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Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf

A. Introducing the Report Subdivision A's Chapters: Page 4. Beginning the Report: Preliminary Information 83 5. Referral Reasons 92 6. Background Information and History 97 Every report should begin with orienting information about you, the client, and the examination or treatment. Chapter 4 offers a suggested structure for this information, standard phrasings, and some legal and ethical issues about which you should comment. Chapter 5 lists possible reasons the client was referred to you, and Chapter 6 suggests ways to present the client's histories (medical, social, educational, family, and adjustment).

Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf

Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf

83 4 Beginning the Report: Preliminary Information This chapter covers the basic information with which you would begin any report. Reasons for the referral are covered in Chapter 5; more detailed background information about the client is covered in Chapter 6. 4. 1. Heading and Dates for the Report Use prepared stationery or include full identification of the evaluator by name, degree, and title; and, where appropriate, affiliation, supervisor, license number, agency, address, and phone number. Use a title for the report that fits the report's contents and audience—for example, “Psychological Evaluation” or “Case Closing Summary. ” Most titles are combinations of the words provided below. Always choose those favored by your practice setting. Choose a word describing the discipline or activity: Psychosocial, Social Work, Psychiatric, Psychological, Neuropsychological, Psychoeducational, Nursing, Multidisciplinary. Forensic, Rehabilitation, Habilitation, Diagnostic, Testing, Case, Mental Status, Intake, Prog-ress, Discharge, Closing. Educational, Intellectual, Personality, Ecological, Individualized, Behavioral, Treatment, Man-agement, Life Management. And then choose a word describing the kind of document: Summary, Evaluation, Assessment, Report, Examination, History, Plan, Update, Note, Formula-tion. Always date the report. In addition, give all dates and locations (e. g., in the hospital room, school's office, private office, home) of examination/evaluation/interview(s)/testing. Indicate time of day, total time of testing, duration of interview, etc., as relevant. 4. 2. Sources of Information for the Report Begin describing information sources with one or more of these statements, as appropriate: In preparation for/advance of the interview, I received and reviewed the following records... The records I received were without clear provenance/were from a source I could not establish. Records were illegible/unavailable/scant/irrelevant/adequate/pertinent/voluminous. BEGINNING THE REPORT

Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf

84 STANDARD TERMS AND STATEMENTS FOR REPORTS BEGINNING THE REPORTSources of information may include the following: Review of documents furnished— treatment summaries and reports, school records, previous evaluations, etc. Observations of the client during a clinical interview. Collateral interviews with friend/spouse/parents/family/relatives/caregiver/interpreter/etc. Testing: List each test or questionnaire separately by its full name, and use abbreviations/acro-nyms in the body of the report. (See Sections 11. 10, “Intelligence, Development, and Cognition: Assessment,” and 13. 1, “Models of Personality Diagnosis,” for tests' names. ) [If appropriate, add this statement: “All tests were administered, scored, and interpreted by this report's author without the use of assistants or supervisees. ”] Consultation with other professionals. Observation by other professionals of/interview with the client/child/family. 4. 3. Identifying Information about the Client The description should be so detailed as to enable the identification of the unique individual. (See Chapter 7, “Behavioral Observations,” for specific language. ) Name Always state the client's given name and surname. As appropriate, also specify family of origin/maiden name, changes, aliases/Also Known As. For a Child: Indicate preferred name/nickname(s) in quotes, or “Prefers to be called . ” Other Identification Give the client's address, phone number, case number (if any), and name of current therapist/physi-cian/referrer/case manager (as appropriate). Gender/Sex Specify the client's gender or sex (the term “gender” is more accurate here). Age For adults, give age in years. For a Child: Use 9 years and 3 months, 9 3/12, 9:3, or 9′3′′, not the ambiguous 9. 3 years. For birth order: Client is the third of a sibship of four/client is third of four children. Marital Status Be consistent in reporting marital status for males and females. Give number and duration of mar-riages/common-law marriages, separations/divorces. Current: Never married [preferable to “single” because it is less ambiguous], living with a { paramour}/partner/fiancé/fiancée, married/common-law marriage, separated/divorcing/ divorced, widow/widower, unknown. Childless/parent of children. (Insert numbers:) children currently reside with the client/are in the client's care. Children have been adopted/placed in foster care, temporarily reside with their mother/father/grandparent(s)/other relatives.

Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf

4. Beginning the Report 85BEGINNING THE REPORTOccupation Specify whether the client is employed/unemployed/underemployed, working full-or part-time, a student, retired, etc. And describe other occupations, previous occupations, etc., not simply jobs held. For a Child: Give date of alleged industrial/other injury, date last worked. Nationality/Ethnicity Report on this for all clients or none. In reporting nationality/ethnicity, note also place of birth ü and what language is used in the home. Race Be consistent across reports in reporting race; do not report it only for minorities. Race does ü not equal skin color. If in doubt about a person's race or about currently, locally, or personally acceptable terms, ask. I personally see no value in the descriptors of “biracial,”“multiracial,” or “of mixed races,” as the concept of race has no scientific basis in humans, and almost all of us are of mixed genetic backgrounds. However, such terms are used in medical and social research, and may in some situations convey meaningful, nongenetic information, although the likeli-hood of erroneous overgeneralization is as great. African American, “white”/European American/“Anglo,” Asian/Asian American {Oriental},1, 2 Hispanic/Latino/Latina,2 Native American, Inuit {Eskimo}, Oceanic/Pacific islander, Carib-bean, etc. Residence/Living Circumstances See Section 14. 8, “Living Situation/Level of Support Needed,” for descriptors. Religion Report on religion only as relevant. Parents' religion/born into, religion baptized into/raised in/converted to/recent if changed/cur-rent. No preference: Unimportant, unaffiliated, nonpracticing, rejected, agnostic, atheist. Preference (↔ by degree): Practicing, pious, devout, righteous, zealous, proselytizing, evangeliz-ing, preoccupied, delusional. Legal Mental Health Status Involuntary/voluntary admission/treatment/commitment. (Perhaps give the number or name of the applicable section of the local law. ) Referral Reason See Chapter 5, “Referral Reasons. ” 4. 4. Self-Sufficiency in Appearing for Examination Came to first (or second, etc. ) appointment, late by minutes/excessively early/appropri-ately early for examination/on schedule/exactly on time for examination. 1My thanks to Fay Murakawa, Ph D, of Los Angeles, CA, for clarification and correction. 2Be wary of using any global term that can obscure the psychological/cultural diversity of large population groups.

Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf

86 STANDARD TERMS AND STATEMENTS FOR REPORTS BEGINNING THE REPORTCame alone/without escort, came with friend/spouse/children/escort/caseworker/etc. [If com-panion is present, specify role of companion in examination, if any. ] Had degree of difficulty finding the office. Drove/was driven/used other mode of transportation (specify). 4. 5. Consent Statements Consent to Assessment or Treatment With regard to the information you should provide to your patients, the guideline is this: “What would a reasonable, prudent adult need to know to decide whether to agree to engage in this assess-ment or treatment or to refuse it?” For assessments, the client has to be informed of who will see the report (e. g., the courts, managed care staff, the referrer, an adolescent client's parents, etc. ); to be advised of what decisions these persons or organizations will be making based on it; and to be offered the opportunity to refuse to participate or discontinue participation at any time if the client decides that specific revelations would not be in her/his best interests. As regards a course of treatment, you must discuss the risks and benefits that can reasonably be anticipated. You might couch your statements to the patient in terms like these, based on ones sug-gested by the Group for the Advancement of Psychiatry (1990): “Although no completely satisfactory statistics are available, I believe that this combination of treatments offers the best chance of success. ” “The success rate of this treatment is about 85%. 3 That is, about 85% of all patients receiving this treatment experience complete or substantial relief of their symptoms. ” The discussions and handouts in Zuckerman (2008) can be very helpful in this regard. Informed Consent We discussed the evaluation/treatment procedures; what was expected of both the client and the evaluator/therapist; who else would be involved or affected; the treatment's risks and benefits; and alternative methods' sources, costs, risks, and benefits. This client understands the risks and benefits of giving and withholding information. The client understands the procedures that he/she is being asked to consent to and their likely consequences/effects, as well as alternative procedures and their consequences. I have informed the client that the information he/she provides will be incorporated into my report, which I will send to , who referred him/her to me for evalua-tion. I advised the client that I am not her/his treating psychologist, that we will not have a continu-ing professional relationship, and that no records will be kept at this/my office. The client knows that the results of this evaluation will be sent to... and used for... In a continuing dialogue, these have been explained in language appropriate to his/her educa-tion, intellect, and experience. Voluntary Consent This client understands and willingly agrees to participate fully. The client understands that she/he may withdraw her/his consent at any time and discontinue the evaluation/treatment. 3Obviously this figure would differ with each proposed treatment.

Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf

4. Beginning the Report 87BEGINNING THE REPORTCompetency to Consent Based on our interactions, I have no reason to suspect that this person is not competent to consent to the evaluations/procedures/treatments being considered. The client is not a minor or mentally defective; nor does he/she have any limitation of commu-nication, psychopathology, or any other aspect that would compromise his/her understand-ing and competency to consent. 4. 6. Reliability/Validity Statements Basis of Data On the basis of the... observations of this person for hours on occasions in (specify settings)... internal consistency of the information and history... absence of omissions/deletions of negative information, contradictions... the character and cohesiveness of the client's responses, spontaneous comments, and behaviors... consistency of information from different sources... client's ability to report situations fully... the data/history are felt to be completely/quite/reasonably/rather/minimally/questionably reli-able. I consider her/him to be an adequately/inadequately reliable informant. Disclaimers Readers of this report are advised that it reflects only the information available at the time of its creation, and not information that may be received later/that may be pertinent but is currently unavailable. Any such information may change the findings or recommendations of the evaluator. This report reflects this person's condition at the time of this consultation and may not reflect this person's condition at the time of discharge or final diagnosis, or at any later or earlier time period. I reserve the right to reappraise and revise my statements and conclusions about this individual made in this report if I receive additional information. Also, over time, the statements and conclusions in this report may come to be no longer accurate. This report is based upon only the information sources noted in the report. No independent corroboration of the factual or background information presented by the cli-ent was attempted. I have relied on the client's report of his/her history and assumed that it was accurate (except as noted), and so I cannot assume any responsibility for any errors of fact in this report. The diagnoses and opinions in this report are offered with a reasonable degree of psychological certainty. The opinions offered in this report have not been influenced by the referrer/referring agency. Representativeness/Validity Results are believed to be a valid sample of/accurately represent this person's current level of functioning/be typical behavioral patterns/behaviors outside the examination setting. Because this client refused no test items/questions, worked persistently/was most cooperative and helpful, and had no interfering emotions such as anxiety or depression, test findings/results of this evaluation are felt to be representative of her/his minimal/usual/optimal level of functioning.

Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf

88 STANDARD TERMS AND STATEMENTS FOR REPORTS BEGINNING THE REPORTThe client's performance on the [name(s) of test(s)/structured interview(s)/task(s)] was not consistent with his/her clinical presentation, educational history, and employment history, and so is not likely to be a valid measure of his/her general intellectual/other ability. Results obtained in this testing are plausible (i. e., within the range of that which I observed). Should information from a neutral third party become available, these results could be reevaluated. Consistency His/her appraisals tended to be supported/corroborated by my observations/others' records. She/he presented personal history in a spontaneous fashion, organized in a chronological sequence and with sufficient detail, consistency, logic, and attention. He/she was a poor/adequate/good/excellent historian. (↔ by degree) Complete/quite organized presentation, accurate recall of details/names and sequences, sparse data/stingy with information/only sketchy history, disorganized/scat-tered/haphazard, nebulous/vague/ambiguous, illogical, contradictory, facetious. Accuracy The client's self-description was credible, forthright, and informed. I believe he/she has been honest/truthful/factual/accurate. Although somewhat dramatized, the core information appears to be accurate and valid for diag-nostic/evaluative purposes. The client tries hard to be accurate in recalling events, but... She/he is not an astute observer. He/she tried to provide meaningful responses to my question, but... She/he had difficulty presenting historical material in a coherent and chronological manner. Client was questioned extensively and creatively, but it was not possible to determine/get a clear picture of/obtain more information on /obtain any delineation of symp-toms other than his/her informal description of “I lost it. ” She/he becomes tangential when pressed for specifics. The patient seemed convinced that she gave an accurate account of her personal situation, although she also seemed unaware of her many limitations and deficits. He expresses himself with great confidence, apparently unaware of any mistakes or confu-sions. Although the client seemed to present the information above in an honest manner, its accuracy must be questioned because of possible difficulties with accurate perception of social/con-sensual/chronological reality/the accepted meaning of behaviors/patterns in relationships/etc., or the very unusual nature of her/his accusations/reported experiences. She/he gave a history that did not so much appear to describe symptoms as to describe a major characterologically disturbed style of living. Trustworthiness/Honesty/Malingering She seemed to be honest in her self-descriptions of her strengths and weaknesses. He appeared to be a truthful witness and an accurate historian. She did not appear to be fabricating any of her history. His response to questions appeared to be free of any deliberate attempts to present a distorted picture.

Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf

4. Beginning the Report 89BEGINNING THE REPORTShe made no special efforts to convince me of the gravity or authenticity of her problems. She gave no evidence of a deliberate distortion of her test-taking efforts. The history offered should be taken with a grain of salt/was fabricated/grandiose. Much of what he said sounded like it was what someone told him/sounded rehearsed. Responded eagerly to leading questions, endorsing the presence of all symptoms or problems suggested. Ganser's syndrome {hysterical pseudodementia}/{ vo r b e i r e d e n }. It should be noted that in each of these complaints her description was vague, self-contradictory, and not completely consistent with any recognized clinical pattern. She is motivated only to obtain financial benefits. Despite allegations of pain and deficiency, he is able to get up and down from a chair without difficulty and sit for long periods comfortably. She offered an exaggerated/minimized description of her behaviors. Client is deliberately deceptive/malingering/faking. This examiner believes the client is very capable of claiming conditions and reporting experi-ences that will enhance his application for disability but that bear little relation to reality. Client was a willfully poor historian. She lies with panache. He presented a staged/rehearsed performance. He indicated a sense of righteous entitlement to his (alcoholism/violence/irresponsibility/ etc. ). Client's attitude toward her illness/disability suggests indifference/tolerance/acceptance/tran-scendence. Note: ü In some medical settings, terms and concepts other than “reliability” or “validity” are used for these headings (Coulehan & Block, 1987). “Objectivity is the removal of systematic biases due to the observer's beliefs, prejudices, and preconceptions” (p. 5). “Precision is how widely observa-tions are scattered around the 'real' value” (p. 9), due to random error. “The sensitivity of a test” expresses its ability to “ 'pick up' real cases of the disease in question” (p. 11)—that is, the ability to separate true positives from false ones. “Specificity, by contrast, refers to a test's ability to 'rule out' disease in normal people” (p. 11)—that is, the ability to separate true negatives from false ones. 4. 7. Confidentiality Notices Guidelines In order to ensure confidentiality, it is not sufficient to stamp the pages of a report “Confidential” or “For professional use only,” because these are too general and vague. Instead, provide a notice (on at least the first page) that makes the following points clear: 1. The contents of this report are considered a legally protected medical document. 2. The information in this report is to be used for a stated/specific purpose. 3. The report is to be used only by the authorized recipient. 4. The report is not to be disclosed to any other party, including the patient/client. [Any excep-tions to this must be clearly and specifically stated. ] 5. The report is to be destroyed after the specified use has been made/stated need has been met.

Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf

90 STANDARD TERMS AND STATEMENTS FOR REPORTS BEGINNING THE REPORTSince the advent of the Health Insurance Portability and Accountability Act of 1996, you must know what information can be released with the HIPAA Consent (signed at the beginning of your relationship with the client after he/she has read your Notice of Privacy Practices) and when a fuller authorization is required by your state's laws. For more on HIPAA, see Zuckerman (2006). See Section 26. 9, “Formats for Therapy Notes,” on the content of routine Progress Notes and HIPAA-compliant Psychotherapy Notes. Examples Any of these examples may be reworded as necessary to meet the requirements of your own setting and the specific communication. This information has been disclosed to you from records protected by federal confidentiality rules (42 C. F. R. Part 2, P. L. 93-282) and state law (e. g., Pennsylvania Law 7100-111-4). These regulations prohibit you from making any further disclosure of this information unless fur-ther disclosure is expressly permitted by the written consent of the person to whom it per-tains or as otherwise permitted by 42 C. F. R. Part 2. A general authorization for the release of information is not sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any patient with alcohol or drug abuse. This is privileged and confidential patient information. Any unauthorized disclosure is a fed-eral offense. Not to be duplicated. Persons or entities granted access to this record may discuss this information with the patient only insofar as necessary to represent the patient in legal proceedings or other matters for which this record has been legally released. I have in my possession a signed and valid authorization to supply these records to you. This information is not to be used against the interests of the subject of this report. This is strictly confidential material and is for the information of only the person to whom it is addressed. No responsibility can be accepted if it is made available to any other person, including the subject of this report. Any duplication, transmittal, redisclosure, or retrans-fer of these records is expressly prohibited. Such redisclosure may subject you to civil or criminal liability. 4 This report may contain client information. Release it only to professionals capable of ethically and professionally interpreting and understanding the information it contains. This report is to be utilized only by professional personnel, because its information will require interpretation for others. It is inappropriate to release the information contained herein directly to the client or other parties. If this information is released to interested individuals before they are afforded an opportunity to discuss its meaning with a trained mental health professional, it is likely that the content of the report may be misunderstood, leading to emotional distress on the part of the uninformed reader. For a Child: The contents of this report have/have not been shared with the child's parent(s)/guardian. She/ he/they may review this report with the evaluator or his/her specific designee. Copies of this report may be released only by the evaluator or his/her departmental administrator, or in accord with the school district's policy. 4This is from The Paper Office (Zuckerman, 2008).

Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf

4. Beginning the Report 91BEGINNING THE REPORTThe information contained in this report is private, privileged, and confidential. It cannot be released outside the school system except by the examining psychologist/evaluator/creator of this report, upon receipt of written consent by the parent or guardian. Not to be dupli-cated or transmitted. 4. 8. Ethical Considerations in Report Writing Ethical concerns permeate all the clinician's activities. They are an inescapable part of the work—not to be added on, or to be addressed only occasionally. The following is only a short and simple list. Respect the client. Clarify not only the way your report's information will be shared, but also the limits on con- fidentiality, since what the client reveals may require you by law to report abuse or other situ-ations/conditions, or to issue warnings. Keep the client's long-term best interests in mind in shaping your work. Respect his/her con- fidentiality, and edit your report's content with this in mind. Inform the client of the implications, and discuss these with her/him, before asking for con- sent. Understand and remember the limits of your competence. Competence depends on the fit between the demands of the tasks and your resources. Com- petence may vary with your understanding of the client's age, sex, gender identity, ethnicity, culture, national origin, religion, sexual orientation, language, socioeconomic status, locale, etc. Remind yourself of what you don't know or understand. The fact that you are legally allowed to do something does not mean that you are competent to do it or that you will do it at the accepted standard of practice. Don't go beyond your data. Select measures appropriate for the goals of the evaluation, and interpret the results validly for the client. Tests and interviews are only a sample of the universe of behaviors the client is capable of performing, not the whole range. Don't draw extensive conclusions from selected data. Being interviewed by a mental health professional is a unique relationship, and your obser- vations may not generalize to other settings and persons. Consider the context and demand characteristics of the evaluation's setting. Use currently valid instruments, and maintain their security. Michaels (2006) offers a more comprehensive discussion of these and related issues.

Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf

925 Referral Reasons This chapter covers reasons for referral only. Everything else that should be included in the intro-duction to a report is covered in Chapters 4 and 6. After a suggested phrasing for a referral statement, this chapter concentrates on referral reasons for children. This has been done because adult referral reasons are thoroughly covered in Chapter 12, “Abnormal Signs, Symptoms, and Syndromes,” and many other chapters. 5. 1. Statement of Referral Reason A statement of the reason for referral should cover the referral source, date, type of evaluation/ service, and purpose, as well as the referral reason itself. Client was referred by (referral source/person and agency) on (date of referral), for (type of evaluation or other service), to (ratio-nale/purpose) in regard to (referral reason). The rest of this section gives descriptors that can be used to fill in the blanks for type of evaluation or other service and for rationale/purpose in this basic statement. As noted above, the remainder of the chapter gives descriptors that can be used as referral reasons for children. Types of Evaluations/Services Mental Status Evaluation. Clinical interview. Diagnostic clarification. Competency evaluation. Forensic evaluation. Custody evaluation. Pretreatment evaluation and recommendations. Reevaluation. Educational placement. Vocational recommendations, rehabilitation potentials/needs. Fitness for duty. Purposes Determine necessary levels of care/intensity of treatment. Assist with placement/admissions/decisions. REFERRAL REASONS

Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf

5. Referral Reasons 93REFERRAL REASONSDetermine the nature and extent of psychiatric/psychological disabilities. Assist with the development of a treatment/rehabilitation/education program. Assist in hiring/promotion evaluations. Evaluate suitability for entry into program. Assess extent of neuropsychological losses and coping abilities. Determine benchmarks of current functioning. Meet organizational needs for evaluation/state and federal regulations/Joint Commission on Accreditation of Healthcare Organizations guidelines. Assist with legal/forensic decisions. 5. 2. Common Referral Reasons for Children at Home For problems at school, see Section 5. 3, below. See also the adult symptoms listed in Chapter 12, “Abnormal Signs, Symptoms, and Syndromes. ” These are presented in alphabetical order, as no theory provides an agreed-upon structure. Abused, consequences of being: Suspected, reported being investigated, founded/confirmed/ not founded, by whom/relationship, duration. Attention-seeking behaviors: Tattling, baiting, provoking others, taunts, teases, overly de manding of attention from siblings/peers/adults, craves 's attention, dis ruptive noises, “clowning around,” pranks, “daredevil,” interrupts, compulsive talking, manipulates. Autistic withdrawal: Lack of responsiveness to people, resistance to change in the environ-ment. Conflicts with parents over: Persistent rule breaking, spending money, doing chores, doing homework, school grades, choices in music/clothes/hair/friends. Dawdles/lingers/procrastinates/wastes time/starts late in dressing/eating/bedtimes/home-work. Eating: Poor manners, refuses, appetite changes, odd combinations, pica. Imaginary playmates/fantasy. Legal difficulties: Truancy, loitering, panhandling, hangs out with delinquent peers, underage drinking, vandalism, fighting, drug sales, “joyriding”/auto theft, trespassing, burglary, extor-tion, steals, shoplifts. Need for degree of supervision at home over play/chores/schedule. Oppositional/resists/noncompliant. Parent's role as disciplinarian: Uses lectures/threats/guilt inductions/force/spankings/ground-ings/allowance reductions/privilege losses as a consequence irregularly/arbitrarily/regularly, with good/mixed/poor success at control. Relationships with sibs/peers: (↔) Rivalry, competition, abuses, teases/provokes, bullies, tyr-annizes, assaults. Running away/wandering off (not “disappearing”), tardiness. Shyness/avoidance/reticence/withdrawal. Sleep problems: Parasomnias, refusing to go to bed, nightmares, night terrors, sleepwalking, excessive drowsiness, refusal to get out of bed. Verbal abuse: Criticizes, berates, belittles, humiliates. Violence: Abusing, aggressive, threatening, bullying. 5. 3. Common Referral Reasons for Children at School Academic Performance Fails tests, difficulty with (specify subject), subject matter appears too difficult, extracurricular activities interfere with academics.

Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf

94 STANDARD TERMS AND STATEMENTS FOR REPORTS REFERRAL REASONSKept back/retained/repeated grade, social promotion. Lacks order and system in work and method of study, disorganized, careless/sloppy, lacks neat-ness, is irregularly/rarely/never prepared. Does not seek help when appropriate, copies from peers. Cheating. lying, plagiarism. Poor academic progress due to low attendance/dropping out. Social Factors With Peers Loner, relates to few students, isolates self, “different,” doesn't belong/fit in, relates to adults only on request. Clique membership/exclusion. Is easily influenced/led, suggestible, engages in risky activities. Verbally criticizes/abuses/insults peers, name-calling, unprovoked attacks, fights with ______, bullies. Does not respect rights and property of others. Does not participate in group activities. Interacts inappropriately with peers. Sexual inappropriateness. With Teachers Noncompliant, resists, disobeys, refuses to complete work assignments, seldom prepared. Unmotivated, reluctantly participates, requires 1:1 supervision. Does not follow classroom rules and procedures, challenges, disrupts. Attention-seeking behaviors: Tattling, baiting, lying, provoking others, overly demanding of attention from teachers/peers/adults, craves 's attention, tantrums, disrup-tive noises, “clowning around,” pranks, “daredevil,” “class clown. ” Overly dependent on teacher. Low respect for authority/confronts teachers/defiant, insults, defies, lies, troublemaker. Conduct/Deportment/Behavior Oral aggression/interrupts/talks out. Disruptive: Agitates/disturbs/disrupts other kids. Bullies/intimidates, teases, manipulates. Overactive, inappropriate, out-of-seat behaviors/in-seat behaviors, restlessness, fidgety. (See Section 12. 3, “Attention-Deficit/Hyperactivity Disorder. ”) School's response to behavior problems: Expulsions/suspensions/disciplinary conferences, other (specify). Motivation/Initiative Does not try, makes little effort, content to “get by. ”Has ability to do better work, but lacks interest to do so, shows no interest in subject matter/ in learning. Does not persevere, needs great encouragement, gives up too easily/at first sign of difficulty, low frustration tolerance/“That's too hard. ” Doesn't pay attention, daydreams, preoccupied, stares out of window, slow to respond. Does not complete homework/in-class assignments. Does not make up missed assignments.

Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf

5. Referral Reasons 95REFERRAL REASONSTurns in assignments late. Careless work. Does not spend enough time on work. Copies assignments from others, does not do own work. Comes to class without necessary work materials. Forgetful. Attendance: Misses excessive days, absenteeism, tardy, tardiness, cuts classes, truancy. School “phobia”/avoidance. (See Section 12. 32, “School Refusal/Avoidance/'Phobia. '”) Student's Perceptions Accurate/distorted perceptions of: grades, source of problems, other problems, fairness of sys-tem, attitude of peers/teachers/administrators. Low/high sense of identity, self-esteem, confidence. Deflects/denies/rejects responsibility for actions. Minimal acceptance/rejection/shunned/ignored. Teased/insulted/humiliated/bullied. Other Aspects Behavior deteriorates when confronted by academic demands. Inappropriate behavior in structured/unstructured situations. Is too tired/hungry during the school day to put forth best effort. Hearing/sight/coordination/medical/medication problem. Behaviors inimical to other students' welfare or exercise of rights (specify). 5. 4. Common Referral Reasons for Children at Both Home and School Cognitive Distractible, hyperactive, inattentive, handles new or exciting situations poorly, lacks foresight, low frustration tolerance, gets confused in group, does not finish his/her work, daydreams, low concentration. (See Section 12. 3, “Attention-Deficit/Hyperactivity Disorder. ”) Behavior Alcohol/drug/substance abuse. (See Section 12. 39, “Substance Use, Abuse, and Dependence. ”)Encopresis, enuresis. Fire setting, plays with matches/cooking equipment. Hypochondriasis. Overactive/restless. Self-Injurious Behavior: Hits, bites/chews, head banging, cuts, crude or excessive tattooing/ piercings/body modification, etc. (See also Section 12. 33, “Self-Injurious Behavior. ”) Sexual behaviors: Sexual preoccupation, public masturbation, inappropriate sexual behaviors, obscenity/ swearing, sexualized gestures and remarks, exhibits genitals/disrobes/public nudity/provocative clothing, etc. Molests/molestation/molested, threatens, touches, fondles/rubs against, battery. Intercourse/entry: Oral/vaginal/anal/femoral. Repeated/single episode/recurrent. Assault/rape/force used/damage/threats.

Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf

96 STANDARD TERMS AND STATEMENTS FOR REPORTS REFERRAL REASONSProtective services/police/court/medical/school/family interventions. Prostitution. Movement: (↔ by degree) Slow-moving or responding, lethargic, hypoactive, <normal>, rest-less, fidgets, out of seat, impulsive, hyperactive/overactive. Speech difficulties, stuttering. (See Section 7. 4, “Speech Behavior. ”)Thumb sucking/rocking, stereotyped movements. Tics: Involuntary rapid movements, noise or word productions. Violence/aggression. (See below. ) Social Aggression/violence: Verbal aggression, intimidation, bullying, repeated threats, throwing things, destructiveness of own/others'/peers'/teacher's/school property, physical fights/attacking/violence, hits parents/caregivers. (See Section 12. 19, “Impulse-Control Disorders. ”) Noncompliance: Antagonistic, “smart-aleck,” disobedience, negativism, resistive, oppositional, argues, “sasses/talks back/mouthy,” ignores, defiant of authority, lying in regard to chores/home-work/house rules, complies only when threatened, independent/autonomous/“stubborn. ” Immaturity: Impaired judgment, does not take responsibility for own work/belongings, own words/actions, own behavior and consequences; does not demonstrate positive/resilient self-concept. Mutism (elective/selective). Prejudiced, bigoted, insults, vandalism, threats, hate crimes. Lacks respect for authority, insults, dares, provokes, acts out. Swearing/blasphemy/obscenities. Temper tantrums: Falls to floor and bangs heels/head, breath-holding episodes, throws objects, screams, weeps, destructive. [Note duration, as well as how handled: time out, spanking, ignored, punished, mocked. ] Timid/shy/dependent/anxiety-prone. Is not accepted/valued as friend, doesn't sustain friendships. Is an object of scorn/ridicule/mockery/teasing/name calling/insults/threats/physical attacks, is scapegoated/picked on, does not defend self when attacked, ostracized. Isolation, withdrawal. Affects Anxiety, fears, phobias; nervous habits (tics, tapping, restlessness, mannerisms, drumming); avoids certain things/actions/situations, “freezes” in these situations. (See Section 10. 3, “Anxiety/Fear. ”) Angry, irritable, outbursts/rage/tantrums/“meltdowns. ”Cries easily, pouts, “thin-skinned,” whines, feelings are easily hurt. Depressed, sad, unhappy, cries, hurt, low energy, easy fatigue, apathy, withdrawn, suicidal. (See Section 10. 7, “Depression. ”) Emotional constriction: Has limited range of emotions, expresses only high-intensity feelings. Emotional dilation: Dramatizes, overreacts. Physical Problems with fine motor coordination (cutting, drawing, writing, etc. ), confuses right-left/ ambidextrous. Problems with gross motor coordination (walking, running, climbing, bicycling, etc. ). Many physical/medical complaints, accident-prone. Dysgraphia, dyslexia, eye preference, hand preference.

Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf

97 6 Background Information and History A primary reason to acquire and report background information and history is to explain the his-torical stressors the client has suffered, the coping methods employed, and the results experienced. Sequentially, the material might be described as predispositions, precipitants/provocations, and presenting problems, with some attention to preventers/protectors. This chapter covers the client's history and adjustment in many areas. Referral reasons are covered in Chapter 5; other prelimi-nary information is covered in Chapter 4. 6. 1. History/Course of the Present/Chief Complaint/Concern/Problem/Illness This section covers the patient's view of the problem in his/her own words, and beliefs about the source(s) of the complaints. It can also cover the following: For a Child: Parents'/teachers'/authority's perception of problem(s). For a Disability Report : Claimant's view of the impairment created by the injury/complaint/ disorder. Onset, Circumstances, and Effects Formal statement of presenting/Chief Complaint. Duration, progression, and severity of com-plaint. Premorbid personality and functioning levels. Circumstances/precipitating stresses/stressors/triggers/cues/situations/events, anniversary reactions. Development of signs/symptoms/behavioral changes, longitudinal/chronological/biographi-cal sequence, periods of/attempts to work/return to functioning since onset, current sta-tus. Effects of the complaint on the functioning of the patient. Effects of treatments on complaint. Reasons and goals for seeking treatment at this time. (Note: This is the important “Why now?” question. ) Evaluator's clarification/reformulation/elaboration of complaint. BACk GROUND INFORMATION

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98 STANDARD TERMS AND STATEMENTS FOR REPORTS BACk GROUND INFORMATIONSummary Statements: Reason for current admission is/Current admission is result of... This is the (#) admission to (name of hospital) and the (#) lifetime psychiatric hos-pitalization, rehabilitation, partial hospitalization, etc. Course See also the “Course Descriptors” heading under Section 23. 1, “General Prognostic Statement. ” First episode, or multiple episodes? If the latter, describe as: Recurrences, relapses, exacerbations, worsenings, flareups, fluctuating course. Duration of each episode? Remissions, if any: Therapeutic/spontaneous. Duration of each? Return to what level of function/symptomatology? Describe as (↔ by degree): Decompensation, damage, recompensation, recovery, adjustment, growth, overcom-pensation. 6. 2. Medical History and Other Findings Medical History Current/recent illnesses. Symptoms. [Consider using a checklist such as the Symptom Check List—Revised 90 (Dero gatis, 1994) for completeness. ] Diseases/disorders with known psychological aspects: e. g., thyroid disorders, mitral valve pro-lapse, AIDS, diabetes, cancer of the pancreas, alcohol abuse, hepatitis (interferon treat-ment), etc. (See Chapter 29, “Psychiatric Masquerade of Medical Conditions. ”) Surgeries and treatments. (For women:) Pregnancies (Gravida), Live births (Para), stillbirths, spontaneous/induced abor-tions (Abortus). Written as G (#), P (#), A (#). Sometimes A is dropped and P is expanded to include term births, preterm births, induced abortion or miscarriage, and living children. For example, G5P 3114 would mean 5 pregnancies with 3 term births, 1 preterm (early) birth, 1 induced abortion or miscarriage, and 4 living children. G1P1002 would mean twins. Injuries/accidents, especially Traumatic Brain Injury, Closed Head Injury, and all unconsciousness-producing incidents. (See Section 12. 26, “Post Concussive Syndrome. ”) Drug treatment, use, and abuse, especially street/illegal/illicit drug use. (See Section 3. 28, “Sub-stance Abuse: Drugs and Alcohol,” for questions, and Section 12. 39, “Substance Use, Abuse and Dependence,” for descriptors. ) Also, use/misuse of prescription drugs and Over-The-Counter medications (sleep and digestive aids, cough and cold remedies, vitamins, herbals, other supplements, etc. ). Exposure history: Toxins, duration and amount, type, source, treatments. Psychiatric History Psychological difficulties in the past, and treatment(s)/professional help sought. Current and past medications/therapies/treatments received, effects of/response to/treat-ments, side effects, condition on discharge(s) from treatment, involvement with other agen-cies/treaters. Hospitalizations: Date(s), name(s), location(s), condition on admission(s), therapies instituted and response to treatment(s), duration(s) of hospitalization(s), condition on discharge(s), time before next hospitalization(s), course (see above).

Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf

6. Background Information and History 99BACk GROUND INFORMATIONPrevious psychotherapy or counseling: Dates, Chief Complaints/problems, provider(s), services provided, outcomes. After discharge: Follow-up treatments, referral, compliance, lost to follow-up? Previous Testing or Evaluations Evaluations: History and Physical, neurological, intellectual, educational, vocational, neuropsy-chological, personality, projectives, organicity, other/specialized. Results/findings: Availability, scores, comparisons with current results, omissions and contra-dictions, “rule-outs. ” 6. 3. Personal, Family, and Social Histories, and Current Social Situation Construction of a genogram ü (see Section 6. 6) may be useful to guide inquiries and to record find-ings as you interview. Parents' Qualities Ages or birth dates/dates of death; cause of death (if deceased); client's age and reaction to death and its consequences (if applicable). General physical and mental health during client's childhood; present health; chronic or severe illnesses, disabilities. Personality characteristics, manner of relating to client, disciplinary methods, client's percep-tion of parents' influences. Marriages/divorces/separations. Qualities of the marital relationship: Stormy, close, distant, warm, functional, abusive, demonic, etc. (See also Chapter 16, “Cou-ple and Family Relationships. ”) Other: Extended family, patterns, obligations, familial “debits and credits. ”Occupation(s), effects of employment/career on client. Parental history of substance abuse or misuse, physical or sexual abuse, traumas, losses. Composition of family during patient's childhood and youth. Family's response to patient's behavior/problems/illness. Client's Development and Early Health/Medical History Pregnancy: Eagerly anticipated/planned, unplanned, unaccepted/accepted. Full-term, premature/postmature by weeks. Uncomplicated/complicated (specify difficulties/illnesses before/during pregnancy). Delivery: Natural, prepared, unprepared, difficult, uneventful, easy. Normal duration/prolonged (specify hours' duration). Uncomplicated/complicated (specify difficulties). Birth weight, Apgar scores, birth defects. Exposure to toxins, drugs, alcohol, diseases, other insults pre-, peri-, postnatally. Development: Postnatal difficulties, weight gain, eating, sleeping, daily routines. Milestones: Timing of crawling, sitting up unaided, walking, toilet training, speech and lan-guage acquisition; delays in development, loss of previously acquired skills (specify); immature behavior patterns.

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100 STANDARD TERMS AND STATEMENTS FOR REPORTS BACk GROUND INFORMATIONGrowth: Charts for growth by weight, height, body mass, and head circumference for boys and for girls from birth to 3 years and from 2 to 20 years are available from the Centers for Disease Control and Prevention (www. cdc. gov/growthcharts) at no cost. Childhood illnesses, medication(s), disabling/handicapping conditions. Siblings/Stepsiblings/Half-Siblings Ages, genders, locations in birth order/sibline/sibship/confraternity/constellation of chil-dren/sibs/siblings. Possible language: The client has a brother age 18, and two sisters age 22 and 16; he is the second of the four children. Or, more briefly: Client is second of four sibs: F22, M19 (client), M18, F16. Relationships among sibs in past and at present. General physical and mental health during client's childhood; present health; chronic illnesses, disabilities. Social Context for a Child Cultural/ethnic background and, as appropriate, country of birth and language spoken in the home. Living arrangements: Specify applicable relationship/legal issues. Lives with both parents/stepparent and remarried parent/blended family/single parent/ grandparents/other relatives (specify), is adopted, lives in foster home/institution, other (specify). Location: City/metropolitan/urban/inner-city, suburban, rural, institution, military base, other (spec-ify). Home supports: Destitute/homeless, poverty, “welfare,” Aid to Dependent Children, Social Security (Supple-mental Security Income, SS Disability Income), “working poor,” one/both parents work-ing part-time/full-time/several jobs, other (specify). Stability: Stable, separated/divorced when client was (age), changing, unstable, multiple moves, placements, changing parental partners, tumultuous, chaotic. Social relationships: Organizational memberships, cultural interests, many/few/no friends, close/best friends, buddies/clique/peer group membership, isolation/exclusion/rejection/“loner. ” (See also Chapter 15, “Social/Community Functioning. ”) Social History and Situation for an Adult This can be integrated with Section 6. 4, “Adjustment History. ” Dating history. Marriage(s): Age at/date of each marriage, termination reason (if applicable). (See Chapter 16, “Couple and Family Relationships. ”) Number, age, gender of children. Possible language: She has sons age 3 and 5, and a daughter age 6. Relationship with ex-spouse(s) (if applicable), spouse(s)/partner(s), children. Adultery/extramarital relationships/satellite relationships, exclusivity/monogamy. Living circumstances: Lives independently, lives with family/relatives/friends/other persons, lives alone but with much family/social/community support.

Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf

6. Background Information and History 101BACk GROUND INFORMATIONVocational/occupational factors: History of sheltered/adapted employment, part-and full-time competitive employment. Nature, demands, duration of previous jobs (if any). Present occupation: Chosen/not chosen, duration, satisfaction, intellectual demands, social- behavioral requirements/demands, advancement, aspirations, frustrations. Military service characteristics: None, rejected, alternate service, avoided, enlisted/volunteer, draftee. Branch of service, training, work performed, promotions/demotions. Combat/combat zone/noncombat location. Reenlistments, duration of service, final grade, kind of discharge. Military adjustment: Article XVs, time spent in the stockade (Army)/brig (Navy), court(s)-martial. Legal/criminal history: Warnings from police, charges as a minor, charges/indictments, arrests, prosecutions, convictions, incarceration/probation/parole, civil suits, current litigation/lawsuits, bankruptcy, violence directed against others (specify). Other: Special skills, career goals, debts/burdens, adequacy of income to meet responsibilities/ needs, religious/spiritual issues, substance use and abuse. Recreational activities. (See Chapter 18, “Recreational Functioning. ”) Sexual History and Situation See Section 3. 25, “Sexual History,” for questions. Educational Situation for a Child or Adult Nature of enrollment: Day, full-time, part-time, other (specify). Type of school/study: Public, charter, private, parochial/religious/sectarian, alternative school (state reasons for placement), itinerant teacher, home schooling (state reasons for placement), cyber-school. Location of school: Rural, suburban, metropolitan/urban/inner-city. Name(s) of teacher(s), relationship(s) with teacher(s), teacher report/description of problems. Class assignment/level (specify), age-grade differential (if any). Educational supports/placement: Special education (life skills, learning support for learning/intellectual/pervasive develop-mental/social and emotional/visual/hearing/other disability/disorder), classroom aide/ Therapeutic Support Staff, Section 504 and other accommodations, mainstreamed, reg-ular classes, scholars' program, gifted/talented. Overall level of academic achievement/performance/grades, Quality/Grade Point Average, standing in class. Major area of study and its relationship to present employment (if any). Educational program: Academic, technical/vocational, General Equivalency Diploma, college preparatory, etc. Extracurricular activities: Athletics, social service, music, scholarly, religious, political, special interests (specify), other (specify). Other aspects: Favorite subjects, peer and teacher relationships, position in peer group, aspira-tions. Level/highest grade completed: Preschool/kindergarten, elementary/middle/junior high/high school, technical school, 2-or

Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf

102 STANDARD TERMS AND STATEMENTS FOR REPORTS BACk GROUND INFORMATION4-year college, graduate school; grades completed; dropped out of school in grade at age because of (specify reason). Summary Statements: The client has received special services/educational support through his/her whole school his-tory/since the grade/in grades . Her/his attainment of developmental milestones was within the normal range of expectation. There are no remarkable factors to suggest the presence of unmeasured potential. Referral Reason See Chapter 5, “Referral Reasons. ” Sexual History, Nonsymptomatic See Section 6. 4, below; see also Section 3. 25, “Sexual History. ” Substance Abuse History See Section 3. 28, “Substance Abuse: Drugs and Alcohol. ” 6. 4. Adjustment History Of concern here are the client's important life events and transitions. Making a table or timeline of the client's significant life events may clarify and suggest connections. With rows for dates and the client's ages at these dates, the columns could be “Child Events/Transi-tions” and “Family and Environment Events. ” These could include moves, changes in schools, shifts in finances, parental separation/divorce, major illnesses, legal difficulties, and so on. Sexual Adjustment See also Sections 3. 4, 3. 14, 3. 25, and 3. 26 for questions and issues. Dysfunctions/disturbed sexual performance: Loss of desire, inhibited arousal, primary/secondary/occasional difficulty getting or keep-ing an erection/“impotence,” fast/premature/delayed ejaculation, inhibited orgasm, dyspareunia, vaginismus. History of sexual/emotional/physical abuse: Involved/threatened exploited/being exploited, victimizing/victimization, violence, trau-mas, legal ramifications, other (specify). (For sexual abuse:) Involved/threatened molestation/touching, penetration, other (specify). [Be aware that sexual abuse is very differently defined in the literature and may involve molestation/touching, obscene phone calls, harassment/insults, exhibitionism, etc. as well as penetration (oral, anal, vaginal, femoral, etc. ). ] Orientation and object choice: Celibate, “sexual addiction,” heterosexual, homosexual, gay, lesbian, bisexual, asexual, etc. Paraphilias/sexual minorities/variations/special interests: Pedophilia, hebephilia, exhibitionism, voyeurism, pornography, prostitution, Sadism and Masochism/Slave and Master, zoophilia, frottage, Bondage and Domination/Disci-pline/Domination and Submission, fetishism, Trans Vestism, “water sports”/“golden showers”/“toilet service”/urolagnia, Greek (anal)/French (oral)/English (whipping) sex, trans sexualism, etc.

Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf

6. Background Information and History 103BACk GROUND INFORMATIONSummary Statements: The client reports no/some traumatic sexual/traumatizing experiences (if any, specify). The patient was not questioned about sexual preferences/orientation, history, or interests. Social Adjustment Acquaintances, clique membership/exclusion, friends/buddies/best friends/confidants, rela-tionship with sibs/other family members/friends/enemies. Ability to adjust to marriages, childbirth/parenthood, losses, aging, illness, health care/ser-vices/treatments, transitions. Ability to conform to social and vocational expectations; hold employment; advance in a career; adjust to superiors/bosses, peers/coworkers/fellow workers, schedules, work load, and task changes. Summary Statements: His/her history is remarkable only for... (specify findings). The client has no history of military service/drug or alcohol difficulties/special training/police involvement. (pathology) is present in the client's bloodline/consanguinity/relations/family tree. The client has a history of having lived for years in an agonizing/tormenting/abusive/ sociopathic/criminal/tumultuous/chaotic/pathogenic family. The family environment was unstable, unstimulating, and unstructured. The client's early life situation was victimizing/traumatic/tragic/disastrous. 6. 5. Social History for a Disability Examination See also Chapter 17, “Vocational/Academic Skills. ” Applicant's description of industrial/workplace stressors, onset of complaints, and (alleged) injuries or illness associated with onset. Psychological response to (alleged) injury situation: History of mental health problems since (alleged) injury. History of treatment(s) since (alleged) injury. Current treatment and medication, including medication taken on day of examination. For each of the following areas, distinguish baseline, periinjury, and postinjury events: Educational level and training: professional, technical, etc. Sequential description of occupations pursued (including military service): Training and skills required. Supervisory responsibilities. Career advancement: upward, downward, lateral, static. Difficulties and/or accomplishments in each occupational setting. Previous occupational injuries, time lost, and outcome. Previous life changes (external stresses and losses) and responses to these. Legal history, when applicable: Previous workers' compensation and other personal injury claims, with the circumstances and outcome. Criminal history if relevant to diagnosis and/or disability. Substance use and abuse. Applicant's description of a typical day.

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104 STANDARD TERMS AND STATEMENTS FOR REPORTS BACk GROUND INFORMATION6. 6. Family Genogram/Family Tree/Pedigree Constructing a genogram can guide you and the client during history taking and can encourage exploration and insight when parallels in family history are visualized. Make as many copies of the genogram as are necessary, and perhaps revisit it during treatment. The symbols and a few words can record demographics (family members' genders, names, dates of births and deaths, marriages, separations, divorces, remarriages, ethnic and religious qualities) and some relationships (e. g., tri-angulations and balances). The figure below shows the conventions for recording a genogram. Draw a line around members of the current household. Other family information for evaluations can be found in Chapter 16, “Couple and Family Relation-ships. ” The design and use of genograms 1 in family therapy is explored in Mc Goldrick et al. (2008) and Kaslow (1995). 1If you do a lot of genograms or want to use them in family therapy, paper forms, checklists, and other quite useful mate-rials are available from Genoware ( www. genogram. org ).

Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf

B. The Person in the Evaluation Subdivision B's Chapters: Page 7. Behavioral Observations 107 8. Responses to Aspects of the Examination 118 9. Presentation of Self 127 10. Emotional/Affective Symptoms and Disorders 132 11. Cognition and Mental Status 146 12. Abnormal Signs, Symptoms, and Syndromes 163 13. Personality Patterns 209

Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf

Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf

107 7 Behavioral Observations This chapter covers the following areas: appearance, including clothing; movement of all kinds; and speech behaviors (but not content). How the client responded to the evaluation interview, and how he/she presented him-/herself in the examination, are covered in Chapters 8 and 9, respectively. Speech behaviors that reflect abnormal cognition are covered in Section 11. 19, “Stream of Thought. ” 7. 1. Appearance Note ü : Because physical beauty is so tightly associated in North American culture with good-ness and health, and has such an impact on a person's life course, all clinicians should be fully informed about the distortions of judgment caused by socially supported prejudices (e. g., sex-ism, racism, ageism, beautyism) and cautiously circumspect of wordings supportive of these. Overall Appearance: Summary Statements The client seems to be well kept, well nourished, and in No Apparent Distress. Hygiene is managed independently, effectively, and appropriately. Clean, well groomed, and well dressed. The client took good care of his/her appearance in regard to dress, hygiene, and grooming. His/her appearance is not unusual. No unusual visible features/deformities/dysmorphic features. Nothing unusual/remarkable/noticeable about his/her posture, bearing, manner, or hygiene. Her/his hygiene and grooming habits were adequate and normative for a socially conscious individual with an active self-interest and common social concerns. This client showed some signs of self-neglect, specifically... Client appears about/older than/younger than chronological/stated age. Haggard, weak, pale and wan, frail, sickly, sleepy/tired. [Note time of day; ask about sleep. ]Disfigured, disabled/“handicapped,” “maimed” by... (specify). Shows the ravages of drug/alcohol/illness/stress/overwork/age/disease, dissipated, ill-looking, wasted-looking, out of shape. Client shows evidence of current alcohol or drug use/physical dependence. [Note presence of recent needle marks, thrombosed veins, etc. ] (See Section 3. 28, “Substance Abuse: Drugs and Alcohol,” for signs. )BEHAVIORAL OBSERVATIONS

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108 STANDARD TERMS AND STATEMENTS FOR REPORTS BEHAVIORAL OBSERVATIONSFor a Child: Appears to be well cared for/assisted/supervised/trained in self-care, ignored/neglected. For a Vocational Evaluation: The client has a suitable appearance for work involving contact with the public. He/she would not be identified as unusual in a group on the basis of physical appearance alone. Build (↔ by degree) emaciated thin average stocky formidable sickly lean well developed/built chubby hulking malnourished wiry weight proportionate heavy-set enormous undernourished slender to height husky underweight lanky well nourished heavy multiple chins cachectic skinny within usual range pudgy jowly frail bony “healthy” barrel-chested “beer belly” gaunt chunky pot-bellied petite large-boned portly flabby small-boned rangy fleshy fat [See note on diminutive large-framed burly obesity below] robust beefy rotund full-framed rugged Height It is preferable to state height objectively (i. e., to give measurement) rather than to use relative ü terms (“short/average/tall”), unless you also include your own height. Weight Ask: “What do you now weigh?” and “Is this your usual weight?” Note: ü “Obesity” and “hardly/mildly/moderately/extremely/massively/morbidly obese” are all misleadingly subjective and subject to changing tastes and styles. It is far preferable to report measured height, weight, and general “build. ” Remember, obesity is not a psychiatric diagnosis. Body types: Android/abdominal/“apples,” truncal obesity, or gynoid/femoral/“pears. ” For a Child: Stature in relation to age is short/normal/tall. Child is at the percentile of the standard table for height, weight, and head circumference for children. [Tables for these are available online (www. cdc. gov/growthcharts). ] Child is at Tanner stage of sexual development. (See Section 19. 7, “Puberty,” for a descrip-tion of the Tanner stages. ) Complexion Ruddy, tanned, sunburned, jaundiced, sickly, pale, wan, washed out, sallow, pallid/pallorous, leathery, pimply, warty, mottled, shows negligence, birthmarks/port-wine marks, scars, acne vulgaris.

