Final Exam

Question 1

Elements of a Good Goal

Answer 1

Goal is stated in a POSITIVE manner
Goal is SPECIFIC 
Goal is MANAGEABLE
Goal is in the pt's OWN language
Goal is MEASURABLE
Goal is within pt's CONTROL

Question 2

What Major things are we Assessing in a Mental Health Interview?

Answer 2

Ruling out risk
Assessing function
Determining symptoms of distress
Hypothesizing diagnoses, spectrum disorders and developing a working formulation of the patient.

Question 3

Seven Variable of Psychiatric Interviewing

Answer 3

1) physiological
2) psychological
3) dyadic system (interpersonal),
4) ,Family system,
5) Group system
6) Societal system
7) Existential (Framework for meaning; core beliefs –self, other, world) (variation of biopsychosocial model)

Question 4

Intentions of the Interview

Answer 4

Establish a relationship – rapport/engagement
Obtain information/data - descriptive
Understand patient concerns (stages of change)
Identifying risk
Assess for mental disorders and addictions
Generating hypotheses - suspected
Provide feedback
Goal Development/Treatment Plan
Instill hope and ensure patient return

Question 5

Empathetic Responses in the Interview

Answer 5

Empathic responses – basic (sounds like) and complex (you’re feeling…) or (it is…e.g. frightening to lose someone in that way)
Use intermittently to strengthen engagement Statements vary in degree of implied certainty, quality attribution and intimacy
Guarded patients – stay basic or avoid empathic statements
Trusting patients – complex statements may be more useful
Successful empathic statements increase patient responsiveness.
Empathy conveyed verbally and non verbally

Rapport can be developed even when the interviewer is more directive in their questioning.

Question 6

Types of Q’s to be aware of

Answer 6

Double Barrelled Questions: Have you had trouble eating and sleeping?
Multiple Choice: Do you have trouble falling asleep, staying asleep or waking up in the morning?

Echo question: “I’m afraid everyone will leave me.” Therapist: Everyone?

Be aware of transference. If the clinician notices a change in affect in the patient the clinician can ask “How are you feeling right now?”.

Question 7

Mood – Suicidality and Homocidality

Answer 7

Do you have or have you had thoughts of harming (killing) yourself?
Do you have specific ideas or plans?
What keeps you alive?
Do you have thoughts of harming anyone else?
Do you think that there are people you love who would be better off dead?

Question 8

Anxiety Related Q’s

Answer 8

Social Anxiety (SAS)
Do you worry that people are judging you?
Does this inhibit you from engaging in social activities?

GAD (GAD-7)
Do you worry a lot of the time? What about?
Do you think you worry more than most people?
Do you have any associated physical sensations? What are they?

Panic (ANSQ-5)
Have you ever experienced (heart palpitations, racing, shortness of breath, sense of doom) that has lasted a half hour or less?
Did you think you were having a heart attack?
If yes, how often has this happened?

OCD (Y-BOCS)
Do you engage in activities you can’t help (e.g. excessive checking, hand washing, cleaning)? Are these activities associated with anxiety?
Do you have thoughts that are intrusive and unwanted? What are these about? Are these thoughts associated with anxiety?

Question 9

Psychosis

Answer 9

Psychosis fluctuates, gains momentum and may evolve over time: hard and soft signs

Hard: delusions, hallucinations, formal thought disorder, gross disorientation, bizarre mannerisms/body language

Soft: intense, inappropriate, agitated, or angry affect, guarded, suspicious, vague, mild thought disorder, pre-occupation with a distant incident, expectation of familiarity from interviewer, inappropriate eye contact, long latency before responding

Question 10

Delerium vs Psychosis

Answer 10

Delerium – need to do complete medical evaluation – many organic causes (e.g. anemia, electrolytes, glucose, calcium, B1 def., infections, neurological disorders, substance withdrawal, intoxication)

Psychosis – Psychosis secondary to a medical condition can present like any other psychosis- “think organic” when evaluating the onset of psychotic symptoms

R/O organic causes if no prior diagnosis. Corroborative reporting from others close to the family is invaluable if you can obtain it

Question 11

Questions if Psychosis Suspected

Answer 11

Do you ever have thoughts that thoughts are being inserted into your mind? Withdrawn?
Do you ever think the TV has special messages for you?
Do you ever think your thoughts are being controlled?
Do you think you have a special purpose for which you have been singled out?
Do you have beliefs that others would not agree with or believe in?
Do you ever think that others are out to harm you or are persecuting you? If yes, who?
Do you ever hear things or voices that other people wouldn’t believe in?
Do you ever experience voices commanding you to harm others or yourself?
Do you ever see things that other people wouldn’t believe in?
- If yes, what?

