Diagnosis treatment of dysfunctional behavior

Diagnosis & Treatment of dysfunctional Behavior Overview of Today’s Class Class #1  Introductions  Review of Syllabus, Assignments, & Course Outline  Brief Review of Historical Influences of DSM-5  Brain Neuroanatomy: Cognitive, Behavioral, & Emotional Functioning  Neuropsychopharmacology: Review of Major Neurotransmitters  Introduction to DSM-5 Introductions! S r e e i s Review of Syllabus, Assignments, Course Outline  Textbook for the Class:   DSM-5 (yes you need this) Recommended Supplemental Texts:   DSM-5 Made Easy DSM-5 Essentials  How to Contact Me:     EMAIL is preferred  Do not use your personal email 972-279-6511 ext 149 Office Hours by Request (office G) Private Practice Phone:    719-433-4388 PLEASE DO NOT TEXT ME USE THIS FOR EMERGENCY’S ONLY Review of Syllabus, Assignments, Course Outline  Assignments   Attendance/Participation   10% of Final Grade Each Absence = point off final grade Mid-Term (10/15/2014)     25% of Final Grade 50 multiple choice questions Closed Book Will be given 75 MC Q’s of which 50 will be on the mid-term: weeks in advance   Final-Exam (11/19/2014)     50% of Final Grade 100 multiple choice questions Will be composed of 50 questions from mid-term and 50 new questions Will be given 50 new MC Q’s: weeks in advance Research Paper:  See syllabus for criteria  15% of final grade Historical Conceptions of Abnormal Behavior  Normal vs Abnormal Behavior   Culturally Defined & Dynamic Philosophical, Theological, Scientific, and Political Influences  Early Theories of Abnormal Behavior  Supernatural Theories Demons, Spirits, Moon, Stars, etc Dualistic Views Body/Brain does not equal Soul/Spirit Descarte Ancient Greece – soul or “psyche” Brain was a radiator to cool blood        Psychological Theories  Freud, Adler, Jung, Skinner, Beck, Maslow, Yalom Etc  Four Major Schools of Thought: Psychoanalytic, cognitivist, behaviorist, humanistic-existential Many “sub”-movements are derivatives  Explain the “mind” portion of why abnormal behavior exists  Biological Theories  Medical model of abnormal behavior Disruption in physical body/brain causes aberrant cognition, emotions, or behavior  American Psychiatric Association  Behavioral Neurology    The Central Nervous System: Brain Anatomy & Psych Functions      Four Lobes of the Brain Cortex = outside of brain/gray matter Sub-Cortex = inside of brain/white matter Neo-Cortex = prefrontal area Limbic Region or “lobe”   Bottom-Up Processing      Inside the brain Basic Life Support = Brain Stem Primitive Drives = Mid-Brain Emotions = Limbic Region Reasoning/Thinking = Cortex Top-Down Processing  Cortex & Neocortex can inhibit / control primitive behaviors and reactions The Central Nervous System: Brain Anatomy & Psych Functions  Neuropsychological Functions  Attention/Alertness  Processing Speed  Working Memory  Memory  Language  Executive Functions  Visuospatial Processing  Sensorimotor Functioning  Emotional/Personality Functions The Central Nervous System: Brain Anatomy & Psych Functions  Brain Stem + Frontal   Motor Cortex   Controls Complex Motor Movements Prefrontal Area   Attention/Alertness/Arousal Judgment, Abstract Reasoning, Planning, Initiation, Self-Monitoring, Social Judgment, Emotional Regulation, Impulse Control, “Outside the box” thinking Orbito-Prefrontal Area   Connects with amygdala and regulates fight or flight response Also implicated with reward/punishment response The Central Nervous System: Brain Anatomy & Psych Functions  Temporal Lobe        Left = Verbal Memory Right = Visual Memory Memory for Faces, Words, Language Left Temporal-Parietal Junction  Reading, Math Also connected to amygdala and hippocampus Hippocampus   Auditory Processing of Sounds Consolidates memories Amygdala  Processing incoming emotional stimuli for fight or flight response  H – P – A axis Personality Disorders  Neuroanatomical Correlates   Frontal/Prefrontal Lobe      Judgment Social Awareness Empathy Abstract Reasoning Emotional Regulation Orbitoprefrontal area     Heavily connected to amgydala Controls Impulses Inhibitions/Social Inhibition Reward/Punishment Quick Case Example  The Case of Dr Doe     45 year old Caucasian male Developmental history = normal Academic history = exceptional grades Social history:      Parents divorced  Med School Abusive father Many failed relationships in high school Promiscuous Arrested four times in past for DUI    Social History Cont’d:    Family friend is an attorney; never charged Difficulty working with supervisors     Married x “My ex-wives always got fat and so I left them.” Children  Not close w/ them anymore Current wife is “forcing” him to go to counseling Hx of depression, alcohol abuse Medical Hx: unremarkable Asked for a copy of your CV and your license before beginning therapy Personality Disorders  What is a disordered personality?  