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280 STANDARD TERMS AND STATEMENTS FOR REPORTS DIAGNOSIS DSM-IV-TR ICD-9-CM 296. 43 Bipolar I Disorder, Most Recent Episode Manic, Severe Without Psychotic Features296. 43 Bipolar I disorder, most recent episode (or current) manic: Severe, without mention of psychotic behavior 296. 44 Bipolar I Disorder, Most Recent Episode Manic, Severe With Psychotic Features296. 44 Bipolar I disorder, most recent episode (or current) manic: Severe, specified as with psychotic behavior 296. 45 Bipolar I Disorder, Most Recent Episode Manic, In Partial Remission296. 45 Bipolar I disorder, most recent episode (or current) manic: In partial or unspecified remission 296. 46 Bipolar I Disorder, Most Recent Episode Manic, In Full Remission296. 46 Bipolar I disorder, most recent episode (or current) manic: In full remission 296. 50 Bipolar I Disorder, Most Recent Episode Depressed, Unspecified296. 50 Bipolar I disorder, most recent episode (or current) depressed: Unspecified 296. 51 Bipolar I Disorder, Most Recent Episode Depressed, Mild296. 51 Bipolar I disorder, most recent episode (or current) depressed: Mild 296. 52 Bipolar I Disorder, Most Recent Episode Depressed, Moderate296. 52 Bipolar I disorder, most recent episode (or current) depressed: Moderate 296. 53 Bipolar I Disorder, Most Recent Episode Depressed, Severe Without Psychotic Features296. 53 Bipolar I disorder, most recent episode (or current) depressed: Severe, without mention of psychotic behavior 296. 54 Bipolar I Disorder, Most Recent Episode Depressed, Severe With Psychotic Features296. 54 Bipolar I disorder, most recent episode (or current) depressed: Severe, specified as with psychotic behavior 296. 55 Bipolar I Disorder, Most Recent Episode Depressed, In Partial Remission296. 55 Bipolar I disorder, most recent episode (or current) depressed: In partial or unspecified remission 296. 56 Bipolar I Disorder, Most Recent Episode Depressed, In Full Remission296. 56 Bipolar I disorder, most recent episode (or current) depressed: In full remission 296. 60 Bipolar I Disorder, Most Recent Episode Mixed, Unspecified296. 60 Bipolar I disorder, most recent episode (or current) mixed: Unspecified degree 296. 61 Bipolar I Disorder, Most Recent Episode Mixed, Mild296. 61 Bipolar I disorder, most recent episode (or current) mixed: Mild 296. 62 Bipolar I Disorder, Most Recent Episode Mixed, Moderate296. 62 Bipolar I disorder, most recent episode (or current) mixed: Moderate 296. 63 Bipolar I Disorder, Most Recent Episode Mixed, Severe Without Psychotic Features296. 63 Bipolar I disorder, most recent episode (or current) mixed: Severe, without mention of psychotic behavior
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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21. Diagnostic Statement/Impression 281DIAGNOSIS DSM-IV-TR ICD-9-CM 296. 64 Bipolar I Disorder, Most Recent Episode Mixed, Severe With Psychotic Features296. 64 Bipolar I disorder, most recent episode (or current) mixed: Severe, specified as with psychotic behavior 296. 65 Bipolar I Disorder, Most Recent Episode Mixed, In Partial Remission296. 65 Bipolar I disorder, most recent episode (or current) mixed: In partial or unspecified remission 296. 66 Bipolar I Disorder, Most Recent Episode Mixed, In Full Remission296. 66 Bipolar I disorder, most recent episode (or current) mixed: In full remission 296. 7 Bipolar I Disorder, Most Recent Episode Unspecified296. 7 Bipolar I disorder, most recent episode (or current) unspecified 296. 80 Bipolar Disorder NOS 296. 80 Bipolar disorder, unspecified. 296. 81 Atypical manic disorder296. 82 Atypical depressive disorder 296. 89 Bipolar II Disorder Specify (current or most recent episode): Hypomanic/Depressed296. 89 Other and unspecified Bipolar II disorder Bipolar Disorders: Other Manic-depressive psychosis, mixed type 296. 90 Mood Disorder NOS 296. 90 Unspecified episodic mood disorder Affective psychosis NOSMelancholia NOS 296. 99 Other specified episodic mood disorder Mood swings: brief, compensatory, rebound 301. 13 Cyclothymic Disorder 301. 13 Cyclothymic disorder Cyclothymic personality 293. 83 Mood Disorder Due to... [Indicate the General Medical Condition] Specify if: With Depressive Features/Major Depressive-Like Episode/Manic Features/Mixed Features 311 Depressive Disorder NOS 311 Depressive disorder, not elsewhere classified Premenstrual Dysphoric Disorder, Recurrent Brief Depressive Disorder, Minor Depressive Disorder, and Mixed Anxiety-Depressive Disorder are diagnoses proposed for further study; see Appendix B of DSM-IV-TR. For clients who have recently lost someone close to them, consider the V code V62. 82, Bereavement (in DSM-IV-TR) or Bereavement, uncomplicated (in ICD-9-CM).
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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282 STANDARD TERMS AND STATEMENTS FOR REPORTS DIAGNOSIS 21. 6. Stress and Adjustment Disorders See also Section 21. 9, “Childhood Disorders,” and the V codes in Section 21. 21. DSM-IV-TR ICD-9-CM 308. 0 Predominant disturbance of emotions Emotional crisis or Panic state as acute reaction to exceptional (gross) stress 308. 1 Predominant disturbance of consciousness. Fugues 308. 2 Predominant psychomotor disturbance Agitation or stupor 308. 3 Acute Stress Disorder 308. 3 Other acute reactions to stress308. 4 Mixed disorders as reaction to stress 308. 9 Unspecified acute reaction to stress 309. 0 Adjustment Disorder With Depressed Mood309. 0 Adjustment disorder with depressed mood. Grief reaction 309. 1 Prolonged depressive reaction309. 2 Adjustment reaction with predominant disturbance of other emotions 309. 21 Separation anxiety disorder309. 22 Emancipation disorder of adolescence and early adult life 309. 23 Specific academic or work inhibition 309. 24 Adjustment Disorder With Anxiety 309. 24 Adjustment disorder with anxiety309. 28 Adjustment Disorder With Mixed Anxiety and Depressed Mood309. 28 Adjustment disorder with mixed anxiety and depressed mood 309. 29 Adjustment reaction: Other Culture shock 309. 3 Adjustment Disorder With Disturbance of Conduct309. 3 Adjustment disorder with disturbance of conduct Conduct Disorder or Destructiveness as adjustment disorder 309. 4 Adjustment Disorder With Mixed Disturbance of Emotions and Conduct309. 4 Adjustment disorder with mixed disturbance of emotions and conduct 309. 8 Other specified adjustment reactions 309. 81 Posttraumatic Stress Disorder 309. 81 Posttraumatic stress disorder Posttraumatic stress disorder NOS or chronic 309. 82 Adjustment reaction with physical symptoms 309. 83 Adjustment reaction with withdrawal
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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21. Diagnostic Statement/Impression 283DIAGNOSIS DSM-IV-TR ICD-9-CM 309. 89 Other specified adjustment reaction: Other 309. 9 Adjustment Disorder, Unspecified 309. 9 Unspecified adjustment reaction In DSM-IV-TR, for all Adjustment Disorders, specify Acute/Chronic. 21. 7. Personality Disorders Code all of these (except V71. 01 and 310. 1) on Axis II of DSM-IV-TR. DSM-IV-TR ICD-9-CM 301. 0 Paranoid Personality Disorder 301. 0 Paranoid personality disorder 301. 10 Affective personality disorder, unspecified 301. 11 Chronic hypomanic personality disorder 301. 12 Chronic depressive personality disorder 301. 13 Cyclothymic disorder 301. 20 Schizoid Personality Disorder 301. 20 Schizoid personality disorder, unspecified 301. 21 Introverted personality [Note: not a disorder] 301. 22 Schizotypal Personality Disorder 301. 22 Schizotypal personality disorder 301. 3 Explosive personality disorder Aggressiveness Emotional instability (excessive)Pathological emotionality Quarrelsomeness 301. 4 Obsessive-Compulsive Personality Disorder301. 4 Obsessive-compulsive personality disorder 301. 50 Histrionic Personality Disorder 301. 50 Histrionic personality disorder, unspecified 301. 51 Chronic factitious illness with physical symptoms Hospital addiction syndrome Multiple operations syndrome Munchausen syndrome 301. 59 Other histrionic personality disorder 301. 6 Dependent Personality Disorder 301. 6 Dependent personality disorder301. 7 Antisocial Personality Disorder 301. 7 Antisocial personality disorder 301. 8 Other personality disorders 301. 81 Narcissistic Personality Disorder 301. 81 Narcissistic personality disorder301. 82 Avoidant Personality Disorder 301. 82 Avoidant personality disorder301. 83 Borderline Personality Disorder 301. 83 Borderline personality disorder 301. 84 Passive-aggressive personality disorder 301. 89 Other personality disorder
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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284 STANDARD TERMS AND STATEMENTS FOR REPORTS DIAGNOSIS DSM-IV-TR ICD-9-CM 301. 9 Personality Disorder NOS 301. 9 Unspecified personality disorder 310. 1 Personality Change Due To... [Indicate the General Medical Condition] V71. 01 Adult Antisocial Behavior V71. 01 Gang activity without manifest psychiatric disorder Passive-Aggressive Personality Disorder (Negativistic Personality Disorder) and Depressive Personality Disorder are diagnoses proposed for further study; see Appendix B of DSM-IV-TR. 21. 8. Impulse-Control Disorders Not Elsewhere Classified See also “Behavior and Conduct Disorders” in Section 21. 9, below. DSM-IV-TR ICD-9-CM 312. 30 Impulse-Control Disorder NOS 312. 30 Impulse control disorder, unspecified 312. 31 Pathological Gambling 312. 31 Pathological gambling 312. 32 Kleptomania 312. 32 Kleptomania 312. 33 Pyromania 312. 33 Pyromania 312. 34 Intermittent Explosive Disorder 312. 34 Intermittent explosive disorder 312. 35 Isolated explosive disorder 312. 39 Trichotillomania 312. 39 Disorders of impulse control, not elsewhere classified: Other Trichotillomania 21. 9. Childhood Disorders Mental Retardation All of these are coded on Axis II of DSM-IV-TR. DSM-IV-TR ICD-9-CM V62. 89 Borderline Intellectual Functioning (IQ 71-84) [Note: not Mental Retardation] 317 Mild Mental Retardation (IQ 50-55 to approximately 70)317 Mild mental retardation (IQ 50-70) 318. 0 Moderate Mental Retardation (IQ 35-40 to 50-55)318. 0 Moderate mental retardation (IQ 35-49) 318. 1 Severe Mental Retardation (IQ 20-25 to 35-40)318. 1 Severe mental retardation (IQ 20-34) 318. 2 Profound Mental Retardation (IQ less than 20-25)318. 2 Profound mental retardation (IQ < 20) 319 Mental Retardation, Severity Unspecified (Not testable)319 Unspecified mental retardation
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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21. Diagnostic Statement/Impression 285DIAGNOSIS Pervasive Developmental Disorders DSM-IV-TR ICD-9-CM (For the codes below, enter the 5th digit as follows: 0, current or active state; 1, residual state) 299. 00 Autistic Disorder 299. 0x Autistic disorder Kanner's syndrome 299. 10 Childhood Disintegrative Disorder 299. 1x Childhood disintegrative disorder299. 80 Asperger's Disorder 299. 8x Other specified pervasive developmental disorders 299. 80 Schizophrenia, childhood type, NOS 299. 80 Rett's Disorder 299. 9 Unspecified pervasive developmental disorder Pervasive developmental disorder NOS Movement Disorders DSM-IV-TR ICD-9-CM 307. 20 Tic Disorder NOS 307. 20 Tic disorder, unspecified Tic disorder NOS 307. 21 Transient Tic Disorder 307. 21 Transient tic disorder Specify if: Single Episode/ Recurrent 307. 22 Chronic Motor or Vocal Tic Disorder307. 22 Chronic motor or vocal tic disorder 307. 23 Tourette's Disorder 307. 23 Tourette's disorder 307. 3 Stereotypic Movement Disorder 307. 3 Stereotypic movement disorder Specify if: With Self-Injurious Behavior 315. 4 Developmental Coordination Disorder315. 4 Developmental coordination disorder Behavior and Conduct Disorders DSM-IV-TR ICD-9-CM (Options for the 5th digit of 312. 0, 312. 1, and 312. 2: 0, unspecified; 1, mild; 2, moderate; 3, severe) 312. 0x Undersocialized conduct disorder, aggressive type 312. 1x Undersocialized conduct disorder, unaggressive type 312. 2x Socialized conduct disorder312. 3x Disorders of impulse control, not elsewhere classified
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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286 STANDARD TERMS AND STATEMENTS FOR REPORTS DIAGNOSIS DSM-IV-TR ICD-9-CM 312. 4 Mixed disturbance of conduct and emotions 312. 81 Conduct Disorder, Childhood-Onset Type312. 81 Conduct disorder, childhood onset type 312. 82 Conduct Disorder, Adolescent-Onset Type312. 82 Conduct disorder, adolescent onset type 312. 89 Conduct Disorder, Unspecified Onset312. 89 Other conduct disorder 312. 9 Disruptive Behavior Disorder NOS 312. 9 Unspecified disturbance of conduct Juvenile delinquency Disruptive behavior disorder NOS 313. 81 Oppositional Defiant Disorder 313. 81 Oppositional defiant disorder V71. 02, Child or Adolescent Antisocial Behavior (in DSM-IV-TR) or Childhood or adolescent anti-social behavior (in ICD-9-CM), should be considered when antisocial behavior in a youth does not appear to be due to a mental disorder. Disturbance of Emotions Specific to Childhood and Adolescence DSM-IV-TR ICD-9-CM 313. 0 Overanxious disorder 313. 1 Misery and unhappiness disorder313. 2 Sensitivity, shyness, and social withdrawal disorder 313. 21 Shyness disorder of childhood313. 22 Introverted disorder of childhood 313. 23 Selective Mutism 313. 23 Selective mutism313. 3 Relationship problems. Sibling jealousy 313. 8 Other or mixed emotional disturbances of childhood or adolescence 309. 21 Separation Anxiety Disorder 309. 21 Separation anxiety disorder Specify if: Early Onset 313. 82 Identity Problem 313. 82 Identity disorder Identity problem 313. 89 Reactive Attachment Disorder of Infancy or Early Childhood313. 89 Reactive attachment disorder of infancy or early childhood Specify type: Inhibited/ Disinhibited Type Other or mixed emotional disturbances of childhood or adolescence: Other 313. 9 Disorder of Infancy, Childhood, or Adolescence NOS313. 9 Unspecified emotional disturbance of childhood or adolescence
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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21. Diagnostic Statement/Impression 287DIAGNOSIS Learning and Developmental Disorders DSM-IV-TR ICD-9-CM 315. 00 Reading Disorder 315. 00 Developmental reading disorder, unspecified 315. 01 Alexia 315. 02 Developmental dyslexia315. 09 Other specific developmental reading disorder 315. 1 Mathematics Disorder 315. 1 Developmental mathematics disorder 315. 2 Disorder of Written Expression 315. 2 Other specific developmental learning difficulties Disorder of written expression 315. 5 Mixed development disorder315. 8 Other specified delays in development 315. 9 Learning Disorder NOS 315. 9 Unspecified delay in development Learning disorder NOS 313. 83 Academic underachievement disorder 309. 23 Specific academic or work inhibition Communication Disorders DSM-IV-TR ICD-9-CM 307. 0 Stuttering 307. 0 Stuttering 307. 9 Communication Disorder NOS 307. 9 Other and unspecified special symptoms or syndromes, not elsewhere classified 315. 31 Expressive Language Disorder 315. 31 Expressive language disorder Developmental aphasia Auditory processing disorder 315. 32 Mixed Receptive-Expressive Language Disorder315. 32 Mixed receptive-expressive language disorder 315. 34 Speech and language developmental delay due to hearing loss 315. 39 Phonological Disorder 315. 39 Developmental speech or language disorder: Other Dyslalia 313. 23 Selective Mutism 313. 23 Selective mutism
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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288 STANDARD TERMS AND STATEMENTS FOR REPORTS DIAGNOSIS Attention-Deficit(/Hyperactivity) Disorder DSM-IV-TR ICD-9-CM 314. 00 Attention-Deficit/Hyperactivity Disorder Predominantly Inattentive Type314. 00 Attention deficit disorder: Without mention of hyperactivity 314. 01 Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type or Combined Type314. 01 Attention deficit disorder: with hyperactivity, predominantly hyperactive, impulsive type 314. 1 Hyperkinesis with developmental delay 314. 2 Hyperkinetic conduct disorder314. 8 Other specified manifestations of hyperkinetic syndrome 314. 9 Attention-Deficit/Hyperactivity Disorder NOS314. 9 Unspecified hyperkinetic syndrome 21. 10. Eating and Elimination Disorders In DSM-IV-TR, the first three of these disorders have their own section; the others are grouped with the Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence. DSM-IV-TR ICD-9-CM 307. 1 Anorexia Nervosa 307. 1 Anorexia nervosa Specify type: Restricting or Binge- Eating/Purging Type 307. 50 Eating Disorder NOS 307. 50 Eating disorder, unspecified 307. 51 Bulimia Nervosa 307. 51 Bulimia nervosa Specify type: Purging/Nonpurging Type 307. 52 Pica 307. 52 Pica 307. 53 Rumination Disorder 307. 53 Rumination disorder 307. 54 Psychogenic vomiting 307. 59 Feeding Disorder of Infancy or Early Childhood307. 59 Other and unspecified disorders of eating: Other 307. 6 Enuresis (Not Due to a General Medical Condition)307. 6 Enuresis Specify: Primary or secondary Specify type: Nocturnal Only/ Diurnal Only/Nocturnal and Diurnal 307. 7 Encopresis, Without Constipation and Overflow Incontinence307. 7 Encopresis Specify: Continuous or discontinuous 787. 6 Encopresis, With Constipation and Overflow Incontinence Binge-Eating Disorder is a diagnosis proposed for further study; see Appendix B of DSM-IV-TR.
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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21. Diagnostic Statement/Impression 289DIAGNOSIS 21. 11. “Organic” Cognitive Conditions DSM-IV-TR no longer uses the term “organic” for these conditions, but the descriptor is still widely used in practice and in ICD-9-CM. DSM-IV-TR ICD-9-CM 290. 0 Senile dementia, uncomplicated Excludes: Dementia due to alcohol (291. 0-291. 2) and dementia due to drugs (292. 82) 290. 10 Dementia of the Alzheimer's Type, With Early Onset, Without Behavioral Disturbance290. 10 Presenile dementia, uncomplicated 290. 10 Dementia of the Alzheimer's Type, With Late Onset, Without Behavioral Disturbance 290. 11 Dementia of the Alzheimer's Type, With Early Onset, With Behavioral Disturbance290. 11 Presenile dementia with delirium 290. 11 Dementia of the Alzheimer's Type, With Late Onset, With Behavioral Disturbance 290. 12 Presenile dementia with delusional features (paranoid type) 290. 13 Presenile dementia with depressive features 290. 20 Senile dementia with delusional features 290. 21 Senile dementia with depressive features 290. 3 Senile dementia with delirium290. 4 Vascular dementia 290. 40 Vascular Dementia, Uncomplicated 290. 40 Vascular dementia, uncomplicated290. 41 Vascular Dementia, With Delirium 290. 41 Vascular dementia with delirium290. 42 Vascular Dementia, With Delusions 290. 42 Vascular dementia with delusions290. 43 Vascular Dementia, With Depressed Mood290. 43 Vascular dementia with depressed mood For all Vascular Dementias, specify if: With Behavioral Disturbance 290. 8 Other specified senile psychotic conditions 290. 9 Unspecified senile psychotic condition 293. 0 Delirium Due to... [Indicate the General Medical Condition]293. 0 Delirium due to CCE 780. 09 Delirium NOS 293. 1 Subacute delirium 293. 81 Psychotic Disorder Due to... [Indicate the General Medical Condition], With Delusions293. 81 Psychotic disorder with delusions in CCE
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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290 STANDARD TERMS AND STATEMENTS FOR REPORTS DIAGNOSIS DSM-IV-TR ICD-9-CM 293. 82 Psychotic Disorder Due to... [Indicate the General Medical Condition], With Hallucinations293. 82 Psychotic disorder with hallucinations in CCE 293. 83 Mood Disorder Due to [Indicate the General Medical Condition]293. 83 Mood disorder in CCE 293. 84 Anxiety Disorder Due to [Indicate the General Medical Condition]293. 84 Anxiety disorder in CCE 293. 89 Catatonic Disorder Due to... [Indicate the General Medical Condition]293. 89 Other specified transient mental disorders due to CCE: Other 293. 9 Mental Disorder NOS Due to... [Indicate the General Medical Condition]293. 9 Unspecified transient mental disorder in CCE 294. 0 Amnestic Disorder Due to... [Indicate the General Medical Condition]294. 0 Amnestic syndrome in CCE Korsakoff's Psychosis or Syndrome 294. 10 Dementia Due to... [Indicate the General Medical Condition], Without Behavioral Disturbance294. 10 Dementia in CCE without behavioral disturbance 294. 11 Dementia Due to... [Indicate the General Medical Condition], With Behavioral Disturbance294. 11 Dementia in CCE with behavioral disturbance Dementia of the Alzheimer's type 294. 8 Amnestic Disorder NOS 294. 8 Other persistent mental disorders due to CCE Amnestic disorder NOSDementia NOS294. 8 Dementia NOS 294. 9 Cognitive Disorder NOS 294. 9 Unspecified persistent mental disorders due to CCE 310 Specific nonpsychotic mental disorders due to organic brain damage 310. 0 Frontal lobe syndrome 310. 1 Personality Change Due to... [Indicate the General Medical Condition]310. 1 Personality change due to CCE 310. 2 Postconcussion syndrome (see note in left column re: the DSM-IV-TR equivalent) 310. 8 Other specified nonpsychotic mental disorders following organic brain damage Mild memory disturbance 310. 9 Unspecified nonpsychotic mental disorder following organic brain damage 780. 9 Age-Related Cognitive Decline In DSM-IV-TR, Postconcussional Disorder and Mild Neurocognitive Disorder are diagnoses proposed for further study; see Appendix B of the manual.