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7. Behavioral Observations 109BEHAVIORAL OBSERVATIONSFace General: Pinched, puffy/swollen, washed out, emaciated, old-/young-looking for chronological/ true age, baby-faced, long-faced, moon-faced. Movement: Tics, twitches, drooping, mobility during interview/over topics. Chewed gum/toothpick/other items. Head: Odd-shaped, microcephalic/macrocephalic, dolichocephalic/mesocephalic/brachy ceph-alic, normal, cretinous, damaged. Teeth: Unremarkable hygiene, dentures, gaps and missing teeth, over-/underbite, carious, eden-tulous, unusual dentistry, bad breath/breath odor/“halitosis. ” Facial hair: See “Beard” under “Hair,” below. Makeup: None, minimal, lipstick only, eye makeup, brows removed, <customary>, excessive, odd, outrageous. Notable features: Ears, nose, cheeks, mouth, lips, teeth, chin, neck. (Examples: Dark circles under eyes, bulbous/red/richly veined nose, large/small features, toothy grin. ) For a Child: Sucked thumb, used pacifier, etc. (See Section 12. 15, “Fetal Alcohol Syndrome. ”) Facial Expressions See also Chapter 10, “Emotional/Affective Symptoms and Disorders. ” Attentive, alert, interested, focused. Tense, worried, indrawn, frightened, alarmed. Sad, frowns, downcast, in pain, grimaces, forlorn, drawn. Tearful, watered/tears up, tears falling, open crying/sobbing. (↔ by degree) Dramatic, expressive, changes with topic, apathetic, preoccupied, inattentive, unspontaneous, withdrawn, vacuous, va cant, absent, detached, mask-like, did not smile/ change expression during the long interview, lacks spontaneous/appropriate/expected facial expression, hypomania, flat, expressionless, lifeless, frozen, rigid. Calm, composed, relaxed, dreamy, head bobbed as if nodding off. Smiling, cheerful, happy, delighted, silly/sheepish grin, beaming. Angry, disgusted, distrust, contempt, defiance, sneering, scowling, grim, dour, tight-lipped, hatch marks between his/her eyes, a chronic sour look. Eyes See also “Eye Contact/Gaze” under Section 7. 3, “Movement/Activity. ” Size, shape, etc. : Large, small, close-set, wide-set, almond-shaped, sunken, bloodshot, reddened, bleary-eyed, bulging, hooded, wide-eyed, cross-eyed, “wall-eyed”/disconjugate gaze. Expression: Staring, unblinking, glassy-eyed, vacant, penetrating, piercing, vigilant, nervous/ frequent blinking, darting, squinting, tired, “eyes twinkled,” limpid, unusual. Brows: Beetling brows, heavy, massive, raised, pulled together, pulled down, shaven, plucked. Glasses: Regular corrective lenses, half-lenses, bifocals, reading glasses, contact lenses, sun-glasses, needed but not worn, broken/poorly repaired. Hair Hairstyle: Unremarkable, fashionable length and style, long, ponytail, “pigtails,” plaits, corn-rows, braided, crew/brush cut, natural/“Afro,” frizzy, curly, finger curls, dreadlocks, wavy, straight, uncombed, tousled, “punk,” “Mohawk,” “mullet,” shaven, currently popular hair-cut, stylish, unusual hair cut/style/treatment, moussed, permed, “relaxed,” unbarbered, simple/easy-to-care-for cut, short, pageboy. Color: Bleached, colored/dyed, frosted, streaks of color, different-colored roots, flecked with

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110 STANDARD TERMS AND STATEMENTS FOR REPORTS BEHAVIORAL OBSERVATIONSgray, salt-and-pepper, gray, white, faded color, albino, platinum/blonde/fair-haired, red- haired/carrot/coppery/rust/auburn, chestnut, brunette, brown, black, raven. Hair loss: Thinning, receding hairline, high forehead, widow's peak, male-pattern baldness, balding, bald spot, bald, head shaven, alopecia. Artificial hair: Wig, toupee, hairpiece, “a rug,” implants, transplants, an obvious hairpiece. Other: Clean, dirty, unkempt, greasy/oily, matted. Beard: Clean-shaven, unshaven/needs a shave, several days' growth, had the beginnings of a beard/ wispy/scraggly, stubble, cultivated/deliberate stubble, poorly/well maintained/groomed, stylish, neatly trimmed, full, closely trimmed, mutton chops, goatee, chin beard/chin strap, unbarbered, Van Dyke, Santa Claus style, wore his facial hair in a . Moustache: Wore/sported/maintained a moustache/moustached/moustachioed, handlebars, pencil-thin, mandarin, colonel, neat, drooping, scraggly, just starting/light. Other Aspects of Appearance/“Body Habitus” Grooming/hygiene/cleanliness: Excellent/good/unremarkable/fair/marginal/poor, scruffy/ be draggled, neglected, indicating indifference, acceptable but not optimal, unremarkable/ as expected, neat, tidy, meticulous. Grooming reflective of: Impoverishment/very limited resources, cultural background, identi-fication with subpopulations/celebrities/ideal, physical limitations, cognitive limitations, pride in appearance. Odor (body or clothing): Musty, noticeable, offensive, ineffective deodorant, lack of bathing, excess perfume, smells of alcohol/tobacco/smoke. Nails: Clean, tobacco-stained, dirty, grimy, bitten down to the quick, overlong, broken, painted/ colored, polished, manicured, artificial/extensions. Skin: Bruises, cuts, abrasions, scabs, sores, scars, damage, tattoos, piercings, acne, acne vulgaris scars, birthmarks. Breathing: Noisy, wheezed, Shortness Of Breath, used oxygen. Notable aspects: Shoulders, chest, belly, back, pelvis, legs, feet, ankles, hands, fingers. Jewelry (rings, earrings, bracelets, pins, piercings, etc. ), makeup. Other: Hearing aid, prosthesis, colostomy bag, catheter, other device, bags carried. 7. 2. Clothing/Attire The relevant perspectives are not fashion, cost, or newness, but what clothing means about the ü client's ability to care for her-/himself and her/his judgment of appropriateness. Appropriateness Appropriate for situation/occasion/weather, nothing unusual for a visit to a professional appointment/office. Presentable, acceptable, suitable, appearance and dress appropriate for age and occupation, businesslike, professional appearance, nothing was attention-drawing, modestly attired. Client's idea of suitable, not suitable for age/suitable for a younger person, not suitable for his/her station in life, too casual to be acceptable, care of person and clothing was only fair. Other: Institutional, odd/unusual/eccentric/peculiar, unique combinations, carefully disor-dered, dressed to offend, un/conventional, attention-seeking/-drawing, outlandish, garish, bizarre.

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7. Behavioral Observations 111BEHAVIORAL OBSERVATIONSQualities of Clothing (↔ by degree) filthy rumpled needing plain neat stylish grimy disheveled repair out of date careful fashionable dirty neglected threadbare old-fash- dresser elegant smelly wrong size seedy ioned clothes-dandified dusty ill-fitting clean but conscious natty musty unkempt worn regional/ in good taste dapper worn foreign food-spotted messy shabby designs overdressed meticulous greasy slovenly tattered eccentric seductive immaculate oily sloppy torn “grunge” revealing baggy prim flashy bedraggled shows somber too tight-raggedy unilateral fitting neglect tasteless unzipped design unbuttoned Other Dressed in a manner typical of today's youth/of an earlier decade (specify), attired in the style of her/his contemporaries. Clothes were loosely fitting/quite tight suggesting a recent change in weight. 7. 3. Movement/Activity Speed/Activity Level (↔ by degree) Frozen, almost motionless, little animation, mask-like facies, psychomotor retar-dation, slowed, showed great economy of movement, slowed reaction time/latency to ques-tions, <normal>, normokinetic, restless, squirming, fidgety, fretful, constant hand move-ments, continual flexing of , hyperactive, overactive, agitated, frenetic. For a Child: High activity level, motorically active, fidgets, difficulty remaining in his/her chair/seat, many out-of-seats, restless and distractible, rambunctious, difficult to redirect, redirectable, inves-tigated all the contents of the room/desk/testing materials, intrusive, overactive/hyperac-tive/aggressive, a darter. (See Section 12. 3, “Attention-Deficit/Hyperactivity Disorder. ”) Coordinated-Uncoordinated (↔ by degree) Awkward, clumsy, “klutzy,” often injures self, “accident-prone,” inaccurate/inef-fective movements, jerky, uncoordinated, <normal>, purposeful, smooth, dextrous, grace-ful, agile, nimble. Note degree of body awareness, body ego, body confidence. ü Noticeably poor manual dexterity, held objects such as pencils and scissors awkwardly, dif-ficulty coordinating hands and fingers when asked to copy designs, hands shaky on tasks, problems in drawing lines (specify).

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112 STANDARD TERMS AND STATEMENTS FOR REPORTS BEHAVIORAL OBSERVATIONSFor a Child: Coordination delayed by months/years, <normal>, good/poor gross and fine motor coor-dination. Note handedness/preference/dominance, presence of astereognosis. ü Dominance: Right/left/mixed, as seen in hopping on a foot, preferred use of one eye, able to use only one hand to flip a coin/catch a thrown object. Praxis Grip: Held pencil in the usual grip/atypical/awkward/in a fist-like grip, in a palmar grasp, per-pendicular to the table, down by the graphite/with fingers too close to the point, thumb overlapping the forefinger/forefinger overlapping the thumb, with two fingers and the thumb, with three fingers and thumb, between the forefinger/index/pointer and third/mid-dle finger, tensely. Handwriting (↔ by degree): Elegant, precise, stylized, legible, sloppy, prints, primitive, scrawls, illegible, no recognizable letters. Handshake (↔ by degree): Avoided, “fishy,” moist/sweaty/nervous, limp, tentative, weak, delayed, <normal>, firm, exaggerated, painfully hard. Ask client to walk, write a sentence, and/or tie shoes/tie, and observe skill/difficulties. ü Mannerisms/Oddities This subsection covers peculiarities of motor behavior, automatisms, unusual uses of hands/body. (See also “Symptomatic Movements,” below. ) If a client exhibits no such peculiarities, use this state-ment: There were no mannerisms, tics, or gestures indicative of any psychopathology or physical distress. Stereotyped movements: Twirling, rocking, self-stimulation, hand flapping, aimless/repeti-tious/unproductive/counterproductive movements, head bobbing, wriggling, hand or finger movements, bounces leg, posturing, picks/pulls at clothing, blinking. Perseverations: Pauses and repeats movements at choice points (as when leaving the room/in doorway), makes same response to different/changed/new stimulus. Manneristic mouth movements: Tongue chewing, lip smacking, whistling, made odd/animal/ grunting sounds, belching, pulls lips into mouth. Squints, made faces/grimaced. Childlike facial expressions/speech (e. g., “Gol-lee”), giggles, snickers. Sniffles repeatedly/loudly, uses/needs but does not use tissues/handkerchief, freely and fre-quently picks his/her nose, repetitively “cleans” ears with fingers. Yawned excessively/regularly/elaborately, rubbed eyes. Made audible breathing sounds. Smoked incessantly/carelessly/dangerously/compulsively/selfishly. Deliberately dropped items so she/he could retrieve them. For a Child: Kept thumb in mouth for minutes of the hour session, sucked fingers. Covered face with hands and peeked out. Walked on toes/heels/ankles.

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7. Behavioral Observations 113BEHAVIORAL OBSERVATIONSSymptomatic Movements Waxy flexibility ( c e r e a flexibilitas ), tardive dyskinesia, dysdiadochokinesia, Parkinsonian/ Extra Pyramidal Symptoms/movements, athetosis, hemiballismus, ataxia, choreiform, aki-nesia, “pill rolling,” “chewing,” “restless leg syndrome,” opened and closed legs repeatedly, paced, hyper/hypotonic, hyper/hypokinetic, echopraxia, cataplexy, denuda tive behavior. (See also Section 12. 36, “Side Effects of Psychotropic Medications/Adverse Drug Reactions. ”) Tremor: None/mild/at rest/essential/familial, intentional/hovering, quivers, shivers, twitches, tics, shakes. Autonomic hyperactivity. (See Section 10. 3, “Anxiety/Fear. ”) Mobility (↔ by degree) Confined to bed/bedfast, uses wheelchair/adaptive equipment, requires support/ assistance/supervision, uses a gait aid (cane, leg/back brace, walker, crutches/Canadian crutch), walks, slow, careful, avoids obstacles, runs, athletic. Stood up frequently, roamed the room, stretched/walked around periodically, attempted to leave. Gait, Carriage, and Station (↔ by degree) Astasia/abasia, ataxic, steppage, waddling, awry, shuffles, desultory, effortful, dilatory, stiff, limps, drags/favors one leg, awkward, walks with slight posturing, lumber-ing, leans, rolling, lurching, collides with objects/persons, broad-based, knock-kneed, bow-legged, <normal>, ambled, no visible problem/no abnormality of gait or station, fully mobile (including stairs), springy, graceful, glides, brisk/energetic, limber. Mincing, exaggerated, strides, dramatic/thespian/for effect, unusual. For a Child: Difficulty climbing stairs, brushed ankles against each other, unsteady forward gait, stumbled at intervals. [Note: Observe the wear patterns on shoes. ] Balance (↔ by degree) Dizzy, vertigo, staggers, sways, fearful of falling/unsure, unsteady, positive Romberg sign, com-plains of light-headedness, <normal>, no danger of falling, steady. Posture/Bearing “Hunkered down,” hunched over, slumped, slouched, stooped, round-shouldered, limp, hangs head, cataplexy, relaxed, <normal>, dignified, stiff, tense, guarded, rigid, erect, “military,” upright, sat on edge of chair, leans, peculiar posturing/atypical/inappropriate (sat sideways in the chair, reversed chair to sit down). Suggests chronic illness, appeared weak/frail, low stamina/endurance/easily winded, listless, labored, burdened. Eye Contact/Gaze (↔ by degree) See also “Eyes” in Section 7. 1, “Appearance. ” None, avoided, stared into space, kept eyes downcast, broken off as soon as made/passing/inter-mittent, wary, alert, looked only to one side, brief, flashes, fleeting, furtive, evasive, appropri-ate, <normal>, expected, modulated, lingering, staring, steady, glared, penetrating, piercing, confrontative, challenging, stared without bodily movements or other expressions.

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114 STANDARD TERMS AND STATEMENTS FOR REPORTS BEHAVIORAL OBSERVATIONSOther If any movement or posture indicates pain, see Section 12. 23, “Pain Disorder/Chronic Pain Syndrome. ” For anxious behaviors, see Section 10. 3, “Anxiety/Fear. ” For depressed behaviors, see Section 10. 7, “Depression. ” 7. 4. Speech Behavior Give quotes/verbatim examples. (See also Section 11. 19, “Stream of Thought. ”) Difficulties noted in at least the first two areas below should be followed up with an assessment ü by a speech therapist (a Speech-Language Pathologist with a Certificate of Clinical Compe-tence. ) Articulation Unintelligible, stammer/stutter, stumbles over words, mumbles, whispers to self, mutters under breath, lisp, sibilance, slurred, “juicy,” garbled, understandable, clear, precise, clipped, choppy and mechanical, poor diction, poor enunciation, misarticulated, unclear, dysfluen-cies, dysarthrias (spastic, flaccid, ataxic), aphasias. Pace/cadence/rate: Too slow/fast, rhythm. Accent: Noticeable, mild, strong, foreign, regional, odd, intense, confusing, drawl, burr. For a Child: Immature, simpler sentences/formation than expected, expected/age-appropriate/inappropri-ate articulation errors, difficulty in speech articulation (especially sounds such as /r/, /sh/, /th/, /z/, or /ch/), slid over some consonant sounds. Voice's Qualities Loud/noisy/almost screaming, strident, brassy, harsh, gravelly/hoarse/raspy, throaty, nasal, screechy, squeaky, shrill, staccato, mellifluous, quiet, soft, weak, frail, thin, “small” voice, barely audible, whispered/aphonic, affected, tremulous/quavery, low-/high-pitched, sing-song, whiny, odd inflection/intonation, monotonous pitch/tone, sad/low tone of voice, muffled, bass/baritone/alto/soprano. Phraseology: Summary Statements Consider these as they apply to writing where relevant, as well as to speaking. Client spoke in “baby talk”/infantile/childish/immature style. He mispronounced words, used uneducated vocabulary/uncultured language/vocabulary reflec-tive of limited education/cultural deprivation, used slang words, made grammatical mis-takes, used nonstandard English. She used dialect, regionalisms, colloquialisms, provincialisms, foreign words/idioms. Speech was notable for cliches, habitual expressions, repetition of catch phrases, much use of “You know”/“like. ” Client's vocabulary was pedantic, pseudointellectual, stilted, excessively formal, jargon. Inappropriately familiar terms were used (e. g., “dear,” “honey”). Client engaged in punning, rhyming, contrived language. Speech included casual and familiar swear words, epithets, hostile cursing, racial/ethnic/reli-gious slurs. Aphasias: Expressive/nonfluent, receptive/fluent, global/total, transcortical (intact repetition

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7. Behavioral Observations 115BEHAVIORAL OBSERVATIONSwith fluent or nonfluent aphasia), anomic, amnestic, auditory/word deafness, visual/word blindness, etc. ). Alexia, alexithymia, agrammatism, syntactical errors. Misspoke; confused words (e. g., “wall” for “while”), requiring repetition and inquiry for clari-fication. For a Child: Child has underdeveloped vocabulary for his/her age. Conversation consisted of three-or four-word phrases rather than sentences. Speech Amount/Productivity/Energy/Rate (↔ by degree) halting slowed normal pressured verbose hesitant minimal initiates loquacious overproductive delays/ed response alert garrulous long-winded inhibited unspontaneous productive excessively bombastic blocked reticent animated wordy nonstop lags terse talkative voluble vociferous slowed/long response timesluggish fluent expansive overabundant paucity easy blurts out copious sparse spontaneous run-together overresponsive mute impoverished smooth raucous excessive detail selective mutism laconic chatty voluminous only nods economical even rapid hyperverbal unresponsive taciturn fast single-word rushed flight of ideas word-finding answers hurried difficulties word searching difficulty generating responses Speech Manner (↔ by degree) distant normal candid empathic hurried responsive open touching pedantic frank insightful somber well modulated guileless wise inarticulate articulate free charming whiny gets ideas across well untroubled witty good-natured easy jovial expressionless engaging warm mechanical well spoken sincere eloquent self-disclosing dramatic realistic in touch with measured own feelings naive thoughtful Summary Statements for Normal Communication/Speech Behaviors I noted no impairments in language functioning reflecting disordered mentation. The client could comprehend and carry out the test/evaluation instructions and tasks, and didn't misinterpret or misunderstand the test materials or questions.

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116 STANDARD TERMS AND STATEMENTS FOR REPORTS BEHAVIORAL OBSERVATIONSHe/she displayed no language impairment, either receptively or expressively. Communication was not impeded in any way; satisfactory/adequate/normal expressiveness. Auditory comprehension was adequate, and oral delivery was effective. The client's speech was without articulatory deficit. The client's comprehension of English/spoken words was normal/defective/abnormal. Her/his ability to understand the spoken word was adequate within the context of this exami-nation, but might not be in other situations, such as... (specify). Client did not have to have the questions/instructions rephrased/simplified/repeated. Summary Statements for Conversational Style She is a reciprocal conversationalist/dialogued spontaneously/is able to carry on a conversa-tion. He is able to initiate topics appropriately. She follows the conventions/social rules of communication (including appropriate phrasing and turn taking), and understood the suppositions and expectations of native speakers of American English. Client participated/did not participate in appropriate social dialogue. She exchanged the expected social amenities of offering and expressing gratitude. He engaged in little/normal/expected/excessive small talk. She did not initiate conversation or develop spontaneous themes. The client's speech was sophisticated, with considerable emphasis on intellectual/personal/ medical/historical/family matters. Client assumed that I, the listener, knew more than I did about her history/ideas/the subject of the conversation. Speech was excessively colloquial for our relationship. Speech was slow, deliberate, and at times evasive. All of the client's speech was defensive/designed to emphasize his degree of disability. Her answers were not to be relied upon, but were pertinent and to the point. (See also Sections 4. 6, “Reliability/Validity Statements,” and 8. 5, “Relationship with the Examiner. ”) Client uses vulgarity/blasphemy/scatology/sexuality to shock. Speech reflects preoccupations. (See Section 11. 19, “Stream of Thought. ”)Client engaged in rote retelling of an often-told story. Uses psychiatric language sophisticated enough to suggest a person who is system-wise. His language choices were, in reality, more odd than I am able to reproduce here. She was reluctant to expand on/denies her complaints/problems/symptoms. Client offered little information but responded readily to direct questions. He was very verbal but not articulate. Where one word would suffice/answer the question asked, she produced a paragraph. He was an excessively verbal person who needed more braking than prompting. Client attempted to be helpful by trying to tell a great deal, and so created pressured speech. For a Child: The child was perseverative/was echolalic/mimicked examiner's speech. Delayed language acquisition is evident. Child had difficulty in comprehending or expressing/oral language/speech.

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7. Behavioral Observations 117BEHAVIORAL OBSERVATIONS7. 5. Other Behavioral Observations Brought items to the examination: Possessions, cigarettes, presents, papers, briefcase, coffee/ refreshments/candy/food, pets, children. Belched, etc., without apology. If a client's responses seem odd, consider unacknowledged hearing loss as a factor. It is more ü common in the older population (from 25% of females over age 65 to 40% of over-65 males; more than 80% of those over 85), but it is not uncommon in younger people. Unacknowledged hearing loss is a common cause of believing that others are against one (Holt et al., 1994). For a Child: Tantrum: Assaultive, destructive to property, aggressive to others, not redirectable, duration of minutes.

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1188 Responses to Aspects of the Examination This chapter describes face-to-face, one-on-one, interpersonal behaviors reflecting the client's responses to aspects of the examination, including responses to the procedures of evaluation, rap-port with the examiner, response to the methods of evaluation, concentration, motivation, response to failure, and approach to the tasks of the examination. Chapter 9 covers self-presentation of the client to the evaluator. 8. 1. Reaction to the Context of the Evaluation See also Sections 8. 2 and 8. 5, below. (↔ by degree) The following five paragraphs are sequenced by increasing degree of responsiveness. Unable to recognize the purposes of the interview/the report to be made, unaware of the social conventions, did not understand or adapt to the testing situation, did not understand give and take of question-and-answer format, did not grasp nature of questions, gave inappro-priate responses, not relevant, not logical, not goal-directed, was not able to comprehend or respond to questions designed to elicit symptoms of , low attend-ing skills, just able to meet the minimum requirements for appropriate social interaction, mis-construed what was said to him/her, unaware, withdrawn, unresponsive, echolalic, preoccu-pied, estranged, didn't grasp essence or goal, autistic. Indifferent, bland, detached, distant, uninvolved, uncaring, lackadaisical, no effort, did not try, no interest in doing anything but playing out her/his time, haphazard responding, insensitive, bored, showed the presence of an interfering emotion, overcautious, related obliquely. Dependent, sought/required much support/reassurance/guidance/encouragement from the examiner, desperate for assistance, self-doubting, ill at ease. Tense, anxiety appropriate/proportionate to the interview situation, initially re sponded only to questions but later became more spontaneous, began inter-view with an elevated level of anxiety that decreased as the evaluation progressed, needed assistance to get started. Understood the social graces/norms/expectations/conventions/demand characteristics of the examination situation, comfortable, confident, relaxed, in terested, curious, eager, intense, carefully monitored the testing situation, RESPONSES TO Ex AMINATION

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8. Responses to Aspects of the Examination 119RESPONSES TO Ex AMINATION oriented, aware, alert, cooperative, no abnormalities, attended, responded, reciprocated, continued, participated, initiated, communicated effectively, clear and efficient, high quality of interaction, with depth. For a Child: Summary Statements Note that “parent” in these statements should be taken to mean biological/custodial parent/ ü grandparent, foster parent, or any other caregiver/major attachment figure. Parental Interaction with Examiner Parent's manner of relating to examiner was arrogant/threatening, suspicious, impatient, coop-erative/trusting, controlling/manipulative, seductive, dependent, plaintive, grudging, etc. Parent's attitude did/did not change during interview. Parent took role and assigned role to examiner during interview (specify). Behavior When with Parent Child played easily/unwillingly/not at all in the waiting room, did/did not put away the toys used. Child exhibited level of play, with playthings appropriate for age. Parent used control in the following ways (specify degree, kind/methods/means, timing), over issues of... (specify). Parent's relationship to child was supportive/unsupportive, negotiated/unilaterally control-ling. Parents showed agreement/disagreement/conflict over discipline, rewards, language, attention given, etc. Separation from Parent Upon separation, child showed excessive/expected/limited/no anxiety, expressed as... (spec-ify). Child used appropriate/a few/no coping mechanisms upon separation (if any, specify). Child separated easily/poorly/reluctantly from the parent/examiner. Child's reaction upon rejoining parent was... (specify). Child/parent described symptoms of separation anxiety: Worry over possible harm to parent/ parent deserting child/disaster keeping child away from parent, school refusal in order to stay with parent, refusal to sleep without parent, “clinging” or “shadowing” behaviors, nightmares about separation, physical complaints when separated, tantrums/pleading not to separate, excessive homesickness, not easily redirected/distracted from parent, need for much reassurance, discomfort with other adults, inability to master own anxiety. Playing Observed Child played eagerly/willingly/unenthusiastically/not at all with same-age/younger/older peers. Child showed eager/expected/limited/no approach to and interest in toys/materials. Toys/materials actually used were... (specify). Mode of play was incorporative/extrusive/intrusive/other (specify). Manner of play was constructive/disorganized/mutual/parallel/distractible/disruptive/other (specify). Child was tractable/intractable to discipline, such as... (specify).

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120 STANDARD TERMS AND STATEMENTS FOR REPORTS RESPONSES TO Ex AMINATIONChild's Attitudes and Feelings Child did/did not grasp purpose of clinic visit(s). Child did/did not seem aware of own difficulties. He showed excessive/expected/limited/no reaction to own symptoms. She showed positive/negative/no feelings about returning to clinic. Child showed positive/negative/no feelings/attitudes about/toward... (specify aspects of self, as appropriate:) behavior, appearance, body, gender/sex, intellect. Child showed positive/negative/no feelings/attitudes about/toward parents/siblings/school/ peers/authorities/others (specify). Feelings Aroused in Examiner by Child Child aroused feelings of irritation, anger, dislike, sympathy/protectiveness, concern, pity, admiration, curiosity, etc. (specify) in examiner. For an Adolescent: Attend to any limited spontaneity that is excessive but not inappropriate/abnormal for the ado-ü lescent's age and the evaluation/evaluator. 8. 2. Attention/Concentration/Effort See also Sections 8. 3, “Response..., ” 8. 4, “Persistence/Motivation..., ” 11. 3, “Attention,” and 11. 4, “Concentration/Task Persistence. ” apathetic sluggish distractible normal energy eager dull worked slowly low attending cooperative animated uninvolved in slow motion skills interested fascinated uninvested slow reactions easily distracted adequate initiates passive slowed from task good effort inquisitive anergic lost concentration spontaneous enthusiastic shunned effort flat did not stick attentive bored no originality with task alert uninterested unchanging had great difficulty following directionsresponsive inattentive expressionless indifferent uncreative paucity of worthwhile ideasnonpersistent tired listless skimpy responses exhaustedresigned inconsistent sporadic effortsvaried with task Summary Statements The client showed adequate attention span/concentration, with little distractibility, anxiety, or frustration.

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8. Responses to Aspects of the Examination 121RESPONSES TO Ex AMINATIONThe source of distractions were... and the client was successfully able to resist distraction by ... (specify). I observed no significant anxiety that would have interfered with the interview or distorted the client's responses. 8. 3. Response to the Methods of Evaluation/Tests/Questions Comprehension of Instructions/Questions See also Section 8. 4, “Persistence/Motivation,” and Section 8. 1, “Reaction to the Context of the Evaluation. ” (↔ by degree) The following two groupings are sequenced by increasing degree of comprehension. Rarely understood instructions, required much repetition/elaboration, needed to have instruc-tions repeated often, became confused, required restructuring of my questions in a manner to make them more concrete and simplistic, required elaboration of the standard instructions before comprehending the nature of the tasks, required excessive time and repetition to under-stand what was required of him/her. Attentive, understood, good comprehension, quickly grasped problem/demands/goals/point of situation, anticipated the response expected/desired, responded well to the interview's implicit rules of conversation and procedures, was respectful and cooperative. Approach/Attack Strategy (↔ by degree) random indifferent scattered organized rigid haphazard inconsistent coordinated compulsive distracted flippant careless controlled ritualistic guessed at giggled disorganized goal- oriented perseverative answers sloppy active perfectionistic acted without uncoordinated diligent manneristic distrusted own instructions caught on fast ability baffled well ordered tense self-doubting thought aloud nonplussed thought through second-guessed absent-minded before acting plodding self used trial-and-perplexed noted details excessively careful insecure error approach bewildered orderly unsure confused methodical refused to guess/ uninformed deliberate take chances persistent underestimated hurried neat own abilities fast contemplative rapid thoughtful speedy efficient rushed reflective hasty self-examining impulsive agitated Summary Statements The client waited/did not wait for full instructions.

