DSM IV-New Developments-Clinical and Multicultural Applications

SW 223 Dr. Demetral, Ph.D., & LCSW e-mail address: [email protected] Weekend Class CSUS Phone #: 916-278-7168 Fall 2009 SUNDAY COURSE OUTLINE Course Dates: Aug. 30th; Sept. 27th; Oct. 18th; Nov. 15th; Dec. 13th, 2009. Time: 8 to 5 Room: ARC (Academic Resource Center) 1009

Course Overview: Social Work 223 is designed to serve as a context of investigation and advanced study of a targeted advanced practice topic of interest to the Social Work graduate student. This three-unit elective will focus on the advanced understanding of the clinical application of the DSM IV. This class will consider the bio-psycho-social etiological base for the major psychological disorders (i.e. Axis I disorders- thought disorder, mood disorders, and anxiety disorders), as well as Axis II or personality disorders as well. Rigorous biological determinism has long been the cultural fashion in general medical and even counseling/clinical practice. However, a holistic view of pathology and treatment is now becoming more widely accepted. This trend is very obvious in the diagnosis and treatment of mental disorders. Even though there is a new and expanding (and very important) biomedical paradigm, it is being expanded to include a more holistic view that includes social and cultural factors in both diagnosis and treatment of mental illness. This class will present a client-centered model of differential assessment and diagnosis, using the DSM IV as the base of exploration, based on a holistic paradigm that integrates known biological, psychological, social, and cultural factors. Cross-cultural studies and their implications for the assessment and diagnosis of mental illness will provide the student of this class with the basis for understanding a new direction in the application of DSM IV to persons experiencing emotional disorder.

Course Objectives: At the conclusion of this class, the student will be able to display mastery of the following clinical social work practice concepts: 1. Advanced understanding and accurate use of the DSM IV when performing differential diagnosis; 2. Integrate cross cultural studies and their implications for the assessment and diagnosis of mental illness; -2-

3. Display written and verbal competence in the articulation of the biological-social- psychological-cultural etiological dimensions of schizophrenia and psychosis, mood disorders, anxiety disorders, personality disorders; 4. Display practice application understanding of specific medications for specific disorders and intervention concerns with special populations. 5. Display advanced competence in the development of differential diagnosis using the DSM IV as a context of accurate diagnosis.

Course Format This course is structured like a professional seminar, or workshop on this vital clinical area of practice. You will be responsible for reading and preparing “response sets” between each class that will be used in the small clinical dialogue groups. Differential diagnosis is a very serious clinical cluster of skills with major legal, ethical, and social implications. I have a responsibility to teach you to use and respect this diagnostic process. This course is a great deal of work, and yet you will find there is no other way to learn the skills needed to accurately diagnosis.

Required Course Texts: 1. Pomeroy, Elizabeth, & Wambach, Kathryn, The Clinical Assessment Workbook: Balancing Strengths and Differential Diagnosis, Thomson- Brookes/Cole, 2003, ISBN # 0-534-57843-8. (Required) 2. DSM-IV or DSM-IVTR, American Psychiatric Publishing Co. 3. Morrison, James, DSM IV Made Easy, The Guilford Press, 1995, ISBN #: 0- 89862-568-8. (Required). 4. Morrison, James, The First Interview: Revised for the DSM-IV, The Guilford Press, Third Edition, 2008, ISBN 13 # 978—1-59385-636-6. (Required) (This is an AWESOME book if you have not had a great deal of exposure to person’s with a mental illness, and/or have not conducted initial interviews, or mental status examinations, and are thus unsure of what you are looking for and how to ask the questions to solicit vital information.)