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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21. Diagnostic Statement/Impression 291DIAGNOSIS 21. 12. Substance-Related Disorders There are also diagnoses not included here related to the use of amphetamines, hallucinogens, inhalants, phencyclidine, sedatives/hypnotics/anxiolytics, and unknown substances. Note: Possible DSM-IV-TR dependence specifiers for substance- related diagnoses include With Physiological Dependence (evidence of tolerance or withdrawal) and Without Physiological Dependence (no evidence of tolerance or withdrawal). Remission specifiers are as follows: Early Full Remission (no criteria met for at least 1 month, but for less than 12 months); Early Partial Remission (one or more criteria met for 1 month but for less than 12 months); and Sustained Full Remission (no abuse or dependence criteria met for 12 months); Sustained Partial Remission (one or more abuse or dependence criteria met during 12-month period, but full criteria for depen-dence not met in that period). Other specifiers are On Agonist Therapy (taking an agonist medi-cation [e. g., Antabuse] and with no criteria for abuse or dependence met for 1 month); In a Con-trolled Environment (in a setting in which access to substances is restricted, with no criteria met for 1 month); With Onset During Intoxication ; and With Onset During Withdrawal. Alcohol-Related Disorders DSM-IV-TR ICD-9-CM 291. 0 Alcohol Intoxication or Withdrawal Delirium291. 0 Alcohol withdrawal delirium (including delirium tremens) 291. 1 Alcohol-Induced Persisting Amnestic Disorder291. 1 Alcohol-induced persisting amnestic disorder 291. 2 Alcohol-Induced Persisting Dementia291. 2 Alcohol-induced persisting dementia 291. 3 Alcohol-Induced Psychotic Disorder, With Hallucinations291. 3 Alcohol-induced psychotic disorder with hallucinations 291. 4 Idiosyncratic alcohol intoxication 291. 5 Alcohol-Induced Psychotic Disorder, With Delusions291. 5 Alcohol-induced psychotic disorder with delusions 291. 81 Alcohol Withdrawal 291. 81 Alcohol withdrawal Specify if: With Perceptual Disturbances291. 82 Alcohol-induced sleep disorder 291. 89 Alcohol-Induced Anxiety Disorder, Mood Disorder, Sexual Dysfunction, or Sleep Disorder291. 89 Other specified alcohol-induced mental disorders: Other 291. 9 Alcohol-Related Disorder NOS 291. 9 Unspecified alcohol-induced mental disorders (Note: ICD-9-CM uses the following 5th digits for all 303, 304, and 305 conditions: 0, unspecified; 1, continuous; 2, episodic; 3, in remission. ) 303. 00 Alcohol Intoxication303. 0x Acute alcoholic intoxication 303. 90 Alcohol Dependence303. 9x Other and unspecified alcohol dependence 305. 00 Alcohol Abuse305. 0x Nondependent alcohol abuse
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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292 STANDARD TERMS AND STATEMENTS FOR REPORTS DIAGNOSIS Other Substance-Related Disorders Except in the diagnoses for intoxication, dependence, and abuse, ICD-9-CM does not distinguish the other drugs by code number, but by an additional E code for External cause (including drugs). Unless noted otherwise, the following categories can apply to cannabis, cocaine, hallucinogens, inhalants, opiates, phencyclidine, sedatives/hypnotics/anxiolytics, amphetamines, and other or unknown substances. DSM-IV-TR ICD-9-CM 292. 0 Withdrawal [State Class of Drug, or Other or Unknown Substance]292. 0 Drug withdrawal 292. 11 Substance-Induced Psychotic Disorder, With Delusions [State Class of Drug, or Other or Unknown]292. 11 Drug-induced psychotic disorder, with delusions 292. 12 Substance-Induced Psychotic Disorder With Hallucinations [State Class of Drug or Other or Unknown Substance]292. 12 Drug-induced psychotic disorder, with hallucinations (excludes brief states, “bad trips”) 292. 2 Pathological drug intoxication (for brief states) 292. 81 [Class of Drug, or Other or Unknown Substance] Intoxication Delirium292. 81 Drug-induced delirium 292. 82 [Class of Drug, or Other or Unknown Substance]-Induced Persisting Dementia292. 82 Drug-induced persisting dementia 292. 83 Sedative, Hypnotic, or Anxiolytic [or Other or Unknown Substance]-Induced Persisting Amnestic Disorder292. 83 Drug-induced persisting amnestic disorder 292. 84 [Class of Drug, or Other or Unknown Substance]-Induced Mood Disorder292. 84 Drug-induced mood disorder 292. 89 [Class of Drug, or Other or Unknown Substance]-Induced Anxiety, Sexual, or Sleep (specify) Disorder292. 89 Other specified drug-induced mental disorders: Other Drug-induced anxiety disorder, sexual dysfunction, sleep disorder, or drug intoxication 292. 9 [Class of Drug, or Other or Unknown Substance]-Related Disorder NOS292. 9 Unspecified drug-induced mental disorder
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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21. Diagnostic Statement/Impression 293DIAGNOSIS Caffeine-Related Disorders DSM-IV-TR ICD-9-CM 292. 89 Caffeine-Induced Anxiety or Sleep Disorder 292. 9 Caffeine-Related Disorder NOS 305. 90 Caffeine Intoxication 305. 9x Caffeine intoxication Caffeine Withdrawal is a diagnosis proposed for further study; see Appendix B of DSM-IV-TR. Cannabis-Related Disorders DSM-IV-TR ICD-9-CM 292. 11 Cannabis-Induced Psychotic Disorder, With Delusions 292. 12 Cannabis-Induced Psychotic Disorder, With Hallucinations 292. 81 Cannabis Intoxication Delirium 292. 89 Cannabis-Induced Anxiety Disorder 292. 89 Cannabis Intoxication Specify if: With Perceptual Disturbances 292. 9 Cannabis-Related Disorder NOS 304. 30 Cannabis Dependence 304. 3x Cannabis dependence 305. 20 Cannabis Abuse 305. 2x Nondependent cannabis abuse Cocaine-Related Disorders DSM-IV-TR ICD-9-CM 292. 0 Cocaine Withdrawal 292. 11 Cocaine-Induced Psychotic Disorder, With Delusions 292. 12 Cocaine-Induced Psychotic Disorder, With Hallucinations 292. 81 Cocaine Intoxication Delirium292. 84 Cocaine-Induced Mood Disorder 292. 89 Cocaine-Induced Anxiety Disorder, Sexual Dysfunction, or Sleep Disorder 292. 89 Cocaine Intoxication Specify if: With Perceptual Disturbances 292. 9 Cocaine-Related Disorder NOS 304. 20 Cocaine Dependence 304. 2x Cocaine dependence 305. 60 Cocaine Abuse 305. 6x Nondependent cocaine abuse
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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294 STANDARD TERMS AND STATEMENTS FOR REPORTS DIAGNOSIS Nicotine-Related Disorders DSM-IV-TR ICD-9-CM 292. 0 Nicotine Withdrawal 292. 9 Nicotine-Related Disorder NOS 305. 1 Nicotine Dependence 305. 1 Nondependent tobacco use disorder. Tobacco dependence Opioid-Related Disorders DSM-IV-TR ICD-9-CM 292. 0 Opioid Withdrawal 292. 11 Opioid-Induced Psychotic Disorder, With Delusions 292. 12 Opioid-Induced Psychotic Disorder, With Hallucinations 292. 81 Opioid Intoxication Delirium292. 84 Opioid-Induced Mood Disorder 292. 89 Opioid-Induced Sexual Dysfunction or Sleep Disorder 292. 89 Opioid Intoxication Specify if: With Perceptual Disturbances 292. 9 Opioid-Related Disorder NOS 304. 00 Opioid Dependence 304. 0x Opioid type dependence 305. 50 Opioid Abuse 305. 5x Nondependent opioid abuse Miscellaneous Substance-Related Conditions DSM-IV-TR ICD-9-CM 304. 10 Sedative, Hypnotic, or Anxiolytic Dependence304. 1x Sedative, hypnotic, or anxiolytic dependence 304. 7x Drug dependence: Combinations of opioid type drug with any other 304. 80 Polysubstance Dependence 304. 8x Combinations of drug dependence, excluding opioid type drug 305. 90 Inhalant, Phencyclidine, Other, or Unknown Abuse 305. 30 Hallucinogen Abuse 305. 3x Hallucinogen abuse 305. 40 Sedative, Hypnotic, or Anxiolytic Abuse305. 4x Nondependent sedative, hypnotic, or anxiolytic abuse 304. 50 Hallucinogen Dependence 304. 5x Hallucinogen dependence 305. 70 Amphetamine Abuse 305. 7x Nondependent amphetamine or related-acting sympathomimetic abuse 304. 40 Amphetamine Dependence 304. 4x Amphetamine and other psychostimulant dependence
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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21. Diagnostic Statement/Impression 295DIAGNOSIS DSM-IV-TR ICD-9-CM 304. 60 Inhalant or Phencyclidine Dependence304. 6x Other specified drug dependence Inhalant dependence Phencyclidine dependence Glue sniffing 305. 8x Nondependent antidepressant type abuse 304. 9x Unspecifed drug dependence305. 9x Nondependent other, mixed, or unspecified drug abuse Caffeine intoxication Inhalant abuse Phencyclidine abuse Nonprescribed use of drugs or patent medicinals 21. 13. Psychotic Disorders See Section 21. 12 for codes for Substance-Induced Psychotic Disorders. In DSM-IV-TR, for all subtypes of Schizophrenia, use these longitudinal course specifiers: Episodic with Interepisodal Residual Symptoms, Episodic with No Interepisodal Residual Symptoms, Single Episode in Partial Remission, Single Episode in Full Remission, Other or Unspecified Pattern. For the first three of these specifiers, also specify if: With Prominent Negative Symptoms. DSM-IV-TR ICD-9-CM (Use the following 5th digits: 0, unspecified; 1, subchronic; 2, chronic; 3, subchronic with acute exacerbation; 4, chronic in acute exacerbation; 5, in remission. ) 295. 0x Simple type schizophrenia 295. 10 Schizophrenia, Disorganized Type 295. 1x Disorganized type schizophrenia 295. 20 Schizophrenia, Catatonic Type 295. 2x Catatonic type schizophrenia295. 30 Schizophrenia, Paranoid Type 295. 3x Paranoid type schizophrenia295. 40 Schizophreniform Disorder 295. 4x Schizophreniform disorder Specify if: With/Without Good Prognostic Features 295. 5x Latent schizophrenia 295. 60 Schizophrenia, Residual Type 295. 6x Residual type schizophrenia Chronic undifferentiated schizophrenia 295. 70 Schizoaffective Disorder 295. 7x Schizoaffective disorder Specify type: Bipolar/Depressive Type
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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296 STANDARD TERMS AND STATEMENTS FOR REPORTS DIAGNOSIS DSM-IV-TR ICD-9-CM 295. 8x Other specified types of schizophrenia 295. 90 Schizophrenia, Undifferentiated Type295. 9x Unspecified schizophrenia Schizophrenia, undifferentiated type 297. 0 Paranoid state, simple 297. 1 Delusional Disorder Specify type: Erotomanic/Grandiose/ Jealous/Persecutory/Somatic/ Mixed/Unspecified Type297. 1 Delusional disorder 297. 2 Paraphrenia Involutional paranoid state 297. 3 Shared Psychotic Disorder 297. 3 Shared psychotic disorder Folie à deux 297. 8 Other specified paranoid states 297. 9 Unspecified paranoid state298. 0 Depressive type psychosis298. 1 Excitative type psychosis298. 2 Reactive confusion298. 3 Acute paranoid reaction298. 4 Psychogenic paranoid psychosis 298. 8 Brief Psychotic Disorder Specify if: With/Without Marked Stressors, With Postpartum Onset298. 8 Other and unspecified reactive psychosis Brief psychotic disorder 298. 9 Psychotic Disorder NOS 298. 9 Unspecified psychosis 21. 14. Sleep Disorders See Sections 12. 37 for different diagnoses, and 21. 12 for codes for Substance-Induced Sleep Disorders. Dyssomnias DSM-IV-TR ICD-9-CM 307. 40 Nonorganic sleep disorder, unspecified 307. 41 Transient disorder of initiating or maintaining sleep 307. 42 Primary Insomnia Specify if: Recurrent307. 42 Persistent disorder of initiating or maintaining sleep 307. 42 Insomnia Related to... [Indicate the Axis I or II Disorder] 307. 43 Transient disorder of initiating or maintaining wakefulness 307. 44 Hypersomnia Related to... [Indicate the Axis I or II Disorder]307. 44 Persistent disorder of initiating or maintaining wakefulness 307. 44 Primary Hypersomnia Specify if: Recurrent 307. 45 Circadian Rhythm Sleep Disorder 307. 45 Circadian rhythm sleep disorder
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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21. Diagnostic Statement/Impression 297DIAGNOSIS DSM-IV-TR ICD-9-CM Specify type: Delayed Sleep Phase/ Jet Lag/Shift Work/Unspecified Type 307. 47 Dyssomnia NOS 307. 47 Other dysfunctions of sleep stages or arousal from sleep 347 Narcolepsy 347. 0 Narcolepsy 780. 52 Sleep Disorder Due to... [Indicate the General Medical Condition], Insomnia Type 780. 54 Sleep Disorder Due to... [Indicate the General Medical Condition], Hypersomnia Type 780. 59 Sleep Disorder Due to... [Indicate the General Medical Condition], Mixed Type 780. 59 Sleep Disorder Due to... [Indicate the General Medical Condition], Parasomnia Type 780. 59 Breathing-Related Sleep Disorder V69. 4 Lack of adequate sleep. Sleep deprivation V69. 5 Behavioral insomnia of childhood Many more sleep-disordered patterns are included in ICD-9-CM under 327. xx. Organic sleep disorders. Sleep disturbances (due to a medical condition) are classified under 780. 5x codes. Parasomnias DSM-IV-TR ICD-9-CM 307. 46 Sleep Terror Disorder 307. 46 Sleep arousal disorder 307. 46 Sleepwalking Disorder Night terror disorder Night terrors Sleep terror disorder Sleepwalking Somnambulism 307. 47 Nightmare Disorder307. 47 Parasomnia NOS 307. 47 Other dysfunctions of sleep stages or arousal from sleep Nightmare disorder Parasonmia NOS 307. 48 Repetitive intrusions of sleep307. 49 Other specific disorders of sleep of nonorganic origin Subjective insomnia complaint
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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298 STANDARD TERMS AND STATEMENTS FOR REPORTS DIAGNOSIS 21. 15. Somatoform Disorders DSM-IV-TR ICD-9-CM 300. 5 Neurasthenia 300. 11 Conversion Disorder 300. 11 Conversion disorder Specify type: With Motor Symptom or Deficit/With Seizures or Convulsions/With Sensory Symptom or Deficit/With Mixed Presentation 300. 7 Body Dysmorphic Disorder300. 7 Hypochondriasis 300. 7 Hypochondriasis Specify if: With Poor Insight 300. 81 Somatization Disorder 300. 81 Somatization disorder 300. 82 Somatoform Disorder NOS300. 82 Undifferentiated Somatoform Disorder300. 82 Undifferentiated somatoform disorder 300. 89 Other somatoform disorders 21. 16. Psychological Factors Affecting a Medical Condition DSM-IV-TR ICD-9-CM 306. xx Physiological malfunction arising from mental factors 306. 0 Musculoskeletal 306. 1 Respiratory306. 2 Cardiovascular306. 3 Skin306. 4 Gastrointestinal306. 5 Genitourinary306. 50 Psychogenic genitourinary malfunction, unspecified 306. 6 Endocrine306. 7 Organs of special sense306. 8 Other specified psychophysiological malfunction 306. 9 Unspecified psychophysiological malfunction 307. 80 Pain Disorder Associated With Psychological Factors307. 80 Psychogenic pain, site unspecified Specify if: Acute/Chronic 307. 81 Tension headache 307. 89 Pain Disorder Associated With Both Psychological Factors and a General Medical Condition307. 89 Pain disorders related to psychological factors: Other Specify if: Acute/Chronic
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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21. Diagnostic Statement/Impression 299DIAGNOSIS DSM-IV-TR ICD-9-CM 307. 9 Other and unspecified special symptoms or syndromes, not elsewhere classified. Nail biting, hair plucking, lalling, masturbation, thumb-sucking 316... [Specified Psychological Factor] Affecting... [Indicate the General Medical Condition] (Choose one of the following for [Specified Psychological Factor]: Mental Disorder, Psychological Symptoms, Personality Traits or Coping Style, Maladaptive Health Behaviors, Stress-Related Physiological Response, and Other or Unspecified Psychological Factors)316 Psychic factors associated with diseases classified elsewhere (Use additional code to identify the associated physical condition. ) 21. 17. Dissociative Disorders DSM-IV-TR ICD-9-CM 300. 12 Dissociative Amnesia 300. 12 Dissociative amnesia 300. 13 Dissociative Fugue 300. 13 Dissociative fugue 300. 14 Dissociative Identity Disorder 300. 14 Dissociative identity disorder 300. 15 Dissociative Disorder NOS 300. 15 Dissociative disorder or reaction, unspecified 300. 6 Depersonalization Disorder 300. 6 Depersonalization disorder Derealization Dissociative Trance Disorder is a diagnosis proposed for further study; see Appendix B of DSM-IV-TR. 21. 18. Sexual Dysfunctions and Disorders See Section 21. 12 for codes for Substance-Induced Sexual Dysfunctions. Sexual Dysfunctions In DSM-IV-TR, specify type: Lifelong/Acquired/Generalized/Situational Type, Due to Psychological Factors/Due to Combined Factors. DSM-IV-TR ICD-9-CM 302. 70 Sexual Dysfunction NOS 302. 70 Psychosexual dysfunction, unspecified 302. 71 Hypoactive Sexual Desire Disorder 302. 71 Hypoactive sexual desire disorder
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300 STANDARD TERMS AND STATEMENTS FOR REPORTS DIAGNOSIS DSM-IV-TR ICD-9-CM 302. 72 Female Sexual Arousal/Male Erectile Disorder302. 72 Psychosexual dysfunction with inhibited sexual excitement Female sexual arousal disorder Male erectile disorder 302. 73 Female Orgasmic Disorder 302. 73 Female orgasmic disorder 302. 74 Male Orgasmic Disorder 302. 74 Male orgasmic disorder 302. 75 Premature Ejaculation 302. 75 Premature ejaculation 302. 76 Dyspareunia (Not Due to... a General Medical Condition)302. 76 Dyspareunia, psychogenic 302. 79 Sexual Aversion Disorder 302. 79 Psychosexual dysfunction: With other specified psychosexual dysfunctions Sexual aversion disorder 306. 51 Vaginismus (Not Due to... a General Medical Condition)306. 51 Psychogenic vaginismus 306. 52 Psychogenic dysmenorrhea 306. 53 Psychogenic dysuria306. 59 Physiological malfunction arising from mental factors: Genitourinary: Other 607. 84 Male Erectile Disorder Due to... ... [Indicate the General Medical Condition] 608. 89 Male Dyspareunia Due to...... [Indicate the General Medical Condition] 608. 89 Male Hypoactive Sexual Desire Disorder Due to...... [Indicate the General Medical Condition] 608. 89 Other Male Sexual Dysfunction Due to...... [Indicate the General Medical Condition] 625. 0 Female Dyspareunia Due to...... [Indicate the General Medical Condition] 625. 8 Female Hypoactive Sexual Desire Disorder Due to...... [Indicate the General Medical Condition] 625. 8 Other Female Sexual Dysfunction Due to...... [Indicate the General Medical Condition] Gender and Sexual Identity Disorders DSM-IV-TR ICD-9-CM 302. 0 Ego-dystonic sexual orientation Sexual orientation conflict disorder 302. 6 Gender Identity Disorder in Children302. 6 Gender identity disorder in children Gender Identity Disorder NOS Gender identity disorder NOS
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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21. Diagnostic Statement/Impression 301DIAGNOSIS DSM-IV-TR ICD-9-CM 302. 85 Gender Identity Disorder in Adolescents or Adults302. 85 Gender identity disorder in adolescents or adults Specify if: Sexually Attracted to Males/Females/Both/Neither Paraphilias DSM-IV-TR ICD-9-CM 302. 1 Zoophilia 302. 2 Pedophilia 302. 2 Pedophilia Specify if: Sexually Attracted to Males/Females/Both, Limited to Incest, Exclusive/Nonexclusive Type 302. 3 Transvestic Fetishism 302. 3 Transvestic fetishism Specify if: With Gender Dysphoria 302. 4 Exhibitionism 302. 4 Exhibitionism302. 50 Trans-sexualism: With unspecified sexual history 302. 51 Trans-sexualism: With asexual history 302. 52 Trans-sexualism: With homosexual history 302. 53 Trans-sexualism: With heterosexual history 302. 81 Fetishism 302. 81 Fetishism 302. 82 Voyeurism 302. 82 Voyeurism 302. 83 Sexual Masochism 302. 83 Sexual masochism 302. 84 Sexual Sadism 302. 84 Sexual sadism 302. 89 Frotteurism 302. 89 Other specified psychosexual disorders: Other Frotteurism 302. 9 Sexual Disorder NOS 302. 9 Unspecified psychosexual disorder Paraphilia NOS Paraphilia NOSSexual disorder NOS 21. 19. Factitious Disorders DSM-IV-TR ICD-9-CM 300. 16 Factitious Disorder with Predominantly Psychological Signs and Symptoms300. 16 Factitious disorder with predominantly psychological signs and symptoms 300. 19 Factitious Disorder with Predominantly Physical Signs and Symptoms
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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302 STANDARD TERMS AND STATEMENTS FOR REPORTS DIAGNOSIS DSM-IV-TR ICD-9-CM 300. 19 Factitious Disorder with Combined Psychological and Physical Signs and Symptoms300. 19 Other and unspecified factitious illness Factitious disorder NOS 300. 19 Factitious Disorder NOS 301. 51 Chronic factitious illness with physical symptoms Munchausen Syndrome 21. 20. Medication-Induced Movement Disorders DSM-IV-TR ICD-9-CM 332. 1 Neuroleptic-Induced Parkinsonism 332. 1 Secondary Parkinsonism 333. 1 Medication-Induced Postural Tremor333. 1 Essential and other specified forms of tremor 333. 7 Neuroleptic-Induced Acute Dystonia333. 7 Acquired torsion dystonia 333. 82 Neuroleptic-Induced Tardive Dyskinesia 333. 85 Subacute dyskinesia due to drugs 333. 90 Medication-Induced Movement Disorder NOS333. 90 Unspecified extrapyramidal disease and abnormal movement disorder 333. 92 Neuroleptic Malignant Syndrome 333. 92 Neuroleptic malignant syndrome 333. 99 Neuroleptic-Induced Acute Akathisia 995. 2 Adverse Effects of Medication NOS 995. 2 Other and unspecified adverse effect of drug, medicinal and biological substance (due to correct medicinal substance properly administered) 21. 21. V Codes, Etc. In ICD-9-CM and DSM-IV-TR, “V codes” are assigned to conditions that are not themselves attribut-able to a mental disorder but that may be a focus of attention or treatment. This section covers most V codes, as well as some additional numerical codes. Relational Problems; Problems Related to Abuse or Neglect See also Chapter 16, “Couple and Family Relationships. ” DSM-IV-TR ICD-9-CM V61 Family Disruption V61. 01 Family disruption due to family member on military deployment. V61. 02 Family disruption due to return of family member from military deployment.
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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21. Diagnostic Statement/Impression 303DIAGNOSIS DSM-IV-TR ICD-9-CM V61. 03 Family disruption due to divorce or legal separation V61. 04 Family disruption due to parent-child estrangement V61. 05 Family disruption due to child in welfare custody V61. 06 Family disruption due to child in foster care or in care of non-parental family member V61. 09 Other family disruption V61. 10 Partner Relational Problem V61. 10 Counseling for marital and partner problems, unspecified V61. 11 Counseling for victim of spousal and partner abuse (use with 995. 81, Physical abuse of adult; or 995. 83 Sexual abuse of adult) V61. 12 Physical Abuse of Adult (if focus of clinical attention is on perpetrator and abuse is of partner)V61. 12 Counseling for perpetrator of spousal and partner abuse (use with 995. 81, Physical abuse of adult; or 995. 83, Sexual abuse of adult) Sexual Abuse of Adult (if focus of clinical attention is on perpetrator and abuse is of partner) V61. 20 Parent-Child Relational Problem V61. 20 Parent-child relational problem V61. 21 Physical Abuse of Child (use 995. 4 if focus of attention is on victim)V61. 21 Counseling for victim of child abuse (use with 995. 52, Child neglect [nutritional]; 995. 53, Child sexual abuse; or 995. 54, Child physical abuse) Sexual Abuse of Child (use 995. 3 if focus of attention is on victim) Neglect of Child (use 995. 52 if focus of attention is on victim) V61. 22 Counseling for perpetrator of parental child abuse (use with 995. 52, Child neglect [nutritional]; 995. 53, Child sexual abuse; or 995. 54, Child physical abuse) V61. 29 Parent-child problems: Other V61. 3 Problems with aged parents or in-laws V61. 7 Other unwanted pregnancy V61. 8 Sibling Relational Problem V61. 8 Other specified family circumstances V61. 81 Relational Problem NOSV61. 9 Relational Problem Related to a Mental Disorder or General Medical Condition V61. 9 Unspecified family circumstance
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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304 STANDARD TERMS AND STATEMENTS FOR REPORTS DIAGNOSIS DSM-IV-TR ICD-9-CM V62. 83 Physical Abuse of Adult (if focus of clinical attention is on perpetrator and abuse is not by partner; use 995. 81 if focus is on victim)V62. 83 Counseling for perpetrator of physical/sexual abuse (of a child or an adult) Sexual Abuse of Adult (if focus of clinical attention is on perpetrator and abuse is not by partner; use 995. 83 if focus is on victim) Additional Conditions That May Be a Focus of Clinical Attention DSM-IV-TR ICD-9-CM V15. 81 Noncompliance with Treatment V15. 81 Noncompliance with medical treatment. V62. 2 Occupational Problem V62. 2 Other occupational circumstances or maladjustment. V62. 21 Personal current military deployment status. Individual (civilian or military) currently deployed in theater or in support of military war, peacekeeping and humanitarian operations V62. 22 Personal history of return from military deployment. Individual (civilian or military) with past history of military war, peacekeeping and humanitarian deployment (current or past conflict) V62. 29 Other occupational circumstances or maladjustment: Other Career choice problem. Dissatisfaction with employment. Occupational problem V62. 3 Academic Problem V62. 3 Educational circumstances V62. 4 Acculturation Problem V62. 4 Social maladjustment V62. 82 Bereavement V62. 82 Bereavement, uncomplicated V62. 89 Phase of Life Problem Religious or Spiritual Problem Borderline Intellectual Functioning (coded on Axis II)V62. 89 Other psychological or physical stress, not elsewhere classified: Other (includes Phase of life problem, Religious or spiritual problem, Borderline intellectual functioning) V65. 2 Malingering V65. 2 Person feigning illness Malingering. V65. 4 Other counseling, not elsewhere classified V65. 5 “Worried well” V71. 09 No Diagnosis (or Condition) on Axis I or IIV71. 09 Observation of other suspected mental condition
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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21. Diagnostic Statement/Impression 305DIAGNOSIS DSM-IV-TR ICD-9-CM 799. 9 Diagnosis (or Condition) Deferred on Axis I or II799. 9 Other unknown and unspecified cause of morbidity and mortality 300. 9 Unspecified Mental Disorder (nonpsychotic)300. 9 Unspecified nonpsychotic mental disorder 307. 9 Other and unspecified special symptoms or syndromes, not elsewhere classified 780. 79 Other malaise and fatigue780. 95 Excessive crying of child, adolescent, or adult 21. 22. Axis IV: Psychosocial and Environmental Problems DSM-IV-TR Axis IV categories (reprinted by permission of the American Psychiatric Association) include the following: Problems with primary support group. Problems related to the social environment. Educational problems. Occupational problems. Housing problems. Economic problems. Problems with access to health care services. Problems related to interaction with the legal system/crime. Other psychosocial and environmental problems. Note: ü Describing the specific stressors experienced by the client, usually over the last year, is more clinically useful than using just the categories above (Segal & Hutchings, 2007). 21. 23. Axis V: Global Assessment of Functioning Scale This is an abbreviated version and does not list examples. It is adapted by permission from DSM-IV-TR. Ratings are made for current level of psychological/social/physical functioning and for highest level in past year. 91-100 Superior functioning in a wide range of areas; no symptoms. 81-90 No or minimal symptoms; generally good functioning in all areas; no more than everyday problems or concerns. 71-80 Transient, slight symptoms that are reasonable responses to stressful situations; no more than slight impairment in social, occupational, or school functioning. 61-70 Mild symptoms, or some difficulty in social, occupational, or school functioning. 51-60 Moderate symptoms, or moderate difficulties in social, occupational, or school functioning. 41-50 Serious symptoms, or any serious impairment in social, occupational, or school functioning.
