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102 Cards in this Set

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In conducting a biopsychosocial assessment, it is important for a psychologist to consider the extent to which the signs, symptoms, syndroms, or disorder are manifested in a give population. This means considering the?
Epidemiological fit
What signifies a Mental Disorder?
1. clinically significant behavioral or psychological syndrome or pattern that is associated with present distress (e.g.painful symptom) or disability (e.g.impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain or disability, or an important loss of freedom.

2. Must NOT be a culturally sanctioned response to a particular event (e.g. a death of a loved one)

3. It must be currently be considered a manifestation of a behavioral, psychological, or biological dysfunction in the individual.

4. Can you work? Can you have a relationship? Occupational and/or social impairment getting in the way of leading their lives.
What is a syndrome?
A group of set or concurrent symptoms which together are indicative of a disorder or disease.
What is a symptom?
Any sign, physical or mental, that stands for or signifies something (e.g. psychopathology), this is what the client REPORTS: "I feel depressed." I feel anxious"
What is a sign?
Observable phenomena which my signify something (e.g. psychopathology, behavioral disturbance), this is what YOU observe: a tear, smiling, crying
True or false: Can ONE sign symptom constitute a disorder?
False:sometimes a symptom (sleep disorder) can appear in a number of disorder descriptions. Sometimes a certain symptom can constitute a certain disorder, BUT do not diagnose on ONE symptom alone.

Take the time to look at the bigger picture, don't telescope.
What are some reasons to DIAGNOSE?
1. definition and organization of clinical information.

2. communication with other professionals and agencies (e.g. reports, insurance companies)

3. prediction of clinical course (prognosis)

4. selection of treatment (MOST IMPORTANT): to know which treatment to prescribe
What are some LIMITATIONS in diagnosing?
1. diagnostic language: can be dehumanizing

2. depersonalization

3. cultural bias:
a. nomenclature
b. evaluator bias

4. variable symptom manifestation: physical vs. mental.

*be sure to be able to justify your diagnosis: why it is this diagnosis and not that diagnosis.
What is an ETIC approach?
assumes/emphasizes universals among human beings, treats people like they are all the same, DSM is beginning to shift away from this thinking.
What is an EMIC approach?
classifies psychological phenomena in appropriate cultural context-considers divergent attitudes, values, and behaviors within a given culture
What is the ICD?
International Classification of Diseases and Related Health Problems (ICD), mostly used in hospital settings, DSM/ICD comparison in DSM
History and evolution of the DSM
1. alternative to ICD
1a. originally a psychiatrist manuel
2. psychiatrist (white, males) making revisions
3. DSM IV: first time there was a cultural aspect
DSM IV-TR MULTI-AXIAL SYSTEM: what is on AXIS 1?
AXIS I:
clinical disorders and other conditions that might be a focus of clinical attention (diagnoses)
DSM IV-TR MULTI-AXIAL SYSTEM: what is on AXIS II?
AXIS II:
personality disorders
metal retardation
(diagnoses)
DSM IV-TR MULTI-AXIAL SYSTEM: what is on AXIS III?
AXIS III:
General Medical Conditions
Any pre-existing conditions? could be affecting mental issue(s) (ex. Alcoholic and had diabetes)
DSM IV-TR MULTI-AXIAL SYSTEM: what is on AXIS IV?
AXIS IV:
psychosocial and environmental problems: homeless
DSM IV-TR MULTI-AXIAL SYSTEM: what is on AXIS V?
AXIS V:
Global Assessment of Functioning GAF p. 34
In the DSM what does the code provisional mean?
pretty sure you know the code number, but need more information and will probably get it soon.
What are specifiers?
specify whether the disorder is mild, moderate or severe? in remission, recurrent, single episodes, nos?
what is NOS?
Not Otherwise Specified (ex. Depression NOS: the person is depressed, but cannot complete the diagnosis; doesn't fill all of the criterias)
DSM IV-TR MULTI-AXIAL SYSTEM: what are some things to keep in mind about this guide?
1. it is not the final version: there will be a DSM V

