Case 10 - Thomas F.

Thomas F. was brought to therapy by his wife, who reported that he was having "crazy ideas about her." Tom maintained that his ideas were not crazy and insisted that his wife was having affairs with at least two men, both family friends.

Tom, forty-seven, and Carmen, forty-two, had married three years ago after a courtship of five year's duration. This was the second marriage for both. Tom had three children from his first marriage; these children lived out of the country with their mother. Carmen's only child from her first marriage had been killed in an accident when he was ten years old. Since they had lost the children from their first marriages, Tom and Carmen hoped that they would be able to have children together and reported being extremely happy when Tom, Jr., was born almost a year ago. However, their son brought considerable stress into their lives.

Tom and Carmen had met at the computer firm where both worked, Tom as a programmer and Carmen as administrative assistant. They were together almost constantly, both at work and at home. However, when their son was born, Carmen took a position at a local hospital, working nights in the admissions room, so that someone would always be available to care for their son. Tom was home with him during the evenings and nights, and Carmen was with the child during the day. They saw very little of each other, and nearly all of their energy was focused on parenting. Both had few friends or outside interests to give them support. They had bought a new house, and added debts prevented them form going out frequently, as they had when they were dating. In addition, Tom's mother had cancer, and Tom and Carmen were trying to spend as much time as possible helping her.

About two months ago, Tom began to express suspicions about how Carmen was spending her daytime at home. She assured him that she was too exhausted to do much more than care for Tommy, maintain the house, and try to get some sleep. However, tom's accusations grew worse, and he insisted that Carmen was having sexual relationships with at least two men in his absence. During this time, he continued his job as a programmer; and, except for several days in which he had left work precipitously in an effort to catch Carmen with her purported lovers, his performance at work had been unaffected. There was no prior history of mental disorder in either Tom or any of his first-degree relatives.

An excellent review of Psych movies

You can find an extensive collection of psychology related films at

http://www.psychmovies.com

While your there, participate in a brief survey of your favorite and worst psych films.

Popular Films With a Theme of Psychological Disorder

A Beautiful Mind
Agnes of God
Amadeus
As Good as it Gets
Awakenings
Benny and Joon
Birdy
Blue Sky
Clean and Sober
Don Juan de Marco
Eating
Eqqus
Fight Club
Frances
Good Will Hunting
I Never Promised you a Rose Garden
I’m Dancing as Fast as I Can
Inside Moves
Interiors
King of Hearts
Madness of King George
Mosquito Coast
Mr. Jones
Nell
One Flew Over the Cuckoo’s Nest
Ordinary People
Prince of Tides
Rainman
Slingblade
Sophie’s Choice
Sybil
The Dream Team
The Shining
The Snake Pit
The Three Faces of Eve
The Fisherking
Thelma and Louise
Truly, Madly, Deeply
Unstrung Heroes
What about Bob
What’s Eating Gilbert Grape
When a Man Loves a Women
Who's afraid of Virginia Woolf?
Whose Life is it Anyway?
Women Under the Influence
Ya Ya Sisterhood

Major Case Study – Movie Review

Purpose: The purpose of this assignment is to observe an individual(s) who is struggling with abnormality. The story may be fiction or non-fiction. To potentially receive a high grade, the focus of your paper will be on the individual, not on the plot or theme of the movie. In some rare cases, the focus of the movie review paper may be on a faulty mental health or family "system."

1. Focus on the individual:

A. What do you observe about the person, their thoughts, feelings, behaviors?
B. According to the definition(s) presented in both lecture and the texts, is this person acting abnormal?
What are their difficulties?
C. Is a diagnosis given in the film? Is it correct? How was it made? How would you alter the diagnosis?
What do you think the diagnosis is?
D. What are the primary, predisposing, or precipitating causes of their disturbance?
E. How does their history relate to the disturbance?
F. Take a particular model of causality (e.g. biological, psychodynamic) and apply it to this case.

2. Focus on the environment:

A. Are there any environmental influences that you believe are influential to the person's disturbance?
(e.g. the era, the institution, the dysfunctional family, the therapist's practice)
B. Does the movie accurately portray the person? Or, do you believe the case is distorted by
"Hollywood"
C. How do others respond to this person? Focus on both mental health professionals and family
members.
D. If treatment was given, was it helpful, harmful?
E. What do you believe would have helped the person improve/change?

3. Do A Client Map

These are just some questions to ask yourself. Be creative. Each movie, each story is different and should provide a different focus to your paper. Work from your own experience and current
knowledge base. Do not feel that you have to do "research." To potentially receive a high grade, you should not simply answer the above questions, but rather address your main character with these prompting questions in your mind.

Remember to write clearly and in a well-organized manner.

Case 9 - More Than a Five-Fingered-Discount

"Fifteen years!" It was how long Winona had been shoplifting, but from the expression on her tear-streaked face, it might have been the length of her sentence.

Winona was 27, and this was her second arrest, if you didn't count the one as a juvenile. Three years earlier, she had been arrested, booked, and released on her own recognizance for walking out of a boutique with a silk blouse worth $150. Fortunately for her, two weeks later the shop fell victim to the recession; the owner, otherwise preoccupied, did not follow through with the prosecution. Badly frightened, she had resisted the temptation to shoplift for several months afterward.