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306 STANDARD TERMS AND STATEMENTS FOR REPORTS DIAGNOSIS 31-40 Serious difficulties in thought or communication, or major impairment in several areas of functioning. 21-30 Behavior influenced by psychotic symptoms, or serious impairment in communication or judgment, or inability to function in almost all areas. 11-20 Dangerous symptoms, or gross impairment in communication. 1-10 Persistent danger to self or others, or persistent inability to maintain hygiene. 0 Inadequate information. The equivalent Children's Global Assessment Scale is available online (see, e. g., www. kidsmental-health. org/documents/CGAS. pdf).
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307 22 Recommendations Making recommendations is usually the chief aim of report construction. If treatment is appropri-ate, its indicators and urgency must be presented to justify it. Selecting treatments from the hun-dreds of interventions available requires extensive knowledge of the structure and method of each intervention, its demands on client and therapist, and its likely outcomes for different syndromes and personalities. While treatment-to-client matching is beyond this book's scope, the sections here provide a large checklist of services to address the client's needs. 22. 1. Need for Treatment Your description of the need for treatment should include the justifications/reasons/clinical ratio-nales/indications for the medical necessity (if any) of, and the risks and benefits of, each proposed treatment choice/option/alternative (including those you did not recommend). Indication(s) for Hospitalization/Intensification of Treatment Efforts: Summary Statements This patient, with a history of severe and/or prolonged psychiatric illness, is showing signifi-cant decompensation. His disorder remains severe or persistent, despite appropriate outpatient treatment. She is exhibiting suicidal ideation/threats/gestures/attempts, or is (considered) a physical dan-ger to herself. There is severe loss of appetite/weight, and/or sleep disturbance, considered to be detrimental to physical health. He is believably threatening to act/acting in a physically destructive manner toward others or property. She is demonstrating bizarre, antisocial, or risky behaviors that will progress unless she is hos-pitalized. There is evidence of cognitive disorders, dementia, or organic brain syndrome requiring psy-chiatric, neuropsychological, or medical evaluation, which can only be provided in an inpa-tient setting. I am/Dr. is starting or modifying psychopharmacological treat-ments that require continuous monitoring and evaluation because of the type of medica-tion or the presence of other medical conditions or complicating factors. The patient's substance abuse is of such intensity and persistence that hospitalization is required to control or prevent the severe physical and psychiatric consequences of withdrawal. Precautions are needed to prevent assault/elopement/homicide/suicide. RECOMMENDA-TIONS
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308 STANDARD TERMS AND STATEMENTS FOR REPORTS RECOMMENDA-TIONSUrgency (↔ by degree) The following groupings are sequenced by degree of decreasing urgency. Emergency, act without delay, immediate intervention required to preserve life or health. Critical/serious disruption of functioning, act today/within 24 hours. Patient is suffering, treatment/evaluation is needed, act soon. Routine intake/evaluation/referral. Wait for (specify). Estimate of Treatability Although currently out of fashion, the issue of treatability is often worth considering, especially when resources are limited. In estimating treatability, weigh these characteristics of the patient: Motivators/pain; demotivators/anxieties/avoidances/resistances. Support needed and availability. Barriers (financial, logistical, cultural, intellectual). Openness to new experiences/the intimacy of therapy/strong affects/new perspectives. Psychological-mindedness, willingness to work, ego strength. Probability of remaining in treatment. 22. 2. Treatments of Choice Although it is clear from meta-analyses that psychotherapy benefits most clients, it is also well docu-mented that very few therapists have used research on the effectiveness of methods of therapy to guide their practices. Of the perhaps 400 “brand-name” therapies, however, only a few dozen have been properly evaluated for effectiveness for any kind of outcomes, and fewer have been empirically supported (in medicine this is called “evidence-based practice”). Variation in treatment practices accounts for about a quarter of the variance in outcomes. Varia-tion in the client- therapist relationship accounts for most of the rest, and yet this has been less studied. These “common factors” (meaning common across different treatment techniques) are comprehensively reviewed in Norcross (2002) and are well worth pursuing. Summaries of the comparative evaluations of treatments can be found in several places. A list of Empirically Supported Treatments with relevant treatment manuals and training resources can be found online at the Website on Research- Supported Psychological Treatments maintained by the Society of Clinical Psychology, Division 12 of the American Psychological Association (www. psychol-ogy. sunysb. edu/eklonsky-/division12 ). (See Chapter 27 for more on treatment resources for specific concerns and disorders. ) Several books contain much useful guidance to the outcome research on treatments. These include Roth and Fonagy (2005), Nathan and Gorman (2007), and, for children, Christophersen and Mortweet (2001). The treatments discussed in these books are primarily behavioral and cognitive, because these have been properly investigated. Many common therapies do not generate empiri-cally testable or falsifiable hypotheses. Also, therapist variables such as competence in and adher-ence to the techniques of a treatment, personality, allegiance, and similarity to the client have all been shown to be important determinants of outcome. See especially Norcross (2002) on this. We really need more research to answer the question framed by Gordon Paul in 1966 as follows: “Which treatment, administered by whom, for what diagnosis/problem, in what kind of person, has what outcome?”
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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22. Recommendations 309RECOMMENDA-TIONS22. 3. Treatment Options/Case Disposition See also Chapter 25, “Treatment Planning and Treatment Plan Formats. ” General Statements Continue current treatment(s). Add further/concurrent treatments (specify). Refer/transfer patient to a different hospital/program/therapist (specify). Discharge to be followed by/at [treater or agency] with first appointment on [date] at [time]. Counseling or Psychotherapy See Chapter 25 for goals and methods. Medication Statement The patient and I have had a full and free discussion of the risks and benefits of the proposed medication, and he/she agrees to this regimen. He/she will start [trade or generic name] at a dose of , times per day, for a period of and then will increase/decrease/taper/stop this medication at a dose of , times per day, for a period of . We have discussed benefits and risks, expectations, ways to deal with problems, etc. This regimen will be supervised/administered by the patient/family/clinic staff/school nurse/other (specify). Referrals Further evaluations/diagnostic studies: physical/medical, intellectual, personality, neuropsy-chological, custody, family, forensic, speech/language, audiological, educational/academic, occupational/vocational/rehabilitative (specify). To a nutritional education program and recommend dietary change. To an exercise education program/exercise program. To recreation counseling, have him/her change social/recreational, etc. activities to (specify), increase activities outside the home/family, take on volunteer activities such as (specify). 22. 4. Types of Therapies/Services Types of therapies and services are listed alphabetically, both to reflect the fact there is no accepted hierarchy and to encourage consideration of the many options available. Aftercare services, case management and monitoring, liaison, intensive outpatient treatment, partial hospital. Behavior modification methods1: Contingency management, contingency contracting, stimulus control, convert sensitization, time out, token economy, modeling, self-control methods, covert aversion therapy, Stress Inoculation Training, etc. Behavior therapies: Systematic desensitization, flooding, implosion, Eye Movement Desensitiza-tion and Reprocessing. Behavior referral: Self-control training, anger management, parenting skills/child management training, Parent Effectiveness Training (Gordon, 2000), assertiveness training, anti victim iza-tion program. 1Kratochwill and Bergan (1990) provide excellent guidance to the implementation of behavioral programs as a consul-tant.
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310 STANDARD TERMS AND STATEMENTS FOR REPORTS RECOMMENDA-TIONSBibliotherapy, self-help (see Norcross et al., 2003), and patient education. Body-mind awareness: Primal (scream), Rolfing, bioenergetics, Autogenic Training, gestalt, Functional Integration, biofeedback, the Alexander method, shiatsu, many kinds of yogas, martial arts training programs, tai chi, etc. Case management (intensive and tailored to client), Assertive Community Treatment. Cognitive and cognitive-behavioral therapies of many kinds, narrative therapies, interpersonal therapies, Dialectical Behavior Therapy, Motivational Interviewing, Acceptance and Com-mitment Therapy, etc. Crisis intervention and management. Expressive therapies: Art, music, dance/movement, journaling, poetry writing. Family support: Crisis care, staff monitoring and ongoing evaluations and interventions, respite care, in-home/mobile therapy, individual behavior support and training, etc. Psychological growth: Transactional Analysis, psychoanalysis, encounter/marathon/Open En counter groups, Morita therapy, Reality Therapy, Psychosynthesis, narrative therapies. Relationship and communication: Sex therapy, Marriage Encounter, Relationship Enhancement. Residential services: Foster care, “group homes,” community living arrangements, community residential services, “halfway house,” structured/supportive living arrangement, transi-tional services, protective services, domiciliary care, etc. Schooling: High school, General Equivalency Diploma classes, local college/general studies/ evening classes, vocational/trade schools. Skill-building groups: Toastmasters International, parenting skills/child management training, PET, anger management, assertiveness training, dating skills, antivictimization program, etc. Support groups (see also Norcross et al., 2003): Grief counseling, victim support services, Mothers Against Drunk Driving, Parents of Mur-dered Children, Compassionate Friends (parents of children who died), Candlelighters (children with cancer), Make Today Count (those with fatal illnesses). Encore Plus (women with breast cancer), Reach for Recovery (women who have had breast cancer surgery). Parents Anonymous (parents who abuse children), Sojourn (battered women), Daughters and Sons United (sexually abused children). Resolve (infertility), Adoptees Liberty Movement Association (adult adoptees and birth par-ents), Tough Love (parents of difficult adolescents), Single Parent Network. Recovery (people with nervous and mental problems), Take Off Pounds Sensibly, HELP (herpes), Mutual Friends (ex-Jehovah's Witnesses), Dignity (gay and lesbian Catholics), etc. Twelve-Step programs for many addictive behaviors: Alcohol/Cocaine/Narcotics/Families/ Overeaters/Gamblers Anonymous, Al-Anon, Alateen. Work adjustment training, work hardening program, work placement, internship program. (See Chapter 17, “Vocational/Academic Skills. ”) Note: ü You may want to create and insert here a reference list of additional or specific services, and their providers, available in your community or system. For a Child: Special Education In-school supportive services for various disabilities/impairments (lists of eligible disabili-ties are readily available online) and of various types (physical support, speech and language support, life skills support, etc. ). Other supportive services: In-home, “cyberschool,” alternative schools, Residential Treatment Facilities, inpatient services, etc.
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22. Recommendations 311RECOMMENDA-TIONSIntensity of services: Itinerant: Special education personnel inside or outside a regular classroom for part of school day. Resource: As above, but provided in a resource classroom. Part-time special education in the regular classroom: Special education services pro-vided outside the regular classroom but in the regular school for most of the day. Full-time special education class: Full-day special education classes with some partici-pation in nonacademic and extracurricular activities inside or outside a regular school. Counseling, medical/psychiatric/medication evaluation/consultation, play and expressive ther-apy, child management skills training, parent-staff conference, social skills training (reme-dial/adaptive/for acceptance), etc. There is endless information on the Internet about educational issues and methods. One good resource on effective practices for children with (and without) disabilities is provided by the National Dissemination Center for Children with Disabilities (www. nichcy. org/Educate Children/Pages ). A good list of modifications can also be found online (www. trumbullps. org/policies/IGBG_modifications. pdf ).
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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31223 Prognostic Statements A model for coming to a prognosis is to list separately and evaluate (1) predisposing factors, (2) precipitating factors, (3) protective factors. 23. 1. General Prognostic Statement This is a general format for a prognostic statement, with blanks to be filled in using the options below: The prognosis for this client's [type of outcome] is [prognosis descriptor]. The course is/is expected to be [course descriptor], because the client is/appears to be [client descriptor]. Types of Outcomes Improvement, full/partial recovery. Employment (competitive/supportive/sheltered workshop), return to original job/alternative work placement at level. Community/family/structured/institutional placement, or other. Prognosis Descriptors (↔ by degree) Excellent/good/positive/uncertain because... (specify)/variable/unknown/guarded/poor/pre-carious/negative/grave/terminal. Course Descriptors (↔ by degree) Benign, acute, waxing and waning, stepwise, fluctuating, with remissions and exacerbations, steady, protracted recovery, chronic, static, intractable, unchanging with or without treat-ment, arduous, declining, worsening rapidly, unrelenting despite our best efforts, malig-nant, fulminating. Client Descriptors (↔ by degree) Recuperating/convalescent, making good progress, reaching a steady state, symptoms continue to disrupt daily functioning, hard to treat, refractory to treatment, suffering from a virulent form of the disorder, failing despite all appropriate treatment. PROGNOSES
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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23. Prognostic Statements 313PROGNOSES 23. 2. Other Statements This client's eventual prognosis for success in later life will be a function of how well the situ-ational demands match his/her individual profile of abilities. The severity and chronicity of her/his symptoms indicate a poor prognosis. His/her course so far has been downhill, and his/her prognosis therefore must be considered negative unless... (specify). This outcome/result of treatment is expected only if (specify) services are received, and prog-ress is expected to be slow and difficult with many reversals. The probable duration of treatment is with these goals of therapy... (specify). The client needs the structure of various social agencies with which she/he is involved. Due to the chronicity of his condition, the present treatment and goals are being maintained. The client reports full/partial/variable/intermittent compliance/adherence with the regimen and/or medications prescribed.
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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31424 Closing Statements 24. 1. Value of the Information I hope this information will be useful to you as you consider this case's/person's/client's needs, and will aid you in your tasks/evaluation/treatment/decisions. I hope this information will be sufficient for you to judge this patient's situation. In the hope that these data will prove of assistance... 24. 2. Thanking the Referrer Thank you for the opportunity/privilege of being able to evaluate your patient/this most inter-esting/challenging/pleasant patient/person/man/woman. We appreciate your sending to us/inviting us to assist in the care of /asking us to see . Thanks again for the opportunity to participate in 's care. Thanks for the chance to help take care of with you. I consider it a privilege to have been able to care for this patient. It goes almost without saying that I appreciate your trust in allowing me to assist in the care of this/your patient. My colleagues and I appreciate... (specify). As always, thank you very much for your kind referrals. 24. 3. Continued Availability I trust that this is the information you desire/require, but if it is not... Please feel free to contact me if I can supplement the information in this report/if other ques-tions or issues arise. Please let me know if you have any other thoughts about this person's condition(s). If there are further questions I may address as a result of/on the basis of my examination of this individual, please contact me at your convenience. I will make myself/am available for further information/consultation regarding this client's needs. With an appropriate release of information, I will be happy to discuss this case further with individuals who are involved with the person's care. If I can be of further benefit to you with this case, do not hesitate to contact me. CLOSING STATEMENTS
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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24. Closing Statements 315CLOSING STATEMENTSIf I can be of any further assistance with reference to this patient's treatment or problem or any patient's treatment, it certainly will be my pleasure to assist you. If clarification is needed, I can best be reached on [days] from to [times] at [phone number]. Should additional examination/evaluation/testing/clarification/information/treatment be needed, I am/am not willing to provide it. I am/am not willing to perform additional examinations/evaluations on this person. I will see this client again in . I am certainly available sooner should problems arise. I remain available to this patient to provide care should it be needed. The client requires no further/active follow-up from our standpoint, but he/she is aware that he/she can contact us should further problems arise. I am returning her/him to your care regarding... (specify). As always, I shall keep you informed of my further contacts with/interactions with/treatment of your patient via/by means of copies of my progress notes, with the patient's full consent. 24. 4. Signature, Etc. Always sign a report with your personal signature, degree, and title, preceded by “Yours truly/Sin-cerely/Respectfully. ” Add any of these statements as appropriate: I authorize that my name may be mechanically affixed to this report. Dictated but not read, to facilitate mailing to you. Typed and mailed in the doctor's absence. If my initials do not follow this sentence, this printed report has not been reviewed/edited by me and may contain errors of typing or words that I would have changed. 24. 5. Disclaimer The reader should understand that this report is based upon all the information available to the writer at the time of this assessment. Other information that may be pertinent but is presently unavailable, or information that may be received after this report is completed, is of course not included. Any such other information that may be supplied to the reader may alter the findings or recommendations in the current report.
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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Part III Useful Resources Part III's Chapters: Page 25. Treatment Planning and Treatment Plan Formats 319 26. Formats for Reports, Evaluations, and Summaries 338 27. Treatments for Specific Disorders and Concerns 345 28. Listing of Common Psychiatric 351 and Psychoactive Drugs 29. Psychiatric Masquerade of Medical Conditions 359
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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319 25 Treatment Planning and Treatment Plan Formats Treatment plans are simply one step in an episode of treatment: Do a comprehensive evaluation; plan treatment thoughtfully; do the treatment consistently, compassionately, and conscientiously; write complete progress notes; evaluate your efforts and outcomes; and write a closing summary. 25. 1. The Flow and Nature of Treatment Planning The sequence of clinical thinking in treatment planning follows four steps: assessment, diagnosis, goals, and only then intervention plans. Treatment planning begins with assessment of the client's presenting problem/C hief Complaint, presenting symptoms, mental status, risks, history (especially of treatment), and expectations of treatment and outcomes. This leads to diagnosis making. Do all of this with the client, ask about all areas of functioning, and prioritize problems jointly and realistically. The planning process then continues with a consideration of outcomes —goals, objectives, and ben-efits. Ask, “If we wish to achieve this goal by this date, what steps need to be taken before then?” Select and prioritize goals. Now planning can proceed to treatment design and selection —the choice of interventions, efforts, methods, and means. Consider the resources available and the limitations imposed by reality, time, finances, etc. (See Section 22. 2, “Treatments of Choice. ”) 25. 2. Some Advice on Writing Treatment Plans Spending the time to develop a plan jointly and collaboratively with the client requires the kind of thoughtful, comprehensive, insightful efforts that will ensure successful therapy. It is not a waste of therapy time but rather a productive focusing of it. A preliminary step could be to list, with the client, the major problems and related effects of these problems on his/her life. Review all the areas of functioning. Then inquire about expectations of treatment and of change for this problem list. Some see goal setting as the client's job, while selecting and implementing the means are the contributions of the therapist/professional. TREATMENT PLANS Much of this chapter is adapted from my book The Paper Office (4th ed. ). Copyright 2008 by Edward L. Zuckerman. Adapted by permission.
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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320 USEFUL RESOURCES TREATMENT PLANSBerg and Miller (1992) offer these criteria for “well-formed treatment goals”: They must be important to the client. They should be concrete, behavioral, and specific [and memorable]. They should focus on the presence rather than the absence of something. They must focus on the first small steps, on what to do first, on a beginning rather than an end. They should be realistic and achievable within the context of the client's life. They should be perceived as requiring “hard work” [like Jay Haley's Prescribed Ordeal Therapy; see Haley (1984)]. A symptom does not have to be absent completely, or for months, in order for a client to demonstrate recovery. It only has to be not significantly interfering with or limiting life func-tions. Treatment planning should logically include the ending of treatment and the client's proceed- ing with her/his life trajectory, which may have been interrupted by the disorder. Therefore, an integral aspect of treatment planning is preparation for ending treatment. Managed Care Organizations may ask what steps have been taken or will be taken to prepare the patient or family for discharge from treatment. Let your writings reflect that you considered all options, rationales, and decisions at each stage of treatment, so that you can review and revise from a solid basis, communicate with peers and patients, evaluate and learn from your outcomes, and protect yourself from mal-practice accusations. In writing plans, you may find yourself struggling between writing a plan that is too specific and will require continual revisions, and a plan that is too general and is an empty exercise because it offers no guidance for treatment. The overly precise plan requires either following it rigidly or constantly revising it in light of the vicissitudes of actual clinical practice. A caution for writing treatment plans: Avoid jargon, especially words understood only by professionals of a particular orientation. MCO reviewers are usually nurses or counselors untrained in more specific techniques and suspicious of ones with idiosyncratic and obscure terminology. Use common-language translations of theory or focus elsewhere. I see writing treatment plans as an ethical as well as a clinical responsibility for us as thera- pists. If we don't write our plans down, our human nature will convince us that we intended to get to wherever we ended up. Treatment plans keep us honest. Much research comparing novices and experts points to the novices' lack of the large internal list of options that experts have developed. Novice treatment planners find it very difficult to design goals and generate methods. Experts may have a parallel difficulty: articulating what has become a “second-nature” understanding of goals and methods. These difficulties have led to the popularity of books and software on treatment planning, but with a little mental effort any clinician can generate perfectly satisfactory plan statements. For more details on how the contents of this book can be of assistance, see the relevant parts of the sections on MCO plans and outcomes, below. 25. 3. Various Formats for Treatment Plans The Tabular Model Each clinician, agency, funder, and monitor seems to have a different preferred format for treatment plans. Many of them use a page turned sideways and divided into columns. If you wish to use this
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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25. Treatment Planning and Treatment Plan Formats 321TREATMENT PLANSapproach, offered below are four commonly used headings for the columns (and some optional oth-ers). For each column heading, I have supplied a series of terms used to express a similar idea. From these, you can choose headings that best fit your way of practicing and your setting. The first column is the “Goal” column. Alternative terms: Problem, Aim,1 Behaviors to Be Changed, Focus of Treatment, Long-Term Goal, Diagnosis- Related Symptoms. The second is the “Outcome” column. Alternative terms: Objective, Subgoal, Outcome Sought/Desired/Expected,2 Observable Indicators of Improvement,3 Symptom-Related Goals, Short-Term Goal, Discharge Level of Problem Behavior, Perfor-mance, Operationalization. The third is the “Intervention” column. Alternative terms: Resources to Be Employed, Methods, Treatments, Means, Strategies, Tactics, Efforts, Inputs. This column should answer these questions: Who is going to do what, where, when, how often and for how long, with whom, and supervised by whom when? The last column is the “Time Frame” column. 4 Alternative terms: Date of Evaluation, Date of Initiation, Target Date, Completion Date, Expected Number of Ses-sions to Achieve Objective, Date of Review/Reevaluation/Progress Evaluation. Other columns may include the following: Intensity, Frequency, Duration of Treatment. Client's Related Strengths or Assets, Degree of Involvement. Liabilities, Resistances/Barriers to Change (in the client or elsewhere). Priorities, Sequence of Objectives. Documentation of Involvement (of client, providers, payors, family, others). Wilson's Social Work Model From social work (Wilson, 1980), this model describes: The ideal means of meeting the needs of this client. What you can do realistically to meet these needs. The client's willingness and ability to carry out these treatment plans. Progress made or not made since the plan was written. What you will now do differently. 1This term is used by Makover (2004). 2Goal A ttainment Scaling is built on rating the expected outcomes. See Kiresuk et al. (1994) and Section 25. 8 below. 3This excellent phrasing was introduced, as far as I know, by Levenstein (1994). 4If you can, write the target for this column in terms of treatment sessions, because clients may miss meetings during a specified time period. Similarly, it is preferable to offer a review date rather than an achievement/completion date.
