Abnormal Psychology - Clinical Persps. on Psych. Disorders, 6th ed. - R. Halgin, et. al., (McGraw-Hill, 2010 WW-81-85

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54 Chapter 2 Classifi cation and Treatment Plans

cultures, psychological disorders may be expressed as par- ticular patterns of behavior, perhaps refl ecting predominant cultural themes that date back for centuries, known as culture-

bound syndromes. For example, “ghost sickness” is a preoc-

cupation with death and the deceased that is reported by members of American Indian tribes. This phenomenon in- cludes a constellation of extreme bodily and psychological reactions ( Table 2.5 ). Such symptoms would have a different meaning if reported by a middle-class White person, rather than by an American Indian. Third, the clinician takes into account how events are interpreted within the individual’s cultural framework. An event may be extremely stressful to members of a given culture who attribute signifi cant mean- ing to that event. In contrast, members of another cultural group may have a more neutral interpretation of that event. For example, within certain Asian cultures, an insult may provoke the condition known as amok, in which a person (usually male) enters an altered state of con- sciousness in which he becomes violent, aggressive, and even homicidal.

Fourth, the cultural supports available to the client form a component of the cultural formulation. Within certain cul- tures, extended family networks and religion provide emo- tional resources to help individuals cope with stressful life events.

By including culture-bound syndromes, the authors of the DSM-IV-TR took a fi rst step toward formal recognition of variations across cultures in the defi nition of abnormal behavior. Critics believe that the DSM-IV-TR did not go far enough and that, in the future, these syndromes should be incorporated into the more general diagnostic nomenclature.

Such a step requires further research specifi cally aimed at taking a multicultural approach both to diagnosis and treat- ment (Mezzich et al., 1999).

In recent years there have been important advances in understanding how cultural factors infl uence mental health. In fact, advances have been made in the very defi - nition of culture. Prior to the 1990s, researchers in the area of cultural psychopathology tended to view a given expres- sion of distress as residing within the specifi c ethnocultural group. More recent conceptualizations of culture attend much more to people’s social world than past views of culture. Cultural investigators now focus on “people’s daily routines and how such activities are tied to families, neighborhoods, villages, and social networks” (Lopez &

Guarnaccia, 2000, p. 574). In this newer conceptualization of culture, researchers and clinicians move away from fl at, unidimensional notions of culture and focus instead on a richer kind of cultural analysis—paying attention to how factors like social class, poverty, and gender affect mental health.

In practical terms, it would be insuffi cient for a clinician writing a cultural formulation to simplistically attribute cer- tain mental health problems to the client’s ethnicity. Con- sider the anxiety condition reported in Latinos known as ataque de nervios, which involves various dramatic expres-

sions of distress such as trembling, crying, and uncontrol- lable shouting in response to a disturbing life event related to family or signifi cant others. Researchers initiated system- atic investigations of ataque de nervios, focusing on how the social world interacts with psychological and physical pro- cesses in the individual. Particularly interesting was the fi nd- ing that this condition is not actually a cultural syndrome or clinical entity residing in individuals, but is rather “a com- mon illness that refl ects the lived experience largely of women with little power and disrupted social relations” (Lopez &

Guarnaccia, 2000, p. 581).

Apart from the role of cultural factors in the formula- tion, clinicians must also take cultural factors into account when conceptualizing the treatment relationship they will have with clients. The clinician should take care not to make assumptions about how the client would like to be treated, based on the clinician’s cultural background. Seemingly minor aspects of the relationship, such as how familiar the clinician acts toward the client, may have tremendous bear- ing on the rapport that is established in their relationship.

In some cultures, for example, it would be regarded as rude for the clinician to use an individual’s fi rst name. Another aspect of the relationship that can be affected by cultural factors is the role of eye contact. The clinician should be aware of whether people within the client’s culture make eye contact during conversation. It could be erroneous for the clinician to assume that a client’s lack of eye contact implies disrespect.

Attention to all of these factors helps the clinician for- mulate a diagnosis and treatment that are sensitive to cul- tural differences. Going a step further, clinicians can benefi t from becoming familiar with the culture-bound syndromes such as those in Table 2.5 . If some of these seem bizarre to you, think about how someone from another culture might regard conditions that are prevalent in Western cul- ture, such as eating disorders. You might also think about

In the process of developing a case formulation, clinicians know that it is important to be aware of the ways in which the client’s age, gender, and ethnicity may be salient.

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The Diagnostic Process 55

TABLE 2.5 Culture-Bound Syndromes in the DSM-IV-TR

Certain psychological disorders, such as depression and anxiety, are universally encountered. Within particular cultures, however, idiosyncratic patterns of symptoms are found, many of which have no direct counterpart to a speciﬁ c DSM-IV-TR diagnosis. These conditions, called culture-bound syndromes, are recurrent patterns of abnormal behavior or experience that are limited to speciﬁ c societies or cultural areas.

