Thursday, June 29, 2006

Into the DSM-IV - Generalized Anxiety Disorder

Generalized Anxiety Disorder is diagnosed when a person suffers from excessive anxiety and worry that takes place for more than half the days in a 6 month time period. Furthermore, the anxiety causes impairment in social, occupational or other areas of functioning. Criteria for this diagnosis includes at least three of the following:

  • Restlessness or feeling keyed up or on edge

  • Easily fatigued

  • Difficulty concentrating

  • Irritability

  • Muscle tension

  • Sleep disturbance

Risk Factors

  • Having a comorbid DSM-IV disorder. Generalized anxiety disorder is often diagnosed in those who have another anxiety disorder, a mood disorder or substance-related disorder

  • Having a family member who suffers with Generalized Anxiety Disorder

  • Being female (it is twice as common in women)

  • Having a history of frequent losses or severe childhood fears

  • Having a poor psychological disposition (irrational thinking, negative thinking, overgeneralizing)

  • Being neurotic or excessively conscientious

  • Experiencing a number of overly stressful life events

Protective Factors

  • Healthy childhood development

  • Appropriate parental attachments

  • Strong social supports

  • Knowledge and use of stress management techniques

  • Optimism and self-confidence

  • Psychotherapy: behavioral approaches involving coping skills, relaxation and medication

Multi-dimensional assessment

As social workers we are charged with assessing multiple sources of information as we examine the lives of our clients. Elizabeth Hutchison, in Dimensions of Human Behavior: The Changing Life Course (1999, Pine Forge Press) lists eight different perspectives that can inform a multidimensional assessment. These eight perspectives are divided between their sociological and psychological roots. What I will quote below is a brief chart from each perspective. Hutchison does a nice job of practically relating each perspective to a case study in her book.

Sociological Perspectives

Systems Perspective (chart, p. 42)

  • Systems are made up of interrelated members that constitute an ordered whole
  • Each part of the system impacts all other parts, and the system as a whole
  • All systems are subsystems of other larger systems
  • Systems maintain boundaries that give them their identities
  • Systems tend to move towards homeostasis, or equilibrium

A key term in the systems perspective is Role, which is described as the behaviors that a person assumes as a part of a particular social position.

Conflict Perspective (chart, p. 45)

  • Groups and individuals try to advance their own interests over the interests of others
  • Power is unequally divided, and some social groups dominate others
  • Social order is based on manipulation and control of nondominant groups by dominant groups
  • Lack of open conflict is a sign of exploitation
  • Social change is driven by conflict, with periods of change interrupting long periods of stability

Rational Choice Perspective (chart, p. 47)

  • People are rational and goal-directed
  • Social exchange is based on self-interest, with actors trying to maximize rewards and minimize costs
  • Reciprocity of exchange is essential to social life
  • Power comes from unequal resources in an exchange

Social Constructionist Perspective (chart, p. 51)

  • Actors are free, active and creative
  • Social reality is created when actors, in social interaction, develop a common understanding of their world
  • Social interaction is grounded in language customs, as well as cultural and historical contexts
  • People can modify meanings in the process of interaction
  • Society consists of social processes, not social structures

Social constructionist positions seem to occupy a majority of the thought in philosophical and therapeutic realms that embrace postmodernity. It has a close relationship with contextualism and is helpful in narrative forms of therapy.

Psychological Perspectives

Psychodynamic Perspective (chart, p. 53)

  • Emotions have a central place in human behavior
  • Unconscious, as well as conscious, mental activity serves as the motivating force in human behavior
  • Early childhood experiences are central in the patterning of an individual’s emotions, and therefore, central to problems of living throughout life
  • Individuals may become overwhelmed by internal and/or external demands
  • Individuals frequently use ego defenses to avoid becoming overwhelmed by internal and/or external demands

Developmental Perspective (chart, p. 55)

  • Human development occurs in clearly defined stages
  • Each stage of life is qualitatively different from all other stages
  • Stages of development are sequential, with each stage building on earlier stages
  • Stages of development are universal
  • All environments provide the support necessary for development
Personally, this perspective is the hardest for me to embrace. It seems to directly contrast the social constructionist point of view, as well as postmodernity and contextualism. However, this perspective also has a great deal of research to back it up. What needs to be said is that the research is myopic in its scope and only really incorporates the perspective of white middle class men.

