Clinician’s Thesaurus: The Guide to Conducting Interviews and Writing Psychological Reports 8th Edition, ISBN-13: 978-1462538805

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Clinician’s Thesaurus: The Guide to Conducting Interviews and Writing Psychological Reports 8th Edition, ISBN-13: 978-1462538805

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• Publisher: ‎ The Guilford Press; Eighth edition (April 16, 2019)
• Language: ‎ English
• 400 pages
• ISBN-10: ‎ 1462538800
• ISBN-13: ‎ 978-1462538805

Hundreds of thousands of students and early-career professionals have relied on this authoritative report-writing tool, now updated for DSM-5/ICD-10-CM and newer types of evaluations. In a convenient 8″ x 10.5″ format, the book covers nearly all areas of concern addressed in intakes, evaluations, treatment plans, progress notes, and closing summaries. The user seeking the right wording for a clinical document can skim and select from thousands of technical terms, behavioral descriptors, and standard statements. Also provided are interview questions for almost every symptomatic behavior, a huge collection of mental status questions, a reproducible Mental Status Evaluation summary form, and links to hundreds of internet resources. The companion website offers all the URLs from the book, the reproducible forms, and a handy reference on current psychiatric medications.

New to This Edition:

* A list of all psychiatric ICD-10 diagnoses (all of the codes in DSM-5, plus many more), including Z codes essential to a comprehensive biopsychosocial evaluation.

* Sample evaluation report keyed to the book’s chapters.

* Sections on additional clinical issues: intimate partner violence, gender identity, human trafficking, recovery-oriented language, and more.

* Many more Internet links, including a wide variety of screening and assessment tools.

Table of Contents:

Half Title Page

Title Page

Copyright

About the Author

Contents

Acknowledgments and an Invitation

Getting Oriented to the Clinician’s Thesaurus

What Is the Clinician’s Thesaurus and What Does It Do?

How This Book Is Organized

Internet Resources in the Clinician’s Thesaurus

Understanding the Style and Format of the Chapters

Example of a Report Constructed with the Clinician’s Thesaurus

Some Ways to Use the Clinician’s Thesaurus

A Cautionary Note and Disclaimer

A Functional Guide to Report Construction

The Nature of Reports, the Steps of Their Construction, and the Corresponding Portions of the Clinic