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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322 USEFUL RESOURCES TREATMENT PLANSThe Analytical Thinking Model Using this model (also described by Wilson, 1980) to think about a client can be a productive exer-cise. 1. Review in your mind everything you know about the case. 2. Make a list of the 10-15 key facts of the case. 3. Imagine what feelings the client might have about his/her situation. a. At whom or what might the feelings be directed? b. Why might he/she feel that way? c. What would be the behavioral manifestations of those feelings? 4. Who are the client's “significant others”? 5. Develop a treatment plan:a. List all the possible outcomes of treatment (whether realistic or not). b. Label each as realistic or not. c. For each realistic goal, list the subgoals or objectives to be achieved, and put them in any necessary sequence. d. State the exact treatment techniques that would accomplish the subgoals. e. Rank the goals in a time sequence so you know where to start. f. Estimate the time needed to achieve each goal. Write a summary of the main thoughts of steps 2 through 4, and discard all the material except this and the lists developed in step 5. A Children's Residential Agency Model Identifying information: Name, date of birth, date of admission, agency, primary worker. Data and needs. 1. Education. 2. Medical/physical. 3. Contacts: Legal, family, etc. 4. Personal development (goals). a. Personal hygiene. b. Peer relationships. c. Adult relationships. d. Group relationships. e. Specialized treatments/therapies/support. f. Specific events. Treatment/program adjustments (to methods). 1. Major incidents. 2. Routine adjustments. 3. Level changes (levels of programming). 4. Attitude and motivation. 5. Target summary (and changes in targets). Family. Multimodal Therapy Model Arnold A. Lazarus (1997) has developed a model of assessment in which treatments of choice (those whose effectiveness for a specific problem has been supported by empirical research) are matched to each problem, analyzed at each of seven levels. The acronym for the levels is BASIC ID. There are no limitations on the methods of treatment that can be used, and so it can fit any paradigm. Proper diagnosis/problem specification is crucial to this model.
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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25. Treatment Planning and Treatment Plan Formats 323TREATMENT PLANSAssessment area/Problematic behaviors Interventions Behavior Affect Sensation Imagery (fantasies, expectations) Cognition (beliefs) Interpersonal relations Drugs/biology (included here are all medical conditions and nutrition, exercise, and hygiene) The Levels-of-Functioning Model Kennedy (2003) offers an inventive, different approach to planning interventions. Using Axis V of DSM-IV-TR (see Section 21. 23), he has built numerous master treatment plans around levels of func-tioning in the seven areas of psychological impairment, social skills, dangerousness, Activities of Daily Living/occupational skills, substance abuse, and medical and ancillary impairments. The Stages-of-Change Model Prochaska et al. (1992) have proposed a set of five stages through which everyone goes when making any kind of behavior change. It addresses a client's readiness or openness to change, with or without professional help. It has been widely used in addictions treatment. Precontemplation No intention to change in the foreseeable future. Client doesn't see that he/she has a problem. In “denial. ” Presenting for treatment due to pressure from others. Contemplation Also known as “ambivalence” because of weighing of pros and cons. Aware of a problem—“Something is wrong. ” Some commitment to action in next 6 months—“Not quite ready. ” Preparation Attempting to put thoughts about change into actions. Some change in behavior (e. g., “cutting down” on substance use, but not abstinent). Cycling in and out of pathological behaviors. Less debate of pros and cons, and more actual decisions or plans. May present for voluntary treatment at this stage. Action More overt behaviors in the direction of change. Some “successes. ” Behavior change (e. g., absti-nence) at least for a period of time, but less than 6 months. Maintenance Behavior change for at least 6 months. Efforts are made to continue the change. In therapy, the goals are stabilizing the changed behaviors and avoiding relapse. The pattern of change is not linear. Some relapses should be expected and planned for. Treatment Implications Treatment must be matched with the client's stage of change, and progress is a function of the pre-treatment stage of change, so some interventions are not appropriate. Treatment should focus on
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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324 USEFUL RESOURCES TREATMENT PLANSthe transition points between stages. Strike (only) while (and where) the iron is hot. Watch out for your countertransference reactions at each stage of change. Change can involve 10 processes: Con-sciousness raising, self-reevaluation, environmental evaluation, self-liberation, counterconditioning, stimulus control, reinforcement management, helping relationships, dramatic relief, and social lib-eration. 25. 4. A Treatment Plan Format for Case Conceptualization Although MCO's demands for oversight and cost containment were the major motivators for for-malizing written treatment plans, they have great value as an aid to case conceptualization. For those who need a brief, checklist-formatted plan, an efficient form can be found in The Paper Office, 4th ed. (Zuckerman, 2008). However, to structure the fuller evaluation of a client's history and situ-ation and assist in comprehensive case formulation, working through Form 2 is recommended. You may photocopy and adapt it for your work with clients without obtaining written permission, but may not use it for teaching, writing, or any commercial venture without written permission. More guidance on treatment plans can be found in The Paper Office. For space considerations, this version eliminates the lines you will need to enter your findings, and it limits the number of responses in each instance to three. Authorization: The Report's Purpose When an MCO Is the Reader Treatment plans are submitted to obtain authorization for reimbursement (payment after delivery) for mental health services. A form such as Form 2 documents the need for mental health services and the plans to deliver them. On the basis of these statements, an MCO will decide to authorize or deny payment for the services of providers. This form is completed at intake and, if treatment is initially authorized, again toward the expiration of the (small) number of authorized sessions (“con-current review”). This micromanagement is still a common format, despite its costs to all involved. See also the comments below under “III. A. Progress in current treatment to date. ” For simplicity, again, the presentation here is confined to the end product—a plan written in a for-mat suitable for and required by MCOs, as illustrated in Form 2. The meanings and rationale of each heading in this form from II onward are discussed below, and advice is offered. II. Case formulation/overview A. Presenting problem(s)/Chief complaint/Chief concern The client comes in with a “complaint” (his/her formulation) or distress (psychic pain), and the clini-cian inquires, tests, weighs evidence, and reinterprets this into a “diagnosis” (in a medical model), a “concern” (in a patient-centered approach), or a “problem” (in common language and MCO terms). For questions to ask, see Chapters 2, “ Mental Status Evaluation Questions/Tasks,” and 3, “Questions about Signs, Symptoms, and Other Behavior Patterns. ” For referral reasons in children, see Chapter 5, “Referral Reasons. ” B. History of presenting problem(s) and current situation Mental health clinicians usually subscribe to an interacting biopsychosocial model for comprehen-siveness, and to a “diathesis (vulnerability) plus stressor (demand for change) yields symptomatic behavior” model to explain abnormal behaviors. All the elements needing clinical attention are conceived of as either stressors, diatheses, or abnormal behaviors. In turn, behaviors may become new stressors.
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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325 [Use the top of this page for your letterhead. ] Individualized Behavioral/Mental Health Treatment Plan This is for Preauthorization for initial certification Concurrent review for reauthorization of care I. Identification Client's name: Soc. Sec. #: ID #: Membership #: Date of birth: Sex: Group name/#: Certificate #: Name of subscriber/member, and address (if other than client): Release-of-records form(s) signed: Yes Not yet II. Case formulation/overview A. Presenting problem(s)/Chief complaint/Chief concern/Reasons for referral or seeking treatment/ crisis(es): Problem Severity1Duration 1. 2. 3. B. History of presenting problem(s) and current situation (precipitants, motivations, stressors and resources/coping skills, comorbid conditions, living conditions, relevant demographics): C. Previous treatments: Name Location/phone Type of services and dates D. Brief summary of abnormal or unusual mental status evaluation results: (cont. ) 1Code for rating the severity of disruption or decreased performance of life routines and personal effectiveness: Mi = Mild, Mod = Moderate, S = Severe, VS = Very severe, or use GAF ratings from Axis V of DSM-IV-TR. TREATMENT PLANS FORM 2. Individualized Behavioral/Mental Health Treatment Plan. Adapted from Zuckerman (2008). Copyright 2008 by Edward L. Zucker man. Adapted by permission in Clinician's Thesaurus, 7th ed., by Edward L. Zuckerman. Permission to photocopy this form is granted to purchasers of this book for personal use only (see copyright page for details).
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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326Individualized Behavioral/Mental Health Treatment Plan (p. 2 of 4) E. Functional limitations and impairments (descriptions and ratings of severity of limitation): 1. Self-care and ADLs— severity1: 2. Academic/occupational— severity1: 3. Intimate relationships/marriage/children/family of origin— severity1: 4. Social relationships— severity1: 5. Other areas— severity1: F. Strengths:1. 2. 3. Code # DSM-IV-TR G. Diagnoses—Current best formulation: Name (indicate which is primary diagnosis with “P”): or ICD? Axis I Axis II Axis III—Significant and relevant medical conditions, including allergies and drug sensitivities: Condition Treatment/medication ( regimen) Provider Status 1. 2. 3. Axis IV—Psychosocial and environmental problems in last year; overall severity rating: Problems with primary support group Problems related to the social environment Educational problems Occupational problems Housing problems Economic problems Health care access problems Other problems: Problems related to interaction with the legal system/crime Axis V—Global Assessment of Functioning (GAF) rating: Currently: Highest in past year: V Codes—Other problems that may be a focus of clinical attention: (cont. )TREATMENT PLANS
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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327 Individualized Behavioral/Mental Health Treatment Plan (p. 3 of 4) H. Current assessment of foreseeable risks: 1. Self-neglect or damage: None Poor self care Significant self-neglect Self-abuse Specifics: 2. Suicide: No evidence Ideation only Plan Intent without means Intent with means 3. Homicide: No evidence Ideation only Plan Intent without means Intent with means 4. Impulse control: Sufficient Inconsistent Minimal Explosive 5. Treatment compliance: Fully compliant Variable Passive noncompliance Resistive 6. Substance use: None/normal use Abusing Unstable remission Dependence 7. Physical or sexual abuse: No evidence Yes Not reportable Date reported: ______ 8. Child or elder abuse or neglect: No evidence Yes Not reportable Date reported: ______ If yes, client is Victim Perpetrator Both Neither, but abuse exists in family 9. If risk(s) exists: Client can cannot meaningfully agree to a contract not to harm self others both III. Treatment concerns A. Progress in current treatment to date—Gains made and current level of severity of problems, reasons for continuing treatment: No treatment yet B. Treatment plan—A recommended program of coordinated liaisons, consultations, evaluations, and treatment services: 1. Based on the current clinical evaluation, these additional consultations or evaluations are necessary: Concern or question Consultant a. b. c. 2. Treatment's objectives and goals: Significant improvement is to be expected, with treatment speci-fied, for: Problem: Behaviors to be changed: Interventions (who does what, how often, with what resources; modality, frequency, duration): Observable indicators of improvement (behaviors, reports): Expected number of visits to achieve each indicator: Discharge level of problem behaviors: Review date: [ü Item 2 is repeated for each additional problem. ] (cont. )TREATMENT PLANS
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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328Individualized Behavioral/Mental Health Treatment Plan (p. 4 of 4) 3. Other current treating professionals: Name Location/phone Treatments provided 4. My signature means that I have participated in the formulation of my treatment plan, that I under-stand and approve of it, and that I accept the responsibility to fully carry out my parts of the plan. Client: Date: ___________ Service provider: Date: ___________ 5. Additional comments, plans, or information:TREATMENT PLANS
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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25. Treatment Planning and Treatment Plan Formats 329TREATMENT PLANSAs a clinician, you can focus on symptoms, complaints, problems, goals, functioning level, behav-ioral excesses and deficits, recovery by stressor reduction, growth and learning to cope, alteration of family dynamics/homeostasis, crisis management, etc. How you understand the problem—its cause, dynamics, and goals— depends on your paradigm and training. C. Previous treatments MCOs want to know about previous treatment so that they may exclude payment for the treatment of preexisting conditions, since as in loco insurers they appear to believe that a previous insurer should pay for services for disorders that continue to exist or have reappeared. Previous treaters are vitally important to you as a clinician for two reasons: (1) Misdiagnosing or mistreating a condition of which you were not aware but should have been (because all good clini-cians always get old records) is a major source of malpractice vulnerability; and (2) you should learn what has and has not worked in the past, in order to make your own treatment more effective. D. Brief summary of abnormal or unusual mental status evaluation results Conducting MSEs is a traditional skill area of clinicians, and you should strive to be a sophisticated evaluator. Here, write a summary of your abnormal findings and disregard all normal findings. Chapter 2 presents the world's largest collection of MSE questions. Chapter 11 offers thousands of descriptors for writing up the MSE. Section 2. 25 offers a form for recording your findings (Form 1). E. Functional limitations and impairments Which areas of function to evaluate and how to label them are controversial topics. For individual clients, you might add or substitute “Affective functioning” (e. g., emotional paralysis from con-tinuing grieving or depression with suicidal preoccupations), “Physical functioning” (e. g., chronic fatigue, dizziness, and incontinence resulting in social isolation), or combinations of these areas. The areas of functioning listed in Form 2 are the only ones of concern to MCOs. If the client has discontinued working, returning her/him to employment is the most valuable service you can pro-vide in the eyes of MCO personnel (who, after all, work for the client's employer). For ADL evaluation, see Chapter 14. For relationships in society, see Chapter 15. For couple and family relationships, see Chapter 16. For the criteria for work or school functioning, see Chapter 17. Legal problems can go under “Social” or “Occupational”; leisure/recreational losses under Other, etc. Do not obsess over the best choice of category for each limitation; it doesn't matter to anyone else. Similarly, the titles of the categories themselves don't matter greatly (“Work,” “Vocational,” “Occupational,” “Employment,” and “Military” are functional equivalents). MCOs are almost uninterested in some clinical areas, such as sexual dysfunctions, traumatic early experiences, and eating disorders, unless they can be shown to have a significant impact on work functioning. MCOs interpret learning disorders and other academic dysfunctions as educational/school problems rather than health problems, and refuse to pay for their assessment or treatment. Only lip service is paid to spiritual/religious, cultural/ethnic, and recreational aspects. A key principle of MCO work is that therapy's goal is just to restore the client to an immediately previous (premorbid) level of functioning. Therapy with any aim higher than recovery to this level (perhaps healthier functioning, understanding, personality change, prevention of relapse, or even reduced costs of further treatment) is simply not the financial responsibility of the MCO.
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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330 USEFUL RESOURCES TREATMENT PLANSI suggest a simple rating scale for severity of impairments. The GAF numbers provide both vague anchors for judgments and the illusion of precision. See Section 21. 23, “Axis V: Global Assessment of Functioning Scale,” for the anchoring statements. F. Strengths We clinicians focus to a great (indeed, excessive) extent on deficits and defects, and yet nothing can be built on deficits or absences. MCOs, the Joint Commission on Accreditation of Healthcare Organizations, and others rightly demand that we consider the client's resources as a foundation for growth and as a font of ideas about previous successes that might be inspirational or repeatable. Therapies such as the “solution-focused approach” and the “miracle cure” deliberately utilize these successes, and you may find that a thorough inquiry into resources makes your job easier. Sections 2. 24 and 19. 1 may help you assess coping ability. See also Section 25. 7, “Checklist of Strengths. ” G. Diagnoses We all know that diagnosis, impairment, and treatment are not tightly related in the mental health area; we don't treat a diagnosis, but a client with patterns and pains. However, the shorthand of a diagnostic label conveys important information about what is and is not present to the profes-sionally educated. MCOs demand that we offer diagnoses based on certain widely acknowledged standards, even when other aspects are the foci of intervention and the diagnoses fail to address interactive or interpersonal aspects. MCOs are also reluctant to pay for treatment of Axis II diagnoses, because they seem to believe that therapy for personality disorders is ineffective. Nevertheless, make sure to record any Axis II con-ditions present. You are not paid by the number of diagnoses, and great precision is not required these days. However, you must be correct, so careful differential diagnosing is required. Morrison (2001, 2006) will teach you all you need to know. Chapter 21 contains almost all of the DSM-IV-TR and ICD-9-CM titles and codes. H. Current assessment of foreseeable risks For their finality, impacts, and legal consequences, homicide, violence, and suicide are risks of greatest concern to both clinicians and MCOs. Of only slightly less concern to MCOs are substance abuse and dependence. Section 12. 40 will help you evaluate suicide potential. Sections 13. 6 and 12. 41 may help you evaluate potential for violence. Form 2 offers simple checkoffs, but if you suspect that any of these risks are of significance or you are unsure and anxious, consult with others and elaborate on your concerns in a narrative. From a malpractice point of view, demonstrating that you were professionally thoughtful before a tragic incident is more important than accurately predicting it (which you generally cannot do). III. Treatment concerns A. Progress in current treatment to date This item is completed when you seek reauthorization for a continuation of your services. These “concurrent reviews” function like progress reports. They do not have to be positive to justify ser-vices, but should be thoughtful. If the client has returned to a previous level of functioning, con-
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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25. Treatment Planning and Treatment Plan Formats 331TREATMENT PLANStinued services will usually be deemed unnecessary, generally without regard to the stability of the recovery. If little or no progress has been demonstrated, you should consider adding treatments (medications, family meetings, drug and alcohol evaluation, psychoeducational community groups) or changing your approach. This is both a financial consideration and an ethical one in the face of little or no progress after sincere and appropriate efforts. B. Treatment plan Chapter 22, “Recommendations,” has a long list of therapeutic services from which to select. 1. ADDITIONAL CONSULTATIONS OR EVALUATIONS Although these questions are often missing from MCOs' forms, it is logical and clinically justifiable to ask them: What else do we need to know, and how can we find this out? MCOs have gutted the assessment function, with the rationale that the treater learns all that is necessary to guide treatment by doing treatment. This is not necessarily the case, nor is it effi-cient. Although testing can be overused, it can still be valuable to know what kind of personality a depressed person has or what other problems are not being currently demonstrated to you during therapy. It is even more clear that treating a person with dementia for depression, no matter how well validated the methods, is unlikely to result in full recovery. I recommend that all therapists learn how to use and interpret at least a few screening tests and whatever instruments they intend to use for outcome assessment. 2. TREATMENT'S OBJECTIVES AND GOALS To conserve space, only one problem is shown on Form 2. As indicated there, you should repeat this format as many times as necessary, based on your conceptualization of the case. Only a few prob-lems should be listed, in order for you and your client to remain focused. Select ones tightly related to the diagnosis and the limitations of function, and present them in order of priority. Behaviors to be changed This is essentially a restatement of the problem in terms of the behaviors demonstrating its dynam-ics—its signs and symptoms or behavioral manifestations. If you can't specify the behaviors, you may need to do a more thorough investigation and interview of the client. But some may remain unarticulated and ineffable. Interventions You can specify interventions by asking yourself questions like these: What approaches have been shown to work for this problem? (See Section 22. 2, “Treatments of Choice. ”) What are you trained to do with these kinds of problems? (If you lack skill in these areas, do not try to fake it. Get training or refer the client. ) What techniques address the symptoms presented? How are these implemented? (How often? For how long? With what tools?) What will you expect your patient to do? Generic, goal-less, unfocused treatment is unethical. Avoid experimental or faddish techniques for most clients, and get fully informed consent. Offer descriptors of the mode of therapy (individual, group, family, etc. ), the orientation or modal-ity (cognitive, interpersonal, psychodynamic, structural, etc. ), and specific techniques (“hot seat,” “covert sensitization,” “relapse prevention”). Indicate the clinical focus of these, such as “traumatic experiences in marriage” or “depressogenic thought patterns. ” MCOs seem fond of interventions with low or no costs to them. Try to include (where appropriate) community support groups, psychoeducational efforts by others, bibliotherapy, etc.
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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332 USEFUL RESOURCES TREATMENT PLANSGoals You may have noticed that there is no heading “Goals” on Form 2. That is deliberate. Instead, the form offers “Observable indicators of improvement” and “Discharge level of problem behaviors,” both of which are more easily understood and stated than the more popular “Goals. ” However, for generalizability, I use the word “goal” in the discussion to follow. Goals are usually understood as long-term destinations, and objectives are the steps needed to reach those goals. But because there is no agreement in the field over the exact meaning of objec-tives, you need not be precise in differentiating them from goals. Objectives are usually more behavioral and concrete than goals. Objectives are also shorter-term and more easily measurable. They are usually described in terms of the client's performance (“The client will be able to... ”). Identifying long-term goals or changes makes little sense when treatment will be limited to 10-12 sessions. Much effort has been spent in distinguishing goals from objectives, describing the actions of therapy as methods, and devising ways of articulating measurable outcomes. We clinicians have usually been more anxious and precise than is necessary. Take a problem, consider how it might change with therapy, and then state some goals. Observable indicators of improvement Being able to assess change is absolutely crucial. Write desired outcomes in behavioral language. This means what a camera would see (actions and expressions), not the invisible emotions, cognitive processes, history, and intentions. Consider the manifestations of these, and not your well-trained formulations and shorthands for them. Avoid very broad terms like “communication skills” or “depression,” because the client and reviewer will not be able to know what counts as change. Tie each indicator of change (objective or step toward the goal or longer-range outcome) to the presenting limitations of function. Make these observable objectives measurable or at least quantifiable. Frequency, duration, intensity, and latency are the classic dimensions for describing changes in symptomatic behaviors. This objectification allows impartial evaluation. Avoid steps of change that are too difficult (so as not to reinforce failure, anxiety, or low confi-dence) or too easy (so as to make reaching them irrelevant and unmotivating) to achieve. Because you cannot observe the client in her/his life circumstances, accept and use “client reports” of the new behaviors, as necessary. It would be best if you could get confirmation of changes from someone else who observes the client frequently (this person, you, and the client would then create an elegant “triadic” assessment). Expected number of visits to achieve each indicator You may notice that no time frames or dates are offered, because sessions may be missed or other issues may arise. Besides, payment is based on services rendered, not calendar time. Discharge level of problem behaviors This is another way of saying “long-term goals,” but for MCOs it is the criterion of recovery of func-tion. There is no specific mention here of dates for evaluation of progress or more formal reevalu-ations of the client's status, which would normally be part of the treatment plan. 3. OTHER CURRENT TREATING PROFESSIONALS You need this information to coordinate treatment; to prevent the loss of information crucial to your or another's treatment of the client (e. g., side effects of medications); perhaps to receive medi-
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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25. Treatment Planning and Treatment Plan Formats 333TREATMENT PLANScal oversight to treat a client; to indicate supervision; to reduce duplication of services; to obtain backup in an emergency; to consult in regard to problems; etc. 4. My SIGNATURE MEANS... Fully informed consent is an ethical necessity. Treatment is seen more these days as a contractual arrangement between a capable client and a professional, and not as a process taking place between a passive patient and an active expert. If treatment is a shared adventure, both parties must know about and voluntarily agree to it. It may be very therapeutically productive to share the planning with the client, and not to treat this document as simply a burden required for payment. 5. ADDITIONAL COMMENTS, PLANS, OR INFORMATION This is self-explanatory and is included mainly to remind you of any other less tidy details. 25. 5. Treatment Plan Components for Clients with Substance Abuse See also “Responses to Treatment” under Section 12. 39, “Substance Use, Abuse, and Dependence. ” The lists below of goals and methods are derived from statements from the literature and are designed to be comprehensive but not exhaustive. They should, of course, be tailored to each client. Treatment Goals Abstinence: Obtain and maintain sobriety, live a chemical-free life, cope with life without chemicals. Controlled drinking: Follow patterns of use that reduce harm. (See below. ) Stabilize one's health, finances, vocation/school, employment, living arrangements. Complete a physical examination as prescribed, and comply with medical advice. Enhance health and fitness. Get medical checkups. Take medications as prescribed; report on adherence to regimen/schedule, effectiveness, and side effects. Resolve and avoid legal problems. Develop sober leisure skills. Stabilize one's intimate relationships, marriage, family. Include significant others such as spouse/partner, children, relatives, friends, etc., in the recov-ery program as prescribed. Improve social skills, assertiveness, emotional expression, communication. Improve social support, friendships, social pursuits. Deal/cope with/resolve emotional problems/feelings such as rejection, depression, unresolved grief/mourning, shame, guilt, abandonment. Improve coping skills, stress management skills, relaxation abilities, self-control. Enhance self-esteem, confidence, and self-acceptance. Accept responsibility for the consequences of one's behavior. Improve problem-solving ability, setting of priorities, persistence, frustration tolerance. Be an active participant in the treatment program by attending/participating in: Scheduled education classes about chemical dependency and the process of recovery. Scheduled counseling, psychotherapy, and educational groups (e. g., spirituality groups, men's and women's groups).