Paranoid Personality Disorder  Schizoid Personality Disorder  Schizotypal Personality Disorder  Antisocial Personality Disorder  Borderline Personality Disorder  Histrionic Personality Disorder  Narcissistic Personality Disorder  Avoidant Personality Disorder  Dependent Personality Disorder  Obsessive-Compulsive Personality Personality Disorders   Most Commonly Seen:  Narcissistic PD  Borderline PD  Histrionic PD  Antisocial PD Not DX, in my opinion, before age 18 Frontal lobes continue to develop through mid-20’s  Treatment:  Long-term, insight-oriented therapies  Can be very challenging and emotionally draining  Rapport is easy to establish but often difficulty to maintain  Medications treat symptoms but not disorder  Family therapy often necessary Sociopathy vs Antisocial PD  Q: What’s the different between a sociopath and antisocial PD?  A: It depends who you ask Good illustration:  An abused dog vs a wolf   Very similar in behaviors Very different origins of behaviors  https://www.youtube.com/watch?v=oaBTbMW3vbc  Treatment for ASPD     Very challenging Behaviorally-based Research is mixed on if this disorder is truly “treatable” Meds are usually treating secondary symptoms but many patients with ASPD are med seeking for abuse (e.g., stimulants, benzo’s, pain meds, etc.) Borderline Personality Disorder  Often difficult to diagnose in the first few sessions due to the client’s impression management   Common signs/history for BPD:        Often very cordial/nice at first Report of past sexual abuse  Usually diagnosed with PTSD before BPD      Report of cutting Eating disorders common Previous attempts of “failed” suicides  Often used instrumentally Long history of social difficulties  Other diagnoses often include:  Very at risk for accidental suicide  Substance abuse risk very high  Bipolar II disorder Depression Panic attacks Treatment:  Work & Personal PTSD Dialectic Behavior Therapy  http://behavioraltech.org/resources/whatisdbt.cfm Medication management  Usually a wide-range of meds but none treat BPD directly, only secondary symptoms Other Caveats:   Higher risk for complaints May manufacture “transgressions” and spread them to other providers and/or the state board Narcissistic Personality Disorder   Very difficult to dx initially    Often your “best” client initially  Substance abuse common Very charming/respectful at first Can become demanding/entitled over time and expect you to treat them “different” than your other clients A short story about my second patient during practicum…  Treatment:      Challenging to “break through” shiny exterior A lot of subsurface pain man manifest as anger Shame, doubt, narcissistic wounds Meds:   Long-Term, insight-oriented therapy can be effective Usually treat secondary symptoms such as anxiety, depression Can also be at an increased risk for suicide due to fearing failure in front of others  Many would rather die than be perceived as imperfect Histrionic Personality Disorder  Often “easier” to dx after first few sessions due to      Overt hyper sexuality Flamboyant/dramatic personality However, there is overlap with this and ASPD and BPD Very superficially charming Common signs/symptoms:       Extravagant makeup Revealing clothing Expressively dramatic Promiscuity in history Somatoform disorder common Very flirtatious and/or hypersexual  Treatment:  Often difficulty to break through superficiality  A lot of active 1) suppression or 2) repression   Shame and socially insecure  Meds: Afraid of losing control with emotions and “scaring” others away with “inner ugliness”   Can be med-seeking with benzo’s, pain meds, stimulants Often abuses substances Avoidant/Dependent Personality Traits  A/D not commonly “pure” dx but traits that are comorbid with other personality and emotional disorders  Avoidant Traits      Hyper self-consciousness Social Withdrawal High Level of Introversion Interpersonally Sensitive Treatment:    Difficult to establish rapport sometimes  Dependent Traits Comorbid Anxiety present – social anxiety  Long-term therapy helpful if client can stay committed and learn how to be vulnerable Often comorbid with depression, anger problems, anxiety, and approach/avoidance attachment styles  Associated with:       Low