Table
of Contents
|
|
|
|
|
|
Acknowledgments
and an Invitation |
xvii |
|
|
Getting
Oriented to the Clinician’s Thesaurus |
1 |
|
|
What is the Clinician’s Thesaurus and What
does it Do? |
1 |
|
|
How this Book is Organized |
2 |
|
|
Understanding the Style and Format of
the Chapters |
3 |
|
|
A Functional Guide to Report
Construction |
7 |
|
|
Further Guidelines and Advice on
Report Writing |
13 |
|
|
Some Ways to Use the Clinician’s Thesaurus |
16 |
|
|
A Cautionary Note and Disclaimer |
17 |
|
PART I |
CONDUCTING A MENTAL HEALTH EVALUATION |
|
|
1 |
Beginning
and Ending the Interview |
21 |
|
1.1 |
Structuring the Interview |
21 |
|
1.2 |
Introducing Yourself and Noting Possible Communication Difficulties |
21 |
|
1.3 |
Assessing the Client’s Understanding of the Interview Situation |
22 |
|
1.4 |
Obtaining Informed Consent |
23 |
|
1.5 |
Other Points for All Interviews |
23 |
|
1.6 |
Eliciting the Chief Concern/Complaint/Issue |
24 |
|
1.7 |
Eliciting the Client’s Understanding of the Problem |
24 |
|
1.8 |
Dimensionalizing the Concern/Problem |
24 |
|
1.9 |
Ending the Interview |
25 |
|
2 |
Mental Status Evaluation Questions/Tasks |
26 |
|
2.1 |
Introduction to the Mental Status Questions |
26 |
|
2.2 |
Background Information Related to Mental Status |
27 |
|
2.3 |
Rancho Los Amigos Cognitive Scale |
27 |
|
2.4 |
Glasgow Coma Scale |
28 |
|
2.5 |
Orientation |
28 |
|
2.6 |
Attention |
30 |
|
2.7 |
Concentration |
30 |
|
2.8 |
Comprehension of Language |
31 |
|
2.9 |
Eye-Hand Coordination/Perceptual-Motor Integration/ Dyspraxia/
Constructional Ability |
31 |
|
2.10 |
Memory |
32 |
|
2.11 |
Fund of Information |
34 |
|
2.12 |
Opposites |
35 |
|
2.13 |
Differences |
36 |
|
2.14 |
Similarities/Analogies |
36 |
|
2.15 |
Absurdities |
36 |
|
2.16 |
Calculation Abilities |
37 |
|
2.17 |
Abstract Reasoning/Proverbs |
38 |
|
2.18 |
Paired Proverbs |
38 |
|
2.19 |
Practical Reasoning |
39 |
|
2.20 |
Social Judgment |
39 |
|
2.21 |
Decision Making |
40 |
|
2.22 |
Self-Image |
40 |
|
2.23 |
Insight into Disorder |
40 |
|
2.24 |
Strengths and Coping |
41 |
|
2.25 |
Mental Status Evaluation Checklist |
41 |
|
3 |
Questions About Signs, Symptoms, and Other Behavior Patterns |
44 |
|
3.1 |
Introduction to the Questions About Signs, Symptoms, and Behavior Patterns |
44 |
|
3.2 |
Abuse (Nonsexual)/Neglect of Spouse/Elder |
45 |
|
3.3 |
Abuse (Nonsexual)/Neglect of Child |
46 |
|
3.4 |
Abuse (Sexual) of Child or Adult |
46 |
|
3.5 |
Affect/Mood |
47 |
|
3.6 |
Anxiety |
48 |
|
3.7 |
Body Dysmorphic
Disorder |
48 |
|
3.8 |
Compliance-Noncomphance
with Treatment |
48 |
|
3.9 |
Compulsions |
49 |
|
3.10 |
Delusions |
50 |
|
3.11 |
Depression |
51 |
|
3.12 |
Dissociative Experiences |
53 |
|
3.13 |
Eating Disorders |
54 |
|
3.14 |
Gay and Lesbian Identity Formation |
56 |
|
3.15 |
Hallucinations |
56 |
|
3.16 |
Illusions |
58 |
|
3.17 |
Impulse Control |
58 |
|
3.18 |
Mania |
58 |
|
3.19 |
Obsessions |