Question 12

What is the DSM?

Answer 12

Diagnostic manual used by both psychologists and psychiatrists
Intended to be descriptive rather than theoretical
Intended to facilitate communication

Based on consensus interpretation o f available research and data

Alternative Resource is the ICD - but DSM is synchronized with ICD.

Question 13

DSM Limitations

Answer 13

Not an exhaustive list of phenomena
No objective indicators
Overlap in disorder criteria

Question 14

Epidemiology of Depression

Answer 14

Canada 1.2 million affected (2002)
Women >Men - in fact women are 70% more likely than men to experience depression during their lifetime.

Avg age of onset - 32 yrs

Question 15

Course of Major Depressive Disorder (MDD)

Answer 15

1 episode ≥ 60% chance of a second.
2 episodes ≥ 70% chance of a third,
3 episodes ≥ 90% chance of a fourth

Mortality by suicide = 15%

Question 16

MDD DSM Criteria (A)

Answer 16

5+ of the following symptoms;
(at least one of either (1) depressed mood or (2) loss of interest or pleasure)

1) depressed mood.
(2) markedly diminished interest or pleasure in all, or almost all, activities
(3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite
(4) insomnia or hypersomnia
(5) psychomotor agitation or retardation (must be observable by others)
(6) fatigue or loss of energy
(7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) (not merely self-reproach or guilt about being sick)
(8) diminished ability to think or concentrate, or indecisiveness, (either by subjective account or as observed by others)
(9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

Minimum of 2 weeks in duration and is a deviation form ‘normal’

Question 17

MDD DSM Criteria (B)

Answer 17

The symptoms do not meet criteria for a Mixed Episode.

Question 18

MDD DSM Criteria (C)

Answer 18

Significant distress or impairment in functioning.

Question 19

MDD DSM Exclusion Criteria

Answer 19

SX are NOT due to:
Substance Abuse
Bereavement
General medical Condition

Question 20

Generalized Anxiety Disorder Epidemiology/Course

Answer 20

Women > Men
Comorbidity with MDD - 60%
Average age of onset 31 - from childhood to late adulthood.

Tends to be long lasting and recurrent
Moderate to severe impairment in occupational function: 38%

Question 21

GAD DSM Criteria

Answer 21

A. Excessive anxiety and worry (apprehensive expectation), minimum 6 months, about a number of events or activities.

B. Difficult to control the worry

C. The anxiety associated with ≥ 3 of 6:

1. restlessness or feeling keyed up or on edge
2. being easily fatigued
3. difficulty concentrating or mind going blank
4. irritability
5. muscle tension
6. sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

D. The focus of the anxiety and worry is not focused on a particular domain – e.g. Worry about illness

E. Causes impairment in functioning.

F. Exclusions
effects of a substance
a general medical condition
exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder.

Question 22

Somatiform DIsorders

Answer 22

May be associated with a heightened awareness of normal bodily sensations.
Heightened awareness may be paired with a cognitive bias to interpret any physical symptom as indicative of medical illness.

Autonomic arousal is common.
Autonomic arousal may be associated with tachycardia, gastric hypermotility, muscle tension and pain associated with muscular hyperactivity (e.g., muscle tension headaches)

Question 23

Somatitization vs Hypochondriasis

Answer 23

Hypochondriasis: Fear of having a specific dx, sx will be focused on one condition.

Somatization Not a specific disease rather the symptoms themselves and concern of multiple diseases and multiple parts of the body affected.

Both have similar ddx Q’s - both share a connection with higher rates of early life abuse.

Question 24

Hypochondriasis

Answer 24

Fear of having a specific Dx.