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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334 USEFUL RESOURCES TREATMENT PLANSRecreational activities to expand pleasures of physical activity, healthy competition, skill acquisition, socializing, interest areas, etc. Alcoholics Anonymous/Narcotics Anonymous/etc. groups to develop a sober support fel-lowship in the community. The design and carrying out of a discharge plan that includes plans for employment, a place to live, sobriety. Become a sponsor, substance educator, role model. Offer and receive effective constructive feedback in groups. Assume leadership roles in the community. Methods Education Learn about the following (alternate phrasings can include “be exposed to,” “understand,” “appreciate,” “apply,” and “explain”):The disease concept of addiction. The consequences of accepting one's identity as having alcoholism/drug abuse. Cross-addiction, multiple addictions, dual diagnoses. Addictive behavior not involving chemicals, etc. The nature and processes of addiction and recovery. The issues of dysfunctional families, codependence, Adult Children Of Alcoholic Parents, cycles. Write and share one's chemical history, the progression of addiction, and the consequent prob-lems. Read recommended books and discuss their contents. Therapeutic Activities Define, in one's own words, all the words in one of the Twelve Steps. Interview five peers on powerlessness, their understanding of the Twelve Steps, etc. List five examples of one's personal unmanageableness. Identify specific negative consequences of one's substance use. Keep a “feelings journal” and make at least two entries a day. Interview counselors on how to deal with anger. Interview peers about a positive and a negative quality of oneself. Write a “feelings letter” to one's parents (about feelings of inadequacy, history of emotional/ physical/sexual abuse or neglect, abandonment, etc. ). Identify and practice other ways to achieve the benefits previously obtained from substance abuse. List five things to be grateful for each day. Therapeutic Planning Prepare an aftercare plan, including a daily plan, home group meetings, and attendance at (#) of meetings per week for a total of (#) meetings/weeks/days. Prepare a plan to cope with typical triggers of relapse: Hungry, Angry, Lonely, Tired. For more triggers, see a fine list online (www. psychpage. com/learning/library/assess/relapse). Relapse prevention (Marlatt & Donovan, 2005): Learn about the abstinence violation effect statements and develop counters to these; identify high-risk situations, warning signs, and triggers; rehearse coping responses; write a relapse prevention plan for oneself; teach relapse prevention to others.
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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25. Treatment Planning and Treatment Plan Formats 335TREATMENT PLANSDevelop multiple alternatives to chemical use for high-risk situations (e. g., recreation skills, time management planning, calling on one's support system); use Stress Inoculation Train-ing (Meichenbaum, 1996). Learn and utilize harm reduction approaches (Marlatt, 1998; Denning, 2000; and Tatarsky, 2002). 25. 6. Treatment Plan Components for Crisis Interventions Acknowledge/appreciate/validate/take seriously the subject's distress. Encourage ventilation of feelings. Reassure subject/family of your continued availability. Reinforce/support all positive responses. Reinforce/support problem-solving efforts. Offer alternative methods of coping. Negotiate a contract of not doing anything to worsen the situation for a period of time. Negotiate what to do during periods when feeling bad. Provide assured and continual support. 25. 7. Checklist of Strengths Partly in reaction to the pathology-based focus of most clinical work, the search to articulate, evalu-ate, and build upon the strengths of humans has gained momentum in recent years. See especially Peterson and Seligman (2004) and two websites (www. ppc. sas. upenn. edu and www. authentichappiness. com). Related terms worth researching include these: Resilience, posttraumatic growth, wellness, competence, human strengths, protective factors, optimism, empowerment, self-efficacy, salutogenesis. Social/Community Has multiple, extensive, and accessible support systems. Productive member of viable groups or communities. Has endeared self to a large number of people and enjoys their company quite frequently. Has long-term relationships; a supportive, capable partner/spouse, relatives, close friends. Social life remains intact. Pursues justice/fairness, is brave/courageous. Interpersonal Socially skilled/competent, intelligent, popular, likable, works on a team. Assertive, strong, powerful, dominant, acts as a leader, decisive. Respectful, tolerant, offers and accepts feedback. Friendly, comfortable, outgoing, extroverted, has good sense of humor, playful, shares, helpful. Socially sensitive, aware of own impact on others, empathetic, good listener, concerned for others, compassionate. Sensitive to the examiner's needs and the social demands of the examination. Supports/provides for others, nurturing, generous, kind, loving, merciful, forgives appropri-ately. Maintains appropriate boundaries, prudent, cautious, discreet.
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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336 USEFUL RESOURCES TREATMENT PLANSOccupational/Educational Good adjustment, normal, well adjusted, happy, satisfied. High task motivation, ambitious, hard-working, persistent, diligent, industrious, school/career success, skilled at problem solving. History of triumphs over challenges, nonavoidance/counterphobic, coped effectively with losses, benefited from previous counseling, no substance abuse. Consistent employment/vocation/career. Has adequate income, financial resources, savings, insurance. Manages finances well. Knowledgeable, well-informed, loves learning. Personality Shows integrity/honesty, trustworthy, accepts responsibility for own behavior, dependable, reliable, stable. Resilient, hardy, coping skills, adaptable, flexible, able to self-correct. Self-confident and has self-esteem, accurate self-perceptions, positive self-regard. Can attend/concentrate/focus for long periods. Can recall well. Spiritual, has religious faith, hopeful, optimistic, attitude of gratitude, thankful. Understands interactions of cognitions, affects, and behaviors, understands own motivations, insightful, psychological-minded, sophisticated. Curious, rational, skillful, intellectually competent, flexible. Creative, imaginative, ingenious, inventive, artistic in any medium, talented, appreciates beauty and excellence, feels awe. Wise, has good judgment, keeps perspective, good reality testing, accurate appraisal of demands, realistic, open-minded. Affective Aware and comfortable with feelings in self and others, expressive, shows a range of affects. Self-disciplined/regulated/controlled, modulates impulses, thinking and feeling are inte-grated. Tolerates painful emotions. Emotionally intelligent. Has zest and enthusiasm. Physical Healthy, energetic, vital. Has stamina, athletic, exercises. Sleeps well, good hygiene, satisfying recreation, sexually satisfied. Adapts to physical limitations and losses. 25. 8. Outcome Measures/Goal Achievements The evaluation of the effects of one's work is a professional and ethical as well as a scientific obliga-tion. As part of the privilege of being in clinical practice, we owe our current and future patients the most effective care, and we owe ourselves the feedback to guide the development of our skills. For the clinician who wishes to evaluate his/her own practice, much guidance is available in Clement (1999), Wiger and Solberg (2001), and Ogles et al. (2002). An example of a comprehensive package is OQ-Analyst from OQ Measures (www. oqmeasures. com/site).
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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25. Treatment Planning and Treatment Plan Formats 337TREATMENT PLANSMany aspects of treatment can be evaluated. Clients and MCOs focus most on the goal of symp-tom reduction. This book contains much detail about particular symptoms from which to develop goals: Emotional/affective symptoms are presented in Chapter 10, cognitive ones in Chapter 11, personality disorder symptoms in Chapter 13, and most of the other symptoms in Chapter 12. In addition, Chapter 5, “Referral Reasons,” describes many symptomatic behaviors. Use the index for more specific areas. For the goals of increasing functionality, Chapter 14 covers ADLs, Chapter 15 social/community functioning, Chapter 16 relationships, and Chapter 17 vocational and academic functioning. Common Foci of Outcome Evaluations Clinicians and MCOs define outcomes from very different perspectives. Clinicians tend to focus on building realistic self-esteem; providing a supportive context for the exploration of feelings/ history; bolstering defenses and preventing further decompensation; improving insight; increasing behavior controls, coping skills, and the tolerance of stressors at work/home; improving sexual adjustment; etc. The most common focus of MCOs is client satisfaction with services. This has most often been defined in its more easily measured but less clinical aspects, such as physical accessibil-ity, scheduling/availability, comfort of setting, etc. More recently, MCOs have been asking clients whether they would return for care or recommend the service to another, about their comfort with level of autonomy/control, and about their relationship with the providers (including respect, trust, competence, availability, etc. ). Obviously, these additional factors are difficult to assess, and so the measurements are open to interpretation. The larger picture of assessing the role of therapy in improving the quality of life; reducing other health care costs; lengthening lifespan; and increasing human happiness, satisfaction, and produc-tivity has yet to be addressed by MCOs. However, Frisch (1999) has made an excellent start. Goal Attainment Scaling The strengths of GAS, a little-known method for assessing outcomes, are its simplicity and flex-ibility: Any kind of goal, in any paradigm, in any area, with any definition can be used. All that is needed is the ability to specify five levels of outcome (least favorable likely outcome, less than expected, expected, more than expected, and most favorable likely outcome), in observable terms, for each of at least five goals. Each level is given a relative weight. At review time the current status of each goal is assessed, and a simple mathematical formula determines the success of the interven-tion. For more information, see Kiresuk et al. (1994).
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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33826 Formats for Reports, Evaluations, and Summaries This chapter offers templates, formats, or outlines for many kinds of reports to organize and convey your information for specific audiences or purposes. Although neuropsychological, forensic, devel-opmental, vocational, rehabilitation, and some other specialized psychiatric nursing and psychoso-cial evaluations are beyond the scope of this book, you will find guidance here for common reports and some examples of uncommon but heuristic alternatives. 26. 1. A Standard Format for Reports of Evaluations The sequential structure of Part II of this book can be used. (See also Table 1 in “Getting Oriented to the Clinician's Thesaurus. ”) Use your agency's letterhead, or your own letterhead with credentials of relevance. Give the title or type of report as the heading. Then provide the following: Name of person to whom report is being sent. Name of subject of report; case/identification number; subject's gender and age. Date(s) of examination(s) and report. Evaluator's name (if not the same as the name on the letterhead). A report should meet the needs of the reader, not the writer. The 12 content areas below, with my specifics, are recommended by Rivas-Vasquez et al. (2001) for the initial evaluation. You should select from these and expand on the ones most relevant to the purpose and audience of your report. 1. Identifying information. 2. Chief Complaint or Concern. In the client's language. Referral source and reason. 3. History of present illness. Symptoms, treatments, conflicts. 4. Medical history. Conditions, medications, treatments, treaters, nutrition. 5. Prior psychiatric history. 6. Substance abuse history. 7. Family psychiatric and substance abuse histories. FORMATS FOR REPORTS
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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26. Formats for Reports, Evaluations, and Summaries 339FORMATS FOR REPORTS 8. Psychosocial history. Traumas, educational and vocational functioning, legal issues. 9. Mental Status Examination. Appearance, behavioral observations. Mood and affect. Cognitive functioning. 10. Psychometric data base (when applicable). Summary of findings. 11. Diagnostic impression. Case formulation/summary. Reliability or cautions. Diagnoses. 12. Treatment plan or recommendations. Referrals. Resources. Motivation and barriers. Rivas-Vasquez et al. (2001) state: “The outline presented above is intended to allow clinicians to structure the documentation of the initial diagnostic evaluation in order to produce a clinical and legal record that can attest to the work that was performed. It will also serve to outline the psycholo-gist's diligence and thoroughness, serve as a communication between health care providers, and satisfy reimbursement requirements for third party payers” (p. 199). In a follow-up, Lewis (2002) points out that since the purposes of consultations differ, so should the content of reports, and that most often a limited number of the items listed above is more appropri-ate. He adds that the accepted practice in a given setting shapes the content. 26. 2. Format for Psychodynamic Evaluations: Developmental Model Huber (1961) offers an outline for what he calls the “sequential report,” which combines the chron-ological (to understand causation) with the topical (to understand the presentation) and frames the questions of dynamics. 1. Intellectual functioning. Level of present functioning, comparison with his/her group. Level of capacity. Reasons for failure to function up to capacity. Areas of strength and weakness. 2. Dynamics. What is he/she attempting to accomplish with her/his present mode of behavior?What thoughts and feelings is she/he having?What events or people produce conflict? Anxiety?Major and minor conflicts. People with whom the conflicts are manifested. Times and places where the conflicts arise. How did her/his present situation arise? What pressures and supports were given by significant figures? What was the sequence of learning the defenses, symptoms, adaptations, etc. ? 3. Methods of handling conflicts. Overt behavior manifesting anxiety, defense mechanisms, symptoms. 4. Strengths and weaknesses in relation to goals. Needs and wishes, both manifest and latent. Strengths for pursuing them: What are the pressures, supports, and strengths (environmen-
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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340 USEFUL RESOURCES FORMATS FOR REPORTStal and intrapsychic) that can change her/his life? Weaknesses: What can produce dangerous and/or crippling behaviors (suicide, psychotic reactions, psychosomatic difficulties, antisocial acts)? What does she/he need to function more effectively? How much impairment is there? What is the nature of the impairment? 5. Recommendations. Therapy/no therapy, environmental change. Form(s) of therapy. Predictions about therapy. 26. 3. The Psychodynamic Diagnostic Manual The PDM (PDM Task Force, 2006) represents the most sophisticated, comprehensive, research-based, current, psychodynamic approach to case conceptualization. Using it allows integration of symptoms and personality with functioning and adaptability. Codes and descriptions for adults are assigned along three axes: Personality type and dynamics; Mental functioning and adaptability; and Symptom patterns that address the person's subjective experiences. There are equivalent axes for children and adolescents; the P, M, and S codes are used with the suffix CA. For infants and young children, there are additional codes addressing Interactive disorders, Regulatory-Sensory Processing disorders, Neurodevelopmental disorders, and other patterns appropriate for their life stages. These diagnoses have multiply supported causative, functional, and treatment implications, as described in the PDM. (See also R. Gordon, 2010. ) 26. 4. Themes for Evaluations from an Existential Perspective Enhancing the capacity for self-awareness so as to make choices and live more fully. Acceptance of responsibility: Because we are free to act, we must accept responsibility for our actions. We cannot change without accepting this responsibility. Striving for an identity from within rather than based on others' expectations. The continuous search for the meaning of one's life: “What do I want from this life? Where is my source of meaning?” Acceptance of anxiety as a normal, inescapable part of living. Fuller awareness of death and nonbeing. 26. 5. Adlerian Evaluations1 Life Style Analysis Activity level and radius: Friendships, social life, occupation, recreation, love, and sex. Degree of cooperation and social interest: Thinking about needs and feelings of others, actions to help others. Courage and conquests. Discouragements and stopping points. Excesses and omissions. Level and type of intelligence. Emotions and feelings: Conjunctive and disjunctive, depth and range. 1These are courtesy of Henry T. Stein, Ph D, of San Francisco, CA.
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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26. Formats for Reports, Evaluations, and Summaries 341FORMATS FOR REPORTSScheme of apperception: Antithetical scheme of apperception, perceived minus and plus situ-ations. Use of capabilities: Intelligence (social purpose), abilities and talents (socially useful and use-less), feelings and emotions (move ahead or stop), and memory and imagination (encour-agement/discouragement). Pattern of dealing with tasks and difficulties: Childhood prototype, adolescent experimentation, repetitive adult style. Inferiority feelings, compensatory goal, and style of life: Inferiority feelings (what to avoid, painful insecurity); fictional goal of superiority (imagined compensation, security and suc-cess); style of life (how to get to goal and deal with life's major tasks: social relationships, occupation, love, and sex); connection of presenting problem with life style and goal; use of symptoms to excuse avoidance of normal tasks. Theory Interpersonal focus: Social beings moving through and interacting with their environments. Goals of psychotherapy: Expansion of the individual, self-realization, enhancement of social interest, enhancement of choices (ability to choose to shape the internal and external envi-ronment, and to choose posture adopted toward life's stimuli). Terms and Concepts Inferiority, superiority, and their complexes. Compensation, overcompensation. Life style, style of life. Confluence and transformation of drives. Masculine protest. Fictionalism, fictional finalisms. Striving for perfection, self-enhancement. Social embeddedness, social interest. Early/first recollections. 26. 6. Transactional Analysis2 Almost all clinical models examine only the individual. Eric Berne's (1964) TA combines interac-tional and psychodynamic perspectives. Ego states: Parent, Child, Adult; contaminations, exclusions; critical, nurturing; defining/struc-turing. Adapted Child, Natural Child, Little Professor. Strokes: Stroke Economy, Stroke Hunger, for being/doing, conditional/unconditional, dis-counting, compromise. Transactions: Complementary, crossed, ulterior, congruent, angular, duplex. Relationships: Companionate, intimate, symbiotic. Scripts, counterscript, script injunction, positive script decisions, messages. Ways of structuring time: Withdrawal, intimacy, ritual, activities, pastimes, games, rackets. Pastimes: PTA, Psychiatry, Small Talk (General Motors, Who Won?, Grocery, Kitchen, Wardrobe, How To?, How Much?, Do You Know?, Ever Been?, What Became Of?, Morning After, Martini). 2Resources for TA materials include these: For information, International Transactional Analysis Association, 436 14th St., Suite 1301, Oakland, CA 94612-2710; (510) 625-7720; www. itaa-net. org.
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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342 USEFUL RESOURCES FORMATS FOR REPORTSGames: Degrees of games: Hard, soft, ulterior transactions. Elements of games: Steps, Gambits, Moves, Payoffs. Types of games: Alcoholic games: Roles for the game of Alcoholic include Alcoholic, Patsy, Connection, Rescuer, Persecutor. (Variations of this game include Drunk and Proud; Lush; Wino; High and Proud; etc. —for these and other games people with alcoholism play, see Steiner, 1971. ) Marital games: Corner; Courtroom; Frigid Woman; Frigid Man; Harried; If It Weren't for You; Look How Hard I've Tried; Sweetheart. Sexual games: Let's You and Him Fight; Perversion; Rapo; Stocking Game; Uproar. Party games: Ain't It Awful; Blemish; Schlemiel; Anti-schlemiel; Why Don't You-Yes, But; You Got Me into This; You Got Yourself into This; There I Go Again. Underworld games: Cops and Robbers; How Do You Get Out of Here; Let's Pull a Fast One on Joey. Consulting room games: Greenhouse; Stupid; Wooden Leg; Do Me Something; Indigence; Peasant; I'm Only Trying to Help You; Psychiatry. Good games: Busman's Holiday; Cavalier; Happy to Help; Homely Sage; They'll Be Glad They Knew Me. Other games: Kick Me; Harass; I Am Blameless; NIGYSOB (Now I've Got You, Son Of a Bitch); See What You Made Me Do; Debtor; Creditor. Rackets: Stamp Collecting, Nobody Loves Me. 26. 7. Nursing Diagnoses and Treatment Planning3 Each profession approaches the facts of abnormal behavior from its own perspective, history, and traditions. Many clinicians are surprised to find that nursing thinks clearly and comprehensively (nursing diagnoses—NANDA International, 2003) and productively (nursing care plans) about psy-chological conditions, and that many nurses are trained and certified as psychiatric specialists. The basic psychiatric credential is Certified Specialist, which requires 2 years of supervised practice beyond the Master of Science in Nursing level. With courses in medication, etc., nurses are called Advanced Practice Registered Nurses and can prescibe in 42 states as of late 2009. Nursing diagnoses tend to be quite behavior specific and can add “potential for” additional behav-iors of concern, such as suicide or substance abuse. 26. 8. Vocational and Nonclinical Personality Evaluations Huber (1984) quotes these skeletal industrial/organizational report outlines: From Roher, Hibler, and Replogle: 1. Intelligence. 2. Emotional control. 3. Skill in human relations. 4. Insight and self-criticism. 5. Organization and planning ability, direction of others. 6. Recommendations and prognosis (for candidates) or conclusions and prognosis (for noncan-didates). 3I am most grateful to Patricia Hurzeler, MS, APRN, CS, of Bloomfield, CT, for these suggestions.
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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26. Formats for Reports, Evaluations, and Summaries 343FORMATS FOR REPORTSFrom Fear (1958): 1. Test results: Mental ability, numerical ability, verbal ability, clerical aptitude (or other appro-priate testing), social intelligence. 2. Evaluation: Work history, education and training, early home background, present social adjustment, personality, motivation, and character. 3. Summary of assets and liabilities. 4. Summary. From Richardson, Bellows, Henry, and Co. : 1. Intellectual functioning. 2. Relations with others. 3. Work characteristics. 4. Aspirations and drive. 5. Interests and values. 6. Personal adjustment. 7. Family background. 8. Potential and recommendations. Huber (1961) also suggests asking the reader or recipient of the report these questions: “Describe the characteristics of the most satisfactory/ideal candidate in this job. ” “What characteristics of this person stand in the way of your hiring him/her without any hesita-tion?” “What specific questions keep coming into your mind about this candidate?”“What do you not want to see in a candidate for this job?” 26. 9. Formats for Therapy Notes First decide on the answers to these questions: (1) To/for whom am I writing? (2) For what purpose am I making these notes? (3) What is my system for recording data? Include the content (facts, actions, words) and some interpretations, and keep these distin-guished. There is no universally accepted standard for therapy notes, and it appears that the H ealth Insur-ance P ortability and Accountability Act of 1996's rules will become the default for most records. HIPAA delineates “P sychotherapy Notes” whose content excludes medication prescription and monitoring, as well as these elements of the counseling session: starting and stopping times, the modalities of treatment (individual, family, etc. ), the frequency of sessions, and summaries of the following: symptoms, diagnosis/es, the treatment plan, functional status, progress to date, progno-sis, and results of clinical tests. By default, the items just mentioned become the elements of what are customarily called “Progress Notes. ” Simply, the Progress Notes can be, under HIPAA, released to other Covered Entities (other treaters, insurance companies, and billers) for almost any purpose. In contrast, PNs are for the personal use of the clinician and are not to be released, so they are the place for speculations, discussions with oneself, comments on the relationship, etc. HIPAA-defined PNs need not be kept (or at least not on every patient), but should be clearly marked as protected by or compliant with HIPAA to prevent their accidental unauthorized release. The mechanics of implementing HIPAA are complex, and so you might want to look into Zuckerman (2006; see also www. hipaahelp. info ). See also Zuckerman (2008) for guidance, forms, and examples of formats, and Wiger (1998) for suggestions and examples of good and bad notes.
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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344 USEFUL RESOURCES FORMATS FOR REPORTSA Simple Format Huber (1961) suggests this format. The tips in brackets indicate my way of noting various ele-ments. Content (or behavior): What each did and said. [I record these with no modifiers. ]What the therapist thought and felt about the content and may have said to the patient. [I put these in parentheses. ] What the therapist thought and felt about the patient, the interview, the content—and probably did not tell the patient. [I put these comments in square brackets, along with my observa-tions and hypotheses about games played, emotional and cognitive styles, etc. ] Outside: Anything bearing on the therapy that happened outside the interview. Menninger (1952) adds to this: Compliance with the therapeutic program, steps taken to overcome the patient's resistance and who took them, telephone calls, consultations with colleagues and the results. Plans for the next interview (promises made, what to pursue, questions). [I use the headings “HW” for work to be done by either of us, and “RX” for topics to be followed up. ]
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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345 27 Treatments for Specific Disorders and Concerns This chapter is a listing of resources on treatments for many of the disorders and concerns discussed elsewhere in this book. 27. 1. Abuse/Aggression/Violence/Impulsive Behaviors Deffenbacher, J., & Mc Kay, M. (2000). Overcoming situational and general anger (2nd ed. ). Oakland, CA: New Harbinger. Dutton, D. G. (2007). The abusive personality: Violence and control in intimate relationships (2nd ed. ). New York: Guilford Press. Gottlieb, M. M. (1999). The angry self: A comprehensive approach to anger management. Phoenix, AZ: Zeig, Tucker. Kassinove, H., & Tafrate, R. C. (2002). Anger management: The complete treatment guidebook for practitioners. San Luis Obispo, CA: Impact. Webster, C. D., & Jackson, M. A. (Eds. ). (1997). Impulsivity: Theory, assessment, and treatment. New York: Guilford Press. A guide to domestic violence: Risk assessment, risk reduction, and safety plan. Retrieved from www. police. nashville. org/ bureaus/investigative/domestic/stalking. asp. Violence Against Women Online Resources. Available at www. vaw. umn. edu. 27. 2. Anorexia Nervosa and Bulimia Nervosa Fairburn, C. G. (2008). Cognitive behavior therapy and eating disorders. New York: Guilford Press. Grilo, C. M., & Mitchell, J. E. (Eds). (2009). The treatment of eating disorders: A clinical handbook. New York: Guilford Press. Le Grange, D., & Lock, J. (2007). Treating bulimia in adolescents: A family-based approach. New York: Guilford Press. Lock, J., Le Grange, D., Agras, W. S., & Dare, C. (2001). Treatment manual for anorexia nervosa: A family-based approach. New York: Guilford Press. Werne, J. (1996). Treating eating disorders. San Francisco: Jossey-Bass. Gurze Books is a publisher that specializes in eating disorders. Available at www. bulimia. com. SPECIFIC DISORDERS
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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346 USEFUL RESOURCES SPECIFIC DISORDERS27. 3. Antisocial Personality Disorder Hervé, H., & Yuille, J. C. (Eds. ). (2007). The psychopath: Theory, research, and practice. Mahwah, NJ: Erlbaum. Reid, W. (Ed. ). (1986). Unmasking the psychopath: Antisocial personality and related syndromes. New York: Norton. 27. 4. Anxiety Disorders See also Sections 27. 15, “Obsessive-Compulsive Disorders,” 27. 17, “Phobias,” and 27. 18, “Post Traumatic Stress Disorder. ” Butler, G., Fennell, M., & Hackmann, A. (2008). Cognitive-behavioral therapy for anxiety disorders: Mastering clini-cal challenges. New York: Guilford Press. 27. 5. Asperger Syndrome Gaus, V. L. (2007). Cognitive-behavioral therapy for adult Asperger syndrome. New York: Guilford Press. 27. 6. Attention-Deficit/Hyperactivity Disorder Barkley, R. A. (2005). Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment (3rd ed. ). New York: Guilford Press. Barkley, R. A., & Murphy, K. R. (2005). Attention-deficit hyperactivity disorder: A clinical workbook (3rd ed. ). New York: Guilford Press. Barkley, R. A., Murphy, K. R., & Fischer, M. (2008). ADHD in adults: What the science says. New York: Guilford Press. Du Paul, G. J., & Stoner, G. (2003). ADHD in the schools: Assessment and intervention strategies (2nd ed. ). New York: Guilford Press. Goldstein, M. (1998). Managing attention deficit hyperactivity disorder in children: A guide for practitioners (2nd ed. ). New York: Wiley. Tuckman, A. (2007). Integrative treatment for adult ADHD: A practical, easy-to-use guide for clinicians. Oakland, CA: New Harbinger. 27. 7. Bipolar I Disorder Basco, M. R. (2006). The bipolar workbook: Tools for controlling your mood swings. New York: Guilford Press. Basco, M. R., & Rush, A. J. (2005). Cognitive-behavioral therapy for bipolar disorder (2nd ed. ). New York: Guilford Press. Frank, E. (2005). Treating bipolar disorder: A clinician's guide to interpersonal and social rhythm therapy. New York: Guilford Press. Lam, D. H., Jones, S. H., Hayward, P., & Bright, J. A. (1999). Cognitive therapy for bipolar disorder: A therapist's guide to concepts, methods and practice. New York: Wiley. Bipolar (manic-depressive) disorder. Retrieved from www. psycom. net/depression. central. bipolar. html. 27. 8. Body Dysmorphic Disorder Phillips, K. (2009). The broken mirror: Understanding and treating body dysmorphic disorder (rev. and expanded ed. ). New York: Oxford University Press. Wilhelm, S. (2006). Feeling good about the way you look: A program for overcoming body image problems. New York: Guilford Press. Zerbe, K. J. (2008). Integrated treatment of eating disorders: Beyond the body betrayed. New York: Norton.
