Chapter 2 Abnormal Psychology: Diagnosis and Treatment

Problems related to education and literacy:

Underachievement in school

Problems related to certain psychosocial circumstances:

Unwanted pregnancy

Clinicians also may want to include their overall judgment of a client's psychological, social, and occupational functioning. An instrument known as the:

WHO Disability Assessment Schedule (WHODAS) is included as a section of the DSM-5 so clinicians can provide such a rating. -An example of a question from the WHODAS the clinician might ask is "In the past 30 days, how much difficulty have you had in concentrating on doing something for ten minutes?" The client indicates whether the difficult is None, Mild, Moderate, or Severe. -Other questions ask about the client's difficulty in taking care of household duties, engaging in community activities, and activities such as washing and getting dressed.

Brain fag

West Africa Difficulties in concentration, memory, and thought, usually experienced by students in response to stress. Other symptoms include neck and head pain, pressure, and blurred vision.

Bouffée délirante:

West Africa and Haiti Sudden outburst of agitated and aggressive behavior, confusion, and psychomotor excitement. Paranoia and visual and auditory hallucinations possible.

Most mental health professionals outside the United States and Canada use instead of the DSM-5, the?

World Health Organization's (WHO's) diagnostic system, the International Classification of Diseases (ICD). -WHO developed the ICD as an epidemiological tool and it includes all forms of disease, not just psychological disorders. -The advantage of using the ICD is that it provides a common diagnostic system that the 110 member nations of WHO can use for epidemiological purposes, providing assurance that countries employ the same terminology for the sake of consistency. -The tenth edition (ICD-10) is currently in use; it is undergoing a major revision, which will be the "ICD-11." -The ICD is available in WHO's six official languages (Arabic, Chinese, English, French, Russian, and Spanish), as well as in 36 other languages. -In the area of psychological disorders, although there are differences in specific areas, the two systems share more than 90% of diagnostic categories

In these cases, clinicians can use a set of codes in the ICD that indicate the presence of psychosocial and environmental problems known as?

Z codes. -We have selected several examples of ICD-10 Z codes in Table 2. -These may be important because they can affect the diagnosis, treatment, or outcome of a client's psychological disorder. -A person first showing signs of an anxiety disorder shortly after becoming unemployed presents a very different diagnostic picture than someone whose current life circumstances have not changed at all in several years.

The mental health field also includes a large group of individuals who do not have graduate-level training but serve?

a critical role in the functioning and administration of the mental health system. -Included in this group are occupational therapists, recreational therapists, and counselors who work in institutions, agencies, schools, and homes.

Even if a client's symptoms do not specifically represent that of a culture-bound syndrome, clinicians must consider the individual's cultural background as?

a framework for interpreting these symptoms. -For example, members of a given culture attach significant meanings to particular events. -Within certain Asian cultures, an insult may provoke the condition known as amok, where a person (usually male) enters an altered state of consciousness in which he becomes violent, aggressive, and even homicidal. Without taking this background into account, the clinician may very well draw the wrong conclusions, assuming that the symptoms reflect a disturbance within the individual when they in fact reflect the playing out of a culturally influenced scenario.

Once the clinician makes a formal diagnosis, he or she is still left with a formidable challenge—to piece together a what?

a picture of how the disorder evolved. -With the diagnosis, the clinician can assign a label to the client's symptoms. Although informative and necessary for treatment, this label does not tell the client's full story.

Clinical psychologists have?

an advanced degree in the field of psychology and are trained in diagnosis and therapy. -Clinical psychologists cannot administer medical treatments, but three U.S. states (Louisiana, Illinois, and New Mexico, as of 2015) grant those with specialized training prescription privileges. -Other states are pushing to pass similar legislation, based in part on the position that psychologists offer medication in the context of a larger therapeutic relationship, rather than as the sole focus of treatment, as may be true with a psychiatrist.

Culture-bound syndromes are:

behavior patterns that exist only within particular cultures. -To qualify as a culture-bound syndrome, the symptoms must not have any clear biochemical or physiological sources. -Furthermore, only people in that particular culture exhibit its symptoms for the disorder to be considered a culture-bound syndrome. Table 3 describes examples of the most well-documented culture-bound syndromes.

