptoms
continuous illness for at least six months with at least one month of an active phase of psychotic symptoms
DSM-5: Schizophrenia Criteria
may be catatonic, disorganized type, paranoid type, undifferentiated type, or residual type
Schizophrenia: Catatonic Type
stupor, negativism, rigidity, mutism
Schizophrenia: Disorganized Type
incoherence, flat, or grossly inappropriate affect
Schizophrenia: Paranoid Type
delusions or frequent auditory hallucinations often persecutory or grandiose
Schizophrenia: Undifferentiated Type
prominent hallucinations, incoherence, or grossly disorganized behavior
Schizophrenia: Residual Type
absence of prominent psychotic features
DSM-5: Schizophrenia Treatment
medication and ego supportive therapy aimed at containing psychotic symptoms and maintaining the person’s highest level of functioning
DSM-5: Schizophreniform Disorder Criteria
illness of less than six months duration
a greater likelihood of an acute onset preceded by turmoil/high stress
a range of prognoses and characterized by the absence of blunted or flat affect
DSM-5: Schizoaffective Disorder
psychotic symptoms of schizophrenia concurrent with the presence of either a major depressive episode, a manic episode, or a mixed episode
DSM-5: Delusional Disorders Criteria
characterized by the presence of a persistent delusion
hallucinations are either absent or not prominent
may be persecutory type, jealous type, somatic type, or grandiose type
Delusional Disorders: Persecutory Type
delusion that one is being malevolently treated
Delusional Disorders: Jealous Type
that one’s sexual partner is unfaithful
Delusional Disorder: Erotomaniac Type
that someone is in love with delusional person
Delusional Disorders: Somatic Type
that one has some physical defect or disease
Delusional Disorders: Grandiose Type
that one has a great but unrecognized talent, has made a great discovery, or is a prominent person or close to a prominent person
DSM-5: Brief Psychotic Disorder Criteria
usually sudden onset and duration of less than one month
DSM-5: Shared Psychotic Disorder
a delusion is held with another person in a close relationship
What’re the types of treatment of schizophrenic and other psychotic disorder?
Psychopharmacology
Individual Psychotherapy
Family Therapy
Group Therapy
Milieu Therapy
Social Network Intervention/Case Management
Self-Help Groups
Treatment of Psychotic Disorders: Psychopharmacology
anti-psychotic medication with consistent administration and monitoring for response and side effects
Treatment of Psychotic Disorders: Individual Psychotherapy
supportive in nature, little anxiety inducement, contain psychotic symptoms, and focus on realistic goals to maintain highest level of functioning
the goal is to facilitate coping and self-acceptance
Treatment of Psychotic Disorders: Family Therapy
provide education and support to family members
Treatment of Psychotic Disorders: Group Therapy
practical, supportive
helps develop social skills to begin or sustain relationships
Treatment of Psychotic Disorders: Milieu Therapy
often hospital/institutional treatment involving a therapeutic combination of staff, program, social structure, respite, and expectations of reasonable behavior
Treatment of Psychotic Disorders: Social Network Intervention/Case Management
help with housing, income, social contacts, educational and vocational opportunities, medical care, or other resources
Treatment of Psychotic Disorders: Self-Help Groups
for support and education to the client and family members
Differential Diagnosis: Dementia and Other Medical Conditions
dementia, medical conditions, and substance disorders may also cause psychotic symptoms
illnesses that may have less severe or transient psychotic features include major depressive disorder, BPD, or personality disorder such as schizotypal personality disorder
Differential Diagnosis: Psychotic Disorder and Paranoid Personality Disorder
there may be a paranoid ideation or pathological jealousy, but there are no delusions or hallucinations
Treatment of Psychotic Disorders: Course
varies from chronic to remission within a few months
DSM-5: Mood Disorders Criteria
characterized by persistent abnormal mood, either depressed or euphoric
symptoms may be somatic, affective, cognitive, and/or behavioral
impact is psychological distress and impaired role functioning
culture may affect presentation
DSM-5: Mood Disorders
Major Depressive Disorder
Persistent Depressive Disorder
Bipolar I Disorder
Bipolar II Disorder
Cyclothymic Disorder
DSM-5: Major Depressive Disorder Criteria
vegetative or classic symptoms
significant weight loss or gain
insomnia
sleeping too much
motor agitation or low energy
feeling sad, empty, or worthless
