1

Study Guide for Selected DSM-IV-TR Disorders

Rachel M. Hoffman
Kent State University
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Contents

I. Disorders Diagnosed in Childhood

a. Attention Deficit Hyperactivity Disorder
b. Mental Retardation
c. Conduct Disorder
d. Oppositional Defiant Disorder

II. Mood Disorders

a. Major Depressive Disorder
b. Dysthymic Disorder
c. Bipolar Disorder

III. Anxiety Disorders

a. Generalized Anxiety Disorder
b. Panic Disorder
c. Posttraumatic Stress Disorder

IV. Reproducible Study Guide

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Attention Deficit Hyperactive Disorder

Overview of the Disorder:

The underlying nature of ADHD remains controversial. Early research focused on motor over-
activity and implicated sub cortical brain regions in neural models. Twenty years ago, focus shifted to
underlying attentional processes and deficient self-regulation.
The common feature in elementary school-age children is difficulty sustaining attention,
particularly during long tasks. Other common symptoms include poor impulse control, restlessness, and
overactive.

3 Subtypes:
1) Predominately Hyperactive-Impulsive Type
2) Predominately Inattentive Type
3) Combined Type

Criteria:
1) Onset prior to age seven
2) Present in 2 or more settings
3) Interferes in social, academic, or occupational functioning.
4) Six or more symptoms of hyperactivity, impulsivity, or inattentiveness that have persisted for at least 6
months.

Potential Risk Factors:

x Moderate heritability of both dimensional and categorical conceptions of ADHD.
x Prenatal and peri-natal difficulties.
x Over-stimulation parenting during infancy and childhood.
x Coercive parenting styles are implemented in the development of aggressive and antisocial
behaviors.

Treatment:
The therapist needs to present as calm and patient. Development of a trusting, accepting
relationship with the therapist is critical. Primarily use behavioral interventions ² based on operant
conditioning. Cognitive-behavioral models have been used to improve social skills and provide parent
training.
Structured but highly supportive and empathetic treatment approach. Goal is to foster short- and
long-term client responsibility. Reinforcement of successful approximations to the desired behaviors.
Initially, the sessions would occur twice a week and the frequency would subsequently be reduced to once
per week as treatment progresses. Parents should be informed of how medication offers the family, the
child, and the school possible additional options for treatment. Assess for comorbid disorders and
determine need for educational tutoring. Prognosis is good for alleviation of the major symptoms of
ADHD.

Interventions:
x Behaviorally Based ²
ƒ Direct Contingency Mgmt. ² Intensive reward and punishment procedures are established
in specialized treatments facilities and demonstration in classroom. Treatment usually takes
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place in special classrooms over brief time periods and large reductions in problem
behaviors. Short term gains are confined to the specialized setting.
ƒ Clinical Behavior Therapy ² Procedures for which consultation (via group or individual
sessions) is provided to families and teachers, who in turn, implement behavior in the
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ƒ Ideally have children eventually monitor their own progress.
ƒ All behavior techniques must progress / evolve as the child ages.
x Stimulant Medication ² can be effective when used in conjunction with counseling and parent
training.
x Parent Training and Counseling ²
ƒ Can be effective in reducing activity level, conflict, anger intensity an in increasing on-task
behavior of children with ADHD.
ƒ Second most widely used intervention (next to medication).
x Self-Esteem Education ²
ƒ Low self-esteem may precede depressed affect or depression in many children with
ADHD.
ƒ Foremost goal for many children and adolescents with ADHD should be enhancing their
self-esteem.
x Social-Skills Education ²
ƒ Children with ADHD often experience difficulty within social groups.
ƒ Need to acquire a more successful repertoire of social skills.
ƒ Interventions designed to improve social skills and social competency have been shown to
reduce peer-interaction difficulties for many children and adolescents.
x Family Counseling ²
ƒ Normal disagreements are magnified by core ADHD symptoms.
ƒ Child or adolescent with ADHD may suffer from low academic achievement, low self-
esteem, social isolation, and depression from the effects of the disorder.

From: Erk, 2004; Nathan & Gorman, 1998; Seligman, 1998.

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Mental Retardation

Overview of the Disorder:

Has a pervasive impact on cognitive, emotional, and social development. Mental retardation is
diagnosed from the results of individual IQ tests. Client sometimes presents with aggression, overactive, or
SIB. Tend to be concrete in thinking, reasoning, and problem solving.

Criteria:
1) Onset prior to age 18
2) Sub-average IQ below 70
3) Impaired adaptive functioning in at least 2 areas

Subtypes:
1) Mild: 50-55 to 70
2) Moderate: 35-40 to 50-55
3) Severe: 20-25 to 35-40
4) Profound: IQ below 20-25

Potential Risk Factors:

x Genetic and chromosomal abnormalities
x Prenatal and peri-natal difficulty
x Childhood disease
x Can also be associated with physical disorders such as cerebral palsy.
x Mild and moderate retardation is fifteen times more common among children from the lowest
socioeconomic classes (Harris, 1995).

Treatment:
Therapists must establish realistic goals and accept limited progress. Must have knowledge about
human development. Early intervention using a developmental approach is essential to treatment. A
behavioral approach is most often used to develop appropriate social interaction and self help skills such as
dressing, taking a bath, and grocery shopping. The prognosis is poor. Mental retardation has implications
for the entire life span.

Interventions:
x Nezu & Nezu (1994) adopt a five-step problem solving approach.
1) Identifying beliefs and assumptions
2) Defining problems
3) Generating alternate solutions
4) Evaluating options
5) Implementing solutions
x Behavior Modification ²
ƒ Long viewed as treatment of choice for mental retardation ² helpful for decreasing SIB.
x Family counseling ²
ƒ improve parent-child relationship
ƒ Case management ² important component
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Conduct Disorder
Overview of the Disorder:
Overriding feature of this disorder is a persistent pattern of behavior in which the rights of the
others and age-appropriate social norms are violated. Conduct disorder is not the result of a single cause.
Focus on the characteristics, events, experiences that increase the risk of Conduct Disorder.
Among the most prevalent and serious disruptive behavior disorders seen in mental health centers.
Conduct problems in children and adolescents are age-inappropriate actions and attitudes that violate family
expectations or rules, and the personal or property rights of others. Display sever aggressive and antisocial
acts involving the infliction of pain on others or interfering with the rights of others through physical and
verbal aggression, stealing, or committing acts of vandalism. The essential feature of CD are antisocial
behaviors that are linked to a repetitive and persistent pattern of behavior which violates the rights of others
and involves the violation of major age-appropriate societal norms or rules.