Behavioral Perspective (chart, p. 57)

  • Human behavior is learned when individuals interact with the environment
  • Similar learning processes taking place in different environments produce differences in human behavior
  • Human behavior is learned by association of environmental stimuli
  • Human behavior is learned by reinforcement
  • Human behavior is learned by imitation
  • Human behavior is influenced by personal expectations and meanings.

Several key terms function in this perspective. First, Classical Conditioning Theory (Pavlov), uses the relationship of conditioned and unconditioned stimulus to describe the reasons for a particular behavior. Second, Operant Conditioning Theory (Skinner, Watson), uses reinforcement as the primary motivator for behavior. Finally, Cognitive Social Learning Theory (Bandura), uses imitation and cognitive processing as the primary motivators in developing a behavior.

Humanistic Perspective (chart, p. 59)

  • Humans are “spiritual, rational, purposeful, and autonomous” (Monte, 1995, p. 665)
  • Human behavior can be understood only from the vantage point of the phenomenal self—from the internal frame of reference of the individual
  • People make psychologically destructive demands on each other, and attempts to meet those demands produce anxiety
  • Human behavior is driven by a desire for growth and competence, and by a need for love and acceptance

The humanistic perspective has its roots in philosophy and grew through existentialism (Kierkegaard, Nietzche, Camus, Buber, Tillich). Rogerian therapeutic paradigms are probably the quintessential example of the humanistic perspective. Maslow’s work also fits into this perspective.

For the purpose of assessment, these eight perspectives provide an introduction to the possible forms of information that one can gather about an individual’s situation and self. I have to believe that no one can use one perspective exclusively. Therefore, it is necessary to understand the basics of each so that we can utilize their features and theories when particular forms of information appear. Furthermore, while we do not operate out of one perspective totally, we often favor one perspective over others. In order to best serve our clients it is necessary to realize our perspectives and their biases.

Into the DSM-IV - Anorexia Nervosa

Anorexia Nervosa is an eating disorder characterized by the following symptomatic clues:

  • An inability to maintain a healthy or minimum body weight
  • A distorted body image
  • An intense fear of gaining weight or becoming overweight
  • An excessive emphasis on weight
  • The denial of the seriousness of their condition
  • In females an additional characteristic is the cessation of the menstrual cycle.
Anorexa Nervosa can be further classified as a Restricting type, which involves volutary starvation, Binge/Purging (including the use of laxatives or vomit induction). The onset of Anorexa Nervosa typically occurs in adolescence and affects about 1% of the female population.

Risk Factors
  • Having a history of dieting (diets do not cause, instead all eating disorders originate through dieting attempts
  • Being female (95% of diagnoses are in females)
  • Having a parent in the family system who is overly concerned with weight issues
  • Being a prepubscent or adolescent female (due to the incongruence of actual and ideal female body types portrayed in cultural situations)
  • Biological predispostion.
  • Psychological characteristics: distorted thinking, low self-esteem, stress, anxiety, perfectionism, and fear of rejection
  • A history of trauma, sexual or physcial abuse
  • Socio-cultural factors such as media or peer influences.
Protective Factors

  • Psychological characteristics: high self-esteem, internal locus of control, high self-efficacy, mature defense mechanisms and coping strategies
  • Personality characteristics: easy temperment, ability to make and maintain friendships, optimism
  • Secure attachment to a parent
  • Good parental adjustment. Parents with healthy attitudes towards weight and food can pass these along to children
  • Socio-cultural factors: low levels of stress, high levels of support, minimal exposure to media images.

Into the DSM-IV – OCD

Obsessive-Compulsive Disorder is an anxiety related disorder that is marked by recurrent obsessions and compulsions that persist for more than one hour daily. Moreover, these obsessions and compulsions cause significant amounts of distress or impairment in daily functioning.