difficulty concentrating or making decisions
general loss of pleasure and interest
recurrent thoughts of death or suicide
DSM-5: Persistent Depressive Disorder
similar symptoms to major depressive disorder, but less severe and more chronic
last at least two years
DSM-5: Bipolar I Disorder
formerly called manic-depression
one or more manic episodes characterized by persistent abnormally elevated or irritable mood
pressured speech
grandiosity
sleeplessness
excessive pleasurable, high-risk activity
DSM-5: Bipolar II Disorder
major depressive episodes with at least one hypomanic episode (manic symptoms at a less severe intensity)
DSM-4: Cyclothymic Disorder
chronic, fluctuating mood with many hypomanic and many depressive symptoms, but not as severe as either bipolar I or bipolar II
DSM-5: Treatment of Mood Disorders
Psychopharmacology
Interpersonal/Psychodynamic Therapy
Behavioral Therapy
Cognitive Therapy
Group Psychotherapy
Self-Help Groups
Generalized Anxiety Disorder (GAD)
Treatment of Mood Disorders: Psychopharmacology
antidepressants for major depressive disorder and dysthymia
anti-psychotics if mood disorder is accompanied by psychotic features
mood stabilizers if bipolar I
administration and monitoring for effectiveness and side effects
DSM-5: Anxiety Disorders Criteria
characterized by excessive worry, fear, and/or avoidance rituals or repetitive thoughts
DSM-5: Panic Disorder Criteria
brief recurrent intense fear in the form of panic attacks with physiological or psychological symptoms
may include agorophobia, anxiety about being in places or situations from which one cannot escape or where one might have a panic attack and not be able to get help
DSM-5: Phobia Criteria
fear of specific objects or situations
DSM-5: Social Phobia Criteria
social anxiety disorder
unreasonable fear of embarrassment or humiliation in social settings
DSM-5: Obsessive Compulsive Disorder
intrusive recurrent thoughts or compulsive behaviors distressing the person and which are time-consuming, even interfering with the person’s routine or functioning
DSM-5: Post-traumatic Stress Disorder (PTSD) Criteria
more than one month of persistently re-experiencing a severe trauma
avoidance of things associated with the trauma or numbness
person demonstrates arousal-anxiety symptoms
DSM-5: Acute Stress Disorder Criteria
within one month of experiencing a trauma, anxiety and dissociative symptoms develop
DSM-5: Generalized Anxiety Disorder
excessive worry, cognitive, and physiological symptoms of distress
chronic and last at least six months in duration
DSM-5: Treatment of Anxiety Disorders
Psychopharmacology
Psychotherapy
Group Therapy
Inpatient Hospitalization
Treatment of Anxiety Disorders: Psychopharmacology
short-acting anti-anxiety medications may be used for episodic symptoms such as panic attacks
antidepressants are used in the longer term for diagnoses such as social phobia or obsessive compulsive disorder
Treatment of Anxiety Disorders: Psychotherapy
supportive therapy, cognitive-behavioral therapy, dialectical behavior therapy, and EMDR for PTSD
Treatment of Anxiety Disorders: Inpatient Hospitalization
when there is danger to self or others
DSM-5: Somatoform Disorders Criteria
characterized by multiple physical/somatic symptoms with no organic findings
symptoms cause distress and impair functioning in social work arenas
DSM-5: Somatoform Disorders
Body Dysmorphic Disorders
Conversion Disorder
Hypochondriasis
Somatization Disorder
Pain Disorder
DSM-5: Body Dysmorphic Disorders Criteria
Preoccupation with some imagined defect in appearance
DSM-5: Conversion Disorder Criteria
motor or perceptual symptoms suggesting physical disorder, but reflect emotional conflicts
DSM-5: Conversion Disorder Criteria
motor or perceptual symptoms suggesting physical disorder, but which reflects emotional conflicts
DSM-5: Hypochondriasis Criteria
unrealistic interpretation of physical signs as abnormal, and preoccupation with a fear or belief of serious illness
DSM-5: Somatization Criteria
recurrent and multiple somatic complaints of several years
DSM-5: Pain Disorder Criteria
preoccupation with pain that causes impaired functioning
DSM-5: Treatment of Somatoform Disorders
As there is no definitive treatment, the goal is early diagnosis to stop unnecessary medical/surgical interventions
Attempt to turn attention from symptoms to problems of living
Supportive Therapy
A long-term relationship with a single physician
No medication
Treatment of Somatoform Disorders: Supportive Therapy
helping to cope with symptoms
DSM-5: Dissociative Disorders Criteria
characterized by a disturbance in the normally integrative functions of identity, memory, consciousness, or perception of the environment