Criteria:
1) Childhood-Onset- Prior to 10 yrs ² exhibit more severe, aggressive, and antisocial behaviors.
2) Adolescent-Onset ² After 10 yrs old ²better prognosis.

Potential Risk Factors:

1) Low family income
2) Large family size
3) Overcrowding
4) Poor housing conditions
5) Poor paternal supervision
6) Parent criminality
7) Parental marital discord

Often comorbid with ADHD and ODD. Children with Conduct Disorder often exhbit academic
difficulties, poor interpersonal relations, deficits and distortions on social skills and interacting.Most
researched pattern of behavior is coercion. Coercion refers to deviant behavior (e.g. the child) that is
rewarded by another person (e.g. the parent). Aggressive children are inadvertently rewarded for their
aggressive interactions and their escalation of coercive behaviors as part of the discipline practices that
sustain aggressive behaviors.

Parent-Family Characteristics:
1) Criminal behavior
2) Alcoholism
3) Parental discipline and attitudes ² harsh, erratic, lax, inconsistent
4) Dysfunctional relations ² less warmth, affection, emotional support, less supportive, and more
defensive.
5) Poor parental supervision
6) Unhappy marital relationship
7) Interpersonal conflict
8) Dysfunctional relationships
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Contextual Characteristics
1) Financial hardship
2) Untoward living conditions
3) Transportation obstacles
4) Psychiatric impairment of one of the parents
5) Stress related to significant others
6) Adversarial contact with an outside agency

Treatment:
Therapist plays an active role in therapy. Therapy usually combines several different procedures,
including modeling and practice, role playing and reinforcement, and mild punishment. Treatment utilizes
structured tasks involving games, academic activities, and stories.
Cognitively-based therapy significantly decrease aggressive and antisocial behavior at home, at
school, and in the community and have surpassed the impact of other treatments. Controlled outcome
studies indicate that cognitively-based treatments lead to therapeutic change.

Interventions:
x Cognitive Problem-Solving Skills Training (PSST) ²
ƒ Broad class of constructs that pertain to how the individual perceives, codes, and
experiences the world.
ƒ CD individuals show distortions and deficiencies in various cognitive processes.
ƒ Generate alternative solutions to interpersonal problems. Identify the means to obtain
SDUWLFXODUHQGVRUFRQVHTXHQFHVRIRQH·VDFWLRQ
ƒ Develop interpersonal cognitive problem solving skills
ƒ Children engage in a step-by-step approach to solve interpersonal problems
ƒ Behaviors selected and solutions to interpersonal situations are important.
x Parent Management Training (PMT) ²
ƒ In this model, the counselor serves as an educator and tainer whose prime responsibility is
WRHIIHFWDFKDQJHLQWKHSDUHQW·VUHVSRQVHVWRZDUGDFKLOGRUDGROHVFHQW
ƒ 3DUHQWVWUDLQHGWRDOWHUWKHLUFKLOG·VEHKDYLRULQWKHKRPH
ƒ Based on the general view that CD problem behavior is inadvertently developed and
sustained in the home by maladaptive parent-child interactions.
ƒ Multiple facets of parent-child interaction that promote aggressive and antisocial behavior.
ƒ Important to remember: Influences are bidirectional ² the child influences the parent as
well. Sometimes children engage in deviant behavior to help promote interactions.
ƒ Goal: Alter the pattern of interchanges between parent and child so that prosocial, rather
than coercive behavior is directly reinforced and supported within the family.
x Functional Family Therapy (FFT) ²
ƒ Clinical problems are conceptualized from the standpoint of the functions they serve in the
family as a system.
ƒ Treatment is based on learning theory and focus on specific stimuli and responses that can
be used to produce change.
ƒ Family requires that the family see the clinical problem from the relational functions it
serves within the family.
ƒ Has shown effectiveness, and produces consistent effects.
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x Multi-systemic treatment ²
ƒ Approach to treatment based on family systems but considers the family only one system.
ƒ Treatment procedures ² XVHG´DVQHHGHGµWRDGGUHVVLQGLYLGXDOIDPLO\DQGV\VWHPLVVXHV
that contribute to problem behavior.
ƒ Draws on other techniques PSST, PMT.
ƒ MST has demonstrated effectiveness.

From: Erk, 2004; Nathan & Gorman, 1998; Seligman, 1998.

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Oppositional Defiant Disorder

Overview of the Disorder:

Oppositional Defiant Disorder is characterized by a pattern of negativistic, hostile, and defiant
behavior lasting at least six months. To qualify for a diagnosis of ODD, symptoms must of greater intensity,
IUHTXHQF\DQGGXUDWLRQWKHQZRXOGEHH[SHFWHGIRUWKHFKLOG·VDJH7KHVHV\PSWRPVPXVWDOVRFDXVH
impairment in social, occupational, and academic functioning. This disorders tends to begin around the pre-
teen age (from approx. 8- 11 years old).
The differentiation between Oppositional Defiant Disorder and Conduct Disorder is in terms of
interpersonal relations. Children diagnosed with ODD tend to have stronger interpersonal bonds, more
successful social interactions, and do not demonstrate the cunning, calculated behaviors associated with
Conduct Disorder.

Criteria:
1. In adolescence: ODD is manifested by the following:
a. /RVLQJRQH·VWHPSHU
b. Arguing with adults
c. Resistence toward following the rules
d. Blaming others
e. Being vindictive
2. In childhood: ODD includes the following:
a. Temper tantrums
b. Disobedience
c. Screaming
d. Low tolerance frustration

Potential Risk Factors:

x Presence of aggression in preschool aged children
x Low frustration tolerance
x Poor problem solving skills
x Negative self-statements
x ODD is associated with diagnoses of ADHD, Learning Disorders, and communication disorders.
x Parental discord
x Poor-parent child communication and interactions.