The cornerstone of a thorough case formulation is an understanding of the client from a?

biopsychosocial perspective that also takes into account the client's developmental history. In some cases, family history information would also inform this part of the diagnostic process

As you can appreciate, then, cultural formulations are important to understanding psychological disorders from a what?

biopsychosocial perspective.

To gain a full appreciation of the client's disorder, the clinician develops a ?

case formulation, an analysis of the client's development and the factors that might have influenced his or her current psychological status.

The Client: People working in the area of abnormal psychology refer to individuals seeking psychological intervention as what?

client and patient. -In this book, we prefer to use the term client, reflecting the view that the people in treatment collaborate with those who treat them. -We feel that the term patient carries with it the connotation of a passive rather than active participant. -However, there are times when it is appropriate to use the term patient such as in the context of "outpatient treatment" and "patients' rights."

Counseling psychologists, with either a doctorate in education (EdD) or a PhD, also serve as ?

clinicians. -In order to qualify for a license to practice, doctoral-level clinicians must pass an examination.

The doctor of philosophy (PhD) is typically awarded for:

completing graduate training in a research-based program. -In order to be able to practice, people who get their PhDs in clinical psychology must also complete an internship and at least 1 year of supervised postdoctoral training.

The diagnostic process can take anywhere from a few hours to weeks depending on the what?

complexity of the client's presenting symptoms. -The client and clinician may accomplish therapeutic work during this time, though, particularly if the client is in crisis. The course of therapy would then be adjusted as needed to match the client's emerging diagnosis.

Clinicians should look within the client's cultural background not only for diagnostic purposes but also as a way of determining what?

cultural supports may be available to them. -Clients from cultures that incorporate extended family networks and religious connections can provide emotional resources to help individuals cope with stressful life events.

In order to treat psychological disorders, clinicians must first be able to do what?

diagnose them. -The diagnostic process requires, in turn, that clinicians adopt a systematic approach to classifying the disorders they see in their clients. -A diagnostic manual serves to provide consistent diagnoses across people based on the presence or absence of a set of specific symptoms. -Without an accurate diagnostic manual, it is impossible for the clinician to decide on the best treatment path for a given client. -Researchers use standard forms of diagnostic manuals to provide investigators with consistent terminologies to use when reporting their findings. -These may be the same manuals as those used by clinicians, or they may be research-based criteria accepted within the profession as providing terminology that can be translated into clinical use.

Clinicians first listen to clients as they describe the experience of their symptoms, but then they follow this up with a more systematic approach to?

diagnosis.

For many clients, the symptoms they experience reflect the presence of more than one principal ?

diagnosis.

Clinicians within each specialty must train according to the standards of their?

discipline and maintain credentials, such as licenses, required by their state, province, or country in order to provide mental health services.

The prior edition, the DSM-IV-TR, organized diagnoses using:

five separate axes. -It defined an axis as a category of information regarding one dimension of an individual's functioning. -The multiaxial system intended to allow professionals to characterize clients in a multidimensional way.

As you will learn in the chapter "Assessment", a variety of assessment tools give the clinician a what?

framework for determining the extent to which these symptoms coincide with the diagnostic criteria of a given disorder. -The clinician must determine the exact nature of a client's symptoms, the length of time the client has experienced these symptoms, and any other abnormalities that may represent important symptoms that the client may not report. -In the process, the clinician also obtains information about the client's personal and family history. By asking questions in this manner, the clinician begins to formulate the principal diagnosis—namely, the disorder most closely aligned with the primary reason the individual is seeking professional help.

We might expect cultural norms and beliefs to have a stronger impact on clients who strongly what?

identify with their culture of origin. -The client's familiarity with and preference for using a certain language is one obvious indicator of cultural identification - A culture's approach to understanding the causes of behavior may influence clients who strongly identify with their culture. Exposure to these belief systems may, in turn, influence the expression of a client's symptoms.

The fact that psychological disorders vary from one society to another supports the claim of the sociocultural perspective that cultural factors play a role in?

influencing the expression of abnormal behavior.

The diagnostic process involves the clinician's using all relevant information and arriving at a what?

label that best seems to capture the client's disorder. -This information includes the results of any tests given to the client, material gathered from interviews, and knowledge about the client's personal history.

