Final Exam

1. Please explain the central determining factors that will lead you to diagnose a client with an Axis I vs. an Axis II disorder? While there are numerous variables and facets distinguishing a clinician s capacity to diagnose clients with disorders respective to Axis I or Axis II, several distinctions should be explored and conceptualized with a client prior to adefinitive diagnosis. Together, clients with Axis I and Axis II diagnoses share some level of impairment, however the etiology of that impairment varies greatly between the two. The trajectory of human development involves the formation of a foundational blueprint for individual thinking, perceiving, feeling and behaving. Altogether, the aforementioned phenomena comprise an individual s personality. Depending on the individuals experience, this process of personality formation can be dynamic and on going or arrested through the life span. In the latter case, the past developmental experience serving as the impetus for arrested personality development results in a chronic and pervasive means of functioning that is characteristic of an individuals inherent personality as opposed to the onset or presence of an mental illness. Thus, an Axis II diagnosis presents as a chronic, inflexible and pervasive pattern of maladaptive personality characteristics while Axis I diagnoses presents in a more acute and dynamic fashion. The acuity of symptoms in anAxis I client is prognostically critical as it indicates a level of client distress and an insight into their connection with reality. Meanwhile, insight in the Axis II client is virtually absent due to the ego-syntonic nature of their symptomology, which is commonly perceived as an integral, acceptable or rational part of their being. With Axis I clients, the maladaptive functioning or impairment is often mediated by environmental variables that increases their receptiveness to treatment. Therefore, an Axis I client may be able to communicate some insight regarding the onset, frequency, duration or intensity of their symptoms whereas the Axis II client may only exhibit behaviors indicative of a developmental stage at which their growth became stunted. As such, Axis II client s functioning or experience is consistent regardless of present environmental variables, which complicate their treatment trajectories and responsiveness to those treatments. One of the most significant barriers impeding clinical work with Axis II clients is the frequent employment of primitive defense mechanisms. The more frequent, severe and primitive the defense mechanism(s) utilized, the more likely the client s diagnosis fits on Axis II.

Maxmen& Ward (2009) Personality or character refers to longstanding, deeply ingrained patterns of thinking, feeling, perceiving and behaving. Axis II = psychopathological. Personality traits are so excessive, inflexible and maladaptive that they cause significant distress or impairment. Axis II is chronic, consistent, developmental and resistant to treatment. Intensity may fluctuate, but chronic. Are considered ego-syntonic & nonpsychotic (except for APD +BPD) because they are seen as integral and acceptable parts of the individual. Axis I (Mental Disorders) tend to be more acute, florid and responsive to treatment. *Advantage of separating Axis I and Axis II is the prevention of confusion between the acute/florid presentation of Axis I and the chronic/subtle Axis II symptomology. y y y y y y Poor attachment style, poor reality testing & weakened/no sense of self Ego is fragmented or cohesive = fragmented personality on developmental trajectory Ego support extensive work with ego support before beginning work with ego modicationb The Big Five Personality Classification System o Introversion, Disagreeableness, impulsiveness, neuroticism and rigidity Object constancy? A linear sense of time? Something is arrested in development o Primitive functioning, o Defenses and o Understanding of reality Rarely is a clinician able to diagnose an Axis II disorder after one session because hallmark of Axis II is the pervasiveness of pathology/symptoms, which do not dissipate from session to session. Pattern of Axis II behavior/symptomology develop in either adolescence or early adulthood Enduring/Pervasive pattern of inner experience and behavior that deviates markedly from expectations of the individual s culture Symptoms pervasive and inflexible Interfere with social and occupational functioning. Endlessly looking for meaning in life *Environment has little variability on diagnosis or pathology of client Unconscious is primitive on Axis II More often, Client s presentation of insight indicates Axis I diagnosis, whereas Axis II client presents no insight Level of incongruency inform both: o Relationship with reality or lack there of o The primitive level of the diagnosis

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Evaluating defenses: o Axis II defense used in rigid, inflexible and exclusive manner o Motivation for using the defense comes from compulsion to fulfill past needs than present or future reality. Defense mechanisms protect individuals from intimacy + truth which would result in the: o Axis II client = ANIHILATION o Axis I = Marked DISCOMFORT o *Useful to note because they serve as landmines for treatment and impact treatment accordingly by level Primitive Functioning Important assessment questions: o How long have you been feeling this way? o What are the intensity, frequency and/or duration of the symptoms or problem behaviors o Have environmental factors been considered possible explanations?