Recommended Texts: 1. Morrison, James, Diagnosis Made Easier , The Guilford Press, 2007, ISBN 13 # 978-1-59385-331-0; ISBN 10 #1-59385-331-91. Required 2. Fauman, Michael A., Study Guide to DSM-IV-TR, American Psychiatric Publishing Company, 2002, ISBN # 1-585-62-046-7. (This book is not as good as the Morrison Text in providing you with the format for decision making when using the DSM IV). 3. Dziegielewski, Sophia, F. DSM IV In Action, Wiley, 2002, ISBN #: 978-0-471- 41441-4. Note: You will find that there is a large array of books that are designed to help you with the “process of differential diagnosis” and “the mechanics of the DSM IV (or DSM-IV- TR)”. You will find that they are very redundant, and most add little to your ability to do either task. The best instructor’s manual is experiential or just using the manual, as well -3- as the Morrison Text. There is no better way to learn the subtleties of differential diagnosis than trial and error and group processing!

Course Assignments: 1. Psychiatric Diagnosis Competency Quizzes: There will be a competency test of your knowledge of each of the disorders being discussed. These quizzes are made up of essential material on the disorder (i.e. schizophrenia). These quizzes are broken up into multiple-choice clinical case descriptions, true/false; fill ins, and matching items. You must have the test done prior to the class that the content is being discussed. We will grade these in class and discuss the content. 50 points each. 2. DSM-IV Differential Diagnosis Probes: You will be assigned DSM-IV cases related to the diagnostic area being considered (i.e. Thought Disorders) from the Pomeroy & Wambach Text “The Clinical Assessment Workbook”. You are expected to answer the short answers for each disorder group. You are to type these answers up. These probes are used in “clinical roundtable” during each session devoted to that diagnostic category. These will be handed in and graded on the following scale:  Minimal effort/quality = D (65)  Average effort/quality = C (75)  Above average effort/quality = B (85)  Excellent effort/quality= A (95) To determine your grade on these sets, simply multiply your total by the number of question sets (i.e. 6 x 95= 570 A+). NOTE: if you do not have your sets (which are required per class, you will get a zero for each. No late sets will be accepted no exceptions). 3. Culture and Mental Health Roundtable Discussion: You are to go to the web-sites indicated on the September 27th, 2009 session (session #2) and read the material on culture and the diagnosis of mental illness. You are then to develop a critical thinking question that requires some “in depth” critical thinking to answer based on the readings. Make seven copies of your question and answer, with references. Your answer can be in “bullet points”. You will dialogue in your small groups about your critical thinking culture and mental illness question(s). 4. Attendance: Because this is a weekend class with only five sessions you cannot miss a class without severe consequence. Each class is equivalent to three (3) sessions in a fifteen (15) week class. So, if you miss one full day, you will be not be given credit for the class, and must see Dr. Demetral. If you miss one half day your final grade will be lowered one full grade.

Course Outline Session One: August 30th, 2009 Mental Status Examination; Multi-Axial & Differential Diagnosis; The Bio-Psycho Interface & Schizophrenia & Other Psychotic Disorders -4- Please pay attention to the materials that are being e-mailed to you. You have a competency test to complete and bring to class, and the assignment that must be completed and brought to class.

A. Morning Session: “The Healing Science Within the DSM-IV-TR” *Evolution of the DSM *The Multi-Axial System *The Notion of Multi Axial Assessment Sample vignettes exercise & Discussion *The Initial Interview: *The Mental Status Definitions *The Mental Status Examination Simulation

B. Afternoon Session: *Schizophrenia & Other Psychotic Disorders *Schizophrenia Competency Test: Discussion *APA Diagnostic Training Tapes & Discussion *Pomeroy Vignette “practice”

Readings:  Morrison, DSM-IV Made Easy, Chapter 4. (Real important), and Chapter 18 especially pages 544 through 548, & Appendix A, B, & C.  Pomeroy & Wambach, The Clinical Assessment Workbook, Chapter 5. (pages 118-143) Case 5.1 through and including 5.4  DSM IV sections on Multi-Axial Assessment, DSM IV Classification, and Schizophrenia and other Psychotic Disorders.  The First Interview, Chapters 1-4; & 11-14. Review Appendix A. (This set of readings is real critical if you have not had a great deal of experience with mental disorders, interviewing persons with mental disorders, or with the process of “structuring” your interview elicit the necessary information and impression to help make your differential diagnosis. Although this seems like a great deal of reading, you will appreciate the pragmatism).