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122 STANDARD TERMS AND STATEMENTS FOR REPORTS RESPONSES TO Ex AMINATIONHe listened attentively to the interviewer's questions. No problems with test directions or instructions. Directions/instructions did not have to be repeated or rephrased/simplified. Only repetition/slowed presentation, not simplification, of test directions was required. She was able to follow multistep directions. He responded fully to all tasks' demands. The client was consistent and organized. He organized his ideas before responding to test questions. She stepped back and reviewed behavior when she failed; did not stick with an obviously inef-fective approach. The client worked quickly, with little deliberation. She took a marginal approach to the evaluation, reflective of... mildly/moderately/severely reduced intellectual capacity. poorly developed cognitive/problem attack/problem-solving skills/strategies. generalized undisciplined mental processing. lack of self-evaluation/little concern for the quality of her responses. The client used a random approach on most tasks, showed little comprehension/visualization/ analysis of the overall tasks, little learning from attempts, low planning skills. Client perseverated, in that he had difficulty adjusting and responding appropriately to the next task's demands/instructions. There was no change in her approach toward the more difficult items. She used avoidance techniques in the examination, such as dropping test materials, starting conversations between tasks/subtests, attending to sounds in the hallway, asking repeated questions regarding the test materials and procedures, wandering off task, etc. He gave impulsive responses with poor organization and planning skills, without forethought, minimal reflection/consideration before answering, before the instructions were com-pleted. She was apparently satisfied with/unaware of poor-quality performance/failure. 8. 4. Persistence/Motivation (↔ by degree) The following groupings are sequenced by increasing degree of involvement in tasks. Refused test items/subtests/questions, withdrew, showed irritation/anger, complained. Only brief responses, had to be prompted to elaborate, gave up on easy items, sought to terminate interview, quit quickly, gave up easily, “defeatist,” terminated responding after minimal effort, performed halfheartedly, showed minimal compliance, responded slowly/gave purposefully erroneous responses as a form of resistance. Variable level of interest/motivation, slowed/varying reaction time to questions, hesitant, sustained effort only for time period, often discouraged, low frustration tolerance, preferred only easy tasks, little tolerance for ambiguity, initially refused to attempt tasks but upon re-presentation later was cooperative, no motivation to succeed with difficult tasks/perform well for the examiner, became frustrated and wanted to give up when the test materials became necessarily too difficult, took breaks and recovered willingness to continue, began to lose interest in the evaluation tasks and in conversing with the examiner after time, offered only perfunc-tory cooperation. Average perseverance and effort were demonstrated, only rarely discouraged or inattentive, completed all tasks fully and competently, work- oriented, applied her-/

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8. Responses to Aspects of the Examination 123RESPONSES TO Ex AMINATIONhimself to the tasks presented, was cooperative and put forth best effort on each evaluation task administered, willingly/eagerly attempted each task presented, participated well and fully in the evaluation process, demonstrated serious efforts to respond to tasks' demands, became quite involved in the tasks, changed tasks appropriately. Eager to continue, challenged by difficult tasks, concentrated on one task for a long time, finished every task, distracted only by extreme circumstances, sus-tained effort, persisted, diligent, systematic, conscientious, wanted to do well, evaluation seemed to be challenging to him/her. 8. 5. Relationship with the Examiner Cooperation/Positive Behaviors (↔ by degree) pleasant cooperative dependent indifferent seductive affable helpful institutionalized noncommittal plaintive friendly easy to agreeableness nonchalant help-seeking familiar interview docile blasé bartered eager neutral affection chummy enjoyed deferential minimal wanted to please outgoing interview ingratiating cooperation practical joker socially graceful responded with-trying to please careless clowned around amiable out hesitation eager to please responsive accommodating submissive exhibitionistic answered readily passive tactful obliging effusive spooky cordial agreeable obsequious solicitous amicable pleading curt warm conciliatory oversolicitous monosyllabic compliant legalistic genial civil obedient passive-joked around polite aggressive breezy courteous oily “sassy” playful well-mannered fawning flippant easy flattering “upbeat” spontaneous engageable eulogistic inoffensive available apple-polishing “laid-back” open deferential low-key humble “mellow” frank overpolite placid forthright overapologetic candid mealy-mouthed confiding Resistance/Negative Behaviors (↔ by degree) See also Section 10. 2, “Anger. ” guarded surly resentful demanding hostile argumentative belligerentreserved sulky subtle imposing irritating territorial insultingreticent petulant hostility insistent instigating possessive defiant recalcitrant balky uncoop-erativeindignant obnoxious antagonistic obstreper-ous resistive touchy confrontative tested limits contentious

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124 STANDARD TERMS AND STATEMENTS FOR REPORTS RESPONSES TO Ex AMINATIONreluctant pouty “sick and presump-tuousrebellious oppositional scolding peevish tired” had an inaccessible sullen defensive “attitude” manipulative name- calling distant brooding noncom-pliantfrustrated bristled when questionedprovocative remote crabby complaining quibbled vilifying evasive testy refused domineering questioned slandering wary gruff rude superior hypercritical menacing withdraws snappish nagging condescend-ingirascible intimidating withholding quarrelsome venomous avoidant grouchy stubborn pitying challenging threatening not forth-irritated mulish nasty coming bored intractable aloof abusive malicious tight-lipped scowled unbending disdainful derisive caustic “snippy” unyielding egocentric scornful loathing suspicious unadaptable entitled overbearing cagey childish rigid cocky arrogant sneaky immature adamant contemp-tuoussarcastic obtuse carping overcon-inflexible supercilious berating trolled negativistic toyed with derogatory businesslike abrasive examiner mocking stiff opinionated “know-it-all” taunting unfriendly willful smart-alecky sneering desultory contrary cantankerous facetious habit-bound pushy “chutzpah” teasing only perfunctory/ superficial cooperation“brassy” sarcastic smug quips demeaning For a Child: “Mouthy,” “mouthed off,” “sassed,” talked back, mimicked examiner's speech, noncompliant, threw things, hit. Summary Statements about Rapport See also Chapter 9, “Presentation of Self,” and Section 4. 6, “Reliability/Validity Statements. ” Client appeared relaxed and comfortable with the interview process/shared thoughts without hesitation/gave responses that appeared genuine and thoughtful. Rapport was easily/intermittently/never established and maintained. Response to authority was cooperative/respectful/appropriate/productive/indifferent/hostile/ challenging/undermining/unproductive/noncompliant/contemptuous. The client required/allowed another to answer none/some/all of the questions posed. She seemed to enjoy the attention received. I could easily understand his/her meanings. I found it hard to like/feel for this person. Summary Statements about Cooperation The client made every effort to be cooperative and maintained a cordial attitude toward the examiner. She put forth good effort to collaborate in the evaluation. He was aware of the social norms and was able to conform to them.

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8. Responses to Aspects of the Examination 125RESPONSES TO Ex AMINATIONClient was cooperative within limits; she refused some test items/tests/topics. He was fully cooperative with the examination only after determining my credentials. Client would not accept direction from people in authority. She repeatedly/irrelevantly/provocatively interrupted the interviewer. He talked over me/interrupted, made efforts to control the interview. She was equally unresponsive to an empathic tone, matter-of-fact interviewing style, confron-tation about her hostility/lack of cooperation/self-defeating behaviors, etc. Client showed inappropriate forwardness toward male/female staff. The testing/questions/history taking/examination was particularly trying for this client. Eye Contact See “Eye Contact/Gaze” under Section 7. 3, “Movement/Activity. ” 8. 6. Response to Success/Failure/Feedback The items in this section describe the client's responses to his/her performance and to the evalua-tor's reaction; they also describe self-awareness/self-monitoring/self-criticism. (See also Section 8. 5, “Relationship with the Examiner. ”) (↔ by degree) The following groupings are sequenced by increasing degree of responsiveness. Oblivious to failure, no response to either success or failure, unaware of/unconcerned about/ failed to recognize errors, unaware of the low level at which he/she performed, low self-monitoring/error correction skills, accepted own inferior performance, satisfied with inad-equate work, minimal concern and care about doing well on evaluations, indifferent, hypo-critical, inappropriately overconfident, examiner's questions/suggestions/hints didn't improve performance, gave up easily. Flustered, embarrassed, ashamed, chagrined, apologetic, self-reproached, self-derogated, feelings easily hurt, reluctant to expose weaknesses, rationalized failures, extremely critical of own work/hypercritical, disparaged own performance, not satisfied with less than per-fection, vulnerable to humiliation, loath to say he/she didn't know so clammed up instead, discouraged/dejected/very angry at failure, attempted to cheat or compromise. Tensed, grimaced, tense breathing, nervous cough, bit nails, cleared throat, looked around, asked to go to the bathroom/to go home/if the session were over. Normal responsiveness and coping with failure, tried his/her best, surprised at failure, accepted mistakes with regret, accepted need to go on despite failure/mistake/incorrect answers, confident, calm, understood easily, adapted, modulated, good balance of self-criticism and self-confidence, self-sufficient, learned from errors/experience, accepted own limitations so failure had little effect. Self-congratulatory, sought help appropriately, proud, took pride in accomplish-ments, delighted with success, persisted, worked harder, self-monitored, sought errors in own work and self-corrected, gave up only on items clearly beyond ability, refused to concede defeat, wasn't discouraged by errors, was easily moti-vated by “Try again,” redoubled efforts when faced with increased difficulty/ challenged. Summary Statements The client required/did well with/ignored no/usual/copious praise. Needed frequent/constant reinforcement/encouragement/reassurance/praise/commendation for continued performance.

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126 STANDARD TERMS AND STATEMENTS FOR REPORTS RESPONSES TO Ex AMINATIONResponded to help with distrust/indifference/gratitude, rejected it with indignation/thanks/ learned and altered own approach. The client was not so skillful as he thought. Her perception of her status and abilities was somewhat inflated. Efforts at compensation through (e. g., a pedantic style) created a negative impres-sion of which he was apparently unaware. The evaluation setting, which was generally empathic, reinforcing, and accepting of the client's behavior, proved to be... (specify).

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127 9 Presentation of Self This chapter covers the client's self-presentation to the evaluator, as seen by the evaluator. These behaviors can also be seen as interpersonal skill and impression management. Many of the descriptors in this chapter are inferences and judgments about a client, and not objec-tive assessments. They should be used sparingly and only when well supported by information from multiple sources and repetitions over time and places. 9. 1. Dependency-Surgency See also Section 9. 3 below, as well as Sections 13. 13, “Dependent Personality,” and 13. 17, “Narcissistic Personality. ” (↔ by degree) “Spineless,” meek, a follower, servile, dependent, clinging, whining/whiny, tenta-tive, docile, defers/deferential, inoffensive, passive, yielding, acquiescent, amenable, “wishy-washy,” lacking in self-sufficiency, socially immature, compliant, assenting, consenting, cooperative, <normal>, self-confident, spunky, forceful, overbearing, pushy, self-centered, demanding, dominant, masterful, high-handed, autocratic, dictatorial, blustery, pugnacious. 9. 2. Presence/Style (↔ by degree) See also Section 8. 5, “Relationship with the Examiner. ” withdrawn threatened shy friendly autonomous isolating distrustful timid inviting direct estranged fearful bashful jocular self-assured distant anxious demure warm dominant suspicious distraught passive outgoing surgent guarded reserved jolly businesslike asocial vulnerable retiring extraverted assertive introverted weak humble chipper solitary delicate subdued animated stubborn seclusive would crumble reticent engaging insistent detached fragile introverted charming aloof low resilience restrained eccentric dejected threat-sensitive composed bizarre placid dramatic mild-mannered unassuming plaintive PRESENTATION OF SELF

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128 STANDARD TERMS AND STATEMENTS FOR REPORTS PRESENTATION OF SELF9. 3. Self-Image/Self-Esteem The concepts of self-image/self- esteem include components/functions relating to the interior self and ones relating to the social self. Aspects of the interior self include the following: Self-concept, identity, ego boundaries. Self-perception, self-consciousness, self-assessment, self-evaluation, self-monitoring, self- disclosure. Self-determination, self-management, self-control, self-direction, self-efficacy, self- reinforcement. Self-differentiation, self-discovery, self-knowledge, self-realization, self-actualization. And aspects of the social self include the following: Age and gender roles, gender identity, sexual identity. Body image, appearance, body ego, boundaries, personal space, personal property. Other aspects of the self in relation to others (self as child, parent, spouse/partner, friend, worker, etc. ). Be alert for the client's manifestations of these aspects. In particular, watch for evidence of self-defeating/self-destructive behaviors, such as suicidal ideation/attempts (see Section 12. 40, “Suicide”), self-injury (see Section 12. 33, “Self-I njurious Behavior”), and high-risk activities (specific coverage of these is provided in many other sections of this book). The following are descriptors that apply to a few particular components of self-image/self-esteem. Confidence Levels Expressed an exaggerated opinion of him-/herself, believes he/she is exceptionally capable despite evidence to the contrary, grandiose, self-exalting, boastful, vain, has “chutzpah,” cocky, pompous, conceited. (↔ by degree) Confident, accepting, congruent, self-respecting, modest, unassuming, humble, self-doubting, unrealistic, inadequate, pessimistic, self-deprecatory, self-accusing, self- abasing, described self as “a loser”/untalented/failure/misfit/unworthy. Goals for Self Hopeful, optimistic, eager, anticipates improvement, proactive, high aspirations, future orien-tation. Has plans, plans are clear/comprehensive/realistic, has alternative approaches/backups. Plans are vague/unrealistic/poorly thought out, below reasonable expectations, pessimistic. (↔ by degree) Describes life as stagnant/unraveling, presents self as a victim of her/his life, has no apparent interest in improving/motivation to improve her/his lot in life, is at least aware that improvements could be made, is willing to try to work on problems, is strongly motivated for change. Pride (↔ by degree) Dignity, good self-respect/esteem/regard/image, confidence, self-righteousness, vanity, ego, puts on airs, arrogance, conceit, condescension, narcissism, paints the consequences of his/her actions in a very rosy color. 9. 4. Social Sophistication/Manners Sophistication (↔ by degree) The following groupings are arranged by increasing degree of sophistication.

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9. Presentation of Self 129PRESENTATION OF SELFNaive, unsophisticated, gullible, overly trusting, wide-eyed, suggestible, “Pollyanna”-like, unschooled, backward, inept, culturally unsophisticated, medically/psychologically naive, naive attempts at manipulation, guileless, overused “Yes, Ma'am/Sir” and “No, Ma'am/Sir. ” Immature, socially inept/unskilled, awkward, graceless, limited ability to interact, “nerdy,” simple, simplistic, self-conscious, giddy, flighty. Sophisticated, socially skilled, cultured, articulate, able to lobby/defend her/his inter-ests, “street-smart. ” Opportunistic, callous, predatory, indignant, righteous, “innocent”/blames others, denies, irresponsible, “finesses,” seductive, manipulative, Machiavellian, socio-pathic. Manners (↔ by degree) Polite, well-behaved, mannerly, graceful, poised, tactful, gracious, knows etiquette's rules, care-less, thoughtless, blunt, pointed, tactless, offered outspoken criticisms, provocative, abra-sive, offensive, vulgar, rude. 9. 5. Warmth-Coldness See Section 8. 5, “Relationship with the Examiner. ” (↔ by degree) The following groupings are arranged by degree of decreasing warmth. Overindulgent, soft-hearted, doting, overly affectionate, sweet, saccharine, oily, phony. Responsive, warm-hearted, sympathetic, considerate, compassionate, intimate, gentle, ten-der, yielding, solicitous, thoughtful, fond, loving, benevolent, charitable, humane, forgiv-ing, merciful, tolerant, devoted. Friendly, affable, kindly, genteel, outgoing, convivial, companionable. Reticent, taciturn, subdued, shy, inhibited, restrained, reluctant, aloof, uninter-ested, tough, remote, distant, cold, detached, indifferent, unresponsive. Uncharitable, unfeeling, cold, callous, harsh, rough, severe, forbidding. 9. 6. Other Aspects of Self-Presentation Self-Containment/Rigidity See Section 13. 8, “Authoritarian Personality. ” Self-contained and in good charge of him-/herself, reserved, collected, matter of fact, static, mechanical, stereotyped, compulsive about neatness/order/planning, rigid, expressionless, stoic toward his/her illness/limitations. Prim and proper, straight-laced, prudish, dour, austere, prissy, “stuffed shirt,” self-righteous, puritanical, pious, sanctimonious, overreligious. Childishness Childish, immature, juvenile, silly, excessively attention-seeking, needy, pleading, begging, coaxing, manner suggestive of a much younger person/suggestive of a person much younger emotionally than physically, preoccupied with irrelevancies, feelings are easily hurt, easily upset. The client seems to be suggestible to the whims and commands of his peers, who victimize him/expose him to ridicule.

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130 STANDARD TERMS AND STATEMENTS FOR REPORTS PRESENTATION OF SELFShe tempts peers to take her money/books/possessions so that an adult/another will intervene on her behalf. He is often teased/taunted/bullied/harassed/insulted/humiliated/tortured. Dullness/Inattention Dull, “airhead,” vapid, bland, insipid, inattentive, forgetful, wistful, preoccupied, mind else-where, “space cadet,” “spacey,” “zombie-like,” “burned out. ” Worry/Anxiety See “Cognitive Facets” in Section 10. 3, “Anxiety/Fear. ” Worrisome, a “worry wart” or excessive worrier, easily threatened, feels inept, manifested anxi-ety throughout the interview around every topic. Flamboyance/Histrionics See also Section 13. 15, “Histrionic Personality. ” Flamboyant, exaggerated, dramatic, melodramatic, theatrical, overdone, affected, artificial, thespian, histrionic, vivacious, bubbly, volatile, labile. Seductive, oversexualized, saucy, coy, titillating, suggestive, flirtatious, excessively girlish/boy-ish. Responds to the interviewer's innocuous questions with dramatized surprise/as if they had high emotional import. A “character,” individualistic, idiosyncratic, “marches to her/his own drummer,” unusual ways of perceiving/behaving, eccentric, “oddball,” does not fit in, outlandish, strange, odd, pecu-liar, bizarre, weird. Antisocial Features See also Section 13. 7, “Antisocial Personality. ” Arrogant, bragging, cocky, disdainful, tended to praise self excessively, cavalier, limited empathy, assumed/maintained an attitude of tolerant amusement, has a rapid-fire/smooth-talking style. Swaggering in order to impress interviewer with youthfulness/energy/toughness, “has a chip on his/her shoulder,” uses embellishments to appear as a “bad actor” or powerful and dan-gerous person (e. g., uses vulgarity to shock, presents as a “tough cookie”) or as possessing a high potential/many friends/social power/etc. Menacing, frightening, imposing, intimidating, manipulating, “spooky,” vaguely but intensely frightening, enjoys sadistic humor/is prankish. Intellectualization Intellectualizes all experiences, provides psychological jargon/“psychobabble”/labels when asked for descriptions of behaviors/symptoms, “reports” feelings. Sense of Victimization A “victim,” recites life as a series of mishaps, melodramatically enumerates life's misfortunes, made a saga of his/her life in the telling, offered a woeful tirade/jeremiad of woes/baleful stories/“Oliver Twist”-like story, presented self as a “born loser”/perpetual victim/outcast. Presented self as frail and inadequate person of whom one should not expect much. Guilt/Shame See also Section 10. 8, “Guilt/Shame. ” Apologetic, described failures/mistakes/harm, apologized indirectly/simply/fully/appropriately/ effusively. Embarrassed, ashamed, self-blaming, self-reproaching, guilty, “worthless,” became apprehen-sive when talking of behavior she/he now realizes was inappropriate.

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9. Presentation of Self 131PRESENTATION OF SELFOff-Task Behaviors Clock-watched. Repeatedly asked when we would be finished. Offered/desired inappropriate bodily contacts. Focused on examiner's office/speech/clothing/manner/role/appearance rather than the content of his/her/examiner's speech or the point of the interview. Other Statements There are no obvious behavioral stigmata that would set this client apart from other individuals of his age, social, or cultural group. Her responses reflect wishful thinking rather than realistic plans. He is dependent on institutional support and content to be hospitalized/taken care of. Client put up a good front to cover... (specify). She made sure to tell me what she thought I should hear and know, and then it seemed that she felt satisfied. He had his story to tell and went on without any assistance from me. Client describes (symptoms) that she labels as (behaviors). For a Child: Child is pseudomature, uncommonly independent. Child exhibits primitive, socially inappropriate, nonaggressive behavior. Speech and Verbal Interactions See Sections 7. 4, “Speech Behavior,” and 8. 5, “Relationship with the Examiner. ”

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13210 Emotional/Affective Symptoms and Disorders 10. 1. General Aspects of Mood and Affects See Section 3. 5, “Affect/Mood,” for questions. “Mood” refers to pervasive and sustained emotional coloring of one's experience, a persistent emo-tional trend (like the climate). It is usually self-reported (but is sometimes inferred). “Affect” is of shorter duration, such as what the clinician observes during the interview, and is more variable and reactive (like the weather) to the subjects discussed. Note and document any differences between the two during the interview. Give quotes/self- reports/verbatim descriptions of mood/affect/emotion. In addition, note or report the following: Behavior reflecting emotional state: See sections on individual emotions below. In general, note tears, flushing, movements (tremor, etc. ), respiratory changes and irregularities, voice changes, facial expression and coloring, wording, somatic expression of affects through... (specify). Nature/source: Is the emotion reactive, endogenous, exogenous, characterological, lifelong?Degree: Is the client mildly, moderately, severely, or profoundly depressed (for example)? Amount/Responsiveness/Range of Affect (↔ by degree)1 flat blunted constricted normal broad affectless apathetic contained usual deep bland inexpressive low-intensity average intense unresponsive unspontaneous shallow responsive generalized vacant stare dispassionate muted normal range pervasive absent detached subdued supple remote unattached “low-key” adequate levels of emotional energy passive-appearing uninvolved restricted expressionless uncomplaining uninflected no/some/great difficulty in initiating, sustaining, or terminating emotional expression unvaryingunchanging 1Consider the possible effects of medications. (See Chapter 29, “Psychiatric Masquerade of Medical Conditions,” especially Sec-tions 29. 4 and 29. 5. )EMOTIONS/ AFFECTS

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10. Emotional/Affective Symptoms and Disorders 133EMOTIONS/ AFFECTSDuration of Mood or Affect Changes (↔ by degree) Mercurial/quicksilver, volatile, affective incontinence, dramatic, transient, unstable, fickle, rapid mood fluctuation, labile, turbulent, plastic, changeable, mood swings, excitable, flex-ible, diurnal/seasonal mood cycles, short cycles (days), long cycles, shifts in tension, mobil-ity of emotional state, appropriate, consistent, showed little/normal/much variation in emotions, frozen, permanent. Appropriateness/Congruence of Affect or Mood and Behavior (↔ by degree) The following groupings are sequenced by degree of increasing appropriateness/ congruence. Inappropriate, incongruent, inconsistency of reported/observed feelings and those expected in the circumstances described. Indifferent to problems, floated over his/her real problems and limitations, l a b e l l e indif-f é r e n c e, showed no/very minimal/much less than expected affect when discussing experi-ences that would normally be accompanied by intense feelings, treated own intense experi-ences too lightly. Affect variable but unpredictable from the topic of conversation, modulations/shifts inconsistent and unrelated to content or affective significance of statements. A range of emotions/feelings, appropriate emotions for the ideational content and circumstances, emotional reactions relevant to the thought content and situ-ation, emotions seemed appropriate during the interview/examination, although depressed he was able to smile at the comic elements of his history. Emotions highly appropriate to/congruent with situation and thought content/subject of discussion, face reflects emotions reported, all thoughts colored by emotional state. Episodes of Mood Disorder Is this an initial/single episode? Or are episodes repetitive, recurrent, irregular, cyclothymic, cyclical, seasonal, annual, anniversary reactions? Is the disorder presently exacerbated, chronic, in full/partial remission? Do recurrent episodes appear to be worsening over time?Does the client have longer/shorter symptom-free periods?Do periods of improvement not produce as much improvement as before? And does medication produce slower/less improvement? Consider drawing a time-by-mood timeline for diagnostic accuracy (see, e. g., the mood charts at www. manicdepressive. org/tools_clinical. html). 10. 2. Anger See also Section 8. 5, “Relationship with the Examiner,” for more behavioral aspects. General Aspects Look for the following: Sources of anger. Intensity and variability. Direction, target. Handling/coping methods, impulse control, anger out/in.

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134 STANDARD TERMS AND STATEMENTS FOR REPORTS EMOTIONS/ AFFECTSSituational/state or personality/trait nature of anger. Guilt over anger. Hostility/Verbal Hostility (↔ by degree) irritated temperamental hostile furious annoyed whining provoked enraged disgruntled piqued embittered incensed cranky “pissed off” exasperated choleric miffed “burned up” indignant displeased “bugged” simmering threatens “snippy” smoldering seething shouts “bothered” ill-tempered infuriated yells restive bad-tempered bristled bellicose insults combative grudging irascible swears assaultive resentful abrasive curses violent sarcastic chronically angry foul-mouthed complaining pugnacious Violence/Aggressive Behaviors See Sections 12. 19, “Impulse-Control Disorders,” and 3. 31, “Violence. ” 10. 3. Anxiety/Fear See Section 3. 6, “Anxiety,” for questions; see also Section 10. 10, “Panic. ” Depression coexists (is “comorbid”) with anxiety in more than half of all cases, and is more com-ü mon than either alone in primary care settings (Rivas-Vasquez et al., 2004), so consider both diagnoses. Autonomic Nervous System/Somatic Hyperactivity/Overarousal Facets pallor or flushing Shortness Of Breath dizziness clamminess heart palpitations difficulty breathing vertigo sweaty palms racing heartbeat/ chest pain/tightness room spinning cold sweats/chills tachycardia choking/smothering light-headedness excessive perspiration fast and deep faintness sweaty forehead diarrhea respiration syncope dry mouth urgent urination air hunger “wobbly” stomach hyperventilation “wobbly knees” piloerection/ “butterflies” sneezing “goose bumps” stomach churned yawning overall weakness queasiness sighing unsteadiness hot flashes nauseadry heaves tingling paresthesias “lump in throat” numbness Fight-or-flight response/arousal: Any of the above, plus more acute hearing, spleen contracts, peripheral blood vessels dilate, bronchioles widen, pupils dilate, more coagulates and lym-phocytes in blood, adrenaline secreted, stomach acid production decreases, loss of bladder/anal sphincter control, decreased salivation, etc.