59 |
|
3.20 |
Organicity/Cognitive Disorders |
60 |
|
3.21 |
Pain, Chronic |
60 |
|
3.22 |
Paranoia |
61 |
|
3.23 |
Phobias |
62 |
|
3.24 |
Self-Injury |
62 |
|
3.25 |
Sexual History |
63 |
|
3.26 |
Sexual Identity/Transgender Issues |
65 |
|
3.27 |
Sleep |
66 |
|
3.28 |
Substance Abuse: Drugs and Alcohol |
67 |
|
3.29 |
Substance Use: Tobacco and Caffeine |
75 |
|
3.30 |
Suicide and Self-Destructive Behavior |
76 |
|
3.31 |
Violence |
78 |
|
PART II |
STANDARD TERMS AND STATEMENTS FOR WORDING PSYCHOLOGICAL
REPORTS |
|
|
A |
Introducing the Report |
|
|
4 |
Beginning
the Report: Preliminary Information |
83 |
|
4.1 |
Heading and Dates for the Report |
83 |
|
4.2 |
Sources of Information for the Report |
83 |
|
4.3 |
Identifying Information About the Client |
84 |
|
4.4 |
Self-Sufficiency in Appearing for Examination |
85 |
|
4.5 |
Consent Statements |
86 |
|
4.6 |
Reliability/Validity Statements |
87 |
|
4.7 |
Confidentiality Notices |
89 |
|
4.8 |
Ethical Considerations in Report Writing |
91 |
|
5 |
Referral Reasons |
92 |
|
5.7 |
Statement of Referral Reason |
92 |
|
5.2 |
Common Referral Reasons for Children at Home |
93 |
|
5.3 |
Common Referral Reasons for Children at School |
93 |
|
5.4 |
Common Referral Reasons for Children at Both Home and School |
95 |
|
6 |
Background Information and History |
97 |
|
6.1 |
History/Course of the Present/Chief Complaint/Concern/Problem/Illness |
97 |
|
6.2 |
Medical History and Other Findings |
98 |
|
6.3 |
Personal, Family, and Social Histories, and Current Social Situation |
99 |
|
6.4 |
Adjustment History |
102 |
|
6.5 |
Social History for a Disability Examination |
103 |
|
6.6 |
Family Genogram/Family
Tree/Pedigree |
104 |
|
B |
the Person in the Evaluation |
|
|
7 |
Behavioral
Observations |
107 |
|
7.1 |
Appearance |
107 |
|
7.2 |
Clothing/Attire |
110 |
|
7.3 |
Movement/Activity |
117 |
|
7.4 |
Speech Behavior |
114 |
|
7.5 |
Other Behavioral Observations |
117 |
|
8 |
Responses to Aspects of the Examination |
118 |
|
8.1 |
Reaction to the Context of the Evaluation |
118 |
|
8.2 |
Attention/Concentration/Effort |
120 |
|
8.3 |
Response to the Methods of Evaluation/Tests/Questions |
121 |
|
8.4 |
Persistence/Motivation |
122 |
|
8.5 |
Relationship with the Examiner |
123 |
|
8.6 |
Response to Success/Failure/Feedback |
125 |
|
9 |
Presentation of Self |
127 |
|
9.1 |
Dependency-Surgency |
127 |
|
9.2 |
Presence/Style |
127 |
|
9.3 |
Self-Image/Self-Esteem |
128 |
|
9.4 |
Social Sophistication/Manners |
128 |
|
9.5 |
Warmth-Coldness |
129 |
|
9.6 |
Other Aspects of Self-Presentation |
129 |
|
10 |
Emotional/Affective
Symptoms and Disorders |
132 |
|
10.1 |
General Aspects of Mood and Affects |
132 |
|
10.2 |
Anger |
133 |
|
10.3 |
Anxiety/Fear |
134 |
|
10.4 |
Bipolar I Disorder |
136 |
|
10.5 |
Bipolar II Disorder |
136 |
|
10.6 |
Cyclothymia |
137 |
|
10.7 |
Depression |
137 |
|
10.8 |
Guilt/Shame |
142 |
|
10.9 |
Mania |