Winona was married and had a four-year-old daughter. Her husband worked as a musician. After her previous arrest, he had threatened to divorce her and obtain custody of their child if she did it again. She worked an actress prior to being a homemaker. A conviction could doom her return to work.

"I don't know why I do it. I've asked myself that question a thousand times." Aside from stealing, Winona considered herself a pretty normal person. She had lots of friends and no enemies; most of the time she was quite happy. In every other respect she was law-abiding; she wouldn't even let her husband cheat when he prepared their taxes.

The first time Winona had ever stolen from a store was when she was six or seven, but that was on a dare from two school friends. When her mother found the candy she had taken from the convenience store, she had gone with Winona and made her return it to the store manager. It was years before she was tempted to steal again.

In junior high, she noticed that periodically a certain tension would build up inside her. it felt as if something deep within her pelvis itched and she couldn't scratch it. For several days she would feel increasingly restless, but with an excited sense of anticipation. Finally she would dart into whatever store she happened to be passing, whisk some article under her coat or into her handbag, and walk out, flooded with relief. For a time it seemed to be associated with her menstrual periods, but by the time she was 17, these episodes had becomoe completely random events.

"I don't know why I do it," Winona said again. "Of course, I don't like being caught. but I deserve to be. I've ruined my life and the lives of my family. Its not as if i needed another compact - I must have 15 of them at home."

Case 8 - The Case of George W.

George w., a thirty-six-year-old white male, was referred for therapy by the courts. Following his third conviction for driving while intoxicated, George had been sentenced to a six-month stay in a work-release program. Therapy was required as part of his participation in that program.

George began using alcohol when he was fourteen years old and had been drinking excessively since that time. His father, his maternal grandfather, and two of his three brothers all abused alcohol. George had been married to his second wife for two years and had a one-year-old child. his first marriage had ended in divorce four years earlier, partly because his wife would no longer tolerate George's drinking. He had maintained contact with his two children from that marriage.

George was employed as a supervisor for a construction firm. He had been with the same company for over ten years and had a good work record. He consumed little alcohol during the day, but on most evenings he would begin drinking beer as soon as he returned home from work, and he also drank on most weekends. He had tried to stop drinking on his own repeatedly and had been alcohol free for six months when he married his present wife. However, he stated that financial difficulties associated with the birth of their child led him to resume drinking. George reported frequent weekend episodes of binge drinking and occasional blackouts. He said that his wife was unhappy about his drinking and expressed disappointment that they never went out; but sincee she was always absorbed in caring for the baby, he did not believe going out mattered any more to her than it did to him.

George reported some mild depression and stated that he was very shy and never felt comfortable around people. Alcohol had helped him feel more self-confident, so that he was able to establish relationships with a group of male peers who also drank to excess. The possibility of an underlying avoidant personality disorder was considered. Otherwise, George's difficulties all seemed related to his alcohol use.

Case 7 - The Misdirected Gentleman

Henry McWilliams had been born in London. Dressed in his short grey pants, white shirt, and school tie, he rode the London underground every day to his exclusive school. One day, when he was nine, he saw a man rubbing up against a woman on the Underground.

Henry was small when he was nine, and even in the crowded subway car he has an excellent eye-level view. The woman (she was an adult, though Henry had no idea how old) was a bit overweight and dressed in a tight-fitting mini-skirt. She was facing away from the man, who allowed the weight of the crowd surging through the doors top press him up against her. The man tugged at his crtoch, and then, as the train began to move, rubbed himself against her.

"I never saw her face, but I could tell she didn't like it," said Henry. "She tried to push him away, she tried to move, but there was no place for either of them to go. Then the train stopped and he ran out the door."

Henry the adult, age 24, had now referred himself for treatment. He had moved with his parents to the United States when he was 15. Since his graduation from high school, he had worked as a messenger for a large legal firm. Many days he spent on the subway in his official capacity. He guessed that he had rubbed against 200 women in five years. He was seeking help at the insistance of one of the partners in his law firm, who the week before had happened to ride the same train and watched him in action.

When Henry was in need, he would go into the men's room and put on a condom so as not to stain his trousers. Then he would roam up and down the outskirts of a crowd on a subway platform until he found a woman who interested him. This would be someone who was youngish but not young ("They're less likely to scream."), and well-rounded enough to stretch tight the material of her skirt or slacks. He especially liked it if the material was leather. He would board after she did, and if she did not turn around, would rub his erection up and down against her buttocks as the train began to roll.

"I'm very sensitive, so it doesn't take much pressure." Sometimes the woman didn't even seem to realize what was going on, or maybe she didn't want to admit it, even to herself. He usually climaxed within a minute. Then he would bolt out the door at the next stop. In the event that he was interrupted, he would hang out around the platform until he spotted another woman in another crowd.

"It helps if I imagine that we're married or engaged," he explained. "I'll pretend that she's wearing my ring, and I've come home for a quickie."

Case 6 - Melvin B.