Culture-bound syndromes may ﬁ t into one or more of the DSM-IV-TR categories, just as one DSM-IV-TR category may be thought to be several different conditions by another culture. Some disorders recognized by the DSM-IV-TR are seen as culture-bound syndromes, because they are speciﬁ c to industrialized societies (e.g., anorexia nervosa).

This table describes some of the best-studied culture-bound syndromes and forms of distress that may be encountered in clinical practice in North America, as well as the DSM-IV-TR categories they most closely resemble.

Term Location Description DSM-IV-TR Disorders Amok Malaysia Dissociative episode consisting of brooding followed by

violent, aggressive, and possibly homicidal outburst.

Precipitated by insult; usually seen more in males. Return to premorbid state following the outburst.

Ataque de Latin America Distress associated with uncontrollable shouting, crying, tremb - Anxiety nervios ling, and verbal or physical aggression. Dissociation, seizure, Mood

and suicidal gestures possible. Often occurs as a result of a Dissociative stressful family event. Rapid return to premorbid state. Somatoform Bilis and Latin America Condition caused by strong anger or rage. Marked by

colera disturbed core body imbalances, including tension, headache, trembling, screaming, and stomach disturbance.

Chronic fatigue and loss of consciousness possible.

Bouffée West Africa Sudden outburst of agitated and aggressive behavior, Brief psychotic délirante and Haiti confusion, and psychomotor excitement. Paranoia and

visual and auditory hallucinations possible.

Brain fag West Africa Difﬁ culties in concentration, memory, and thought, usually Anxiety experienced by students in response to stress. Other Depressive symptoms include neck and head pain, pressure, and Somatoform

blurred vision.

Dhat India Severe anxiety and hypochondriacal concern regarding semen discharge, whitish discoloration of urine, weakness, and extreme fatigue.

Falling out Southern A sudden collapse, usually preceded by dizziness. Conversion or United States Temporary loss of vision and the ability to move. Dissociative

blacking out and the

Caribbean

Ghost sickness American A preoccupation with death and the deceased. Thought to be Indian tribes symbolized by bad dreams, weakness, fear, appetite loss,

anxiety, hallucinations, loss of consciousness, and a feeling

of suffocation.

Hwa-byung Korea Acute feelings of anger resulting in symptoms including insomnia, (wool-hwa- fatigue, panic, fear of death, dysphoria, indigestion, loss of byung) appetite, dyspnea, palpitations, aching, and the feeling of a

mass in the abdomen.

Koro Malaysia An episode of sudden and intense anxiety that one’s penis or vulva and nipples will recede into the body and cause death.

Latah Malaysia Hypersensitivity to sudden fright, usually accompanied by symptoms including echopraxia (imitating the movements and gestures of another person), echolalia (irreverent parroting of what another person has said), command obedience, and dissociation, all of which are characteristic of schizophrenia.

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56 Chapter 2 Classifi cation and Treatment Plans

TABLE 2.5 Culture-Bound Syndromes in the DSM-IV-TR (continued)

Term Location Description DSM-IV-TR Disorders Mal de ojo Mediterranean Means “the evil eye” when translated from Spanish. Children

cultures are at much greater risk; adult females are at a higher risk than adult males. Manifested by ﬁ tful sleep, crying with no apparent cause, diarrhea, vomiting, and fever.

Pibloktog Arctic and Abrupt dissociative episode associated with extreme excitement, sub-Arctic often followed by seizures and coma. During the attack, the Eskimo person may break things, shout obscenities, eat feces, and communities behave dangerously. The victim may be temporarily withdrawn

from the community and report amnesia regarding the attack.

Qi-gong China Acute episode marked by dissociation and paranoia that may psychotic occur following participation in qi-gong, a Chinese folk health-

reaction enhancing practice.

Rootwork Southern Cultural interpretation that ascribes illness to hexing, witchcraft, United States, or sorcery. Associated with anxiety, gastrointestinal problems, African weakness, dizziness, and the fear of being poisoned or killed.

American and

European

populations,

and Caribbean

societies

Shen-k’uei Taiwan and Symptoms attributed to excessive semen loss due to frequent or Shenkui China intercourse, masturbation, and nocturnal emission. Dizziness,

backache, fatigue, weakness, insomnia, frequent dreams, and sexual dysfunction. Excessive loss of semen is feared, because it represents the loss of vital essence and therefore threatens

one’s life.

Shin-byung Korea Anxiety and somatic problems followed by dissociation and possession by ancestral spirits.