Assignment(s): 1. Differential Diagnosis Case Write ups -this will be used for our practice in class in Pomeroy. Page 125 through 141, cases 5.1 through 5.4 are to be completed prior to coming to class. Read the case(s) and type up your answers to the short questions and the differential diagnosis. I want you to defend your diagnostic impression with the specific criteria that are met or not met directly quoted from the DSM IV. (Bring to Class). 2. Completed Schizophrenia competency Quiz. This is being e- mailed with the course outline. (Bring to class)

-5- Session Two: September 27th, 2009 Mood Related Disorders A. Morning & Afternoon Session: *Discussion & feedback on Psychosis Case Vignettes *Final thoughts and considerations on Psychotic Disorders *Cultural Influences on the Diagnosis of Mental Disorders *Affective Disorders/Mood Disorders/Other Depressive Disorders Competency Probe *Suicide Considerations & Assessment-In Class Exercise *Using the DSM in the differential diagnosis of Mood Disorders * APA Diagnostic Training Tapes

Readings:  Morrison, DSM-IV Made Easy, Chapter 5. (Real important).  Pomeroy & Wambach, The Clinical Assessment Workbook, Chapter 6. (pages 143-173)  DSM IV sections on Mood. Assignment(s): 1. Differential Diagnosis Case Write ups for the four (4) DSM Cases in Pomeroy. Page 149 through 166, cases 6.1 up to 6.5. Read the case(s) and type up your answers to the short questions and the differential diagnosis. I want you to defend your diagnostic impression with the specific criteria that are met in the DSM IV. (Bring to Class). 2. Completed Mood Disorders competency Quiz. This will be handed out at session one. (Bring to class) 3. Cultural Considerations when Diagnosing “Disorders” across cultures “roundtable dialogue question) 1. Culture and Mental Illness Washington Post staff writer Shankar Vedantam discusses his series about how culture influences the diagnosis, treatment and outcome of mental illness. http://www.washingtonpost.com/wp- dyn/content/discussion/2005/06/27/DI2005062701082.html 2. Unit 9, Online Readings in Psychology and Culture , Center for ... While various cultures have unique treatments for mental illness, no culture claims to have all the answers. The chapters in this unit address some of the ... http://www.ac.wwu.edu/~culture/unit9.htm - 10k 3. Online Readings in Psychology and Culture , Unit 9, Chapter 1 The mutual embeddedness of culture and mental illness. .... Culture does not just influence mental health and illness, but rather it is a constituent of ... http://www.ac.wwu.edu/~culture/Sam_Moreira.htm - 42k 4. Medical Anthropology: Culture Specific Diseases Dec 14, 2007 ... What is defined as a mild form of mental illness in one culture may be defined as normal behavior in another. ... http://anthro.palomar.edu/medical/med_4.htm - 27k -6- 5. Mental Health: Culture , Race, Ethnicity MENTAL HEALTH: CULTURE, RACE, AND ETHNICITY A Supplement to. Mental Health: A Report of the ... Mental health and mental illness are points on a continuum. ... http://www.surgeongeneral.gov/library/mentalhealth/cre/execsummary-1.html - 11k - 6. In other countries, symptoms of mental illness vary, with ... Mar 24, 2008 ... The American Psychiatric Association's diagnostic manual includes a glossary of "culture-bound syndromes" - forms of mental illness reported ... http://www.boston.com/news/health/articles/2008/03/24/culture_gap/ - - Cached - Similar pages