Question 25

DSM Criteria for Hypochondriasis

Answer 25

fear of having a serious disease for at least 6 months. preoccupation persists despite appropriate evaluation and reassurance. belief is not of delusional intensity not restricted to a concern about appearance (as in persons with BDD). causes clinically significant distress or impairment. not explained better by a mood or anxiety disorder. Normal rates: 10-20% of people who are healthy intermittent unfounded worries about illness. When prolonged and persistent and not responsive to reassurance is when to consider hypochondriasis Men=Women Most common in early adulthood.

Question 26

Comorbidity with Hypochondriasis

Answer 26

``` high rate of psychiatric comorbidity. generalized anxiety disorder major depression panic disorder benzodiazepine misuse ```

Question 27

Course of Hypochondriasis

Answer 27

usually episodic, but last from months to years and equally long quiescent periods. one third of patients with hypochondriasis eventually improve significantly.

Question 28

Mood Related Phenomenon

Answer 28

Altered sensation, experience, perception and expectation of the past, present and future states of the self and the world Pervasive, persistent and minimally responsive to external events Either in a POSITIVE or NEGATIVE direction These 'mood' related ideas can affect all aspects of life.

Question 29

Anxiety

Answer 29

Fear of demise Self or others The nature of the “demise” can be hidden by the other phenomena

Question 30

Physiological Correlates to Anxiety

Answer 30

Cardio Pulmonary Chest pain, chest tightness Palpitations, pounding heart, or accelerated heart rate Sensation of smothering or shortness of breath Gastrointestinal Nausea or abdominal distress Neurologic Frequent headaches, migraine headaches Ringing, pulsing or throbbing sounds in the ears Feeling dizzy, unsteady, lightheaded or faint Paresthesias (numbness or tingling sensations) Urogenital Urgency to urinate, frequent urination Sexual dysfunction ``` Chills or hot flushes Persistent muscle tension, stiffness Startle easily Sweating Trembling or shaking Feeling of choking ```

Question 31

Panic Attack

Answer 31

A discreet period of time during which the individual has extreme physiological signs and symptoms of anxiety Associated with thoughts of imminent harm, death or other demise (e.g., losing mind)

Question 32

Obsession

Answer 32

A thought or image which repeatedly intrudes upon a persons awareness and heralds future harm to self or others Intellectually, the experience is subjectively absurd Despite the subjective sense of absurdity distressing anxiety is triggered

Question 33

Compulsion

Answer 33

A mental or physical act performed to reduce the probability of negative future event and the associated anxiety In some cases the person is only aware that the act reduces anxiety or makes them feel better

Question 34

Tic

Answer 34

A spontaneous, automatic mental or physical act not associated with anxiety or cognitions unless attempts are made to voluntarily inhibit the act

Question 35

Phobia

Answer 35

An irrational or excessive fear of a stimulus

Question 36

Agoraphobia

Answer 36

Fear associated with the perceived inability to escape

Question 37

Avoidance

Answer 37

The most common response to anxiety – when possible. | Simple to describe but can be extremely complex in behavioural manifestation

Question 38

Psychotic Phenomena

Answer 38

Delusions a fixed false belief that is resistant to reason or confrontation with actual fact Hallucinations a sensory experience in the absence of a stimulus Illusions A stimulus is present but the sensory experience is misperceived Reality testing the level of awareness that a hallucination, delusion or illusion are misperceptions or misinterpretations

Question 39

Common Types of Delusions

Answer 39

Persecutory Somatic – concerns body image, function or disease Grandiose Erotomanic – belief of being loved by other Jealous – belief of infidelity Nihilistic – nothingness, missing parts of body or property or decay of same

Question 40

Common Types of Hallucinations

Answer 40

``` Any sense organ Commonly Auditory Ranges from easily distinguishable to indistinguishable Somatosensory External or internal Olfactory Gustatory Uncommon Visual ```

Question 41

Other Psychotic Phenomena

Answer 41

Disorganized speech Circumstantial, tangential, difficult to follow, incoherent – e.g. Word salad Disorganized behavior Affect flattening or disconnected Avolition: is a psychological state characterized by general lack of drive, or motivation to pursue meaningful goals. A person may show little participation in work or have little interest in socializing Alogia: is a general lack of additional, unprompted content seen in normal speech