Axis I Discomfort Distress Neurotic Self object differentiation Lack of self object differentiation = primitive & Axis II Annihilated Primitive Psychotic

Axis II

Ability to utilize relationships with an individual (e.g., caregiver) without the physical presence of the individual to self-sooth: INTERNALIZATION Internalization ------------------------------------------------------------- Introjection

Capacity to tolerate ambivalence w/o Splitting, distancing, devaluing Own voice present and loudest

Two-dimensional internal objects Arrested development Objects are concrete, Not abstract outside of image

2. Illuminate your understanding of what case conceptualization means to you and the role that diagnosis plays in that idea? Conceptualization of a client serves as the foundation for all work with individuals or families in a clinical setting. Because mental illness is one of the only illnesses that are prematurely treated, reliably assessed and ultimately diagnosed, conceptualization is not a terminal process, but instead a journey of understanding the client s experiences. While the information gathered in the process informs a potential diagnosis, a valid diagnosis requires a clinician s thorough understanding of the etiology, course of development, presence of mediating psychosocial variables, patterns of functioning and historical relevance rooted in the conceptualization of the client. By thoroughly exploring the aforementioned, a clinician increases the precision and validity of their diagnosis while ensuring the most appropriate trajectory of client treatment, which equally impacts the prognosis of a client s presenting problems. Case conceptualization involves a relentless dedication to the exploration of a client s current, past and future experience of self and reality. By engaging a client in the exploratory process, seemingly subjective details, cognitions, perceptions and affect can be organized in a collaborative and systematic fashion. Organizing the content presented by a client is both linear and abstract. Content should be assessed for patterns, themes and correlations as they relate to both the client sand clinician s experience (e.g., countertransference). Considering the salience of duration in the majority of DSM-IV-TR diagnostic criteria, the timing, historical significance and consistency of the themes or patterns presented by the client should as well be assessed in relation to the content itself. For example, Client A has a seemingly irrational fear of authority figures, but after further exploration, Client A reveals that as a child she was removed from her home by the police/child protective services and has not seen her parents ever since. In sum, organizing and assessing the content presented by a client into a historical or somewhat sequential narrative provides the clinician with insight and a means for systematically categorizing the presenting challenges experienced by the client. It is with the insight and understanding gained through the aforementioned process that informs a client diagnosis when necessary. A diagnosis is critical because it informs, guides and determines the client s treatment. More often than not, a treatment regiment is costly and requires some assistance from an insurance body, whether it is public or private. Regardless, assistance from an insurance company to cover mental illness treatment requires a diagnosis. By default, the interaction required to gain meaningful insight into a client s experience is also an opportunity to experience and analyze countertransference, which is invaluable to the assessment of a client. Case conceptualizations are predominantly discussed as relevant to guiding the clinician s work with a client. However, I think that the process of formulating a comprehensive case conceptualization through rigorous exploration is simultaneously

beneficial to the client s understanding of self when executed properly. That is, when a clinician provides clients with the space and opportunity (e.g., relentless open questions for insight, exploration, clarification etc) to verbally make sense of their own internalized cognitions, the potential for self-actualization is increased and clients are empowered.

Considering the salience of duration in the majority of DSM-IV-TR diagnostic criteria, the time and consistency of the themes or patterns presented by the client can be assessed in relation to content. Conceptualizing the narrative and experience of a client allows both the client and the clinician to assess and organize patterns in the clients experience through dialogue.

Maxman& Ward (2009) Disorders should have a natural history a typical age of onset, life course, prognosis and complications. A diagnosis should reflect the etiology orgins of the disorder and the pathogenesis course of development of the condition. Although the same disorder may arise in more than one way, a diagnostic category should indicate whether the disorder runs in families, is genetically transmitted, initiated by psychosocial forces, and exacerbated or aggravated by specific biological or environmental conditions. Ultimately, the aforementioned inform and determine treatment. Because mental illness is one of the only illnesses that is often treated before adequately assessed and because of the dynamic nature of mental illness, one intake session or assessment does not negate misdiagnoses. When starting with a whole deck of cards , the process of differential diagnoses is flushed out with case conceptualization. In turn, the case conceptualization informs the diagnosis which guides treatment. Conceptualization informs prognosis, treatment trajectory, Axis IV and goals for treatment y y y y What exceeds the boundaries of routine experience : better way to consider deviance Effort to turn the subjective into objective Patterns that appear atypical are made typical by our shared understanding of them Diagnosis is important for several reasons: o Informs treatment& prognosis

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o Shared language in multi-disciplinary settings typifying most institutions today o Insurance purposes o Axis IV allows for the inclusion of psycho-social stressors that are often overlooked or unattended to. Prior to diagnosis, we must determine who or what needs to be diagnosed: o Information we gather from client o Reports from family members o Own experience of client o Relationships maintained by client and an assessment of those relationships Questions for assessment: o How long have you been feeling this way o What are the frequency, intensity and duration of the symptoms or problem behaviors o Are there environmental stressors o Ability to obtain clear, narrative history when client is unclear, it becomes diagnostic Conceptualization is founded in the events leading to a clients current level of functioning Termination, like all other purposeful behavior in a theraputic dyad, is based off of the case conceptualization what each action means for a respective client Counter transference informs a case conceptualization

3. Describe one preconception you had about a particular disorder and how that has shifted since you have taken this course.