Session Three: October 18th, 2009 Adjustment and Anxiety/Stress Disorders

Morning Session & Afternoon Session *Feedback and Discussion of Mood Cases *Final thoughts regarding Mood Disorders *Cultural Influences on the Diagnosis of Anxiety Disorders *Anxiety Disorders Competency Probe *Anxiety Disorders: Conceptual Overview *Panic Attacks and Panic Disorders *Obsessive-Compulsive Disorder *APA Diagnostic Training Tapes

Readings:  Morrison, DSM-IV Made Easy, Chapter 6.  Pomeroy & Wambach, The Clinical Assessment Workbook, Chapter 7. (pages 173-208)  DSM IV sections on Anxiety.

Assignment(s): 1. Differential Diagnosis Case Write ups for the six (6) DSM Cases in Pomeroy. Page 179 through 197, cases 7.1 to 7.6. Read the case and type up your answers to he short questions and the differential diagnosis. I want you to defend your diagnostic impression with the specific criteria that are met in the DSM IV. (Bring to Class). 2. Completed competency Quiz. This will be handed out at session two. (Bring to class) -7- Session Four: November 15th, 2009 Personality Disorders & Disorders Usually Diagnosed in Infancy, Childhood, & Adolescence

Morning Session: *Cultural Influences on the Diagnosis of Personality Disorders *Personality Disorders Competency Probe *Personality Disorder APA Diagnostic Training Tapes Afternoon Session *Cultural Influences on the Diagnosis of Childhood Disorders *Disorders Diagnosed in Infancy, Childhood, and Adolescence Competency Probe

Readings:  Morrison, DSM-IV Made Easy, Chapter 15 & 16.  Pomeroy & Wambach, The Clinical Assessment Workbook, Chapter 14 & 2.  DSM IV sections on Disorders usually first diagnosed in Infancy, Childhood, or Adolescence, and Personality Disorders.

Assignment(s): 1. Differential Diagnosis Case Write ups for the four (6) DSM Cases in Pomeroy. Complete case 14.1 & 14.2 & 14.3 (pages 311 to 319) on Personality Disorders. Then complete case 2.1 & case 2.2 & 2.3 (pages 27 to 37) on Childhood Disorders. Read the case and type up your answers to he short questions and the differential diagnosis. I want you to defend your diagnostic impression with the specific criteria that are met in the DSM IV. (Bring to Class). 2. Completed competency Quiz on Personality Disorder. This will be handed out at session three. (Bring to class)

Session Five: December 13th, 2009 Alcohol and Drug Related Disorders & Cognitive Disorders and Neurological Disorders Due to a Medical Condition A. Morning Session: *Course Evaluation *Alcohol & Drug Related Disorders *APA Training Tapes B. Afternoon Session *Cognitive Disorders & Neurological Disorders Due to a Medical Condition *APA Training Tapes -8- Readings:  Morrison, DSM-IV Made Easy, Chapter 1, 2, & 3.  Pomeroy & Wambach, The Clinical Assessment Workbook, Chapter 3 & 4.  DSM IV sections on Alcohol and Drug Related Disorders & Delirium, Dementias, and other cognitive disorders.

Assignment(s): 1. Differential Diagnosis Case Write ups for the four (4) DSM Cases in Pomeroy. Complete case 4.1 & 4.2 (pages 95 to 103) on Drug and Alcohol Related Disorders. Then complete case 3.1 & case 3.2 (pages 75 to 83) on Cognitive Disorders. Read the case and type up your answers to he short questions and the differential diagnosis. I want you to defend your diagnostic impression with the specific criteria that are met in the DSM IV. (Bring to Class). 2. Completed competency Quiz on Cognitive Disorders. This will be handed out at session four. (Bring to class) Dr. David Demetral, Ph.D., & LCSW Social Work 223 Fall 2009

Schizophrenia and Other Psychotic Disorders Competency Test One

Multiple Choice Questions:

1. Zoë, aged twenty-two, gave birth to her first child, Alexia, four days ago. Zoë’s initial complaints included insomnia, restlessness, and emotional labiality that progressed to confusion, irritability, delusions, and thoughts of wanting to kill her baby. Which diagnosis would you consider first?

a) Induced delusional disorder b) Brief psychotic disorder, post-partum onset c) Autoscopic psychosis d) Conversion disorder

2. Ozell Turner has been re-hospitalized with schizophrenia. The social worker indicated on his chart that he had been pathologically repeating the same cluster of words over, and over, and over again. This is an example of:

a) Verbigeration b) Neologism c) Echolalia d) Echopraxia

3. The following factor is most closely related to relapse in persons with schizophrenia.

a) Whether or not the person is gainfully employed b) The age and gender of the person c) Compliance with psychotherapy d) Lack of adherence to psychotropic medications

4. Morgan Carpenter once met the full criteria for schizophrenia. However, she no longer has pronounced symptoms of catatonic behavior, delusions, hallucinations, or disorganized speech or behavior. She occasionally exhibits odd beliefs and peculiarities of behavior. What would be the correct diagnosis?

a) Schizophrenia, disorganized type b) Schizophrenia, residual type c) Schizophrenia, NOS d) Schizoaffective disorder, NOS 5. Eighteen year-old Patricia Wilson was taken to the North Shore emergency room by her family after she complained that she couldn't sleep because of the “voices” she heard. She couldn't really say what the voices were saying but the family reported that Patricia went on rambling and they could not understand her conversations. For the past six months Patricia's family tried to ignore these symptoms but became more worried as the symptoms continued. Their concerns became more emergent when Patricia started talking gibberish, giggled inappropriately, made silly faces, and neglected her hygiene and appearance.

a) Schizophrenia, disorganized type b) Schizoaffective disorder c) Schizophreniform disorder d) Schizophrenia, undifferentiated type

6. Alphonso de la Portia has been experiencing abnormal, involuntary, irregular movements of the muscles of his head, limbs and trunk. His symptoms include twisting, chewing, and thrusting movements of his tongue. The only other relevant information the social worker knows is he has been on long-term anti-psychotic medication (Thorazine). This disorder is known as:

a) Huntington's disease b) Tardive dyskensia c) Ataques de Nervios d) Hydrangiea Chorea

7. Johann Wojcik emigrated from Poland ten years ago. His past mental health history is unknown. According to the police, he was found sitting motionless in the middle of the highway. The mobile crisis unit took him to the state mental hospital where he refuses to make eye contact, is mute, and resists attempts to be moved and does not interact or participate in any way. Which of the following would be your beginning diagnosis?

a) Schizophrenia, paranoid type b) Schizophrenia, residual type c) Schizophrenia, disorganized type d) Schizophrenia, catatonic type

8. In order to meet the diagnostic criteria for schizophrenia, those characteristic symptoms of the active phase need to be present in the individual for:

a) Six months b) Three months c) One month d) Two weeks 9. Sue Anne Brinkley is an eighteen-year old college freshman enrolled at Cameron State University. She presents herself at the campus counseling center following the unexpected death of her best friend. She exhibits the following symptoms --- disturbance in her thought process (tangential thinking) as well as delusions of grandeur (she believes herself to be Joan of Arc) and bizarre behaviors (repeatedly cleaning her sorority house stove with a toothbrush). According to her roommate, Alison, these symptoms started about eight or nine days ago (approximately 36 hours after hearing the news of her best friend's death). Sue Anne has no prior history of mental illness and her level of premorbid functioning was noted as "excellent". Based on this information, what do you believe is Sue Anne's most likely diagnosis?

a) Hypomania, with psychotic features b) Schizoaffective disorder c) Brief psychotic disorder d) Schizophrenia, residual type