2.the DSM system is not for amateurs

3.It is no uniformly applicable to all cultures

4. Is not the law
EGO FUNCTIONS:
REALITY TESTING
the ability to test the accuracy of your perceptions, used in psychosis
EGO FUNCTIONS:
JUDGMENT
ability to evaluate the consequences/appropriateness of your behavior; doesn't usually form until your 20's, (ex. alcohol and dementia can impair your judgment)
EGO FUNCTIONS:
SENSE OF REALITY OF THE WORLD AND OF THE SELF
dissociate: external events or one's physical bodies events are experienced as real, "out of body experience," (ex. in a bad car accident, traumatic event/dream like, this is the mind's way of protecting itself)
EGO FUNCTIONS:
REGULATION AND CONTROL OF DRIVES, AFFECTS, IMPULSES (IMPULSE CONTROL).
ability to control one's urges, frustrations; impaired judgment and poor impulse control of often related.
EGO FUNCTIONS:
THOUGHT PROCESSES (COGNITION)
Memory, concentration, and attention: how is the brain working? how is everything functioning?
EGO FUNCTIONS:
ADAPTIVE REGRESSION IN THE SERVICE OF THE EGO
self-observed; ability to play to serve the ego, play, spontaneity: overtime notice people, sense of humor
EGO FUNCTIONS:
DEFENSIVE FUNCTIONING (DEFENSES)
success or failure of defenses, but if not working we will see signs and symptoms (acting out); evaluate how they affect a person's thinking, behavior, and maturity.

Primitive defenses: denial, splitting = suitable for a 5 year old

EX: if a 45 year old has primitive defenses then there is a problem
EGO FUNCTIONS:
STIMULUS BARRIERS
EX: someone who studies all night and then is angry the next morning and cannot screen out the stimuli; compared to someone who utilizes self-care
EGO FUNCTIONS:
AUTONOMOUS FUNCTIONING
can the person FUNCTION despite stressers?
EGO FUNCTIONS:
SYNTHETIC FUNCTIONING
psychological management of potentially conflictive things/trouble with conflictory roles, material, information,

EX: client likes you but your car has been having trouble and you've been late a few times to sessions, most people understand, but some have trouble (they like you but you've hurt them)
EGO FUNCTIONS: Mastery Competence
Looking at someone's actual level of competence compared to their assessment of their competence, ability to adapt to unexpected things, surprised
EGO FUNCTIONS:Object Relations
kind and degree of relatedness to others; person's present relationship and seeing how they are adaptive or maladaptive because of previous relationships
what is object constancy?
ability to sustain relatedness even if the person is not there, it forms between 2 1/2 & 3, this type of person freaks out every time this person leaves

EX: hide and go seek, child has to be old enough to understand that person is behind the hands)

EX: person who panics when a fight/argument occurs b/c they think the relationship has ended.
ASSESSMENT: Some General Information
ASSESSMENT SHOULD BE:
1. accurate and comprehensive

2. Is a larger concept than diagnostic classification

3. Is a particularly complex process

4. is a process of progressive decision-making

5. what is important to the presenting problem and what is no
ASSESSMENT: Some General Information
1. involves considerable subjectivity (what info. to collect, what to leave out); can increase when client/therapist are different and to be careful of focusing on what you think is the presenting problem

2. a sound assessment has clinical utility (used for treatment planning)
ASSESSMENT: Some General Information
1. should include dispositional (personality) and environmental factors

EX: If a person is an addict; that is how they will respond to the world
BIOPSYCHOSOCIAL: APPROACH TO ASSESSMENT, What is it?
One comprehensive approach that involves soliciting information about:
a. biological system
b. psychological system
c. social system

*each system is affected by the other
BIOPSYCHOSOCIAL: APPROACH TO ASSESSMENT: Biological Information: What are the biological predispositions?
1. genetics
2. physical conditions
3. medications/substances: includes over the counter drugs, look for drug interaction in the elderly

*Epidemiological fit
BIOPSYCHOSOCIAL: APPROACH TO ASSESSMENT: Psychological information: what are the psychological themes?
1. disruption in psychological development: any trauma, any pre-existing disabilities

2. recurrent difficulties in relationships (what works and what doesn't)

3. revelatory statements and behavior: content vs. process: what is being said vs. how they said it, when, why...all behavioral observations
BIOPSYCHOSOCIAL: APPROACH TO ASSESSMENT: Psychological Information: What are the theories?
1. psychodynamic
2. cognitive
3. behavioral

* theory is going to have a lot to do with what you take in from the client
ex: recurring themes
BIOPSYCHOSOCIAL: APPROACH TO ASSESSMENT: Psychological Information
1. Current psych. stressors: why now, themes in the person's history, what factors are contributing to their problem(s)?

