How do you manage Post-traumatic Stress Disorder?

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  • Assess clients presenting with posttraumatic stress disorder
  • Analyze therapeutic approaches for treating clients presenting with posttraumatic stress disorder
Evaluate outcomes for clients with post-traumatic stress disorder

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Posttraumatic Stress Disorder • • • • • • Assess clients presenting with posttraumatic stress disorder Analyze therapeutic approaches for treating clients presenting with posttraumatic stress disorder Evaluate outcomes for clients with posttraumatic stress disorder Review this week’s Learning Resources and reflect on the insights they provide. View the media Academic Year in Residence: Thompson Family Case Study and assess the client in the case study. For guidance on assessing the client, refer to pages 137–142 of the Wheeler text in this week’s Learning Resources. The Assignment Give an explanation of your observations of the client William in Thompson Family Case Study, including behaviors that align to the PTSD criteria in DSM-5. Then, explain therapeutic approaches you might use with this client, including psychotropic medications if appropriate. Finally, explain expected outcomes for the client based on these therapeutic approaches. Support your approach with evidence-based literature. Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company. Appendices, Figures, and Tables Provided to Supplement Psychotherapy for the Advanced Practice Psychiatric Nurse Second Edition Kathleen Wheeler, PhD, PMHCNS-BC, PMHNP-BC, APRN, FAAN ISBN: 978-0-8261-3625-1 Digital Product Contents 1. The Nurse Psychotherapist and a Framework for Practice Table 1.1 Table 1.2 Table 1.3 Figure 1.1 Figure 1.2 Figure 1.3 Figure 1.4 Table 1.4 Figure 1.5 Figure 1.6 Figure 1.7 Figure 1.8 Figure 1.9 Appendix 1.1 Appendix 1.2 Appendix 1.3 Appendix 1.4 Appendix 1.5 Appendix 1.6 Appendix 1.7 Appendix 1.8 Basic Education, Orientation, and Setting of Psychotherapy Practitioners   6 Comparison of Benner’s Model and the Stages of Learning   7 Timeline of the History of the Nurse Psychotherapist   8 Paradigms of care   9 Cyclical psychodynamics of a person with borderline personality disorder   10 Therapeutic window of arousal   11 Maslow’s hierarchy of needs   12 Cultural Competence: Have You Asked the Right Questions?   13 Adaptive information processing model   14 Treatment hierarchy framework for practice   15 Trauma and resource balance   16 Spiral of treatment process   17 Ms. A’s psychotherapy outcomes   18 Suggestions for Presenting a Case   19 Weekly Plan for Increasing Resources   21 Weekly Plan   23 Treatment and Case Management   24 Stage I   29 Stage II   30 Safe-Place Exercise   31 Container Exercise   32 2. The Neurophysiology of Trauma and Psychotherapy Figure 2.1 Figure 2.2 Figure 2.3 Table 2.1 Figure 2.4 Figure 2.5 Figure 2.6 Figure 2.7 Figure 2.8 Continuum of stress/trauma   33 Neuron and receptor site   34 Stages of brain development, regulation, and memory   35 Attachment Schemas   36 Therapeutic window of arousal    37 Structures of the brain   38 Cerebral cortex and brainstem   39 Right- and left-hemisphere functions   40 Trauma response pathway   41 3. Assessment and Diagnosis Table 3.1 Assessment Questions: Continuum of Openness   42 Table 3.2 Ego Functions for Assessment   43 Table 3.3 Observer-Rated Ego Function Assessment Tool   44 Table 3.4 A Fragment of the Inventory of Interpersonal Problems   45 Table 3.5 A Portion of the World Health Organization’s Spirituality, Religiousness, and Personal Beliefs Field-Test Instrument   46 From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC   Contents Table 3.6 Commonly Used Clinical Rating Scales   47 Figure 3.1 An elaborated genogram with demographic, occupational, and major life event ­information    48 Appendix 3.1 Outline of the Comprehensive Psychiatric Database   49 Appendix 3.2 Sample Assessment Form   54 Appendix 3.3 Dissociative Experiences Scale (DES)   57 Appendix 3.4 The Impact of Event Scale (IES)   60 Appendix 3.5 Zung Self-Rating Depression Scale (ZSRDS)   61 Appendix 3.6 Geriatric Depression Scale (GDS) (Short Form)   62 Appendix 3.7 Patient Health Questionnaire-9 (PHQ-9)   63 Appendix 3.8 Young Mania Rating Scale (YMRS)   64 Appendix 3.9 Hamilton Anxiety Rating Scale (HAM-A)   66 Appendix 3.10 Generalized Anxiety Disorder Questionnaire (GAD-7)   67 Appendix 3.11 Yale-Brown Obsessive–Compulsive Scale (Y-BOCS)   68 Appendix 3.12 Quality-of-Life Scale (QOL)   70 Appendix 3.13 CAGE Questionnaire   72 Appendix 3.14 Michigan Alcohol Screening Test (MAST)–Revised   73 Appendix 3.15 Child Attachment Interview (CAI) Protocol   74 Appendix 3.16 Adverse Childhood Experiences Scale   75 4. The Initial Contact and Maintaining the Frame Figure 4.1 Table 4.1 Appendix 4.1 Appendix 4.2 Appendix 4.3 Appendix 4.4 Appendix 4.5 Appendix 4.6 Treatment hierarchy and continuum of therapeutic communication.   77 Selected Therapeutic Communication Techniques   78 Notice of Privacy Practices   79 Contract   82 Process Note   84 Progress Note   85 Process Recording   86 Sample Termination Letter   89 5. Supportive and Psychodynamic Psychotherapy Figure 5.1 Cyclical psychodynamics   90 Table 5.1 Freud’s Psychosexual Stages   91 Table 5.2 Mahler’s Stages of Separation–Individuation   92 Table 5.3 Erikson’s Psychosocial Stages   93 Table 5.4 Comparison of Classical Psychodynamic Therapy With Relational Psychodynamic ­Therapy   94 Table 5.5 Selected Meta-Analytic Studies of Psychodynamic Psychotherapy   95 Table 5.6 Practice Guidelines for Psychiatric Disorders   96 Figure 5.2 Psychodynamic case formulation   97 Table 5.7 Basic Strategies of Dynamic Supportive Therapy   98 Figure 5.3 Case formulation and psychodynamic therapy   99 6. Eye Movement Desensitization and Reprocessing Therapy Table 6.1 EMDR Research: Selected Randomized Clinical Trials and Meta-Analyses   100 Table 6.2 EMDR Clinical Applications   103 Table 6.3 Eight-Phase Protocol for Eye Movement Desensitization and Reprocessing   105 Figure 6.1 Components of EMDR   106 Appendix 6.1 Lightstream Exercise   107 Appendix 6.2 Circle of Strength   108 7. Motivational Interviewing Table 7.1 Meta-Analyses of Motivational Interviewing With Substance Use, Smoking, and Health-Related Behaviors   109 From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 3 4 Contents 8. Cognitive Behavioral Therapy Table 8.1 Table 8.2 Table 8.3 Table 8.4 Table 8.5 Table 8.6 Table 8.7 Table 8.8 Table 8.9 Appendix 8.1 Evidence-Based Research for CBT   110 Socratic Dialogue   111 Socratic Dialogue Basic Rules   112 Cognitive Distortions   113 Steps in Cognitive Restructuring   114 Checklist of Patient Outcomes for Contingency Contract    115 Maladaptive Schemas   116 Hierarchy for Driving Fear of Bridges   117 CBT Therapist Website Resources for Specific Populations    118 Automatic Thought Record   119 9. Interpersonal Psychotherapy Table 9.1 Interactive Dialogue: Evidence of Abnormal Grief Task   120 11. Group Therapy Table 11.1 Table 11.2 Table 11.3 Examples of Theoretical Approaches and Focus of Approach   121 Evidence-Based Research for Group Psychotherapy   123 Phases of Group Formation/Development   124 12. Family Therapy Table 12.1 Four Major Family Therapy Approaches   125 13. Stabilization for Trauma and Dissociation Figure 13.1 Table 13.1 Table 13.2 Table 13.3 Appendix 13.1 Appendix 13.2 The spectrum of traumatic response   126 Diseases and Disorders of Trauma   127 Assessment/Outcome Instruments for Dissociation   128 Assessment/Outcome Instruments for Trauma   129 SPRINT 05-30-13   130 Progressive Muscle Relaxation   131 14. Dialectical Behavior Therapy for Complex Trauma Figure 14.1 Figure 14.2 Table 14.1 Figure 14.3 Figure 14.4 Figure 14.5 Figure 14.6 Figure 14.7 Characteristics of the DBT therapist   133 Behavioral chain analysis worksheet   134 Skills Modules in DBT   135 Sample diary card for standard DBT treatment   136 Sample behavioral chain analysis for teen conflict with mother   137 Sample behavioral chain analysis for medication adherence   138 Behavioral chain analysis for Mr. M   139 Mr. M’s early diary card   140 15. Psychopharmacotherapy and Psychotherapy Appendix 15.1 Appendix 15.2 Appendix 15.3 Collaborative Agreement   141 Collaborative Agreement (Optional Language Added)   142 Pharmacotherapy Consultation and Collaboration Request Form   143 16. Psychotherapeutic Approaches for Addictions and Related Disorders Table 16.1 Worldwide Prevalence, Health Risks, and Economic Burden of Addictions   145 Table 16.2 U.S. Prevalence, Health Risks, and Economic Burden of Addictions   146 Figure 16.1 Current, binge, and heavy alcohol use among persons (age 12 years and older) by age group  147 Table 16.3 Guiding Principles of Recovery   148 Table 16.4 Principles of Effective Treatment for Addictions   149 From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC   Figure 16.2 Figure 16.3 Table 16.5 Table 16.6 Table 16.7 Contents Components of comprehensive drug abuse treatment   150 Co-occurring disorders by severity   151 Screening Tools for Alcohol and Drug Use   152 Biopsychosocial Addiction Assessment   153 Feeling-State Addiction Protocol   154 17. Psychotherapy With Children Table 17.1 Key Events and Principles in Family-Centered Care Approach    155 18. Psychotherapy With Older Adults Table 18.1 Table 18.2 Table 18.3 Table 18.4 Treatment Options for Common Psychiatric Disorders in Older Adults   156 Modification of CBT for Older Adults   157 Modificationn of Interpersonal Psychotherapy for Older Adults   158 Distinguishing Reminiscence and Life Review   159 19. Reimbursement and Documentation Table 19.1 Revised Psychotherapy Codes All CPT Codes are Registered Exclusively to the American Medical Association   160 Table 19.2 Commonly Used CPT Codes   161 Table 19.3 Language Associated With E/M Codes   162 Table 19.4 CPT Requirements: History   163 Table 19.5 CPT Physical Exam Requirements for Psychiatry   164 Table 19.6 Tabulation of MDM Elements (Marshfield Criteria) Score Based on Highest 2 out of 3 in the Office or Other Outpatient Settings   165 Table 19.7 Determination of Level of MDM   166 Table 19.8 All Required E/M Elements   167 Appendix 19.1 Evaluation and Management Established Patient Office Progress Note   168 20. Termination and Outcome Evaluation Table 20.1 Figure 20.1 Appendix 20.1 Selected Holistic Outcome Measures   174 Level of outcome measurement in psychotherapy   175 Selected Instruments for Psychotherapy Outcome Measurement   176 From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 5 1 The Nurse Psychotherapist and a Framework for Practice TABLE 1.1 Basic Education, Orientation, and Setting of Psychotherapy Practitioners Discipline Education Orientation/Setting Psychiatrist MD (medical doctor) or DO (Doctor of Biological treatment, acute care, Osteopathy); 3-year psychiatric residency ­psychopharmacology and specific after medical school ­psychotherapy competencies for psychiatric MD residents; often inpatient orientation Psychologist PhD (research doctorate in p ­ sychology) or PsyD (clinical d ­ octorate in ­psychology); both u ­ sually 1-year ­internship after ­doctorate Psychotherapy and p ­ sychological testing Master’s level ­psychologist MA (Master of Arts) or MS (­Master of ­Science) or MEd (Master of E ­ ducation) Psychotherapy: some modalities, ­psychological testing Social worker MSW (Master of Social Work) Psychotherapy: interpersonal, family, group; community o ­ rientation Marriage and family therapists MA (Master of Arts) Systems and family therapy, marriage ­counseling; community outpatient ­orientation Counselor MA (Master of Arts in counseling) or Counseling, vocational, and educational MEd (Master of Education in c­ ounseling) testing; outpatient orientation Advanced practice ­psychiatric nurse (APPN) (clinical ­specialist in psychiatric nursing or ­psychiatric-mental health nurse ­practitioner) MSN (Master of Science in Nursing) or DNP (Doctor of Nursing Practice) Psychopharmacology and p ­ sychotherapy; group and i­ndividual, sometimes family From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 1 The Nurse Psychotherapist and a Framework for Practice TABLE 1.2 Comparison of Benner’s Model and the Stages of Learning Stages of Learning Benner’s Model Unconscious incompetency Novice no experience, governed by rules and regulations Conscious incompetency Advanced beginner recognizes aspects of situations and makes judgments Conscious competency Competency/Proficiency 2 to 5 years experience, coordinates complex care and sees situations as wholes, and long-term solutions Unconscious competency Expert flexible, efficient, and uses intuition From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 7 8 1 The Nurse Psychotherapist and a Framework for Practice TABLE 1.3 Timeline of the History of the Nurse Psychotherapist  1947 Eight programs established for advanced preparation of nurses to care for psychiatric patients  1952 Hildegard Peplau establishes the first master’s in clinical nursing and a “Sullivanian” framework for practice for psychotherapy with inpatients and outpatients Perspectives in Psychiatric Care first published as a forum for interprofessional p ­ sychiatric articles  1963   1967 American Nurses Association (ANA) Position Paper on Psychiatric Nursing—PCS (psychiatric clinical specialist) assumes role of individual, group, ­family, and milieu therapist  1979  2000 ANA certification of PMHCNS American Nurses Credentialing Center (ANCC) certification of PMHNP  2001 Family PMHNP ANCC Exam  2003 PMHNP Competencies developed and delineate “conducts individual, group, and/or f­ amily psychotherapy” for PMHNP practice  2011 APNA and ISPN endorse PMHNP as the entry role for all advanced practice psychiatric nurses  2013 PMHNP Competencies revised  2014 Only PMHNP Across the Life Span ANCC certification From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 1 The Nurse Psychotherapist and a Framework for Practice Biomedical/Allopathic model Holistic model lationship Re dication Me Relationship Medication Selfcare Aim is to cure Aim is to heal FIGURE 1.1 Paradigms of care. From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 9 10 1 The Nurse Psychotherapist and a Framework for Practice Depression Projection/ Acting out Abandonment Anxiety FIGURE 1.2 Cyclical psychodynamics of a person with borderline personality disorder. From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 1 The Nurse Psychotherapist and a Framework for Practice Therapeutic window Hyperarousal (sympathetic system) Hypoarousal (parasympathetic system) FIGURE 1.3 Therapeutic window of arousal. From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 11 12 1 The Nurse Psychotherapist and a Framework for Practice Selfactualization Self-esteem Love and belonging Safety and security Physiological needs FIGURE 1.4 Maslow’s hierarchy of needs. Adapted from Maslow, A. H. (1972). The farther reaches of human nature. New York: Viking. From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 1 The Nurse Psychotherapist and a Framework for Practice TABLE 1.4 Cultural Competence: Have You Asked the Right Questions? Awareness Are you aware of your personal biases and prejudices toward cultures different than your own? Skill Do you have the skill to conduct a cultural assessment and perform a culturally based physical exam? Knowledge Do you have the knowledge of the patient’s worldview, cultural-bound ­illnesses, and the field of ­biocultural ecology? Encounters How many face-to-face encounters have you had with patients from diverse cultural backgrounds? Desire What is your desire to “want to be” culturally competent? From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 13 14 1 The Nurse Psychotherapist and a Framework for Practice Interventions Body Emotion Beliefs Images Behavior Relationships Adaptive information processing Community and culture FIGURE 1.5 Adaptive information processing model. From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 1 The Nurse Psychotherapist and a Framework for Practice 15 Enhance future visioning Processing Stabilization Increase ability to tolerate negative/positive affect/distress Case management provide safety Increase internal resources Increase external resources FIGURE 1.6 Treatment hierarchy framework for practice. Adapted from Davis, K., & Weiss, L. (2004). Traumatology: A workshop on traumatic stress disorders. EMDR Humanitarian Assistance Programs. From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 16 1 The Nurse Psychotherapist and a Framework for Practice Resources: Traumas: Poverty Caregiver depression Learning disability Pet recently died Physical health Loving extended family Impulse control FIGURE 1.7 Trauma and resource balance. From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 1 The Nurse Psychotherapist and a Framework for Practice Integration Processing leads to expansion of consciousness… FIGURE 1.8 Spiral of treatment process. From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 17 18 1 The Nurse Psychotherapist and a Framework for Practice 100 90 80 70 Anxiety 60 DES 50 BDI 40 HRU 30 GAF 20 10 s on th #4 m k #3 6 w k w #1 R #2 k w k w D R EM D #3 #4 EM k w k w #2 k w w k #1 0 FIGURE 1.9 Ms. A’s psychotherapy outcomes. Anxiety, Spielberger trait anxiety scale; BDI, beck depression inventory; DES, dissociative experiences scale; GAF, global assessment of functioning; HRU, health resource utilization. From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 1 The Nurse Psychotherapist and a Framework for Practice 19 APPENDIX 1.1 Suggestions for Presenting a Case Presenting a case can seem overwhelming, especially with complex patients. The following guidelines are intended to help you organize your thinking, summarize salient information about your patient in a coherent manner, identify areas where the therapy is stuck (resistance), and formulate questions that may offer insight into the process. Identifying information should be disguised. Basic Information Demographics: age, race/ethnicity, gender, sexual orientation, education, occupation Family: relationship status, living arrangement, members of immediate family, extended r­ elevant family members Working Diagnosis and Symptoms: dissociation, anxiety, depression, eating disorder, ­substance abuse, ­self-injury, and suicide attempts, destructive or violent behavior Relevant Medical Problems and Physical Disabilities: diabetes, asthma, chronic pain, birth defects, sensory impairment, impaired mobility, and so on Patient’s Coping Mechanisms: both healthy and unhealthy, defenses, ego functioning Treatment History: inpatient, outpatient, how long and intensive, treatment failures and responses Current Treatment: inpatient, outpatient, partial individual, group, family Medication(s): current and past history Case Conceptualization 1. 2. 3. 4. 5. 6. 7. 8. What are the reasons the patient came for treatment now? What are the patient’s goals? How would the person know if the treatment was s­ uccessful? When did the current symptoms start? What other situations may be contributing to the problem now? Speculate on what experiential contributors from the past might be driving the current symptoms? Is there a current crisis? Resources and strengths Draw a timeline with the patient of the most disturbing and pleasant events in the person’s life and rate ­ disturbances on a 0 to 10 scale with 10 being the most disturbing. See Chapter 13 for example of timeline. Questions to Ponder What’s going well in the therapeutic process, and what is problematic? Have you established a therapeutic ­alliance? Is the patient’s life stabilized? Is the patient avoiding or working on issues? Undermining the therapy? Flooding with memories or decompensating? From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 20 1 The Nurse Psychotherapist and a Framework for Practice What makes you want to present this patient? What’s unusual, special, difficult, confusing, arousing, frustrating, scary, overwhelming? What do you experience with this patient that is unusual for you? Do you feel intense emotions, like or dislike, anger, admiration, humiliation, fear, revulsion, sleepy, dizzy, disoriented, a desire to nurture or rescue, the urge to confront. Do you wish you could get rid of this patient, or are you afraid of losing him or her? Treatment Hierarchy Based on this information and the hierarchy of treatment in your book, what do you think is the most appropriate interventions/treatment for this person now? What are treatment priorities? From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 1 The Nurse Psychotherapist and a Framework for Practice 21 APPENDIX 1.2 Weekly Plan for Increasing Resources Check off, in the column to the left, all activities that you currently do and keep track of how often you do them for 1 week in the columns to the right. Then put a + in the column to the left of those activities you would like to try in the future. Select one with your therapist to try for the following week, and check off how often you do it. Some of these are learned skills that your therapist may teach you. The idea is to gradually build up and integrate more resources into your life. Mon Tues Wed Thurs Fri Sat Sun Practice deep breathing technique Practice safe place Practice yoga Practice meditation/mindfulness Practice progressive muscle relaxation Exercise for 30 minutes Keep a thought diary Develop a list of positive attributes of self Practice stopping negative self-talk Use affirmations to counter mistaken beliefs Practice imagery Chant or pray or sing Engage in soothing activities (warm bath, nature walk, gardening, …) Practice real-life desensitization Keep a feelings journal Identify and rate feelings (0–10) Express feelings Practice assertive communication Develop a list of actual positive ­memories Practice grounding techniques (counting, holding object, stomping feet, …) Take a step toward achieving goal(s) Keep a dream journal Develop a healing ritual for a specific loss Implement a contingency contract Keep a food diary Eliminate caffeine/sugar/stimulants (continued) From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 22 1 The Nurse Psychotherapist and a Framework for Practice Mon Tues Wed Thurs Eat only whole unprocessed food (­especially fruits & vegetables) Color, draw, or paint Keep a log about life’s purpose and ­meaning Watch inspiring or funny movies Keep alcohol consumption to one or less drinks per day Use spiritual beliefs and practices Read self-help literature Listen to helpful audiotapes Reach out to others Listen to or play music Talk to a nurturing person Attend an appropriate group (AA, ­support group, …) Pet and/or play with dog or cat Sleep 6 to 8 hours at night From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC Fri Sat Sun 1 The Nurse Psychotherapist and a Framework for Practice APPENDIX 1.3 Weekly Plan Please fill in two to three goals for the week and check off each day that you meet that goal. Mon Tues Wed Thurs Fri Sat Goal #1 Goal #2 Goal #3 From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC Sun 23 24 1 The Nurse Psychotherapist and a Framework for Practice APPENDIX 1.4 Treatment and Case Management Client: Address: Date: Phone: Insurance: Note: At the end of this form is the form for Client Case Management Needs, which clients can fill out before the session to identify their key areas of need. However, it is still important for the therapist to assess each goal directly, because clients may not be aware of some needs. 