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10. Emotional/Affective Symptoms and Disorders 135EMOTIONS/ AFFECTSBehavioral Facets Motor Tension Agitation, trembling, tightness, twitching, fidgets, feeling shaky, tremulous, body swaying, rigid posture, stiff neck/back/muscles, muscle aches, sits on edge of chair, inhibited movements, restlessness, easy fatigability. “Nervous Habits” (↔ by degree) self-grooming can't sit still hair twirling panicked scratching leg/arm swinging combing fingers rushed out nail biting rocking through hair vomited pacing hair pulling fainted repetitive move-stretching ments body swaying facial expressions fretful tapping of fear muscle tension fidgeting worried look wringing hands tense face clutching hands hands restrained/ flashes of smilesyawning/sighing in pockets tears/crying self-hugging rigid arms wide-eyed shuffles feet brow grooves moistens lips “deadpan”coughing avoids eye contact swallowingclears throatheavy breathing Speech/Voice See also Section 7. 4, “Speech Behavior. ” Strained, quavery, tremor, stuttering, voice cracks, uncompleted/disconnected sentences. Inappropriate/”nervous” laughter/smiling, titters, giggles. Vigilance and Scanning Easily startled, jumpy, oversensitive to stimuli, overreactive. Lessened concentration, erratic, mind goes blank, unable to proceed, unable to function, immo-bilized, freezes. Difficulty falling asleep or staying asleep, mind racing. Affective Facets (↔ by degree) imperturbable calm “nervous” fearful terrified stolid phlegmatic uneasy apprehensive horrified inhibited steady harried frightened rigid unemotional irritable alarmed frozen stable vulnerable distraught petrified composed fragile paralyzed nonchalant tense “on edge” “cool” edgy frazzled panicky confident unable to relax flighty panic attacks s a n g f r o i d “uptight” distressed jittery

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136 STANDARD TERMS AND STATEMENTS FOR REPORTS EMOTIONS/ AFFECTSCognitive Facets “A worrier,” “a worry wart,” apprehensive, worrisome, fretful, ruminates, thoughts of impend-ing doom, exaggeration of the objective danger, anticipates dreadful occurrences/doom/ catastrophe, “my world is caving in”/“getting out of hand,” feels threatened by people or events commonly seen as of little or no concern, upset by fantasies/imagined scenarios/crit-icisms/attacks/hurts, dread, desire to escape, fear of losing control/dying/being attacked/losing consciousness/going crazy/being rejected or abandoned. Baffled, confused, jumbled thoughts, blurred thoughts, perplexed, lessened concentration, unable to recall/indecisive, forgetful, preoccupied, many errors, diminished initiative/pro-ductivity/creativity. Depersonalization, derealization, preoccupied with bodily sensations, “fluttery,” “quavery. ” (See Section 12. 12, “Depersonalization and Derealization,” for descriptors. ) Overwhelmed/can't manage/can't get control/can't control thoughts, high internal tension, feels inept/nervous, can't handle stress/pressure/demands, “feels like I'll explode/my heart will burst through my chest,” vulnerable, low self-confidence/efficacy, insecure. No depth of feeling when recounting events, erratic, guardedness, rigidity, confuses self, self- induced pressures, jumps from one subject/topic to another, low frustration tolerance, low stress tolerance, low tolerance for ambiguity. For a Child: Fears of animals, ghosts, demons, “the bogeyman,” darkness, getting lost, parental illness/dis-ability/death/loss, punishment, being embarrassed/humiliated, separation anxiety. Interpersonal Facets See also Chapter 9, “Presentation of Self. ” Thin-skinned, easily threatened/aroused to anxiousness, insecure, vulnerable, oversensitive, self-conscious, timid, timorous, uncertain what to say/how to act, dependent, clinging. Avoids eye contact, withdraws, reduced involvement. Hypercritical, self-deprecation. Blames others, impulsive/acts out. Ill at ease, uneasy, social anxiety. 10. 4. Bipolar I Disorder The ICD-9-CM and DSM-IV-TR codes for Bipolar I Disorder are various 296. xx codes. (See Section 21. 5, “Mood Disorders. ”) Because of the presence of both depressive and manic components in different intensities, mixtures, and sequences, see Sections 10. 7, “Depression,” and 10. 9, “Mania,” for descriptors. 10. 5. Bipolar II Disorder The DSM-IV-TR code for Bipolar II Disorder is 296. 89. The same code is used for Other and unspecified bipolar disorders: Other (which includes Bipolar II as a “Note”) in ICD-9-CM. The cardinal features are chronic mood instability and at least one major depressive episode with at least one episode of hypomania (but not full mania, as in Bipolar I). Hypomanic episodes may be missed without a complete family and individual history, which also helps to distinguish Bipolar II from personality disorders, anxiety disorders, unipolar depression, and Bipolar I. The diagnosis

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10. Emotional/Affective Symptoms and Disorders 137EMOTIONS/ AFFECTSmay be hidden by substance abuse (60% of individuals with Bipolar II have substance use disorders as well), and the suicide risk may be higher in Bipolar II than in Bipolar I. 10. 6. Cyclothymia In both ICD-9-CM and DSM-IV-TR, Cyclothymic Disorder is coded as 301. 13. (In ICD-9-CM, how-ever, it is classified as a personality disorder rather than a mood disorder. ) See also Sections 10. 4 and 10. 5, above, and Section 10. 9, below. Cyclothymia runs a biphasic course, milder than Bipolar I or II Disorder, alternating between hypo-manic and depressive symptom patterns. 10. 7. Depression See Section 3. 11, “Depression,” for questions. See also Sections 10. 11, “Seasonal Affective Disorder,” and 12. 28, “Pre Menstrual Dysphoric Disorder. ” Affective Facets Anhedonia See also Section 10. 1, “General Aspects of Mood and Affects. ” Absence of pleasure, loss of pleasure in living, “nothing tastes good any more,” joylessness, lack of satisfaction in previously valued activities/hobbies, loss of interests, no desire/motiva-tion/energy to do anything, no fun in his/her life, indifference, “couldn't care less,” apa-thy, boredom, lowered/no desires, nothing good to look forward to in life, indifference to praise/reward, emotional impoverishment, drabness, colorless, coldness, emptiness, “life is a chore,” “just marking time. ” Dysphoria (↔ by degree) wretched melancholy sad moody inconsolable despondent blue plaintive anguished dejected somber pessimistic suffering sorrowful gloomy miserable forlorn beaten down desperate bitter glum pathetic dysphoric tearful in pain morose distraught funereal cheerless suicidal despairing dour self-destructive grave disconsolate profoundly sad dismayed woeful downcast profoundly unhappy down in the dumpsmorbid “down” doleful “wiped out” sour troubled cynical dispirited“bummed out”downhearted

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138 STANDARD TERMS AND STATEMENTS FOR REPORTS EMOTIONS/ AFFECTSThoughts of Suicide See Section 3. 30, “Suicide and Self-Destructive Behavior,” for questions; see Section 12. 40, “Suicide,” for descriptors. Behavioral Facets Included here are the vegetative signs/physical malfunctioning. Sleep Patterns See Section 12. 37, “Sleep Disturbances,” for descriptors. Eating Appetite/hunger increase or decrease, anorexia, fewer/more frequent meals, fasting, selective hungers, “comfort foods,” binges, weight increase/decrease. Energy Anergic, lowered energy, slowed down, listless, sluggish, “needs to be pushed to get things done,” “everything is an effort,” easy fatigue, tired, feels “run down,” mopes, muddles through, weakened, lethargic, deenergized, torpid, lassitude, “can't shake off the blues,” “can't get out of bed,” energy is just adequate for life's tasks, inability to cope with routine responsibilities, weary, drained, exhausted. Psychomotor Retardation/Acceleration See also Section 7. 3, “Movement/Activity. ” Absence of/lessened spontaneous verbal/motor/emotional expressiveness, long response time to questions [indicate number of seconds], thoughts slowing/laborious/impoverished/rac-ing. Libido See Section 10. 12, “Sexuality,” for descriptors. Remember that libido is sexual interest, not activity. ü Lessened/no interest, indifferent, passive, “I'd like to but it is too much trouble,” “I can take it or leave it,” “My partner wants to but I don't care. ” Bowel/Bladder Habit Changes Increased frequency of urination, diarrhea/constipation, overconcern with elimination, chron ic use or abuse of laxatives, sensations of abdominal distention or incomplete evacuation of bowels. Substance Use Overuse of prescription and over-the-counter medications (analgesics, laxatives, sleeping aids, vitamins), alcohol, caffeine, stimulant drugs. Appearance/Presentation See also Section 7. 1, “Appearance. ” Sad/fixed/expressionless/unsmiling/downcast face, scowl, downward gaze, distracted look, glum, blank stare, furrowed brow, smiled without warmth, “smiling depression. ” (↔ by degree) Close to tears/tearful/teary, tears well up, weepy/weeps, cries, cries openly/fully, blubbers, sobs. Dissipated, worn, drained, “a shell of a person,” haphazard self-care, self-neglect. Wrings hands, rubs forehead, shuffling gait. Little inflection, flat/expressionless/monotonous voice. Audible sighs, moans.

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10. Emotional/Affective Symptoms and Disorders 139EMOTIONS/ AFFECTSSummary Statements All appetites are muted. Client has persistent physical symptoms that do not respond to medical treatment. [Note espe-cially headaches, digestive disorders, and chronic and migratory pains. ] Cognitive Facets Caring/Energy Investment (↔ by degree) hopeless pessimistic cold bored helpless suspicious unconcerned indifferent unchangeable disappointed stoic unspontaneous drained disillusioned phlegmatic apathetic defeated cynical ennui matter-of-fact futile discouraged weary negative demoralized humorless bleak disenchanted malaise feeling lost defeatist {w e lt s c h m e r z } dreary repetition/urging nihilistic needed meaninglessness exhausted No plans for self, no future, nothing to look forward to in life, only an empty repetition of meaningless actions, loss of ambition, no goals/plans, resigned, futureless, no anticipa-tion. Mental Dullness Inadequate, unable to cope, empty, exhausted. Slowed, ruminative, mulls over, indecisive, decreased concentration, trouble mobilizing thoughts, abulia. Confused, perplexed, “I'm not mentally here,” worsened memory, spotty memory, vague, unclear. Excessive worrying, worrisome, frustrated. Self-Criticalness/Brooding (↔ by degree) See also Section 10. 8, “Guilt/Shame. ” self-doubting sorry self-pitying self-distrusting regretful “poor me” self-deprecating chagrined “ruined/wasted life” low self-esteem embarrassed “my life is over” ashamed bitter self-blaming humiliated sarcastic/ironic self-critical suppressed rage self-reproaching vulnerable self-condemning fault-finding threat-sensitive self-hating criticism-sensitive self-abusing “inept” rejection-sensitive caustic “ineffectual” overawed “a misfit” “unproductive” cowed “of no value” “inadequate” intimidated “a failure” “inferior” overwhelmed “a loser” “a piece of shit”

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140 STANDARD TERMS AND STATEMENTS FOR REPORTS EMOTIONS/ AFFECTSDysfunctional Cognitions Clinicians such as Beck et al. (1979), Burns (1999), and Ellis and Dryden (1997) have described the following types of dysfunctional cognitions in the depressed: Arbitrary inference: Drawing a negative conclusion not supported by the evidence. Dichotomous thinking: Oversimplifying; black or white, good or bad, right or wrong, all or nothing. Mind reading: Assuming one knows the other's thoughts (usually negative). Magnification or minimization: Loss of proportion; exaggerating or minimizing the impor-tance of an event. Overgeneralizing: Basing a general conclusion on too few data or one incident; jumping to conclusions, “always” or “never. ” Personalization: Relating negative events to oneself without an empirical or rational basis. Selective abstraction: Attending to only the negative aspect(s) of a situation and ignoring the other (positive) ones; mental filter; selective attention; disqualifying the positive. Catastrophizing: Automatically assuming that the worst-case scenario will occur. Telescoping of time and options so that a single, final, negative outcome is seen as inevi-table. Emotional reasoning: “Because I feel afraid, there must be danger. ”“Fortune teller” error: Overprediction; the future will be repetitions of the past. “Shoulding” on oneself or others; “should” statements. “Musterbation. ” Summary Statements Client demonstrated Aaron Beck's (Beck et al., 1979) depressive triad of negative views of the self, world, and future. Cyclic negative thought processes/dysfunctional cognitions were revealed. Client's attributions are negative, stable/unstable, global/specific/situational, internal/exter-nal. She/he dwelled on past failures, lost opportunities, what could never be, roads not taken, etc. Alexithymia was evident. He/she appeared to be feigning good spirits. Social Facets Interpersonal reclusive avoidant envious irritable strained inaccessible distances resentful low frustration relationships asocial self-absorbed argumentative tolerance dependent withdraws bitter passive barricades self low social feels scorned demanding unassertive away interest feels abandoned crabby isolates subdued easily irritated wary hermit-like painfully shy easily annoyed distrustful secludes separates from life/others petulant suspicious only watches self-righteous less interactive Support- Seeking See also Section 9. 1, “Dependency-Surgency. ” Complains of life's unfairness, gossips, gripes, futilely indignant, sympathy-seeking, whiny, self-pitying, manipulative, emotionally hungry, seeks support only when in crisis, finds others always inadequately supportive or sympathetic.

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10. Emotional/Affective Symptoms and Disorders 141EMOTIONS/ AFFECTSOther Facets of Depression Bear the following possibilities in mind: Is client depressed because forced into dependency by disability/losses/injury? Does client interpret deaths as desertions, yet is simply alone because she/he has outlived oth-ers? Is depression worse during winter? (See Section 10. 11, “Seasonal Affective Disorder. ”)Is client self-defeating, self-victimizing? (See Section 13. 26, “Self-Defeating Personality. ”) Are there diurnal mood variations? Are depression's symptoms worse in the morning and lessen as day wears on? Is there day-night reversal of activities? Depression in Children (5-15 y ears) Note: ü Children under 7 are usually unable to characterize internal mood states. Most symptoms are similar in children and adults, but some listed below are slightly different or in addition to adult ones. Scales for depression in children include the Children's Depression Inventory (Kovacs, 1992) for ages 7-17 years, and the Children's Depression Rating Scale—Revised for ages 6-12 years. Cognitions: Catastrophizing, assumption of personal responsibility for negative outcomes. Lack of interest in playing/favorite activities, isolation, agitation, despair, hypersensibility, insecurity, boredom, temper tantrums, fugues, feelings of inferiority, nihilistic thoughts, suicidal impulses, obsessive thoughts, loneliness. Irritability, difficulty getting out of bed in morning. School problems: Learning difficulties, school refusal/“phobia,” dyslexia, concentration diffi-culties. Vegetative symptoms: Fatigue, anergia, sleep disorders/terrors, appetite changes (very com-mon at different ages), weeping, abdominal pains, alopecia aureata, tics, eczema, allergies, anorexia, bulimia. Other: Fears of parents' dying, clinging, isolation in room, aggression, substance abuse. Grief/Bereavement Normal Grief Distress, sorrow, anguish, despair, heartache, pain, woe, suffering, affliction, troubles. Preoccupied with loss/loved one/consequences/memories, poignant. Easily made/becomes tearful, slowed thinking and responding with long latencies of response, stares into space. Feels helpless/vulnerable/useless/lowered self-esteem. Kübler-Ross (1969) identified five stages of the normal reaction to loss: denial, anger, bargaining, depression, and acceptance. Unresolved/Morbid/Pathological Grief Partial denial of death, absence of grieving, pathological identification, hypochondriasis, chronic depression, bitterness, chronic grieving, avoidance of cues to the deceased, isolation, reat-tachment. Decreased immune system functioning, increased use of drugs and alcohol, depression, over-/ misuse of medical care for grief. Suicide See Sections 3. 30, “Suicide and Self-Destructive Behavior,” for questions, and 12. 40, “Suicide,” for descriptors.

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142 STANDARD TERMS AND STATEMENTS FOR REPORTS EMOTIONS/ AFFECTSEmbarrassment See Section 10. 8, “Guilt/Shame,” just below. 10. 8. Guilt/Shame See also Kohlberg's stages of moral development in Section 19. 3, “Developmental Stages. ” General Descriptors Apologetic, penitent, begging, pleading, repentant, sorry, chagrined, contrite, remorseful, bur-dened. Guilty, responsible, guilt proneness, mortified, self-condemning, self-reproaching, has a puni-tive superego, transgressed superego boundaries, unacceptable impulses, fears of annihila-tion. Embarrassed, humiliated, disgraced, reproached, depreciated, devalued, humbled, wishes to disappear/become invisible, avoids disclosure of flaws, hides inadequacies. Ashamed, feels inferior, fears rejection/abandonment, fails to attain goal/measure up. Guiltless, cold, hardened, cynical, unrepentant, conscienceless, shameless, unscrupulous, para-sitic, incorrigible, predatory. Distinctions between Shame and Guilt The following distinctions are adapted by permission from Potter-Effron (1989). Central trait Shame Guilt Failure Of being, of meeting goals, of whole self. Of doing, of moral self. Primary feelings Inadequate, deficient, worthless, exposed, disgust, disgrace. Bad, wicked, evil, remorseful. Precipitating event Unexpected, possibly trivial event. Actual or contemplated violation of values. Involvement of self Total self-image involvement: “How could I have done that?”Partial self-image involvement: “How could I have done that?” Central fear Of abandonment. Of punishment. Origins Positive identification with parents. Need to control aggressive impulse. Primary defenses Desire to hide (withdrawal), denial, perfectionism, grandiosity, shamelessness. Obsessive thinking, paranoid, intellectualization, seeking excessive punishment. Positive functions Awareness of limits of human condition, discovery of separate self, sense of modesty, identification with community, mastery, autonomy. Sublimation, moral behavior, initiative, reparation. Assessment Tests have been developed by Mosher (1988), Tangney and Dearing (2002), Harder and Greenwald (1999), O'Connor et al. (1997), Rüsch et al. (2007), and others.

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10. Emotional/Affective Symptoms and Disorders 143EMOTIONS/ AFFECTS10. 9. Mania See Section 3. 18, “Mania,” for questions; see also Sections 10. 4, “Bipolar I Disorder,” 10. 5, “Bipolar II Disorder,” and 10. 6, “Cyclothymia. ” Affective Facets (↔ by degree) cheerful high hypomanic exuberant manic ecstatic light-hearted gay happy elated laughing exalted positive laughing silly ebullient binges rapturous bright buoyant giddy euphoric vivid jovial excessively irritability false joy panics intense elevated boisterous anger false elation effervescent rages labile optimistic rapid accelerating unstable self-confident fluctuations course Behavioral Facets (↔ by degree) Unkempt, disheveled, poorly groomed, overdressed, decorated, garish. (↔ by degree) Pressured speech, fast/rapid speaking, rapid-fire speech, hyperverbal, overtalk-ative, overabundant, loud, verbose, rhyming, punning, word play, hyperbole, over pro-ductive, garrulous, tirades, singing. (↔ by degree) Animated periods of hyperactivity/overactivity, paces, gesticulates, restless, speeded up, accelerated, quickened, fast, going fast, cannot be calmed, dancing, racing, frenzied, frenetic, manic, anger, rages, assaultive. Overconfident, exaggerated view of own abilities, starts many activities but does not finish or follow through with most, makes grandiose plans. Insomnia, decreased total sleep time, decreased need for sleep, no acknowledgment of fatigue. Incautious, frivolous, poor social judgment, fearless, engaging in reckless activities (e. g., dan-gerous driving, foolish business investments or impulsive spending), disinhibited activi-ties, increased smoking, telephoning. Cognitive Facets (↔ by degree) See also the speech descriptors under “Behavioral Facets,” above. expansive overproductive flight of ideas loosened delusions exaggeration illogical associations incoherent grandiosity idiosyncratic racing thoughts disjointed bizarre associations thought bom-disorganized little or no ideas of ref- bardment disoriented hallucinatory insight erence disconnected experiences sexual/religious thoughts echolalic limited concen- preoccupa-abrupt topic tration tions changes brief attention rhyming span distractible Social/Interpersonal Facets (↔ by degree) Impatient, intolerant, irritable, annoyed, oversensitive, touchy, insulting, unco-operative, resistive, negativistic, critical, sarcastic, provocative, angry, easy/inappropriate

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144 STANDARD TERMS AND STATEMENTS FOR REPORTS EMOTIONS/ AFFECTSanger, nasty, loud, abusive, crude, foul language, swears, curses, blasphemes, vulgar, bath-room language, obscene. Suspicious, guarded, distrustful, believes that others collude against him/her, asserts that he/ she was tricked into... (specify), denies validity or reality of all criticisms. (↔ by degree) Gregarious, likeable, dramatic, entertaining, pleasant, vivacious, seductive, cracks jokes, prankish, naive, infantile, silly, { w i t z e l s u c h t }. Sexual indiscretions or acting out, sexualize all interactions, greatly increased need for sexual activities, increased sexual drive/interests, hypersexual. Entitled, self-important, grandiose, cocksure, self-confident, “chutzpah. ” Dominating, controlling, boastful, challenging, surgent, conflicts with authority figures, threat-ens. Hypomania Hypomania is a less severe set of symptoms than mania proper, but it is different from joy or normal happiness because of sudden onset, lapses in judgment, and the fact that it is out of proportion to the situation causing the high mood. It and the bipolar disorders of which it is a component are occasional consequences of treating depression with antidepressants. Delusions See Section 12. 10, “Delusions. ” 10. 10. Panic See also Section 10. 3, “Anxiety/Fear. ” The DSM-IV-TR and ICD-9-CM codes for Panic Disorder With and Without Agoraphobia are 300. 21 and 300. 01, respectively. Fear of fear, rapid escalation of anxiety, loss of control over anxiety, intense fear/discomfort. Feelings of impending/near “doom. ”Unexpected/unpredictable/“out of the blue” onset. Fears of loss of control/dying/going crazy/embarrassing oneself/doing something uncontrolled (loss of bladder control, falling down). A cascade of physical symptoms, especially autonomic. 10. 11. Seasonal Affective Disorder Seasonal Affective Disorder can be given the ICD-9-CM code 296. 90 (Unspecified episodic mood disorder) or 296. 99 (Other specified episodic mood disorder). No particular DSM-IV-TR code applies, but the “With Seasonal Pattern” specifier can be added to the appropriate mood disorder diagnosis. SAD can be bipolar or manic, but it presents primarily as depression. A milder form is called “win-ter blues” (Rosenthal, 2005). The symptoms are worse or occur only in the fall/winter. The rate increases from south (1. 4%) to north (9. 7%) of the United States, but is affected by cloud cover and storms. SAD usually begins in a person's 30s; 75-80% of people with SAD are female. Light treatment to the eyes controls sero-tonin levels (10,000 lux for 30 minutes per day, starting before 8 a. m. and in the fall, is common). Symptoms include the following: Lethargy, easy fatigue (especially in the mornings), nonrestorative although prolonged sleep (hypersomnia). Ravenous appetite/weight gain/carbohydrate cravings.

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10. Emotional/Affective Symptoms and Disorders 145EMOTIONS/ AFFECTSWithdrawal from relationships, decreased libido. Inability to concentrate, problems at work, inefficiency. Anxiety and despair. 10. 12. Sexuality See Section 3. 25, “Sexual History,” for questions; see also “Sexual Adjustment” in Section 6. 4, “Adjustment History. ” (↔ by degree) Asexual, celibate, abstinent, apathetic, inhibited, disgusted, ashamed, puritanical, prudish, prim, restrained, passive, hesitant, permissive, romantic, amorous, erotic, sen-sual, assertive, passionate, seductive, overactive, soliciting, compulsive, demanding, lust-ful, lewd, wanton, aggressive, assaultive. Increased or decreased libido/desire, arousal, activity/relations, satisfaction, hypo-/hyper-sexuality. Reluctance to initiate, slowness to respond. Previously inhibited interests. Shame See Section 10. 8, “Guilt/Shame. ” 10. 13. Other Affects/Emotional Reactions Sense of Humor (↔ by degree) Spontaneously humorous, excellent/normal/adequate/diminished/absent sense of humor, humorless, “stuffed shirt,” takes self too seriously. Mirth response is brief/flashes, “grim little smile,” capable of responding to but not initiating humor. Gentle, mirthful, playful, jovial, jesting, impish, funny, entertaining, tells stories/jokes, flip, puns, wisecracks, mocks, silly, slapstick. Cosmic/existential/absurdist sense of humor, wry, deadpan, dry, ironic, cynical, sophisticated, witty. Sarcastic, tendentious, teasing, hostile, offensive “humor,” off-color jokes, inappropriate remarks excused as “just kidding. ” Ambivalence Mixed feelings, conflicted, at cross-purposes, approach-avoidance conflicts, “left hand doesn't know what right hand is doing,” alternates, “I want and don't want it at the same time,” indecisive, can't decide/make up mind, repetitive weighing of alternatives, seeking of other options, stuck, abulia.