trauma is a common precipitant, but dissociative symptoms may occur in other disorders
trance states are a variation of dissociative disorders in some cultures
DSM-5: Types of Dissociative Disorders
Dissociative Identity Disorder (formerly multiple personality disorder)
Dissociative Fugue
Dissociative Amnesia
Depersonalization Disorder
DSM-5: Dissociative Identity Disorder Criteria
existence within the person of two or more personalities, of which each is dominant at a particular time
DSM-5: Dissociative Fugue Criteria
sudden and unexpected travel from home, with assumption of a new identity and inability to recall ones previous identity
DSM-5: Dissociative Amnesia Criteria
sudden inability to recall important personal information, not due to organic causes and more than forgetfulness
DSM-5: Depersonalization Disorder Criteria
feeling detached from, and an observer of, one’s mental processes or body
DSM-5: Treatment of Dissociative Disorders
psychotherapy with goals of working through unconscious conflict or recovering memories of trauma, and integrating feeling states with memories or events
DSM-5: Sexual Gender Identity Disorders
Sexual Desire Disorder
Sexual Aversion disorder
Sexual Arousal Disorder
Premature Ejaculation
Sexual Pain Disorders
Paraphilias
Gender Identity Disorder
DSM-5: Sexual Dysfuntions
characterized by problems in sexual functioning due primarily to psychological factors
DSM-5: Sexual Desire Disorder Criteria
lack of desire for sex that causes distress or interpersonal problems
DSM-5: Sexual Aversion Disorder Criteria
aversion or avoidance of genital sexual activity
DSM-5: Sexual Arousal Disorder Criteria
inability to maintain an erection or to attain and maintain sexual excitement
DSM-5: Paraphilia Disorder
unusual or bizarre imagery or act typically concealed and engaged in by a small percentage of the population for sexual excitement
these acts adapt to societal changes and are widely divergent from societal norms or are harmful to others
examples include exhibitionism, fetishism, frotteurism, pedophilia, sexual sadism, sexual masochism, voyeurism, zoophilia)
DSM-5: Treatment of Sexual Disorders
Psychopharmacology
Psychotherapy
Treatment of Sexual Disorders: Psychopharmacology
medications such as Viagra
Treatment of Sexual Disorders: Psychotherapy
sex therapy
behavioral techniques
DSM-5: Gender Identity Disorder Criteria
characterized by strong and long-standing cross-gender identification and discomfort with one’s assigned gender
DSM-5: Eating Disorders
Anorexia Nervosa
Bulimia Nervosa
DSM-5: Anorexia Nervosa Criteria
refusal to maintain body weight at minimal norms
intense fear of gaining weight and becoming fat
patients have distorted body image and may suffer from amenorrhea
DSM-5: Bulimia Nervosa Criteria
recurrent episodes of binge eating, and self-induced vomiting/laxatives/fasting/vigorous exercise to prevent weight gain
persistent over-concern with body shape and weight
at least two binge eating episodes a week for three months
DSM-5: Treatment of Eating Disorders
Psychopharmacology
Individual and/or Family Therapy
Medical Supervision
Hospitalization
Treatment of Eating Disorder: Medical Supervision
weight, vital signs, and blood values
Treatment of Eating Disorder: Hospitalization
if necessary for close behavioral and medical supervision
DSM-5: Sleep Disorder Criteria
sleep difficulties that which is normal and transient
examples include insomnia, hyperinsomnia, narcolepsy, nightmare disorder, sleep terror disorder, sleepwalking disorder
DSM-5: Factitious Disorders Criteria
intentionally produced or feigned physical or emotional symptoms
motivated by wish to play the role of a sick person
DSM-5: Impulse-control Disorders
Intermittent Explosive Disorder
Pathological Gambling
Kleptomania
Pyromania
Trichotillomania
DSM-5: Intermittent Explosive Disorder Criteria
episodes of aggression in the form of serious assaults on others or destruction of property
DSM-5: Kleptomania Criteria
impulsively stealing things not needed
DSM-5: Pyromania Criteria
fire-setting for pleasure or tension relief
DSM-5: Trichotillomania Criteria
hair pulling for pleasure or tension relief that results in hair loss
DSM-5: Adjustment Disorders Criteria
response to specific psychosocial stressors characterized by anxiety, depression, or conduct problems starting within three months of the stressor and lasting less than six months
chronic stressors or stressors that have long-term consequences may cause chronic adjustment disorders
DSM-5: Personality Disorders Criteria
characterized by an enduring and inflexible pattern or maladaptive personality traits that cause either significant impairment in social or occupational functioning, or subjective distress