1. Housing Characteristics Goal Stable and safe living situation. Notes Unhealthy living situations include short-term shelter, living with a person who abuses substances, an unsafe neighborhood, and a domestic violence situation. Status If the goal is already met, check here      and describe. If the goal is not met, check here      and fill out the Case Management Goal Sheet. 2. Individual Psychotherapy Goal Treatment that client finds helpful. Notes Try to get every client into individual psychotherapy. Inquire whether the client has any preferences (e.g., gender, theoretical orientation). Status If the goal is already met, check here      and describe. If the goal is not met, check here      and fill out the Case Management Goal Sheet. 3. Psychiatric Medication Goal Treatment that client finds helpful for psychiatric symptoms (e.g., depression, sleep problems) or substance abuse (e.g., naltrexone for alcohol cravings). Notes If the client has never had a psychopharmacologic evaluation, one is strongly recommended, unless the client has serious objections; even then, evaluation and information are helpful before making a decision. Status If the goal is already met, check here      and describe. If the goal is not met, check here      and fill out the Case Management Goal Sheet. 4. HIV Testing and Counseling Goal Test as soon as possible, unless one was completed in the past 6 months and there have been no highrisk behaviors since then. For a client at risk for human immunodeficiency virus (HIV) infection who is unwilling to get testing and counseling, it is strongly suggested that the therapist hold an individual session with the client to explore and encourage these goals. Notes Assist patient with accessing community resources in your geographic area. Status If the goal is already met, check here      and describe. If the goal is not met, check here      and fill out the Case Management Goal Sheet. From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 1 The Nurse Psychotherapist and a Framework for Practice 25 5. Job, Volunteer Work, and School Goal At least 10 hours per week of scheduled productive time. Notes If the client is unable to meet the goal of 10 hours/week, have the client hand in a weekly schedule with constructive activities out of the house (e.g., library, gym). Status If the goal is already met, check here      and describe. If the goal is not met, check here      and fill out the Case Management Goal Sheet. 6. Self-Help Groups and Group Therapy Goal As many groups as the client is willing to attend. Notes Elicit the client’s preferences, and consider a wide range of options (e.g., dual-diagnosis groups, women’s groups, veterans’ groups). For self-help groups (e.g., Alcoholics Anonymous), give the client a list of local groups, strongly encourage attendance, and mention that the sessions are free. However, do not insist on self-help groups or convey negative judgment if the client does not want to attend. If the client participates in self-help groups, encourage seeking a sponsor. Status If the goal is already met, check here      and describe. If the goal is not met, check here      and fill out the Case Management Goal Sheet. 7. Day Treatment Goal As needed and based on the client’s level of impairment, ability to attend a day program, and schedule. Notes If possible, locate a specialty day program (e.g., substance abuse, post-traumatic stress disorder). If the client is able to attend (e.g., job, school, volunteer activity), do not refer to day treatment, because it is usually better to have the client keep working; however, if the client is working part-time, some programs allow partial attendance. Status If the goal is already met, check here      and describe. If the goal is not met, check here      and fill out the Case Management Goal Sheet. 8. Detoxification and Inpatient Care Goal To obtain an appropriate level of care. Notes Detox is necessary if the client’s use is so severe that it represents a serious danger (e.g., likelihood of suicide, causing severe health problems, withdrawal requires medical supervision, such as for painkillers or severe daily alcohol use). If the client is not in acute danger but cannot get off substances, detox may or may not be helpful; many clients are able to stay off substances during the detox but return to their usual living environment and go back to substance use. For such clients, helping set up adequate outpatient supports is usually preferable. Inquiring about client’s history (e.g., number of past detox episodes and their impact) can be helpful in making a decision. Psychiatric inpatient care is typically recommended if the client is a serious suicide or homicide risk* (i.e., not simply ideation, but immediate plan, intent, and inability to contract for safety) or the client’s psychiatric symptoms are so severe that functioning is impaired (e.g., psychotic symptoms prevent a mother from caring for her child). In some circumstances, the client may need to be involuntarily committed; seek supervision and legal advice on this topic. Status If the goal is already met, check here      and describe. If the goal is not met, check here      and fill out the Case Management Goal Sheet. 9. Parenting Skills and Resources for Children Goal If the client has children, inquire about parenting skills training and about referrals to help the children obtain treatment, health insurance, and other needs. Notes You may need to gently inquire to assess whether the client’s children are being abused or neglected. If so, you are required by law to report it to your local protective service agency. The same rule applies for elder abuse or neglect. Status If the goal is already met, check here      and describe. If the goal is not met, check here      and fill out the Case Management Goal Sheet. 10. Medical Care Goals Annual examinations for (1) general health, (2) vision, (3) dentistry, and (4) gynecology (for women), including (5) instruction about adequate birth control and prevention of sexually transmitted ­diseases. From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 26 1 The Nurse Psychotherapist and a Framework for Practice Notes Status Other medical care may be needed if the client has a particular illness. If all five goals are already met, check here      and describe. If any of the five goals is not met or other medical issues need attention, check here      and fill out the Case Management Goal Sheet for each. 11. Financial Assistance (e.g., food stamps, Medicaid) Goal Health insurance and adequate finances for daily needs. Notes It is crucial to help the client obtain health insurance and entitlement benefits (e.g., food stamps, Medicaid), if needed. The client may need help filling out the forms; the client may be unable to manage the task alone, because the bureaucracy of these programs can be overwhelming. If much help is needed, you may want to refer the client to a social worker or other professional skilled in this area. If the client is a parent, be sure to check whether the children are eligible. Status If the goal is already met, check here      and describe. If the goal is not met, check here      and fill out the Case Management Goal Sheet. 12. Leisure Time Goal At least 2 hours per day in safe leisure activities. Notes Leisure includes socializing with safe people and activities such as hobbies, sports, outings, and movies. Some clients are so overwhelmed with responsibility that they do not find time for themselves. Adequate leisure is necessary for maintaining a healthy lifestyle. Status If the goal is already met, check here      and describe. If the goal is not met, check here      and fill out the Case Management Goal Sheet. 13. Domestic Violence and Abusive Relationships Goal Freedom from domestic violence and abusive relationships. Notes It may be extremely difficult to get the client to leave a situation of domestic violence. Be sure to consult a supervisor and a domestic violence hotline representative. Status If the goal is already met, check here      and describe. If the goal is not met, check here      and fill out the Case Management Goal Sheet. 14. Impulses to Harm Self or Others (e.g., suicide, homicide) Goal Absence of such impulses, or if such impulses are present, a clear and specific safety plan is in place. Notes Many clients have thoughts of harming self or others; however, to determine whether the client is at serious risk for action and how to manage this risk, see the guidelines developed by the International Society of Study for D ­ issociative Disorders in Chapter 3. Status If the goal is already met, check here      and describe. If the goal is not met, check here      and fill out the Case Management Goal Sheet. 15. Alternative Treatments (e.g., acupuncture, meditation) Goal The client is informed about alternative treatments that may be beneficial. Notes Clients should be informed that some people in early recovery benefit from acupuncture, meditation, and other nonstandard treatments. Try to identify local referrals for such resources. Status If the goal is already met, check here      and describe. If the goal is not met, check here      and fill out the Case Management Goal Sheet. 16. Self-Help Books and Materials Goal The client is offered one or two suggestions for self-help books and other materials, such as audiotapes or Internet sites, that offer education and s­ upport. Notes All clients should be encouraged to use self-help materials outside of sessions as much as possible. For clients who do not like to read, alternative modes (e.g., audiotapes) are suggested. Self-help can address posttraumatic stress disorder, substance abuse, or any other life problems (e.g., study skills, parenting skills, relationship skills, leisure activities, medical problems). Status If the goal is already met, check here      and describe. If the goal is not met, check here      and fill out the Case Management Goal Sheet. 