Melvin B. a sixty-two-year-old black male, was referred for therapy by his physician. He had been diagnoses as having gastric ulcers

Case 5 - The Case of the Quiet Zombie

An eleven-year-old girl asked her mother to take her to a psychiatrist because she feared she might be "going crazy." Several times during the last two months she has awakened confused about where she is until she realizes she is on the living room couch or in her little sister's bed, even though she went to bed in her own room. When she recently woke up in her older brother's bedroom, she became very concerned and felt quite guilty about it.

Her younger sister says that she has seen the patient walking during the night, looking like a "zombie," that she didn't answer when she called her, and that the patient has done that several times, but usually goes back to her bed.

The patient fears she may have "amnesia" because she has no memory of anything happening during the night.

There is no history of seizures or of similar episodes during the day. An electroencephalogram and physical examination prove normal. The patient's mental status is unremarkable except for some anxiety about her symptoms and the usual early adolescent concerns. School and family functioning are excellent.

Child Case - Baby Susan

Susan was admitted to the hospital at age 6 months by an aunt for evaluation of failure to gain weight. She had been born into an impoverished family after an unplanned, uncomplicated pregnancy. During the first four months of life, she gained weight steadily. Regurgitation was noted during the fifth month, and increased in severity to the point where she was regurgitating at every feeding.

After each feeding, Susan would engage in one of two behaviors:

1) She would open her mouth, elevate her tongue, and rapidly thrust it backward and forward, after which milk would appear at the back of her mouth and slowly trickle out; or

2) She would vigorously suck her thumb and place fingers in her mouth, following which milk would slowly flow out of the corner of her mouth.

In the past two months, Susan had been cared for by a number of people, including her aunt and paternal grandmother. Her parents were making a marginal marital adjustment. Nevertheless, Susan often smiled and was responsive to all of her caregivers.

Case 4 - Wally Graham

"The news is good," announced Wally Graham's clinician. "Your x-rays and the other tests show nothing wrong - no cancer, no ulcer, not even gastritis."

Wally Graham did not look pleased. "I don't understand it."

"I mean I don't understand why I'm still having the pain and why I'm throwing up nearly every morning." He slowly began to put on his shirt.

The clinician leafed through his chart. "I checked with your previous HMO. They said you'd had the same set of tests done there six months ago. And the year before that."

"Yes, I told you all about that, last time I was here. I haven't held anything back." Wally had begun to sound angry. "This has been going on for four or five years now. I don't like being this way, you know."

"No, of course not," said the clinician. "I didn't mean that. I meant that for years you've had stomach pains, nausea, vomiting, and diarrhea, and for years you've been afraid you have cancer. You've had at least four workups by excellent clinicians; they've all reassured you that nothing is wrong. Only you don't feel reassured. Last week you were even gastroscoped by our gastroenterologist. That's the most definitive test you can get. There weren't even enough findings to diagnose an upset stomach! I'm not saying you don't have pain, but I think your problem is somewhere besides your stomach. I'd like to check out some other possibilities, to see if we can get to the bottom of this."

"I hope so." Wally Graham was less angry, but he still sounded unconvinced. Fully dressed now in his tie and sports jacket, he looked somehow smaller than he had before. He was a 42-year-old, unmarried accountant who worked for a branch of one of the large national firms that advertised on TV. He liked his job (except during tax season, which nobody liked). but several days a month he had to stay in bed with abdominal pains. His supervisor was becoming restive.

Of course, Wally had been worried, maybe even a little depressed. He had felt this way occasionally throughout his ordeal of the past several years, but his concentration had been good and his interest in work and leisure activities had been high. Any problems with sleep or appetite had been due to the abdominal distress, which only lasted for a few days each time. He had never had suicidal ideas.

Wally had never tried street drugs; for years he avoided alcohol in any form. Except for his abdominal distress, his health was good. He denied everything on an impressively long list of symptoms that included headache, dizziness, chest pain, painful urination, and musculoskeletal and neurological complaints. Over the years he had quite a lot of anxiety about having cancer, but he never experienced a full-blown panic attack. He had never heard voices or seen visions, nor did he believe that people were plotting or talking about him behind his back.

The first few times a clinician told Wally that he did not have cancer, he felt relieved, but after a few days, the symptoms would start again and he would worry. "What if the lab had switched somebody else's tests with his?" "Suppose the radiologist had misread the film." "Or perhaps, I didn't have cancer then, but I've developed it since the last tests were made. How's anyone going to reassure me about that?"

*Note, You are looking for an Axis I diagnosis. Also, how is this case different from that of Jason Bird in Case 3?

Case 3 - Jason Bird

Jason Bird was a 47 year old man who was admitted to a cardiac intensive care unit despite having no health care card-- he claimed he had lost his billfold to a mugger a few hours earlier. He came to the emergency room of a Midwestern hospital late on Saturday night, complaining of crushing sub-sternal chest pain. Although his electrocardiogram (EKG) was markedly abnormal, it did not show the changes typical of an acute myocardial infarction (MI). The cardiologist on call, noting his ashen pallor and obvious distress, ordered him admitted and then waited for the cardiac enzyme results.

