Psychiatric Classification And Assessment Flashcards
What is the purpose of psychiatric classification from a clinical perspective?
- provides a means to identify mental illness
- Assists in choosing appropriate treatment
- Helps to predict prognosis
- Provides an efficient manner to communicate information to professionals
What is the benefit of psychiatric classification from a scientific perspective?
Provides a way for researchers to study homogeneous sample of patients
The homogeneity enhances the likelihood of discovering important facts about the condition
What is the benefit of psychiatric classification from the patient’s perspective?
A label often brings relief to patients and their families
-often reduces sense of isolation and confusion about their psychological experiences
What are classification concerns/detrimental effects to labeling?
- social stigma of mental illness can lead to discrimination
- labeling may cause doctors to overlook unique differences between patients, which can lead to suboptimal treatment
- mislabeling can lead to wrong treatment
What are classification concerns about the accuracy of a diagnosis?
There are concerns about the reliability(reproducibility ) of the diagnoses
There are concerns about the validity (accuracy) of the diagnostic systems
What are the problems with the current labeling system?
Current labeling system is categorical while behavior is dimensional
In a categorical system, the criteria that define abnormality mag change over time
- Type and number of systems
- Duration and frequency
Give 2 examples of psychiatric classification systems
International Statistical Clarification of diseases and health related problems
- published by the WHO
- Includes “Mental and behavioral disorders”
Diagnostic and Statistical Manual of Mental 5 th edition
Published by the American Psychiatric Association 2013
Describe the DSM 5
Includes diagnostic criteria for 300+vspecific mental disorders, grouped across 22 broad categories of mental illness
Describe the basic features of the DSM 5 (come back for chart)
Includes diagnostic criteria for each psychiatric disorder-
-number of symptoms required from a specified symptom list and frequency and time duration requirement
Has descriptive information -epidemiology, risk factors, lab findings , differentials
-DSM 5 considered a theoretical (no discussion of etiology or treatment)
DSM 5 is described as able to give provisional diagnoses , why is that?
Used if one presumes the criteria are or will be met for the disorder but either
- patient information is unavailable and expected to be confirmed upon inquiry or
- Required symptoms are present, but the duration criterion is NOT YET but expected to be met
Insert the word “provisional” after the name I’d the specific disorder
DSM 5 is described as being able to give “unspecified” diagnoses, why is that?
-Used if a patient does NOT meet criteria for a specific disorder but has significant symptoms within a given diagnostic category
Insert the word “unspecified” before the name of the diagnostic category.
According to the DSM 5 when should the terms “prior history” or “in remission” be used?
Descriptors are used when a patient has been previously diagnosed with a disorder but the symptoms are no longer present
Give examples of diagnosticcautions
- Consider cultural factors before diagnosing
- avoid tendencies to under or over diagnose
What tools are used to assess behavior?
- The diagnostic behavior
- mental status exam
- iq testing
- Psychological testing (objective tests, projective tests)
- neuropsychological testing
- other assessment techniques
What is a diagnostic interview?
Goal is to gather sufficient information to arrive at a diagnosis and treatment plan
Interviews may be structured or have a semi-structured format
Rapport setting is essential to gathering accurate and honest information
Describe structured diagnostic interviews
Information is gathered by asking questions in a check-list fashion using standardized questionnaires such as:
- Diagnostic Interview Schedule ( DIS)
- Structured Clinical Interview for DSM (SCID)
Describe a semi-structured diagnostic interview
Information is gathered by asking open-ended questions, covering key topic areas including :
- Identifying information
- History of complaint
- Psychological history
- Medical and psychiatric history (including substance use)
What is a mental status exam (MSE)?
An assessment of a patient’s current mental functioning
What aspects of a person’s functioning does the MSE include?
“ASEPTIC “
A- appearance and behaviors S- speech (rate, amount) E- emotions (mood and affect) P-perception(hallucinations) T-thought content(delusions, obsessions) and logical ness ofthought I- insight and judgement C-Cognition (formally tested)
Describe the cognition testing for the MSE
Involves a brief screening
- orientation(time and place)
- attention and memory
- visuospatial functioning
- language
What is the mini-mental state examination (MMSE)?
- A 30 part screening test “Folstein”
- Screens for cognitive impairment for the first part of the mental state exam
What is intelligence testing?