Treatment:
The first step is to assess the degree of danger the children pose to themselves or others and
evaluate the impact that the environment may be having on their continued development (King & Noshpitz,
,WLVLPSRUWDQWWRDOVRHYDOXDWHWKHDELOLW\RIWKHFKLOG·VSDUHQWVFDUegivers to adequately care for
them. In some incidents, crisis care / residential treatment may need to considered.
Treatment for children and adolescents should include multiple modalities. Individual therapy,
parent intervention, school intervention, and community based interventions should all be considered.
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Interventions:
x Individual Psychotherapy
ƒ Problem Solving Skills Training (PSST) ² based on a social-cognitive approach. This approach
teaches children to identify a problem, define goals, generate options, choose the best option, and
evaluate the outcome.
ƒ Reality therapy ² provides a framework for challenging the distorted perception held by delinquent
youth. This approach was developed by William Glasser and it is typically used in hospital settings.
The main techniques involve using contracts and rewarding good behavior.
ƒ Anger management training ² a cognitive approach that has received some positive results.
x Group Psychotherapy
ƒ Social Skills group training ² has been successful in decreasing ODD in some children
ƒ Group Therapy ² has not demonstrated great efficacy among children and teens. May be a risky
WUHDWPHQWEHFDXVHRIWKHWHQGHQF\IRUJURXSPHPEHUVWR´ERQGµDQGJORULI\ULVN\EHKDYLRUVVXFKDV
drug use.
x Family Interventions ² a key factor in the successful treatment of ODD.
ƒ Parent Management Training (PMT) ² A cognitive-behavioral approach that teaches skills like
PRQLWRULQJFKLOGUHQ·VEHKDYLRUVPDLQWLDQJGLVFLSOLQHDQGSURYLGLQJUHZDUGV
ƒ Functional Family Thearpy (FFT) ² dervived from communication taining and behavioral.
Structural, and systems theories. FFT attempts to reduce defenisvness among family members and
to increase positive interactions.
x Pharmacologcial Interventions ² Medication may be necessary to treat comorbid disorders such as
ADHD.

From: Seligman, 1998

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Mood Disorders ² Overview

Primary Symptoms ²
1) Feelings of depression
2) Discouraement
3) Hoplessness
4) Dysphoria
5) Loss of energy
6) Worthlessness
7) Excessive guilt

Physiological Symptoms ²
1) Changes in appetite
2) Insomnia

Exogenous Depression ² Reactive to event / situation

Endogenous Depression ² Melancholic, biochemical depression (less common)

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Client Map: Treatment Recommendations for Mood Disorders

Objectives of treatment: Stabilize mood; alleviate depression, mania, and hypomania; prevent relapse;
improve coping mechanism, relationship, career, and overall adjustment; establishment a consistent and
healthy lifestyle.

Assessments: Measures of Depression and suicidal ideation, medical examination for physical symptoms.

Clinician characteristics: +LJKLQFRUHFRQGLWLRQVFRPIRUWDEOHZLWKFOLHQW·VGHSHQGHQFHDQG

discouragement; resilient; able to promote motivation, independence, and optimism; able to be structured
and present-oriented.

Interventions used: CBT , interpersonal, education about disorder, relapse prevention.

Emphasis of treatment: Emphasis on cognitions and behavior, initially directive and supportive emphasis ²
later on, less directive and more exploratory emphasis.

Numbers: Primarily individual therapy, family therapy often indicated, group therapy useful after
symptoms have abated.

Timing: Medium duration ² three to six months; moderate pace ² one to two sessions per week;
maintenance and extended follow-up phases common.

Adjunct services: Increased activity, homework assignments, career counseling, development of social and
coping skills, homogeneous support groups.

Prognosis: Good for recovery from each episode; fair for complete remission; relapses common.
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Major Depressive Disorder

Overview of the Disorder:

A Major Depressive Disorder (MDD) is the most commonly diagnosed psychiatric disorder among
adults. Clinical depression is a debilitating and pernicious cluster of symptoms that may persist for a period
of weeks, months, or even years. This disorder is associated with significant cognitive, emotional,
behavioral, somatic, and social impairments. MDD is a heterogeneous syndrome that is characterized by
either depressed mood or markedly diminished interest or pleasure in most activities.
Research indicates that the onset of particular episodes of adult depression is usually provoked by
life events or ongoing difficulties. The majority of these events involve some element of loss.
Major Depressive Disorder consists of one or more Major Depressive Episodes. 1) Severity ² mild,
moderate, severe, in-partial remission, or in-full remission. 2) Presence of psychotic features ² mood
congruent (consistent with depression), mood incongruent (inconsistent with depressive themes).
3)Chronic ² consistent episode for at least 2 years. 4) Presence of melancholic features ² depression of
endogenous of biochemical origin. 5) Presence of atypical features ² weight gain, increased sleep, etc. 6)
Presence of postpartum onset. 7) Presence of full interepisode recovery. 8) Presence of seasonal pattern.
Usually accompanied by dysphoria and anhedonia. The typical age of onset is mid-twenties. The
initial episode is usually proceeded by a stressor. There is a correlation between severe depression and a
preexisting personality pattern that includes low self-esteem, dependence, anxiety, dysfunctional thinking,
fragility.
Tends to co-occur with most Axis I disorders. Particularly high rates between depression and
schizophrenia, substance abuse, anxiety disorders, and eating disorders.

Criteria:
Four of the following symptoms for at least two weeks ²
1) Weight or appetite change
2) Insomnia or hypersomia
3) Psychomotor retardation or agitation
4) Fatigue or loss of energy
5) Feelings of guilt or worthlessness
6) Reduced ability to think
7) Recurrent thoughts of death / suicide

Potential Risk Factors:

$FDUHIXODVVHVVPHQWRIWKHSDWLHQW·VULVNIRUsuicide is crucial. An assessment of the presence of
suicidal ideation is essential. This should include the degree to which the patient intends to act on suicidal
ideation, the extent to which the patient has made any suicidal ideation and the extent to which the patient
has made plans or began to prepare for suicide. The availability of means of suicide should be inquired about
and judgments should be made about the lethality of stated means.
Any impairment should be identified. Impairments include deficits in interpersonal relationships,
work, living conditions, and other medical or health-related needs. As treatment progresses, it is critical to
PRQLWRUWKHSDWLHQW·VVWDWXVIRUWKHHPHUJHQFHRIFKDQJHVLQGHVWUXFWLYHimpulses toward self and others.
Given the chronic nature of MDD, exacerbations are common. Patients should be educated about the
significant risk of relapse, as well as the identification warning signs and symptoms preceding an episode.
 14