2. the psychological consequences of their current psychosocial stressors

3. stress management: how they cope with stress: adaptive vs. maladaptive
BIOPSYCHOSOCIAL: APPROACH TO ASSESSMENT: Social information: what factors fall in this category?
1. family
2. friends/significant others
3. social environment
4. education
5. work
BIOPSYCHOSOCIAL: APPROACH TO ASSESSMENT: Social information
1. housing
2. income/SES
3. access to health-care services
4. legal problems/crime
5. other
BIOPSYCHOSOCIAL: APPROACH TO ASSESSMENT:Social Information: Multicultural and Spiritual Assessments
1. Culture: relevant to psychological assessment, how and to what extent is it relevant? Be aware of the role of culture in client's symptoms and signs and how it affects you

EX: reluctance in speaking about sexuality because it is considered taboo in some cultures

2. Spirituality and religion in a person's life need to be assessed

EX: a person may avoid topics or complaining and suffer in silence
BIOPSYCHOSOCIAL: APPROACH TO ASSESSMENT:Social Information: Multicultural and Spiritual Assessments
1. Identity of the individual: the language they use, use native tounge "It's from the heart"

2. Explanations of the individual's illness/presenting problem

3. factors related to the psychosocial environment and levels of functioning

EX: what impact does spirituality have on the person's life and to what extent and degree are they involved?
BIOPSYCHOSOCIAL: APPROACH TO ASSESSMENT:Social Information: Multicultural and Spiritual Assessments: what is the Idioms of distress?
They way people behave to prove they are ill; cultures have their own way of expressing distress, what meaning is given?, person might want to talk to a priest instead of a therapist
BIOPSYCHOSOCIAL: APPROACH TO ASSESSMENT:Social Information: Multicultural and Spiritual Assessments
1. relationship between the individual and the therapist: what does their relationship look like with you? It might impact treatment

EX: If you cannot communicate in their native tounge what do you do about it?Difference in spiritual beliefs? will this cause problems?

2. overall cultural and spiritual assessment for diagnosis and treatment: how does this impact diagnosis and treatment
MULICULTURALLY-INFORMED ASSESSMENT: What are some common sources of cultural bias in the process and content of assessment?
1. Content problems:
a. "norms" and applicability: norms were not usually created for diverse populations

b. test items

2. Process Problems:
a. instructions for tests (language used)
b. setting
c. clinician: how you present yourself, degree of skill
d. client
e. language
MULICULTURALLY-INFORMED ASSESSMENT:
1. more inclusive and complex

2. acknowledges potential bias in assessment

3. calls for the use of de-biasing strategies in differentiating salient from non-salient client data
MULICULTURALLY-INFORMED ASSESSMENT: What is the Cultural Data:
1. History Taking: What is "normal?," history of oppression.
a. cultural data vs. idiosyncratic data
b. salient vs. non-salient data (important vs not important)

2. Use multiple data collection methods:
a. clinical interview - overt clinical data (obvious)

b. other methods - covert clinical data

*non-verbal data collection, referring a person out for testing might make the client feel "studied"
MULICULTURALLY-INFORMED ASSESSMENT: How to Interpret Cultural Data
1. cultural data vs. idiosyncratic data


2. using normative information

3. dispositional stressors (within the client) vs. environment stressors (outside of the client)

4. clinically significant data vs. clinically insignificant data

5. formulate a "working hypothesis:" psychological consequences: maladaptive vs. adaptive

*asking about gender roles and comparing to "norms" of culture, but also they are individuals and there are variations within culture
MULICULTURALLY-INFORMED ASSESSMENT: INCORPORATE THE CULTURAL DATA (checking out the "working hypothesis" and addressing other possibilities)
1.rule out medical explanations: BUT we are not phsycians and do not diagnosis medical conditions, can refer, ask the client, and obtain records.