Assessment of a complex set of mental abilities that relate to a persons capacity to solve problems
Describe the Stanford-Binet intelligence test
- First standardized IQ test
- Good for extremes in intelligence
Describe the Wechsler intelligence test
The most commonly used IQ test,
Includes verbal comprehension, perceptual reasoning, working memory and processing speed
Describe the ages for the Wechsler intelligence tests
Wechsler adult intelligence scale - ages 16 -90
Wechsler intelligence scale for children- ages 6-16
Wechsler preschool and primary scale ages 2:6-7:7
What are objective psychological tests?
Tests that use ambiguous stimuli and do not require interpretation by a patient
These are the T/F question …”am I high strung?” For example
Describe the Minnesota Multiphasic Personality inventory (MMPI-2)
- About 600 T/F questions
- Self report
- Validity scales(e.g. consistency)
- Clinical scales(e.g. depression)
- Interpret pattern(even if within normal limits)
Describe the Millon Clinical Multiaxial inventory as an objective psych test (MCMI)
- About 175 T/F questions
- Designed to correspond to the DSM classification system
- Used Pyruvate screen people for serious psychological problems
Describe the Beck Depression Inventory ( BDI) as an objective psychological test
21-item self-report inventory
Patient indicates which statement best describes the way they have been feeling
Level of depression can be quantified and monitored
What are projective psychological tests?
Tests that use ambiguous stimuli, which requires interpretation
- ambiguous Stimuli serve as a way for patients to project their thoughts
- interpret themes in answers provided by patient (not just one answer)
Describe the Rorschach test as a projective psychological test
Ink blots, patient states what ink blot is and their rationale
Describe the thematic appreciation test ( TAT) as a protective psychological test
- select relevant pictures (out of 30)
- patient tells a story with description of thoughts and feelings of characters
Describe Children’s Appreception Test (CAT) as a projective psychological test
-Children’s version of the TAT (3-10)
What is neuropsychological testing ?
A comprehensive evaluation of a person’s cognitive functions (e.g. attention, memory, language, visuospatial)
Tests are used to help determine whether brain dysfunction is present
Give examples of Neuropsychological testing
- Bender Gestalt Test- copying geometric figures) of visuospatial abilities (parietal lobe test)
- Wisconsin Card Sorting Test- of executive functions (prefrontal lobe test)
- Stroop test -prefrontal love test
Describe behavioral inventory as a behavioral assessment
Provides a baseline frequency of an undesired behavior so that any change from baseline can be monitored (e.g. the frequency of insomnia)
Describe cognitive inventory as a behavioral assessment
Identifies thoughts preceding, during and after a maladaptive behavior (e.g. thoughts that lead to binge eating )
Describe bodily inventory as a behavioral assessment
It documents physiological measures( e.g. blood pressures, muscle tension in association with thoughts/behaviors)
Helps to gain insight into behavioral/psychological state and thus guide treatment
What is stress?
The unpleasant emotional experience triggered by various stimuli
Typically experienced, when a person perceives that demands exceed their resources
What are the components of stress?
- Behavioral
- Physiological
- Psychological
Explain the physiological component of stress
Increased heart rate, blood pressure and pulse rate; sweating, muscle tension, teeth clenching, shortness of breath, etc.
Explain the psychological component of stress
Anxiety, dysphoria, anger, irritability, inattention, memory loss, reduced, confidence, disinterest
Explain the behavioral component of stress
Social withdrawal, change in sleep/eating patterns, aggression, conduct disturbance, drug use
What are stressors?
Events that cause stress, varies from person to person and how the event is perceived and handled
Explain the physiological basis of stress
Stressors activate the amygdala (fear center) which stimulates the Hypothalamic-Pituitary-Adrenal (HPA) Axis and
causes release of cortisol and adrenaline
These hormones are related stress related activities including anxiety
Why are certain people more vulnerable to stress ?
Due to physiological make up and life experiences
What is the goal of therapy?
To assist vulnerable people in becoming more resilient to stressors by increasing their coping skills
What are general strategies of treatment of Stress-Related Problems?
- Having knowledge of the situation
- Being prepared for adversity, being prepared for stressful situations
- utilizing social support
Discuss Relaxation Training as a treatment for stress
PMR, diaphragmatic breathing: patient is shown how to release muscle tension and slow breathing rate to reduce anxiety
Discuss Cognitive Therapy as a treatment for Stress
Patient learns to have a productive internal dialogue (I.e. to think about things in a more adaptive framework)
Discuss medications as a treatment for stress
Medications, (benzodiazepines, antidepressants): they help to diminish the acute intense feelings of stress that disrupts problem-solving
Stress serves as a ….
