Psychobabble 101: Mental Health Professions, Diagnoses, Terminology, and Methods April 17, 2007

Psychobabble 101:
Mental Health Professions, Diagnoses,
Terminology, and Methods
April 17, 2007
Michael Jenuwine
Notre Dame Law School
Common Feature?
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Moron
Idiot
Maniac
Retard
Lunatic
Imbecile
Mental Health:
A Report of the Surgeon General
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We have allowed stigma and a now
unwarranted sense of hopelessness
about the opportunities for recovery
from mental illness to erect these
barriers. It is time to take them down.
Dr. David Satcher
Surgeon General
How Common is MI?
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Mental illnesses account for
approximately 15% of all cases of
disease in the United States.
How Common is MI?
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About 1 in 5 Americans
(approximately 44 million people)
experiences a mental disorder in
the course of a year. This figure is
roughly the same for children and
adolescents (21%) as for adults.
Understanding Mental
Health Professions
Who are the MH Professionals
in Your Neighborhood?
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Counselor
Social Worker
Psychiatrist
Psychologist
Psychoanalyst
People receiving services may not
understand the differences, so they
often use these titles interchangeably.
Mental Health Credential Scramble
IV
EdD
ACSW
HSPP
MSW
HTTP
PsyD
CADC
KFC
PsyF
MD
LSW
LMHC
DSW
EIEIO
AARP
LMNO
MPh
LMFT
QMHP
BSA
TGIF
OPP
ABPP
BSW
OSW
LCSW
Mental Health Credential Scramble
IV
EdD
ACSW
HSPP
MSW
HTTP
PsyD
CADC
KFC
PsyF
MD
LSW
LMHC
DSW
EIEIO
AARP
LMNO
MPh
LMFT
QMHP
BSA
TGIF
OPP
ABPP
BSW
OSW
LCSW
Psychiatrists: MD or DO
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Physicians
Training focused on
psychopathology and treatment
Prescription Privileges
Expertise
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Distinguishing physical disorders
with emotional manifestations from
psychiatric disorders
Organic/Neurological impairment
Psychologists: PhD or PsyD
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Doctoral level psychologists
Training focused on assessment and
treatment of psychopathology
Expertise:
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Psychological testing and standardized
assessment of psychopathology,
intellectual functioning, behavioral
functioning, and academic achievement
Verbal and behavioral interventions
Social Workers: MSW or MA
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Master’s level social work training
Training focused on assessment
and treatment of
psychopathology using a systems
perspective
Expertise
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Social and family systems as they
affect the individual
Social services and programs
available for persons with
emotional/behavioral problems
Educational
Degree
Board
Certification
HSPP
ABPP
BSW
Social Work MSW
DSW & PhD
Psychiatry
MD
LSW
LCSW
ACSW
Other
QMHP
CADC
LMHC
LMFT
Psychology
PhD
EdD
PsyD
State
License
BA
BS
MA
Understanding Diagnosis
of Mental Disorders
Name that book?
Classification of Mental Disorders
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DSM is a Categorical Classification System
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Communication Tool Only
Uses Polythetic Classification
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First published in 1952
Current version?
Defines a class in terms of characteristic features
Individual presents with a subset of items from a
larger list (overall similarity)
Two people with completely different symptoms can
have the same diagnosis
Multiaxial Classification System
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How many DSM axes?
DSM-IV Disclaimers
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There is no assumption that each category of
mental disorder is a completely discrete entity
with absolute boundaries dividing it from all
other metal disorders or from no mental
disorder
There is also no assumption that all
individuals described as having the same
mental disorder are alike in all important
ways
Structure of the DSM
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Uses Polythetic Classification
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Defines a class in terms of characteristic
features
Individual presents with a subset of items
from a larger list (overall similarity)
Two people with completely different
symptoms can have the same diagnosis
Multiaxial Classification System
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How many DSM axes?
Multiaxial Classification
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Axis I:
All clinical disorders or other
conditions that may be a focus of
clinical attention
Axis II: Personality Disorders & Mental
Retardation
Axis III: General Medical Condition
Axis IV: Psychosocial & Environmental
Problems
Axis V: Global Assessment of Functioning
DSM Diagnosis Example 1
Axis
Axis
Axis
Axis
I
II
III
IV
Axis V
Major Depression, Recurrent
Paranoid Personality Disorder
Hearing Loss
Unemployment, Inadequate
Finances
GAF= 30 (current); 65 (highest
level past year)
Diagnostic Uncertainty
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Diagnosis Deferred
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Used when there is insufficient information to
make a definite diagnosis
v. 799.9
Specific Diagnosis – Provisional
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Used when there is sufficient information for a
tentative, but not firm diagnosis
“working” diagnosis is given but indicates
significant uncertainty
Diagnostic Uncertainty (cont’d.)