The following day, Jason's EKG was unchanged and the serum enzymes showed no evidence of heart muscle damage. His chest pain continued. He complained loudly that he was being ignored. The cardiologist urgently requested a mental health consultation. Jason was a slightly built man with a bright, shifting gaze an a four day growth of beard. He spoke with a nasal Boston accent. His right shoulder bore the tattoo of a boot and the legend "Born to Kick Ass". Throughout the interview he frequently complained of chest pain, but had no difficulty breathing or talking, and he showed no signs of anxiety about his medical condition.

He said he had grown up in Quincy, Massachusetts, the son of a physician. After high school, he attended college for several years, but found he was "too creative" for a profession or conventional job. Instead, he had turned to inventing medical devices, and numbered among his successes a positive-pressure respirator that bore his name. Although he had made several fortunes, he had lost nearly everything to his penchant for playing the stock market. He had been visiting in the area, relaxing, when the chest pain struck.

"And you've never had it before?" asked the interviewer, looking through the chart.
Jason denied that he'd had any previous heart trouble.
"Not even a twinge. I've always been blessed with good health."
"Ever been hospitalized?"
"Nope. Well, not since a tonsillectomy when I was a kid."
Further questioning was similarly unproductive. As the interviewer left, Jason was demanding an extra meal service. Playing a hunch, the interviewer began telephoning emergency room physicians in the Boston area to ask about a patient with Jason's name or peculiar tattoo. The third try struck pay dirt.

"Jason Bird? I wondered when we'd hear from him again. Hes been in and out of half the facilities in the state. His funny looking EKG-- probably an old MI looks pretty bad, so he always gets admitted, but there's never any evidence that anything acute is going on. I don't think that he's addicted. A couple of years ago he was admitted with genuine pneumonia and got through a week without pain medication and with no withdrawal symptoms. He'll stay in the ICU a couple of days and rag on the staff. Then he'll split. He seems to enjoy needling medical people."

"He told me that he was the son of a physician and that he was a wealthy inventor."

The physician at the other end of the line chuckled. "The old respirator story. I checked into that one when he was admitted here for the third time. That was a different Bird altogether. I don't know that Jason's ever invented anything in his life. As for his father, I think he was a chiropractor." Returning to the ward to add a note to the chart, the interviewer discovered that Jason had discharged himself against medical advice and departed, leaving behind a complaining letter to the hospital administrator.

Case 2 - The Story of the Dizzy Electrician

A 27-year-old married electrician complains of dizziness, sweating palms, heart palpitations, and ringing in the ears of more than 18 months duration. He has also experienced dry mouth and throat, periods of extreme muscle tension, and a constant "edgy" and watchful feeling that has often interfered with his ability to concentrate. These feelings have been present most of the time over the previous 2 years; they have not been limited to discreet periods. Although these symptoms sometimes make him feel "discouraged," he denies feeling depressed and continues to enjoy activities with his family.

Because of these symptoms the patient has seen a family practitioner, a neurologist, a neurosurgeon, a chiropractor, and an ear-nose-throat specialist. He had been placed on a hypoglycemic diet, received physiotherapy for a pinched nerve, and told he might have "an inner ear problem."

He also has many worries. He constantly worries about the health of his parents. His father, in fact, had a myocardial infarction 2 years previously, but is now feeling well. He also worries about whether he is a "good father," and whether his wife will ever leave him (there is no indication that she is dissatisfied with the marriage), and whether he is liked by co-workers on the job. Although he recognizes that his worries are often unfounded, he can't stop worrying.

For the past 2 years the patient has had few social contacts because of his nervous symptoms. Although he has sometimes had to leave work when the symptoms become intolerable, he continues to work for the same company he joined for his apprenticeship following high school graduation. He tends to hide his symptoms from his wife and children, to whom he wants to appear "perfect," and reports few problems with them as a result of his nervousness.

(For those of you who prefer a directive approach)
Please give the Axis I diagnosis; defend your diagnosis with three to five characteristic
symptoms/situations; possible etiology, onset and prognosis; and suggest a treatment.

Online Diagnostic Resources

This link will take you to the ICD-10 online

Here is a specific link to the Mental and Behavioral Health Classifications.

Here is a link to psyweb.com which has assessments, flow charts, DSM classifications and more.

Here is a link to BehaveNet's extensive DSM resources.

Using www.turnitin.com

Here is the link to turnitin.com

This is where you will be sending your written assignments. Because, this is only now available, you may turn in assignments in person or via email to me. Thank you.

Evidence for Effective Treatment of PTSD

The Institute of Medicine (IOM) Committee on Treatment of Posttraumatic Stress Disorder (PTSD) was charged by the Department of Veterans Affairs (VA) to review and assess the evidence on the efficacy of pharmacologic and psychologic treatment modalities for PTSD
(see Box S-1 for the complete Statement of Task).

The committee was given five major tasks: review the scientific evidence and make conclusions regarding efficacy; note restrictions of the conclusions to certain settings, populations, and so on; comment on gaps and future research; answer several questions related to the goals, timing,
and length of treatment; and finally, note areas where the evidence base is limited by inadequate attention or poor quality.