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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27. Treatments for Specific Disorders and Concerns 347SPECIFIC DISORDERS27. 9. Borderline Personality Disorder Layden, M. A., Newman, C. F., Freeman, A., & Morse, S. B. (2002). Cognitive therapy of borderline personality disorder. Boston: Pearson, Allyn & Bacon. Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press. 27. 10. Dementia Zarit, S. H., & Zarit, J. M. (2007). Mental disorders in older adults: Fundamentals of assessment and treatment (2nd ed. ). New York: Guilford Press. 27. 11. Dissociative Identity Disorder Krakauer, S. (2001). Treating dissociative identity disorder: The power of the collective heart. London: Routledge. Putnam, F. W. (1989). Diagnosis and treatment of multiple personality disorder. New York: Guilford Press. Spira, J. L. (Ed. ). (1996). Treating dissociative identity disorder. San Francisco: Jossey-Bass. 27. 12. Dual Diagnosis Evans, K., & Sullivan, J. M. (2001). Dual diagnosis: Counseling the mentally ill substance abuser (2nd ed. ). New York: Guilford Press. Mueser, K. T., Noordsy, D. L., Drake, R. D., & Fox, L. (2003). Integrated treatment for dual disorders: A guide to effective practice. New York: Guilford Press. Watkins, T. R., Lewellen, A., & Barrett, M. C. (2000). Dual diagnosis: An integrated approach to treatment. Thou-sand Oaks, CA: Sage. 27. 13. Gambling, Pathological Ciarrocchi, J. W. (2002). Counseling problem gamblers: A self-regulation manual for individual and family therapy. San Diego, CA: Academic Press. Ladouceur, R., & Lachance, S. (2007). Overcoming pathological gambling: Therapist guide. New York: Oxford University Press. Mc Cown, W. G., & Howatt, W. A. (2007). Treating gambling problems. New York: Wiley. Whelan, J. P., Meyers, A. M., & Steenbergh, T. A. (2007). Problem and pathological gambling. Cambridge, MA: Hogrefe & Huber. Gamblers Helpline. Available at (888) LAST BET (527-8238). National Council on Problem Gambling. Available at (800) 522-4700 and www. ncpgambling. org. 27. 14. Hypochondriacal Personality Furer, P., Walker, J. R., & Stein, M. B. (2007). Treating health anxiety and fear of death: A practitioner's guide. New York: Springer. Taylor, S., & Asmundson, G. J. G. (2004). Treating health anxiety: A cognitive-behavioral approach. New York: Guilford Press. Woolfolk, R. L., & Allen, L. A. (2007). Treating somatization: A cognitive-behavioral approach. New York: Guilford Press.
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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348 USEFUL RESOURCES SPECIFIC DISORDERS27. 15. Obsessive-Compulsive Disorders Antony, M., Purdon, C., & Summerfeldt, L. J. (Eds. ). (2007). Psychological treatment of obsessive-compulsive disor-der: Fundamentals and beyond. Washington, DC: American Psychological Association. Clark, D. A. (2004). Cognitive-behavioral therapy for OCD. New York: Guilford Press. March, J. S., & Mulle, K. (1998). OCD in children and adolescents: A cognitive-behavioral treatment manual. New York: Guilford Press. Steketee, G. (1999). Overcoming obsessive-compulsive disorder [Therapist protocol and client manual]. Oakland, CA: New Harbinger. 27. 16. Pain, Chronic Caudill, M. A. (2009). Managing pain before it manages you (3rd ed. ). New York: Guilford Press. Eimer, B., & Freeman, A. (1998). Pain management psychotherapy: A practical guide. New York: Wiley. Thorn, B. E. (2004). Cognitive therapy for chronic pain: A step-by-step guide. New York: Guilford Press. Turk, D. C., & Gatchel, R. J. (Eds. ). (2002). Psychological approaches to pain management: A practitioner's handbook (2nd ed. ). New York: Guilford Press. Turk, D. C., & Melzack, R. (Eds. ). (2001). Handbook of pain assessment (2nd ed. ). New York: Guilford Press. 27. 17. Phobias Bourne, E. J. (1998). Overcoming specific phobias [Therapist protocol and client manual]. Oakland, CA: New Harbinger. Craske, M. G., Antony, M. M., & Barlow, D. H. (2006). Mastering your fears and phobias: Therapist guide (2nd ed. ). New York: Oxford University Press. Hope, D. A., Heimberg, R. C., & Turk, C. L. (2010). Managing social anxiety: A cognitive-behavioral therapy approach. Therapist guide (2nd ed. ). New York: Oxford University Press. 27. 18. Post Traumatic Stress Disorder Foa. E. B., Keane, T. M., Friedman, M. J., & Cohen, J. A. (Eds. ). (2009). Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies (2nd ed. ). New York: Guilford Press. Najavits, L. M. (2002). Seeking safety: A treatment manual for PTSD and substance abuse. New York: Guilford Press. Smyth, L. (1999). Overcoming post-traumatic stress disorder [Therapist protocol and client manual]. Oakland, CA: New Harbinger. Taylor, S. (2006). Clinician's guide to PTSD: A cognitive-behavioral approach. New York: Guilford Press. Zayfert, C., & Becker, C. B. (2007). Cognitive-behavioral therapy for PTSD: A case formulation approach. New York: Guilford Press. David Baldwin's Trauma Pages. Available at www. trauma-pages. com. National Center for PTSD. Available at www. ncptsd. org. 27. 19. Religious and Spiritual Concerns Dowd, E. T., & Nielsen, S. L. (2006). The psychologies in religion: Working with the religious client. New York: Springer. Pargament, K. I. (2001). The psychology of religion and coping: Theory, research, practice. New York: Guilford Press. Richards, P. S., & Bergin, A. E. (Eds. ). (2000). Handbook of psychotherapy and religious diversity. Washington, DC: American Psychological Association.
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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27. Treatments for Specific Disorders and Concerns 349SPECIFIC DISORDERSSpilka, B., Hood, R. W., Jr., Hunsberger, B., & Gorsuch, R. (2003). The psychology of religion: An empirical approach (3rd ed. ). New York: Guilford Press. 27. 20. Schizophrenia and Psychosis Burns, T., & Firn, M. (2002). Assertive outreach in mental health: A manual for practitioners. New York: Oxford University Press. Corrigan, P. W., Mueser, K. T., Bond, G. R., Drake, R. E., & Solomon, P. (2008). Principles and practice of psychi-atric rehabilitation: An empirical approach. New York: Guilford Press. Hofmann, S. G., & Tompson, M. C. (Eds. ). (2002). Treating chronic and severe mental disorders: A handbook of empirically supported interventions. New York: Guilford Press. Rapp, C. A., & Goscha, R. J. (2006). The strengths model: Case management with people with psychiatric disabilities. New York: Oxford University Press. Stein, L. I., & Santos, A. B. (1998). Assertive community treatment of persons with severe mental illness. New York: Norton. Torrey, E. F. (2006). Surviving schizophrenia: A manual for families, consumers, and providers (5th ed. ). New York: Harper Paperbacks. 27. 21. Sleep Disturbances Edinger, J. D., & Carney, C. E. (2008). Overcoming insomnia: A cognitive-behavioral therapy approach: Therapist guide. New York: Oxford University Press. Morin, C., & Espie, C. A. (2003). Insomnia: A clinician's guide to assessment and treatment. New York: Springer. Perlis, M. L., Jungquist, C., Smith, M. T., & Posner, D. (2005). Cognitive behavioral treatment of insomnia: A session-by-session guide. New York: Springer. 27. 22. Stalking Meloy, J. R. (Ed. ). (1998). The psychology of stalking: Clinical and forensic perspectives. San Diego, CA: Academic Press. Pinals, D. A. (Ed. ). (2007). Stalking: Psychiatric perspectives and practical approaches. New York: Oxford University Press. Stalking Resource Center. Available at www. ncvc. org/src. 27. 23. Substance Abuse Beck, A. T., Wright, F. D., Newman, C. F., & Liese, V. S. (2001). Cognitive therapy of substance abuse. New York: Guilford Press. Connors, G. J., Donovan, D. M., & Di Clemente, C. D. (2001). Substance abuse treatment and the stages of change: Selecting and planning intervention: New York: Guilford Press. Denning, P. (2000). Practicing harm reduction psychotherapy: An alternative approach to addictions. New York: Guil-ford Press. Johnson, S. L. (2003). Therapists' guide to substance abuse intervention. San Diego, CA: Academic Press. Martin, P. R., Weinberg, B. A., & Bealer, B. K. (2007). Healing addiction: An integrated pharmacopsychosocial approach to treatment. New York: Wiley. Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed. ). New York: Guilford Press. Monti, P. M., Kadden, R. M., Rohsenow, D. J., Cooney, N. L., & Abrams, D. B. (2002). Treating alcohol depen-dence: A coping skills training guide (2nd ed. ). New York: Guilford Press. Rotgers, F., Morgenstern, J., & Walters, S. T. (Eds. ). (2003). Treating substance abuse: Theory and technique (2nd ed. ). New York: Guilford Press.
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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350 USEFUL RESOURCES SPECIFIC DISORDERSVelasquez, M. M., Maurer, G. G., Crouch, C., & Di Clemente, C. D. (2001). Group treatment for substance abuse: A stages-of-change therapy manual. New York: Guilford Press. Habit Smart Treatment. Available at www. habitsmart. com. National Institute on Drug Abuse. Available at www. nida. nih. gov. SMART Recovery. Available at www. smartrecovery. org. 27. 24. Types of Therapies Barlow, D. H. (Ed. ). (2008). Clinical handbook of psychological disorders: A step-by-step treatment manual (4th ed. ). New York: Guilford Press. Christophersen, E. R., & Mortweet, S. L. (2001). Treatments that work with children: Empirically supported strategies for managing childhood problems. Washington, DC: American Psychological Association. Lambert, M. J. (Ed. ). (2004). Bergin and Garfield's handbook of psychotherapy and behavior change (5th ed. ). New York: Wiley. Norcross, J. C. (Ed. ). (2002). Psychotherapy relationships that work: Therapist contributions and responsiveness to patients. New York: Oxford University Press. Norcross, J. C., Santrock, J. W., Campbell, L. F., Smith, T. P., Sommer, R., & Zuckerman, E. L. (2003). Authorita-tive guide to self-help resources in mental health (rev. ed. ). New York: Guilford Press. Weisz, J. R. (2004). Psychotherapy for children and adolescents: Evidence-based treatments and case examples. New York: Cambridge University Press.
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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351 28 Listing of Common Psychiatric and Psychoactive Drugs 28. 1. List of Medications by Trade and Generic Names See also Section 12. 36, “Side Effects of Psychotropic Medications/Adverse Drug Reactions. ” A majority of mental health clients are taking some kind of psychoactive medication, and since such medications are likely to affect their assessment and treatment, clinicians should have some aware-ness of these drugs. Much information is available online (see Section 28. 4) but a printed list can be handy. The following is a checklist of dosages and uses for over 100 medications commonly used in psy-chiatry. Drugs are listed in the alphabetical order of their trade names, followed by their generic names. The list is updated several times a year at www. The Clinicians Tool Box. com (click on “Free Tools” for the latest version). The present version is copyright 2010 by Edward L. Zuckerman, Ph D, and Dan Egli, Ph D. See the “Disclaimer” at the end for conditions governing the use of the list. Name Drug class Usual adult daily dosage (range in mg)FDA-approved indication(s)Common “Off-label” uses, if any Trade Generic Abilify aripiprazole Atypical 10-15 Schizophrenia, Bipolar, adjunctive Tx adult MDD, Agitation Adderall, XR d-& l-amphetamine Stimulant 5-40 ADHD, Narco Ambien, CR zolpidem Nonbenzo. hypnotic5-12. 5 DFA, SCD (short-term use) Anafranil clomipramine Tricyclic AD 100-250 OCD Antabuse disulfiram Alcohol antagonist125-500 Manage chronic alcoholism Aplenzin bupropion DNRI 174-522 MDDPSy CHOACTIVE MEDICATIONS
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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352 USEFUL RESOURCES PSy CHOACTIVE MEDICATIONS Name Drug class Usual adult daily dosage (range in mg)FDA-approved indication(s)Common “Off-label” uses, if any Trade Generic Aricept donepezil Cholinesterase inhibitor5-10 Mild/ moderate/severe dementia Artane trihexyphenidyl Antidyskinetic 1-15 Anti-Parkinson's Extrapyramidal symptoms Ativan lorazepam Benzodiazepine 2-6 Anxiety Alcohol withdrawal, Seizures, Insomnia Aventyl/Pamelornortriptyline Tricyclic AD 25-100 MDD Depr Bu Spar buspirone Antianxiety 15-60 GAD Campral acamprosate Alcohol antagonist1332-1998 Alcohol dependence Catapres, TTSclonidine Antihypertensive. 1-. 3 Hypertension Drug detox, Pain, Impulse, ADHD Celexa citalopram SSRI 20-40 MDD Depr, Pm DD, PTSD, BDD, Soc. Anxiety Centrax prazepam Benzodiazepine 30-60 Anxiety Alcohol withdrawal, Seizures Chantix varenicline Nicotinic receptor agonist0. 5-2 Smoking cessation Cialis tadalafil PDE-5 inhibitor 5-20 Erectile dysfunction Clozaril/Faza Cloclozapine Atypical 300-450 Schizophrenia Bipolar Cogentin benztropine Antidyskinetic 1-8 Anti-Parkinson's Extrapyramidal symptoms Cognex tacrine Cholinesterase inhibitor40-160 Mild/moderate dementia Concerta methylphenidate Stimulant 18-54 ADHD Cymbalta, DRduloxetine SNRI 20-80 MDD, GAD, Neuropathic pain, Fibro Depr, Pm DD, PTSD, Soc. Anxiety Dalmane flurazepam Benzodiazepine 15-30 Insomnia (short-term use) Daytrana, TTSmethylphenidate Stimulant 10-27 ADHD (ages 6-12) Depakote/-ene/-condivalproex Anticonvulsant 750-3000 Bipolar, Epilepsy, Migraine
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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28. Listing of Common Psychiatric and Psychoactive Drugs 353PSy CHOACTIVE MEDICATIONS Name Drug class Usual adult daily dosage (range in mg)FDA-approved indication(s)Common “Off-label” uses, if any Trade Generic Deplin l-methylfolate Medical food 7. 5 Augment antidepressant in MDD, T-R Depr Desoxyn methamphetamine Stimulant 5-25 ADHD, Anorexiant EDS, Narco Desyrel trazodone SARI 150-400 MDD Depr, Hypn Dexedrine dextroamphetamine Stimulant 5-40 ADHD, Narcolepsy EDS Doral quazepam Benzodiazepine 7. 5-15 Insomnia (short-term use) Edluar zolpidem Nonbenzo. hypnotic5-10 Insomnia Effexor, XR venlafaxine SNRI 75-375 MDD, GAD, Panic Depr, PTSD, Soc. Anxiety, Pm DD Elavil amitriptyline Tricyclic AD 75-150 MDD Depr Eldepryl selegiline MAOI 5-10 Anti-Parkinson's Depr, Smoking cessation Emsam, TTS selegiline MAOI 6-12 MDD Equetro, ER carbamazepine Anti-manic 200-1600 Bipolar Eskalith/ Lithobidlithium carbonate Anti-manic 900-1800 Bipolar Exelon, patchrivastigmine Cholinesterase inhibitor3-12 Mild/moderate dementia, Parkinson's dementia Fanapt iloperidone Atypical 12-24 Schizophrenia Focalin, XR dexmethylphenidate Stimulant 5-20 ADHD Gabitril tiagabine Anticonvulsant 4-32 Epilepsy Bipolar Geodon ziprasidone Atypical 40-160 Schizophrenia, Bipolar Halcion triazolam Benzodiazepine. 25-. 50 Insomnia (short-term use) Inderal propranolol Antihypertensive 10--80 Hypertension Anxiety, Alcohol withdrawal, Akathisia, Panic Intuniv, ER guanfacine Antihypertensive 1-4 ADHD Invega, ER paliperidone Atypical 3-12 Schizophrenia (acute and chronic) Kemadrin procyclidine Antidyskinetic 7. 5-20 Anti-Parkinson's Keppra, XR levetiracetam Anticonvulsant 1000-3000 Epilepsy Bipolar
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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354 USEFUL RESOURCES PSy CHOACTIVE MEDICATIONS Name Drug class Usual adult daily dosage (range in mg)FDA-approved indication(s)Common “Off-label” uses, if any Trade Generic Klonopin, wafersclonazepam Benzodiazepine. 25-40 Seizures, Panic GAD, Hypn Lamictal, ODTlamotrigine Anticonvulsant 100-200 Epilepsy, Bipolar Levitra vardenafil PDE-5 inhibitor 5-20 Erectile dysfunction Lexapro escitalopram SSRI 10-20 MDD (down to ages 12-17), GADBDD, PTSD, Soc. Anxiety, Depr, Pm DD Librium chlordiazepoxide Benzodiazepine 5-100 Anxiety, Alcohol withdrawal Ludiomil maprotiline Tetracyclic AD 75-225 MDD Depr Lunesta eszopiclone Nonbenzo. hypnotic2-3 Insomnia (≤6 months use) Luvox, CR fluvoxamine SSRI 50-300 OCD, Soc. Anxiety MDD, PTSD, Pm DD, BDD Lyrica pregabalin Anticonvulsant 300-600 Seizures, Neuropathic pain, Fibro GAD Marplan isocarboxazid MAOI 20-60 MDD Meridia sibutramine Anorexiant 10-15 Obesity Metadate, CR, ERmethylphenidate Stimulant 20-60 ADHD Methylin methylphenidate Stimulant 20-60 ADHD, Narco Mirapex pramipexole Dopamine agonist1. 5-4. 5 Anti- Parkinson's, RLST-R Depr Namenda memantine NMDA antagonist5-20 Moderate/ severe dementia Narcan naloxone Opioid antagonist. 4-2 Opioid overdose Nardil phenelzine MAOI 45-90 MDD Neurontin gabapentin Anticonvulsant 900-1800 Epilepsy Bipolar Niravam alprazolam, ODT Benzodiazepine. 3-5 Panic, GAD Nuvigil armodafinil Wakefulness promoter150-250 Sleep apnea, Narco, SWSD Parnate tranylcypromine MAOI 30-60 MDD Paxil, CR/Pexevaparoxetine SSRI 20-60 MDD, GAD, OCD, Panic, Soc. Anxiety, PTSDDepr, Anxiety, Pm DD Pristiq desvenlafaxine SNRI 50 MDD Pro Som estazolam Benzodiazepine 1-2 Insomnia (short-term use)
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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28. Listing of Common Psychiatric and Psychoactive Drugs 355PSy CHOACTIVE MEDICATIONS Name Drug class Usual adult daily dosage (range in mg)FDA-approved indication(s)Common “Off-label” uses, if any Trade Generic Provigil modafinil Wakefulness promoter100-400 EDS, OSA, SWSDADHD, MDD Prozac/Sarafemfluoxetine SSRI 20-80 OCD, Panic, Pm DD, MDD, PTSD, Bulimia Depr, Soc. Anxiety, Anxiety, BDD Razadyne, ERgalantamine Cholinesterase inhibitor8-32 Mild/moderate dementia Remeron/Sol Tabmirtazapine Tetracyclic AD 15-45 MDD Depr Requip, XL ropinirole Dopamine agonist. 75-3 Anti-Parkinson's, RLST-R Depr Restoril temazepam Benzodiazepine 15-30 Insomnia, short-term use Revia/Revex naltrexone/ nalmefene Opioid antagonist50 Opioid dependence Alcohol dependence Risperdal/Constarisperidone Atypical 1-8 Bipolar & Schizophrenia (in adults and teens), Irritability (in autism) Ritalin methylphenidate Stimulant 20-60 ADHD, Narco EDS Rozerem ramelteon Hypnotic 8 Insomnia Sabril vigabatrin Anticonvulsant 1000-4000 Bipolar, Epilepsy Serax oxazepam Benzodiazepine 30-120 Anxiety, Alcohol withdrawal Anti-itch, Seizures, Hypn Seroquel, XRquetiapine Atypical 150-800 Schizophrenia, Bipolar, T-R Depr [Serzone] nefazodone SNRI + 5HT2a 300-600 MDD Anxiety, PTSD Sinequan/Adapindoxepin Tricyclic AD 150-300 MDD Depr Sonata zaleplon Nonbenzo. hypnotic5-10 Insomnia (short-term use) Stavzor, DR valproic acid Anticonvulsant 250-750 Bipolar, Seizures, Migraine Strattera atomoxetine Non-stimulant 40-100 ADHD Suboxone buprenorphine & naloxone Opioid agonist 12-16 Opioid dependence Subutex buprenorphine Opioid agonist 12-16 Opioid dependence Symbyax olanzapine & fluoxetine Atypical & SSRI 6/25-12/50 Bipolar Schizophrenia
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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356 USEFUL RESOURCES PSy CHOACTIVE MEDICATIONS Name Drug class Usual adult daily dosage (range in mg)FDA-approved indication(s)Common “Off-label” uses, if any Trade Generic Tegretol carbamazepine Anticonvulsant 400-1200 Epilepsy Bipolar Tenex guanfacine Antihypertensive. 5-3 Hypertension Drug withdrawal Tofranil/IM imipramine Tricyclic AD 75-200 MDD, Enuresis Depr Topamax topiramate Anticonvulsant 400-1600 Epilepsy, Migraine Bipolar Tranxene clorazepate Benzodiazepine 15-60 Anxiety, Seizures Trileptal oxcarbazepine Anticonvulsant 600-1200 Epilepsy Bipolar Valium diazepam Benzodiazepine 4-40 Anxiety, Muscle spasm, Seizures Viagra/ Revatiosildenafil PDE-5 inhibitor 25-100 Erectile dysfunction Vivitrol, IM naltrexone Opioid antagonist190-380/mo. Alcohol/Opioid dependence Vyvanse lisdexamfetamine Stimulant 30-70 ADHD (child & adult) Wellbutrin/Zyban/Budeprion, ERbupropion DNRI 200-450 MDD, Smoking cessation, SAD Xanax, XR alprazolam Benzodiazepine. 25-40 Panic Anxiety Xenical/Alli orlistat Lipase inhibitor 360 Obesity Xyrem sodium oxybate Stimulant 3-9 g EDS, Cataplexy Zoloft sertraline SSRI 50-200 Panic, OCD, MDD, PTSD, Soc. Anxiety, Pm DDBDD, Depr, Anxiety Zonegran zonisamide Anticonvulsant 100-400 Epilepsy Bipolar Zyprexa/Zydis, IMolanzapine Atypical 5-30 Schizophrenia, Bipolar Key: [ ] means trade drug withdrawn from market by manufacturer, but still available as generic. Drug name and class: Anorexiant = Drug used to treat obesity. Antidyskinetic = Drug used to treat Parkinson's disease and extrapyramidal effects of antipsychotics. Atypical = Newer antipsychotic/neuroleptic (The conventional, older antipsychotics/neuroleptics are now rarely used and so are not listed). DNRI = Dopamine-Norepinephrine Reuptake Inhibitor. MAOI = Monoamine Oxidase Inhibitor. PDE-5 inhibitor= Phosphodiesterase type 5 inhibitor. SARI = Serotonin-2 Antagonist/Serotonin Reuptake Inhibitor. SNRI = Serotonin-Norepinephrine Reuptake Inhibitor. SSRI = Selective Serotonin Reuptake Inhibitor. Tetracyclic AD = Tetracyclic Antidepressant. Tricyclic AD = Tricyclic Antidepressant (almost replaced by SSRIs, and thus few are listed). IM = Intramuscular. ODT = Orally Disintegrating Tablet. TTS = Transdermal Therapeutic System (a skin patch). CR, DR, ER, XL, XR = Slowed release. Indications and “off-label” uses: ADHD = Attention-Deficit/Hyperactivity Disorder. Anorexiant = For exogenous obesity. Anxiety = Anxiety Disorder NOS. BDD = Body Dysmorphic Disorder. Bipolar = Bipolar I Disorder (manic). Depr = Depression (see MDD). DFA =Difficulty Falling Asleep. EDS = Excessive Daytime Sleepiness. EMA = Early Morning Awakening. Fibro = Fibromyalgia. GAD = Generalized Anxiety Disorder.