143 |
|
10.10 |
Panic |
144 |
|
10.11 |
Seasonal Affective Disorder |
144 |
|
10.12 |
Sexuality |
145 |
|
10.13 |
Other Affects/Emotional Reactions |
145 |
|
11 |
Cognition and Mental Status |
146 |
|
11.1 |
No Pathological Findings: Summary Statements |
146 |
|
11.2 |
Arithmetic |
147 |
|
11.3 |
Attention |
147 |
|
11.4 |
Concentration/Task Persistence |
147 |
|
11.5 |
Consciousness Levels |
148 |
|
11.6 |
Decision Making |
148 |
|
11.7 |
Dementia |
149 |
|
11.8 |
Information |
149 |
|
11.9 |
Insight |
150 |
|
11.10 |
Intelligence, Development, and Cognition: Assessment |
151 |
|
11.11 |
Intelligence Scores: Classifications |
152 |
|
11.12 |
Memory |
153 |
|
11.13 |
Moral/Social Judgment and Knowledge |
156 |
|
11.14 |
Motivation for Change: Summary Statements |
157 |
|
11.15 |
Orientation |
157 |
|
11.16 |
Reality Testing |
157 |
|
11.17 |
Reasoning/Abstract Thinking/Concept Formation |
158 |
|
11.18 |
Social Maturity |
159 |
|
11.19 |
Stream of Thought |
159 |
|
11.20 |
Test Judgment: Summary Statements |
162 |
|
11.21 |
Other Summary Statements for Mental Status |
162 |
|
12 |
Abnormal
Signs, Symptoms, and Syndromes |
163 |
|
12.1 |
Abuse |
163 |
|
12.2 |
AIDS Dementia Complex |
164 |
|
12.3 |
Attention-Deficit/Hyperactivity Disorder |
164 |
|
12.4 |
Autism Spectrum Disorders |
168 |
|
12.5 |
Battered-Woman Syndrome |
169 |
|
12.6 |
Body Dysmorphic
Disorder |
170 |
|
12.7 |
Chronic Fatigue Syndrome |
171 |
|
12.8 |
Compulsions |
171 |
|
12.9 |
Conduct Disorder |
172 |
|
12.10 |
Delusions |
173 |
|
12.11 |
Denial |
174 |
|
12.12 |
Depersonalization and Derealization |
175 |
|
12.13 |
Dual Diagnoses |
175 |
|
12.14 |
Eating Disorders |
175 |
|
12.15 |
Fetal Alcohol Syndrome |
178 |
|
12.16 |
Gambling |
178 |
|
12.17 |
Hallucinations |
179 |
|
12.18 |
Illusions |
180 |
|
12.19 |
Impulse-Control Disorders |
180 |
|
12.20 |
Malingering |
182 |
|
12.21 |
Obsessions |
183 |
|
12.22 |
Oppositional Defiant Disorder |
184 |
|
12.23 |
Pain Disorder/Chronic Pain Syndrome |
184 |
|
12.24 |
Paranoia |
185 |
|
12.25 |
Phobias |
185 |
|
12.26 |
Postconcussive Syndrome |
186 |
|
12.27 |
Posttraumatic Stress Disorder |
186 |
|
12.28 |
Premenstrual Dysphoric
Disorder |
188 |
|
12.29 |
Rape Trauma Syndrome |
189 |
|
12.30 |
Reactive Attachment Disorder |
190 |
|
12.31 |
Schizophrenia |
191 |
|
12.32 |
School Refusal/Avoidance/“Phobia,” 192 |
|
|
12.33 |
Self-Injurious Behavior |
193 |
|
12.34 |
Sexual Abuse, Child |
193 |
|
12.35 |
Sexual Impulsivity/“Addiction”/“Compulsion” |
194 |
|
12.36 |
Side Effects of Psychotropic Medications/Adverse Drug Reactions |
195 |
|
12.37 |
Sleep Disturbances |
196 |
|
12.38 |
Stalking |
198 |
|
12.39 |
Substance Use, Abuse, and Dependence |
198 |
|
12.40 |
Suicide |
202 |
|
12.41 |
Violent Behaviors |
207 |
|
13 |
Personality Patterns |
209 |
|
13.1 |
Models of Personality Diagnosis |
209 |
|
13.2 |
Assessment Methods |
211 |
|
13.3 |
Cognitive or Thinking Styles |
212 |
|
13.4 |
A and B Personality Types |
212 |
|
13.5 |
“Addictive” Personality |
214 |
|
13.6 |
Aggressive Personality |
214 |
|
13.7 |
Antisocial Personality |
214 |
|
13.8 |
Authoritarian Personality |
216 |
|
13.9 |
Avoidant Personality |
217 |
|
13.10 |
Borderline Personality |
218 |
|
13.11 |
Codependent Personality |
219 |
|
13.12 |
Compulsive Personality |
221 |
|
13.13 |
Dependent Personality |
222 |
|
13.14 |
Dissociative Identity Disorder |
224 |
|
13.15 |
Histrionic Personality |
225 |
|
13.16 |
Hypochondriacal Personality |
226 |
|
13.17 |
Narcissistic Personality |
227 |
|
13.18 |
“Nervous” Personality |
228 |
|
13.19 |
Normal/Healthy Personality |
229 |
|
13.20 |
Obsessive Personality |
230 |
|
13.21 |
Paranoid Personality |
231 |
|
13.22 |
Passive-Aggressive Personality |
232 |
|
13.23 |
Sadistic Personality |
233 |
|
13.24 |
Schizoid Personality |
234 |
|
13.25 |
Schizotypal Personality |
235 |
|
13.26 |
Self-Defeating Personality |
235 |
|
C |
the Person in the Environment |
|
|
14 |
Activities
of Daily Living |
239 |
|
14.1 |
Assessment |
239 |
|
14.2 |
Assistance Level Required/Degree of Independence |
239 |
|
14.3 |
Child Care |
240 |
|
14.4 |
Chores/House Care/Domestic Skills |
240 |
|
14.5 |
Cooking |
240 |
|
14.6 |
Financial Skills |
240 |
|
14.7 |
Hazard Recognition and Coping |
241 |
|
14.8 |
Living Situation/Level of Support Needed |
242 |
|
14.9 |
Quality of Performance |
242 |
|
14.10 |
Self-Care Skills |
242 |
|
14.11 |
Shopping |
243 |
|
14.12 |
Transportation |
243 |
|
14.13 |
Caregiver Burden |
243 |
|
14.14 |
Summary Statements |
243 |
|
15 |
Social/Community
Functioning |
245 |
|
15.1 |
General Lifestyle |
245 |
|
15.2 |
Involvement in Social/Community Activities |
246 |
|
15.3 |
Problems/Conflicts in Community Relating |
246 |
|
16 |
Couple and
Family Relationships |
247 |
|
16.1 |
Systemic Family Constructs |
247 |
|
16.2 |
Assessment of Families at Intake |
248 |
|
16.3 |
Family Interviewing Method |
249 |
|
16.4 |
Child Rearing/Raising: Aspects |
250 |
|
16.5 |
Couple Relationships: Aspects |
251 |
|
16.6 |
Summary Statement |
251 |
|
17 |
Vocational/Academic Skills |
252 |
|
17.1 |
Basic Work Skills |
252 |
|
17.2 |
History of Work |
255 |
|
17.3 |
Language Skills: Reading and Writing Ability |
256 |
|
17.4 |
Math Ability |
257 |
|
17.5 |
Special Considerations for Disability Reports, 257 |
|
|
17.6 |
Vocational Competence/Recommendations |
257 |
|
18 |
Recreational Functioning |
260 |
|
18.1 |
Entertainment: TV/Radio/Music |
260 |
|
18.2 |
Hobbies |
260 |
|
18.3 |
Sports |
260 |
|
18.4 |
Reading Materials |
261 |
|
18.5 |
Participation/Performance Quality |
261 |
|
19 |
Other Specialized Evaluations |
262 |
|
19.1 |
Coping Ability/Stress Tolerance |
262 |
|
19.2 |
Culturally Sensitive Formulations |
262 |
|
19.3 |
Developmental Stages |
264 |
|
19.4 |
Financial Competence/Competence to Manage Funds |
264 |
|
19.5 |
Homosexual Identity: Stages of Formation |
265 |
|
19.6 |
Impairment’s Effects on a Person |
266 |
|
19.7 |
Puberty |
266 |
|
19.8 |
The Refugee Process |
267 |
|
19.9 |
Religious and Spiritual Concerns |
268 |
|
19.10 |
Testamentary Competence/Competence to Make a Will |
269 |
|
D |
Completing the Report |
|
|
20 |
Summary of
Findings and Conclusions |
273 |
|
20.1 |
Overview |
273 |
|
20.2 |
Beginning the Summary |
273 |
|
20.3 |
Summary of Previous Information |
273 |
|
20.4 |
Relevant Findings and/or Conclusions |
274 |
|
20.5 |
Diagnostic Statement |
274 |
|
20.6 |
Consultations and Further Evaluations |
274 |
|
20.7 |
Summarizing Treatment |
274 |
|
21 |
Diagnostic
Statement/Impression |
276 |
|
21.1 |
Qualifiers for Diagnosis |
276 |
|
21.2 |
ICD Versions |
276 |
|
21.3 |
DSM-IV-TR |
277 |
|
21.4 |
Anxiety Disorders |
277 |
|
21.5 |
Mood Disorders |
278 |
|
21.6 |
Stress and Adjustment Disorders |
282 |
|
21.7 |
Personality Disorders |
283 |
|
21.8 |
Impulse-Control Disorders Not Elsewhere Classified |
284 |
|
21.9 |
Childhood Disorders |
284 |
|
21.10 |
Eating and Elimination Disorders |
288 |
|
21.11 |
“Organic” Cognitive Conditions |
289 |
|
21.12 |
Substance-Related Disorders |
291 |
|
21.13 |
Psychotic Disorders |
295 |
|
21.11 |
Sleep Disorders |
296 |
|
21.11 |
Somatoform Disorders |
298 |
|
21.12 |
Psychological Factors Affecting a Medical Condition |
298 |
|
21.13 |
Dissociative Disorders |
299 |
|
21.14 |
Sexual Dysfunctions and Disorders |
299 |
|
21.15 |
Factitious Disorders |
301 |
|
21.16 |
Medication-Induced Movement Disorders |
302 |
|
21.17 |
V Codes, Etc. |
302 |
|
21.18 |
Axis IV: Psychosocial and Environmental Problems |
305 |
|
21.19 |
Axis V: Global Assessment of Functioning Scale |
305 |
|
22 |
Recommendations |
307 |
|
22.1 |
Need for Treatment |
307 |
|
22.2 |
Treatments of Choice |
308 |
|
22.3 |
Treatment Options/Case Disposition |
309 |
|
22.4 |
Types of Therapies/Services |
309 |
|
23 |
Prognostic Statements |
312 |
|
23.1 |
General Prognostic Statement |
312 |
|
23.2 |
Other Statements |
313 |
|
24 |
Closing
Statements |
314 |
|
24.1 |
Value of the Information |
314 |
|
24.2 |
Thanking the Referrer |
314 |
|
24.3 |
Continued Availability |
314 |
|
24.4 |
Signature, Etc. |
315 |
|
24.5 |
Disclaimer |
315 |
|
PART III |
USEFUL RESOURCES |
|
|
25 |
Treatment
Planning and Treatment Plan Formats |
319 |
|
25.1 |
The Flow and Nature of Treatment Planning |
319 |
|
25.2 |
Some Advice on Writing Treatment Plans |
319 |
|
25.3 |
Various Formats for Treatment Plans |
320 |
|
25.4 |
A Treatment Plan Format for Case Conceptualization |
324 |
|
25.5 |
Treatment Plan Components for Clients with Substance Abuse |
333 |
|
25.6 |
Treatment Plan Components for Crisis Interventions |
335 |
|
25.7 |
Checklist of Strengths |
335 |
|
25.8 |
Outcome Measures/Goal Achievements |
336 |
|
26 |
Formats for
Reports, Evaluations, and Summaries |
338 |
|
26.7 |
a Standard
Format for Reports of Evaluations |
338 |
|
26.2 |
Format for Psychodynamic Evaluations: Developmental Model |
339 |
|
26.3 |
The Psychodynamic Diagnostic Manual |
340 |
|
26.4 |
Themes for Evaluations from an Existential Perspective |
340 |
|
26.5 |
Adlerian Evaluations |
340 |
|
26.6 |
Transactional Analysis |
341 |
|
26.7 |
Nursing Diagnoses and Treatment Planning |
342 |
|
26.8 |
Vocational and Nonclinical
Personality Evaluations |
342 |
|
26.9 |
Formats for Therapy Notes |
343 |
|
27 |
Treatments for Specific Disorders and Concerns |
345 |
|
27.1 |
Abuse/Aggression/Violence/Impulsive Behaviors |
345 |
|
27.2 |
Anorexia Nervosa and Bulimia Nervosa |
345 |
|
27.3 |
Antisocial Personality Disorder |
346 |
|
27.4 |
Anxiety Disorders |
346 |
|
27.5 |
Asperger Syndrome |
346 |
|
27.6 |
Attention-Deficit/Hyperactivity Disorder |
346 |
|
27.7 |
Bipolar I Disorder |
346 |
|
27.8 |
Body Dysmorphic
Disorder |
346 |
|
27.9 |
Borderline Personality Disorder |
347 |
|
27.10 |
Dementia |
347 |
|
27.11 |
Dissociative Identity Disorder |
347 |
|
27.12 |
Dual Diagnosis |
347 |
|
27.13 |
Gambling, Pathological |
347 |
|
27.14 |
Hypochondriacal Personality |
347 |
|
27.15 |
Obsessive-Compulsive Disorders |
348 |
|
27.16 |
Pain, Chronic |
348 |
|
27.17 |
Phobias |
348 |
|
27.18 |
Posttraumatic Stress Disorder |
348 |
|
27.19 |
Religious and Spiritual Concerns |
348 |
|
27.20 |
Schizophrenia and Psychosis |
349 |
|
27.21 |
Sleep Disturbances |
349 |
|
27.22 |
Stalking |
349 |
|
27.23 |
Substance Abuse |
349 |
|
27.24 |
Types of Therapies |
350 |
|
28 |
Listing of Common Psychiatric and Psychoactive Drugs |
|
|
28.1 |
List of Medications by Trade and Generic Names |
351 |
|
28.2 |
Finding Street Drugs’ Names |
357 |
|
28.3 |
Results of Medication Treatment: Descriptors |
357 |
|
28.4 |
Drug Resources for the Clinician |
357 |
|
29 |
Psychiatric Masquerade of Medical Conditions |
359 |
|
29.1 |
Introduction |
359 |
|
29.2 |
Anxiety |
360 |
|
29.3 |
Sexual Dysfunction |
360 |
|
29.4 |
Depression |
360 |
|
29.5 |
Mania |
361 |
|
29.6 |
Organic Brain Syndrome/Dementia |
361 |
|
29.7 |
Psychosis |
363 |
|
29.8 |
Medication-Induced Psychiatric Conditions |
364 |
|
|
APPENDICES |
|
|
A |
Abbreviations
in Common Use |
367 |
|
A.1 |
Clinicians/Mental Health Professionals |
367 |
|
A.2 |
Treatment |
368 |
|
A.3 |
Diagnoses and Conditions |
368 |
|
A.4 |
Relations |
369 |
|
A. 5 |
General Aids to Recording |
369 |
|
A.6 |
Legal Terms |
370 |
|
A.7 |
Medication Regimens |
370 |
|
A.8 |
Educational Services |
370 |
|
B |
Annotated Readings in Assessment, Interviewing, and Report Writing |
371 |
|
|
Assessment |
371 |
|
|
Interviewing |
372 |
|
|
Report Writing |
372 |
|
|
Feedback
Solicitation Form |
374 |
|
|
About the Clinician’s Electronic Thesaurus, Version
7.0 |
375 |
|
|
Additional Productivity Features |
375 |
|
|
Hardware Requirements |
376 |
|
|
Software Requirements |
376 |
|
|
References |
377 |
|
|
Index |
387 |
|
|
|
|