This report contains the committee’s conclusions about the strength of the evidence regarding the efficacy of various treatment interventions.

http://www.nap.edu/catalog.php?record_id=11955

If you have any trouble getting this article post a comment.

Case 1 - The Story of Maggie

Maggie is a 22 year old lady who has been diagnosed with cerebral palsy and severe mental retardation. Over her life, she has made great improvements in her ability to communicate and understand the world around her. She was very social as a child and young adolescent. Her cognitive and social growth, however, stalled in early adulthood. She began having angry outbursts, violent nightmares, and appeared to be fearful of things that did not bother her in the past. Her willingness to socialize also reduced. Her mother later found out that a family member sexually assaulted her. She pressed charges and ensured that Maggie would never interact with him again. Maggie’s behaviors did not improved and, after the ceiling in her bedroom fell while she was sleeping, they worsened. It was difficult to get Maggie to go anywhere without her mother. She would have bouts of crying and throwing “tantrums”. She refused to sleep in her bedroom, even after repairs were made to the ceiling. Maggie’s mother took her to a psychologist who diagnosed her with PTSD in relation to the sexual assault and falling ceiling. She is now takes Zoloft, an SSRI. Her behaviors are slowly improving.

Does she meet the criteria for PTSD? Can you tell from this brief case study? If not, what is missing?

Post Traumatic Stress Disorder

by Erika Donaldson

Abstract

Posttraumatic stress disorder (PTSD) begins with exposure to a traumatic event. The disorder is marked by reexperiencing, avoidance of reminiscent stimuli, numbing of responsiveness, and increased arousal associated with the traumatic event. Traumatic events can be experienced directly, witnessed, or learned about. In addition, as with all mental disorders, the symptoms must also cause distress or impairment in areas of functioning to meet the diagnostic criteria. The prevalence of PTSD in adults is 8% over a lifetime (American Psychological Association, 2000). Many psychological, biological, and social factors appear to contribute the development of this disorder (Barlow & Durand, 2009). Other factors, such as the intensity and source (human design vs. nature) of the traumatic effect appear to affect the likelihood of PTSD development (American Psychological Association, 2000). Treatments for PTSD are relatively effective and include cognitive-behavioral therapy, eye movement desensitization and reprocessing (EMDR), and serotonin reuptake inhibitors (SSRIs) (National Center for PTSD, 2008). Special attention for this research review will be given to the experience of PTSD for individuals with developmental disabilities as it relates to the case study.

Diagnostic criteria for 309.81 Posttraumatic Stress Disorder

The person has been exposed to a traumatic event in which both of the following are present:

• the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
• the person’s response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior

The traumatic event is persistently reexperienced in one (or more) of the following ways:

• recurrent and intrusive recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed
• recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable context
• acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur
• intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
• physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
  

Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:

• efforts to avoid thoughts, feelings, or conversations associated with the trauma
• efforts to avoid actual activities, places, or people that arouse recollections of the trauma
• inability to recall an important aspect of the trauma
• markedly diminished interest or participation in significant activities
• feeling of detachment or estrangement from others
• restricted range of affect (e.g., unable to have loving feelings)
• sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:

• difficulty falling or staying asleep
• irritability or outbursts of anger
• difficulty concentrating
• hypervigilance
• exaggerated startle response
  

Duration of disturbance (symptoms in Criteria B, C, and D) is more than 1 month.

The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

Specify if:
Acute: if duration of symptoms is less than 3 months
Chronic: if duration of symptoms is 3 months or more

Specify if:
With Delayed Onset: if onset of symptoms is at least 6 months after the stressor.

Related Links

The Center for Trauma Recovery (CTR) www.umsl.edu/divisions/artscience/psychology/ctr/index.html
The National Institute of Mental Health (NIMH)
http://www.nimh.nih.gov/
US Department of Veteran Affairs
http://www.ncptsd.va.gov/

Know Your ABCs: Behavioral Assessment Basics

Behavioral assessment takes the mental status exam a step further by using direct observation to formally assess an individual’s thoughts, feelings, and overt behaviors in specific situations or contexts. This information is used to explain the maintenance of present problems in the here and now. Observations may occur in the therapy context, in the home, schools, the workplace, or in other real life situations.

The purpose of behavioral assessment is to identify target behaviors (problematic behaviors) and environmental events that may become targets of therapeutic intervention. This is accomplished via a functional analysis of antecedents, behaviors, and consequences (i.e., the ABCs of observation) following the behavior.

Observational assessment is usually focused on the here and now. Therefore, the clinician's attention is usually directed to the immediate behavior, its antecedents (what happened just before the behavior), and its consequences (what happened afterward) (Hersen 2006)

Behavioral observation may be either formal or informal. In formal observation, the observation procedures are usually structured and systematic, and involve behavior rating scales or checklists (such as the Brief Psychiatric Rating Scale) and clear operational definitions of target behaviors. Informal observation is less standardized and systematic.