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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28. Listing of Common Psychiatric and Psychoactive Drugs 357PSy CHOACTIVE MEDICATIONSHypn = Hypnotic (sleep inducer) for many sleep disorders. Impulse = Impulse-Control Disorders. MDD = Major Depressive Disorder (not Dysthymia or Depression NOS). Narco = Narcolepsy. OCD = Obsessive- Compulsive Disorder. OSA = Obstructive Sleep Apnea. Panic = Panic Disorder, with or without Agoraphobia. Pm DD = Premenstrual Dysphoric Disorder. PTSD = Posttraumatic Stress Disorder. RLS = Restless Leg Syndrome. SAD = Seasonal Affective Disorder. SCD = Sleep Continuity Disturbance. SWSD = Shift Work Sleep Disorder. Soc. Anxiety = Social Anxiety/Social Phobia. T-R Depr = Treatment-Resistant Depression. Disclaimer: The information presented here is intended as general health information and as an educational tool, but is not precise enough for making prescription decisions and is not to be construed as medical advice. The indications/diagnoses are not exclusive, exhaustive, or precise. We have tried to be accurate, but errors may exist here. Listing here is in no sense an endorsement by us of the use of any medication for any treatment purpose. The dosages offered here are for maintenance, and authorities differ on these. Starting doses may be lower, and for some people higher (supratherapeutic) dosages are warranted. All trade names are the property of their respective manufacturers, distributors, and copyright holders. Noncommercial copying and distribution of this list are permitted as long as NO changes are made to it. Any other uses require written permission. 28. 2. Finding Street Drugs' Names The commonly used names of street drugs— increasingly, medicines obtained and sold illegally, as well as illegal and abusable substances—vary by location and change frequently, but here are some websites: www. watton. org/drugsinfo/a-zwww. soberrecovery. com/alcoholdrugtreatment/category/drug-street-names www. whitehousedrugpolicy. gov/streetterms ( Note: This site offers thousands of names in a down-loadable list. ) 28. 3. Results of Medication Treatment: Descriptors Good/fluctuating/poor adherence/compliance. Tolerated without difficulty, rapid and dramatic improvement, abatement of symptoms, symp-tomatology improved. No signs of addiction, diversion, misuse, or excessive use. Highly sensitive to all medications, multiple/distressing side effects, quite difficult to find a medication regimen that was tolerated, distressing and extreme reactions to all medica-tions tried despite changes in dosage and schedule, adverse drug reactions. Contraindicated, use not advisable because... (specify). Polypharmacy, more than one/several/multiple drugs being taken, drug interactions, drug aug-mentation. 28. 4. Drug Resources for the Clinician Books Although books' information often cannot be completely current, the books listed below have been recently revised and provide extensive information. (See www. psychmeds. info for current materials. ) Information on current uses, adverse effects, and interactions of medications can be found in the latest editions of the Physicians' D esk Reference and the PDR Guide to Drug Interactions, Side Effects, and Indications (both 2010 at this writing).
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358 USEFUL RESOURCES PSy CHOACTIVE MEDICATIONSDiamond, R. J. (2009). Instant psychopharmacology (3rd ed. ). New York: Norton. All the basics are here, as well as advice on compliance and the relationship with the patient, prices, side effects, and interactions. A fine starting place. Patterson, J., Albala, A. A., Mc Cahill, M. E., & Edwards, T. M. (2006). The therapist's guide to psychopharmacology: Working with patients, families, and physicians to optimize care. New York: Guilford Press. An ideal introduction to the subject for those working with prescibers. Preston, J. D., O'Neal, J. H., & Talaga, M. C. (2010). Handbook of clinical psychopharmacology for therapists (5th ed. ). Oakland, CA: New Harbinger. Practical, user-friendly, and comprehensive. Stahl, S. (2009). Stahl's essential psychopharmacology: The prescriber's guide (3rd ed. ). New York: Cambridge University Press. Rich in expertise, pragmatic, current, and comprehensive. Virani, A. S., Bezchlibnyk-Butler, K., & Jeffries, J. (2009). Clinical handbook of psychotropic drugs (18th rev. ed. ). Cambridge, MA: Hogrefe & Huber. Lots of objective data displayed in tables for easy access, and organized by disorder. No narrative explanation or interpretation, but bits of advice on interactions, comparisons, side effects, etc. Wilens, T. E. (2009). Straight talk about psychiatric medications for kids (3rd ed. ). New York: Guilford Press. Comprehensive; like listening to a wise and informed counsel or sharing his wealth. There are many other books, and new ones come out monthly, so just visit your favorite bookstore or website for the most current information. Online Drug Information www. rxlist. com (Very extensive information on each drug, somewhat like the PDR. )www. drugs. com (Extensive information in a Q&A format, and some useful tools. )online. epocrates. com (Lists of every drug and of medical conditions; drug interactions checker; images; pictures of pills; printable handouts; etc. Requires free registration. ) Two valuable resources for report writers are available at www. The Clinicians Tool Box. com under the “Free Tools” tab: a list of drugs' generic and trade names (a periodically updated version of the list in Section 28. 1, as noted earlier), and a list of all the terms used in the diagnostic labels. Why down-load them? Copy and paste them into a new document in your word processor, and run your spelling checker to teach it these spellings, and you will never misspell any of these again.
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359 29 Psychiatric Masquerade of Medical Conditions 29. 1. Introduction The well-trained and responsible clinician must consider all possible causes of a client's symptoms: developmental, dynamic, existential, learned, cultural, and medical/physiological. “Psychiatric masquerade” is the commonly accepted term for the situation in which a patient pres-ents to the clinician with psychological or psychiatric symptoms caused by a medical condition or illness that is not immediately (and, sadly, sometimes never) recognized. In other words, it is the case in which a medical condition wears the “mask” of a psychiatric condition. Adams (1991) notes that calling it “psychiatric masquerade” focuses on the presentation; if we were to focus on the cau-sation, we would call it “medical masquerade. ” It is not to be confused with malingering (see Section 12. 20) or the somatoform disorders. Although there are numerous excellent articles and books that describe the psychological effects of medical conditions or of medications, they are useless to the professional who sees only the patient presenting with psychiatric symptoms, unaccompanied by a medical diagnosis. However, as clini-cians, all of us have the ethical obligation to be sensitive to the possibility of masquerade and to investigate any such possibilities appropriately. Common causes of the presentation of psychiatric symptoms are the side effects and interactions of prescribed drugs with each other and with herbals, dietary supplements, O ver-The-Counter (nonprescription) drugs, and abusable substances. Because this is a complex and changing area, consultations with experts, current books, and online data bases are necessary to achieve clarity. The individual clinician can do his/her part by making a comprehensive inventory of all substances the client takes in. Good guides to this complex area are Pincus and Tucker (2003), Lishman (1998), Morrison (1997), and Taylor (2007). Surprisingly, the last two are quite accessible and are recommended to the non-medical clinician. Especially for children and adolescents is Reed's (2005) list. PSy CHIATRIC MASQUERADE
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360 USEFUL RESOURCES PSy CHIATRIC MASQUERADE29. 2. Anxiety See Section 10. 3, “Anxiety/Fear. ” Medications/Substances That May Induce Anxiety Stimulants and sympathomimetics: Amphetamines, cocaine, amethylphenidate, pemoline, eph-ü ed rine, pseudoephedrine, phenylpropanolamine, xanthine derivatives (caffeine, theobromine, theophylline). Withdrawal states (especially from alcohol, sedatives, narcotics). Anticholinergics and antihistamines. Antidepressants: Fluoxetine and other Selective Serotonin Reuptake Inhibitors, Mono Amine Oxidase Inhibitors, tricyclic antidepressants (especially early in therapy). Benzodiazepines (paradoxical reactions, withdrawal states). Euphoriants and hallucinogens: Cannabis, LSD, mescaline, psilocybin, phencyclidine (PCP). Hormones: Androgens, estrogens, progesterones, corticosteroids, thyroid supplements. Others: Cycloserine, metrizamide, quinacrine, nasal decongestant sprays. Medical Conditions That May Present as/with Anxiety Mitral Valve Prolapse, adrenal tumor, alcoholism, carcinoid syndrome, Central Nervous Sys-tem degenerative diseases, Cushing's disease, coronary insufficiency, delirium, hypoglyce-mia, hyperthyroidism, Meniere's disease (early stages), postconcussion syndrome, chronic ob structive lung disease, AIDS, diabetes, fibromyalgia. 29. 3. Sexual Dysfunction Many common medications may cause sexual dysfunctions (difficulties with arousal or orgasm). A good source of information is the book by Segraves and Balon (2003). 29. 4. Depression See Section 10. 7, “Depression. ” Medications/Substances That May Induce Depression Antiarrhythmics: Digitalis, disopyramide, nifedipine. Antihypertensives: Clonidine, guanethidine, hydralazine, methyldopa, prazosin, propranolol, and other b-blockers; reserpine; trichloromethiazide. Antimicrobials: Cycloserine, isoniazid, metronidazole, nalidixic acid. Anti-Parkinsonian agents: Levodopa, amantadine, carbidopa. Chemotherapeutic agents: Asparaginase, vinblastine, vincristine. Hormone preparations: Corticosteroids, oral contraceptives, thyroid supplements. Sedatives: Alcohol, barbiturates, benzodiazepines, hypnotics, marijuana, hallucinogens. Withdrawal states (especially from cocaine and other stimulants, amphetamines). Other: Cimetidine, ranitidine, disulfiram, levodopa, a-methyldopa, carbidopa, metoclopra-mide, metrizamide, cholinesterase inhibitors, insecticides. Interferon treatment of hepatitis almost always causes significant depression.
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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29. Psychiatric Masquerade of Medical Conditions 361PSy CHIATRIC MASQUERADEDiseases That May Present as/with Depression Influenza, tuberculosis, general paresis/tertiary syphilis, hypothyroidism, Cushing's disease, Addison's disease, Parkinson's disease, Systemic Lupus Erythematosus, Rheumatoid Arthri-tis, stroke, Multiple Sclerosis, End-Stage Renal Disease (with hemodialysis),1 cerebral tumors, sleep apnea, early stages of dementing diseases, epilepsy, diabetes, brain trauma, Lyme dis-ease, pancreatic cancer. 29. 5. Mania See Section 10. 9, “Mania. ” Medications/Substances That May Induce Mania Amphetamines, bromides, cocaine, isoniazid, procarbazine, corticosteroids, levodopa, MAOI and tricyclic antidepressants, methylphenidate, OTC stimulants/appetite suppressants, vita-min deficiencies, excess of fat-soluble vitamins. Diseases That May Present as/with Mania Influenza, general paresis/tertiary syphilis, St. Louis encephalitis, Q fever, thyrotoxicosis, rheu-matic chorea, stroke, MS, cerebellar/diencephalic/third-ventricle tumors, hyperthyroidism, Cushing's disease, hyperparathyroidism. 29. 6. Organic Brain Syndrome/Dementia See Section 11. 7, “Dementia. ” Medications/Substances That May Induce Delirium, Hallucinations, or Paranoia Antiarrhythmics: Digitalis, lidocaine, procainamide, quinacrine. Anticholinergics. Antimicrobials, antiparasitics, antivirals: Amantadine, amphotericin B, metronidazole, thiaben-dazole, cycloserine, isoniazid, chloroquine, hydroxychloroquine, dapsone, penicillin G pro-caine. Antihistamines: H 2 blockers (cimetidine, rantidine). b-blockers. Chemotherapeutic agents (especially intrathecal administration): Asparaginase, cisplatin, vin-cris tine. Euphoriants and hallucinogens: Cannabis, LSD, mescaline, psilocybin, PCP. Hormone preparations: Corticosteroids. Sedatives: Alcohol, barbiturates, benzodiazepines, hypnotics. Stimulants and sympathomimetics: Amphetamines, cocaine, methylphenidate, pemoline. Withdrawal states (especially from alcohol, sedatives). Other: Albuterol, bromides, bromocriptine, disulfiram, levodopa, carbidopa, methyldopa, methysergide, metrizamide. The most frequent causes of demented/delirious presentations, especially in elderly persons, ü are these: drug-drug, drug-food, drug-OTC medication, and drug-herbal interactions; alcohol abuse; polypharmacy or over-, under-, and misuse of medication; diabetes; depression; and, for paranoia, partial deafness. 1I am grateful to Renee F. Bova- Collis of Richmond, VA, for pointing this out.
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362 USEFUL RESOURCES PSy CHIATRIC MASQUERADENeurological Conditions That Commonly Exhibit Psychological Symptoms Bondi (1992) offers this basic orienting information about this issue: Neurological conditions have a base rate of 2. 5% of general population. General symptoms: Paranoia, attentional deficits, mood swings, euphoria, sleep disturbance, personality changes, depression, impaired memory, anxiety, apathy, violence. Temporal lobe epilepsy/complex partial seizure disorder global diminution in sexual behav-ior, impulsive-irritable behaviors, especially in a context of hyperethical and hyperreligious history, hypergraphia, and overconcern and overemphasis on the trivial. Frontal lobe damage apathy (empty indifference as contrasted with the depressive's preoc-cupation with worry), total loss of initiative, euphoria, lack of adult restraint/tact, inconti-nence. Traumatic Brain Injury like frontal lobe damage as well as depression (psychomotor retarda-tion, apathy, lack of initiative, blunted or flat affect), and memory dysfunction. Huntington's disease intermittent mood disorder with onset before the chorea and dementia. Besides the affective components, there may be paranoia, delusions, hallucinations, and mood swings. Always seek a family history. Hypothyroidism progressive cognitive deterioration, insidious onset, sluggishness, lethargy, poor attention and concentration, memory disturbances. MS muscle weakness, fatigue, double vision, numbness, paresthesia, pain, bowel and bladder dysfunction, sexual disturbance. Euphoria and/or depression, “conversion” symptoms. Headache: If it is the worst ever experienced by the patient, a new type of headache, or accompanied by neurological signs, it is much more likely to be organic than one that is dull, generalized, familiar, or present for a year. Tumor-caused headaches have no one quality. They may occur on awakening and recede dur- ing the day; they are often bifrontal or bioccipital, lateralized or localized, and ameliorated or exacerbated by changes in body position. Some Clues Suggestive of Organic Mental Disorder The following is adapted by permission from Hoffman and Koran (1984). Psychiatric symptom onset after age 40. Psychiatric symptoms beginning... a. during a major illness. b. while taking drugs known to cause mental symptoms (see above). c. suddenly, in a patient without prior psychiatric history or known stressors. A history of... a. alcohol or drug abuse. b. a physical illness impairing a major organ's function (e. g., hepatitis). c. taking multiple medications (prescribed or OTC). d. poor response to apparently adequate psychiatric treatment. A family history of... a. degenerative or inheritable brain disease. b. metabolic disease (diabetes, pernicious anemia, etc. ). Mental signs including... a. altered level of consciousness. b. fluctuating mental status. c. cognitive impairment. d. episodic, recurrent, or cyclic course. e. visual, tactile, or olfactory hallucinations.
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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29. Psychiatric Masquerade of Medical Conditions 363PSy CHIATRIC MASQUERADEPhysical signs that include... a. signs of organ malfunction that can affect the brain. b. focal neurological deficits. c. diffuse subcortical dysfunction (slowed speech/mentation/movement, ataxia, incoor di-na tion, tremor, chorea, asterixis, dysarthria, etc. ). d. cortical dysfunction (dysphasia, apraxias, agnosia, visuospatial deficits, or defective corti-cal sensation, etc. ). Treatable/Possibly Reversible Causes of OBS The following list is adapted by permission from Slaby et al. (1994): Addison's disease, some angiomas of the cerebral vessels, anoxia secondary to chronic cardiac or respiratory disease, cerebral abscess, some cerebral neoplasms, chronic subdural hema-tomas, electrolyte imbalance, endogenous toxins (as with hepatic or renal failure), exog-enous toxins such as carbon monoxide, hypothyroidism, hypoglycemia, cerebral infections (such as tuberculosis, syphilis, parasites, or yeasts), intracranial aneurysms, normal-pressure hydrocephalus, pseudodementia (e. g., in schizophrenia or depression), vitamin deficiencies, Wilson's disease. Irreversible Causes of OBS The following list is reprinted by permission from Slaby et al. (1994): Alcoholic encephalopathy, Alzheimer's disease, arteriosclerosis, cerebral metastases, some primary cerebral neoplasms, Creutzfeldt-Jakob disease, dementia pugilistica, familial myo clonic epilepsy, Friedreich's ataxia, Huntington's chorea, Kuf's disease, Marchiafava- Bignami disease, multiple myeloma, MS, collagenoses, Parkinsonism/dementia complex of Guam, Pick's disease, presenile dementia with motor neuron disease, presenile glial dystro-phy, primary parenchymatous cerebellar atrophy with dementia, primary subcortical gliosis, progressive supranuclear palsy, sarcoidosis, Schilder's disease, senile dementia. 29. 7. Psychosis Medications/Substances That May Induce Psychosis Sympathomimetics (e. g., cocaine, “crack,” many OTC cold medications). Antinflammatory drugs: Steroids. Anticholinergics: Anti-Parkinsonian agents (especially levodopa, in patients with schizophre-nia). Hallucinogens. The top 10 drugs or drug classes associated with hallucinations, based on reports received by the West Midlands Centre for Adverse Drug Reaction Reporting (www. yccwm. org. uk/factsheets/hallucina-tions. pdf), are as follows: SSRIs, tramadol, bupropion, venlafaxine, quinolones, proton pump inhibitors, clarithromycin, zopliclone, ropinirole, beta-adrenoreceptor antagonists. Medical Conditions That May Present as/with Psychosis Addison's disease, CNS infections, CNS neoplasms, CNS trauma, Cushing's disease, folic acid deficiency, Huntington's chorea, MS, myxedema, pancreatitis, pellagra, pernicious anemia, porphyria, SLE, temporal lobe epilepsy, thyrotoxicosis.
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364 USEFUL RESOURCES PSy CHIATRIC MASQUERADE29. 8. Medication-Induced Psychiatric Conditions See also Section 12. 36, “Side Effects of Psychotropic Medications... ” Medication-induced psychiatric conditions can be due to mistaken failure to research known inter-actions and risks; to unknowable misadventure; or to anticipated and accepted risks that are out-weighed by the benefits, either actual or anticipated. There is a peculiar lack of current books on this subject. A British website, the Adverse Psychiatric Reactions Information Link (www. april. org. uk) has many links to articles and lists.
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Appendices Appendices Pages A. Abbreviations in Common Use 367 B. Annotated Readings in Assessment, Interviewing, 371 and Report Writing
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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367 A Abbreviations in Common Use Throughout the book, initials of common acronyms are capitalized and underlined. The abbreviations presented below include many in common use, as well as some I personally find useful. In the columns below, the abbreviation is given on the left and the full term on the right. A. 1. Clinicians/Mental Health Professionals Academic Degrees BSW Bachelor of Social Work DO Doctor of Osteopathy MA Master of Arts Ed D Doctor of Education MS Master of Science MD Doctor of Medicine MSW Master of Social Work Ph D Doctor of Philosophy Psy D Doctor of Psychology Psychology The two most widely recognized credentials in the field of psychology beyond the Ph D/Psy D and state licensure are entry into the National Register of Health Service Providers in Psychology and receipt of a diploma in any of 13 specialty areas from the American Board of Professional Psy-chology. In particular, the ABPP diploma is awarded only after an extensive evaluation of clinical skills and expertise. Beware: There are dozens of “vanity boards” and “diploma mills” conferring impressive-sounding and-looking credentials, whose standards of experience and skill are nonexis-tent or too low to impress those of your peers who have earned their credentials. Social Work Titles may differ by state. ACSW Academy of Certified Social Workers CSW Clinical or Certified Social Worker LCSW Licensed Certified Social Worker LGSW Licensed Graduate Social Worker LICSW Licensed Independent Clinical Social Worker LSW Licensed Social Worker LSWA Licensed Social Work Associate
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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368 APPENDICES Counseling Again, titles may vary. CAS Certified Addictions Specialist LPC Licensed Professional Counselor NBCC National Board for Certified Counselors NCC National Certified Counselor Nursing APRN Advanced Practice Registered Nurse BSN Bachelor of Science in Nursing CNA Certified Nursing Assistant CRNP Certified, Registered Nurse Practitioner LPN Licensed Practical Nurse MSN Master's of Science in Nursing RN Registered Nurse RNCS Registered Nurse, Certified Specialist PHN Public Health Nurse Other AT Art Therapist CAC Certified Alcoholism Counselor CCC Certificate of Clinical Competence (speech and language pathologist) COTA Certified Occupational Therapist Assistant LMFT Licensed Marriage and Family Therapist NCSP Nationally Certified Speech Pathologist OTR or OTR/L Occupational Therapist, Registered or Licensed PA Physician's Assistant PT Physical Therapist SLP Speech and Language Pathologist A. 2. Treatment IV Interview P/T Psychotherapy P/A Psychoanalysis S Summary Rx, Tx Treatment Th Therapist Hx History Px Prognosis h/o History of HW Homework Sx Symptom d/c Discontinue/ed NOS Not otherwise Dx Diagnosis d/ch Discharge/ed specified AMA Against medical PTA Prior to admission WNL Within normal advice limits A. 3. Diagnoses and Conditions Needless to say, only a small sampling of the many possible abbreviations in this category can be provided here.
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A. Abbreviations in Common Use 369 A Anxiety h/a Headache AOD Alcohol and other drugs H/A Heart attack Bip Bipolar disorder HBP Hypertension/high CHI Closed head injury blood pressure COPD Chronic obstructive LBP Low back pain pulmonary disease MCA Motorcycle accident CUS or CUSc Chronic undifferentiated MV A Motor vehicle accident schizophrenia MVP Mitral valve prolapse CV A Cerebral vascular accident P Panic D Depression Pa Paranoia D+A Drug and alcohol R/O Rule out D+H Delusions and hallucinations SI Suicidal ideation DM Diabetes mellitus sz Seizures GAD Generalized anxiety disorder TBI Traumatic brain injury GSW Gunshot wound tt Temper tantrum TT Toilet training A. 4. Relations 1 B Brother gf Girlfriend s Son bf Boyfriend GP1 Grandparent S Sister bil Brother-in-law H Husband sil Sister-in-law d Daughter HH Household W Wife Fa Father Mo Mother A. 5. General Aids to Recording a Before (ante) FTKA Failed to keep × 3 Times 3 @ At appointment ~ Approximate AO Anyone NO No one D Change c. About (circa) p or s/p After, by history ↓ Decreasing/-ed c With (cum) (post) ↑ Increasing/-ed d or d/ Divorced Q, ? Question < Less, lesser, D Died RTC Return to clinic smaller d/o Disorder RTW Return to work > More, greater, DNKA Did not keep s or w/o Without (sine) larger appointment S+S Signs and ∅ or -Not present, DNS Did not show symptoms absent DOB Date of birth w/d Withdrawal/ # Number DOD Date of death withdrew ⊕ Present, EO Everyone w/i or c/in Within positive for f Frequency 1° Primary \ Therefore 2° Secondary 1Grandparents may be further specified as follows: maternal grandmother/grandfather, MGM/MGF; paternal grand-mother/grandfather, PGM/PGF.
