DSM IV-New Developments-Clinical and Multicultural Applications s1

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 Spring 2008 SATURDAY COURSE OUTLINE Course Dates: January 26; February 16, March 15, April 12, and May 10, 2008. Time: 8 to 5 Room: ARC 1007 except February 16th when we are in ARC 3006.

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;

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. Morrison, James, DSM-IV Made Easier, The Guilford Press, 2007. ISBN # 10 1-59385-331-9 or ISBN-13 978-1-59385-331-0. Amazon used $32.79; 2. Pomeroy, Elizabeth, & Wambach, Kathryn, The Clinical Assessment Workbook: Balancing Strengths and Differential Diagnosis, Thomson-Brookes/Cole, 2003, ISBN # 0-534-57843-8. Amazon used $82.27 3. DSM-IV or DSM-IVTR, American Psychiatric Publishing Co. Amazon used $48. 94 (Note: You can buy or use the DSM IV- Amazon used $33.00); 4. Morrison, James, DSM-IV Made Easy, The Guilford Press, 1995. ISBN # 0-89862-568-8. Amazon used $42.00;

Recommended Texts: 1. Morrison, James, The First Interview: Revised for the DSM-IV, The Guilford Press, 1995, ISBN # 0-89862-569-6. Amazon Used $10.56 (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.) 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).

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 as the Morrison Texts. 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 point 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 Roundtable Critical Thinking Question:You are to go to the web- sites indicated on the Februaryth session 16 and read the material on culture and mental illness. You then are to develop a critical thinking question that requires some in depth thinking to answer based on the readings. Then bullet points your “points of consideration” or your answer. Make seven copies of your question/answer and distribute your question/answer to your other members of your group. You discuss your question in your small group roundtable.

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 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

Course Outline

Session One: January 26th, 2008 ARC 1007 (We start at 8:00) General Issues & Schizophrenia & Other Psychotic Disorders

Please pay attention to the materials which are being e-mailed to you (or that you downloaded from the SW web site. You have a competency test to complete and bring to class, and the assignments that must be completed and brought to class.

A. Morning Session: “The Healing Science Within the DSM-IV-TR  The Basics of Diagnosis  The Diagnostic Method  The Building Blocks of Diagnosis  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 Vignettes

Readings:  Morrison, DSM IV Made Easier, Chapters 1-10 (pages 3-  Morrison, DSM-IV Made Easy, Chapter 4 (Real important), and Chapter 18 especially pages 544 through 548, &  Pomeroy & Wambach, The Clinical Assessment Workbook, Chapter 5. (Pages 118-143) Case 5.1, 5.2, 5.3, 5.4  DSM IV sections on Multi-Axial Assessment, DSM IV Classification, and Schizophrenia and other Psychotic  The First Interview, Chapters 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, disorders, or with the process of “structuring” your the necessary information and impression to help make differential diagnosis. Although this seems like a great deal reading, you will appreciate the pragmatism).

Assignment(s): 1. Differential Diagnosis Case Write ups for the four (4) DSM Cases in Pomeroy. Page 125 through 141, cases 5.1, 5.2, 5.3, & 5.4. 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 2. Completed Schizophrenia competency Quiz. This is being e-mailed with the course outline or you will see it attached to the course outline if you are downloading it from the SW web site. (Bring to

Session Two: February 16, 2008 Mood Related Disorders

Location: ARC 3006 A. Morning & Afternoon Session: *Discussion & feedback on Psychosis Case Vignettes *Final thoughts and considerations on Psychotic *Cultural Influences on the Diagnosis of Mood Related Disorders *Affective Disorders/Mood Disorders/Other Depressive Disorders Competency Probe *Suicide Considerations & Assessment-In Class *Using the DSM in the differential diagnosis of Mood * APA Diagnostic Training Tapes * Roundtable Discussion of Cultural Formulations Diagnosis Readings:  Morrison, DSM IV Made Easier, Chapter 11;  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. Go to http://www.surgeongeneral.gov/library/mentalhealth/cre/execsummary-6.html read the summary, main findings, main message, & each of the chapter summaries and conclusions; then go to: http://mental health.samhsa.gov/cre/ch2_culture_of_the_patient.asp and read “Culture Counts: The Influence of Culture and Society on Mental Health, Mental Illness”

Assignment(s): 1. Differential Diagnosis Case Write-ups for the four (4) DSM Cases in Pomeroy. Page 149 through 166, cases 6.1, 6.2, 6.3, 6.4. 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 2. Completed Mood Disorders competency Quiz. This will be handed out at session one. (Bring to class) 3. Culture Roundtable Critical Thinking Question: You are to go to the web-sites indicated on the February 16th session and read the material on culture and mental illness. You then are to develop a critical thinking question that requires some in depth thinking to answer based on the readings. Then bullet points your “points of consideration” or your answer. Make seven copies of your question/answer and distribute your question/answer to your other members of your group. You discuss your question in your small group roundtable.

Session Three: March 15, 2008 Adjustment Disorders, Anxiety/Stress Disorders, & the V Codes

Location: Mendocino Hall 1005 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 Easier, Chapter 12  Morrison, DSM-IV Made Easy, Chapter 6 & Chapter 14 & 17.  Pomeroy & Wambach, The Clinical Assessment Workbook, Chapter 7. (Pages 173-208) & Chapter 15 (pages 329-360)  DSM IV sections on Anxiety & Adjustment disorders.

Assignment(s): 1. Differential Diagnosis Case Write-ups for the six (6) DSM Cases in Pomeroy. Page 179 cases 7.1, 7.2, 7.3; & page 335 cases 15.1, 15.2, 15.3. 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 Anxiety competency Quiz. This will be handed out at session two. (Bring to class)

Session Four: April 12, 2008 Location: ARC 1007 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 Easier, Chapter 16;  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 six (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 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 competency Quiz on Personality Disorder. This will be handed out at session three. (Bring to class)

Session Five: May 10, 2008 Alcohol and Drug Related Disorders & Cognitive Disorders and Neurological Disorders Due to a Medical Condition

Location: ARC 1007

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

Readings:  Morrison, DSM IV Made Easier, Chapters 14 & 15;  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 (5) DSM Cases in Pomeroy. Complete case 4.1 & 4.2 & 4.3 (pages 95 to 104) on Drug and Alcohol Related Disorders. Then complete case 3.1 & 3.2 & 3.3 (3.3 is extra credit)- (pages 75 to 86) on Cognitive Disorders. Read the case 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 competency Quiz on Cognitive Disorders. This will be handed out at session four. (Bring to class)

Have an excellent summer and congratulations to the graduates! Dr. David Demetral, Ph.D., & LCSW Social Work 223 Spring 2007

Schizophrenia and Other Psychotic Disorders

Multiple Choice Questions:

1. Zoe, aged twenty-two, gave birth to her first child, Alexa, four days ago. Zoe'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 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 at least:

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 Camyron 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) Both Schizophrenia and Bipolar disorder d) Delusional disorder

13. Josette's mother, Erlange St. Villien, (age 79) has been having 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. Up until five months ago, Josette tried to convince her mother that the radio transmitter really did not exist. However, Josette has changed her mind and now believes that her mother's story may well be true. Josette’s mother is most likely experiencing:

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

True/False Questions:

14. Schizophreniform disorder refers to prodomal, active, and residual schizophrenic symptoms that have existed for less than six months duration.

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 has a significant mood disturbance lasting for more than two weeks should be diagnosed as schizoaffective disorder. 18. When you tell a client that his cat was just hit by a car and died, he falls down and rolls around on the ground laughing. He is displaying derailment.

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

Fill in the Missing Answer:

20. Symptoms of schizophrenia are divided into both "positive" and "negative" categories. Please list three positive symptoms that are experienced by persons with schizophrenia.

21. Symptoms of schizophrenia are divided into both "positive" and "negative" categories. Please list three negative symptoms that are experienced by persons with schizophrenia.

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