Current diagnostic manuals are based on the medical model in that they focus on accurately doing what?

labeling groups of symptoms with the intention of providing targeted treatments. -This would seem to be a worthwhile goal, but not everyone in the mental health community is comfortable with this model. -As we will discuss frequently, a diagnosis requires that an individual's behavior can be classified as either normal or abnormal without allowing for gradations in between.

Psychologists are:

licensed health care professionals offering psychological services.

In these cases, we use the term comorbid:

meaning literally two (or more) disorders that co-occur. -Diagnoses involving comorbidity are remarkably common. -As shown in the National Comorbidity Survey (NCS), a major investigation intended to document the prevalence of comorbidity in the population, over half of respondents with one psychiatric disorder also have a second diagnosis at some point in their lives. -The most common comorbidities involve the combined occurrence of substance use with other psychiatric disorders. Thus, an individual may have a history of a depressive disorder as well as alcohol use disorder, both occurring at the same time in the person's life.

A diagnostic manual's ability to do its job hinges upon its?

meeting two sets of standards. -The first is reliability, meaning that those who use the manual apply the diagnoses consistently across individuals who have a particular set of symptoms. A manual would not be very useful if the symptom of sad mood led one clinician to assign one diagnosis and another to adopt a completely different one. -Secondly, a diagnostic manual must have validity, meaning that the diagnoses represent real and distinct clinical phenomena.

Psychiatrists are:

physicians (MDs) who receive specialized advanced training in diagnosing and treating people with psychological disorders.

The doctor of psychology (PsyD) is the degree that:

professional schools of psychology award and typically involves less training in research. -These individuals also must complete an internship in order to practice.

It is important to be sensitive to the language you use to refer to people with?

psychological disorders, regardless of whether your preference (or that of the setting in which you work) refers to them as clients or patients. -We highly recommend that you refer to people as "clients" (or "patients") who have a certain disorder, and not refer to them by the name of their disorder. -In other words, if you call someone a "schizophrenic" you equate the person with the disorder. People are more than the sum of their disorders. By using your language carefully, you communicate greater respect for the total person.

The case formulation transforms the diagnosis from a label and set of diagnostic code numbers to a what?

rich piece of descriptive information about the client's personal history. With this descriptive information, the clinician can more confidently design a treatment plan that is attentive to the client's symptoms, unique past experiences, and future potential for growth.

In whatever form clinicians use it, DSM-5 is divided into 22 chapters that each include:

sets of related disorders. -The chapters are organized so that the closer disorders appear sequentially in the text, the more closely related they are believed to be. -Furthermore, because psychological and biological diseases often relate to each other, a number of diagnoses in DSM-5 have embedded within them a medical diagnosis such as a neurological disease that produces cognitive symptoms.

Professionals with master's degrees also provide psychological services. These include:

social workers, master's-level counselors, marriage and family therapists, nurse clinicians, and school psychologists.

As part of the diagnostic process, clinicians may wish to add information about the medical or psychosocial status of their clients. If illnesses that are primarily medical are not specified in DSM-5, clinicians may use the?

standard ICD diagnoses for the conditions. -These diagnoses would include all medical conditions, not just those with psychological relevance. -By specifying these illnesses, clinicians transmit information that has important therapeutic implications. -For example, a person with chronic heart disease should not receive certain psychiatric medications. For the most part, environmental stressors are negative. However, we might consider positive life events, such as a job promotion, as stressors. A person who receives a major job promotion may encounter psychological difficulties due to his or her increased responsibilities and demands with the new position. Even going on vacation may present stress, although for most individuals, the rewards of the vacation offset the cost of the planning, travel headaches, and change in daily schedules.

Furthermore, because users of diagnostic manuals label a collection of behaviors as constituting a disease, they are more likely, knowingly or not, to do what?

stigmatize those with that particular disease.

If instead behaviors were rated for what they were, rather than as a collection of symptoms within the category of disease, people would not become what?

stigmatized by receiving a diagnosis.

In providing a total diagnostic picture of the client's psychological disorder, clinicians may also decide it is important to specify particular?

stressors that are affecting the individual's psychological status.

Within particular cultures are idiosyncratic patterns of?

symptoms, many of which have no direct counterpart to a specific DSM-5 diagnosis.