Spell African Trance state in which communication with deceased relatives or American and spirits takes place. Sometimes connected with a temporary European personality change.

American

communities in

the southern

United States

Susto Latinos in the Illness caused by a frightening event that causes the soul to leave Major depressive United States the body. Causes unhappiness, sickness (muscle aches, stress Post-traumatic stress and Mexico, headache, and diarrhea), strain in social roles, appetite and Somatoform Central sleep disturbances, lack of motivation, low self-esteem, and

America, and death. Healing methods include calling the soul back into the South America body and cleansing to restore bodily and spiritual balance.

Taijin Japan Intense fear that one’s body parts or functions displease, kyofusho embarrass, or are offensive to others regarding appearance,

odor, facial expressions, or movements.

Zar Ethiopia, Somalia, Possession by a spirit. May cause dissociative experiences Egypt, Sudan, characterized by shouting, laughing, hitting of one’s head

Iran, and other against a hard surface, singing, crying, apathy, withdrawal, North African and change in daily habits.

and Middle

Eastern societies

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.

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the meaning of these culture-bound syndromes for our understanding of abnormal behavior. The fact that psycho- logical disorders vary from one society to another supports the claim of the sociocultural perspective that cultural fac- tors play a role in infl uencing the expression of abnormal behavior.

her problems with her father, she has had academic diffi cul- ties all semester. Tomorrow she has an important exam, and she is panic-stricken.

Now, consider what you would do in helping your friend.

Your fi rst reaction would be to help her calm down. You might talk to her and try to get her in a better frame of mind, so that she will be able to take the exam. However, you would also realize that she has other problems, which she will need to attend to after she gets through the next day.

In the short term, she needs to catch up on the rest of her course work. Over the long term, she will need to deal with the diffi culties that recur between her and her father. A clini- cian treating a client would also think in terms of three stages: immediate management, short-term goals, and long- term goals.

In dealing with immediate management, the clinician addresses the most pressing needs at the moment. Short- term goals involve change in the client’s behavior, thinking, or emotions but do not involve a major personality restruc- turing. Long-term goals include more fundamental and deeply rooted alterations in the client’s personality and relationships.

These three stages imply a sequential order, and in many cases this is the way a treatment plan is conceived.

First the clinician deals with the crisis, then handles prob- lems in the near future, and fi nally addresses issues that require extensive work well into the future. However, in other cases, there may be a cyclical unfolding of stages. New sets of immediate crises or short-term goals may arise in the course of treatment. Or there may be a redefi nition of long- term goals as the course of treatment progresses. It is per- haps more helpful to think of the three stages not as consecutive stages per se, but as implying different levels of treatment focus.

Immediate management, then, is called for in situa- tions involving intense distress or risk to the client or oth- ers. A person experiencing an acute anxiety attack would most likely be treated on the spot with antianxiety medica- tion. A client who is severely depressed and suicidal may need to be hospitalized. In the case of Peter, Dr. Tobin decides that Peter’s possible dangerousness to others war- rants hospitalization. Furthermore, his manic symptoms of irrational behavior and agitation suggest that he needs intensive professional care. Not all clinical situations re- quire that action be taken in the immediate management stage, but it is important for the clinician to think about various options to help the client deal with pressing concerns of the moment.

When a client’s most troubling symptoms are under control, it is possible for the clinician to work with the cli- ent in developing more effective ways of resolving current diffi culties. The plan at this point might include establishing a working relationship between the clinician and client, as well as setting up specifi c objectives for therapeutic change.

If Dr. Tobin is to treat Peter’s mood disorder, she must

REVIEW QUESTIONS

1.

What term is used to describe a series of simply yes/no questions that lead to a diagnosis?

2.

____________ is an analysis of the client’s development and the factors that might have infl uenced his or her current psychological status.

3.

When clients present with psychological symptoms that seem to be rooted in their particular ethnic, religious, or cultural backgrounds, how does a clinician approach diagnosis?

Treatment Planning 57

Treatment Planning

We have discussed the steps through which a clinician develops an understanding of a client’s problem. This understanding provides the basis for the clinician’s next phase, which is to plan the most appropriate treatment for the client. In an optimal situation, the clinician has the client’s cooperation in addressing several questions regard- ing treatment choices: What are the goals of the treat- ment? What would be the best treatment setting? Who should treat the client? What kind of treatment should be used? What kind of treatment is fi nancially feasible and available? Finally, What theoretical orientation would be best suited to the client’s particular needs? All of these considerations would form Dr. Tobin’s treatment plan for Peter as she moves from the diagnostic phase toward the treatment phase.