Sample Report Using the Clinician’s Thesaurus

Further Guidelines and Advice on Report Writing

Part I. Conducting a Mental Health Evaluation

1. Beginning and Ending the Interview

1.1. Structuring the Interview

1.2. Introducing Yourself and Noting Possible Communication Difficulties

1.3. Assessing the Client’s Understanding of the Interview Situation

1.4. Obtaining Informed Consent

1.5. Other Points for All Interviews

1.6. Eliciting the Chief Concern/Complaint/Issue

1.7. Eliciting the Client’s Understanding of the Problem

1.8. Dimensionalizing the Concern/Problem

1.9. Ending the Interview

1.10. Collections of Tools for Screening and Monitoring

2. Mental Status Evaluation Questions/Tasks

2.1. Introduction to the Mental Status Questions

2.2. Background Information Related to Mental Status

2.3. Rancho Los Amigos Cognitive Scale

2.4. Screening Tests for Cognitive Impairment

2.5. Orientation

2.6. Attention

2.7. Concentration

2.8. Comprehension of Language

2.9. Eye–Hand Coordination/Perceptual–Motor Integration/Dyspraxia/Constructional Ability

2.10. Memory

2.11. Fund of Information

2.12. Opposites

2.13. Differences

2.14. Similarities/Analogies

2.15. Absurdities

2.16. Calculation Abilities

2.17. Abstract Reasoning/Proverbs

2.18. Paired Proverbs

2.19. Practical Reasoning

2.20. Social Judgment

2.21. Decision Making

2.22. Self-Image

2.23. Insight into Disorder

2.24. Strengths and Coping

2.25. Mental Status Evaluation Checklist

3. Questions about Signs, Symptoms, and Other Behavior Patterns

3.1. Introduction to the Questions about Signs, Symptoms, and Behavior Patterns

3.2. Abuse (Nonsexual)/Neglect of an Adult (Partner or Elder)

3.3. Abuse (Sexual) of an Adult

3.4. Affect/Mood

3.5. Anxiety

3.6. Body Dysmorphic Disorder

3.7. Compliance–Noncompliance with Treatment

3.8. Compulsions

3.9. Delusions

3.10. Depression

3.11. Dissociative Experiences

3.12. Eating Disorders

3.13. Gay, Lesbian, and Bisexual Identity Inquiry

3.14. Gender Identity

3.15. Gender Identity: Transgender and Gender-Nonconforming

3.16. Hallucinations

3.17. Illusions

3.18. Impulse Control

3.19. Mania

3.20. Obsessions

3.21. Organicity/Cognitive Disorders

3.22. Pain, Chronic

3.23. Paranoia

3.24. Phobias

3.25. Self-Injury

3.26. Sexual History

3.27. Sleep

3.28. Substance Abuse: Drugs and Alcohol

3.29. Substance Use: Tobacco and Caffeine

3.30. Suicide and Self-Destructive Behavior

3.31. Violence

Part II. Standard Terms and Statements for Wording Psychological Reports

A. Introducing the Report

4. Beginning the Report: Preliminary Information

4.1. Heading and Dates for the Report

4.2. Sources of Information for the Report

4.3. Identifying Information about the Client

4.4. Self-Sufficiency in Appearing for Examination

4.5. Consent Statements

4.6. Reliability/Validity Statements

4.7. Confidentiality Notices

4.8. Ethical Considerations in Report Writing

5. Referral Reasons

5.1. Statement of Referral Reason

6. Background Information and History

6.1. History/Course of the Present Problem/Illness/Chief Complaint/Concern

6.2. Medical History and Other Findings

6.3. Personal, Family, and Social Histories, and Current Social Situation

6.4. Adjustment

6.5. Social History for a Disability Examination

6.6. Family Genogram/Family Tree/Pedigree

B. The Person in the Evaluation

7. Behavioral Observations

7.1. Appearance

7.2. Clothing/Attire

7.3. Movement/Activity

7.4. Speech Behavior

7.5. Other Behavioral Observations

8. Responses to Aspects of the Examination

8.1. Reaction to the Context of the Evaluation

8.2. Attention/Concentration/Effort

8.3. Response to the Methods of Evaluation/Tests/Questions

8.4. Persistence/Motivation

8.5. Relationship with the Examiner

8.6. Response to Success/Failure/Feedback

9. Presentation of Self

9.1. Dependency–Surgency

9.2. Presence/Style

9.3. Self-Image/Self-Esteem

9.4. Social Sophistication/Manners

9.5. Warmth–Coldness

9.6. Other Aspects of Self-Presentation

10. Emotional/Affective Symptoms and Disorders

10.1. General Aspects of Mood and Affects

10.2. Anger

10.3. Anxiety/Fear

10.4. Bipolar I Disorder

10.5. Bipolar II Disorder

10.6. Cyclothymia

10.7. Depression

10.8. Guilt/Shame

10.9. Mania

10.10. Panic

10.11. Seasonal Affective Disorder

10.12. Sexual Interest

10.13. Other Affects/Emotional Reactions

11. Cognition and Mental Status

11.1. No Pathological Findings: Summary Statements

11.2. Arithmetic

11.3. Attention

11.4. Concentration/Task Persistence

11.5. Consciousness Levels

11.6. Decision Making

11.7. Dementia

11.8. Executive Functions

11.9. Information

11.10. Insight

11.11. Intelligence and Cognition: Assessment

11.12. Intelligence Scores: Classifications

11.13. Memory

11.14. Moral/Social Judgment and Knowledge

11.15. Orientation

11.16. Reality Testing

11.17. Reasoning/Abstract Thinking/Concept Formation

11.18. Social Maturity

11.19. Stream of Thought

11.20. Test Judgment: Summary Statements

11.21. Other Summary Statements for Cognitive Components of Mental Status

12. Abnormal Signs, Symptoms, and Syndromes

12.1. Abuse

12.2. AIDS Dementia Complex

12.3. Attention-Deficit/Hyperactivity Disorder

12.4. Autism Spectrum Disorders

12.5. Body Dysmorphic Disorder

12.6. Chronic Fatigue Syndrome/Myalgic Encephalomyelitis

12.7. Compulsions

12.8. Delusions

12.9. Denial

12.10. Depersonalization and Derealization

12.11. Dual Diagnoses

12.12. Eating Disorders

12.13. Fetal Alcohol Syndrome

12.14. Gambling

12.15. Hallucinations

12.16. Hoarding

12.17. Hypochondriasis

12.18. Illusions

12.19. Impulse-Control Disorders