Treatment:
Establishing a therapeutic alliance with the patient is important. Because MDD is a chronic
condition, requiring active participation of the patient, therefore a strong treatment alliance is critical to
positive treatment outcomes. Structured, focused on present, able to attend to interpersonal issues and
difficulties. Cognitive behavioral therapy and interpersonal therapy are most effective. Results are visible in
8 sessions but treatment should usually last about 16. Medication is particularly indicated for people with
endogenous (rather than reactive) depressions.
Collaboration requires that the patient trust the therapist. Warmth, accurate empathy, and
genuineness are desirable personal qualities for the cognitive therapist, as for all therapists. Rapport
between the patient and therapist is crucial in the treatment of depressed patients.
Antidepressant medication is typically recommended when the episode of depression is severe,
recurrent, or chronic. Medication is also preferred when there is psychosis, if there is a family history of
depression, or if there was a previous positive response to medication. Combined treatment is advocated
for more severe and chronic depression.
The therapies that have achieved the status of empirically supported for depression include
cognitive therapy, behavioral therapy, and interpersonal psychotherapy. CBT and IPT have the best
documented efficacy in the literature. To adequately formulate a case and generate a strategy for
intervention, it is important to make appropriate diagnoses, to have a clear understanding of the range of
WKHSDWLHQW·VSUHVHQWLQJSUREOHPVDQGWKHLUVHYHULW\DQGWRSULRULWL]HWKLVSUREOHPOLVW
Obtaining an appropriate diagnosis is an important step in treatment planning, as depression is
often comorbid with other psychiatric conditions. Treatments of choice for depression include: somatic
interventions (medication), psychosocial interventions (behavior therapy, CBT, interpersonal
psychotherapy).

Interventions:
x Behavioral therapy ²
ƒ Based on theoretical models drawn from behavioral theory and social learning theory.
ƒ Focused largely on improving social and communication skills, increasing adaptive
behaviors, positive and negative assertion, increasing response-contingent positive
reinforcement for adaptive behaviors, and decreasing negative life experiences.
ƒ Specfic techniques include: activity scheduling, self-control therapy, social skills training,
problem solving.
x Behavior Marital Therapy ²
ƒ Employment of behavior marital therapy (BMT) with individuals who are concurrently
suffering from an MDD and in a discordant marriage.
ƒ Marital problems are common in the course of mood disorders, and comprehensive
treatment often demands that these problems be assessed and addressed.
ƒ Results from individual studies suggest that the efficacy of marital therapy depends on
whether martial distress is present.
x Cognitive-Behavioral Therapy (CBT) ² œ
ƒ CBT maintains that irrational beliefs and distorted attitudes toward the self, the
environment, and the future perpetuate depressive affects. The goal of CBT is to reduce
depressive symptoms by challenging and reversing these beliefs and attitudes.
ƒ The most extensively evaluated ps\FKRVRFLDOWUHDWPHQWIRU0''LV%HFN·V&%7
ƒ CBT is short-term (16-20 sessions over a period of 12-16 weeks) ² directive therapy
GHVLJQHGWRFKDQJHWKHGHSUHVVHGSDWLHQW·VQHJDWLYHYLHZRIWKHVHOIZRUOGDQGIXWXUH
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ƒ Research indicates that CBT is a viable treatment of choice of MDD.

ƒ A main therapeutic goal of the first interview is to produce some symptom relief. Relief of
symptoms VHUYHVWKHSDWLHQW·VQHHGVE\UHGXFLQJVXIIHULQJDQGDOVRKHOSVWRLQFUHDVH
rapport, collaboration, and confidence in the therapeutic process.
ƒ Problem definition continues to be a goal in the early stages of therapy. The therapist
works with the patient to define specific problems to focus on during therapy sessions.
ƒ Research demonstrates that CBT may be more effective than other treatments for
depressed individuals with personality disorders.
ƒ Factors associated with poor outcome to CBT: unemployment, male gender, comorbidity,
dysfunctional attitudes.
x Interpersonal Psychotherapy (IPT) ²
ƒ Originally developed as a time-limited (12-16 weeks), weekly intervention for unipolar,
unpsychotic depression.
ƒ ,37PRGHOLVGHULYHGIURP6XOOLYDQ·VLQWHUSHUVRQDOWKHRU\DQGWKHSV\FKRELRORJLFDOWKHRU\
of Meyer. The therapist takes an active and supportive role in the treatment. The therapist
needs to be well informed about depression, as well as comfortable providing
psychoeducation and assuming an expert role with regards to depression.
ƒ In the early phase of treatment, the two major tasks are: the establishment of a
collaboration working alliance with the patient and the identification of the interpersonal
IRFXVEHVWUHSUHVHQWLQJWKHSDWLHQW·VUHSRUWHGLQWHUSHUVRQDOUHODWLRQVKLSV
ƒ IPT intervention focuses on the identification DQGDPHOLRUDWLRQRIWKHSDWLHQW·VGLIILFXOWLHV
in interpersonal functioning associated with the current MDD; the primary problem areas
include unresolved grief, interpersonal disputes, role transitions, and interpersonal deficits.
ƒ IPT intervenes by facilitating mourning and promoting recognition of related affects,
resolving role disputes and overcoming deficits in social skills to permit the acquisition of
social skills.
ƒ Demonstrated effectiveness: patients with comorbid MDD & OCD and for patients that
are single & non-cohabitating.
ƒ IPT is currently recommended as an acute treatment for symptom removal, prevention of
relapse and recurrence, correction of causal psychological problems for secondary
symptom resolution, and corrections of secondary consequences of depression.
ƒ Less effective: Patients with comorbid personality disorders, especially avoidant personality
pathology and patients with severe or psychotic depression.
ƒ IPT appears to be an effective and efficacious treatment if an MDD and as a maintenance
treatment for chronic and treatment resistant depression (especially when combined with
meds.)and for mild and moderate depression.
x Psychodynamic psychotherapy ²
ƒ Interventions share a basis in psychodynamic theories regarding the etiologic nature of
psychological vulnerability, personality development and symptom formation as shaped by
developmental deficit and conflict occurring during the life cycle from early childhood
forward
ƒ Longer-term duration than other therapies and usually associated with goals beyond that of
immediate symptom relief.
 16

ƒ Goals are usually associate with an attempt to modify the nderlying psychological conflicts
DQGGHILFLWVWKDWLQFUHDVHWKHSDWLHQW·VYXOQHUDELOLW\WRPDMRUGHSUHVVLYHDIIHFWDQGWKH
development of MDD.
ƒ Although widely used in clinical practice, the efficacy of long-term psychodynamic in the
acute phase of MDD has not been adequately studied.
x Group therapy ²
ƒ CBT & IPT demonstrate effectiveness when administered in group format.
ƒ Efficacy of self-help groups has not been well-studied.