17. Additional Goal Goal Notes *For homicide risk or any other intent to physically harm another person, the therapist must follow “duty to warn” legal standards, which usually involve an immediate warning to the specific person the client plans to assault. Always seek supervision and legal advice, and be knowledgeable in advance about how to manage such a situation. From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 1 The Nurse Psychotherapist and a Framework for Practice CASE MANAGEMENT GOAL SHEET Client: Date: Goal: Referrals given to client, date given, and deadline (if any) for each: Describe client’s motivation to work on this goal: Emotional obstacles that may hinder completion (and strategies implemented to help client overcome these): Therapist to do: Follow-up (date and update): From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 27 28 1 The Nurse Psychotherapist and a Framework for Practice CLIENT CASE MANAGEMENT NEEDS Do you need help with any of the following? (circle one) 1. Housing characteristics Yes/Maybe/No 2. Individual psychotherapy Yes/Maybe/No 3. Psychiatric medication Yes/Maybe/No 4. HIV testing and counseling Yes/Maybe/No 5. Job, volunteer work, and school Yes/Maybe/No 6. Self-help groups and group therapy Yes/Maybe/No 7. Day treatment Yes/Maybe/No 8. Detoxification and inpatient care Yes/Maybe/No 9. Parenting skills and resources for children Yes/Maybe/No 10. Medical care Yes/Maybe/No 11. Financial assistance (e.g., food stamps, Medicaid) Yes/Maybe/No 12. Leisure time Yes/Maybe/No 13. Domestic violence and abusive relationships Yes/Maybe/No 14. Impulses to harm self or others (e.g., suicide, homicide) Yes/Maybe/No 15. Alternative treatments (e.g., acupuncture, meditation) Yes/Maybe/No 16. Self-help books and materials Yes/Maybe/No 17. Additional goal Yes/Maybe/No Permission to photocopy this form is granted to purchasers of this book for personal use only. Adapted from Najavits, L. M. (2002). Seeking safety: A treatment manual for PTSD and substance abuse. New York, NY: Guilford Press. From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 1 The Nurse Psychotherapist and a Framework for Practice APPENDIX 1.5 Stage I STABILIZATION CHECKLIST Please check all indicators below to help assess whether client is stabilized and ready to move to Stage II. Comfort with own body and physical experience Client is able to establish a useful distance from the traumatic event No current life crisis such as impending litigation or medical problems Client accepts diagnosis and has a working knowledge of trauma Client’s mood is stable, even if depressed Client has at least two or more people to count on Client knows and uses self-soothing techniques Client gives honest self-reports Client’s living situation is stable Client is able to communicate Client has stable therapeutic relationship and adequate trust of others Client has adequate impulse control, no injurious behavior to self or others Client stays grounded and oriented x3 when distressed No major dissociation present Client can identify triggers and reports significant symptoms Client can set limits and is able to leave dangerous situations if necessary Client can tolerate positive and negative affect, and shame If DID, is cooperative and has contractual agreement among parts Client can establish “useful distance” from traumatic event From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 29 30 1 The Nurse Psychotherapist and a Framework for Practice APPENDIX 1.6 Stage II PROCESSING CHECKLIST Please check all indicators below to help assess whether client has adequately processed trauma and is moving to Stage III, future visioning. The stabilization checklist should already have been achieved. No significant affect changes Self-referencing cognitions are positive in relation to past event Can dismiss thoughts of trauma at will Relationships are adaptive Work is productive Good quality of decision making Creativity begins to emerge Boundaries improve Complaints tend to deal with present day events Affect is proportionate to current events Congruence between behavior, thoughts, and affect From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 1 The Nurse Psychotherapist and a Framework for Practice 31 APPENDIX 1.7 Safe-Place Exercise The safe-place exercise described below helps the client to enhance skills during s­ tabilization as well as to decrease distress after processing. Through the ability to create one’s own safe place, the person is empowered. As with all learning, the more it is practiced, the more readily available it is when needed. Thus, it should be used on a dayto-day basis. If a client feels there is no place—real or imaginary—that is safe, have the client focus on one time in his or her life when he or she felt safe or on a person he or she admires who exemplifies positive attributes, such as strength or control. If the person still cannot find a safe place, ask them to think of a place where they feel relaxed or comfortable. Sometimes clients become more distressed when they relax and it may take some time before the person is able to identify a positive resource. Identifying a safe place resource may take several sessions. Ask the person to sit with his or her feet firmly planted on the floor. Sometimes this exercise is conducted with soothing music and/ or background nature sounds. Some therapists tape the exercise with their voice to give to the client to practice at home. The safe-place exercise follows. Ask the person to identify an image of a safe place that he or she can easily evoke that creates a personal feeling of calm and safety. Use soothing tones to enhance the imagery, asking the person to “see what you see,” “feel what you feel,” “notice the sounds, smells, and colors in your special place.” Once identified, ask the person to focus on the image, feel the emotions, and identify the location of the pleasing physical sensations and where he or she is in the body. “Concentrate on those pleasant sensations in your body and just enjoy as you breathe deeply, relaxing and feeling safe.” After you have slowly deepened his or her experience of this, slowly ask the person to come back and tell you a description of the place. Ask for details so that you can assist the person in accessing this place in the future. Ask how he or she feels and if the experience has been difficult for the person and/or no positive emotions are experienced, explore other resources that might be helpful. If at any time the person indicates that he or she is not feeling safe, the exercise should be stopped immediately. If successful in accessing a safe place, the person is asked for a single word that fits the picture (i.e., beach, forest…) and then asked to repeat the exercise using the person’s words for the experience along with deep breathing. Then ask the person to repeat on his or her own, bringing up the image, emotions, and body sensations. Reinforce, after this exercise, that his or her safe place can be used as a resource and ask the client to practice over the next week, once a day. During the next session, practice again with the person. Then ask the client to bring up a minor annoyance and notice the negative feelings while guiding the person through the safe place until the negative feelings have dissipated. Then ask the person to bring up a negative disturbing thought once again and to access the safe place but this time on his or her own without your assistance. Occasionally the safe-place exercise triggers intense negative affect. Clients should be made aware about the possible activation of issues during the safe-place exercise. Reassure the person that even if temporary activation of issues does occur, this is not beyond the limits of expectation, and that it may identify issues that will be addressed in the course of therapy anyway. From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 32 1 The Nurse Psychotherapist and a Framework for Practice APPENDIX 1.8 Container Exercise This exercise is an important affect management strategy that can be taught to the client and practiced so that the person can feel in control and develop mastery over his or her emotions. It also assists with self-soothing, decreasing arousal, and reinforces a sense of safety. The person should already have a safe place. This exercise should be initiated toward the end of the session when the person has intense negative feelings of anxiety, anger, fear, and/or sadness. The therapist introduces by saying something like: “Did you know that we can put those bad feelings into a container so you won’t feel so overwhelmed when you leave?” The person’s curiosity is usually piqued at this point even if he or she does not believe you. Continue with: “I can help you do this and then you can take out those feelings when you want and deal with them the next time we meet or when you decide it is okay.” Usually the person agrees if for no other reason than he or she is curious and may think you are really strange to suggest such a thing. The therapist continues in a soothing tone: “So, just imagine you have a container, you can close your eyes or not as you wish. It can be made out of anything that you want and be any size you want but be sure it has a tight lid that you can cover or lock because we are going to put all those negative feelings in. Let me know once you have an image in your head.” Once the person says he or she has the image, ask him or her for a few details regarding size and so on. Then ask the client to “return to the image and imagine all those bad feelings going into the container. Once you have all the bad feelings in the container, lock it up. Let me know when they are in there.” Once the person says they are in the container, ask the person whether there is any percentage that is still not in the container and usually the person will say something like 10% or 20%. At that point, ask the person: “Do you need a bigger container to accommodate all the bad feelings? You can make it as big as you want. See whether you can put the rest of those feelings in the container now. Let me know when the rest of the feelings are all in the container and locked.” If more negative feelings come up, continue with either imaging another container or making the one he or she has bigger. Ask the person what this was like for him or her, checking to see whether he or she is okay. It is important to do this exercise slowly and use pacing so that the person does not feel rushed. The session can then be ended with the safe place exercise. Ask the person to practice the container exercise during the week when negative feelings come up. The client can also practice allowing the feelings to come out if they think they can manage this and journal about these feelings between sessions. Asking the person at in the next session: “What was different for you this past week?” and exploring how feelings were or were not manageable are important follow-up steps and help to assess how to increase the effectiveness of this exercise. Modified and adapted with permission from Ginger Gilson, from Gilson, G., & Kaplan, S. (2000). The therapeutic interweave in EMDR. From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 2 The Neurophysiology of Trauma and Psychotherapy Stress Trauma >>helplessness FIGURE 2.1 Continuum of stress/trauma. From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 34 2 The Neurophysiology of Trauma and Psychotherapy Neuron Neurotransmitters Receptors Neuron FIGURE 2.2 Neuron and receptor site. From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 2 The Neurophysiology of Trauma and Psychotherapy Selfregulation EXPLICIT MEMORY (conscious) Semantic Declarative Episodic CORTEX Attentional regulation LIMBIC BRAINSTEM Emotional regulation IMPLICIT MEMORY (unconscious) Procedural Emotional Relationship Somatic Physiological regulation Complexity Plasticity FIGURE 2.3 Stages of brain development, regulation, and memory. From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 35 36 2 The Neurophysiology of Trauma and Psychotherapy TABLE 2.1 Attachment Schemas Infant Strange Situation Adult Attachment Interview Secure Secure/Autonomous Avoidant Dismissing Ambivalent/Resistant Preoccupied Disorganized/Disoriented Unresolved/Disorganized Source: Ainsworth, M. D. (1967). Infancy in Uganda. Baltimore: Johns Hopkins; Hesse, E. (1999). The adult attachment interview: Historical and current perspectives. In J. Cassidy & P. R. Shaver (Eds.), Handbook of attachment: Theory, research, and clinical applications (pp. 395–433). New York, NY: Guilford Press. From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 2 The Neurophysiology of Trauma and Psychotherapy First response: Social engagement parasympathetic ventral vagal Therapeutic window Second response: Hyperarousal sympathetic system Third response: Hypoarousal parasympathetic unmyelinated dorsal vagal FIGURE 2.4 Therapeutic window of arousal. Adapted from Porges, S. W. (2011). The polyvagal theory. New York, NY: W.W. Norton. From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 37 38 2 The Neurophysiology of Trauma and Psychotherapy Anterior cingulate cortex Corpus callosum Cerebral cortex Hippocampus Amygdala Thalamus Hypothalamus Pituitary gland Brainstem Spinal cord Cerebellar vermis Cerebellum Pons Locus ceruleus FIGURE 2.5 Structures of the brain. From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 2 The Neurophysiology of Trauma and Psychotherapy FRONTAL PARIETAL OCCIPITAL