Key to diagnosis is gaining as clear a description as possible of a client's symptoms, both those that?

the client reports and those that the clinician observes. -Dr. Tobin, when hearing Pedro describe himself as "anxious," assumes that he may have an anxiety disorder. However, clients do not always label their internal states accurately. Therefore, the clinician also must attend carefully to the client's behavior, emotional expression, and apparent state of mind. The client may express anxiety, but his behavior may suggest that instead he is experiencing a mood disorder. Dr. Tobin would therefore keep open the possibility that mood disturbances, rather than or in addition to anxiety, are involved in Pedro's diagnosis.

Making a diagnosis involves taking multiple factors from the client's life into account that include the client's sociocultural context. A cultural formulation includes:

the clinician's assessment of the client's degree of identification with his or her culture of origin, the culture's beliefs about psychological disorders, the ways in which people in the culture interpret particular events, and the cultural supports available to the client.

The Clinician: In this book, we refer to the person providing treatment as?

the clinician. -There are many types of clinicians who approach clinical work in a variety of ways, based on their training and orientation.

In addition, knowing about a client's medical condition can provide important information about?

the mental disorder's etiology, which is its presumed cause. -It would be useful to know that a middle-aged man appearing in treatment for a depressive disorder for the first time had a heart attack 6 months ago. The heart attack may have constituted a risk factor for the development of depression, particularly in a person with no previous psychiatric history.

Differential diagnosis:

the ruling out of alternative diagnoses, is a crucial step in the diagnostic process. -The clinician conducts a differential diagnosis by comparing the client's symptoms with those associated with similar disorders until other possibilities can be ruled out. -This is important primarily so that the clinician can be sure to embark on the appropriate treatment. The clinician must also rule out medical diagnoses as well as those considered psychological in nature.

Despite these criticisms, mental health professionals must rely on diagnostic systems if for no other reason than to allow their clients to receive?

treatment in hospitals and reimbursement from health care providers. -Insurance companies utilize the diagnostic codes they provide to determine payment schedules for both in-hospital and outpatient care. -For our purposes, it is worthwhile to be alert to the criticisms of these diagnostic systems, particularly because they serve as a reminder that it is the person, not the disease, that clinicians aim to help.

Now, DSM-5 contains a "Section III," which includes assessment measures and diagnoses not considered?

well established enough to be part of the main system. -These diagnoses may become incorporated into the next edition of DSM-5 or a "DSM-5.1," should clinical and research data support their inclusion.

Problems related to employment and unemployment :

-Change of job -Sexual harassment on the job -Military deployment status

Problems related to housing and economic circumstances :

-Homelessness -Extreme poverty -Low income

Other problems related to primary support group, including family circumstances:

-Problems in relationship with spouse -Disappearance and death of family member -Alcoholism and drug addiction in family

Problems related to social environment:

Acculturation difficulty

Spell:

African American and European American communities in the southern United States Trance state in which communication with deceased relatives or spirits takes place. Sometimes connected with a temporary personality change.

Changes in the DSM-5 Structure:

All editions of the DSM have generated considerable controversy, and the fifth edition seems to be no exception. The importance of a diagnostic manual meeting criteria of reliability and validity forms the heart of controversy regarding the DSM-5. In its current form, it reflects the collective wisdom of clinicians and researchers who believed they were providing criteria that would result in the consistent application of diagnoses (reliability) of disorders that individuals actually experience (validity). Although criticized on both counts, the DSM-5 was written in such a way as to maximize its scientific and clinical merits. Much of what you will read about in this book regarding DSM-5 controversies revolves around validity but there are also challenges to its reliability. The challenge for the authors of any diagnostic system are to settle on agreed-upon categories of symptoms and translate them into terms that anyone who is trained in the system can apply. The most significant changes concern the multiaxial system—the categorization of disorders along five separate axes. The DSM-5 task force decided to eliminate the DSM-IV-TR multiaxial system and instead follow the system in use by the World Health Organization's International Classification of Diseases (ICD). Axis I of the DSM-IV-TR contained major "syndromes," or illness clusters. Axis II contained diagnoses of personality disorders and what was then called mental retardation. Axis III was used to note the client's medical conditions. Axis IV rated the client's psychosocial stresses, and Axis V rated the client's overall level of functioning. The task forces also considered using a dimensional model in which disorders are viewed along a continuum instead of the categorical model represented by DSM-IV-TR. However, in the end, they chose not to do so. The current organization begins with neurodevelopmental disorders and then proceeds through "internalizing" disorders (characterized by anxiety, depressive, and somatic symptoms) to "externalizing" disorders (characterized by impulsive, disruptive conduct and substance-use symptoms). The hope is that eventually there will be new research allowing future diagnostic manuals to be based on underlying causes rather than symptoms alone.