From: Seligman, 1998; Anthony & Barlow, 2002; Nathan & Gorman, 1998; APA, 2000; Barlow, 2001;
 17

Dysthymic Disorder

Overview of the Disorder:

Characterized by the presence of chronic depression, usually mild to moderate in severity, most
days for at least two years. Patients usually face chronic environmental stressors and most commonly have a
rejecting, confusing, affectionless, controlling family, and low self-esteem.

Criteria:
At least two of the following symptoms:
1) Poor appetite or overeating
2) Insomnia or hypersomnia
3) Low energy or fatigue
4) Low self-esteem
5) Difficulty in concentrating or decision making
6) A sense of hopelessness

Establishing the diagnosis and determinants:

1) Age of Onset
2) Presence of atypical features
3) No clear point of onset or obvious precipitant

Potential Risk Factors:

x Age 60 years + demonstrate an increased risk
x More common among females until the age of 60+years old when males begin to outnumber females

Treatment:
&%7DQGLQWHUSHUVRQDOWUHDWPHQWXVHGLQFRPELQDWLRQZLWKSDWLHQW·VGHYHORpment of social and
related skills as assertiveness and decision making. Individual treatment seems to be superior to group
therapy. The goals of treatment are generally relief of depression and amelioration of somatic symptoms.

Interventions:
x Individual treatment
ƒ Cognitive behavioral strategies such as self-monitoring checklists demonstrate efficacy.
ƒ Affect modulation and regulation
ƒ ,GHQWLI\DQGUHVROYHGVRXUFHVRIVWUHVVPRELOL]HFOLHQW·VHQHUJ\LPSURYHVHOI-esteem.
ƒ Supportive treatment
x Group Psychotherapy
ƒ Has demonstrated moderate efficacy
ƒ Having energy to participate in group treatment is necessary to successful outcomes.
 18

Bipolar Disorder

Overview of the Disorder:

The core characteristic of Bipolar disorder is extreme affective dysregulation, or the swinging of
mood states from extremely low to extremely high. Patients in manic episode experience euphoria elevate
mood, irritability, behavioral activation, altered cognitive functioning. For the diagnosis of a manic episode
² there must be evidence that the SHUVRQ·V psychosocial functioning is disrupted.
Episodes of dysfunctional mood often separated by periods of normal mood. Classified as Bipolar I
or Bipolar II disorder. Bipolar II disorder differs from Bipolar I disorder primarily in its lack of any manic
episodes. BP II includes at least one hypomanic episode and at least one depressive episode ² but lacks the
full-blown manic episode that is part of BP I.
Bipolar disorder tends to begin at times of high stress. Individuals with BPD are more independent
and dominate, they are less guilty and anxious and prone to instability. BPD is an episodic, long-term illness
with a variable course.
The first episode of BPD may be manic, hypomanic, mixed, or depressive and may be followed by
several years during which the patient is symptom-free. The illness may be associated with substance-
related disorders, recklessness, impulsivity, truancy, and other antisocial behavior, the diagnosis of bipolar
disorder must be carefully differentiated from substance-related disorders, antisocial behavior or personality
disorders.

Criteria:
Depression associated with Bipolar disorder:
1) Less anger
2) Somatizing
3) Oversleeping and psychomotor retardation
4) Anxiety
5) Psychotic thinking
6) Worse in the morning

Manic episode ² an elevated, expansive mood last at least one week with at least three of the following:
1) Grandiosity
2) Decreased need for sleep
3) Increased talkativness
4) Racing thoughts
5) Distractibility
6) Increased activity
7) Excessive pleasure seeking

Potential Risk Factors:

One leading view of the etiology of bipolar disorder is that it results form biological dysregulation
(with a major genetic componenet) that are either activiated of maintained by psychosocial stressors such as
negative family environments or stressful life events.
Stressful family environments are also predicitive of the course of BPD. Specifically, if an episodic
bipolar patient returns to a high expressive-emotion (EE) family, the patient has a greater risk of relapse.
 19

Treatment:
Very important to form a therapeutic alliance ² important to form a partnership to monitor
medication, to chart moods, to educate patients, and develop a treatment plan. Bipolar patients frequently
express resentment at how little information they receive about their disorder or their medication.
When treating mania, it is important to be empathic but do not support inappropriate behavior. Be
directive, set limits, and promote reality testing. Goals for treatment should include alleviating acute
symptoms, preventing future episodes, and remedying occupational and interpersonal problems.
Medication tends to be the primary mode of treatment, especially first-line treatment. Individual
psychotherapy during a manic phase must be very structured and concrete. Cognitive Behavioral therapy
shows promise. Therapy that improves the family environment might help prevent relapses.
Psychiatric management and pharmacologic therapy are essential components of treatment for
acute episodes and for prevention of future episodes in patients with BPD. The goals of psychotherapeutic
WUHDWPHQWVDUHWRUHGXFHGLVWUHVVDQGLPSURYHWKHSDWLHQW·VIXQFWLRQLQJEHWZHHQHSLVRGHVDQGWRGHFUHDVH
the frequency of future episodes.