Orbital prefrontal cortex TEMPORAL Broca area (motor speech) Insula and anterior cingulate (hidden under frontal and temporal lobes) Wernicke area (sensory speech) Pons Brainstem Cerebellum FIGURE 2.6 Cerebral cortex and brainstem. From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 39 40 2 The Neurophysiology of Trauma and Psychotherapy Left hemisphere Right hemisphere Right side control of body Appraisal of safety and danger of others Organizes body and emotional self Left side control of body Spoken and written language Numerical and scientific skills Space and pattern perception Insight and imagination Reasoning and logic Positive emotions Negative emotions Daydreaming Reality-based Practical Musical and artistic awareness Corpus callosum Symbols and images FIGURE 2.7 Right- and left-hemisphere functions. From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 2 The Neurophysiology of Trauma and Psychotherapy ORBITOFRONTAL CORTEX Organizes response to threat CEREBRAL CORTEX HYPOTHALAMUS HPA AXIS ANTERIOR CINGULATE GYRUS Modulates amygdala 41 TRAUMA SENSORY INPUT – HIPPOCAMPUS Declarative memory Cognitive meaning AMYGDALA Emotional content LOCUS CERULEUS Early warning FIGURE 2.8 Trauma response pathway. Courtesy of Scaer, R. (2005). The trauma spectrum: Hidden wounds and human resiliency. New York, NY: W.W. Norton & Co. From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 3 Assessment and Diagnosis TABLE 3.1 Assessment Questions: Continuum of Openness Type Example Open-Ended Types Open-ended questions What brings you in today? How can I help you? How would you describe your relationship with…? Gentle commands Tell me about your family situation. Try to describe how you felt when… Share with me what you think a good outcome would be. Intermediate Types Swing questions (client can say “no” or client can elaborate) Can you describe the depressive symptoms? Qualitative questions How have you been sleeping? Can you tell me anything more about that? Can you tell me what you’re thinking right now? How is school going? How have you been getting along with your mom? Statements of inquiry So you have never before received any therapy? Your mother decided to go back to school when you did? You say you just want to stay in bed all the time? Empathic statements You must have been so hurt by that. That is very frustrating. It is hard to lose someone you love. Facilitating statements Go on. I see. Closed-Ended Types Closed-ended questions How many drinks did you have? How often do you feel that way? Closed-ended statements You can sit down here. We’ll take about 50 minutes to… Medications can be very effective in these cases. Adapted from Shea, S. C. (1998). Psychiatric interviewing: The art of understanding (2nd ed.). Philadelphia: W. B. Saunders. From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 3 Assessment and Diagnosis 43 TABLE 3.2 Ego Functions for Assessment Reality Testing Differentiating Inner From Outer Stimuli Judgment Aware of appropriateness and likely c­ onsequences of intended behavior Sense of reality of the world and of the self Experiences external events as real; ­differentiates self from others Affect and impulse control Maintains self-control; can tolerate intense affect and delay of gratification Interpersonal functioning Sustains relationships over time despite s­ eparations or hostility Thought processes Attention, concentration, memory, language, and other cognitive processes are intact; t­ hinking is realistic and logical Adaptive regression in the service of the ego Relaxation of ego controls, allowing ­creative p ­ erceptual or conceptual ­integrations to increase adaptive potential Defensive functioning Defenses satisfactorily prevent anxiety, ­depression, and other unpleasant affects Stimulus barrier Aware of sensory stimuli without stimulus o ­ verload Autonomous functioning Cognitive and motor functions (i.e., primary autonomy) and routine behavior (i.e., secondary autonomy) are free from disturbance Synthetic-integrative functioning Integrates contradictory attitudes, values, affects, behavior, and ­self-representations Mastery competence Performance consistent with existing capacity Object constancy Ability to provide for oneself, caretaking and soothing in the absence of the caretaker Adapted from Bellak, L. (1989). The broad role of ego function assessment. In S. Wetzler & M. Katz (Eds.), Contemporary approaches to ­psychological assessment (pp. 270–295). New York, NY: Brunner/Mazel. From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 44 3 Assessment and Diagnosis TABLE 3.3 Observer-Rated Ego Function Assessment Tool* Assessment Item Ego Function Always (1)    Almost Always (2)     Usually (3)    Sometimes (4)    Hardly Ever (5)    Never (6) 1. When dealing with strong feelings, has trouble with getting too upset or l­osing control with words or actions Regulation and control of affects and impulses 2. Explains problems as being caused almost entirely by others Defensive functioning; interpersonal functioning 3. Has trouble sitting back and looking at own behavior in a realistic way Defensive functioning; interpersonal functioning 4. Believes he or she is basically a good person, worth caring about, but with some problems Synthetic-integrative functioning 5. Seems to feel good or bad about self, depending mostly on how others are feeling about him or her Affect regulation and control of affect; synthetic-integrative functioning 6. Seems able to recognize how he or she is feeling Regulation and control of affect; defensive functioning 7. Seems able to express his or her feelings in an appropriate manner Regulation and control of affect and impulses 8. Seems really weird, bizarre, or out of touch with reality Reality testing; sense of reality of the world and of the self; thought processes 9. Able to look at self fairly realistically in terms of good and bad qualities Sense of reality of the world and of the self; synthetic-integrative ­functioning 10. Explains his or her problems by means of hallucinations, false beliefs, control by supernatural power Reality testing; sense of reality of the world and of the self; thought processes 11. Seems as if he or she does not notice other people exist Interpersonal functioning 12. Seems afraid of being close to others Interpersonal functioning 13. Tends to see others as having both good and bad qualities Synthetic-integrative functioning 14. Seems to need others to lean on Interpersonal functioning 15. Can structure his or her own time and enjoy it Autonomous functioning 16. Tends to lump people together and see them as much the same Interpersonal functioning 17. When left alone, has a hard time taking care of himself or herself Autonomous functioning 18. Seems to perform up to his or her capabilities Mastery competence 19. Seems basically to trust other people Interpersonal functioning 20. Seems to use people to get things he or she needs Interpersonal functioning 21. Sees his or her problems as resulting from being a bad person Regulation of affect; synthetic-integrative functioning 22. Seems able to recognize and respond to the feelings of others in an appropriate manner Regulation and control of affect and impulses 23. Is the type of person others want to be friends with Interpersonal functioning 24. Recovers from significant emotional upset relatively quickly with previous capacities intact or improved Adaptive regression in the service of the ego *Not a validated tool. Adapted from Tulloch, J. D. (1984). Unpublished handout. Denver, CO: University of Colorado Health Sciences Center. From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 3 Assessment and Diagnosis 45 TABLE 3.4 A Fragment of the Inventory of Interpersonal Problems It is hard for me to: Not At All (0) A Little Bit (1) How much have you been distressed by this problem? Moderately (2) Quite a Bit (3) Extremely (4) Example 1. Get along with my relatives 0 1 2 3 4 Part I. The following are things you find hard to do with other people: 1. Trust other people 0 1 2 3 4 2. Say “no” to other people 0 1 2 3 4 3. Join in on groups 0 1 2 3 4 4. Keep things private from other people 0 1 2 3 4 5. Let other people know what I want 0 1 2 3 4 6. Tell a person to stop bothering me 0 1 2 3 4 Adapted from Horowitz, L. M., Rosenberg, S. E., & Bartholomew, K. (1993). Interpersonal problems, attachment styles, and outcome in brief dynamic psychotherapy. Journal of Consulting and Clinical Psychology, 61(4), 549–560. Copyright 1993, with permission from the ­American Psychological Association. From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 46 3 Assessment and Diagnosis TABLE 3.5 A Portion of the World Health Organization’s Spirituality, Religiousness, and Personal Beliefs Field-Test Instrument 1 = Not at all 2 = A little 3 = A moderate amount 4 = Very much 5 = An extreme amount To what extent does any connection to a spiritual being help you to get through hard times? 1 2 3 4 5 To what extent does any connection to a spiritual being help you to understand others? 1 2 3 4 5 To what extent does any connection to a spiritual being ­provide you with comfort/reassurance? 1 2 3 4 5 To what extent do you find meaning in life? 1 2 3 4 5 To what extent do you feel your life has a purpose? 1 2 3 4 5 To what extent does faith contribute to your well-being? 1 2 3 4 5 To what extent does faith give you comfort in daily life? 1 2 3 4 5 To what extent does faith give you strength in daily life? 1 2 3 4 5 To what extent do you feel spiritually touched by beauty? 1 2 3 4 5 To what extent are you grateful for the things in nature that you can enjoy? 1 2 3 4 5 To what extent are you able to experience awe from your ­surroundings, for example, nature, art, music? 1 2 3 4 5 To what extent do you feel any connection between your mind, body, and soul? 1 2 3 4 5 To what extent do you feel the way you live is consistent with what you feel and think? 1 2 3 4 5 How much do your beliefs help you to create coherence between what you do, think, and feel? 1 2 3 4 5 How much does spiritual strength help you to live better? 1 2 3 4 5 To what extent does your spiritual strength help you to feel happy in life? 1 2 3 4 5 To what extent do you feel peaceful within yourself? 1 2 3 4 5 To what extent do you feel a sense of harmony in your life? 1 2 3 4 5 To what extent does faith help you enjoy life? 1 2 3 4 5 How satisfied are you that you have a balance between body, mind, and soul? 1 2 3 4 5 To what extent do you consider yourself to be a religious person? 1 2 3 4 5 To what extent do you consider yourself to be a part of a r­ eligious community? 1 2 3 4 5 To what extent do you have spiritual beliefs? 