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Not Otherwise Specified (NOS)
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Used when there’s enough information to know a
disorder belongs to a particular category, but
insufficient to make a more specific diagnosis
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Either not enough info or symptoms don’t match any
specific categories
Rule Out (R/O)
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Enough information is available to indicate that a
certain diagnosis needs further consideration in
the future, but further specification is not possible
DSM Diagnosis Example 2
Axis I
315.00
Axis II
V71.09
Axis III
382.9
Axis IV
Axis V
Depressive Disorder, NOS
Reading Disorder
R/O Alcohol Abuse
No diagnosis, histrionic
personality features
Otitis Media, recurrent
Threat of Job Loss
GAF=83 (highest level past year)
Disorders First Diagnosed in
Infancy, Childhood, or Adolescence
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Mental Retardation
Learning Disorders
Motor Skills Disorder
Communication Disorders
Pervasive Developmental Disorders
Attention Deficit and Disruptive
Behavior Disorders
Mental Retardation
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Three diagnostic criteria must be met„
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Significantly subaverage intellectual
functioning (below 70 on IQ test: 2 S.D.
below mean)
Concurrent deficits in adaptive functioning
in at least two areas:
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Communication, self-care, home living,
social/interpersonal skills, use of community
resources, self-direction, functional academic
skills, work, leisure, health, and safety.
Onset prior to age 18
Severity of Mental Retardation
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Mild Mental Retardation
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IQ score between 50 and 69
Roughly comparable to 6th to 8th grade
functioning level
Persons with Mild MR can live
independently as adults and work in the
community
Severity of Mental Retardation
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Moderate Mental Retardation
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IQ Score between 35 and 49
Roughly comparable to 2nd grade
functioning level
Persons with moderate MR may perform
unskiled or semi-skilled tasks with
supervision as adults
Severity of Mental Retardation
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Severe Mental Retardation
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IQ Score between 20 and 34
Can acquire elementary self-care skills
Can learn to count and read simple
“survival” words
Can perform simple tasks under close
supervision
Severity of Mental Retardation
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Profound Mental Retardation
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IQ Score below 20
May show improvement in self care and
communication with training
Require highly structured environments
Require constant supervision and care
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Residential Facilities
Pervasive Developmental
Disorders: Autism (onset <3 y/o)
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Impaired Social Interactions (impaired nonverbal behavior)
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Impaired Communication
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No eye contact, babies stiffen when picked-up
Lack social or emotional reciprocity
No language, echolalia (without meaning), pronoun
reversal (“you” for “me”), metaphorical language
(can only be understood by caregiver)
Restricted/Repetitive Behavior, Interests, &
Activities
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Stereotyped movements & Preoccupation with parts
of objects
Trends in Adult Diagnoses
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The majority of disorders seen by
therapists are Axis I disorders
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Person feels distress (i.e. depressed) and
seeks help for it
Many can be medicated
In general, medication PLUS therapy is
most beneficial
Major Mental Illnesses are on Axis I
Trends in Adult Diagnoses
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Axis II Personality Disorders cannot be
cured
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Often do not seek treatment on their own
Cannot be medicated
Difficult people with whom to interact
Long-term, ongoing issues
Often co-morbid with Axis I
Axis II Diagnoses ARE NOT considered
major mental illnesses
Axis I Disorders
Overview of Axis I disorders
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Mood Disorders
Anxiety Disorders
Psychotic Disorders
Substance Related Disorders
Mood Disorders
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Predominant symptom is a disturbance
of mood (self-reported feeling state)
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Mood = what person reports feeling
Affect = what is observable
i.e. Patient reports mood as sad and
exhibits flat affect.
i.e. Patient reports mood as euthymic.
Patient’s affect is labile.