Motivator
What is Yerkes-Dodson Law?
Low and high levels of stress are associated with low performance levels
Although stress exacerbated almost all mental illness…
There are several DSM diagnoses particularly related to stress
What diagnostic Categories are related to Stressors?
A. Post traumatic Stress Disorder
B. Acute Stress Disorder
C. Adjustment Disorders
D. Reactive Attachment Disorder
E. Disinhibited Social Engagement Disorder
Explain PTSD
Exposure to traumatic stress disorder whether exposure is direct or witnessing
What are the 4 types of symptoms of PTSD?
- Intrusion symptoms
- avoidance symptoms
- negative alterations in cognition and mood
- alterations in arousal and reactivity
What are the intrusion symptoms of PTSD?
- dreams
- recollections
- feeling event reoccur
- psychological or physiological distress when encounters symbols
Explain the avoidance symptoms of PTSD
Symptoms such as avoidance of thoughts, places or conversations, that rare reminders event
Explain the negative alterations in cognition and mood in PTSD
Symptoms include:
- Negative beliefs/expectations
- negative emotional stress
- inability to experience positive emotion
- diminished interest/participation in activities
- detachment from others
- dissociative amnesia
Discuss the arousal and reactivity symptoms of PTSD
Symptoms such as:
- Sleep disturbance
- irritable and angry outbursts
- reckless or self-destructive behavior
- concentration problems
- hypervigilance
- exaggerated startle response
Discuss duration and onset of PTSD
Symptoms must last over 1 month
Symptoms usually begin within 3 months of the trauma but can begin anytime in the future
What populations are vulnerable to PTSD?
In young adults but cam happen to anyone, orthopedic patients have a high rate of PTSD
Describe Acute Stress Disorder
Exposure to traumatic stressor
Numerous PTSD like symptoms are experienced
Duration of disorder is 3 days to 1 month
Discuss treatments for PTSD/ASD
General Psychotherapy
Behavioral psychotherapy ( desensitization techniques)
Pharmological
- Benzodiazepines (for short-term responses)
- Antidepressants
What is the diagnostic criteria of adjustment disorder?
development of significant and disproportional emotional/behavioral symptoms in direct response to an identifiable psychosocial stressor
Stressor are often an ordinary life experience but can be traumatic
What is the cause of adjustment disorder?
Inferred by acute onset (symptoms develop within a few months of stressor onset) and brief duration
(symptoms are expected to resolve within a few months after stressor termination, if stressor termination is possible)
What are the adjustment disorder subtypes?
- with depressive mood
- with anxiety
- with disturbance of conduct(external I zing behavior)
- with mixed anxiety and depressed mood
- with mixed disturbances of emotion and conduct
- unspecified (maladaptive )
Give the details on adjustment disorder being diagnosed with another disorder
If enough symptoms are present following the stressor such that another disorder’s diagnostic criteria are met, then that other disorder is diagnosed, NOT adjustment disorder
Adjustment disorder is only diagnosed if there is a causal stressor AND no other disorder explains the symptoms
Upon relocating to a new residence 2 months ago, a woman feels sad , disinterested and lethargic. The woman blames her symptoms on the relocation
What is the diagnosis?
Since relocating, she feels sad, disinterested and lethargic.
She has difficulty sleeping has lost weight and can’t concentrate
Symptoms meet criteria fir major depressive disorder MDD
Discuss treatment of Adjustment Disorder
Treatment typically involves:
- Psychotherapy (e.g. learning of coping strategies)
- Involvement in support groups
Treatment MAY involve crisis intervention:
- Hospitalization
- psychotropic medications
Describe a Reactive Attachment Disorder (RAD)
Child has a history of extremely insufficient care(e.g. social neglect, repeated changes in caregivers)
What are symptoms of Reactive attachment disorder RAD?
- Inhibited, emotionally withdrawn behavior toward adult caregivers
- Social and emotional disturbance such as:
- minimal social emotional responses
- limited positive affect
- unexplained irritability, sadness, fearfulness during interactions with caregivers
Symptoms emerge before age 5
Describe RAD treatment
Short term: medical support for any associated physical neglect
Long term:
Psychotherapy
Parental education, training, and support
Residential treatment programs-enriched environment with strict, consistent rules
-goals build on trust, self esteem and empathy
What are the diagnostic criteria for Disinhibited Social Engagement Disorder (DSED)?
Child has a history of extremely insufficient care (e.g. social neglect, changes in caregivers)
Causing:
A child approaches and interacts with unfamiliar adults and exhibits disinhibition
Symptoms emerge before age 5
Compare RAD and DSED
DSED kids can have NORMAL attachment to caregivers
However, DSED is unmodulated and indiscriminate social behavior
What is the treatment for DSED?
Psychotherapy
What are the adult manifestations of DSED?
Unknown
What is the most widely used to gather information about verbal and nonverbal information?
Diagnostic interview
What is the purpose of a mental status exam?
Composed of:
clinical observation made during the interview
A brief screening of cognitive functioning
What are tested in the Wechsler intelligence test?
- verbal comprehension
- Perceptual reasoning
- Working memory
- Processing speed
What manifests along with gender Dysphoria?
Manifested with Atleast 6 of the following
- A strong desire to be the other gender
- strong preference for playmates of other gender
- Strong rejection of typical masculine/feminine toys, games and activities
- Preference for cross gender roles in play
- Strong dislike of one’s sexual anatomy
- Strong preference for cross dressing / strong resistance to wearing typical masculine/feminine clothing
- Preference for toys, games, activities stereotypically used by the other gender
- Strong desire for primary +/- secondary sex characteristics that match one’s experienced gender
Give the onset and course of gender dysphoria
Onset of symptoms is early in life and independent of social pressures to conform to stereotypical gender role
Course:
-great distress
- increased suicide risk
- often victims of violence
What is the etiology of gender dysphoria ?
A transgender identity is thought to result from an alteration in androgen exposure during critical periods of in-utero development as follows:
- if XY and brain not androgenized at typical time, then a female gender identity develops
- if XX and brain is adrogenized, then a male gender identity develops
How can gender dysphoria be managed in adolescencts?
As they approach puberty, there is intense fear about the physical changes they will experience
-Supportive psychotherapy- to address issues of depression, anxiety
- Puberty blocking medication
- gonadotropin releasing hormone agonists
How can gender dysphoria be managed in adults?
Supportive psychotherapy- to address issues of depression, anxiety
Hormone treatment
Surgical treatment
- phalloplasty- creation of penis
- vaginoplasty- creation of vagina
Summarize what is sexual dysfunction
Problems with normal sexual response cycle
- Desire
- arousal
- orgasm
Problem persist for at least 6 months
What are the phases of sexual response ?
Desire
Arousal: excitement phase
Orgasm
Pain
Explain desire as a phase of sexual response
Characteristics: drives, motivation, desires
Disorders: Male hypoactive sexual desire disorder: no fantasies or desires —> R/O depression, low testosterone, stress, marital problems
Explain Arousal: excitement phase as a phase of the sexual response
Characteristics: sexual pleasure+ physiological response
Disorders:
-female sexual interest /arousal disorder: unable to achieve/maintain lubrication during sexual act, 1 in 3 women, R/O meds (antihistamine, anticholinergics)
-Erectile disorder: inability to attain or maintain erection until completion of sexual act —> R/O alcohol, smoking, diabetes, marital conflict
Explain orgasm as a phase of sexual response
Characteristics: physiological state- sexual tension released, contractions of organs
Disorders
Female orgasmic disorder =inability to achieve an orgasm- masturbation of intercourse, 1 in 3 women, likelihood of orgasm increases with age.
Premature ejaculation= before the man wishes, before penetration, just after penetration —> public intercourse, prostitutes, backseat of car
Delayed ejaculation: delay in or absence of ejaculation
Explain pain as a phase of the sexual response
Characteristics: subjective sense of pain with sexual act
Disorders:
Genito-pelvic / penetration disorder: difficulties with vaginal penetration or vulvovaginal/pelvic pain during intercourse /penetration attempts
What are the specifies of gender dysphoria?
- generalized or situational
- life-long or acquired
Explain the Non-DSM terms of gender dysphoria
- dyspareunia: Genital pain during intercourse
- Vaginismus: involuntary vaginal contraction upon attempting coitus, making penetration difficult or painful. Sexual trauma, rape, anticipation of pain, strict religious upbringing associated with vaginismus