2. use of psychological testing: used to explore a specific question, use it to explain a hypothesis not come up with one because you do not know the answer

3. compare with DSM-TR-IV criteria
MULICULTURALLY-INFORMED ASSESSMENT: OTHER ISSUES
1. Limitations with ETIC and EMIC approaches to assessment
a. etic: over-generalizations, belieft that everyone is the same
b. emic: over emphasizing culture and prescribing certain things to culture

2. Using standardized instruments with caution

3. defensive dynamics related to culture: transference (over identifying with the culture), being colorblind: color, disability, sexuality doesn't matter

4. using interpreters: be mindful of miscommunications that can occur, don't ever use family members, use a professional from that same culture, gender, has somewhat of a psychological background, what impact does the interpreter in the room have, and do not be tempted to talk to the interpreter
PSYCHOLOGICAL OBSERVATION AND EVALUATION: PSYCHOLOGICAL ASSESSMENT: Clinical Interviews
1. Clinical interviews: any interpersonal encounter in which language is used to gather information about a client

a. structured interviews:diagnosis focused, won't get much information for theory, "magazine interviewing," a lot of yes and no answers, good for training students, increases reliability and validity, rapport isn't as good

b. unstructured interviews:depends on what theory you're using the questions you will ask, wanting to find out demographics (age, gender, client's presenting problem)
i. basic information
PSYCHOLOGICAL OBSERVATION AND EVALUATION: PSYCHOLOGICAL ASSESSMENT: Clinical Interviews (continued): what is the MENTAL STATUS EXAMINATION
MSE:
1. can be incorporated into a standardized interview

2. method of organizing and evaluating clinical observations in the here-and-now

3. focuses upon cognitive processes although other processes/functions may be included

*most psychologist use it when they need a snap shot of a client NOW, use when a client has a substance dependence issue, dementia, head injury.

most important is to evaluate cognition
PSYCHOLOGICAL OBSERVATION AND EVALUATION: PSYCHOLOGICAL ASSESSMENT
1. Presentation: appearance, attitude toward examiner, level of consciousness

2. Cognition: orientation, memory and intelligence

3. Thought: speech and thought, perceptual disturbances, reliability, judgment, and insight

4. Affect/mood: affect and mood

5. Behavior: behavior/psychomotor activity
PSYCHOLOGICAL OBSERVATION AND EVALUATION: PSYCHOLOGICAL ASSESSMENT: Clinical Interviews (continued) Mental Status Examination
PRESENTATION:

a. appearance: self-care, personal hygiene, decreased facial expressions, culture, gender

b. attitude toward the examiner: responsiveness to you, compliance? non-verbal behavior (be mindful that these could be cultural), hostile, manipulative, seductive

c. level of consciousness: response latency: how long does it take them to answer the question,

*everything is behavior data for the therapist
PSYCHOLOGICAL OBSERVATION AND EVALUATION: PSYCHOLOGICAL ASSESSMENT: Clinical Interviews (continued) Mental Status Examination
COGNITION:
a. orientation: oriented to time, place, person, could have had brain injury, dementia, long-term substance abuse

b. memory: look at nature and extent

i. short-term/immediate: info. one is exposed to, like a list of words

ii. long term/recent: events, info. and people within the last week, 24 hours

iii. remote: events, info. and people in the past

iv: confabulation: construct things to fill up hole in memory gap, not trying to lie

Intelligence: basic fund of knowledge (affected by comprehension of language, culture, education), Where are we? What is the capitol of the state?
PSYCHOLOGICAL OBSERVATION AND EVALUATION: PSYCHOLOGICAL ASSESSMENT: Clinical Interviews (continued) Mental Status Examination
THOUGHT:

i. speech and thought:pressured speech, poverty of speech: will say words but they're not saying anything, linear thinkers or not? organized thought, capacity for insight: important to know b/c it could alter which theory you would want to use, is the client having delusions, preoccupied thought suicide? has the person tried to hurt themselves before? has the person crossed the line between thinking and doing, planning: impulsivity: drugs and alcohol

ii. perceptual disturbances

iii: reliability, judgment, and insight
PSYCHOLOGICAL OBSERVATION AND EVALUATION: PSYCHOLOGICAL ASSESSMENT: CLINICAL INTERVIEWS (CONTINUED): Mental Status: Affected and Mood
1. AFFECT: SIGNS is the visual/observable emotional state, look at the ranges of emotionality the client has: appropriate, shallow, also affected by culture

