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
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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
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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
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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
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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
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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.
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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.
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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.
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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?
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Interventions
Body
Emotion
Beliefs
Images
Behavior
Relationships
Adaptive information
processing
Community
and culture
FIGURE 1.5 Adaptive information processing model.
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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
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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.
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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?
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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
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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)
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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
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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
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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.
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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.
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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):
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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
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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.
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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
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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
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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.
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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.
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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.
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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
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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.
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Assessment and Diagnosis
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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.
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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
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Assessment and Diagnosis
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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.
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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
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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.
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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.
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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
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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?
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XI.
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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
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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
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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.
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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.
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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:
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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.
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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%
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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%
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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
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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
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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
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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
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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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