Goals of Treatment

The fi rst phase of treatment planning is to establish treat- ment goals, which are the objectives the clinician hopes to accomplish in working with the client. These goals range from the immediate to the long term. To understand this critical phase of the process, put yourself in the shoes of a clinician for the moment and think of an analogous situ- ation in which you are trying to help a friend through a crisis. Although you are not “treating” your friend in a pro- fessional sense, the steps you take would be very much like the approach a clinician takes with a client in developing a treatment plan. Let’s say this friend knocks on your door late one night, in tears because she has had another of her many arguments on the phone with her father. Because of

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R E A L S T O R I E S

PATTY DUKE: MOOD DISTURBANCE

A

t the beginning of this chapter, you began reading about Peter Dickinson, a man whose wild mood swings caused him to lose control over his thinking and behavior. Peter was experiencing the symptoms associated with a serious mood disturbance called bipolar disorder. This technical label might not be familiar to you; the condition is more commonly, in non- professional discussions, called manic- depressive illness. Patty Duke, a legend- ary star of stage and screen, brought international attention to the seriousness and prevalence of this condition when she began speaking and writing pub- licly about her struggles with it.

The story of Patty Duke’s fame dates back to her early childhood, when her managers renamed the young Anna Marie in an attempt to make her sound

“perkier.” Patty/Anna became a celebrity while starring on Broadway as Helen Keller in The Miracle Worker and sub- sequently in a popular television series, The Patty Duke Show, in which she played the dual role of identical cousins.

She was a talented and proliﬁ c actress, appearing in more than 50 ﬁ lms and winning numerous awards, including a People’s Choice Award and an Oscar.

Although she achieved an enormous level of success both on stage and in the movies, Patty Duke’s personal life was turbulent for more than three de- cades. Her father suffered from alcohol- ism and had trouble holding down jobs.

He left home when Patty was 6 and she rarely saw him afterward. He died at age 50, leaving Patty to carry an emo- tional pain she still feels. Patty also speaks of her mother’s depression, which was so severe that her mother re- peatedly threatened to kill herself and had to be hospitalized. Patty also describes her mother as having an explo- sive temper that occasionally led to physical abuse, particularly of Patty’s brother, Raymond.

As a child, Patty Duke was interested in becoming a nun and had very little interest in acting until she was signed by professional managers John and Ethel Ross, a demanding duo who insisted that Patty’s career would go nowhere without their direction. In the early days of her working with the Ross couple, Patty would go to their luxurious apartment after school for coaching.

Eventually she moved in with them, and at their insistence, Patty’s contact with her family diminished; eventually the only times Patty saw her mother were when she came to the Ross household to do housework or to baby-sit Patty.

In her adult years, Patty Duke had a number of troubled relationships and two failed marriages. Perhaps partly due to her turbulent childhood, she experienced wild mood swings that often left her feeling either sad and hopeless or energetic and agitated. Her mood disorder was ﬁ nally diagnosed when Patty was 35, and she came to understand the nature of her swings between suicidal depression and the soaring manic highs. Once she began taking lithium, she began to feel normal for the ﬁ rst time in her life.

She also decided to revert to her birth name, Anna.

In the passages that follow, taken from her autobiography A Brilliant Madness: Living with Manic Depressive Illness, Anna/Patty describes some of her experiences.

In the depressions, I was interested only in pleasing, but even that didn’t make me feel satisﬁ ed. For instance, let’s say I would cry all Friday night, Saturday night, Sunday—then Mon- day, get up and go to work, do a good job, but on the way home Monday night I’d be crying again, more fearful, more fretful.

There were times when this leveled off, but I never knew what made it stop, what made the crying stop, what made me not be afraid that day. I also didn’t question it. Once things seemed to be okay, I didn’t mess with it. This was also a way to deal with the shame attached to that kind of behavior. It’s everyone’s shame, the family’s as well. It’s as if we said, “Oh, okay, it’s stopped now, let’s not talk about it anymore.” Number one, talking might bring it back, and number two, it’s just too embarrassing to look at. But the depressions always came back. They defi ned my life. During this time I became very clever about how to obtain and stockpile pills—tranquilizers, usually Valium. At home, I picked fi ghts with Harry; then I would fl y into the bathroom and swallow half a bottle of whatever pills I had. . . .

The mania started with insomnia and not eating and being driven, driven to ﬁ nd an apartment, driven to

“do” New York, driven to see every- body, driven to never shut up. The ﬁ rst weekend I was there, Bobby Kennedy was assassinated. . . . I had an over- whelmingly out-of-proportion reaction to his assassination. I know those were insane times and we all had enormous reactions to those assassi- nations, but for me it was as if he had been my brother or my father. This is not an exaggeration—at least two weeks went by without sleep.

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