EX: person talking about death and laughing (inappropriate affect)

2. MOOD:SYMPTOMS: what the client reports feeling
PSYCHOLOGICAL OBSERVATION AND EVALUATION: PSYCHOLOGICAL ASSESSMENT: CLINICAL INTERVIEWS (CONTINUED): Mental Status: Behavior
Behavior: observable behavior: ticks, twitches surrounding anxiety, psychomotor skills
PSYCHOLOGICAL OBSERVATION AND EVALUATION: PSYCHOLOGICAL ASSESSMENT: Psychological Testing
Psychological testing:
1. intellectual/neuropsychological testing:
2. personality inventories (MMPI)
3. Projective tests: TAT, Roarsch
4. Self-report inventories/self-monitoring: Beck depression inventory: EX given to a depressed person over time and not progress or lack there of
DELIRIUM, DEMENTIA, AMNESTIC, AND OTHER COGNITIVE DISORDERS: What are the essential features?
Essential features: impairments in cognition that appear to be caused by one or more substances and/or general medical condition:
a. medical condition
b. language
c. perceptual
d. capacity to plan and organize
e. failure to recognize or identify objects
f. (in delirium) disturbance in consciousness
DELIRIUM, DEMENTIA, AMNESTIC, AND OTHER COGNITIVE DISORDERS:What are the 3 major syndromes:
*syndromes are NOT disorders

*syndrome identification necessary step to diagnosing the appropriate disorder

*symptom identification needed to identify syndrome

1. delirium syndrome
2. dementia syndrome
3. amnestic syndrome
DELIRIUM, DEMENTIA, AMNESTIC, AND OTHER COGNITIVE DISORDERS: Delirium
1. disturbance in consciousness: represents a change

2. change in cognition

3. rapid onset/fluctuation: EX: think of a fever and how it goes up and goes down

4. direct consequence of substance or general medical condition
DELIRIUM, DEMENTIA, AMNESTIC, AND OTHER COGNITIVE DISORDERS: Dementia
1. Memory deficit + one or more of the following:

a. language disturbance (aphasia)

b. cannot carry out motor activities despite intact motor function (apraxia)

c. failure to recognize or identify objects despite intact sensory function (agnosia)

d. cannot plan, organize, sequence, abstract (disturbance in executive functioning): ability to carry out, organize

* do not think of this as a normal ageing process. this is caused by some underlying condition based on substance abuse or general medical condition
DELIRIUM, DEMENTIA, AMNESTIC, AND OTHER COGNITIVE DISORDERS: Dementia
1. slow, insidious onset or sudden onset/mostly progressive

2. consciousness clear (NOT disturbed like in delirium)

3. There are incurable causes of dementia:
a. Alzheimer's cannot be fixed
*MULTI-INFARCT VASCULAR DEMENTIA: person has a stroke and recovers a little bit but never to the point they were before

4. curable causes of dementia: depression, thyroid disorder, brain tumors, vitamin B-12 deficiency, infectious diseases, polypharmacy
DELIRIUM, DEMENTIA, AMNESTIC, AND OTHER COGNITIVE DISORDERS: Amnestic syndrome (amnesia)
1. MEMORY DEFICIT ONLY

2. may be caused by substance, general medical condition, or both

3. can evolve into dementia in progressive conditions

4. do not confuse this with dissociative amnesia (has to do with something psychological)
DELIRIUM, DEMENTIA, AMNESTIC, AND OTHER COGNITIVE DISORDERS: Symptoms, Syndromes, Disorder
1. questions and process of elimination

2. DSM-IV-TR, P. 76

3. NOTICE: initial questions involve symptoms regarding syndrome identification
i. diagnosis of the disorder - syndrome + etiology
DELIRIUM, DEMENTIA, AMNESTIC, AND OTHER COGNITIVE DISORDERS: Amnestic syndrome (Amnesia)
1. MEMORY DEFICIT ONLY

2. may be caused by substance, general medical condition, or both

3. can evolve into dementia in progressive conditions

4. do not confuse this with dissociative amnesia (has to do with something psychological)
DELIRIUM, DEMENTIA, AMNESTIC, AND OTHER COGNITIVE DISORDERS: Symptoms --> syndrome --> disorder
1. questions and the process of elimination