1 2 3 4 5 Adapted from the World Health Organization (WHO). (2002). WHOQOL-SRPB field-test instrument. Retrieved from www.who.int/mental _health/media/en/622.pdf From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 3 Assessment and Diagnosis TABLE 3.6 Commonly Used Clinical Rating Scales Scale Reference Quality of Life Scales Quality of Life Enjoyment and Satisfaction Questionnaire Q-LES-Q Endicott et al. (1993) Quality of Well-Being Scale (QWB) Kaplan and Anderson (1988) Quality of Life in Depression Scale (QLDS) Hunt and McKenna (1992) Medical Outcome Survey (MOS) Ware and Sherbourne (1992) Mental Health Status and Functioning Scales Clinical Global Impression (CGI) NIMH (1970) Endicott Work Productivity Scale Endicott and Nee (1997) Global Assessment of Functioning (GAF) APA, 2000: DSM-IV-TR Sheehan Disability Scale Leon et al. (1992) Social and Occupational Functioning Assessment Scale (SOFAS) APA, 2000: DSM-IV-TR Work and Social Adjustment Scale Mundt et al. (2002) Adverse Effects Scales Abnormal Involuntary Movement Scale (AIMS) Guy (1976) Simpson–Angus Extrapyramidal Symptom Rating Scale Simpson and Angus (1970) Cognitive Disorders Scales Delirium Rating Scale Revised—98 (DRS—R98) Trzepacz et al. (2001) Mini-Mental State Examination (MMSE) Folstein et al. (1975) Alcohol Use Disorders Scales CAGE Questionnaire Ewing (1984) Michigan Alcoholism Screening Test (MAST) Selzer (1971) Mood Disorders Scales Beck Depression Inventory, 2nd Revision (BDI-II) Beck et al. (1961) Hamilton Depression Rating Scale (HAM-D) Hamilton (1960) Inventory of Depressive Symptomatology (IDS) Rush et al. (1996) Quick Inventory of Depressive Symptomatology (QIDS) Rush et al. (2003) Patient Health Questionnaire (PHQ-9) www.pfizer.com Geriatric Depression Scale (GDS) Yesavage et al. (1983) Montgomery–Asberg Depression Rating Scale (MADRS) Montgomery and Asberg (1979) Zung Self-Rating Depression Scale (ZSRDS) Zung (1965) Young Mania Rating Scale (YMRS) Young et al. (1978) Anxiety Disorders Scales Hamilton Anxiety Rating Scale (HAM-A) Hamilton (1959) Yale-Brown Obsessive–Compulsive Scale (Y-BOCS) Goodman et al. (1989) Psychotic Disorders Scales Brief Psychiatric Rating Scale (BPRS) Overall and Gorham (1962) Positive and Negative Symptom Scale (PANSS) Kay et al. (1987) Aggression and Agitation Scale Overt Aggression Scale—Modified (OAS-M) Coccaro et al. (1991) Sources: APA. (2006). Practice guideline for psychiatric evaluation of adults. In American Psychiatric Association ­practice guidelines for the treatment of psychiatric disorders: Compendium 2006. Washington, DC: American ­Psychiatric ­Association; Bresee, C., Gotto, J., & Rapaport, M. H. (2009). Treatment of depression. In A. F. Schatzberg & C. B. ­Nemeroff (Eds.), The American psychiatric publishing textbook of psychopharmacology (4th ed., chapter 53). Arlington, VA: ­American Psychiatric Publishing. From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 47 48 3 Assessment and Diagnosis Polish/Jewish Irish/Catholic d. Heart attack Suicide d. Emphysema Smoker 55 35 75 Hank Catherine 55 54 d. in childbirth 28 Mike Did not complete HS ETOH 50 BA Schoolteacher Smoker Depression BS Retired engineer Depression Keith BA No job ETOH 5/04 Suicide 35 attempt 11/06 Psychotic episode DX schizophrenia William Jennifer 31 BSN Nurse 31 Stockbroker Jewish m. 2004 Ethan Jackson 4 2 Relationship lines: Key: Close Male Female Identified patient Close/conflictual Conflictual Death Miscarriage Divorce Distant d., died; DX, diagnosis; ETOH, alcohol; HS, high school; m., married. FIGURE 3.1 An elaborated genogram with demographic, occupational, and major life event information. Adapted from Varcarolis, E. M., Carson, V. B., & Shoemaker, N. C. (Eds.). (2006). Foundations of psychiatric mental health nursing (5th ed.). Philadelphia, PA: W. B. Saunders. From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 3 Assessment and Diagnosis 49 APPENDIX 3.1 Outline of the Comprehensive Psychiatric Database I. Identifying data A. Age B. Sex/Gender preference C. Race/Ethnicity D. Marital status E. Children F. How arrived? G. Who referred? Why? H. Mental health providers? I. Sources of information J. Number of times seen in this setting II. Client-identified problem A. What the client states he or she wants help with B. Verbatim statement 1. “I’m depressed.” 2. “My mother brought me. I don’t need help.” III. History of current illness A. Onset, duration, or change in symptoms over time 1. Organized chronologically 2. Client’s perception of changes in himself or herself over time 3. Others’ perception of changes in the client (e.g., spouse, employer, and friend) B. Precipitating factors 1. Why now? C. Baseline functioning D. Last period of stability IV. Psychiatric history A. Inpatient 1. Location, dates, and lengths of stay 2. Diagnoses 3. Previous episodes of current symptoms 4. Previous episodes of other disorders not described in history of current illness 5. Legal status 6. Use of medications or other treatments, including doses, blood levels, clinical response 7. Perception of helpfulness B. Outpatient 1. Dates, duration, and frequency of sessions 2. Location, type, and focus of treatment or therapy 3. Perception of helpfulness V. Medical history A. Past and current medical problems 1. Illnesses, operations, and hospitalizations, especially history of open or closed head injury, birth trauma, seizure disorder, and encephalitis or meningitis From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 50 3 Assessment and Diagnosis B. Past and current medications 1. Dosages, blood levels, and clinical response 2. Adherence C. Primary care physician, specialists, and phone numbers D. Allergies (and reactions) VI. History of substance use and abuse A. Episodes of alcohol abuse 1. What, how much, and consequences (e.g., charges for driving under the influence [DUI], other legal sequelae, and loss of relationships, jobs, and opportunities) 2. Does the client or others think he or she has a problem? 3. Typical pattern of use 4. History of blackouts, seizures, complicated withdrawal, or delirium tremens 5. History of suicide ideation, gestures, or attempts while intoxicated or withdrawing 6. Longest period of sobriety 7. What facilitates sobriety? 8. Previous treatments (e.g., detoxification, rehabilitation, counseling, and Alcoholics Anonymous) B. Episodes of illicit or prescription drug abuse 1. What, amount, route of administration, and consequences (e.g., DUIs, other legal sequelae, and loss of relationships, jobs, and opportunities) 2. Does the client or others think he or she has a problem? 3. Typical pattern of use 4. History of suicide ideation, gestures, or attempts while intoxicated or withdrawing 5. Longest period of sobriety 6. What facilitates sobriety? 7. Previous treatments (e.g., detoxification, rehabilitation, counseling, and Narcotics Anonymous) C. Tobacco 1. Number of cigarettes or packs per day 2. Years client has smoked 3. Cessation attempts D. Caffeine 1. Form (coffee, cola, tea, and pills) 2. Amount consumed per day 3. Cessation attempts E. Over-the-counter drugs or “herbal” medications 1. What, how much, purpose, frequency, side effects, and interactions with prescribed medications 2. Perceptions of helpfulness or efficacy VII. Developmental history A. Developmental milestones and family of origin 1. Information about mother’s pregnancy and delivery 2. Were developmental milestones reached as expected? 3. Childhood temperament and important family events (e.g., death, s­ eparation, and divorce) 4. Information about early experiences and relationships (e.g., school experiences, academic performance, delinquency, family of origin relationships, family stability, early sexual experiences, and history of abuse or neglect) 5. Important cultural or religious influences 6. Values, beliefs, or framework for meaning B. Educational history C. Occupational and military history 1. Number and types of jobs; reasons for termination 2. Highest rank attained; conditions of discharge 3. History of disciplinary problems or combat D. Legal history VIII. Family history A. Psychiatric or substance use disorders 1. Have any family members undergone psychiatric or substance abuse treatment (inpatient or outpatient), attempted or completed a suicide, had problems with drugs or alcohol, and behaved strangely? From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 3 IX. X. XI. XII. Assessment and Diagnosis 51 2. Have any family members successfully used any psychotropic medications for the same or s­ imilar symptoms? 3. Family attitudes toward mental illness B. Pertinent medical disorders in blood relatives (e.g., seizure disorder or thyroid disease) Social history A. Current social situation 1. Living arrangements (e.g., where, with whom, for how long, how stable, and how satisfactory or desirable) 2. Employment (e.g., where, for how long, how stable, and how satisfactory or desirable) 3. Financial (e.g., current sources of income, how stable, and how adequate) 4. Insurance coverage B. Breadth of client’s social life 1. Is he or she a loner or involved in an intimate relationship? 2. How difficult is it to get into and out of relationships? C. Past and present levels of functioning 1. Marriage, parenting, and work 2. Client strengths and strategies used to manage stress, resources, or positive memories (draw a line and place important positive memories and events) 3. Current functional deficits (e.g., activities of daily living, task performance, and relationships) Trauma history A. Ten most significant disturbing events in life B. Violence 1. To self a. What, when, where, how, why; warning signs or symptoms, triggers, and consequences b. How intense, specific, and controllable is current ideation 2. To others or property a. What, when, where, how, why; warning signs or symptoms, triggers, and consequences b. How intense, specific, and controllable is current ideation 3. Current access to weapons a. What, where, why; plan for use; plan for disposition of weapon b. How will disposition of weapons be verified? Psychiatric review of systems (ROS) A. Includes all symptoms not part of the current episode or presentation B. May have to ask specific questions about the presence or absence of these symptoms 1. “Are you now or have you ever had any of the following …” C. Anxiety symptoms 1. Shortness of breath, heart palpitations, panic attacks, sweating, flushing, hyperventilation, sense of doom, fear of death or collapse, cold or clammy skin, and tingling sensations in extremities D. Mood symptoms 1. Sadness, irritability, anergia, fatigue, lethargy, tearfulness, increased or decreased appetite or energy, changes in sleep or libido, suicide ideation, homicide ideation, hypomania (e.g., spending sprees, increased energy, and religious preoccupation beyond baseline), and feelings of hopelessness, helplessness, or worthlessness E. Psychotic or cognitive symptoms 1. Hallucinations, delusions, thought insertion, thought blocking, thought broadcasting, flight of ideas, hyper-religiosity, tangentiality, looseness of associations, and circumstantiality Mental status examination (MSE) A. Informal: begins immediately on contact with the client and includes an i­ nformal assessment of the client’s characteristics 1. Appearance 2. Manner of relating 3. Use of language 4. Mood and affect 5. Content of speech 6. Perceptions 7. Abstracting ability 8. Judgment 9. Insight From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 52 3 Assessment and Diagnosis B. Formal: focused, structured assessment of the client’s characteristics 1. Appearance: overall appearance, dress, grooming 2. Attitude: attitude toward examiner (e.g., hostile, cooperative, evasive) 3. Behavior and psychomotor activity: gait, carriage, posture, activity level 4. Speech a. Rate, amount, tone, impairment, aphasia 5. Mood and affect a. Mood (i.e., how the client reports feeling) in relation to affect (i.e., e­ motional expression ­observed by the therapist) b. Depth and range of emotional expression 6. Perception a. Hallucinations i. Auditory ii. Visual iii. Gustatory: taste (temporal lobe dysfunction?) iv. Olfactory: smell (temporal lobe dysfunction?) v. Tactile: Skin sensations (alcohol withdrawal and intoxication?) vi. Kinesthetic: feeling movement when none occurs vii. Hypnagogic: occurs while falling asleep viii. Hypnopompic: occurs while waking up b. Illusions: misinterpretations of actual sensory stimuli c. Depersonalization: feels detached and views self as unreal d. Derealization: experiences objects and persons outside of self as unreal 7. Thought process a. The pattern of a client’s speech allows the therapist to observe the quality of the thought process, including its flow, logic, and associations. Abnormalities include the following: i. Loose associations (LOAs) ii. Tangentiality iii. Circumstantiality iv. Thought blocking (TB) v. Thought insertion (TI) vi. Flight of ideas (FOAs) vii. Perseveration viii. Echolalia 8. Content of thought a. Delusions i. Paranoid or persecutory ii. Grandiose iii. Nihilistic iv. Somatic v. Bizarre b. Ideas of reference c. Obsessions d. Suicidal thoughts e. Homicidal thoughts 9. Judgment a. An assessment of social judgment involves determining whether a client understands the consequences of his or her actions b. Must recognize differences in cultural values when assessing ­judgment c. “What would you do if you found a sealed, stamped, addressed ­envelope on the sidewalk?” 