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14611 Cognition and Mental Status This chapter contains descriptors for all the aspects of cognitive functioning assessed in a Mental Status Examination; the questions to elicit these behaviors and functions are provided in Chapter 2. 11. 1. No Pathological Findings: Summary Statements The relevant ICD-9-CM and DSM-IV-TR code is V71. 09, No Diagnosis or Condition on Axis I/No Diagnosis on Axis II. Based on behavior observed during the interview, I believe... In my professional judgment... Examination is entirely normal/benign. Examination was entirely Within Normal Limits. The client seems average/unremarkable/intact. Nothing unusual was found. No limitations in any of the domains assessed by these instruments/this examination. No evidence/signs of a thought disorder or a major affective/cognitive/behavioral disorder was/ were elicited. No abnormalities of thought, affect, or behavior/no gross abnormalities/nothing bizarre. I did not find any unusual kinds of logic or strange associations. No obvious indications of psychosis or organicity, no hallucinations in any field. He/she experiences thoughts in a spontaneous and normal manner, and is lucid and coherent. No indication of disordered mentation in the form of incoherent or incomprehensible speech. Speech is relevant as to content and spontaneous as to delivery. He/she is in full/partial/marginal/recent/fragile remission. I failed to elicit any symptomatic behaviors/indications of previously described symptoms or disorders. Based on current observations, there is no decompensation, deterioration, or exacerbation of past conditions. I find no indication of notable decline of intellectual abilities. No evidence of drug or alcohol abuse/legal record/psychiatric history of diagnosis or treat-ment. MENTAL STATUS

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11. Cognition and Mental Status 147MENTAL STATUS 11. 2. Arithmetic See also Section 17. 4, “Math Ability”; see Section 2. 16, “Calculation Abilities,” for questions. Overall (↔ by degree) Anumerate, lacks practical/everyday/survival/basic mathematical skills, dyscalculia, skills approx imately equivalent to those mastered in school grade . Financial See Section 14. 6, “Financial Skills. ” 11. 3. Attention See Section 2. 6, “Attention,” for questions. See also Section 12. 3, “Attention-Deficit/Hyperactivity Disorder. ” (↔ by degree) The following groupings are sequenced by degree of increasing attentiveness. Unaware, unable to attend, unengaged, daydreams, autistic reverie, muses, pensive, “wool- gathering,” ignored questions, attention could not be gained or held, attention limited by extra-neous sounds/concurrent activities/fantasies/affects/memories. Distractible, inattentive, attention wandered, redirectable, attentive only to irrelevancies, responses were irrelevant, unable to reject interfering stimuli from environment/viscera/affects, guided by internal rather than external stimuli, easily overloaded by stimulation, needed much repetition, could not repeat familiar lists/phrases, attended only for brief intervals, fleeting attention, can't absorb details needed for responsible judgments beyond the routine. Low attending skills, preoccupied, had difficulty with tasks requiring vigilance, selec-tive attention/inattention, showed lapses of attention. Attends, could focus on/select the relevant from among the irrelevant aspects of a situation, could maintain the focus/resist distraction, attention is sufficient for question responding/interview/psychotherapy/effective life management, showed freedom from distractibility, capable of prolonged attention but occasionally dis-tracted, vigilant. 11. 4. Concentration/Task Persistence See Section 2. 7, “Concentration,” for questions. See also Section 12. 3, “Attention-Deficit/ Hyperactivity Disorder. ” General Descriptors Unable to maintain concentration for more than several minutes/duration of the examination, defective when compared with peers, could not follow a three-stage command/written directions, cannot attend to coping/adaptive/purposeful tasks, could not spell words for-ward and backward. For a Child: Daydreams, has strong/weak subjects, doesn't complete assignments in class/homework, mate-rials are disorganized/messy, forgets teacher's instructions, has to be reminded to sit still/

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148 STANDARD TERMS AND STATEMENTS FOR REPORTS MENTAL STATUS pay attention, loses needed supplies and materials. (See also Section 8. 3, “Response to the Methods of Evaluation... ”) Interfering Factors Concentration intact to direct questioning, but subtle recall deficits are evident when certain topics (e. g., symptoms or denied behaviors) are inquired into. Performance anxiety, fear of failure, fear of being found wanting/inadequate, general anxiety, preoccupations with self or others. Performance on Serial Sevens Was able to subtract 7 from 100 times/fully/down to 2 accurately. Did serial sevens down to in seconds with errors, at which point I stopped her/ him. Was able to do serial sevens times before making an error. Self-corrected errors in the sequence. Performed serial sevens with errors, but subsequent subtractions were accurate based on the prior numbers. Could sustain concentration only to the plateau/on trials, even with sincere effort. Demonstrated adequate numerical reasoning, but made incorrect computations because of interfering anxiety. 11. 5. Consciousness Levels See also Sections 2. 3, “Rancho Los Amigos Cognitive Scale,” and 2. 4, “Glasgow Coma Scale. ” (↔ by degree) The following groupings are sequenced by degree of increasing consciousness. Coma, comatose, coma vigil, unarousable, unresponsive, obtunded. Stuporous, delirious, responsive only to persistent noxious stimulation, postictal, twilight/dreamy state, drifts off, fluctuates, arousable/rousable, semicoma. Lethargic, reduced wakefulness, somnolent, only briefly responsive with a return to unconsciousness. Clouded consciousness, drowsy, falls asleep, responding requires special effort, lessened ability to perform tasks, frequent hesitations, starting/startles, disori-ented, groggy, “drugged,” under the influence of medications that... (specify), in a daze. Alert, responds to questions, attentive, makes eye contact, interacts, asks ques-tions, converses, lucid, intact, was spontaneously verbal. 11. 6. Decision Making See also Section 11. 13, “Moral/Social Judgment... ”; see Section 2. 21, “Decision Making,” for questions. (↔ by degree) The following groupings are sequenced by degree of increasing decision-making abil-ity. Easily confused, easily overwhelmed in choice situations, lacks understanding of options, fails to evaluate choices. Indecisive, flounders, dithers, procrastinates, ponders endlessly, avoids decision situations, reverses decisions, wishy-washy, vacillates, ambivalent, seeks/requires others to decide.

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11. Cognition and Mental Status 149MENTAL STATUS Unable to carry out choices verbalized, deficient in carrying out instructions/in finish-ing tasks started, can make only simple/work-related decisions. Decisive, effective, follows through, tolerates frustration/ambiguity/delay/errors/peers/setbacks/changes/ambivalence. 11. 7. Dementia See also Sections 11. 12, “Memory,” 11. 17, “Reasoning..., ” and 11. 13, “Moral/Social Judgment... ”; see Section 2. 10, “Memory,” for screening questions. Types of Dementia Alzheimer's dementia (most common type), multi-infarct dementia/vascular dementia (second most common), dementia with Lewy bodies, Fronto Temporal Dementia/Pick's dementia. Treatable dementias due to hypothyroidism, cardiovascular disease, vitamin B1 deficiency, folate deficiency, hypoglycemia, hypercalcemia, etc. Rarer dementias: neurosyphilis, AIDS dementia complex, dementia pugilistica, porphyria- related dementia. Reminders First, do not use “senility” to mean “dementia,” because aging doesn't cause dementia. Aging ü is not a disease. At no age is dementia a normal state, and in many cases dementia is reversible while age isn't. “In the absence of disease there is no dementia. ” Differential diagnoses include depression, the “mindlessness” created by routine and passivity (Langer, 1989), diabetes, alco-hol abuse, infections, trauma, tumors, vascular disease, sensory restrictions, normal-pressure hydrocephalus, metabolic disturbances, poor nutrition, drug interactions/toxicity, sleep depri-vation, and a variety of Central Nervous System conditions. (See Sections 12. 36, “Side Effects of Psychotropic Medications/Adverse Drug Reactions,” and 29. 6, “Organic Brain Syndrome/Dementia. ”) Second, be alert to the possibility of ü AIDS Dementia Complex, whose onset is insidious. (See Section 12. 2, which covers this topic. )Third, consider whether dementia-like symptoms may be caused by another psychiatric disor-ü der—most commonly depression (in which case the symptoms are called “the dementia syn-drome of depression”), but sometimes schizophrenia or somatoform disorders. This condition was formerly called “pseudodementia,” but it is not functionally a “pseudo-. ” Differentiating the dementia syndrome from depression can be difficult, but a website (neuro. psyc. memphis. edu/Neuro Psyc/np-dx-demen. htm) provides guidance. Phases of Decline in Alzheimer's Disease: Global Deterioration Scale A commonly accepted and detailed seven-stage model can be found online (www. alzinfo. org/clinical-stages-of-alzheimers-disease. asp). 11. 8. Information See Section 2. 11, “Fund of Information,” for questions. Impoverished/deficient fund of information/general knowledge, unaware of current/practical/ general information, doesn't know facts regarding his/her culture, fund of factual knowl-edge is low/spotty, unaware of many basic factual/measurement/historical/geographical concepts.

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150 STANDARD TERMS AND STATEMENTS FOR REPORTS MENTAL STATUS Summary Statements: Limited education was apparent/demonstrated in low levels of the information typically acquired in elementary school. Considering his/her cultural background, level of formal education, and self-education, this cli-ent's information was... (specify). 11. 9. Insight See Section 2. 23, “Insight into Disorder,” for questions. Nil or Little No insight, blindly uncritical of own behavior, denies presence of psychological problems/illness/ symptoms, aware of problem but blames others/circumstances/physical factors/something unknown or mysterious for problems, rebuts psychological or motivational interpretations of behavior, fights the system and does little or nothing to help self, fatalistic resignation. Denies (despite the evidence) that current symptoms are important or that he/she needs help, feels no need to change attitude/behavior/feelings in some specific way, minimizes/denies/obfuscates/evades staff evaluations/findings during discussion. Confused, perplexed, befuddled. Does not know what to make of his/her situation. Superficial, shallow, platitudinous, difficulty in acknowledging the presence of psychological problems, self-deceiving, unable to focus on issues, lacks objectivity. Some Understanding is more peripheral than central or visceral. Unable to make use of correct insights, only flashes of insight, doesn't understand self too well. Is aware of not functioning up to capacity/potential. Seems to recognize some symptomatology but not to have any understanding of its mecha-nisms or processes. Insight is emerging/coalescing/accumulating. Continues trying to make sense of own psychotic thinking. Has some insight into behavior, but apparently is not able to respond appropriately or perceive satisfactory solutions to life situation. Full Believes/accepts that he/she is ill, recognizes need for treatment, came to treatment voluntarily, labels own illness, takes medicines, attends therapy sessions, works in therapy, acknowl-edges psychological/physical/historical limitations present. Accepts that her/his symptoms/problematic behaviors/failures in adaptation are at least in part due to irrational thoughts/feelings/internal states/defenses/personal history, can identify the emotional/cognitive antecedents and consequents of symptomatic behaviors, recog-nizes relation of symptomatic behavior (e. g., alcohol abuse) to emotional states, acknowl-edges its impact on life's duration/quality/satisfaction. Open to new ideas/perspectives on self and others, self-aware, psychologically minded, accepts explanations offered by caregivers, can apply understanding to change actions/direction of his/her life, understands causes/dynamics/treatments/implications of illness. Understands outcomes of behavior and is influenced by this awareness, is able to identify/dis-tinguish/comprehend behaviors contrary to social values/socially nonacceptable/personally counterproductive.

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11. Cognition and Mental Status 151MENTAL STATUS For a Disability Report: Note applicant's perception of relationship between injury/illness and psychological conditions. 11. 10. Intelligence, Development, and Cognition: Assessment For assessment of Activities of Daily Living, see Section 14. 1. For personality assessment, see Section 13. 2. For assessment of Attention-Deficit/Hyperactivity Disorder, see Section 12. 3. For memory assessment, see Section 11. 12. For vocational assessment, see Section 17. 1. Keep in mind that there are more kinds of “intelligence” than are assessed by widely available tests. Gardner (2006) has suggested at least eight. If you suspect the presence of a learning disability, information-processing disorder, mental ü retardation, or any physical condition that would affect school performance, consultation with or referral to a school psychologist or educational specialist who can utilize the many special-ized instruments for evaluation and remediation is usually appropriate. There are thousands of published instruments for evaluating almost any aspect of mental function-ing, and hundreds of these have good reliability and validity. Inclusion in the listing below does not indicate endorsement of the named purpose or validity of any test by the present author or pub-lisher. Inclusion is based on the presumed likelihood of encountering the test in clinical practice. Each entry offers the title of the current edition or version of each test (with acronym, abbreviation, or common name indicated as usual by underlining); its copyright date if available; its current pub-lisher or distributor; and the applicable age range. Child Development Battelle Developmental Inventory-2 (2004), Riverside, birth-8 years. Bayley Scales of Infant and Toddler Development-III (2005), Pearson Assessments, 1-42 months. Brigance Early Childhood Complete Assessment Kit (2009), Curriculum Associates, 0-5 years. Denver Developmental Screening Test-II, Denver Developmental Materials, birth-6 years. Developmental Activities Screening Inventory-II, PRO-ED, birth-60 months. Hawaii Early Learning Profile, Vort, birth-6 years. Learning Accomplishment Profile-III, Kaplan Early Learning, 3-6 years. Intelligence (Screening Tests) Slosson Intelligence Test—Revised-3rd ed., Slosson, 4-65 years. Kaufman Brief Intelligence Test-2, Pearson Assessments, 4-90 years. Reynolds Intellectual Screening Test (2003), Psychological Assessment Resources, 3-94 years. Intelligence (Individualized Administration for More Precise Evaluations) Bracken Basic Concept Scale-3 (2006), Pearson Assessment, 3:0-6:11 years. Das-Naglieri Cognitive Assessment System (1997), Riverside, 5-17:11 years. Kaufman Adolescent and Adult Intelligence Test, Pearson Assessments, 11-85+ years. Kaufman Assessment Battery for Children—II, Pearson Assessments, 3-18 years. Stanford-Binet Intelligence Scales, 5th ed. (2003), Riverside, 2 years-adult. Wechsler Abbreviated Scale of Intelligence (1999), Pearson Assessments, 6-89 years. Wechsler Adult Intelligence Scale-IV (2008), Pearson Assessments, 16-90 years. Wechsler Intelligence Scale for Children-IV (2003), Pearson Assessment, 6-16:11 years.

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152 STANDARD TERMS AND STATEMENTS FOR REPORTS MENTAL STATUS Wechsler Preschool and Primary Scale of Intelligence-III (2002), Pearson Assessments, 2:6-7:3 years. Wide Range Intelligence Test (2000), Psychological Assessment Resources, 4-85 years. Nonverbal Scales of Intellectual Functioning Test Of Nonverbal Intelligence—3 (1997), PRO-ED, 6-90 years. Comprehensive Test Of Nonverbal Intelligence—2 (2009), PRO-ED, 6-91 years. Leiter International Performance Scale—Revised, Western Psychological Services, 2-20 years. Merrill-Palmer Revised Scales of Development (2004), Western Psychological Services, 1 month-6:6 years. Naglieri Nonverbal Ability Test— Individual Administration (2003), Pearson Assessments, 5-17:11 years. Raven's Progressive Matrices (1986), Pearson Assessments, 5 years-adult (three levels for differ-ent age and ability groups). Universal Nonverbal Intelligence Test (1998), Riverside, 5-17:11 years. Educational Achievements Peabody Individual Achievement Test—Revised/Normative Update (2001), Pearson Assess-ments, 5-22 years. Wechsler Individual Achievement Test—III (2009), Pearson Assessments, 4-20 years. Wide Range Achievement Test, 4th ed. (2006), PAR, 5-94 years. Woodcock-Johnson III (2001), Riverside, 2-90+ years. 11. 11. Intelligence Scores: Classifications See Chapter 21, “Diagnostic Statement/Impression,” for DSM-IV-TR/ICD-9-CM diagnoses and codes for Mental Retardation (and DSM-IV-TR Borderline Intellectual Functioning). IQ Categories for Adults Category IQ score range% of population included in each Gifted 130 and above 2. 27 Above average 115-129 13. 59 High average 100-114 34. 13 (Average) (85-115) (68. 26) Low average 85-99 34. 13 Borderline 71-84 13. 59 Mild mental retardation 50-55 to 70 2. 14 Moderate mental retardation 35-40 to 50-55 0. 13 This table is based on Wechsler (2003, 2008) and DSM-IV-TR (American Psychiatric Association, 2000). Validity of Scores: Summary Statements The obtained test scores are believed to be valid indicators of/significantly underestimate cur-rent intellectual functioning. The scores are consistent with developmental history and degree of functional loss but not with potential, because... (specify).

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11. Cognition and Mental Status 153MENTAL STATUS Notes Weigh the levels of adaptive behavior ( ü Activities of Daily Living, needs for assistance), as well as the results of intelligence testing (and the standard errors of these scores), into your diagnosis. Consider the potential effects of education, depression, dementia, distracting anxiety, relation-ü ship with the examiner, intercurrent medical illnesses, etc., on intellectual functioning. After 3 years from the date of the evaluation, test data and findings (especially on a child) ü should be treated with caution. Generally, IQ scores below 40 (or near the floor of scores available on a test) are not meaningful ü discriminators. Consider the possibility that current functioning represents a decline; if so, offer an estimate of ü premorbid intelligence based on current subtest results, earlier testing, changed levels of adap-tive behavior, etc. 11. 12. Memory See Section 2. 10, “Memory,” for questions. See also Section 11. 7, “Dementia. ” Indications of Defect (↔ by degree) Forgetful, “spotty memory,” “absent-minded,” uncertain/expresses doubts, perplexed, foggy, hesitating, dreamy presentation, “spaced out,” detached, confused, befuddled, confabu-lates, falsifies, perseverates, contaminations, diffusions. Confuses time frames/sequences, nonsequential, overfocused on externals/situational issues, vague, guesses/estimates/approximates, Ganser's syndrome, disjointed, gaps, skips over, skimpy/superficial history, contradictions, a poor historian/reporter of past events. Can only recognize, sluggish recall, recalls only with much prompting/cueing, reproduces/ reconstructs with much difficulty/inaccuracy. Amnesias Anterograde, retrograde, Total Global Amnesia, “infantile,” fugue, amnestic/amnesic disorder, Korsakoff's syndrome, Wernicke's syndrome. Paramnesias Fausse r e c o n n a i s s a n c e, retrospective falsification, confabulation, preknowledge of events/oth-ers' speech, d é j à v u, d é j à e n t e n d u, d é j à p e n s é, j a m a i s v u, hypermnesia, anomia, agnosia, prosopagnosia, Tip-Of-the-Tongue phenomenon. Impact of Memory Defect on Patient (↔ by degree) Maximal/effective/poor/no use of compensatory mechanisms/coping skills, constricts lifestyle, ignores, denies. Summary Statements about Memory Performance Normal Memory All components of memory are grossly intact. The client is able to recount personal history normally/at all time stages.

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154 STANDARD TERMS AND STATEMENTS FOR REPORTS MENTAL STATUS His/her remote, recent, and immediate memories appear to be intact, as far as I can determine without independent verification of the historical facts. Normal forgetfulness/age-related memory loss/age-consistent memory decline/Age-Associated Memory Impairment/Age-Related Cognitive Decline is present. AAMI is the term most often used by the National Institute of Mental Health, and ARCD is the term used in DSM-IV-TR (the code is 780. 9). As Historian The client was un/able to give an account of his/her activities/life events in a chronological order. Memory, as reflected in her/his ability to provide an intact, substantial, sequential, detailed, and logical history/narrative, was defective/quite poor/poor/adequate/normal/exceptional/ unusual because... (specify). Memory for events in temporal sequence was vague/incomplete/contradictory/chaotic. He/she could not recall the time frames of school/work/family development/treatments. Defective Memory The client was able to recall no/one/two/three objects/words after 5/10 minutes of different/ unrelated activities. Memory was limited/deficient/defective/a problem in all time frames. Memory is organically intact, but anxiety/depression interfere. She seems defective/normal/exceptional in immediate/short-term retention/recent/recent past/ remote memory. Client shows the pattern of memory deficits typical of those with/with a history of (specify diagnosis). memory is not affected/normal, but memory is defective/excep-tional. Remote and recent memories appeared to be intact, but there was an emptiness and lack of color in client's descriptions of critical events. Client did not offer a rich description of important events from personal history. Client's recall appeared deliberately vague/evasive/distorted by distrust/self-protectively edited. Other Aspects of Memory Types of Memory Storage: Retrograde Current memory Anterograde Past storage Recent storage Registration Retention Retrieval New storage Future storage Typologies: Implicit (automatic behaviors and skills) Motor Conditioning Priming Declarative (information) Working memory (over seconds)Short-term memory (over minutes)Long-term memory (hours to years) Visuospatial Verbal Semantic (words, ideas)Episodic (narratives, sequences)

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11. Cognition and Mental Status 155MENTAL STATUS Clinical: Recognition (“identify, select, pick, or find”), reproduction (“say, repeat, or copy”), recall (remember without cueing). Types: Immediate, short-term/active/working, long-term, generic, eidetic, narrative, declara-tive/explicit vs. procedural/implicit, automatic vs. effortful, semantic vs. episodic, ver-bal (words, phrases, stories, associated word pairs), visual (colors, designs, pictures), spa-tial (positions of objects), episodic (contexts, situations, components, details, sequences, themes), practical/praxis (ability to demonstrate/pantomime how to open a can, brush one's teeth, butter bread, etc. ). Functions or processes: Acquisition, registration, encoding, recoding, chunking, consolidation, rehearsal, transfer, storage, retention, decay, retrieval, recall, reconstruction. 1 Possible causes of forgetting: Decay, displacement, interference, retroactive and proactive inhibi-tion, consolidation block theory, retrieval failure theory, explicit memory defect. Factors affecting recall: Primacy, recency, vividness, frequency. Methods for enhancing recall: Method of loci, mnemonics, elaborative rehearsal, priming, spa-tiotemporal markers, Tip-Of-the-Tongue phenomenon. Characteristics of Senescent Forgetfulness The following table is adapted from Kral (1978). Malignant Age-Associated Memory Impairment {Benign Senescent Forgetfulness} Shortened retention time. Inability to recall an event of the recent past, including not only unimportant facts but the experience itself. Failure to recall accompanied by dis orien-tation to place and time and, gradually, to person. Absent self-awareness of deficiencies. Failures to recall are limited to relatively unimportant parts of an experience (e. g., a name or date). Details forgotten on one occasion may be recalled at another time. “Forgotten” data belong to remote as opposed to recent past. Subjects are aware of shortcomings and may apologize or compensate. No language or praxis impairments. Assessment Instruments for Memory As in the listing of tests in Section 11. 10, each entry here gives the title of the current edition or ver-sion of each test (with acronym, abbreviation, or common name indicated as usual by underlining); its copyright date if available; its publisher or distributor; and the applicable age range. Wechsler Memory Scale-IV (2009), Pearson Assessments, 16-90 years. Benton Visual Retention Test, 5th ed. (1991), Pearson Assessments, 8-adult. Wide Range Assessment of Memory and Learning 2 (2003), PAR, 5-90 years. Rey Complex Figure Test and Recognition Trial (1995), Pearson Assessments, 6-89 years. Rivermead Behavioural Memory Test-3, Pearson Assessments, adult. 1I am indebted to Mustaq Khan, Ph D, of London, Ontario, Canada, for several corrections in this section.

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156 STANDARD TERMS AND STATEMENTS FOR REPORTS MENTAL STATUS11. 13. Moral/Social Judgment and knowledge See also Sections 11. 6, 11. 9, 11. 16, 11. 17, and 11. 18. See Section 2. 20, “Social Judgment,” for questions. Defective Understanding/Lack of “Common Sense” Substantial defects in capacity to appreciate common/consensual reality. Impaired ability to make reasonable and realistic life decisions. Makes major decisions without sufficient information/impulsively/depending on hearsay/so as not to refuse a friend, impulsive. Makes decisional errors under even the mildest stress. Seems guided by false beliefs. Heedless/reckless/feckless/careless, irresponsible. For a Child: Excessive imagination, confuses wishes/fears/impulses with objective/consensual reality. Normal Judgment/“Common Sense” Has common-sense understandings, common-sensical, is “street-smart,” realistic. Subscribes to usual explanations of people's motivations. Has sought treatment for medical/psychological problems. Learned from experience/feedback/others' mistakes/correction/instruction. Understands/anticipates the likely outcome of behavior and thinks/plans ahead effectively. Responsible, understands/anticipates the likely consequences of his/her behavior/actions. Has strong/weak executive functions (decision making, social perception, flexibility of think-ing/judgment), generates good/poor alternatives/solutions/positions. Shows discernment, discretion, wisdom. Propriety/Impropriety Distinguishes socially acceptable from unacceptable behaviors and acts on this understand- ing. Able to identify and control behaviors harmful to self and others/contrary to acceptable rules/ beyond the limits of the community. Does not display outlandish or bizarre behaviors inappropriate to social interactions. Acts contrary to acceptable behavior. Judgment intact in terms of understanding (e. g., the demand characteristics of social settings), but not in terms of the social acceptability of the behaviors. Does not comprehend/anticipate/defer to the expected/usual consequences of his/her behav-iors or the impact/impression upon others. Inadequately cognizant/aware of basic social conventions. Victimization Engages in actions harmful to self. Has been taken advantage of repeatedly. Easily misled and swindled/misused/taken advantage of. Not discriminating in choice of companions. Makes blatantly defective and self-damaging choices.

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11. Cognition and Mental Status 157MENTAL STATUS Might unwittingly enter a situation of jeopardy or be unable to extricate self from one. Requires close support/monitoring to avoid loss/harm/exploitation. Judgment insufficient for independent living/assisted living. Has a lifelong history of ineffective coping. Other Statements The client has difficulty with performing the tasks supportive of/related to carrying out the decisions made. Given the defective quality of her/his thinking/understanding, judgment has to be impaired. Evaluation of client's judgment, as based on a comparison with premorbid state or with expected ability based on intellect/age/education/social experience, is... (specify). 11. 14. Motivation for Change: Summary Statements See also Chapter 23, “Prognostic Statements”; Section 11. 9, “Insight”; the “Responses to Treatment” heading in Section 12. 39, “Substance Use, Abuse, and Dependence”; and “The Stages-of-Change Model” heading in Section 25. 3, “Various Formats for Treatment Plans. Motivation is limited by low frustration tolerance/dependency/ambivalence/low initiative. Increased motivation is needed for change/therapy/habilitation/rehabilitation/self- improvement. Client is aware of problems but is not yet sufficiently motivated to take action. Client is powerfully motivated for change, as seen in... (specify). 11. 15. Orientation (↔ by degree) See Section 2. 5, “Orientation,” for questions. Incorrectly/inadequately identified self by name, mistook/confused present location/correct time/objects/others, mistook/confused dates/persons/places, was off the mark by years/ months/days. Appeared to be oriented only in the most simple sense/on basic measures, oriented to but not to . Fully oriented times three/to time, place, and person; times four/to time, place, person, and common things. 11. 16. Reality Testing See also Section 11. 13, “Moral/Social Judgment... ” Intact, functional, not distorted by psychodynamics/defenses/psychopathology, perceives the social world as most people do, understands cause-effect links as other people do, shares common attributions of causality, functional/adequate/good/extensive fund of knowledge/awareness of the external world, shows maturity. Defective reality testing, repeatedly makes poor judgments, easily misled and taken advan-tage of, misinterprets common-sense reality, cannot anticipate others' reactions to her/his behaviors, overresponds to stimuli/others' behavior, distorted/idiosyncratic interpretations of events and their meanings, acts as if the world was as she/he would like it to be, lives in a fantasy world.

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158 STANDARD TERMS AND STATEMENTS FOR REPORTS MENTAL STATUS11. 17. Reasoning/Abstract Thinking/Concept Formation See also Section 11. 13, “Moral/Social Judgment... ”; see Sections 2. 12-2. 15 and 2. 17-2. 18 for questions. Level of Interpretation (↔ by degree) Greatly defective, failed to grasp nature of question, it was not possible to find proverbs simple enough for him/her to interpret, no evidence of abstract thinking or even extended thought processes, “I've heard that one before” (without elaboration). Distorted by thought disorder, showing personification/bizarre features/delusions. Concrete (noted only surface features or appearance aspects of stimuli), offered only very specific examples, paraphrases, reasoned in a concrete manner, stimulus-bound associations. Simplistic, difficulty with concept formation/judgment, abstraction, opposites/sim-ilarities/differences, comparative analogies, absurdities, proverbs. Couldn't use appropriate/expected levels of abstraction in dealing with test materials, mixed up categories in hierarchies, poor abstract thinking and concept-handling ability, degree of generalization was overly broad/narrow, some difficulty with reasoning at an easy/moderately difficult/difficult level, offered unusual/idiosyncratic/antisocial interpretations. Functional levels of interpretation, responded only in terms of the uses for the stimulus item or literal meanings. Offered popular interpretations of proverbs, adequate reasoning skills, common sense. Abstracted common properties of the stimuli (noted the verbal or log-ical relationships between the stimuli), used principles, reasoned abstractly, offered similar proverbs/spontaneous re phrasings, com-prehensive level of reasoning. Overly abstract, attended only to selected/irrelevant aspects of stimuli, stylized, overly philosophical/obscure/arcane refer-ences, highly theoretical, Byzantine reasoning. Summary Statements Normal Abstraction The client had a common-sense/functional understanding of everyday objects. She was able to respond with an abstract relationship between pairs of terms/items I presented to her. He was able to form concepts well and without concreteness. She was able to identify opposites, similarities, differences, and absurdities. Client was able to analyze the meaning of simple proverbs, all at appropriate levels of abstrac-tion. He could give me the deep meanings of the proverbs I offered. Faulty Reasoning The client engaged in faulty inductive/deductive inference/reasoning. She reached conclusions based on false/faulty premises. He made errors of logic and judgment/came to incorrect conclusions.

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11. Cognition and Mental Status 159MENTAL STATUS She was unable to relevantly support answers given. His reasoning appears autistic/dereistic/idiosyncratic. n o n s e q u i t u r s /p a r s p r o t o t o /trance logic/ a d h o m i n e m /p o s t h o c e r g o p r o p t e r h o c/other errors were evident. See also “Dysfunctional Cognitions” in Section 10. 7, “Depression. ” 11. 18. Social Maturity See also Section 11. 13, “Moral/Social Judgment... ” Irresponsibility See also Section 13. 7, “Antisocial Personality. ” Denies/distorts responsibilities, steals/destroys others' property, refuses to pay debts/for prop-erty destroyed, cheats, blames innocents, shows no guilt or remorse, offers no explanations, fakes guilt, offers only empty/“phony” apologies, falsely begs/pleads, “crocodile tears. ” On the job he/she resists/doesn't cooperate with/ignores/defies rules/directions/deadlines, starts many tasks but does not complete any, manipulates coworkers into doing his/her work, “cons,” needs close/continuous supervision, absent without excuse/slips away, tardy/takes too many/overlong rest periods/breaks/leaves early, intoxicated at work, conducts own business during work hours. Self-Centeredness See also Section 13. 17, “Narcissistic Personality. ” Manipulates, lacks/has unrealistic/has only immediate goals, selfish, uncaring, resents limits, self-indulgent, impulsive, arousal-seeking, acts out, immature, infantile. Financial Behavior See Section 14. 6, “Financial Skills. ” Social Interaction See also Chapters 15, “Social/Community Functioning,” and 16, “Couple and Family Relationships. ” Resistant to authorities (parents, supervisor, police, human service professionals), chooses/ imitates inappropriate or pathological models. Touches others without consent, touches self inappropriately. Threatens vaguely to leave/take revenge/destroy property/commit violence, threatens when confronted with own irresponsible behaviors, bullies/intimidates, harasses. Has only limited contact with others, so little opportunity to behave inappropriately. Client never/rarely/often/usually plays/socializes with/relates to persons of her own age group. He prefers to relate to things/paper/numbers/ideas/people. Summary Statements Child is as mature as same-age peers/is only pseudomature/has been “parentified” by his fam-ily/is overly mature. When/as compared with others of same age/culture/education, she demonstrated degree of maturity. 11. 19. Stream of Thought This section covers speech as a reflection of cognition. See also Section 7. 4, “Speech Behavior,” and Section 11. 17, “Reasoning... ”

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160 STANDARD TERMS AND STATEMENTS FOR REPORTS MENTAL STATUS Amount/Productivity (↔ by degree) impoverished laconic normal rapid flight of ideas paucity slowed spontaneous overabundant restricted hesitant average “logorrhea” decreased abundant copious unelaborated underproductiveblockedslowed speed of cognitive process-ing Continuity/Coherence (↔ by degree) incoherent loose idiosyncratic disconnected clear incomprehensible circumstantial unusual topic changes realistic clang associations irrelevancies associations difficult to rational neologisms tangential personalized follow lucid word salad vague meanings fragmented consistent confabulations derailed flighty coherent {verbigerations} rambling conjectural confusing relevant perseverative garbled disjointed integrated chaotic confused preoccupied goal-directed jabbers sidetracked baffling logical babbles evasive Byzantine pertinent prattles distracted perplexing easy to “rattles on” digressive follow silly conclusions drifting irrelevant intact circumlocutions sequential paraphrases incorrect not pre-word substitutions conclusions occupied nonsequential unclear articulate jumbled imprecise linear illogical indefinite repetitive poorly defined Coherence (↔ by degree) The following groupings are sequenced by increasing degree of coherence: No stepwise progressions, no logical sequences, lacking internal logic/structure. Loosening of associations, connected associations by small and/or unusual similarities, needed to be refocused/redirected, failed to answer the questions asked. Clear cause-and-effect thinking, responses cohered with/addressed the questions asked, common/realistic associations, coherent, to the point, linear. Qualities of Thought Content Personalized, idiosyncratic, carefully chosen, eccentric, odd, monothematic, overvalued ideas. Sexual, earthy, erotic, scatological, pornographic, obscene, profane, blasphemous, vulgarities. Bizarre themes, magical thinking, fabulized. Trivial, platitudes, sentimental, oversimple, empty.

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11. Cognition and Mental Status 161MENTAL STATUS Preoccupations See above; see also Sections 12. 10, “Delusions,” 12. 21, “Obsessions,” and 12. 24, “Paranoia. ” mental health religion sexuality obsessions piety compulsions excessive prayer somatic/hypochondriacal fears/phobias blasphemous ideas concerns symptoms denigrating activities current physical illness irreligious practices/acts mortal illnesses death fears/delusions about popular diseases suicide clergy/theology homicide escape dying his/her plight running away morbid thoughts life situation losses stressors tragedies frustrations disappointmentsshame/embarrassmentregretsambivalences Other Problems with Stream of Thought Loss of goal, spontaneous but unproductive speech, condensations, overinclusive thinking, autoecholalia, interpenetration of themes, loss of segmental set, cognitive slippage. Paraphrastic errors/dysnomias/unusual word and sentence formations/errors of syntax/con-structional dyspraxia/malapropisms/alexia/alexithymia. Summary Statements for Normal Thought Content The client showed an average number of thoughts, which were neither speeded nor slowed/ moved at a normal pace/normal flow of ideas. His/her thinking seems normal from the perspective of productivity, relevance, and coherence. The client answered questions appropriately. She presented her thoughts in an appropriately paced, understandable, and relevant fashion. His thoughts were coherent, well organized, and relevant to the subject at hand. She reached the goal of her thought processes without introducing any irrelevant material. His train of thought was goal-directed, relevant, logical, coherent, focused, without digressions, irrelevancies, disturbances of logic, or bizarreness. There was no tangentiality, circumstantiality, or distractibility. Speech was relevant, appropriate, and without evidence of unusual ideation. Speech showed good grammatical complexity. The client showed no obsessions or phobias, ideas of reference, hallucinations, delusions, faulty perceptions, perceptual disturbance, misinterpretations of consensual reality, or psy-chotic distortions. Her logic was easy to follow, although the responses were superficial. He is very concerned about his health, but understandably and appropriately so. Her thoughts about (e. g., health problems) dominate her thinking but are not exclusive or preoccupying. Summary Statements for Problematic Stream of Thought The client will refer to topics in a symbolic or associational manner, which requires deciphering by the listener.

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162 STANDARD TERMS AND STATEMENTS FOR REPORTS MENTAL STATUS The client apparently does little analytic or discriminatory thinking. He conversed in response to questions rather than speaking spontaneously. Self-sufficient in providing responses, but volunteered little additional information. Would not enlarge/expand/elaborate on topics of interest or responses to my questions. She showed word retrieval deficits/reported “forgetting”/had difficulty finding words/groped for words, would stop suddenly in middle of a sentence/speech. He had great difficulty gathering thoughts rather than in finding words. She substituted related words approximating the definitive/appropriate term. When interrupted, he became confused and rambled. She shows a tendency toward anecdotal thinking that could, if unchecked, become tangential. 11. 20. Test Judgment: Summary Statements The client gave reasonable responses to hypothetical judgment questions. He/she responded appropriately to imaginary/contrived situations requiring social judgment/ knowledge of the norms/usual rules/customs and expectations of society. Performance on the judgment questions asked/tests used was poor/adequate/good/normal/ expected/excellent, which suggests that in the external/social/“real” world this client would... (specify). 11. 21. Other Summary Statements for Mental Status This client appears to have impaired mental control functions. He/she seems unable to shift cognitive sets/rigid/inflexible/unable to learn or plan ahead. Cognitive functioning seems limited rather than faulty. He/she showed a good balance of self-esteem/confidence and self-criticism. Cognitive functioning is intact, according to my casual office-based testing. This client is precocious/very learned/brilliant. Problem-solving ability is lacking/defective/distorted/limited by intelligence/disorder. Considering this client's age and education... Critical judgment was fine, given his/her viable responses to standard hypothetical situations. For a Child: This child showed evidence of incoordination, poor balance, poor speech, delayed develop-ment, etc. Disclaimer Assessments and conclusions in this report about cognitive processes, including , are based primarily on verbal expressions and secondarily on behavioral expressions representing those processes. They are inferences about and not signs of such processes. As such, other conditions (such as receptive-expressive language disorders, medications and other substances used, individual history, etc. ) may have affected these expressions and made inferences based on them inaccurate. 2 2This disclaimer is courtesy of Joe Elwart, Psy D, of Royal Oak, MI.

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163 12 Abnormal Signs, Symptoms, and Syndromes In this chapter you will find ways to report areas of psychopathology that are not purely emotional/ affective symptoms and disorders (for those, see Chapter 10) or purely cognitive dysfunctions (for those, see Chapter 11). It is a somewhat heterogeneous collection containing some actual diagnoses (such as conduct disorder and schizophrenia), as well as many symptoms (such as compulsions, denial, hallucinations, and paranoia). You are likely to be asked to evaluate conditions that are not yet formal diagnoses but are more than isolated symptoms. Some of these conditions are included here: battered-woman syndrome, Chronic Fatigue Syndrome, chronic pain syndrome, P re Menstrual Dysphoric Disorder, and Rape Trauma Syndrome. Other sections in this chapter address topics of similar concern, such as the risk factors for homicide and suicide, the commonly encountered and confusing side effects of psycho-tropic medications, sexual “addiction,” and malingering. The topics are presented in simple alphabetical order. 12. 1. Abuse See also Sections 12. 5, “Battered-Woman Syndrome,” 12. 19, “Impulse-Control Disorders,” 12. 34, “Sexual Abuse, Child,” 12. 41, “Violent Behaviors,”and 13. 6, “Aggressive Personality. ” The relevant ICD-9-CM and DSM-IV-TR codes are complex. (See Section 21. 21, “V Codes, Etc. ”) Since often there are several kinds of abuse, you can use this format: “P (hysical)/ V(erbal)/ E(motional)/ M(ental/ S(exual) abuse. ” Be aware that each of these terms is quite inclusive and should be described more fully and less ambiguously. Consider the following risk factors for abusing families (described by Nietzel and Himelein, 1987): Parents' histories: Experienced abuse/neglect, lack of parental affection, large families, started family early. Current family status: Socially isolated/lack of social support, marital discord/conflict, impul-sivity of parents, parental illiteracy, parental mental retardation, stressful situation (poverty, generational conflict, incarceration, absence of a parent, etc. ). Parental child-rearing practices: Rarely praising children, strict demands, ignorance of devel-opment/unrealistic expectations, low level of supervision of children, early toilet training, dislike of caretaking, caregivers' disagreement over child-rearing practices. ABNORMAL Sy MPTOMS

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164 STANDARD TERMS AND STATEMENTS FOR REPORTS ABNORMAL Sy MPTOMSDepending on the work you do, you should keep a list of contacts and phone numbers for the local police, women's shelters, programs for both victims and perpetrators of abuse, supportive social and legal agencies, and so on. Addictions See Sections 12. 16, “Gambling,” 12. 35, “Sexual Impulsivity...,” and 12. 39, “Substance Use, Abuse, and Dependence. ” Adult Children Of Alcoholic Parents See Section 13. 11, “Codependent Personality. ” Affects See Chapter 10, “Emotional/Affective Symptoms and Disorders. ” Aggression See Section 12. 19, “Impulse-Control Disorders. ” 12. 2. AIDS Dementia Complex The relevant DSM-IV-TR code is 294. 1x, Dementia Due to HIV Disease. The relevant ICD-9-CM code is 294. 8, Other persisting mental disorder due to conditions classified elsewhere (specify HIV disease). Other names include HIV-1 mild neurocognitive disorder, HIV-1-associated cognitive/motor disor-der, and HIV-1-associated dementia. Although now rarer (under 10%) in People L iving With AIDS, this complex is insidious and still seen in untreated individuals. Kalichman (2003) offers informa-tion in an accessible format, and Grant and Atkinson's (1995) textbook chapter is psychiatrically complete. A comprehensive website is provided by the N ational Institutes of H ealth ( www. aidsinfo. nih. gov ). The following material is adapted from Greenwood (1991) with permission. Cognitive Changes (↔ by degree) Loss of memories, inability to concentrate, loses train of thought in midsentence, mild confu-sion, absentmindedness, verbal deficits across intellectual/memory/language tests, mental slowness, forgets to practice safer sex, agitation, inability to speak, loss of self-care func-tions, unaware of degree of illness/losses, seizures, indifference to surroundings, hyper-somnolence, coma. Motor Dysfunctions (↔ by degree) Leg weaknesses, unsteady gait, poor coordination, handwriting difficulties, tremor, paraplegia, incontinence. Other Changes Headache, lethargy, reduced sexual drive, apathy, indifference, suicide risk, withdrawal (especially in previously gregarious personalities), cerebral atrophy/edema/areas of demyelina tion. 12. 3. Attention-Deficit/Hyperactivity Disorder See Sections 2. 6, “Attention,” and 2. 7, “Concentration,” for questions; see Sections 11. 3, “Attention,” and 11. 4, “Concentration/Task Persistence,” for additional descriptors. The relevant DSM-IV-TR codes are 314. 00, ADHD, Predominantly Inattentive Type; 314. 01, ADHD,

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12. Abnormal Signs, Symptoms, and Syndromes 165ABNORMAL Sy MPTOMSPredominantly Hyperactive-Impulsive Type or Combined Type. The diagnostic criteria in DSM-IV-TR are the same for adults as for children. The most relevant ICD-9-CM codes are as follows: 314. 00, Attention D eficit Disorder: Without mention of hyperactivity; Predominantly inattentive type; 314. 01, ADD: With hyperactivity; ADD combined type; Simple disturbance of attention with overactivity; 314. 1, Hyperkinesis of childhood with developmental delay; and 314. 2, Hyperkinetic conduct disorder of childhood, without devel-opmental delay. ADHD can be seen as a concentration disorder. Also consider high lead levels, heavy metal poi-soning, maternal drug/alcohol use, etc., as causes of impulsivity, distractibility, low frustration tolerance, etc. Barkley (2005) is the standard reference. Although ADHD may present differently with maturation, it is not outgrown, as two- thirds of children diagnosed with ADHD still meet the criteria as adults (Resnick, 2000). High rates of comorbidity exist with oppositional defiant disorder, conduct disorder, anxiety, depression, learning disorders, and cognitive processing disorders. Behavior Restless, fidgets, wriggles, twists, squirms, “antsy,” much out-of-seat/off-task behavior, does not sit through an interview or meal, always “on the go,” prefers to run rather than walk, climbs on furniture, hops/skips/jumps rather than walking, fiddles with objects, taps/hits and makes noises, moves unnecessarily, disrupts shopping and family visits, acts “wild” in crowded settings, babysitters complain about his/her behavior. Shifts from one incomplete task to another, does not finish what she/he starts, play is frenetic/ nomadic, rushes/jumps from one topic of conversation to another, avoids conversing at any length. Noncompliant, does not obey instructions, does not sit when told to, breaks school/game's rules, unable to follow a routine, resistant, “sassy”/“talks back,” argumentative [and these are not due to oppositional patterns or failure to understand the instructions, so child should not be called defiant]. Does not play quietly, talks excessively, does everything in the noisiest way, makes odd noises. Needs constant/continual/one-to-one supervision/monitoring/redirection, needs closeness and eye contact to understand instructions, fails to attend to details in schoolwork or other activities, disregards instructions. Impulsive, blurts out answers, reacts without considering, acts before thinking, limited self- regulatory functions, is disorganized/forgetful and careless with possessions. Senseless/repetitive/eccentric behaviors, darts around aimlessly, destroys toys and property. Ignores consequences of own behaviors and so engages in physically dangerous activities. Adapts to changes in situation/routine/personnel poorly. Poor fine motor skills, clumsy, low concern for accuracy/neatness/quality of work. Has difficulty only at specific times, behavior/mood deteriorates during course of day. Cognitive Features Attention Easily distracted, self-distracting, lessened ability to sustain attention/concentration on school task/work/play, low attending skills, often stares into space, reports daydreaming. Needs/asks for repetitions of instructions, gets confused, doesn't “listen” although hears nor-mally, inattentive to significant details, misses announcements, needs excessive individual supervision. Low short-term memory skills (two-or three-step instructions), fails to remember sequences, loses place when reading, poor self-monitoring, makes careless mistakes.

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166 STANDARD TERMS AND STATEMENTS FOR REPORTS ABNORMAL Sy MPTOMSAcademic Difficulties Problems with counting/telling time/recognizing letters, adds/substitutes/reverses letters/ words/sounds, copies letters and words poorly, word-finding difficulties, stops in middle of a sentence or thought, confuses/reverses word order in sentences, mistakes similar- sounding words. Performs below ability level, refractory to usual instructional approaches, may seem unrespon-sive to punishment or rewards. Disorganized Work Habits Difficulty organizing schoolwork, does not study/prepare/organize/protect own work/do prob-lem's steps in sequence, does not complete assignments on time, starts work before receiv-ing full instructions, has great difficulty organizing goal-directed activities, poor at gather-ing materials and sequencing activities toward a goal, fails to finish tasks, is destructive of materials, loses things necessary for an activity (such as toys, pencils, keys, assignments, books, equipment), unprepared for school assignments, does not use study times. Affects Unpredictable and unrelated mood changes, often sad/pessimistic/gloomy, has low self- esteem/image, feels worthless, feelings are easily hurt/offended, cries easily or frequently, easily angered/upset, gets overexcited, irritable/touchy, easily frustrated/low frustration tolerance, no patience, impulsive, excitable, explosive, temper outbursts, unpredictable behavior. Social Characteristics Interrupts/intrudes/“butts in,” talks out in class, talks out of turn, shouts/blurts out answers/ comments, makes disruptive noises, does not wait turn in group situations, grabs others' possessions, breaks school behavior rules/norms, continually argues. Fights with sibs/peers/teachers, violent, aggressive, destructive, plays “tough guy/girl,” often involved in physically dangerous activities without considering possible risks/dangerous consequences, hits/punches/strikes/kicks/bites, cries/withdraws, verbal conflict/insults/harasses/threatens, coerces/intimidates/manipulates/“bosses,” provokes/disrupts other children's activities, betrays friends, peers avoid/reject him/her, has great difficulty keep-ing friends, blames others for own mistakes/misbehaviors, takes anger out on others, tries to get even, is avoided/rejected by peers. Tolerates only a minimum of questions about mood/behavior, reacts adversely if pressed, avoids talking about own problems. Developmental Pattern of People with ADHD Infancy: Very frequent crying, sleep difficulties, restless sleep, overactivity, difficult to soothe. Preschool: Inattentiveness, overactivity, temperamental/emotional, misconduct/aggression, rejection by peers. Elementary school: Overactivity, impulsivity, inattention, fidgeting, poor school achievement, low self-esteem, slightly below-average IQ, much subtest scatter/variability, clumsiness, dis-organization. High school: Restlessness, poor grades, rebelliousness, difficulty studying, lying, defiance, alco-hol/drug use, failure to graduate. Post-high school: Restlessness, poor concentration, impulsivity, motor vehicle accidents, alco-hol/drug abuse, antisocial personality patterns, low self-esteem, emotional/behavioral problems. (See “Characteristics of Adult ADHD,” below. )

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12. Abnormal Signs, Symptoms, and Syndromes 167ABNORMAL Sy MPTOMSAssessment For accuracy, multiple informants and multiple measures of the traits are essential (Du Paul, 2003). These can include teacher and parent ratings based on observations at school and in the home; computerized measurement of inattention and impulsivity; and medical, educational, and intellec-tual evaluations. Some commonly used rating scales include the following: ADHD Comprehensive Teacher Rating Scale (1991, 2nd ed. ) (ACTe RS; available at www. metritech. com/Metritech). ADHD scales from the parent report form of the Achenbach Child Behavior Check List (CBCL/6-18 and CBCL/11/2-5) and the Teacher's Report Form of the CBCL for ages 6-18 (all available at www. aseba. org). Barkley Home Situations Questionnaire and School Situations Questionnaire (available in Bar-kley & Murphy, 2005). Brown Attention Deficit Disorder Scales (2001), for ages 3 years-adult (available at pearsonassess-ments. com). Conners 3 (2008), with forms for child, parent, and teacher, for ages 6-18 (available at www. mhs. com or www. pearsonassessments. com). These are timed computerized tests: Conners Continuous Performance Test-II (available at www. mhs. com). Intermediate Visual and Auditory +Plus Continuous Performance Test for ages 6 years-adult, and IV A Advanced Edition Continuous Performance Test for adults (available at www. brain-train. com). Tests Of Variables of Attention (available at www. tovatest. com). The following tests are specifically designed to assess characteristics of ADHD in adults (see below): Amen's Adult ADHD Checklist (available at w3addresources. org/?9=node/43). Conners Adult ADHD Rating Scales (available at www. pearsonassessments. com). Possible Adverse Effects of Stimulant Medications Irritability, sad/weepy, anxious, “spaced-out”/blank stares. Withdrawn, isolates self, overly quiet. Unusually cheerful, talkative. Decreased appetite, difficulty falling asleep. Headaches, upset stomach, dizziness. Tics, twitches, nail biting, unusual limb movements. Characteristics of Adult ADHD Inattentive Type Difficulty initiating tasks, procrastination, indecision, avoiding tasks or jobs that require sus-tained attention. Chronic forgetfulness, poor time management, losing track of time, tardiness, taking on more tasks than he/she can complete, relying on a spouse or sibling for reminders of commit-ments and obligations. Difficulty recalling and organizing details required for a task, difficulty shifting attention from one task to another, difficulty multitasking. Hyperactive-Impulsive Type Prefers more active/stimulating jobs, avoids low-physical-activity or sedentary work. Frequent job changes, may work long hours or two jobs, underachievement despite ability.

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168 STANDARD TERMS AND STATEMENTS FOR REPORTS ABNORMAL Sy MPTOMSSeeks constant activity, easily bored, intense interest followed by boredom (even after substan-tial investments), inability to stick with long-term projects. Impatient, low frustration tolerance, easily irritated, loses temper easily/angers quickly, poor self-control. Interrupts others' conversations, heedless of the effects of statements on others. Impulsive, poor-quality/snap decisions without appropriate planning, irresponsible behaviors. Resources Tuckman (2007) and Resnick (2000) have written comprehensive books on ADHD in adults. Work Taking on too many projects to complete them, poor time management, frequent job changes, underachievement compared to peers or sibs (despite intelligence), intense interest fol-lowed by boredom (even after substantial financial commitment), inability to stick with long-term projects. 12. 4. Autism Spectrum Disorders The major relevant DSM-IV-TR codes are 299. 00, Autistic Disorder; 299. 80, Asperger's Disorder; and 299. 80, Pervasive Developmental Disorder Not Otherwise Specified. The major relevant ICD-9-CM codes are 299. 0, Autistic disorder; 299. 8, Other specified PDD (which includes Asperger's disorder); and 299. 9, Unspecified PDD. In addition to these disorders, the PDDs or ASDs include Rett's, and Childhood Disintegrative Disorders. They share many elements, some of which are listed below and may present with differ-ent severity. Aloneness Fails to develop attachment, no social smile, does not seek comforting from others or seeks it in strange ways when distressed/upset/frightened, ignores people, avoids eye contact and gaze monitoring, looks “through” people. Emotionally distant, no affection or interest when held, going limp/stiff when held, preoccu-pied so is neither receptive to nor defensive of touch, does not need caregiver, unaware of caregiver's absence. Lacks social give and take/reciprocity/turn taking/modulation/resonance/mutuality, marked lack of awareness of the existence of feelings in others (lacks a “theory of mind”), lacks imitation/pretend play, lacks parallel/social play, plays alone, ignores/withdraws from/does not return affection, uses others in mechanical way, no friendships, lacks understanding of social rules, little imagination. Relates to inanimate objects, carries objects, ritual behaviors (see below). Communication Delayed speech or muteness, lack of verbal spontaneity/sparse expressive speech, does not imitate or does it strangely/mechanically, echolalia (immediate or delayed). Affirmation by repetition (repetition of the question asked as agreement), pronoun reversal (refer-ring to self in second and third persons and by name), neologisms, extreme literalness or “metaphorical language” (e. g., using a specific “No” situation to mean all other “No” situa-tions), part-whole confusion (e. g., “ketchup” to mean dinner).