thought to serve as coping and defensive styles due to ego deficits and early developmental problems
DSM-5: Differential Diagnosis for Schizoid Personality Disorder
no psychotic symptoms such as delusions and hallucinations
as seen in delusional disorders and schizophrenia
DSM-5: Schizoid Personality Disorder
indifference to social relationships, and a restricted range of emotional experience and expression
inability to form intimate social relationships or experience warmth and tenderness for others, and uncaring about the responses of others
DSM-5: Differential Diagnosis for Schizotypal Personality Disorder
deficits in interpersonal relatedness
various thought, perception, speech, and behavior pecularities
DSM-5: Treatment of Paranoid Personality Disorder
as there is trouble with trust and intimacy, the social worker should respond in a straightforward manner with courtesy, honesty, and respect
DSM-5: Antisocial Personality Disorder Criteria
a history of chronic irresponsible and antisocial behavior that began in childhood or early adolescence
violations of the rights of others and failure at work over several years
often starts with lying and stealing, and continues with acting-out sexual behavior, drinking, and drugs
continues with adult failure at work and at home, and adult violations of social norms
DSM-5: Treatment of Antisocial Personality Disorder
long-term therapy
self-help groups
establishing limits and boundaries
DSM-5: Borderline Personality Disorder Criteria
instability in relationships. mood, and self-image
impulsive and unpredictable acting-out, at times self-destructive
intense mood shifts from rage to normal state
chronic fear of being alone and dread of feelings of emptiness
may have transient paranoid or dissociative symptoms
DSM-5: Treatment of Borderline Personality Disorder
supportive counseling
clear boundaries and limit setting
avoid splitting, and help client verbalize rather than act on feelings
DSM-5: Histrionic Personality Disorder Criteria
excessive emotionality and attention seeking
constantly seeking reassurance, approval, or praise
overly dramatic and intense behavior
DSM-5: Treatment of Histrionic Personality Disorder
psychotherapy to temper egocentricity and increase capacity for empathy in relationships
DSM-4: Narcissistic Personality Disorder Criteria
a grandiose sense of self-importance
fantasies of unlimited success
chronic exhibitionism
difficulty in dealing with criticism
indifference to others
difficulty in relationships characterized by feelings of entitlement
taking advantage of an exploiting others
extreme polarities of idealizing and devaluing others
DSM-5: Treatment of Narcissistic Personality Disorder
supportive counseling
empathic mirroring
increase capacity for empathy in relationships
DSM-5: Avoidant Personality Disorder Criteria
social discomfort
fear of negative evaluation
timidity leading to extreme sensitivity to the possibility of social rejection
fear of social relationships
social withdrawal despite the desire for closeness
low self-esteem
DSM-5: Dependent Personality Disorder Criteria
a pervasive pattern of dependent and submissive behavior
lack of self-confidence
inability to function independently
individual seeks others to assume responsibility for his/her life
limited ability to show positive emotions
perfectionism with over-concern for trivial detail
demands others submit
preoccupied with work
miserly with money
DSM-5: Treatment of Personality Disorders
the purpose of intervention is often to alleviate symptoms, decrease social or emotional disability, or deal with societal/interpersonal need for symptom management
psychotherapy promotes recognition of the person’s covert dependence and often unexpressed fearfulness
awareness of countertransference is important because of treatment-resistant and other behaviors displayed, including mistrust of the social worker, lack of boundaries, and lack of recognition of the worker as a person
psychoactive medication is not used
Defense Mechanisms: Substance Abuse
- Regression, Projection, Rationalization, Denial
- Fragmentation: form of denial, refers to time
- Minimization refers to quantity
Defense Mechanisms: Schizophrenia
- Fixation, Regression
- Symbolization: keeps demons away
- Identification
Defense Mechanisms: Delusional Disorders
- Paranoid - Projection
- Erotomania - Projection
- Grandeur - Reaction formation, Omnipotence
- Somatic - Regression
Defense Mechanisms: Mood Disorders (Depression)
- Introjection: Loss, Anger
- Reaction Formation: Mania
Defense Mechanisms: Generalized Anxiety Disorder
Regression or Repression
Defense Mechanisms: Phobias