10. Georgio Ferrari displays loose associations, tangentiality, inappropriate affect and disorganized behavior. Georgio is most likely diagnosed with:

a) Schizophrenia, disorganized type b) Schizophrenia, hebephrenic type c) Schizophrenia, catatonic type d) Schizophrenia, residual type

11. Sammie Arnold Carvey has the major symptoms of schizophrenia but she does not meet the criteria for one of the specific sub types of schizophrenia. How would you list her diagnosis?

a) Undetermined b) Schizophrenia, NOS c) Schizophrenia, residual type d) Schizophrenia, undifferentiated type

12. Tom Wang has experienced disorganized speech and delusions for the past three months. After this time period, his symptoms quickly disappeared without any treatment. Tom would most likely receive a diagnosis of:

a) Schizophrenia, residual type. b) Schizophreniform disorder c) Rule out Delirium d) No diagnosis

13. Josette's mother, Erlange St. Villien, (age 79) has had a sudden onset of delusional beliefs that some kind of highly specialized radio transmitter was inserted into her tooth filling as part of an experiment being conducted by aliens from the planet Mars. Josette tried to convince her mother that the radio transmitter really did not exist. However, Josette has become increasingly worried as these bizarre statements and behaviors have gone on for three days. Your first differential diagnosis that must be considered is:

a) Schizophrenia, NOS b) A brief psychotic episode c) Delirium d) Schizophrenia, disorganized type

True/False Questions:

14. Schizophreniform disorder refers to prodromal, active, and residual schizophrenic symptoms that have existed for less than six months duration, but more than one month.

15. Tardive dyskinesia includes the voluntary movement of one's head, neck and limbs manifested by long-term antipsychotic medication.

16. Schizophrenia, catatonic type, describes a person who can sit for hours on end virtually motionless, refuses to make eye contact and resists attempts to be moved.

17. Persons who meets the full criteria for a diagnosis of schizophrenia, and also have a significant mood disturbance lasting for more than two weeks should be diagnosed as Schizoaffective disorder.

18. During your intake interview with Sylvia Martin you notice that it takes a very long time for her to respond . Sylvia is displaying avolition.

Definition: 19. The negative symptoms of Schizophrenia include affective flattening, alogia, or avolition. Describe and define these terms, and how they may be clues to a co-morbid mood disorder.

Critical Thinking question(s)

20. Symptoms of schizophrenia are divided into both "positive" and "negative" categories. Please describe the three positive symptoms that are experienced by persons with schizophrenia. (Hint: Define, describe, and share what to be aware of when you are interviewing)

21. Delusional Disorder is one of the differential diagnosis” that must be considered when diagnosing Schizophrenia. Describe how you would make the differential diagnosis between Schizophrenia and Delusional disorder. 22. Matching Items: a) Echopraxia 1.Pathological imitation of another person’s movements b) Echolalia 2. Pathological repeating of the same cluster of words c) Tardive dyskensia 3. False beliefs d) Delusions 4. Abnormal, involuntary irregular movement of the head, limbs and trunk muscles e) Dysphoria 5. Individuals believe they are persons of exalted position (Jesus or the President of the U.S.) f) Delusions of grandeur 6. Anger, depression and increased anxiety are common emotional reactions to ensuing psychosis g) Persecution 7. This subtype includes delusions and hallucinations that are less prominent than negative symptoms and disorganized speech and behavior h) Shared psychotic disorder 8. This disorder includes at least one of the basic psychotic symptoms and lasts less than one month i) Brief psychotic disorder 9. Symptoms include motoric immobility, excessive motor activity, extreme negativism (or mutism), or peculiar posturing j) Disorganized type 10. Individuals feel they are being pursued when they are not k) Catatonic type 11. Previously known as Folie a Deux l) Schizoaffective disorder 12. These individuals have met the criteria for schizophrenia, however the symptoms have lasted for less than six months m) Schizophreniform 13. Individuals have all the symptoms of schizophrenia; at the same time they have prominent symptoms of mania or depression