Ghost sickness:

American Indian tribes A preoccupation with death and the deceased. Thought to be symbolized by bad dreams, weakness, fear, appetite loss, anxiety, hallucinations, loss of consciousness, and a feeling of suffocation.

Reflecting the increasing reliance of mental health professionals on online tools and mobile applications, the DSM-5 is available for use on?

Apple and Android devices. -In this form, the text behind the diagnoses is more difficult to read, but it is far easier to scroll through categories of disorders and symptoms than is true for the bound version of the manual.

Pibloktog:

Arctic and sub-Arctic Eskimo communities Abrupt dissociative episode associated with extreme excitement, often followed by seizures and coma. During the attack, the person may break things, shout obscenities, eat feces, and behave dangerously. The victim may be temporarily withdrawn from the community and report amnesia regarding the attack.

Qi-gong psychotic reaction:

China Acute episode marked by dissociation and paranoia that may occur following participation in qi-gong, a Chinese folk health-enhancing practice.

Other conditions that may be a focus of clinical attention:

Conditions or problems for which a person may seek medical help -Problems related to abuse or neglect -Occupational problem

Other mental disorders:

Conditions or problems for which a person may seek professional help -Other specified mental disorder due to another medical condition

Clinicians use the standard terms and definitions contained in the:

Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association. -We have organized this text according to the most recent version, which is the DSM-5, or fifth edition (American Psychiatric Association, 2013).

Paraphilic disorders:

Disorder in which a paraphilia causes distress and impairment -Pedophilic disorder -Fetishistic disorder -Transvestic disorder

Disruptive, impulse-control, and conduct disorders:

Disorders characterized by repeated expression of impulsive or disruptive behaviors -Kleptomania -Intermittent explosive disorder -Conduct disorder

Feeding and eating disorders:

Disorders characterized by severe disturbances in eating behavior -Anorexia nervosa -Bulimia nervosa -Binge eating disorder

Personality disorders:

Disorders in an individual's personality -Borderline personality disorder -Antisocial personality disorder -Narcissistic personality disorder

Dissociative disorders:

Disorders in which the normal integration of consciousness, memory, sense of self, or perception is disrupted -Dissociative identity disorder -Dissociative amnesia

Elimination disorders:

Disorders involving bladder and bowel disturbances -Enuresis (bladder) -Encopresis (bowel)

Sexual dysfunctions:

Disorders involving disturbance in the expression or experience of sexuality -Erectile disorder -Female orgasmic disorder -Premature ejaculation

Sleep-wake disorders:

Disorders involving disturbed sleep patterns -Insomnia disorder -Narcolepsy

Bipolar and related disorders:

Disorders involving elevated mood -Bipolar disorder -Cyclothymic disorder

Neurocognitive disorders:

Disorders involving impairments in thought processes caused by substances or medical conditions -Mild neurocognitive disorder -Major neurocognitive disorder

Obsessive-compulsive and related disorders:

Disorders involving obsessions and compulsions -Obsessive-compulsive disorder -Body dysmorphic disorder -Hoarding disorder

Somatic symptom disorders:

Disorders involving recurring complaints of physical symptoms that may or may not be associated with a medical condition -Illness anxiety disorder -Functional neurological symptom disorder

Depressive disorders:

Disorders involving sad mood -Major depressive disorder -Persistent depressive disorder

Schizophrenia spectrum and other psychotic disorders:

Disorders involving symptoms of distortion in perception of reality and impairment in thinking, behavior, affect, and motivation -Schizophrenia -Brief psychotic disorder

Anxiety disorders:

Disorders involving the experience of intense anxiety, worry, fear, or apprehension -Panic disorder -Agoraphobia -Specific phobia -Social anxiety disorder

Substance-related and addictive disorders:

Disorders related to the use of substances -Substance use disorders -Substance-induced disorders

Neurodevelopment disorders:

Disorders that usually develop during the earlier years of life, primarily involving abnormal development and maturation -Autism spectrum disorder -Specific learning disorder -Attention-deficit hyperactivity disorder

Medication-induced movement disorders and other adverse effects of medication:

Disturbances that can be traced to use of medication -Tardive dyskinesia -Medication-induced postural tremor

Zar:

Ethiopia, Somalia, Egypt, Sudan, Iran, and other North African and Middle Eastern societies Possession by a spirit. May cause dissociative experiences characterized by shouting, laughing, hitting of one's head against a hard surface, singing, crying, apathy, withdrawal, and change in daily habits.

Dhat:

India Severe anxiety and hypochondriacal concern regarding semen discharge, whitish discoloration of urine, weakness, and extreme fatigue.

Taijin kyofusho:

Japan Intense fear that one's body parts or functions displease, embarrass, or are offensive to others regarding appearance, odor, facial expressions, or movements.

Hwa-byung (wool-hwa-byung):

Korea Acute feelings of anger resulting in symptoms including insomnia, fatigue, panic, fear of death, dysphoria, indigestion, loss of appetite, dyspnea, palpitations, aching, and the feeling of a mass in the abdomen.

Shin-byung:

Korea Anxiety and somatic problems followed by dissociation and possession by ancestral spirits.

Bilis and colera:

Latin America Condition caused by strong anger or rage. Marked by disturbed core body imbalances, including tension, trembling, screaming, and headache, stomach disturbance. Chronic fatigue and loss of consciousness possible.

Ataque de nervios:

Latin America Distress associated with uncontrollable shouting, crying, trembling, and verbal or physical aggression. Dissociation, seizure, and suicidal gestures possible. Often occurs as a result of a stressful family event. Rapid return to premorbid state.

Susto:

Latinos in the United States and Mexico, Central America, and South America Illness caused by a frightening event that causes the soul to leave the body. Causes unhappiness, sickness (muscle aches, stress headache, and diarrhea), strain in social roles, appetite and sleep disturbances, lack of motivation, low self-esteem, and death. Healing methods include calling the soul back into the body and cleansing to restore bodily and spiritual balance.

Koro:

Malaysia An episode of sudden and intense anxiety that one's penis or vulva and nipples will recede into the body and cause death.

Amok:

Malaysia Dissociative episode consisting of brooding followed by violent, aggressive, and possibly homicidal outburst. Precipitated by insult; usually seen more in males. Return to premorbid state following the outburst.

Latah:

Malaysia Hypersensitivity to sudden fright, usually accompanied by symptoms including echopraxia (imitating the movements and gestures of another person), echolalia (irreverent parroting of what another person has said), command obedience, and dissociation, all of which are characteristic of schizophrenia.

Mal de ojo:

Mediterranean cultures Means "the evil eye" when translated from Spanish. Children are at much greater risk; adult females are at a higher risk than adult males. Manifested by fitful sleep, crying with no apparent cause, diarrhea, vomiting, and fever.

Gender dysphoria:

Mismatch between biological sex and gender identity -Gender dysphoria

Trauma and stressor-related disorders:

Responses to traumatic events -Post-traumatic stress disorder -Acute stress disorder -Adjustment disorder

Falling out or blacking out:

Southern United States and the Caribbean A sudden collapse, usually preceded by dizziness. Temporary loss of vision and the ability to move.

Rootwork:

Southern United States, African American and European populations, and Caribbean societies Cultural interpretation that ascribes illness to hexing, witchcraft, or sorcery. Associated with anxiety, gastrointestinal problems, weakness, dizziness, and the fear of being poisoned or killed.

Shen-k'uei or Shenkui:

Taiwan and China Symptoms attributed to excessive semen loss due to frequent intercourse, masturbation, and nocturnal emission. Dizziness, backache, fatigue, weakness, insomnia, frequent dreams, and sexual dysfunction. Excessive loss of semen is feared, because it represents the loss of vital essence and therefore threatens one's life.