Interventions:
x Comprehensive Rehabilitation Model of Treatment ²
ƒ Dion & Pollack 1992
ƒ Empathic and positive treatment
ƒ Dyadic education about BPD
ƒ Plotting the course of the disorder
ƒ Symptom management
ƒ Improvement of lifestyle and the environment
ƒ $VVHVVPHQWRIWKHFOLHQW·VIXQFWLRQLQJDQGdevelopment
ƒ $VVHVVPHQWRIFOLHQW·s coping skills and support.
x CBT ²
ƒ Cochran (1984) identified the effects of a six-session protocol of CBT focusing on the
improvement of medication adherence in BPD.
ƒ CBT emphasized education about BPD and its management, as well as cognitive
restructuring, problem-solving, and routine and sleep-management interventions.
ƒ Elements of treatment include psychoeducation, cognitive restructuring, assertiveness, and
problem-solving training, activity management, and medication adherence.
ƒ Treatment has demonstrated effectiveness in significantly reducing the number of new
episodes and increasing euthymic periods relative to medication-alone comparison.
ƒ The first phase of treatment consists of nine sessions devoted to the treatment of depressive
symptoms and utilizes the psychoeducational, cognitive restructuring, and activity
assignments interventions commonly applied to unipolar depression.
ƒ Treatment is initiated with a discussion of a model of the disorder and rationale for CBT,
combined with instruction of the interplay between thoughts, feelings, and behavior.
Attention is placed on the used of vivid metaphors and stories to crystallize important
 20

information on the nature of the disorder, the process of change, pr a specific assignment of
skill.
ƒ Early sessions are also devoted to helping patients adopt a theoretic perspective toward
their own care, emphasizing self-empathy in response to distress and the search for useful
problem solving alternatives.
ƒ In the second phase of treatment, three sessions are devoted to discussion and complex
treatment contract and delineation of targets for the next phase of treatment.
ƒ A variety of CBT protocols emphasize early intervention strategies to reduce the impact of
hypomanic or manic episodes. These interventions are discussed to help prevent manic
episodes and the poor financial, social, or sexual decisions that accompany them.
x Marital and family therapy
ƒ Appears to be useful
ƒ Bipolar disorder occurs and maintained within a family context that both affects and is
affected by the disorder.
ƒ Difficulties in marital and family relationships may increase the likelihood of bipolar
relapse.
ƒ The family or spouse needs to be educated about the disorder in order to cope with the
effects of interpersonal interactions.
ƒ Psychoeducation important

From: Seligman, 1998; APA, 200; Barlow, 2001; Hofmann & Thompson, 2002;
 21

Anxiety Disorders ² Overview

Overview of Disorders:
Characterized by both emotional and physiological symptoms. Fear and apprehension are the
primary emotional symptoms. Confusion, impaired concentration, selective attention, and avoidance are
considered secondary symptoms. Physiological symptoms include the following: dizziness, heart
palpitations, changes in bowel movements, perspiration, muscle tension, restlessness, headaches,
queasiness.
Patients normally present with severe anxiety typically precipitated by marital and family problems.
Long standing anxiety is linked to early trauma and learned fears and individuals tend to view themselves as
powerless.
Treatment Guidelines:
The therapist must be a model of patience and persistence. Therpaist should be stable and calm and
untroubled by anxiety. Treatment generally includes cognitive and behavioral interventions.
Specific interventions for various anxiety disorders vary considerably but approaches generally
include the following:
1) (VWDEOLVKPHQWRIDVWURQJWKHUDSHXWLFDOOLDQFHWKDWSURPRWHVWKHFOLHQW·VPRWLYDWLRQDQGIHHOLQJVRI
safety.
2) Exploration of manifestations of anxiety and identification of triggers of fear.
3) Referral for medical evaluation and determination of any contributing physical disorders
4) Teaching of relaxation skills
5) Analysis of dysfunctional cognitions
6) Exposure to feared objects
7) Homework
8) Solidification of efforts to cope.
Other techniques: Anxiety Management Training (AMT) ² Relaxation based self-control treatment. Stress
Inoculation Training ² (SIT) Michenbaum
 22

Client Map: Treatment Recommendations for Anxiety Disorders

Objectives of treatment: Reduce anxiety and related behavioral and somatic symptoms of the disorder.
Improve stress management, social and occupational functioning, sense of mastery.

Assessments: Include physical examination to rule out medical disorder. Measures of anxiety or fear.

Clinician characteristics: Patient, encouraging, supportive yet firm and flexible, concerned but not
controlling, calm and reassuring, comfortable with a broad range of behavioral and cognitive interventions.

Interventions used: CBT and behavioral therapy, especially in vivo and imaginal desensitization, exposure,
and response prevention. Training in anxiety management, stress inoculation, problem solving, relaxation,
assertiveness training, self-monitoring of progress, homework assignments.

Emphasis of treatment: Usually person-oriented, moderately directive, supportive, cognitive and

behavioral.

Numbers: Individual or group therapy, according to the nature of the disorder. Ancillary family therapy as
needed, particularly for heritable disorders.

Timing: Usually weekly treatment of brief to moderate duration (eight to twenty sessions). Moderate
pacing.

Adjunct services: Hypnotherapy, biofeedback, meditation, exercise, other approaches to stress

management, planned pleasurable activities.

Prognosis: Variable according to the specific disorder. Generally good for amelioration of symptoms. Fair
for complete elimination of signs of the disorder.

Seligman, 1998
 23

Generalized Anxiety Disorder

Overview of the Disorder:

A pervasive disorder that affects almost every system of the body; physiological, cognitive,
motivational, affective, and behavioral. The essential feature of GAD is chronic worry about a number of
life matters that is judged to be excessive and uncontrollable. Most common affective and somatic
complaints: inability to relax, tension, jumpiness, unsteadiness. Also common: dry mouth, intestinal
discomfort, cold hands. Most prevalent cognitive and behavioral symptoms: difficulty concentrating,
apprehension about losing control, fear of rejection, inability to control thinking, confusion. Common
secondary symptoms: emotional outbursts and hypersensitivity, reduced sexual and interpersonal activity,
perfectionism, hyper-vigilance, exaggerated startle response. Typically, clients suffer from low self-esteem,
feel insecure, indecisive, socially inadequate, and have strong needs for affection and approval. People with
GAD also are prone to anxiety-laden dreams.
Anticipatory anxiety: future-oriented mood state in which people are in a constant state of hyper-
vigilance and over-arousal in expectation of threat-related stimuli. The disorder tends to have a fairly
gradual onset, often beginning in childhood or adolescence. People generally seek treatment when they are
in their twenties. Without treatment the disorder is pervasive, much like a personality disorder, and tends
to be chronic throughout the lifespan.
Barbaree and Marshall (1985) suggest the intake interview for a person believed to have GAD
include the following:
1) Relevant cognitions
2) Somatic and physiological complaints
3) Relevant behaviors
4) Severity and generalizability of the disorder
5) Antecedents and precipitants
6) Consequences for relationships and for responses from others
7) Family and individual history of emotional disorders
8) Previous attempts to manage anxiety
9) Overall lifestyle

Criteria:
According to the DSM: Excessive anxiety and worry about at least two life circumstances for most
days during a period of at least six months. The worry is difficult to control, causes appreciable distress and
impairment and is accompanied by at least three of the following physiological symptoms (one in children):
1) Edginess or restlessness
2) Tiring easy
3) Difficulty concentrating
4) Irritability
5) Muscle tension
6) Difficulty in sleeping

Potential Risk Factors:

Typically, GAD is most prevalent in young adults with long-standing feelings of nervousness and a
history physical disease or substance misuse. Feelings of tensions, vulnerability, and lack of control,
common in individuals with GAD, are believed to result from early life experiences. Individual with GAD
 24

were likely to have has one or more negative, important, and unexpected life events associated with the
onset of the disorder.