Displacement, Symbolization, Avoidance
Defense Mechanisms: Obsessive Compulsive Disorder
- Isolation of Affect: Ignore others’ feelings
- Undoing: Washing
- Reaction Formation
- Regression
Defense Mechanisms: Somatoform
- Repression, Somatization, Conversion
- Body Dysmorphia Disorders: Repression, Dissociation, Distortion, Symbolization
Defense Mechanisms: Dissociative Disorders (amnesia, multiple personalities)
Repression, Dissociation
Defense Mechanisms: Personality Disorders
- Paranoid - Projection
- Histrionic - Dissociation
- Borderline - Splitting, Acting Out, Projective Identification
Defense Mechanisms: Always Pathological
conversion
somatization
Schizophrenia and Psychotic Symptoms: Old Antipsychotics
Haldol (haloperidol)
Thorazine (chlorpromazine)
Mellaril (thioridazine)
Stelazine (trifluoperazine)
Prolixin (fluphenazine)
Navane (thiothixene
Clozaril (clozapine)
Schizophrenia and Psychotic Symptoms: Newer or Atypical Antipsychotics
Clozaril
Risperdal
Seroquel
Olanzapine
Abilify
Schizophrenia and Psychotic Symptoms: Clinical Notes
old antipsychotics are effective, but major drawback is the potential side effect, Tardive Dyskinesia
T.D. is irreversible and causes involuntary movements of the face, tongue, mouth, or jaw
other potential side effects such as Parkinson-like tremor or muscle rigidity are reversible and may be countered with the addition of Cogentin
Schizophrenia and Psychotic Symptoms: Clinical Notes (newer or atypical antipsychotics)
Clozaril requires biweekly blood blood testing due to the risk of agranulocytosis, a blood disorder that decreases white blood cells and increases the risk of infection
other atypical antipsychotics carry much less risk of Tardive Dyskinesia, however they are very expensive and can cause weight gain, affect blood sugar, and lipid profile
Bipolar Disorder: Drugs
Mood Stabilizers: Lithium, Tegretol, Depakote, Lamictal
Bipolar Disorder: Clinical Notes
Mood stabilizers are effective
Often cause weight gain
Regular blood work is required to monitor for therapeutic drug levels and for potential side effects
Lithium can cause kidney or thyroid problems
Tegretol and Depakote can cause liver function problems
Unipolar Depression: Drugs
- SSRI’s (Selective Serontonin Reuptake Inhibitors): Prozac, Zoloft, Paxil, Luvox, Celexa, Lexapro
- Atypical Antidepressants: Effexor, Wellbutrin, Cymbalta
- Tricyclic Antidepressants: Imipramine, Amitriptyline, Elavil
- MAO Inhibitors: Nardil, Parnate, Marplan
Unipolar Depression: Clinical Notes
SSRI’s have fewer side effects than other antidepressants
Cannot overdose on SSRI’s alone
They take several weeks to be effective
SSRI’s are expensive, often cause a loss of libido, and can lose effectiveness after years of usage
In a small number of clients, SSRI’s have the paradoxical effect of creating agitation or suicidal ideation or manic symptoms in the first days or weeks of usage and should be discontinued by the prescriber
Unipolar Depression: Clinical Notes (Atypical Antidepressants)
Wellbutrin does not cause loss of libido
It is sometimes prescribed in combination with SSRI to potentiate the positive antidepressants effect of an SSRI or to counter sexual side effects
Cymbalta is recommended for depression associated with somatic complaints
Unipolar Depression: Clinical Notes (Tricyclic Antidepressants)
Can cause sides effects such as dry mouth
These medications are not commonly used now due to cardia monitoring issues
Unipolar Depression: Clinical Notes (MAO Inhibitors)
not commonly used as they require a special diet to be safe
Anxiety: Drugs
Benzodiazepines: Ativan (Lorazepam), Xanax, Klonopin, Valium
Anxiety: Clinical Notes
Effective, quickly relieve anxiety, short-acting
These medications should be used for as short a time as possible and with appropriate therapeutic intervention because of their potential for addiction
In the elderly, long-term use of Benzodiazepines can cause psychotic symptoms that are reversible by discontinuing the medication
Attention Disorders: Drugs
Amphetamine-like: Ritalin (short-acting), Long-Acting Ritalin, Concerta, Adderall (short-acting), Adderall XR (long-acting)
Non-Amphetamine-like: Strattera
Attention Disorder: Clinical Notes (Amphetamine-like)
Relieve symptoms quickly
Can take these medications on selected days or part-days if desired
Can be abused
Can suppress appetite and cause weight loss
Cause an edgy feeling like too much caffeine and can cause increased pulse rate
Attention Disorder: Clinical Notes (Non-Amphetamine)
Less appetite suppressing, so weight loss is less a problem
Takes two-four weeks to be effective
Must take everyday
Monitor for rarely occurring liver problem
Cannot be abused