Question 42

Substance Related Phenomena

Answer 42

Loss of volitional control over use Continued use despite undesired harm Denial of harm associated with use Development of tolerance to neurophysiologic effects of substance Neurophysiologic effects when substance is not being used or use is markedly reduced Significant time and resources are focused on obtaining or using the substance

Question 43

Somatic Illness

Answer 43

Multiple physical complaints without the worry of a specific disease Preoccupation/worry/fear of having a disease Preoccupation with an imagined defect in appearance

Question 44

Somatic Illness with regard to Weight/Shape

Answer 44

Intense fear of gaining weight or becoming fat despite being underweight Disturbance in the way in which one's body weight or shape is experienced Undue influence of body weight or shape on self-evaluation Objectively under weight Denial of the seriousness of very low body weight May Include: Binge eating with compensatory mechanisms afterward to prevent weight gains (induced vomiting, laxatives etc)

Question 45

Mechanisms of Mindfulness

Answer 45

Awareness = discernment (I know when I am breathing in, I know when I am breathing out) Intention = doing something deliberately, on purpose Attitude = bringing a particular view or evaluation of a situation, person, idea etc Attention = Sustained Focus(breath, body etc), Shifting (holding & releasing),Open and Receptive Attention Changing relationship to experience = working with patterns of automatic reactivity, decentering, reducing experiential avoidance, turning toward the difficult, working with the body, increasing direct experience Skills = mindfulness practices on and off the cushion (mindfulness in everyday life)

Question 46

Why be in the present moment, non-judgmentally?

Answer 46

Increase awareness - noticing Reduce rumination on the past/future catastrophic thinking; disrupt automaticity (attention regulation) Decrease experiential avoidance Increase tolerance of difficult emotions and stressful events (affect regulation) Decenter: Awareness can bring the space to respond skillfully to difficult situations

Question 47

Therapeutic Benefit to Risk Assessment

Answer 47

``` Reduced isolation Reduced alienation Opportunity for normalization Opportunity for empathic attunement Help client organize thoughts and feelings Demystify phenomena Reduce feelings of guilt ```

Question 48

Suicide - Epidemiology

Answer 48

24% of all deaths among Canadians aged 15 – 24 | 16% of all deaths for the age group 25 – 44.

Question 49

Suicide Assessment - clues

Answer 49

Positive Signs: Hope of improving Subjective unwanted negative impact on others Religious beliefs - strong Negative Signs: ``` MDE Psychosis Specific targets Hopelessness Method Considered Preparation ```

Question 50

Biopsychosocial Risk Factors for Suicide

Answer 50

Mental disorders, mood disorders, schizophrenia, anxiety disorders and certain personality disorders Alcohol and other substance use disorders Hopelessness Impulsive and/or aggressive tendencies History of trauma or abuse ``` Serious adverse childhood experience e.g., family violence, physical or sexual abuse, incarcerated family members, or familial mental illness Chronic physical illness Previous suicide attempt Family history of suicide ```

Question 51

Environmental Risk Factors for Suicide

Answer 51

``` Job or financial loss Relational or social loss Easy access to lethal means Local clusters of suicide that have a contagious influence Geography ```

Question 52

Social-cultural Risk Factors for Suicide

Answer 52

Lack of social support and sense of isolation Stigma associated with help-seeking behavior Barriers to accessing health care, especially MHA treatment Indigenous populations

Question 53

MOST protective factor for suicide?

Answer 53

Relationships! Also Important: Effective clinical care for mental, physical and substance use disorders Easy access to a variety of clinical interventions and support for helpseeking Restricted access to highly lethal means of suicide Strong connections to family and community support Cultural and religious beliefs that discourage suicide and support self preservation

Question 54

Approach to Suicide Risk Assessment

Answer 54

Gathering information related to risk factors, protective factors, and warning signs of suicide. Collecting information related to the patient’s suicidal ideation, planning, behaviors, desire, and intent. Making a clinical formulation of risk based on these 2 databases.