Treatment:
The therapist should have a wide variety of anxiety-management techniques so that those
approaches likely to work with a given client can be selected. People diagnosed with GAD are sometimes
resistant to treatment , primarily because of the ego-syntonic nature of their symptoms, or because of their
attribution of the symptoms to medical causes. Nonspecific therapeutic qualities like warmth, empathy,
acceptance, and the ability to encourage trust and collaboration are important in addressing resistance and
SURPRWLQJFOLHQWV·LQYROYHPHQWLQWreatment.
The two targets of intervention: excessive, uncontrollable worry and the persistent over-arousal
that accompanies it. Treatment approaches tend to be active and multifaceted and to include cognitive
therapy, relaxation, training in anxiety management, and other cognitive and behavioral interventions.
Because this disorder does not typically remit spontaneously, treatment design should include training in
the use of preventive and coping mechanisms VRWKDWFOLHQW·VFDQPRQLWRUDQGPDQDJHDQ[LHW\ and stress on
their own.

Interventions:
x Anxiety Management Training (AMT) ²
ƒ Teaching individuals to cope with anxiety via self-administered relaxation and distraction.
ƒ Help individuals take greater control of their lives and to schedule more pleasurable
activites.
x Exposure & Response Prevention (Brown et al., 1993)
ƒ Involves exposure to worry and prevention of worry-related behavior.
ƒ Clients encouraged to confront their worries without using distraction or any other means
of avoidances.
ƒ The following techniques were used to help clients deal with worries: 1) self-monitoring of
mood levels, 2) analysis and modification of catastrophizing and other cognitive distortions,
3) relaxation training, including cue-controlled relaxation, 4) problem solving, 5) cognitive
countering 6) time management.
x AWARE (Beck & Emery, 1985) ²
ƒ A five step process for dealing with the affective component of anxiety disorders.
ƒ A: Accept feelings ² normalize, identify, and express them.
ƒ W: Watch the anxiety ² seek objectivity and distance.
ƒ A: Act with the anxiety rather than fighting it in dysfunctional ways.
ƒ R: Repeat the steps ² will establish learning.
ƒ E: Expect the best ² maintain optimism.
x Cognitive Therapy ²
ƒ A brief, time-limited approach (five to twenty sessions) for treating GAD.
 25

ƒ Approach emphasizes an inductive / Socratic method of teaching (questions are the

primary form of intervention).
ƒ Homework is an important component.
ƒ )RXUVWDJHVRIWUHDWPHQWUHOLYLQJWKHFOLHQW·VV\PSWRPVKHOSLQJWKHFOLHQWUHFRgnize
distorted automatic thoughts, 3) teaching the client logic and reasoning, 4) helping the
client modify long-held dysfunctional assumptions underlying major concerns.
ƒ This approach is logical, and organized, emphasizing good therapist-client rapport and
collaboration as well as specific interventions.
ƒ Most clients show significant improvement.
x Behavior Therapy ²
ƒ Primary goal: stress management
ƒ Some approaches: progressive muscle relaxation, autogenic training, guided imagery, yoga,
self-monitoring via logs of anxiety-levels, diaphragmatic breathing, medication,
ELRIHHGEDFNH[HUFLVHH[SUHVVLYHWKHUDS\V\VWHPDWLFGHVHQVLWL]DWLRQ0LFKHQEDXP·VVHOI-
instruction
x Medication ²
ƒ Generally not necessary in the treatment of GAD.
ƒ When indicated, benzodiazepines are usually the medication of choice.
 26

Panic Disorder

Overview of the Disorder:

The hallmark of Panic Disorder is attacks of panic that are unexpected. A panic attack is a
circumscribed period of intense fear of discomfort that develops suddenly, usually begins with cardiac
symptoms and difficulty in breathing, and peaks within ten minutes. A full panic attack is accompanied by at
lest dour physiological symptoms, which may including sweating, nausea, and trembling in addition to rapid
heartbeat, chest pain, and difficulty in breathing. Panic attacks typically last three to ten minutes and rarely
last longer than thirty minutes.
Three types of panic attacks: unexpected or uncued attacks ² with no apparent trigger;
situationally bounded or cued attacks ² in anticipation of or on contact with specific stimuli, and
situationally predisposed attacks ² usually but not always associated with specific triggers. Beck and
Emery (1985) hypothesize that one of three dears is at the core of an acute attack of panic: fear of serious
physical disease or illness, fear of mental disorder, or fear of social catastrophe or public disgrace.
Individuals with PD report feeling anxiety about future panic attacks. They tend to avoid situations
that would trigger panic attacks, such as crowded shopping malls, restaurants, and movie theaters. Panic
disorder typically has a sudden onset, beginning with a severe panic attack. The mean age of onset for Panic
Disorder ranges from twenty-three to twenty-nine, with treatment usually sought around the age of thirty-
four.

Criteria:
Panic disorder is characterized by at least two unexpected panic attacks, neither of which can be
explained by medical conditions or substance use, with one or more followed by at least a month of
persistent fear of another attack, worry about the implications of the attack, and/or behavioral change in
response to the attack.

Specify: Panic Disorder w/ Agoraphobia or Panic Disorder w/o Agoraphobia.