Obsessions consist of the repetition of distressing thoughts, impulses, ideas or images.

Compulsions are repetitive behaviors or mental acts that are intended to quell the anxiety of the obsession.

Risk factors

  • Having a history of eating disorders in first degree relatives
  • Having another mental disorder (OCD is comorbid in over 50% of cases)
  • Being biologically pre-disposed to the condition
  • Having a reduced rate of serotonin (persons who suffer with OCD have difficulty entering REM sleep)

Theoretical risk factors

  • Psychodynamics – the person is stuck in the anal stage of development seeking rigidity and over control
  • Learning theory – the person plays out classical and operant conditioning and negative reinforcement
  • Family Systems – OCD develops to serve as a function of the family.

Protective Factors

  • The development of better diagnostic categories to capture a better understanding of the disorder in adolescence
  • Better education of family members in order to better recognize and monitor OCD inclinations.

Wednesday, June 28, 2006

Into the DSM-IV – Major Depression

As of 1996, Major Depression was diagnosed in roughly 17% of the total population, with a majority of that population being women (21%). Major Depression is the single largest disease that affects the US population in terms of economic scale.

To be diagnosed with Major Depression the symptoms must not have been the result of substance use, a general medical disorder or bereavement in the previous two months.

Furthermore, the client must have exhibited four of the following symptoms for at least two solid weeks:

1) Depressed mood for most of the day (irritability in adolescents and males)
2) Loss of interest or pleasure in all activities
3) Gains or losses in weight or increased/decreased appetite
4) An interruption in sleep patterns (sleeping more or less)
5) Fatigue
6) Others view the person as speeding up or slowing down
7) Feelings of worthlessness or inappropriate guilt
8) Inability to concentrate
9) Experiencing repeated thoughts about death

Risk factors for Depression

Gender – More females are diagnosed with depression than males
Age – Major Depression occurs in 1 in 6 adults over the age of 59
Health – Poorer general health increases risks, as well as a medical illness
Substance Abuse – increases risks (cannot be comorbid with Major Depression)
Genetics – There is some research that posits a genetic component to Major Depression
Comorbidity – Major Depression is often comorbid with anxiety, dysthymia or other disorders
History – Recurrence of depression is likely over the life-span
Abuse – Women who experience abuse are more likely to exhibit Major Depressive features
Economics – Lower socio-economic classes have higher rates of depression
Support – Isolation, divorce, widowed, separated and single individuals have greater risks
Stress – Major life events contribute to risks of major depression

Protective Factors for Depression

Social – Extended education, employment, financial stability, close relationships, marriage (for men), and adequate social support can protect against depressive symptoms
Medication – Can help resolve chemical imbalances in some individuals (must be weighed against side-effects and often work better in conjunction with psychotherapy)
Exercise – This is especially important for older adults, but has some protective factors for others as well.

Treatment Possibilities

Three forms of therapy have been researched and have proven effective for the treatment of Major Depression. Cognitive, Behavioral and Interpersonal therapeutic paradigms have provided the best outcomes for clients who suffer from Major Depression. Furthermore, a fourth paradigm that combines Cognitive and Behavioral treatments is effective. Finally, there is some research that states that therapy in conjunction with medication provides for the most effective and longest lasting results in the treatment of Major Depression.

Freud - In the Beginning...

In the beginning there was Freud. While mental processes had been tweaked throughout the years in philosophy, it was Freud who really began to systematize and bring together psychological thought into a coherent framework. Regardless of Freud’s current status in the psychological and therapeutic community, his work is nonetheless foundational and important (all quotes in this essay are from Gleitman, Psychology (3rd ed.), W.W. Norton and Company, 1991).