Depressive Disorders
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Major Depressive Disorder: Marked by one
or more depressive episode
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Can be mistaken as dementia in older adults
General Features:
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Negative beliefs about oneself
Negative beliefs about the future
Negative beliefs about the world & environment
Before puberty equally common in both sexes
After puberty women are twice as likely to
suffer from depression
Occurs in 16 million Americans
Depression and Psychosis
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Depression can specified as “with psychotic
features”
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Delusions or hallucinations (usually auditory)
Mood Congruent psychotic features:
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delusions of guilt: being responsible for the illness of a loved
one
Delusions of deserved punishment: being punished because of
some personal inadequacy
Nihilistic delusions: beliefs of world or personal destruction
Somatic delusions: false beliefs of body rotting away
Delusions of poverty: false beliefs of being bankrupt
Mood incongruent psychosis is less common
Dysthymic Disorder
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Fairly constant symptoms
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Chronically depressed mood for 2 or more
years in adults
Chronically depressed mood for 1 or more
years in children and adolescents
Cannot be a period of two months or more
during which the person is symptom-free
Symptoms cannot be severe enough to rise
to the level of MDD
Bipolar Disorders
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Bipolar I - Essential feature is a clinical
course characterized by one or more
Manic episodes or Mixed episodes
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Individuals typically also have one or more
Major Depressive Episodes
Bipolar II – Essential feature is a clinical
course characterized by one or more
Major Depressive Episodes with at least
one Hypomanic episode
Major Affective Disorders & Suicide
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50% to 80% of people who attempt or
commit suicide have a history of depression
Suicide rate increases with increasing age
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80 year olds are twice as likely to commit suicide
as 20 year olds
Gender Differences in Suicidal Behavior
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Males (especially white males aged 70 and older)
are at highest risk for COMPLETED suicide
Females aged 24 to 44 are at highest risk for
ATTEMPTED suicide
Anxiety Disorders: Panic
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Panic Attacks
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Discrete period with sudden onset of
apprehension, fearfulness, and terror
Often associated with feelings of
impending doom
Shortness of breath, heart palpitations,
chest pain, choking, smothering sensations
Fear of “going crazy” or losing control may
be present
Anxiety Disorders: Agoraphobia
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Anxiety about or avoidance of places
and situations
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from which escape might be difficult or
embarrassing
in which help may not be available in the
event of having a panic attack or panic-like
symptoms
Agoraphobia can be with or without
panic attacks
Anxiety Disorders: Phobias
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Specific Phobia - Characterized by a clinically
significant anxiety provoked by exposure to a
feared object or situation, often leading to
avoidance behavior
Social Phobia - Characterized by a clinically
significant anxiety provoked by certain types
of social or performance situations, often
leading to avoidance behavior
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May manifest as fear of how others will judge you
Anxiety Disorders: OCD
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Obsessive-Compulsive Disorder: troubled by
obsessions or compulsions, and these thoughts
and/or behaviors take up a significant amount of
time, cause considerable distress to the individual,
and frequently interfere with occupational or
social adjustment
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Obsessions = recurrent and persistent thoughts,
impulses, or images that are experienced as intrusive
and inappropriate and cause marked anxiety and stress
Compulsions = repetitive behaviors that serve to
reduce anxiety
Anxiety Disorders: PTSD
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Post Traumatic Stress Disorder- Personally
witnessed or experienced some event that
involved
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Actual or threatened death or
Serious injury, and
Responded with intense fear, helplessness, or horror
Persistently re-experience the event
Persistently avoid stimuli associated with the
event
Persistent symptoms of increased arousal
Psychotic Disorders
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Substance induced psychotic disorder
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Prominent hallucinations or delusions
Due to direct physiological effects of a drug
of abuse, medication, or toxin exposure
Hallucinations the individual realizes are
substance-induced don’t count
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Substance intoxication or Substance withdrawal
with perceptual disturbances
Schizophrenia
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At least six months with one month of activephase symptoms
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Positive Symptoms
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Delusions (fixed false beliefs)
Hallucinations (see/hear/feel something not there)
Disorganized Speech (loosening of associations, rhyming)
Disorganized or Catatonic Behavior (also frenetic activity)
Negative Symptoms
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Avolition (can’t start things, no goal-directed behavior)