A panic disorder is characterized by a sudden rush of fear or anxiety that includes four or more of the
following physical and cognitive symptoms:
1) Palpatations, pounding heart, or accelerated heart rate
2) Sweating
3) Trembling or shaking
4) Shortness of breath or smothering sensations
5) Feelings of chocking
6) Chest pain or discomfort
7) Nausea or abdominal distress
8) Dizziness, unsteadiness, lightheadedness, or faintness
9) Feelings of unreality (derealization) or being detached from oneself (depersonalization)
10) numbing or tingling sensations (parathesias)
11) chills or hot flushes
12) Fear of going crazy or losing control
13) Fear of dying

Potential Risk Factors:

Both Panic Disorder and Agoraphobia seem to familial disorder. People with Panic Disorder have a
high incidence of early separations and of very disturbed childhood environments. They have a high
 27

likelihood of having experienced episodes of MDD and Sepeartaion Anxiety Disorder, or other Anxiety
Disorders as children. Many people with PD were deoressed, dependent, and passive even before the panic
attacks began. Relationship and occupationak difficulties are often present in people with PD.

Treatment:
The first session with clients experiencing PD is cirical in establishing a successful therapeutic
alliance. People with this disorder typically feel angry for being refered to a mental health professional for
what they believe to be a physical or medical problem. Individuals with PD typically have a history of
unsuccessful personal and professional efforts to ameliorate it and may feel demoralized as well as ashamed
at not having been successful.
Cognitive therapy, enhanced by behavioral interventions and sometimes combined with
PHGLFDWLRQ7KHFRJQLWLYHLQWHUYHQWLRQVVHHNWRFKDQJHSHRSOH·VFDWDVWURSKLFDQGGLVWRUWHGWKLQNLQJDQG
such behavioral techniques as distractions, comforting rituals, mediation, and relaxation contribute to the
control of anticipatory anxiety and of any panic attacks that may occur.
A challenging aspect of treating panic attacks is their unpredictable and intermittent nature. People
with this disorder also tends to have concerns such as low self-esteem and interpersonal difficulties that
XQGHUOLHDQGSUHFHGHWKH3$·V² HOLPLQDWLRQRIWKH3$·VPD\QRWEHVXIILFLHQW&KURQLFLW\DQGLQFRPSOHWH
remission are significant concerns in the treatment of this disorder.
The prognosis for treatment, primarily via short-term CBT, is excellent ² especially if treatemtn is
sought early in the course of the disorder.

Interventions:
x Cognitive Behavioral Therapy (CBT) ²
ƒ Found to be more effective than other interventions, including medication alone and
behavior therapy alone.
ƒ Disorder seems to stem from misrepresentation of physical symptoms ² cognitive
LQWHUYHQWLRQVVHHNWRFKDQJHSHRSOH·VFDWDVWURSKLFDQGGLVWRUWHGWKinking.
Panic-Control Therapy (Barlow & Cerny, 1988; Craske & Barlow, 1993)
a) $XQLTXHFRPSRQHQWRI%DUORZ·VSDQLF-control therapy is progressive evocation
of the somatic sensations of panic attacks (i.e. ² exposing the patient to
sensations similar to physiological panic sensations.
b) People are asked to induce physical symptoms of a PA by running upstairs,
spinning in a chair, etc.
c) Treatment interventions: education, combination of exposure and
desensitization to the panic attacks, and cognitive restructuring; help people
recognize their fears and understand that they are not life threatening.
d) Behavioral techniques: breathing retraining and relaxation
x Insight-oriented treatment strategies ²
ƒ These strategies can help people understand the underlying meaning of their anxiety and
the anxiety-related behaviors and attitudes they probably have manifested for many years.
x Family & Group Therapy ²
ƒ Family interventions combined with specific treatments fro panic attacks, can help
ameliorate the impact that this disorder has on family funcitioning.
 28

ƒ Group therapy using CBT has demonstrated high levels of effectiveness.

x Medication ²
ƒ Sometomes a part of the treatment plan ²but it can interfere with the impact of
psychotherapy by artificially promoting relaxation and lLPLWLQJSHRSOH·VDELOLW\WRVHOI-
soothe and credit themselves with overcoming the disorder.
ƒ TCAs, MAOIs, SSRIs
ƒ Medication should almost never be the sole modality of treatment.

Seligman, 1998; Nathan & Gorman, 1998; Antony & Barlow, 2002 .
 29

Posttraumatic Stress Disorder & Acute Stress Disorder

Overview of the Disorder:

Both disorders involves a reaction to an extreme stressor that has caused or threatened death or
severe injury ² extreme stressors include rape, combat, car accidents, and natural disasters. Common
symptoms include shame, survivor guilt, self-blame, lack of interest in usual activities, withdrawal from
close relationships, difficulty in self-soothing.

Criteria:
1) Great fear and helplessness in response to the traumatic event
2) Persistent re-experiencing of the event
3) Loss of general responsiveness, and at least three indicators of avoiding reminders of the trauma
4) At least two persistent symptoms of arousal and anxiety, that are apparently due to the stressor and are
severe enough to cause significant distress or impairment

Potential Risk Factors:

x Exposure to traumatic events
x Exposure to rape, military combat and capaitivey, and genocide.
x Feelings of guilt (survivor guilt)
x Interpersonal stressor (i.e., domestic violence)

Treatment:
Treatment should begin as soon as possible after the trauma. Treatment typically utilizes cognitive
approaches including exposure to the memory of the trauma. Effective treatment promote the accessing and
processing of trauma, the expression of feelings, increasing coping with and control over memories,
reducing cognitive distortions, reducing self-blame, increasing a sense of safety and stability, and increasing
self-esteem.

Interventions:
x Critical Incident Stress Debriefing (CISD) ²
ƒ Provides early help for those that have experienced trauma
ƒ Designed primarily for those that have experienced the same trauma (i.e. those that have survived a
natural disaster).
ƒ Groups of 8-12 participants meet with facilitators for one or more sessions.
x Cognitive-Behavioral Therapy ²
ƒ Exposure to the memory through discussion of the trauma meanings.
ƒ Development of coping skills
ƒ Changes in maladaptive beliefs.
ƒ Exploration of emotions
x Anxiety Management Training (AMT)
ƒ Pairs activation of traumatic memories with techniques designed to promote relaxation and reduce
fears.
x Stress Inoculation Training (SIT)
 30

ƒ Combines education with training in muscle relation, thought stopping, breath control, guided self-
dialogue, covert modeling, and role playing.
x Group Psychotherapy
ƒ Group experiences which involving others who have has similar experiences can prove helpful
x Medication ² Generally not indicated with trauma-related disorders, however medication can be
prescribed for some symptom relief.
 31

Study Guide for DSM-IV-TR Disorders

Overview of the Disorder:

Criteria:

Potential Risk Factors:

Treatment:

Interventions: