Assessment 10 Project 2 Needs Assessment Community Name Saint Helena Island Description of the community needs Saint Helena Island found within the county of Beaufort, South Carolina. The city is scenically and has a string reservation of the culture of antebellum. There is a reconstruction monument that symbolizes the after civil war reconstruction. There are military establishments that are located in Beaufort, such as the US Naval Hospital, Paris Island, and the Marine Air Station. Two thousand eighteen census statistics indicate the population of the area as being 188,715 within the city boundaries. The racial distribution stands at Asians being 1.4 %, African Americans 18.2 %, and whites 77.9%. The possible needs for this population are providing affordable facilities, proper care to help those in the community that is suffering from substance abuse. Another need is eliminating the ongoing violence in the community. Community Needs that are Currently Being Met The community needs that are currently being met are the mayor and police department working together to try to cut down the crime rate for a safer community. Beaufort County Sheriff Department is working with the community and taking the necessary steps to provide more safety checks, holding town hall meetings to educate the community, and providing safety tips on how to stay safe. Youth and adult males ages 18- 50 would benefit from seeking assistance from Human Services. Substance abuse is one of the biggest problems in the community, and seeking help from human services professionals would be beneficial. Services available to the population is a program provided through the Department of Social Services. The program provides referrals to the local outpatient treatment center, which allows people to return home, and send those that are willing to Morris Village located in Columbia, SC, which is a temporary live-in facility. The program provides referrals to the local outpatient treatment center, which allows people to return home, and send those that are willing to Morris Village located in Columbia, SC, which is a temporary live-in facility. The program provides referrals to the local outpatient treatment center which allows people to return home, and send those that are willing to Morris Village located in Columbia, SC which is a temporary live in facility. Community that were identified as not being met or population not being served Thecommunity is not being served as it should be because of the lack of facility treatment centers in the community. Crimes are something else that needs to be addressed in the community. The police are slow in the process of stopping and solving crimes in a timely matter. The community is afraid to come forward because of the lack of protection. Funding and facilities are needed to help the people in the community overcome their addiction, which needs to be affordable for people without insurance. There is only one facility in the ...

1. Assessment 10
Project 2
Needs Assessment
Community Name
Saint Helena Island
Description of the community needs
Saint Helena Island found within the county of Beaufort, South
Carolina. The city is scenically and has a string reservation of
the culture of antebellum. There is a reconstruction monument
that symbolizes the after civil war reconstruction. There are
military establishments that are located in Beaufort, such as the
US Naval Hospital, Paris Island, and the Marine Air Station.
Two thousand eighteen census statistics indicate the population
of the area as being 188,715 within the city boundaries. The
racial distribution stands at Asians being 1.4 %, African
Americans 18.2 %, and whites 77.9%. The possible needs for
this population are providing affordable facilities, proper care
to help those in the community that is suffering from substance
abuse. Another need is eliminating the ongoing violence in the
community.
Community Needs that are Currently Being Met
The community needs that are currently being met are the mayor
and police department working together to try to cut down the
crime rate for a safer community. Beaufort County Sheriff
Department is working with the community and taking the
necessary steps to provide more safety checks, holding town
hall meetings to educate the community, and providing safety

2. tips on how to stay safe. Youth and adult males ages 18- 50
would benefit from seeking assistance from Human Services.
Substance abuse is one of the biggest problems in the
community, and seeking help from human services professionals
would be beneficial. Services available to the population is a
program provided through the Department of Social Services.
The program provides referrals to the local outpatient treatment
center, which allows people to return home, and send those that
are willing to Morris Village located in Columbia, SC, which is
a temporary live-in facility. The program provides referrals to
the local outpatient treatment center, which allows people to
return home, and send those that are willing to Morris Village
located in Columbia, SC, which is a temporary live-in facility.
The program provides referrals to the local outpatient treatment
center which allows people to return home, and send those that
are willing to Morris Village located in Columbia, SC which is
a temporary live in facility.
Community that were identified as not being met or population
not being served
Thecommunity is not being served as it should be because of the
lack of facility treatment centers in the community. Crimes are
something else that needs to be addressed in the community.
The police are slow in the process of stopping and solving
crimes in a timely matter. The community is afraid to come
forward because of the lack of protection. Funding and facilities
are needed to help the people in the community overcome their
addiction, which needs to be affordable for people without
insurance. There is only one facility in the city, and before you
are allowed to attend, you have to be referred by a professional.
For those who need more advanced treatment, the closet facility
is three hours away, and it is not affordable for people without
insurance. The city of Beaufort or Saint Helena Island does not
provide these kinds of treatment facilities locally. Families have
to drive their loved one long distances to get the help that they
need. The people are not getting help, and they continue to