Question 55

Real Suicidal Intent = Stated Intent + Reflected Intent + Withheld Intent

Answer 55

Stated intent: what the patient directly tells the clinician about his or her suicidal intent Reflected intent: the amount of thinking, planning, or actions taken on suicidal ideation that may reflect the intensity of the actual suicidal intent Withheld intent: suicidal intent that is unconsciously or purposefully withheld from the clinician

Question 56

Somatization

Answer 56

The tendency to experience and communicate somatic distress and symptoms; unaccounted for by pathological findings, to attribute them to physical illness, and to seek medical help for them…, this tendency becomes manifest in response to psychosocial stress…

Question 57

Three Forms of Somatizing

Answer 57

Medically unexplained symptoms (MUS) Hypochondriacal somatization bodily preoccupation and worry about having a serious illness Somatic presentations of psychiatric disorders e.g. Depression, Panic

Question 58

Somatic Symptom Disorder

Answer 58

Excessive thoughts, feelings or behaviours related to these somatic symptoms Symptoms persist for more than six months The change from DSM-IV is that you don’t have to prove that the symptom is NOT organic; rather the response to the symptoms is seen as markedly excessive and disrupts life significantly This would include “Undifferentiated Somatoform Disorder” and Somatization Disorder” from DSM-IV It also includes “Pain due to Psychological Issues” and “Pain due to Physical and Psychological Issues” from DSM-IV