12.20. Intimate Partner Violence/Domestic Violence

12.21. Malingering

12.22. Obsessions

12.23. Pain Disorder/Chronic Pain Syndrome

12.24. Paranoia

12.25. Phobias

12.26. Postconcussive Syndrome

12.27. Posttraumatic Stress Disorder

12.28. Premenstrual Dysphoric Disorder

12.29. Rape Trauma Syndrome

12.30. Schizophrenia

12.31. Self-Injurious Behavior

12.32. Sexual Impulsivity/Addiction/Compulsion, Hypersexuality

12.33. Side Effects of Psychotropic Medications/Adverse Drug Reactions

12.34. Sleep Disturbances

12.35. Stalking

12.36. Substance Use, Abuse, and Dependence

12.37. Suicide

12.38. Trafficking in Persons

12.39. Violent Behaviors

13. Personality Patterns

13.1. Models of Personality Diagnosis

13.2. Adult Children of Alcoholic/Addicted Parents

13.3. Antisocial Personality

13.4. Authoritarian Personality

13.5. Avoidant Personality

13.6. Borderline Personality

13.7. Codependent Personality

13.8. Compulsive Personality

13.9. Dependent Personality

13.10. Dissociative Identity Disorder

13.11. Histrionic Personality

13.12. Narcissistic Personality

13.13. Normal/Healthy Personality

13.14. Obsessive Personality

13.15. Paranoid Personality

13.16. Passive–Aggressive Personality

13.17. Sadistic Personality

13.18. Schizoid Personality

13.19. Schizotypal Personality

13.20. Self-Defeating Personality

C. The Person in the Environment

14. Activities of Daily Living

14.1. Assessment

14.2. Assistance Level Required/Degree of Independence

14.3. Child Care

14.4. Chores/House Care/Domestic Skills

14.5. Cooking

14.6. Financial Skills

14.7. Hazard Recognition and Coping

14.8. Living Situation/Level of Support Needed

14.9. Quality of Performance

14.10. Self-Care Skills

14.11. Shopping

14.12. Transportation

14.13. Caregiver Burden

14.14. Summary Statements

15. Social/Community Functioning

15.1. General Lifestyle

15.2. Involvement in Social/Community Activities

15.3. Problems/Conflicts in Community Relating

16. Couple and Family Relationships

16.1. Systemic Family Constructs

16.2. Assessment of Families at Intake

16.3. Family Interviewing Method

16.4. Child Rearing/Raising: Aspects

16.5. Couple Relationships: Aspects

17. Vocational/Academic Skills

17.1. Basic Work Skills

17.2. History of Work

17.3. Language Skills: Reading and Writing Ability

17.4. Math Ability

17.5. Special Considerations for Disability Reports

17.6. Vocational Competence/Recommendations

18. Recreational Functioning

18.1. Entertainment: TV/Radio/Online Programming/Music

18.2. Hobbies

18.3. Sports

18.4. Reading Materials

18.5. Participation/Performance Quality

19. Other Specialized Evaluations

19.1. Bariatric Surgery

19.2. Coping Ability/Stress Tolerance

19.3. Culturally Sensitive Formulations

19.4. Financial Competence/Competence to Manage Funds

19.5. The Refugee Experience

19.6. Religious and Spiritual Concerns

D. Completing the Report

20. Summary of Findings and Conclusions

20.1. Overview

20.2. Beginning the Summary

20.3. Summary of Previous Information

20.4. Relevant Findings and/or Conclusions

20.5. Diagnostic Statement

20.6. Consultations and Further Evaluations

20.7. Summarizing Treatment

21. Diagnostic Statement/Impression

21.1. ICD and DSM

21.2. Introduction to the Reference List of Psychiatric Diagnoses

21.3. Qualifiers for Diagnosis

21.4. The Reference List of Psychiatric Diagnoses from ICD-10-CM

22. Recommendations

22.1. Need for Treatment/Medical Necessity of Treatment

22.2. Offering Effective Treatments

22.3. Treatment Options/Case Disposition

22.4. Types of Therapies/Services

23. Prognostic Statements

23.1. General Prognostic Statement

23.2. Other Statements

24. Closing Statements

24.1. Value of the Information

24.2. Thanking the Referrer

24.3. Continued Availability

24.4. Signature, Etc.

24.5. Disclaimer

Part III. Useful Resources

25. Treatment Planning and Treatment Plan Formats

25.1. The Flow and Nature of Treatment Planning

25.2. Some Advice on Writing Treatment Plans

25.3. Various Formats for Treatment Plans

25.4. A Treatment Plan Format for Case Conceptualization

25.5. Treatment Plan Components for Clients with Substance Abuse

25.6. Treatment Plan Components for Crisis Interventions

25.7. The Recovery Paradigm and Its Language

25.8. Checklist of Strengths

25.9. Outcome Measures/Goal Achievements

26. Formats for Reports, Evaluations, and Summaries

26.1. A Standard Format for Reports of Evaluations

26.2. Format for Psychodynamic Evaluations: Developmental Model

26.3. The Psychodynamic Diagnostic Manual–2 Format

26.4. Themes for Evaluations from an Existential Perspective

26.5. Formats for Therapy Notes

27. Listing of Common Psychiatric and Psychoactive Drugs

27.1. Lists of Medications by Trade and Generic Names

27.2. Street Drugs’ Names

27.3. Results of Medication Treatment: Descriptors

27.4. Drug Resources for the Clinician

28. Psychiatric Masquerade of Medical Conditions

28.1. Introduction

28.2. Anxiety

28.3. Sexual Dysfunction

28.4. Depression

28.5. Mania

28.6. Organic Brain Syndrome/Dementia

28.7. Psychosis

28.8. Medication-Induced Psychiatric Conditions

Appendices

A. Abbreviations in Common Use

A.1. Clinicians/Mental Health Professionals

A.2. Treatment

A.3. Diagnoses and Conditions

A.4. Relations

A.5. General Aids to Recording

A.6. Legal Terms

A.7. Medication Regimens

B. Annotated Readings in Assessment, Interviewing, and Report Writing

Assessment

Interviewing

Report Writing and Person-First Language

Feedback Solicitation Form

References

Index

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