10. Insight a. Must assess whether a person is aware of a problem, the cause of the problem, and what type of help is needed to address the problem 11. Cognition a. A formal mental status examination measures the ability of the brain to function by assessing the following cognitive functions: i. Consciousness: alert, confused, drowsy, somnolent, obtunded, delirious, stuporous, and comatose From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 3 Assessment and Diagnosis 53 ii. Orientation: knows who he or she is, where he or she is, and what day it is iii. Memory: can remember what was eaten for breakfast today; has remote memory for long-past events iv. Recall: can recall three objects after 5 minutes v. Registration: can name three objects immediately vi. Attention: can spell world forward and backward vii. Calculation: can do serial 7’s or count backward from 20 viii. Language: can name items, repeat a phrase, follow simple ­commands, read, write, and copy a design XIII. Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) ­differential diagnosis A. On a single axis, lists the principal psychiatric, neurodevelopmental, n ­ eurocognitive, and other disorders requiring further assessment, along with the corresponding ICD code(s) B. Includes so-called “rule-out” and/or “provisional” diagnoses C. ICD-9 codes are listed before each disorder name, followed by ICD-10 codes in parentheses D. ICD-9 codes will be used in the United States through September 30, 2014. IDC-10 codes will be used starting October 1, 2014. XIV. Case formulation A. Presents a brief summary of the client and rationalizes the diagnoses 1. Minimal identifying data, including past diagnosis 2. Abbreviated recapitulation of presenting symptoms, onset, and course 3. Draws from all sections of the database as needed B. Outlines the contributing factors, precipitants, and stressors C. Summarizes the logic behind the differential diagnoses D. Identifies information still needed to confirm the diagnoses XV. Treatment plan A. Biologic 1. Medications (e.g., name, dose, route, for what purpose, and client’s level of understanding of medication education) 2. Diagnostic tests (e.g., where, when, and who will administer) 3. Referrals for primary care B. Psychological 1. Therapeutic modalities to be used and with what focus a. Individual psychotherapy? b. Group psychotherapy? c. Family therapy? d. Case management? C. Social 1. Support or self-help groups 2. Mobilization of family resources 3. Vocational rehabilitation 4. Financial planning D. Strengths 1. Overt identification of client strengths, values, and beliefs to support or draw from in implementing the identified treatment plan Data from APA. (2006). Practice guideline for psychiatric evaluation of adults. In American Psychiatric Association practice guidelines for the treatment of psychiatric disorders: Compendium 2006. Washington, DC: American Psychiatric Association; Gordon, C., & Goroll, A. (2003). Effective psychiatric interviewing in primary care medicine. In T. A. Slavin, J. B. Herman, & P. L. Slavin (Eds.), The MGH guide to psychiatry in primary care (pp. 19–26). New York, NY: McGraw-Hill; Marken, P. A., Schneiderhan, M. E., & Munro, S. (2005). Evaluation of psychiatric illness. In J. T. DiPrio, R. L. Talbert, G. C. Yee, G. R. Matzke, B. G. Wells, & L. M. Posey (Eds.), Pharmacotherapy: A pathophysiologic approach (6th ed., pp. 1123–1132). New York, NY: McGraw-Hill; Morrison, J. (2008). The first interview (3rd ed.). New York, NY: Guilford Press; Sadock, B. J., Sadock, V. S., & Ruiz, P. (2009). Kaplan & Sadock’s comprehensive textbook of psychiatry (9th ed.). Philadelphia, PA: Lippincott ­Williams & Wilkins; Scully, J. H., & Thornhill, J. T., IV. (2012). The clinical examination. In J. T. Thornhill, IV (Ed.), The national ­medical series for independent study: Psychiatry (6th ed., pp. 1–16). Philadelphia, PA: Lippincott Williams & Wilkins; Shea, S. C. (1998). Psychiatric interviewing: The art of understanding (2nd ed.). Philadelphia: W. B. Saunders. From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 54 3 Assessment and Diagnosis APPENDIX 3.2 Sample Assessment Form INITIAL CLINICAL ASSESSMENT Identifying Data Name of Client:  Date:  DOB: Age:  Sex: Sexual Preference:  Marital Status: Children:  Race/Ethnicity:  Religious Preference:  Client-Identified Problem (Client’s Own Words) and Referral Source 1. History of current illness A. Stressors and symptoms: include current stressors and detailed chronologic history of symptoms for each diagnosis on axes I and II. Detail current substance abuse and the amount and pattern of use. B. Recent suicide or homicide ideation or behavior: include all ideation, gestures, attempts, presence or absence of hopelessness, and extent of actions or plans in the past month. 2. Psychiatric history A. Episodes and treatment: describe previous episodes of current disorder and all other disorders, ­including treatment modalities such as hospitalization, psychotherapy, and medications and their dosages. B. History of trauma: list the 10 most significant traumas. Do a timeline, and rate the disturbance for each event on a scale of 0 to 10; you can also ask for significant positive and negative events in the person’s life. Administer the Impact of Events Scale and Dissociative Experiences Scale if trauma is suspected or reported. C. History of violence To self: To others: To property: 3. Psychiatric review of systems: circle all relevant symptoms, and add any not listed A. Mood: sadness, tearfulness, depressed mood, irritability, fatigue, lethargy, anergia, anhedonia, sleep changes, appetite changes, decreased libido, hopelessness, helplessness, worthlessness, suicide ideation, homicide ideation, spending sprees, ­increased energy or activity, decreased need for sleep, increased libido, pressured speech, tangentiality, and flight of ideas. From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 3 Assessment and Diagnosis 55 B. Anxiety: anxious mood, excessive worry, shortness of breath, heart palpitations, panic attacks, sweating, flushing, hyperventilation, sense of impending doom, fear of death or collapse, cold/clammy skin, and tingling sensations in extremities. C. Thought disorder: auditory or visual hallucinations, other hallucinations, ideas of reference, paranoia, delusions, thought insertion, thought blocking, thought broadcasting, flight of ideas, hyper-religiosity, tangentiality, looseness of associations, and bizarre behavior. 4. Drug and alcohol history A. Episodes and treatment: describe previous episodes of current disorder and all other disorders, including treatment modalities such as hospitalization, psychotherapy, and medications and their dosages. B. Substance abuse profile: Substance Current Amount Date Last Used Alcohol (use CAGE if abuse suspected but denied) Tetrahydrocannabinol (THC) Cocaine, crack, speed LSD, mescaline, psilocybin Barbiturates, other sedatives Caffeine, tobacco Over-the-counter drugs, herbal medications 5. Medical history: List significant past illnesses, surgeries, or hospitalizations A. Primary care physician:  B. Allergies:  C. Medications: use the table to document: Current Medication Dosage Taken as Prescribed? Yes 6. Psychosocial history A. Education: B. Family relationships, social relationships, and abuse history: C. Employment record and military history: D. Religious background, belief system, or meaning framework: E. Client’s strengths: include client resources and how client self-soothes and m ­ anages stress. 7. Family history A. Genogram: CASE FORMULATION Assessment of suicide or violence risk: Treatment recommendations: Admit to:  One-time consultation:  Refer to:  From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC No 56 3 Assessment and Diagnosis Referred for:           Physical examination            Individual psychotherapy            Psychological testing            Group psychotherapy            Hospitalization           Medications            Support group            Community support program services Diagnostic summary: Axis Diagnoses, Factors, or Status I. Clinical psychiatric ­syndromes 1. 2. 3. II. Personality and specific development disorders 1. 2. 3. III. Medical problems 1. 2. 3. IV. Psychosocial stressors* 1. 2. 3. V. Global assessment of functioning (GAF) Current GAF Highest GAF in past year Codes Alternatives to Rule Out *Prioritize and rank severity: 1, none; 2, mild; 3, moderate; 4, severe; 5, extreme; 6, catastrophic; 7, unspecified. Clinician’s signature:  Date:  Location of assessment:  Adapted from Shea, S. C. (1998). Psychiatric interviewing: The art of understanding (2nd ed.). Philadelphia: W. B. Saunders. From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 3 Assessment and Diagnosis 57 APPENDIX 3.3 Dissociative Experiences Scale (DES) Name          Date        Age         Sex          Directions: This questionnaire consists of 28 questions about experiences that you may have in your daily life. We are interested in how often you have these experiences. It is important, however, that your answers show how often these experiences happen to you when you are not under the influence of alcohol or drugs. To answer the questions, please determine to what degree the experience described in the question applies to you and circle the number to show what percentage of the time you have the experience. Example: 0% 10 20 30 40 50 60 70 80 90 100% (never)  (always) 1. Some people have the experience of driving a car and suddenly realizing that they don’t remember what has happened during all or part of the trip. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100% 2. Some people find that sometimes they are listening to someone talk and they suddenly realize that they did not hear all or part of what was said. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100% 3. Some people have the experience of finding themselves in a place and having no idea how they got there. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100% 4. Some people have the experience of finding themselves dressed in clothes that they don’t remember putting on. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100% 5. Some people have the experience of finding new things among their belongings that they do not remember buying. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100% 6. Some people sometimes find that they are approached by people that they do not know who call them by another name or insist that they have met them before. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100% 7. Some people sometimes have the experience of feeling as though they are standing next to themselves or watching themselves do something as if they were looking at another person. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100% From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 58 3 Assessment and Diagnosis 8. Some people are told that they sometimes do not recognize friends or family members. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100% 9. Some people find that they have no memory for some important events in their lives (for example, a w ­ edding or graduation). Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100% 10. S  ome people have the experience of being accused of lying when they do not think that they have lied. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100% 11. S  ome people have the experience of looking in a mirror and not recognizing themselves. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100% 12. S  ome people sometimes have the experience of feeling that other people, objects, and the world around them are not real. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100% 13. S  ome people sometimes have the experience of feeling that their body does not belong to them. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100% 14. S  ome people have the experience of sometimes remembering a past event so vividly that they feel as if they were reliving that event. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100% 15. S  ome people have the experience of not being sure whether things that they remember happening really did happen or whether they just dreamed them. Circle a number to show what percentage of the time this ­happens to you. 0% 10 20 30 40 50 60 70 80 90 100% 16. S  ome people have the experience of being in a familiar place but finding it strange and unfamiliar. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100% 17. S  ome people find that when they are watching television or a movie they become so absorbed in the story that they are unaware of other events happening around them. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100% 18. S  ome people sometimes find that they become so involved in a fantasy or daydream that it feels as though it were really happening to them. Circle a number to show what percentage of the time this ­happens to you. 0% 10 20 30 40 50 60 70 80 90 100% 19. S  ome people find that they are sometimes able to ignore pain. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100% 20. S  ome people find that they sometimes sit staring off into space, thinking of nothing, and are not aware of the passage of time. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100% From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 3 Assessment and Diagnosis 59 21. S  ome people sometimes find that when they are alone they talk out loud to themselves. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100% 22. S  ome people find that in one situation they may act so differently compared with another situation that they feel almost as if they were different people. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100% 23. S  ome people sometimes find that in certain situations they are able to do things with amazing ease and spontaneity that would usually be difficult for them (for example, sports, work, social situations, and so on). Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100% 24. S  ome people sometimes find that they cannot remember whether they have done something or have just thought about doing that thing (for example, not knowing whether they have just mailed a letter or have just thought about mailing it). Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100% 25. S  ome people find evidence that they have done things that they do not remember doing. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100% 26. S  ome people sometimes find writings, drawings, or notes among their belongings that they must have done but cannot remember doing. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100% 27. S  ome people find that they sometimes hear voices inside their head that tell them to do things or comment on things that they are doing. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100% 28. S  ome people sometimes feel as if they are looking at the world through a fog so that people or objects appear far away or unclear. Circle a number to show what percentage of the time this happens to you. 0% 10 20 30 40 50 60 70 80 90 100% Adapted from Carlson, E. B., & Putnam, F. W. (1993). Manual for the dissociative experiences scale. Lutherville, MD: Sidran Foundation. From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 60 3 Assessment and Diagnosis APPENDIX 3.4 The Impact of Event Scale (IES) The table contains comments made by people after stressful life events. Using the scale, please indicate how frequently each of these comments was true for you during the past 7 days. 0 1 3 Not at All Rarely Sometimes Comment 4 Often I thought about it when I did not mean to. I avoided letting myself get upset when I thought about it or was reminded of it. I tried to remove it from memory. I had trouble falling asleep or staying asleep because of pictures or thoughts about it that came into my mind. I had waves of strong feelings about it. I had dreams about it. I stayed away from reminders of it. I felt as if it had not happened or was not real. Pictures about it popped into my mind. Other things kept making me think about it. I was aware that I still had a lot of feelings about it, but I did not deal with them. I tried not to think about it. Any reminder brought back feelings about it. My feelings about it were kind of numb. Total Score ___________ > 26 = moderate or severe impact Adapted from Horowitz, M., Wilner, M., & Alvarez, W. (1979). Impact of event scale: A measure of subjective stress. Psychosomatic Medicine, 41, 209–218; Weiss, D., & Marmar, C. (1997). The impact of event scale—revised. In J. Wilson & T. Keane (Eds.), Assessing psychological trauma and PTSD. New York, NY: Guilford Press. From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 3 Assessment and Diagnosis 61 APPENDIX 3.5 Zung Self-Rating Depression Scale (ZSRDS) Please read each sentence carefully. For each of the 20 statements, place a check mark in the column that best describes how often you have felt that way during the past two weeks. None or Little of the Time Comment Some of the Time Good Part of the Time 1. I feel downhearted, blue, and sad. 2. Morning is when I feel the best. 3. I have crying spells or feel like it. 4. I have trouble sleeping through the night. 5. I eat as much as I used to. 6. I still enjoy sex. 7. I notice that I am losing weight. 8. I have trouble with constipation. 9. My heart beats faster than usual. 10. I get tired for no reason. 11. My mind is as clear as it used to be. 12. I find it easy to do the things I used to do. 13. I am restless and can’t keep still. 14. I feel hopeful about the future. 15. I am more irritable than usual. 16. I find it easy to make decisions. 17. I feel that I am useful and needed. 18. My life is pretty full. 19. I feel that others would be better off if I were dead. 20. I still enjoy the things I used to do. Adapted from Zung, W. W. (1965). A self-rating depression scale. Archives of General Psychiatry, 4, 561–571. From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC Most of the Time 62 3 Assessment and Diagnosis APPENDIX 3.6 Geriatric Depression Scale (GDS) (Short Form) Circle the appropriate answer. ­——————————————————————————————————————–——————————–— 1. Are you basically satisfied with your life? Yes No 2. Have you dropped many of your activities and interests? Yes No 3. Do you feel that your life is empty? Yes No 4. Do you often get bored? Yes No 5. Are you in good spirits most of the time? Yes No 6. Are you afraid that something bad is going to happen to you? Yes No 7. Do you feel happy most of the time? Yes No 8. Do you often feel helpless? Yes No 9. Do you prefer to stay at home rather than go out and do new things? Yes No 10. Do you feel you have more problems with memory than most? Yes No 11. Do you think it is wonderful to be alive now? Yes No 12. Do you feel pretty worthless the way you are now? Yes No 13. Do you feel full of energy? Yes No 14. Do you feel that your situation is hopeless? Yes No 15. Do you think that most people are better off than you are? Yes No Score: _____/15 Assign 1 point for “No” to questions 1, 5, 7, 11, and 13 Assign 1 point for “Yes” to other questions Results: 0–4 5–8 8–11 12–15 normal, depending on age, education, and complaints mild moderate severe Adapted from Yesavage, J. A., Brink, T. L., Rose, T. L., Lum, O., Huang, V., & Adey, M. B. (1983). Development and validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research, 17, 37–49. From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 3 Assessment and Diagnosis 63 APPENDIX 3.7 Patient Health Questionnaire-9 (PHQ-9) Over the past 2 weeks, how often have you been bothered by any of the following p ­ roblems? Not Several More Than at All Days Half the Days Nearly Every Day 0 1 2 3 1. Little interest or pleasure in doing things o o o o 2. Feeling down, depressed, or hopeless o o o o 3. Trouble falling/staying asleep, sleeping too much o o o o 4. Feeling tired or having little energy o o o o 5. Poor appetite or overeating o o o o 6. Feeling bad about yourself—or that you are a failure or have let yourself or your family down o o o o 7. Trouble concentrating on things, such as reading the newspaper or ­watching television o o o o 8. Moving or speaking so slowly that other people could have noticed. Or the opposite—being so fidgety or restless that you have been moving around a lot more than usual o o o o 9. Thoughts that you would be better off dead or of hurting yourself in some way o o o o If you checked off any problem on this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not Difficult at All Somewhat Difficult Very Difficult Extremely Difficult o o o o Total Score: ______________ Developed by Drs. Robert L. Spitzer, Janet B. W. Williams, Kurt Kroenke, and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display, or distribute. Available at www.pfizer.com From Psychotherapy for the Advanced Practice Psychiatric Nurse © Springer Publishing Company, LLC 64 3 Assessment and Diagnosis APPENDIX 3.8 Young Mania Rating Scale (YMRS) Elevated Mood: 0 Absent 1 Mildly, or possibly elevated on ­questioning 2 Definite subjective elevation: optimistic, cheerful, self-confident; appropriate to content 3 Elevated; inappropriate to content; humorous 4 Euphoric; inappropriate laughter; singing Language/Thought Disorde...
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Running head: POSTTRAUMATIC STRESS DISORDER

How do you manage Post-traumatic Stress Disorder?

Student’s name:
Institutional affiliation:

1

POSTTRAUMATIC STRESS DISORDER

2

How do you manage Post-traumatic Stress Disorder?
❖ Assess clients presenting with posttraumatic stress disorder
William Thompson is a middle-aged man aged 38 years. He is presenting with posttraumatic stress disorder symptoms after his service in Iraq as a Captain of his squad. William
has also undergone many life-changing situations including losing his home and becoming
homeless due to failure to pay off his mortgage (Wheeler, 2014). He now resides at his brother’s
place, which is actually a stressing moment in his life. Apart from that, William’s job is in
jeopardy, a situation that can easily trigger trauma attacks. He is also seen engaging in too much
alcoholism, maybe because of his state of affairs, especially having an unstable job and being
homeless.
The client also exhibits flashbacks of the trauma experiences he experienced when in
Iraq. He is also irate and easily angered or irritated by any small thing. He is emotionally
unstable and avoids social encounters (Wheeler, 2014). He tends to shy away from some places
and people, an indicator that he is not socially free. William has also exhibited extreme anxiety
and refrain from engaging in day to day activities with his friends and family.
The client is diagnosed with Post-traumatic stress disorder. This is following the direction
given by DSM 5 that clients diagnosed with PTSD should present at least the following: be...


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