Self-Esteem Depression Difficulty taking responsibility Passive-Aggressive Behaviors Often comorbid with ADHD, developmental disorders, chronic pain/depression, and most personality disorders Treatment:   Can be difficult due to dependency Focus on improving independence and selfefficacy/personal responsibility Sexual Dysfunctions & Gender Dysphoria  Delayed Ejaculation  Erectile Disorder  Female Orgasmic Disorder  Female Sexual Interest/Arousal Dx  Genito-Pelvic Pain/Penetration Dx  Male Hypoactive Sexual Desire  Premature Ejaculation  Gender Dysphoria  Treatment:  THIS IS A SPECIALITY AREA  Multidisciplinary Treatment  Typically, CBT-based strategies integrated with group therapy, psychoeducation, pharmacological/medical intervention, and ancillary follow-up Disruptive/Impulse Control Disorders   Oppositional Defiant Disorder   Frequently comorbid with ADHD   Has to be present in more than one context! No “neurological” explanation, but often “emerging” personality traits Treatment = behavioral strategies, family therapy, treatment of comorbid conditions (usually anxiety,depression, etc), and educational intervention Intermittent Explosive Disorder    “Emotional Impulse Control Dysfunction”  Can be present with Antisocial Personality Disorder, although comorbid ADHD is usually ALWAYS present even in these cases  Usually comorbid with ADHD, autism spectrum, etc CANNOT BE DX’D IF BETTER EXPLAINED BY Disruptive Mood Dysregulation Disorder Treatment: anger management, environmental modification, CBT, stress inoculation  Conduct Disorder  Personality precursor to Antisocial Personality Disorder (often but not always precursor)   Earlier onset = worse prognosis  Treatment: Typically lack of empathy the greatest qualitative difference      Family support/family therapy Educational Intervention Residential Placement (if necessary) Comorbid depression, anger issues, ADHD, etc Can be difficult to treat Neurocognitive Disorders    Mild or Major Qualifiers  Includes formal assessment of neuropsychological abilities before formal diagnoses Defined as cognitive “decline” from premorbid status Typically diagnosed by psychiatrists, neurologists, and neuropsychologists   Will often be provisional prior to testing, however  Treatment:      Not the same as “delirium”    Formal Neurological Evaluation Formal Neuropsych Testing Family Support/Counseling Environmental Modification Inpatient/Outpatient Rehab  Speech, Occupational, Physical Individual Cognitive Rehab  Performed by SLT or neuropsychologist Pharmacological Intervention  Usually requires specialty treatment Dementia, Stroke, TBI, MS, Chronic Substance Use, Encephalopathies, Movement Disorders, neurotoxic exposure, anoxia/hypoxia, and other medical conditions… etc Understanding the “V” Codes  Not-diagnoses but allow for documentation of additional information that is pertinent  Not typically seen in clinical practice very often  Can be necessary for documenting when you report for child abuse, etc Developing a Treatment Plan (individual therapy)    Step 1: KNOW YOUR CLIENT Step 2: KNOW WHO IS PAYING Step 3: DIFFERENTIAL DIAGNOSIS       3a Case Conceptualization Step 4: SELECT LENGTH OF THERAPY Step 5: SELECT TIMING OF THERAPY STEP 6: DETERMINE SPECIFIC GOALS STEP 7: DETERMINE OBJECTIVES STEP 8: DETERMINE INTERVENTIONS   Step 9: Start Therapy   Step 11: Document Effectiveness Step 10: Assess/Evaluate Effectiveness (on a session-bysession basis) Step 12: Plan for Termination    Time-limited vs open-ended Termination issues Maintenance Plan Formulating Reports for Ancillary Providers and Legal Purposes  Rule #1   Rule#2   PROOF READ AGAIN! Treatment Summary         PROOF READ! Beginning date of treatment Interventions Goals Response to treatment Diagnoses  Plan  Put on official letter head with signature If you are a supervisee, ALWAYS CONSULT YOUR SUPERVISOR FIRST Social Security Reports  Want to know:  Can the client comprehend and carry out instructions, tolerate normal workrelated stress, communicate effectively with supervisors, clients, and coworkers, sustain attention and complete work in a timely manner Requests of Records from Attorney’s:     Make sure you have a signed consent from your client ONLY SEND WHAT THEY ASK FOR Anything you’ve written can be discoverable Write summaries very concisely and be sure not to “overstep” your area of competence  Many attorney’s will want you to say things that you cannot say based on your training [...]... review all of these in detail in this class! Dysfunctional Behavior Class # 2 Overview for Tonight:     Research Paper Review   APA Formatting Basic Requirements Brief Review of Last Class  Brain Functions, Neurotransmitters Diagnostic Interviewing  Introduction #1 of 2 reviews DSM-5  Neurodevelopmental Disorders     Brief Historical Review Diagnostic Criteria Brain Implications Treatment. .. performed with individuals, couples, and families Diagnostic Interviewing Lecture 1 of 2  Review of the Client’s Chief Complaint/Main Areas of Concern         Chief Complaint  Client’s spontaneous list of concerns WHY SEEK THERAPY NOW? When did the symptoms begin? How often do they occur? What is the severity of the symptoms? In what context do the symptoms occur? Triggers, etc.? What, if anything,... at most) Reviews a wide range of the client’s history and symptoms  See next slide Purpose is to establish a provisional diagnosis so as to delineate a specific plan for treatment Identifies other conditions in need of a referral to ancillary providers Should be therapeutic in nature and an effective means for “breaking the ice” during initial sessions with the client Often erroneously overlooked when... Aricept, Namenda DSM-5: Basic Overview  Changes from DSM-IV-TR include:       No more 5-axis diagnosis Improved attempt at non-overlapping criteria Integration of neuroscience research Consolidated autism spectrum disorders Improved classification of:  Bipolar, Depression, Mood disorders Addition of Neurocognitive Disorders  Pro’s:     New research, better classifications Enhanced clinical... Borderline Intellectual Functioning Axis III: Medical Conditions of Note Axis IV: Psychosocial Limitations Axis V: Global Assessment of Functioning (GAF)  Scale of 1-100 (very, very, very, subjective) DSM-5 no longer uses Multiaxial system     Axis I: Mental Disorders (not including personality or intellectual functioning) Most important/salient diagnosis at the top when recording Include notes for medical... assessment of adaptive functioning  Intellectual = verbal, non-verbal reasoning, processing speed, working memory  WAIS-IV, WISC-IV – Need FSIQ DSM-5: Neurodevelopmental Disorders  IDD Continued:    Severity is based primarily on adaptive functioning  E.g., patient can have IQ of 50 but have all ADL’s and adaptive behaviors relatively intact In this case, it would likely be mild ID Three Domains of. .. development    Often a history of language delays Cannot be acutely caused by hearing imp Typically diagnosed by speech-language pathologists, psychologists, or physicians Treatment involves speech-language therapy Co-Morbid: Social anxiety, autism, depression, dyslexia  Neuroanatomical Correlates: DSM-5: Neurodevelopmental Disorders    Speech Sound Disorder  DSM-5 encompasses all aspects of oral motor... intelligibility of production of speech sounds Typically phonemes Not caused by congenital or acquired conditions – e.g., CP, TBI Treatment Includes speech therapy Co-Morbid: anxiety, depression, social anxiety, decreased IQ/academic achievement  Childhood-Onset Fluency Disorder      Stuttering Prevalence is high until age 6 or so  Many false-positives Occasionally due to anxiety Treatment includes... weaknesses Behaviors during elementary through college Any special education services (e.g., speech therapy, 504, IEP, etc.) Any learning disabilities diagnosed? – any specific testing? Social development through academic history  Any bullying? DIAGNOSTIC INTERVIEW REVIEW TO BE CONTINUED NEXT CLASS… DSM-IV-TR to DSM-5 A Single Axis for Diagnosis vs The Multiaxial System  DSM-IV-TR had 5 “axis” for diagnosis. .. of the brain dealing with emotional drives, social attachment, and learned emotional responses to triggers  Develops early as an infant but neocortex develops later (i.e., the regulation of emotions come later) The Central Nervous System: Brain Anatomy & Psych Functions  Key Brain Areas Related to Psychiatric Illness:  Basal Ganglia/Amygdala  Basal Forebrain      OCD, Anxiety, Compulsive Behaviors, ...Overview of Today’s Class Class #1  Introductions  Review of Syllabus, Assignments, & Course Outline  Brief Review of Historical Influences of DSM-5  Brain Neuroanatomy: Cognitive, Behavioral,... Attendance/Participation   10% of Final Grade Each Absence = point off final grade Mid-Term (10/15/2014)     25% of Final Grade 50 multiple choice questions Closed Book Will be given 75 MC Q’s of which 50 will... advance Research Paper:  See syllabus for criteria  15% of final grade Historical Conceptions of Abnormal Behavior  Normal vs Abnormal Behavior   Culturally Defined & Dynamic Philosophical,