Freud’s psychoanalytic tradition began with an attempt to "understand the forces of human irrationality through reason and science" (p. 426). Freud’s method of therapy included free association which allowed room for "clients" to tell whatever came to mind. This was precipitated by the notion that everything in the mind was connected and that whatever was mentioned would lead to the problems that hindered an individual. Instead of willing participants, Freud found that people opted to resist instead of comply with his requests. Resistance became one of the things Freud and his clients would look for in the stories they told, believing that revealing whatever repressed memory was resisted would help in the healing process.

For Freud, repression became known as a defense mechanism used to push uncomfortable thoughts out of our consciousness. Furthermore, these thoughts most often dealt with sexual drives and instinctual urges. Unconscious conflict became a source of study for Freud. He used three terms to describe the never-ending internal sources of power and conflict.

The Id became synonymous with the instinctual and primal portions of our personalities. It was governed by the pleasure principle which sought to relieve one’s biological urges with utmost haste. The id is reflexive rather than thoughtful. This idea also gives rise to the second of Freud’s concepts, The Ego. The ego is governed by the reality principle which seeks to alleviate the urges of the id through socially acceptable means. The ego serves the id, but works in some ways as an opposite of the id’s urges. Finally, Freud constructed the Superego as the watchdog of the ego. The superego’s function is to praise or punish the actions of an individual based on the constructed social reality that they have internalized.

The interplay of these three dynamics often results in unconscious conflict, leading a person to incorporate defense strategies and mechanisms. As the conflict plays out our anxiety rises, resulting in the need for strong defenses (repression is the primary defense) against the unsettled nature of the conflict.

Several other defense mechanisms were posited by Freud through his work. These included: displacement or the transferring of repressed urges from one situation to another, reaction formation or the transfer of feelings from one emotional pole to the other (ie – turning hate into a smothering love), rationalization or the attempt to re-interpret a situation into something more acceptable, projection or the attribution of one’s feelings to another person, and isolation or the separation of emotions from memories. For Freud, these many of the conflicts of adults can be traced back to developmental memories that have been repressed.

Psychosexual Development
This is one of Freud’s best known and longest lasting contributions to the psychological realm. Every time someone says, “He’s so anal,” about a neat-freak they pay tribute to Freud.

Freud’s model of psychosexual development takes shape through five stages. If a child’s development is arrested in a particular stage, then that child will manifest certain behaviors in adulthood.

The first stage is the oral stage which is marked by a fixation with the mouth. This stage lasts from birth through about the first year and a half and arrested development here results in passivity or excessive eating or smoking.

The second stage is the anal stage which is concerned with the elimination of bladder and bowel functions; lasting from ages 18 months through about 3 years old, those whose development have stopped here often exhibit obsessions with neatness (anal-retentive) or are excessively reckless and disorganized (anal-expulsive).

The third stage is the phallic stage which focuses on the genitals and lasts from ages 3 to 6. It is in this stage the boys deal with the Oedipus Conflict or girls deal with the Electra Complex (that is, identification or love for the opposite parent (sexual love) and hatred of the same sex parent who dominates the attention).

The fourth stage, latency, lasts from 6 to puberty and everyone gets a break from fixations.

The final stage is the genital stage which begins in puberty and lasts through adulthood and our sexual interests are thought to mature. However, given Freud’s fixation with fixations it is a wonder that any of us ever really reach this stage where our libidinal energy can focus on the tasks at hand.

This has been a brief review of Freudian thought; feel free to add anything I might have missed…

For further review: The Freud Reader, Freud: A Very Short Introduction

Taking the LCSW Exam

I am taking the National Clinical Social Worker exam in late July. So far, most of the online resources that I have found have been either boring or full of editing mistakes. Therefore, I am going to try and write up as much of the material I can before the late July and post it here for myself and others who might want the resources without the hassles. Feel free to comment, request or add to the material I present.

I have the belief that all of those who are taking the test are in it together. Furthermore, those who come after us can benefit from the wisdom and studies of those who have completed the clincal requirements and preparing for the exam. Therefore, let us contribute wisely and succinctly from our reading and our experiences.

I will probably alternate between posting psychotherapuetic theories and DSM-IV disorders. I would appreciate additional information from anyone who has studied for the research, ethics and HIPPA portions of the test.