People may also be asked to observe their own behavior using a technique called self-monitoring or self-observation (e.g., recording the number of cigarettes smoked per day). Self-monitoring may be formal (e.g., using scales, coding sheets, checklists) or informal (e.g., recording overall mood each day).

Reactivity can distort observational data, and refers to changes in behavior as a result of knowing that one is being observed. Anytime you observe how people behave, the mere fact of your presence may cause them to change their behavior (Hersen 2006) Reactivity can occur while being observed by others or when self-monitoring. Behaviors tend to shift in the desired direction with reactivity.

The Importance of Empathy

The Importance of Empathy in the Therapeutic Alliance.
by Candi P. Feller , R. Rocco Cottone

In this investigation of the construct of empathy, the authors report that the literature reflects strong evidence that empathy is an essential component of the therapeutic alliance across theories and that empathy is necessary in the counseling process. The concept of empathy continues to be a central component of new forms of counseling and therapy.
Rogers (1957) conceptualized and specified six conditions that he considered to be both necessary and sufficient for therapeutic client change to occur. Rogers hypothesized that these six conditions apply to all psychotherapy, not just to client-centered therapy. These conditions require counselor congruence or genuineness in the therapeutic relationship, unconditional positive regard for the client (warmth), the ability of the counselor to empathize with the client in this relationship, and communication of empathy and unconditional positive regard to the client. Of the conditions defined by Rogers as both necessary and sufficient, empathy is the construct that has evoked the most attention from psychotherapy theorists and researchers.

An exerpt from The Importance of Empathy in the Therapeutic Alliance. Journal article by Candi P. Feller, R. Rocco Cottone; Journal of Humanistic Counseling, Education and Development, Vol. 42, 2003

Don't Stress when it comes to DSM Diagnosis!

Providing a DSM diagnosis can seem complex, can be frustrating, or even seem "just not right." As clinicians, we want to provide the best possible care for our clients and often a diagnosis is necessary.

Just remember:

• "diagnostic categories are just a convenient format for organizing observations that help professionals communicate, study and plan. If we reify a category (such as depression), we literally make it a 'thing', thus assuming that 'it' has meaning that, in reality, does not exist."(Barlow and Durand 2009)
• This is a young science and the science is changing rapidly. If your client fits two or more categories, that's OK. Don't expend too much energy trying to get a unique client to fit into a category.
• And most importantly, there is strong evidence, that despite your theoretical approach and system of organization, the service that you provide as a clinician is of psychological benefit and the therapeutic alliance contributes to positive outcomes. (See Empathy next)

Resources

The Importance of Empathy in the Therapeutic Alliance
Journal article by Candi P. Feller, R. Rocco Cottone; Journal of Humanistic Counseling, Education and Development, Vol. 42, 2003

Therapeutic alliance perceptions and medication adherence in patients with bipolar disorder.

Therapeutic Alliance and Psychiatric Severity as Predictors of Completion of Treatment for Opioid Dependence Nancy M. Petry, Ph.D. and Warren K. Bickel, Ph.D.

Abnormal Psychology: An Integrative Approach (with Abnormal Psych Live CD-ROM), 5th Edition Barlow/DurandISBN-10: 0-495-09556-7ISBN-13: 978-0-495-09556-9

The Clinical Interview and the Mental Status Exam

The clinical interview is the core of most clinical work and is used primarily to gather information about past and present behavior, attitudes, emotions, and a history of the person's problem(s) and life circumstances. Other important points to cover include precipitating events, family composition and history, sexual development, religious beliefs, cultural concerns, educational achievement, and social-interpersonal history.

To organize information obtained during an interview, many clinicians will use a mental status exam; an exam that involves the systematic observation of a client’s behavior across five domains:

a. Appearance and behavior
b. Thought processes (e.g., rate and flow of speech, clarity, and content of speech and ideas)
c. Mood and affect (e.g., is affect and mood appropriate of inappropriate?)
d. Intellectual functioning (e.g., does the client have a reasonable vocabulary and memory?)
e. Sensorium (i.e., general awareness of surroundings such as date, place, time, knowledge of self).

Clinical interviews may be structured or semistructured.

Unstructured clinical interviews are not standardized with respect to procedure and content and follow no systematic format.

Semistructured clinical interviews contain questions that have been carefully phrased and tested to elicit useful information in a consistent manner, but also allow room for clinicians to depart from the format with additional questions of interest (e.g., Anxiety Disorders Interview Schedule, 4th ed., or the Structured Clinical Interview for DSM).

Clinicians often recommend a physical examination, particularly if the patient has not been seen by a medical doctor in the past year. The reason for the physical exam is to rule out medical conditions that are associated with psychological disorders and those that may masquerade as psychological disorders. Examples of physical conditions that may lead to psychological problems include toxic states, hyperthyroidism (anxiety), hypothyroidism (depression), brain tumor, and drug ingestion.

There are a variety of ways to conduct a clinical interview. The best way is the one that values your client's input and systematically records your clinical observations for later evaluation. It is important to conduct the clinical interview in a way that elicits the patient’s trust and empathy in order to facilitate communication. Alway remember, information provided by patients to psychologists and psychiatrists is protected by laws of confidentiality.

Heisman Trophy Winner Ricky Williams overcame Social Anxiety Disorder

Ricky Williams had it all - fame, fortune, but a treatable problem almost ruined him.

Here is his story as told by Leslie Anderson.

Brochures on Various Anxiety Disorders provided by AADA.org

A Brief Overview of Anxiety Disorders

Obsessive-Compulsive Disorder (OCD)

Panic Disorder

Social Anxiety Disorder (SAD)

Post-Traumatic Stress Disorder (PTSD)

Specific Phobias

Generalized Anxiety Disorder (GAD)

Interactive Tutorial on Stress Management

This tutorial will provide you with basic information regarding stress management.

http://www.makingthemodernworld.org.uk/learning_modules/psychology/07.TU.09/?section=1

The Comorbidity of Anxiety and Eating Disorders

Here is a link to a paper on the association between Anxiety and Eating Disdorders.

http://www.vanderbilt.edu/AnS/psychology/health_psychology/AnxietyandEatingDisorders.html

What is Stress?

Here is a link to an interactive website from the Modern World Museum that covers stress.

http://www.makingthemodernworld.org.uk/learning_modules/psychology/02.TU.01/

DO A CLIENT MAP

DO A CLIENT MAP is a Mnemonic device for therapists to recall the basics of a diagnostic interview. The diagnostic interview is one of the therapists best tools for organizing clinical information pertinent to future diagnosis and treatment.

DO A CLIENT MAP

Diagnosis
Objectives of treatment
Assessments needed (e.g. neurological, personality)
Clinician characteristics viewed as therapeutic
Location of treatment (e.g. hospital, outpatient)
Interventions to be used
Emphasis of treatment (level of directiveness; level of supportiveness; cognitive, behavioral, affective emphasis)
Nature of treatment (individual, couple, family, group)
Timing (frequency, pacing, duration)
Medications needed
Adjunct services (e.g. support groups, legal advice, education)
Prognosis

excerpted from "Selecting Effective Treatments" Linda Seligman 1990

Types of Anxiety Disorders

Here is a link to anxietyconnection.com (sponsored by the ADAA) for
types of anxiety disorders

http://www.healthcentral.com/anxiety/disorder-types.html?ic=4025

Social Anxiety Disorder Interactive Website

Here is a link to a interactive website covering Social Anxiety Disorder (SAD).

http://www.adaa.org/socialanxietydisorder/default.asp

Anxiety Disorder Association of America

The website contains general information on anxiety disorders and a comprehensive listing of ADAA-affiliated groups.

http://www.adaa.org/

National Mental Health Self-help Clearinghouse

The Center For Mental Health Services hosts this website for those with questions about mental health issues.

http://www.mhselfhelp.org/

Introduction to Abnormal Behavior

http://www.makingthemodernworld.org.uk/learning_modules/psychology/02.TU.04/?section=1