2. DSM-IV-TR P. 76

3. Notice: initial questions involve symptoms regarding syndrome identification
a. diagnosis of the disorder --> syndrome + etiology
DELIRIUM, DEMENTIA, AMNESTIC, AND OTHER COGNITIVE DISORDERS: Dementia of the Alzheimer's Type
1. This IS a disorder

2. Assessment:mood swings, memory loss...but non-are definitive
a. no definitive test
i. MRI and psychiatric examination

b. delayed recall: usually immediate or short-term memory loss

c. mini-MSE

3. Diagnosis
a. signs and symptoms
DELIRIUM, DEMENTIA, AMNESTIC, AND OTHER COGNITIVE DISORDERS: Dementia of the Alzheimer's Type (continued)
1. Treatment approaches
a. behavioral symptoms
i. most common problematic behaviors: agitation, aggression, combativeness, suspicion, wandering, depression...
ii. non-pharmacological treatment: working, educating, and counseling the family, making the environment user friendly (don't move things, label them, creating a routine.
iii. pharmacological treatment

b. cognitive symptoms
i. Cholinesterase inhibitors

c. care-giver issues
DELIRIUM, DEMENTIA, AMNESTIC, AND OTHER COGNITIVE DISORDERS: Vascular Dementia (Infarct: dead bring tissue)
1. Assessment
a. cerebrovascular disease
b. frequently associated with stroke-related physical problems
c. risk factors

2. Diagnosis
a. signs and symptoms

*results from cumulative mini-strokes (deprives brain of oxygen and tissue dies)
DELIRIUM, DEMENTIA, AMNESTIC, AND OTHER COGNITIVE DISORDERS: Vascular Dementia (Infarct: dead bring tissue): What is an Ischemic Stroke?
1. Treatment approaches:
a. Ischemic stroke: caused by blocked blood flow in the brain, generally looks at clot busting medication (usually 3 hr. window from onset of symptoms)
i. acute treatment
ii. preventative treatment: eating right, exercising
DELIRIUM, DEMENTIA, AMNESTIC, AND OTHER COGNITIVE DISORDERS: Vascular Dementia (Infarct: dead bring tissue) What is a Hemorrhagic Stroke?
Hemorrhagic Stroke: occurs from ruptured blood cells in the brain and it hemmorages, needs surgical treatment and recovery isn't as successful as other strokes

STROKES: risk factors: high blood pressure, Black, male, smoking, elevated cholesteral, heavy alcohol consumption, family history, diabetes (acquired), sudden numbness, trouble seeing in one or both eyes, loss of cordination
SUBSTANCE-RELATED DISORDERS: What are the essential features and 4 major syndromes?
1. Essential features: effects of drug abuse, side effects of a medication, or effects of exposure to a toxic substance

2. 4 major syndromes:
a. abuse
b. dependence
c. intoxication
d. withdrawal

*a substance abuser puts a block between an individual and the world (life), often the individual has limited social skills, a lot of mourning, learning how to deal with situations, very simplistic (EX: video the man started drinking at 11 yr. old and his verbal and mental process WAS that of an 11yr. old)
SUBSTANCE-RELATED DISORDERS: Abuse (one or more of the following)
1. Abuse (one or more of the following):
a. recurrent failure to fulfill major role obligation(s): @ work, school, neglecting kids, doing regular chores

b. recurrent use in physically hazardous situations: driving buses, operating machinery

c. recurrent substance-related legal problems: DUI's, arrests for disorderly conduct

d. continued use despite social or interpersonal problems: divorce, fights

*easier to qualify for then dependence
SUBSTANCE-RELATED DISORDERS: Dependence (3 or more of the following)
Dependence (3 or more)

1. tolerance and/or withdrawal symptoms: increased amounts of intoxication

2. larger amounts (for longer periods of time)

3. unsuccessful efforts to cut down or control substance

4. substance acquisition, use, or recovery takes up a great deal of time

5. reduction of important activities because of use

6. continued use despite problems caused or exacerbated by substance

*substance becomes the sun and the individual revolves around it, dependence can follow abuse
SUBSTANCE-RELATED DISORDERS: Intoxication
1. Reversible/substance-specific syndrome due to recent ingestion or exposure to substance