Flat Affect (decreased range and intensity of emotions)
Alogia (poverty of thought and speech)
Anosognosia (lack of insight about being sick)
Schizophrenia Subtypes
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Paranoid- Delusions and Hallucinations
organized around a theme
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Disorganized- Disorganized speech,
disorganized behavior, and flat or inappropriate
affect
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Most favorable prognosis & strongest familial link
Delusions and hallucinations are fragmentary and not
organized into coherent theme
Catatonic- Motoric immobility OR excessive
motor activity, extreme mutism, peculiarities in
voluntary movement, echolalia OR echopraxia
Substance Related Disorders
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Substance Induced Disorders
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Dependence - three or more symptoms in
a 12 month period
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i.e. tolerance, withdrawal, persistent efforts to
cut down, give up or reduce normal activities
Abuse - one or more symptom in a 12
month period
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i.e. substance related legal problems, use
substance when physically hazardous
Axis II
Characterological/Personality
Disorders
Personality Disorders:
Overview
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Characterized by a stable, enduring
pattern of behavior that deviates from
the expectations of a person’s culture,
is pervasive and inflexible, has an onset
in adolescence or early adulthood, and
causes distress or impairment
Personality Disorders
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Cluster A: Odd/Eccentric Behaviors
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Cluster B: Dramatic, Irrational or Erratic
Behaviors
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Paranoid Personality d/o, Schizoid Personality d/o,
Schizotypal Personality d/o
Antisocial Personality d/o, Borderline Personality
d/o, Histrionic Personality d/o, Narcissistic
Personality d/o
Cluster C: Anxiety or Fearfulness
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Avoidant Personality d/o, Dependent Personality
d/o, Obsessive-Compulsive Personality d/o,
Paranoid Personality Disorder
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Suspiciousness about
the motives of others
Pervasive distrust
Believes others are
exploiting, harming
or deceiving him or
her (unjustified)
Michael Douglas in
Falling Down
Schizoid Personality Disorder
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Detachment from
social relationships
Restricted range of
emotional expression
No desire for
intimacy with others
James Spader as
“Graham” in Sex,
Lies, and Videotape
Schizotypal Personality Disorder
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Acute discomfort in
close relationships
Distorted cognitions
or perceptions
Behavioral
eccentricities
Peter O’Toole as the
Christ figure in The
Ruling Class
Antisocial Personality Disorder
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Disregard for others’
feelings
Violation of the
rights of others
Lack of empathy
Michael Rooker as
the killer in Henry:
Portrait of a Serial
Killer
Borderline Personality Disorder
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Instability in
interpersonal
relationships
Labile affect
Impulsivity and poor
self-image
Suicidality & Violence
Glenn Close in Fatal
Attraction
Histrionic Personality Disorder
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Excessive
Emotionality
Constantly Seeking
Attention from Others
Overly dramatic
Take over the room
Blanche du Bois in A
Streetcar Named
Desire
Narcissistic Personality Disorder
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Grandiose & too
self-centered to be
empathic to others
Need for validation
& admiration
Lack of empathy for
the problems and
needs of others
Gloria Swanson in
Sunset Boulevard
Avoidant Personality Disorder
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Socially Inhibited
Feelings of
inadequacy
Hypersensitivity to
criticism and
negative evaluation
“Laura” in The Glass
Menagerie
Dependent Personality Disorder
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Submissive
Constant clingy
behavior
Needs other to be
responsible for him
or her
Bill Murray in What
About Bob?
Obsessive-Compulsive D/O
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Preoccupation with
Orderliness,
Perfectionism, and
Control
Lacks flexibility,
efficiency & openness
Painstaking attention
to trivial details
Jack Lemmon as
“Felix Unger” in The
Odd Couple
Child vs Adult Mental Health
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Mental Illness often evidences itself as
behavioral problems in children
It is extremely uncommon for children to
be diagnosed with a personality disorder
(any AXIS II diagnosis)
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More specific criteria required for rare cases
Antisocial PD requires age 18 or older
If you see this, it should raise a red flag
Psychological Testing
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Personality Testing
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Projective Testing
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TAT, CAT, Rorschach, KFD, HFD, HTP
Intellectual Testing
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MMPI, MCMI, PAI
WAIS, WISC, Stanford-Binet, KBIT, SIT
Achievement Testing
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Woodcock-Johnson, WIAT, WRAT
Psychological Testing Terms
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Standardized
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Normed
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Given the same to everyone
Individual scores can be compared to a
normative sample
Battery
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More than one test must be given and
conclusions are drawn based on
overlapping data from different measures