Question 59

Conversion Disorder

Answer 59

``` Affects voluntary motor or sensory function. Linked to psychological stressors. Specify: With weakness or paralysis With abnormal movement With swallowing symptoms With speech symptoms With attacks or seizures With anesthesia or sensory loss With special sesnory symptoms With mixed symptoms ``` ``` 2-5 times more common in women than men (Barsky‘89) Usually adolescence or early adulthood Lower Socioeconomic groups Rural Less education Less psychologically sophisticated ``` Usually acute onset Symptom duration is often relatively brief, usually within two weeks if stressor is removed or addressed Otherwise, may go on for years

Question 60

Conversion Disorder Treatment

Answer 60

Hypnosis and sodium amytal intervals have been used Uncover repressed material and encourage “abreaction” - the free expression and release of previously repressed emotion Not a lot of data supporting this Meds NOT necessary For patients able to identify psychological stressors, appropriate psychotherapy can be very helpful

Question 61

Somatic Symptom Disorder with predominant pain (prior Pain Disorder)

Answer 61

Associated with psychological factors. Associated with both psychological factors and a general medical condition. Pain disorder associated with a general medical condition (not a psychiatric diagnosis). Perhaps 40% of pain patients may be psychologically amplified Usually in fourth or fifth decades Female > Males - 2:1 First degree biologic relatives at higher risk for psychologic pain syndromes

Question 62

Somatic Symptom Disorder with predominant pain - Treatment options

Answer 62

Nerve blocks Muscle relaxation techniques Psychotherapy Medication CBT Challenge cognitions “This pain is not damaging my body” “I can continue activities, even in some mild pain. I don’t have to stop.” Behaviorally activate: e.g. gardening 15 minutes twice/week, then increase

Question 63

Somatic Symptom Disorder(Undifferentiated Somatoform Disorder)

Answer 63

At least six (6) months One (1) or more physical complaints Can be seen as “sub-syndromal somatization disorder” Chronic fatigue syndrome, Fibromyalgia, Irritable Bowel Syndrome Has never been shown thus far to have a biological cause In studies, there is felt to be a major psychiatric co-morbidity Try not to dichotomize: “Perhaps a % of both, thus may work on psychological side to see how far this takes us.” Interesting that in DSM-V, if someone had symptoms of irritable bowel, or chronic fatigue, or fibromyalgia, and it was not affecting their life re excessive worry or behaviours, there would be NO psych dx here Called Persistent/Severe if: ``` Starts before age 30 4 pain symptoms 2 GI symptoms 1 sexual symptom 1 pseudoneurological symptom ```

Question 64

Illness Anxiety Disorder (Hypochondriasis)

Answer 64

Preoccupation with having a serious illness Somatic symptoms are not present or only mild This if there is a symptom occurring with excessive thoughts and behaviours, this will be subsumed under “Somatic Symptom Disorder” 25% Illness Anxiety Disorder 75% Somatic Symptom Disorder High level of anxiety about health Performs excessive health related behaviours At least 6 months 2 Types: care-seeking; care-avoiding Literature discusses link to OCD spectrum E.g., intrusive thoughts, repetitive checking behaviours Would then use CBT and OCD medications, SSRI’s, clomipramine Possibly atypical neuroleptics. May evolve into overvalued ideas, and ultimately delusions Delusional disorder, somatic type Would then use neuroleptics DSM-V did NOT put this under obsessive compulsive and related disorders. I would respectfully disagree CBT works well!!

Question 65

Body Dysmorphic Disorder (BDD)

Answer 65

Preoccupation with an imagined defect in appearance If a slight anomaly is present, concern is markedly excessive This now comes under Obsessive Compulsive and Related Disorders Underlines the OCD spectrum of this disorder. Preoccupations usually involve face and head, skin, hair, nose, overall body Women Breasts, legs Men: Genitals,“muscle dysmorphia”. This is now a specifier. May use anabolic Steroids (Pope ‘97) Can resemble OCD, link with obsessive spectrum disorders. Specifier would be “good or fair insight” Think about flaws 3-8 hours per day (Phillips ‘96) Compulsive behaviours - checking appearance, grooming, seeking reassurance repetitively, may repetitively seek surgery. ``` Comorbidities: Depression 60-80% Suicide attempt 30% Social phobia 38% Substance use 36% ```

Question 66

Factitious Disorder Imposed on Self

Answer 66

Intentional production or feigning of physical or psychological signs or symptoms The motivation for the disorder is to assume “the sick role” External incentives for the behaviour (such as economic gain, avoiding legal responsibility, or improving physical well-being as in malingering are absent Lying or exaggerating signs and symptoms Knowingly tampering with samples or tests Manipulation of ones body to produce positive tests results Overall prognosis is poor Few admitted Very few pursue any psychotherapy

Question 67

Malingering

Answer 67

CONSCIOUS! | If you fake having a seizure because you want to get your insurance policy $millions

Question 68

Somatization, Why?

Answer 68

Psychodynamic issues alternate channel to deflect inner drives; defensive. --> Easier to think that something is wrong with one’s body as opposed to the self Alexithymia “no words for feelings” Learned social behaviour Secondary gain Primary Gain - reduction in intrapsychic conflict and drive gratification accomplished by the defensive operation. Unconscious mechanism. Secondary Gain - “legitimate” interpersonal advantages that result after one has a physical disease, e.g., excused from certain responsibilities, receive attention.

Question 69

Typical CBT session

Answer 69

Collaborative agenda setting Link to previous session (feedback) Target symptom check Medication/Supplement check Review of week/scheduling Review of homework New agenda items-ATRs Collaborative development of new homework Feedback

Question 70

Characteristics of CBT

Answer 70

Based on the cognitive model - your behaviours, your thoughts, your emotions. Structured Explicitly goal-oriented Active/problem-solving Emphasizes skill acquisition (homework) Collaborative empiricism Time limited

Question 71

CBT terminology

Answer 71

Schema - cognitive structure (associative network) - guides information processing Core belief - content of a schema - e.g. “I am a failure” Rules - e.g. “I will always work hard and never make mistakes” Attitudes - e.g. “asking for help is a sign of weakness” Conditional assumptions - e.g. “If I don’t give 110% I will fail”

Question 72

2 Domains of Negative Belief - Affiliative and Affirmative

Answer 72

Affiliative Domain “I’m unlovable” “I’m unworthy” “I’m not good enough” I’m defective” Achievement Domain “I’m helpless” “I’m powerless” “I’m weak” “I’m vulnerable”

Question 73

Misconceptions About CBT

Answer 73

CBT focuses on symptom reduction ignoring personality reorganization CBT is superficial/mechanistic CBT ignores childhood experiences in adult psychopathology CBT neglects interpersonal factors that maintain psychopathology The therapeutic relationship is irrelevant CBT doesn’t address motivation for symptom maintenance Emotion is minimally important

Question 74

Characteristics of a Good CBT Candidate

Answer 74

Responsibility (for change) Ability to form TRUSTING RELATIONSHIPS MOTIVATION FOCUS