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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370 APPENDICES A. 6. Legal Terms CMM Corrupting the morals of a minor IVDU Intravenous drug use IA Indecent assault U A D Underage drinking IDSI Involuntary deviate sexual intercourse A. 7. Medication Regimens b. i. d. Twice a day p. c. After meals q. q. h. Every 4 hours h. s. At night/bedtime p. o. By mouth q. s. As much (hours of sleep) p. r. n. Whenever as required i. m. Intramuscular needed Sig. Schedule i. v. Intravenous q. d. Every day t. i. d. Three times o. m. Every morning q. i. d. Four times a day a day A. 8. Educational Services In this section, acronyms for disability categories are linked by arrows with acronyms for the appropriate services. A Autism AS Autism support ER Evaluation report HI Hearing impairment SIS Sensory impairment support ID Intellectual disability LS or LSS Learning support or life skills support (as appropriate) IEP Individualized education program NORA Notice of recommended assignment LD Learning disability LS Learning support MDT Multidisciplinary team MDE Multidisciplinary evaluation MR Mental retardation LS or LSS Learning support or life skills support (as appropriate) SEM/SED Social and emotional maladjustment/disturbance ES Emotional support SLI Speech and language impairment SLS Speech and language support VI Visual impairment support SIS Sensory impairment See also Section 22. 4, “Types of Therapies/Services. ”
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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371 B Annotated Readings in Assessment, Interviewing, and Report Writing Assessment Antony, M. M., & Barlow, D. H. (Eds. ). (2002). Handbook of assessment and treatment planning for psychological disorders. New York: Guilford Press. The value of this book lies in the successful integration of assessment into clinical care. It is organized by diagnosis, not by test, and the number of assessment tools for each is impressive. Clement, P. W. (1999). Outcomes and incomes: How to evaluate, improve, and market your psychotherapy practice by measuring outcomes. New York: Guilford Press. This book offers dozens of assessment tools specially designed to show changes in symptoms and other client aspects of therapeutic interest. Using one or two of these with each client allows the therapist to document initial levels, change in therapy, and further benefits. Clement also provides all the assistance needed to easily use his tools to evaluate one's clinical practice. Fischer, J., & Corcoran, K. (2007). Measures for clinical practice: A sourcebook (4th ed. ). New York: Oxford Uni-versity Press. If you need a questionnaire for your clinical work and want one with reliability and validity studies, it is probably in here. Groth-Marnat, G. (2009). Handbook of psychological assessment (5th ed. ). Hoboken, NJ: Wiley. The current standard concerning testing and evaluation. Comprehensive, up-to-date, solid data-based weighing of the tests. Strong on integrating data from different sources. For the beginner through the skilled clinician. Hebben, N., & Milberg, W. (2009). Essentials of neuropsychological assessment (2nd ed. ). Hoboken, NJ: Wiley. A basic book that covers administration, scoring, and interpretation of the common tests; the populations tested; and ways of constructing a good report. Lezak, M. D., Howieson, D. B., Loring, D. W., Hannay, J., & Fisher, J. S. (2004). Neuropsychological assessment (4th ed. ). New York: Oxford University Press. The standard in this area. For the beginner through the skilled clinician. Meehl, P. (1996). Clinical vs. statistical prediction: A theoretical analysis and a review of the evidence. Northvale, NJ: Aronson. (Original work published 1954) Still in print because it tells the truth: Mechanical formulas weighing objective data are more accurate than any clinician using his/her favorite test, etc. We clinicians don't like to hear that as we become more experienced, our confidence in our judgments rises, but the judgments do not become more valid. Read this before you go much further.
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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372 APPENDICES Interviewing Greenspan, S. I., & Greenspan, N. T. (2003). The clinical interview of the child (3rd ed. ). Washington, DC: Ameri-can Psychiatric Press. This classic text covers how to interview all ages, what to observe, how to interpret it, how to formulate a developmental profile in a biopsychosocial framework, and how to select diagnoses. It includes full case examples. Lukas, S. (1993). Where to start and what to ask: An assessment handbook. New York: Norton. She starts the beginner or student out right, with specific tools and usable guidance for gathering the information and integrating it into a coherent assessment. Mac Kinnon, R. A., Michels, R., & Buckley, P. J. (2006). The psychiatric interview in clinical practice (2nd ed. ). Washington, DC: American Psychiatric Publishing. Besides describing in detail how to interview, it covers psychodynamics, the major clinical syndromes, special situations, and even note taking and use of e-mail. Morrison, J. (2001). DSM-IV made easy: The clinician's guide to diagnosis (rev. ed. ). New York: Guilford Press. Do not go to DSM-IV to learn to diagnose. All that you need is easily accessible right here. It is like looking over the shoulder of a superb clinician, diagnostician, and interviewer at work. Just paging through it, even over familiar terrain, makes me feel smarter. For example, the discussions of “rule-outs” expand my understanding of dynamics, and the discussions of medical disorders that might be present sharpen my skills. Hundreds of perfectly constructed vignettes invite practice and consideration. Morrison, J. (2008). The first interview (3rd ed. ). New York: Guilford Press. If you are less interested in diagnosing and more interested in the dynamics of the interview, get ready to enjoy Morrison's gifts as a teacher. This book gives especially good advice on handling the many kinds of difficult interview situations clients can present. Rich with perfectly structured cases. Morrison, J., & Anders, T. F. (1999). Interviewing children and adolescents: Skills and strategies for effective DSM-IV diagnosis. New York: Guilford Press. The subtitle is accurate: This book is a step-by-step guide to building rapport, gathering information (for all ages), and constructing a useful report. Detailed diagnostic information is provided on all the disorders of children and the “adult” disorders seen in children. The book is clearly written, with many teaching tools and excellent examples. Perhaps it is the child equivalent of Lukas's book, with more on clinical presentations and diagnoses. Rogers, R. (2001). Handbook of diagnostic and structured interviewing. New York: Guilford Press. Interviewing has low reliability and therefore low validity. Structured interviews are the answer, and this book is a readable and reliable guide to selecting the most appropriate ones available for each disorder. Segal, D. L., & Hersen, M. (Eds. ). (2010). Diagnostic interviewing (4th ed. ). New York: Springer. The next step up from Lukas. Covers the basics, as well as various special and difficult situations. Shea, S. C. (1998). Psychiatric interviewing: The art of understanding. Philadelphia: Saunders. A big book (750 pages) but not intimidating. Absolutely comprehensive, yet simple and clear. Trzepacz, P. T., & Baker, R. W. (1993). The psychiatric mental status examination. New York: Oxford University Press. Just on the MSE, and under 200 pages, but everything you need to know on doing and interpreting it. Report Writing Braaten, E. (2007). The child clinician's report-writing handbook. New York: Guilford Press. The whole language of child mental health evaluations. Goldfinger, K., & Pomerantz, A. M. (2010). Psychological assessment and report writing. Thousand Oaks, CA: Sage. Concise. Covers many tests for gathering relevant information. Harvey, V. S. (2006). Variables affecting the clarity of psychological reports. Journal of Clinical Psychology, 62, 5-18. Provides solid guidelines for writers.
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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B. Annotated Readings 373 Lichtenberger, E. O., Mather, N., Kaufman, N. L., & Kaufman, A. S. (2004). Essentials of assessment report writ-ing. Hoboken, NJ: Wiley. Comprehensive, extensive, perfectly clear advice and guidance. The “gold standard” text for students. Michaels, M. (2006). Ethical considerations in writing psychological assessment reports. Journal of Clinical Psychology, 62, 47-58. Psych Assessment is a very practical webpage generously provided for graduate students by Richard Niolon, Ph D (www. psychpage. com/article_index. html#Psych Assessment).
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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374Feedback Solicitation Form Dear Fellow Clinician, I created this book to meet my needs as a clinician writing reports and gave it my best shot. I really would appreciate your best shot too, so that it may be further developed to aid all of us. New versions can be designed to meet our needs better if we work together. If you will send your suggestions, modifications and ideas (perhaps by photocopying the relevant pages), and they are adopted, I will give you credit in the revised editions and send you a free copy of the next edition. Ed Zuckerman P. O. Box 222, Armbrust, PA 15616 E-mail: edwardzuckerman@gmail. com Would you answer a few questions for me so I can better understand your professional life, please? Your name: Your professional title: Years in practice when you bought this book: Today's date: Your mailing address: Your phone/fax numbers: Your e-mail address(es): How often do you refer to this book? (Check one. ) Whenever I evaluate people. Fairly often, when I need some specific ideas and wording choices. Every time I write a report. Never now, but it was useful when I was learning to write reports. Other times: How do you use it? I use it for questions in evaluating people. I use it to teach evaluation or report writing. I use it to structure my report writing. I refer to it for specific information and wording choices. Other use(s): What is your overall evaluation of the Clinician's Thesaurus, 7th Edition, in just a few words? I would suggest the following changes: Increase these sections: Add coverage of the following: Decrease or eliminate these sections: As a clinician, I really wish there were a “tool” to:
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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375 About the Clinician's Electronic Thesaurus, Version 7. 0 If you write your reports on a computer and find this book helpful, the Clinician's Electronic Thesau-rus, Version 7. 0 (CET 7. 0) can make your report writing even easier. CET 7. 0 is an easy-to-use com-puter program, available on CD-ROM, that is filled with terms, standard phrasings, and common concepts—as found in Part II of this book. The program is also fully searchable and fully compat-ible with any Windows-based word- processing software. Terms can be quickly found, copied, and then pasted into your own word- processing documents. As with the book version, the computerized thesaurus covers the appropriate terms to describe almost any clinical situation from intake and diagnostic workup to psychological evaluations, psychosocial narratives, treatment plans, progress notes, case summaries, and closings. CET 7. 0 is a text library. You will never need to type the same paragraph again. CET 7. 0 can store all of your favorite wordings so you can use them repeatedly. You can store your technical terms, localized referral statements, complex treatment plans, test interpretation statements, or any other text. Then with only a few mouse clicks you can find them under your own choice of headings. CET 7. 0 is completely customizable by you for you. You can move text around or delete it (and reinstall it from the CD-ROM if you need it later). You can add new chapters, sections, and subsections to what is already present in the book. You can also change the fonts, font sizes, and formatting to highlight your preferred word choices in the text windows. Additional Productivity Features Easy-access definitions of numerous mental health and drug/alcohol terms. Ability to copy and paste more than one item at a time from the thesaurus into your docu- ment. Find command that searches the whole thesaurus to locate key words. You can then find similar words nearby. Fully compatible with Windows XP and all newer versions. CET 7. 0 is very simple to learn and use. It has a foolproof installation with our custom installer. Technical support is provided by Guilford by phone, fax, and e-mail. CET 7. 0 works with your word processor's resources, including spell-check, page formatting, and printing. A full set of Help files is available within the program under the Help menu. Witty documentation with many examples and tips is included with the CD-ROM.
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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376 About the Clinician's Electronic Thesaurus, Version 7. 0 Hardware Requirements PC with a Pentium chip or above. A hard disk with at least 11 megabytes (MB) of available space. At least 128 MB of RAM. A CD-ROM drive of any speed. Software Requirements Microsoft operating system of Windows XP or higher. Any word-processing program running under Windows. Want to see how this program can make your life easier? You can download a demonstration of the software at www. guilford. com/cet7. framesoft. html.
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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377 References Ackerman, N. (1982). The strength of family therapy. New York: Brunner/Mazel. Adams, D. (1991). Factitious disorders and malingering: Choosing the appropriate role for the psychologist. American Psychological Association Division 29 Newsletter, pp. 10-13. Adorno, T. W., Frenkel-Brunswik, E., Levinson, D. J., & Sanford, R. N. (1993). The authoritarian personality. New York: Norton. (Original work published 1950) American Academy of Sleep Medicine. (2005). International classification of sleep disorders: Diagnostic and coding manual (2nd ed. ). Westchester, IL: Author. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev. ). Washington, DC: Author. Babcock, M., & Mc Kay, M. C. (Eds. ). (1995). Challenging codependency: Feminist critiques. Toronto: University of Toronto Press. Barkley, R. A. (2005). Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment (3rd ed. ). New York: Guilford Press. Barkley, R. A., & Murphy, K. R. (2005). Attention-deficit hyperactivity disorder: A clinical workbook (3rd ed. ). New York: Guilford Press. Bateson, G. (1972). Steps to an ecology of mind. San Francisco: Chandler. Beavers, R. W. (1990). Successful families. New York: Norton. Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press. Beck, J. C. (1990). The potentially violent patient: Clinical, legal and ethical implications. In E. Margenau (Ed. ), The encyclopedic handbook of private practice. New York: Gardner Press. Benjamin, L. S. (1996). Interpersonal diagnosis and treatment of personality disorders (2nd ed. ). New York: Guilford Press. Berg, I. K., & Miller, S. D. (1992). Working with the problem drinker. New York: Norton. Bernard, S. D. (1991). A substance use checklist. In P. Keller & S. R. Heyman (Eds. ), Innovations in clinical practice: A source book (Vol. 10). Sarasota, FL: Professional Resource Exchange. Berne, E. (1964). Games people play. New York: Grove Press. Bernstein, E. M., & Putnam, F. W. (1986). Development, reliability, and validity of a dissociation scale. Journal of Nervous and Mental Disease, 174, 727-735. Blakiston's Gould medical dictionary (3rd ed. ). (1972). New York: Mc Graw-Hill. Bleuler, E. (1968). Dementia praecox, or the group of schizophrenias (J. Zinkin, Trans. ). New York: International Universities Press. (Original work published 1911) Bondi, M. (1992). Distinguishing psychological disorders from neurological disorders: Taking Axis III seri-ously. Professional Psychology: Research and Practice, 23(4), 306-309. Bongar, B. (2002). The suicidal patient: Clinical and legal standards of care (2nd ed. ). Washington, DC: American Psychological Association. Bornstein, R. (1997). Dependent personality disorder in the DSM-IV and beyond. Clinical Psychology: Science and Practice, 4(2), 175-187. Braaten, E. (2007). The child clinician's report-writing handbook. New York: Guilford Press. Brenner, E. (2003). Consumer-focused psychological assessment. Professional Psychology: Research and Practice, 34(3), 240-247. Breznitz, S. (1988). The seven kinds of denial. In C. Spielberger et al. (Eds. ), Stress and anxiety (Vol. 2). Wash-ington, DC: Hemisphere.
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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378 References Broverman, I. D., Broverman, D. M., Clarkson, F. E., Rosencrantz, P. S., & Vogel, S. R. (1970). Sex-role stereo-types and clinical judgements of mental health. Journal of Consulting and Clinical Psychology, 34, 1-7. Brown, M. L., & Rounsley, C. A. (2003). True selves: Understanding transsexualism—for families, friends, coworkers, and helping professionals. San Francisco: Jossey-Bass. Brown, W. A. (2006, May 26). Acknowledging preindustrial patterns of sleep may revolutionize approach to sleep dysfunction. Psychiatric Times. Retrieved from www. psychiatrictimes. com/display/article/10168/56881. Burgess, T., & Holmstrom, B. (1974). Rape trauma syndrome. American Journal of Psychiatry, 131(9), 981-986. Burns, D. D. (1999). Feeling good: The new mood therapy, revised and updated. New York: Harper. Cameron, N., & Rychlak, J. F. (1968). Personality and psychopathology. Boston: Houghton Mifflin. Campbell, R. J. (2009). Campbell's psychiatric dictionary (9th ed. ). New York: Oxford University Press. Cass, V. C. (1979). Homosexual identity formation: A theoretical model. Journal of Homosexuality, 4(3), 219-235. Cheyne, J. A., Newby-Clark, I. R., & Rueffer, S. D. (1999). Relations among hypnagogic and hypnopompic experiences associated with sleep paralysis. Journal of Sleep Research, 8(4), 313-317. Christophersen, E. R., & Mortweet, S. L. (2001). Treatments that work with children: Empirically supported strategies for managing childhood problems. Washington, DC: American Psychological Association. Cleckley, H. M. (1976). The mask of sanity (5th ed. ). St. Louis, MO: C. V. Mosby. Clement, P. W. (1999). Outcomes and incomes: How to evaluate, improve, and market your psychotherapy practice by measuring outcomes. New York: Guilford Press. Coons, P. M., & Milstein, V. (1986). Psychosexual disturbances in multiple personality: Characteristics, etiol-ogy, and treatment. Journal of Clinical Psychiatry, 47, 107-110. Costa, P. T., Jr., & Mc Crae, R. R. (1995). NEO-PI-R professional manual. Odessa, FL: Psychological Assessment Resources. Costa, P. T., Jr., & Widiger, T. A. (2002). Personality disorders and the five-factor model of personality (2nd ed. ). Washington, DC: American Psychological Association. Coulehan, J., & Block, M. (1987). The medical interview: A primer for students of the art. Philadelphia: Davis. Courtois, C. (2004). Complex trauma, complex reactions: Assessment and treatment. Psychotherapy: Theory, Research, Practice, and Training, 41(4), 412-425. Davis, T. C., Long, S. W., Jackson, R. H., et al. (1993). The Rapid Estimate of Adult Literacy in Medicine: A shortened screening instrument. Family Medicine, 25, 391-395. Denning, P. (2000). Practicing harm reduction psychotherapy: An alternative approach to addictions. New York: Guil-ford Press. Derogatis, L. R. (1994). The Symptom Checklist—90—Revised (SCL-90-R). Minneapolis: Pearson Assessments. Di Clemente, C. D. (2003). Addiction and change: How addictions develop and addicted people recover. New York: Guilford Press. Diener, E., & Biswas-Diener, R. (2008). Happiness: Unlocking the mysteries of psychological wealth. Malden, MA: Blackwell. Drum, D. J., Browson, C., Denmark, A. B., & Smith, S. E. (2009). New data on the nature of suicidal crises in college students: Shifting the paradigm. Professional Psychology: Research and Practice, 40(2), 213-222. Du Paul, G. J. (2003). Assessment of ADHD symptoms: Comment on Gomez et al. Psychological Assessment, 15(1), 115-117. Durkheim, E. (1966). Suicide: A study in sociology (J. Spaulding & G. Simpson, Trans. ). New York: Free Press. (Original work published 1897) Dutton, D. G. (2007). The abusive personality: Violence and control in intimate relationships (2nd ed. ). New York: Guilford Press. Ebert, B. W. (1987). Guide to conducting a psychological autopsy. Professional Psychology: Research and Practice, 18(1), 52-56. Edinger, J. D., & Carney, C. E. (2008). Overcoming insomnia: A cognitive-behavioral therapy approach. Therapist guide. New York: Oxford University Press. Ellis, A. E., & Dryden, W. (Eds. ). (1997). The practice of rational emotive behavior therapy (2nd ed. ). New York: Springer. Erikson, E. (1963). Childhood and society (rev. ed. ). New York: Norton. Esser, T. J. (1974). Effective report writing in vocational evaluation and work adjustment training. (Available from Materials Development Center, Department of Rehabilitation and Manpower, University of Wisconsin, Menomonie, WI 54751) Farberow, N. (Ed. ). (1980). The many faces of suicide: Indirect self-destructive behavior. New York: Mc Graw-Hill.
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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References 379 Fear, R. A. (1958). The evaluation interview: Predicting job performance in business and industry. New York: Mc Graw-Hill. Firestone, L. (1991). Firestone Voice Scale for Self-Destructive Behavior. (Available from The Glendon Association, 2049 Century Park East, Suite 3000, Los Angeles, CA 90067) Folstein, M. F., Folstein, S. E., & Mc Hugh, P. R. (1975). Mini-Mental State: A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189-198. Frisch, M. B. (1999). Quality of life therapy and assessment in health care. Clinical Psychology: Science and Prac-tice, 5(1), 19-40. Frisch, M. B. (2006). Quality of life therapy: Applying a life satisfaction approach to positive psychology and cognitive therapy. Hoboken, NJ: Wiley. Gardner, H. (1999). Multiple intelligences: New horizons. New York: Basic Books. Gardner, H. (2004). Frames of mind: The theory of multiple intelligences. New York: Basic. Garner, D. M., & Garfinkel, P. E. (1979). The Eating Attitudes Test: An index of the symptoms of anorexia nervosa. Psychological Medicine, 9, 273-279. Geller, J. A. (1992). Breaking destructive patterns. New York: Free Press. Gibbs, R. W., & Beitel, D. (1995). What proverb understanding reveals about how people think. Psychological Bulletin, 118(1), 133-154. Gill, D. J., Freshman, A., Blender, J. A., & Ravina, B. (2008). The Montreal Cognitive Assessment as a screening tool for cognitive impairment in Parkinson's disease. Movement Disorders, 23(7), 1043-1046. Goldberg, L. R. (1992). The development of markers for the Big Five factor structure. Psychological Assessment, 4, 26-42. Goleman, D. (1988, November 1). Narcissism looming larger as root of personality woes. The New York Times, pp. C1, C16. Gonsalves, C. (1992). Psychological stages of the refugee process: A model for therapeutic interventions. Profes-sional Psychology: Research and Practice, 23(5), 382-389. Goodman, A. (2005). Sexual addiction: Nosology, diagnosis, etiology, and treatment. In J. H. Lowinson, P. Ruiz, R. B. Millman, & J. G. Langrod (Eds. ), Substance abuse: A comprehensive textbook (4th ed., pp. 504-539). Philadelphia: Lippincott Williams & Wilkins. Goodman, A. (2009, May 26). Sexual addiction update: Assessment, diagnosis, and treatment. Psychiatric Times, 26(6). Available at www. psychiatrictimes. com/display/article/10168/1416827. Goodman, W. K., Rasmussen, S. A., Price, L. H., Mazure, C., Heninger, C. R., & Charney, D. S. (1989). Yale-Brown Obsessive Compulsive Scale. (Available from Clinical Neuroscience Research Unit, Connecticut Men-tal Health Center, 34 Park Street, New Haven, CT 06508). Gordon, R. (2010). The Psychodynamic Diagnostic Manual. In I. Weiner & E. Craighead (Eds. ), Corsini's ency-clopedia of psychology. Hoboken, NJ: Wiley. Gordon, T. (2000). Parent effectiveness training: The proven program for raising responsible children. New York: Three Rivers Press. Grant, I., & Atkinson, J. (1995). Psychiatric aspects of acquired immune deficiency syndrome. In H. I. Kaplan & B. J. Sadock (Eds. ), Comprehensive textbook of psychiatry (6th ed., Vol. 2, Sect. 29. 2, pp. 1644-1669). Balti-more: Williams & Wilkins. Gratz, K. (2003). Risk factors for and functions of deliberate self-harm: An empirical and conceptual review. Clinical Psychology: Science and Practice, 10(2), 192-205. Greenwood, D. U. (1991). Neuropsychological aspects of AIDS dementia complex: What clinicians need to know. Professional Psychology: Research and Practice, 22(5), 407-409. Greist, J. H., Jefferson, J. W., & Marks, I. M. (1986). Anxiety and its treatment: Help is available. Washington, DC: American Psychiatric Press. Groth-Marnat, G. (2009). Handbook of psychological assessment (5th ed. ). Hoboken, NJ: Wiley. Group for the Advancement of Psychiatry (GAP). (1990). Casebook in psychiatric ethics. New York: Brunner/ Mazel. Gruber, H. E., & Von Eiche, J. J. (1977). The essential Piaget. New York: Basic Books. Hagen, C., Malkmus, D., & Durham, P. (1979). Levels of cognitive functioning. In Rehabilitation of the head injured adult: Comprehensive physical management. Downey, CA: Los Amigos Research & Education Insti-tute, Rancho Los Amigos National Rehabilitation Center. Haley, J. (1984). Ordeal therapy. San Francisco: Jossey-Bass. Hamilton, M. (1960). A rating scale for depression. Journal of Neurology, Neurosurgery and Psychiatry, 23, 56-62. Harder, D. W., & Greenwald, D. F. (1999). Further validation of the shame and guilt scales of the Harder Per-sonal Feelings Questionnaire-2. Psychological Reports, 85, 271-281.
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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf
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