Depression and Career Development By Roger Wilcoxen

As a Regional Career Advisor, who is also involved in the religious community, I have found congruence between counseling those in career development and the religious community concerning depression. Three key principles, Focus, Realization and Acceptance are creating a difference between feeling trapped and becoming successful. These principles lay a foundation toward career growth and most importantly, personal growth. Preparing clients for success can be challenging yet fulfilling, even if depression is a factor.
FOCUS: A person’s ability to focus on strengths instead of weaknesses is crucial during career development, and more crucial for an individual with depression. For the depressed, it is easy to permit cognitive distortions, obscure thoughts, and even obstruct the ability to clarify strengths. Individuals who attend to positive attributes of their achievements and goals generate confidence and the ability to progress forward in career growth.
As professionals, extending a fresh outlook on employment processes and offering positive feedback regarding the client’s abilities often provides the assurance clients need. Through the process of resume development, client’s are able to highlight positive aspects of their abilities and create opportunity for personal growth and positive outlook. The use of tools indicating transferable, soft, and hard skills provides opportunity to examine the full spectrum of one’s abilities. Individuals succumbed with depression generally are aware of their weaknesses; focusing on strengths challenges thinking and refocuses one’s attention.
REALIZATION: There are some realizations individuals need to accept during the process of career development.
1. Rejection doesn’t mean elimination. Numerous times I have witnessed individuals coming back from an interview feeling rejected. Applicants need to understand that the employment “pool” is large and unless there are obvious aspects of the interview process needing to be refined, what they are experiencing may be completely natural. In large pools of applicants, it is tough for employers to formulate hiring decisions. Feelings of rejection, especially continual rejection that can be experienced in the job search, can lead to depressive issues. Guiding individuals through this process may be difficult, yet very rewarding. Reassuring clients of their abilities and character strengths often times conveys further hope toward success.
2. Failing doesn’t equal failure. Just because one has not successfully ascertained an interview, or has had character issues, does not mean they are a failure. People generally struggle with the interview process, and some even feel like failures after “bombing” an interview. I remember a colleague who has been in career development over 35 years once telling me, “Roger I have interviewed and been interviewed hundreds of times and I still get nervous and mess up. The important thing isn’t that you have messed up or have flawed your character in the past. The crucial lesson is that we learn from those shortcomings by finding solutions and then moving forward.”
Yet how do we guide clients dealing with failure? This is one of the hardest components of career development and a strong self-sabotaging tool people use. It is important that continual follow up, opportunity for mock interviews and educational interviews be utilized. Once a client appears to be self-sabotaging, immediate intervention is important to help the client refocus and be assured. Help the client see that they can be successful in their career and not doomed for failure.
ACCEPTANCE: Acceptance of abilities, accomplishments and employment availability are crucial in successful establishment of a career.. Generally this is done fairly easy for individuals seeking career transformations, yet, difficult for depressed individuals. Career Counselors guiding people toward realistic expectations need to focus on two main goals:
1. Acceptance of abilities and accomplishments; own them.
Clients wanting to discredit their abilities and overlook their accomplishments may find it complicated to develop a resume and accomplish successful interviewing skills. An important feature of career development is how to “own” abilities and accomplishments in a way that demonstrates self-confidence and professionalism. What may seem as a small accomplishment to one may be huge in the eyes of an employer who desires those abilities.
Professionals provide not only guidance in discovering abilities and accomplishments, but helping a client recognize personal attributes and how to reward oneself. Too many people discredit themselves and therefore cut themselves short. When counselors offer guidance in this area, it opens the door toward confidence and personal growth.
2. Acceptance of character; live it.
Character is critical in career development. Employers often ask for referrals and one question asked is, “Are they a person of character?” Character is the ability to be professional and to exhibit integrity and respect. I have had employers tell me: “Give me a person of character, and I can teach them anything. Give me a person with no character with tremendous abilities, and they will destroy my company.”
Character has become known as “soft skills” throughout most industries. The development of these skills can be challenging and extremely frustrating for professionals who observe individuals self-sabotaging. There is a question of consideration for clients: Would I hire myself based on my character, and why? Once this question is examined, opportunity avails itself for professionals to direct individuals in accepting shortcomings and working toward positive solutions. This process develops not only career success, but allows people the opportunity to grow individually as well.
Depression can be overwhelming during career change, yet career change can be a very positive experience as well. Focus, Realization, and Acceptance are powerful attributes needed to develop a successful and positive experience during career change and also decrease the characteristics of depression.
Roger Wilcoxen holds a MA in Counseling Psychology, serves as a State Board Member for Kansas Association of Master’s in Psychology, is a Regional Career Advisor for Johnson County Workforce Partnership, and serves in various ministry capacities. You may contact him at: roger.w.wilcoxen@hotmail.com.

DSM Multiaxial Model

DSM Multiaxial Model

The disorders in the DSM are grouped in terms of a multiaxial model.

Multiaxial literally means multiple axes. Each axis represents a different kind or source of information. Later, we concentrate on exactly what these sources are; now, we just explain their purpose.

The multiaxial model exists because some means is required whereby the various symptoms and personality characteristics of a given patient can be brought together to paint a picture that reflects the functioning of the whole person.

For example, depression in a narcissistic personality is different from depression in a dependent personality. Because narcissists consider themselves superior to everyone else, they usually become depressed when confronted with objective evidence of failure or inadequacy too profound to ignore. Their usually puffed-up self-esteem deflates, leaving feelings of depression in its wake.

In contrast, dependent personalities seek powerful others to take care of them, instrumental surrogates who confront a cruel world. Here, depression usually follows the loss of a significant caretaker. The point of the multiaxial model is that each patient is more than the sum of his or her diagnoses: Both are depressed, but for very different reasons. In each case, what differentiates them is not their surface symptoms, but rather the meaning of their symptoms in the context of their underlying personalities.

By considering symptoms in relation to deeper characteristics, an understanding of the person is gained that transcends either symptoms or traits considered separately. To say that someone is a depressed narcissist, for example, conveys much more than does the label of depression or narcissism alone.

The multiaxial model is divided into five separate axes (see Figure 1.1), each of which gets at a different source or level of influence in human behavior.

Axis I, clinical syndromes, consists of the classical mental disorders that have preoccupied clinical psychology and psychiatry for most of the history of these disciplines. Axis I is structured hierarchically. Each family of disorders branches into still finer distinctions, which compose actual diagnoses. For example, the anxiety disorders include obsessive-compulsive disorder, posttraumatic stress disorder, and generalized anxiety disorder. The mood disorders include depression and bipolar disorder. Other branches recognize sexual disorders, eating disorders, substance abuse disorders, and so on. Finally, each disorder is broken down into diagnostic criteria, a list of symptoms that must typically be present for the diagnosis to be given.

Axis II, personality disorders, is the subject of this text.

Axis III consists of any physical or medical conditions relevant to understanding the individual patient. Some influences are dramatic, and others are more subtle. exerpt from Personality Disorders in Modern Life By Theodore Millon Carrie M. Millon Sarah Meagher Seth Grossman Rowena Ramnath John Wiley & Sons ISBN: 0-471-23734-5

Welcome to the Adult Diagnosis Blog

The purpose of this weblog is to aggregrate information for the education of graduate students studying abnormal behavior, diagnosis and treatment.