2. clinically significant maladaptive behavioral or psychological changes due to effects of substance developing shortly after use

3. symptoms NOT due to a general medical condition
SUBSTANCE-RELATED DISORDERS: Withdrawal
1. substance-specific syndrome due to cessation of or reduction in use that has been heavy or prolonged

2. substance-specific syndrome causes clinically significant impairment

3. NOT due to a general medical condition
SUBSTANCE-RELATED DISORDERS: Assessment and Diagnosis
1. identity of substance(s) used

2. history of substance use

3. history of substance use emergencies and treatments: ever brought to hospital, repeat offender, suicide attempts, see if client received treatment before and what type?: do not want to repeat treatment that doesn't work

4. assess cognitive impairment: alert, rambling

5. assess physiological signs: alert, oriented, dialated eyes
SUBSTANCE-RELATED DISORDERS: Assessment and Diagnosis (continued)
1. assess neurological signs

2. psychomotor agitation or retardation: gittery, can't sit still

3. changes in mood (odd changes)

4. Personality: externalize blame by not taking responsibility, minimize, avert, rationalize
a. changes in personality
b. defenses: denial

5. process vs. substance addiction
a. process: being a workaholic, excessive eating notoriously more difficult to treat because there is no substance
SUBSTANCE RELATED DISORDERS: Assessment and Diagnosis (continued): What are the biological/physiological and environment considerations?
Biological/physiological issues:
1. Genetics: important factor in alcohol abuse and dependence; almost as important in risk for illicit drug use
a. stronger component for men than for women in alcohol use and dependence

2. Environment considerations:
a. family abuse and associated problems
b. stress: can also have an impact on the amount a person drinks
SUBSTANCE RELATED DISORDERS: Assessment and Diagnosis (continued): What is the Family Disease Model and what role does the ADDICT play?
ADDICT (parent #1):

a. The less power this person has the more the family freaks out
b. keeps the system closed
c. makes spontaneous rules
d. the addict's problems becomes the entire family's problem
SUBSTANCE RELATED DISORDERS: Assessment and Diagnosis (continued): What is the Family Disease Model and what role does the ENABLER play?
ENABLER (parent #1):

a. a little narcissistic, "If only I had done this..."
b. looks strong on the outside but powerless on the inside
c. spends all time and energy supporting the addict and gets support from the hero
d. angry, the rescuer, takes responsibility for the addict
e. controlling: their self-esteem relates to how well they can control the addict (which they can't and it sets them up for failure)
SUBSTANCE RELATED DISORDERS: Assessment and Diagnosis (continued): What is the Family Disease Model and what role does the HERO play?
HERO ("little enabler"):

a. brings home the medals and honor to the family and because of this shows everyone else, "our family doesn't have a problem"
b.supports the enabler who spends all their energy supporting the addict
c. tries to be good all the time and hinders on perfectionism
d. starts to discount their own strengths
e. is likely to go into the care taking profession
f. praised at times and gets all the attention
SUBSTANCE RELATED DISORDERS: Assessment and Diagnosis (continued): What is the Family Disease Model and what role does the SCAPEGOAT play?
SCAPEGOAT (the one who acts out):

a. brings disgrace to the family
b. sometimes the hero and this role can switch
c. their behavior is usually the reason the family is brought into treatment b/c of the scapegoat's bad behavior
d. seems not to care
e. irresponsible
f. shallow
g. self-centered social skills
SUBSTANCE RELATED DISORDERS: Assessment and Diagnosis (continued): What is the Family Disease Model and what role does the LOST CHILD play?
LOST CHILD (3rd child):

a. protected withdrawl
b. withdraws from the family, isolated
c. identity development can suffer
d. self-soothes by binge eating or collecting possessions
e. prognosis is the best of the family because they stay away
f. ignored: all the attention goes to the hero/scapegoat
g. doesn't interact with the parents, lonely
SUBSTANCE RELATED DISORDERS: Assessment and Diagnosis (continued): What is the Family Disease Model and what role does the MASCOT play?
MASCOT (4th child, comedian):

a. amusing kid, craves attention
b. family tries to protect them from their issues
c. nervous and has to create antics to diffuse the tension at home, but does so in a very erratic way in order to distract family, when it works it only encourages the child to continue this behavior
d. doesn't take things seriously and people don't take them seriously
e. extremely frightened of looking inside
f. social skills are very shallow and never learned how to cope with stress
g. can develop substance abuse problems and become suicidal
SUBSTANCE-RELATED DISORDERS: ASSESSMENT AND DIAGNOSIS (CONTINUED):
What are some cultural considerations?
Cultural Considerations:

1. Concept of dependence (intoxication and withdrawal) constant across cultures

2. abuse varies (with culture and gender) and may be difficult to assess

3. cultural variations in attitudes towards use, patterns, effects (US --> violence, Europe --> not as much), Asian populations there is a limiting metabolizing feature
SUBSTANCE-RELATED DISORDERS: ASSESSMENT AND DIAGNOSIS (CONTINUED):
What are some gender differences?
Gender differences:

1. men use/abuse more than women

2. women are historically more socially limiting than men and more suseptable to alcohol (e.g. liver damage)
SUBSTANCE-RELATED DISORDERS: ASSESSMENT AND DIAGNOSIS (CONTINUED):
What are some cultural considerations?
Cultural Considerations:

1. Concept of dependence (intoxication and withdrawal) constant across cultures

2. abuse varies (with culture and gender) and may be difficult to assess

3. cultural variations in attitudes towards use, patterns, effects (US --> violence, Europe --> not as much), Asian populations there is a limiting metabolizing feature
SUBSTANCE-RELATED DISORDERS: ASSESSMENT AND DIAGNOSIS (CONTINUED):
What are some gender differences?
Gender differences:

1. men use/abuse more than women

2. women are historically more socially limiting than men and more suseptable to alcohol (e.g. liver damage)
SUBSTANCE-RELATED DISORDERS: ASSESSMENT AND DIAGNOSIS (CONTINUED):
What are some cultural considerations?
Cultural Considerations:

1. Concept of dependence (intoxication and withdrawal) constant across cultures

2. abuse varies (with culture and gender) and may be difficult to assess

3. cultural variations in attitudes towards use, patterns, effects (US --> violence, Europe --> not as much), Asian populations there is a limiting metabolizing feature
SUBSTANCE-RELATED DISORDERS: 1st STAGE (AKA Prodromal Stage)
1. drinking becomes a means of psychological escape from problems, stress, inhibitions (person drinking for the wrong reasons)

2. dependence upon mood altering effects
SUBSTANCE-RELATED DISORDERS: 2nd STAGE (AKA Early Stage)
1. the need to drink becomes more intense

2. individual starts drinking earlier in the day and more often
SUBSTANCE-RELATED DISORDERS: 3rd STAGE (AKA Middle Stage)
1. loss of control becomes more predominant, becomes the center of their universe

2. avoidance of friends, family, interests, avoid people who might call attention to the problem (even therapist), minimize their lack of social interaction

3. "Eye openers" - crazy things that happen, situations

4. reverse tolerance: initially tolerance increases but at a certain point the liver becomes impaired (can't metabolize) and alcohol stays within the system so a person needs to drink less to become drunk or buzzed
SUBSTANCE-RELATED DISORDERS: 4th STAGE (AKA Late Stage)
1. chronic loss of control

2. cannot hold a job

3. "benders" typical - few days of binge drinking

4. DT's - delirium tremors

*not uncommon to see someone with a mood disorder and also have a substance abuse problem (to hide their disorder)
SUBSTANCE-RELATED DISORDERS: Treatment Phase, *clinical judgment: looking at what needs to happen first
1. acute crisis:
client dealing with a life threatening crisis 5150, is acute psychiatric or med. care needed?, any violence in family of origin

2. withdrawal from substance:
most concerned with safe w/d, maybe a detox or 12 step program, might need services: food, shelter, clothes, legal help

3. Sequelae:
little things that follow, dealing with depression, guilt, grief, psychological craving for substance, work with person on RELAPSE TRIGGERS, need to teach client how to manage these feelings, relapsing is okay as it is part of recovery

4. predisposing factors:
genetic, only when you work on the first #3 stages can you talk about this, it can be distracting to recovery (destiny), trauma, questions and conflicts about sexual orientation and stigma of that