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12. Abnormal Signs, Symptoms, and Syndromes 169ABNORMAL Sy MPTOMSRituals and Compulsions Preservation of sameness: Change in any aspect of daily routine or surroundings leads to persistent crying or temper tantrum. Stereotypic behaviors: Manipulating things, rocking, hand flapping, tiptoe walking, spinning, twirling, staring at spinning things like fans. Unpredictable/bizarre behaviors: Lunging, darting, sudden stops, swaying, head rolling. 12. 5. Battered-Woman Syndrome See Sections 3. 2 and 3. 4 for questions about physical and sexual abuse, 3. 31 for questioning perpetrators, and 12. 1 for physical abuse risk factors. See also Section 12. 27, “Post Traumatic Stress Disorder. ” The relevant DSM-IV-TR codes are V61. 12, Physical Abuse of Adult/Sexual Abuse of Adult when abuse is by partner and focus is on the perpetrator); 995. 81, Physical Abuse of Adult (when focus is on the victim); and 995. 83, Sexual Abuse of Adult (when focus is on the victim). The relevant ICD-9-CM codes are V61. 12, Counseling for perpetrator of spousal and partner abuse, and V61. 11, Counseling for victim of spousal and partner abuse. Battered-woman syndrome is a result of Intimate P artner Violence and a form of PTSD. IPV is com-mon across all demographics; it should be routinely screened for and, when found, fully assessed. Mc Closkey and Grigsby (2005) offer detailed questions and procedures for evaluations of batterer, victim, lethality, and safety factors, as well as other relevant materials. Because 92% of a sample of battered women reported blows to the head, 40% reported loss of ü consciousness, and 77% reported some signs of Post Concussive Syndrome, Jackson et al. (2002) recommend that all cases should be evaluated for mild Traumatic Brain Injury and PCS. (See Section 12. 26 on PCS. ) Characteristics of Victims Denial or minimization of the details of the abuse. [Paralleling the perpetrator's sense of entitlement and his denial—of responsibility, of the fact that it is “abuse,” of its severity/ consequences, etc. ] Fear of accusations of being crazy/exaggerating/making it up, if she seeks help. Caught up in cycles of violence: violence, fear, placating, more violence or leaving, promises to change by the perpetrator, return to the relationship, etc. Low self-esteem (especially efficacy). Putting the perpetrator's needs first even at great cost to herself, remaining in a psychologically and physically harmful situation, passive and dependent behavior. Types of Partner Abuse Nonviolent: Overly calm talking, sulked, withdrew/isolated/ignored/shunned, yelled/swore, insulted, called names, threatened abandonment of children/support/obligations. Intimidation: Prevented movement/restrained freedom/denial of privacy, interrupted activi-ties, financial control. Threats of violence: Driving dangerously, with weapons, toward children/pets/spouse/rela-tives. Violence: Threw items, pushed, painful restraint, wrestled. Assault/battery: Slapped, kicked, bit, punched, choked, raped. Attempted murder: Severe beating, out of control, used weapon.

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170 STANDARD TERMS AND STATEMENTS FOR REPORTS ABNORMAL Sy MPTOMSTen Risk Factors Presence of two of these factors doubles the rate of families with no factors; with seven of these fac-tors, the rate is 40 times greater. However, remember that abuse occurs in all kinds of relationships, so always ask every client. (See Sections 3. 2 and 3. 4. ) The following list is based on Geller (1992). 1. Male is unemployed. 2. If employed, male has blue-collar occupation. 3. Male uses illicit drugs at least once a year. 4. He saw his father hit his mother. 5. He did not graduate from high school. 6. He is age 18-30. 7. Male and female have different religious backgrounds. 8. They cohabit and are not married. 9. They use severe violence toward the children in home. 10. Total family income is below poverty line. Bipolar I and II Disorders See Sections 10. 4 and 10. 5; see also Sections 10. 7, “Depression,” and 10. 9, “Mania. ” Bulimia Nervosa See Sections 3. 13, “Eating Disorders,” for questions, and 12. 14, “Eating Disorders,” for descriptors. 12. 6. Body Dysmorphic Disorder See Section 3. 7, “Body Dysmorphic Disorder,” for questions. The relevant DSM-IV-TR code is 300. 7, Body Dysmorphic Disorder (a somatoform disorder). The code in ICD-9-CM is the same, but BDD is categorized there as a type of hypochondriasis. BDD is also known as “dysmorphophobia,” “body dysmorphia,” or “dysmorphic syndrome. ” It affects men and women equally. It is often comorbid with depression and social phobia; associ-ated suicide risk is high. The best, most accessible, and most thorough resources are by Phillips (2004, 2009). Beliefs Preoccupied by a perceived defect in one or more physical features or general appearance, ugli-ness. Defect is believed to be easily noticeable by others as well. Emotions Embarrassed, ashamed, self-conscious, low self-esteem, fear of ridicule. Depression, social anxiety. Suicidal ideation. Behaviors Checking in mirrors/reflective surfaces, or refusal to be photographed/avoidance of mirrors. Repetitive, compulsive behaviors of examining, improving, or hiding the “defect. ” Excessive/elaborate grooming rituals, shaving, plucking, combing, skin picking.

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12. Abnormal Signs, Symptoms, and Syndromes 171ABNORMAL Sy MPTOMSCamouflaging with one's hand, postures, clothing, hats, or excessive makeup. Distracting with extravagant clothing or jewelry. Consulting dermatologists or plastic surgeons, undertaking painful or risky procedures. Critical comparisons with others, obsessive viewing of favorite celebrities or models. Excessive information seeking about the “defect. ”Repeatedly measuring or touching the “defective” part. Effects on Social Interactions Limited friendships, impaired occupational and/or social functioning. Social withdrawal/isolation, avoidance, dependency. Repeated requests for reassurance about the “defect. ”Avoiding social situations where the “defect” might be seen by others. Anxiety when with other people. Ruminations about appearance limit productivity. Muscle Dysmorphia This is seen primarily in males. Belief that body is puny, musculature inadequate/small. Compulsive working out, abuse of ana-bolic steroids and supplements. “Bigorexia,” “Adonis complex. ” 12. 7. Chronic Fatigue Syndrome The emphasis in CFS is on the fatigue, and that in fibromyalgia is on the pain, but many symptoms overlap. Persistent/interfering/debilitating fatigue, 50% or more decrease from premorbid activity level, easily and persistently fatigued after little exercise, abrupt onset of fatigue, not relieved by rest. Mild/low-grade fever, tender/palpable lymph nodes, inflammation of mucous membranes, sore throat, cough, chronic headaches, joint pain/muscle pain, diffuse pains, weakness. Irritability, confusion, poor concentration, depression, photophobia, sleep disturbances. A fine starting point for resources and learning about CFS is a page on the Centers for Disease Con-trol and Prevention site (www. cdc. gov/CFS/cfssymptoms HCP. htm). Chronic Pain Syndrome See Section 12. 23, “Pain Disorder/Chronic Pain Syndrome. ” 12. 8. Compulsions See Sections 3. 9, “Compulsions,” and 3. 19, “Obsessions,” for questions; see also Section 12. 21, “Obsessions,” for descriptors. The relevant DSM-IV-TR codes are 301. 4, Obsessive-Compulsive Personality Disorder, and 300. 3, Obsessive-Compulsive Disorder, whereas ICD-9-CM offers 301. 4, Compulsive personality disorder, and 300. 3, Obsessive-compulsive disorders. The Goodman et al. (1989) measure, the Y ale-Brown Obsessive Compulsive Scale, is available at many sites on the Internet. Greist et al. (1986) suggest this classification for rituals:

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172 STANDARD TERMS AND STATEMENTS FOR REPORTS ABNORMAL Sy MPTOMSCleaning of real or imagined contamination by dirt or germs (e. g., handwashing). Avoiding of contamination by rituals (to make unnecessary the need to clean). Repeating a ritual behavior a certain number of times. Completing a sequence of actions correctly. Restarting from beginning if interrupted. Checking and rechecking, especially locks, items of potential danger (e. g., knives, stove). Meticulousness about the exact and proper location of objects for balance or symmetry. Hoarding, collecting, or sorting or stacking of nonuseful objects (see below). Hoarding Hoarding is a compulsive disorder of collecting what appears worthless to others and adding to the collection until it is unmanageable, becomes dangerous, and interferes with normal life. People with this compulsion are usually perfectionistic and broadly indecisive, but they are often articulate and offer rationalizations. They may be embarrassed and promise to change, but cannot part with accumulations without treatment. (See www. ocfoundation. org/hoarding. ) People who hoard animals typically start with a few pets that they can manage; they then collect or breed more until the situation is unmanageable, abusive, and horrendous, but they cannot stop by themselves. Recidivism is almost 100%. ( See www. paws. org/help/report/hoarding. php. ) Summary Statements Client denied problems with common compulsions. Client engages in rituals for meals/sleep/dressing, house cleaning/washing/defecation, school or work tasks/other mental tasks, etc. Client feels compelled to repeatedly check the house/kitchen/windows/doors/locks/dangerous objects/children, etc. Client feels compelled to repeatedly touch/rub, count, order, arrange/rearrange objects. 12. 9. Conduct Disorder See also Sections 12. 22, “Oppositional Defiant Disorder,” and 13. 7, “Antisocial Personality. ” The relevant DSM-IV-TR codes are 312. 81, Conduct Disorder, Childhood-Onset Type; and 312. 82, Conduct Disorder, Adolescent-Onset Type. The relevant ICD-9-CM codes are 312. 0, Undersocialized conduct disorder, aggressive type; 312. 1, Undersocialized conduct disorder, unaggressive type; 312. 2, Socialized conduct disorder; 312. 81, Conduct disorder, childhood onset type; and 312. 82, Conduct disorder, adolescent onset type. In both DSM-IV-TR and ICD-9-CM, very similar symptoms are diagnosed as Antisocial Personality Disorder in adults. Aspects Will cheat/lie in order to win/be seen as the winner, believes others are against him/her or that he/she is being treated unfairly, makes an effort on a task or toward others only if it serves his/her interests, selfishly accepts favors without any desire to return them. Aggressive, violent, dangerous, assaults, fights with anyone, threatens, intimidates, bullies, lies/ cheats/breaks any rules, steals, denies truth/blames others, swears offensively/vulgarisms. Violence toward property: Vandalism, deliberate destruction of property known to belong to others, firesetting, stealing, shoplifting, burglary, theft/auto theft, joyriding, purse snatch-ing, armed robbery.

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12. Abnormal Signs, Symptoms, and Syndromes 173ABNORMAL Sy MPTOMSViolence toward people: Extortion/blackmail, physical cruelty to animals or people, mugging, assault, initiating physical fights, using a weapon. Running away, truancy, trading sex for money/goods/drugs, coerced sexual activities, substance use before age 13 and recurrent use after 13. Callousness, toughness, low frustration tolerance, temper, recklessness. Occasionally/often self-injuring without suicidal intent, self-mutilating. Occasional/single/repeated suicidal ideation/preoccupation/threats/gesture/attempt with/with-out clear expectation of death. Prognosis is worsened by ADHD, parental rejection, harsh discipline, absence of a father, delin-ü quent friends, and parental substance abuse. Cyclothymia See Section 10. 6, “Cyclothymia,” for descriptors. 12. 10. Delusions See Section 3. 10, “Delusions,” for questions; see also Sections 12. 24, “Paranoia,” and 12. 31, “Schizophrenia,” for descriptors. Degree of Confidence/Organization/Expression (↔ by degree) Faint/occasional suspiciousness, distrust, allusions to others' trickery or deceit, personalized meanings, ideas of reference, magical thinking, believes in but not in , pervasive distortions, convinced of the truth of , formed delusions/deluded, lives in a fantasy world. (↔ by degree) Fragmented, clustered, poorly organized, well organized, integrated, system-atized. The delusions are... denied, rejected, doubted, trusted, fixed. encapsulated, isolated, circumscribed, spreading, reinforced, extensive, comprehensive. expressed only with exceptionally trusted others/rarely/often/continually expressed. shared with family members. [Shared delusions are described as folie á deux or á trois; DSM-IV-TR and ICD-9-CM offer Shared Psychotic Disorder, 297. 3. ] Contents of Delusions1 2 3 4 grandiosity persecution poverty suicide somatic disease megalomania ideas of homicide hypochondriasis omniscience reference erotomania1approaching infection2 omnipotence being followed sexual identity death distorted body extraordinary being alleged lover image abilities influenced infidelity nihilistic fears foul odors3 self-importance misidentification jealousy self-deprecation disfigurement4 1De Clérambault-Kadinsky complex. 2For example, parasitosis. 3Bromosis. 4Dysmorphophobia. Distinguished from dissatisfaction with appearance.

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174 STANDARD TERMS AND STATEMENTS FOR REPORTS ABNORMAL Sy MPTOMSspecial relation-ship with famous person or deityspecial “lovesickness” self-accusation identity zooanthropic guilt voodoo alien control derogation occult special mission for goverment/ religionthoughts known shame communication to others sin with dead being ridiculed mind reading being watched blamelessness mental telepathy innocence foreknowledge psychokinesis neglect of an urgent responsibility Extra Sensory Perception caused harm to befall another contaminated others accidentally Distinguish delusions (demonstrably false, unshakeable, and idiosyncratic beliefs, not supported ü by the social reality of the client's culture or subculture; for examples, see above) from “overval-ued ideas” (idiosyncratic or shared beliefs that greatly influence the person's actions and seem exaggerated to the observer—e. g., morbid jealousy, racial superiority); from “illusions” (false but reasonable interpretations of perceptions—e. g., perceiving someone lurking in a shadow); from “pseudologica fantastica” (storytelling where the true and false, imaginary and real are mixed); and from “hallucinations” (perceptions without sensations or without an objective stimulus for the perception) (see Section 12. 17, “Hallucinations,” for examples). 12. 11. Denial Denial can be either adaptive or maladaptive. Breznitz (1988) identified several kinds of denial, which are listed below and illustrated with sample client statements. Type Example Denial of provided information “I never knew that. ” “No one ever told me about it. ” Denial of information about a threat “No one ever told me there was anything to worry about. ” “I never saw the risk involved. ” Denial of personal relevance (externalization)“That doesn't apply to me, only others. ” “I have nothing to worry about. ” Denial of vulnerability “Nothing bad will happen to me. ” Denial of urgency “There is no rush. ” “I can think about that later. ” Denial of emotion “I'm not afraid/angry/hurt/upset by it. ” Denial of the emotion's relevance “Yes, I'm scared, but there is no reason to feel that way. ” Other types of denial: of a problem's importance; of one's ability to change; of the problem's per-sistence; of the rationality or necessity of change.

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12. Abnormal Signs, Symptoms, and Syndromes 175ABNORMAL Sy MPTOMS12. 12. Depersonalization and Derealization See Section 3. 12, “Dissociative Experiences,” for questions. The major relevant DSM-IV-TR and ICD-9-CM code is 300. 6, Depersonalization Disorder. DSM-IV-TR also offers 300. 15, Dissociative Disorder NOS. ICD-9-CM offers 3. 15 as Dissociative disorder or reaction, unspecified. Note: ü Most symptoms of depersonalization and derealization can also be symptoms of temporal lobe epilepsy. 5 Reports observing self from a distance/corner of the room, feels as if outside one's body, body appears altered. Self-estrangement, extreme feelings of unreality/detachment from self/environment/surround-ings, floating in the sky, “dreaming”/living a dream, feels as if the world were not real, sometimes not part of the world, feels mechanical/robot-like. Experienced thoughts as not his/her own, felt as if body and mind were not linked. (↔ by degree) Daydreaming, fanciful story, trance, hysterical attack/episode, amnesia, fugue, somnambulism, automatic writing, out-of-body experience, dying and coming back, extra-terrestrial travel, previous lives lived. Note: ü Episodes are pathological if they are more frequent and of longer duration; occur with other symptoms; and are not related to single/severe psychological trauma, fatigue, sleep times, drug and alcohol use, medical illness, etc. Depression See Section 3. 5, “Affect/Mood,” for questions; see Sections 10. 7, “Depression,” and 12. 40, “Suicide,” for descriptors. Dissociative Identity Disorder See Section 13. 14, “Dissociative Identity Disorder. ” 12. 13. Dual Diagnoses See Section 12. 39, “Substance Use, Abuse, and Dependence,” for descriptors. Those with both a major Axis I disorder and substance abuse or dependence are said to have a “dual diagnosis. ” Synonyms include Mental Illness with Substance Abuse; Mental Illness with Chemical Abuse and Addiction; and Co-Occurring Disorder. (Less commonly, this term is used to refer to those with mental retardation and substance abuse or dependence. ) 12. 14. Eating Disorders See Section 3. 13, “Eating Disorders,” for questions. Anorexia Nervosa The relevant ICD-9-CM and DSM-IV-TR code is 307. 1, Anorexia Nervosa. (307. 50, Eating Disorder NOS [DSM-IV-TR] or Eating disorder, unspecified [ICD-9-CM], is used for cases that do not meet the full Anorexia Nervosa criteria. ) 5I am grateful to Frank O. Volle, Ph D, of Darien, CT, for this insight.

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176 STANDARD TERMS AND STATEMENTS FOR REPORTS ABNORMAL Sy MPTOMSPhysical Presentation Cachexia/cachectic, emaciated, amenorrhea, bradycardia, hypothermia, edema, weight loss of at least 15% without disease. Cognitive Aspects “Food phobia,” morbid fear of gaining weight/becoming fat, distorted and implacable attitudes toward food, avoidance of “fattening” foods, overvalued ideas of/dread of fatness, obses-sional, preoccupied with food, obsession with thinness. Dissatisfaction with bodily appearance, distorted body image (believes she/he is always too fat), denial of exhaustion/hunger/illness, fear of pubertal changes. “Positive” view of family, denial of family conflict, enmeshment with a parent. Perfectionism, self-disciplined, overly controlled, pride in weight management/self-inflicted starvation, overly critical of others, does not reveal feelings. Behavioral Aspects Laxative/diuretic misuse/abuse, fasting/starvation/restricted food intake, overexercising. Ritualized food habits (cutting food into very small pieces, chewing for long periods), eating only low-and no-fat/calorie foods. Social Aspects Shy, compliant, dependent. Sexual immaturity/inexperience. Less antisocial behavior than in Bulimia Nervosa. Mistrusting of professionals. Bulimia Nervosa The relevant ICD-9-CM and DSM-IV-TR codes are 307. 51, Bulimia Nervosa; 307. 50, Eating Disorder NOS (DSM-IV-TR) or Eating disorder, unspecified (ICD-9-CM). Physical Presentation Insomnia, constipation, lanugo, premature aging, hair loss, dental erosion due to acid vomitus, amenorrhea, dehydration, weight fluctuations, cardiovascular disorders, electrolyte imbal-ances, irregular menstrual periods. Near-normal weights (sometimes obese), great body weight fluctuations (≥20 lbs. ≥5 times). Cognitive Aspects Distorted/irrational body image, overconcern with body appearance/shape/weight, dissatisfac-tion with bodily appearance, fear of obesity [and this does not decrease as weight drops]. Inability to think clearly, dichotomous thinking, overpersonalization, perfectionism, rational-ization of eating/symptoms. Low self-esteem; weight central to self-evaluation, feels powerlessness about weight, lifelong dieting, self-loathing, disgust over body size. Awareness that eating pattern is abnormal, preoccupation with food, craving/urges/hungers. Behavioral Aspects Purchases large quantities of food that suddenly “disappear,” makes such purchases/eating “on the spur of the moment,” other people's food “disappears,” many takeout meals. Frequently eats large quantities/high-calorie foods yet does not gain weight.

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12. Abnormal Signs, Symptoms, and Syndromes 177ABNORMAL Sy MPTOMSHyperactivity, overexercising. Frequent weighing, attendance at weight control clinics. Overuse of laxatives/diuretics/cathartic/thyroid preparations/appetite suppressants. Junk food consumption, binge eating, vomiting, sneaking binges, severely restrictive diets/fast-ing. Shoplifting, sexual acting out, suicide attempts. Social Aspects Eating alone due to embarrassment over amount eaten, frequent trips to bathroom (for purg-ing). High achievement, academic success. Oversensitivity to criticism, fragility, vulnerability. Affective Aspects Mood swings, impulsivity, depression, masked anger, specific affective precipitants of binge. Feeling disgusted with self/self-deprecation, depressed/guilty/distressed over binge eating/ vomiting. Other Aspects These factors may or may not matter: Diet's composition (various foods or only some such as sweets, salty, snacks, etc. ). Dissociative qualities (“numb,” “spaced out”). Higher-than-usual levels of various psychopathologies and medical conditions. Binge-Eating Disorder DSM-IV-TR offers Binge-Eating Disorder as a diagnosis for further study. It is not in ICD-9-CM. Eats larger quantity than normal, eats rapidly, eats alone, irritation or self-disgust after overeat-ing, doesn't purge. Obesity See “Weight” in Section 7. 1, “Appearance. ” Pica Eats nonfood items: dirt, worms/insects, feces, etc. Additional Note People with eating disorders may and do present as morbidly obese, overweight, average-weight, ü underweight, maintaining periodic control, or unable to control compulsive eating. They may present with only obsession over body size, weight, and shape; grazing, bingeing, compulsive dieting, or starving; overexercising, vomiting, and/or laxative/diuretic abuse; use of food as reward or for comfort; use of diet pills, quick-loss schemes, and/or medical/surgical interven-tions; etc. A full investigation is therefore necessary. They are all very likely to have disordered eating habits and distorted beliefs about body image, effects of food on mood, and dietary rules. Conditions that do not meet all of the DSM criteria for any of the eating disorders are very com-mon and should be diagnosed as Eating Disorder NOS. Explosive Disorder See Section 12. 19, “Impulse-Control Disorders. ”

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178 STANDARD TERMS AND STATEMENTS FOR REPORTS ABNORMAL Sy MPTOMSExtra Pyramidal Symptoms See Section 12. 36, “Side Effects of Psychotropic Medications/Adverse Drug Reactions. ” 12. 15. Fetal Alcohol Syndrome Typical diagnostic features of FAS are (1) thin upper lip, (2) absent or indistinct philtrum (the verti-cal depression under the nose), and (3) short palpebral fissures (the horizontal length of the eyes' openings between the lids). Height and weight are typically below the 10th percentile from birth. Also commonly found are a flat midface with flat nasal bridge and upturned nose tip, underdevel-oped upper ears, narrow forehead, microcephaly, deformities of the fingers, toes, and brain. Common psychological phenomena include mental retardation, developmental delays, poor speech, impulsiveness, incoordination, and ADHD. FAS is the most common cause of mental retardation and the leading preventable cause of birth defects in the United States. Consuming any amount of alcohol during any part of pregnancy is considered likely to result in a defect diagnosed as a F etal Alcohol Spectrum D isorder. A short but comprehensive article can be found at www. aafp. org/afp/20050715/279. html, and a large resource website is that of the U. S. government's FASD Center (www. fasdcenter. samhsa. gov ). 12. 16. Gambling The relevant ICD-9-CM and DSM-IV-TR code is 312. 31, Pathological Gambling. Gambling that war-rants professional attention may also be called “addictive,” “compulsive,” or “problem” gambling. The genders are equally affected, although their courses may differ; in addition, men generally gamble for the excitement and action, while women gamble to cope with stressors. High rates of comorbid substance abuse and suicidality are found. Recreational gambling is very common among teens and students, and may progress after a big win to pathological gambling. Summary Statements His thoughts and speech are filled with stories of and plans for gambling. Her gambling is compulsive— anxiety-controlling, depression-reducing, showing habituation, felt as an irresistible impulse, chronic and repetitive, concealed, demonstrating supersti-tions/special techniques/rituals, etc. He shows the typical cognitive distortions of gamblers: Overconfidence in his ability to predict the outcomes, irrational expectations of a “big win” to compensate for losses/start over fresh, feeling “lucky,” superstitions, illusions of control or prediction of the outcome of a bet, poor sense of probabilities, selective recall, minimization of losses. Her emotional reactions include remorse, lessened ambition, motivation, or efficiency. Gambling has been used to compensate for frustration or disappointment, to escape worry or troubles, to celebrate good fortune. His gambling has been harmful to his family/career/reputation. She has missed work to gamble. He/she has borrowed money to gamble, sold items for money to gamble, gambled for money to pay debts, gambled until the money ran out, considered/committed a crime for money to gamble. The South Oaks Gambling Screen (Lesieur & Blume, 1987) is a reliable assessment device of 20 items and is available at several sites on the Internet. DSM-IV-TR offers 10 criteria to distinguish recreational from pathological gambling.

Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf

12. Abnormal Signs, Symptoms, and Syndromes 179ABNORMAL Sy MPTOMS12. 17. Hallucinations See Section 3. 15, “Hallucinations,” for questions, and 12. 31, “Schizophrenia,” for more descriptors. Hallucinatory experiences are common before sleep (hypnagogic) and on partial awakening ü (hypnopompic), and also in temporal lobe epilepsy. 6 Sensory Modalities Modalities are listed here in rough order of prevalence. Auditory: Noises or voices, whistling/ringing, familiar sounds, whispering, one's name being called. Visual: Unformed/lights/flashes, formed/people/things/animals. (One variant is micropsia/Lil-liputian hallucinations—the perception of objects' being much smaller but retaining all detail. Seen in delirium tremens. ) Olfactory: Disgusting/repulsive/objectionable odors (e. g., of death or disease). 7 Kinesthetic: Twisting, churning, pains, phantom limb. Gustatory: Poisons, acids, metallic tastes, foul tastes. Visceral/somatic: “Hollow insides,” “rotting insides,” “made of glass. ”Vestibular: Falling, flying, lightness. Much less commonly seen are these: Synesthesia: Blending of sense impressions (e. g., “It smells red”). Extracampine: Impossible visual sensations, such as seeing someone behind oneself (Most common in Lewy body dementia. ) There are dozens more. In the case of voices, note whose they are (if this can be identified), what their sex and age seem ü to be, and whether they are clear or muffled. Note also the content of utterances (disconnected words, client's own thoughts, remarks addressed to client, etc. ); Schneider (1959) noted that audible thoughts, voices arguing, and voices commenting are diagnostically most important. Nature Informative, friendly, benign, comforting, helpful, socially focused. Arguing, dialoguing/conversing among themselves, commenting on thoughts/behavior/motives. Condemning, malevolent, accusatory, persecutory, harassing, hateful, spiteful, berating, threat-ening, menacing, terrorizing. Seductive, premonitory, hortatory/imperative/commanding/compelling/controlling, consum-ing. Attitudes toward Hallucinations (↔ by degree) Ego-alien, frightening, terrifying, “bizarre,” resisted/struggled against, engages in conversations/dialogue with imaginary interlocutor, comforting, familiar, ego-syntonic, accepted. (↔ by degree) Convinced of their reality, vivid fantasy, “altered state,” impossibility, “only a fantasy,” doubting its reality/own perceptions, making various efforts to control/cope with it, “rare. ” 6I am grateful to Frank O. Volle, Ph D, of Darien, CT, for this perspective. 7Olfactory hallucinations are common in temporal lobe epilepsy as auras.

Edward L. Zuckerman PhD - Clinicians Thesaurus 7th Edition_ The Guide to Conducting Interviews and Writing Psychological Reports The Clinicians Toolbox 2010.pdf