3. cause problems in the community. Head-on collisions, drug
overdose, rape, and shootings are some of the issues that the
community is experiencing. The community needs to be
addressed through appropriate planning to face these challenges
(Mannix et al, 2018).
Choose and identify one unmet need
Theunmet need that I choose for my project would be providing
facilities that help the people of the community with substance
abuse.
Project 3
Program Design
A logic model is a road map or rather a graphic depiction which
presents diverse shared relationships among the impact,
outcomes, outputs, activities as well as the resources for the
program (Hossain, et.al, 2016). In the figure below:
Question/Decision
Activity/Process
Activity/Process
Yes
No
Ending Symbol
No
Referral
Drop Out
Terminate
· An arrow connects another process, question, or ending
symbol.
· Dotted arrows reflect returning to a previous step.
· Three methods for closing a case are
1. The agency could make a referral to another agency
2. The client could voluntarily discontinue

4. 3. The agency could terminate the client
In addition to the above chart, another model that shows diverse
activities which the program is supposed to include to address
the need include the purpose or mission of the model, the
context, the inputs or resources, activities or interventions, the
outputs and the effects or results. This model is shown below:
or interventions, the outputs and the effects or results. This
model is shown below:
Referral
Sources
Is the client appropriate and eligible?
Intake on assessing the referral
Is the referral suitable?
Does the agency and client approve the plan?
Development of an intervention plan
Facility
Agency No
No
Close case/referral
Are goals met?
Follow up/ Monitor external Referrals
Does the agency Meets the needs of the clients
Coordinate Services

5. Resolve Barriers or refer another service
Close Case
If the client continues and willing to accept terms of the
program, an intervention plan involving the achievement of
specific objectives gets agreed upon mutually between the
agency and the client; a plan will be put in motion and move
forward from there. After treatment and the client is released
from the facility. The staff will do follow-ups, and coordinate
with other agencies if necessary, to prevent relapse. If the client
does not agree to terms of the program or becomes a client and
the goals are not met as agreed, and the client is not willing to
participate as agreed upon, the contract will become null and
void, and the case will be closed.
If the client continues, an intervention plan involving the
achievement of specific objectives gets agreed upon mutually
between the agency and the client.
· Is there only one pathway, or are there multiple pathways
through the system?
· Is the client willingly ready to set their goals and follow
through?
· After going through intake, if the client is referred to a
specialist, must the client return to a central point before going
on to a second specialist, or can the first specialist make a
direct referral?
· Can a client go directly to a specialist, thus bypassing a
central intake?

6. · How permeable are the agency’s boundaries to admitting
people (e.g., eligibility requirements, waiting lists, and
bureaucratic “red tape”)?
· What alternative pathways are open to clients if their
conditions change or their objectives are not met?
· If certain objectives are met, but others are not, what does the
agency do?
· Can clients who prematurely discontinue be recycled back into
the agency’s program at a later point?
.
In the human services field, the person or entity paying for the
service is usually not the consumer of the service (except in
those few instances where clients pay full fee). Because many
organizations experience more demand for their service than
what their resources will allow, because dissatisfied clients who
leave the agency can be replaced by someone else on a waiting
list, and because funding limitations force agencies to reduce
services, agency staff may tend to treat their consumers with
less care and consideration (Hasenfeld, 2015). The
term customer is used as a metaphorical expression to convey
the importance of treating people with care and dignity. One
should be cautious, however, about applying too literally the
language of business in designing human service programs.
Asking staff, for example, to refer to their homeless clients, or
adolescent delinquents, or substance-abusing service consumers
as "customers," could feel awkward and insincere.
A more open-ended approach is to use the Internet so that
people can describe what they like if they are current consumers
or what services they would like if they were to use your
program in the future. Provide an easily accessible part of the
website for people to request more information or for making
suggestions about your services. Also, make sure that someone
responds daily. A word of caution: do not over-rely on the
Internet to obtain feedback on the services. Not all consumers
can access the Internet, and be mindful that overusing internet

7. surveys can be perceived as pestering.
Project 4
Implementation Plan and Funding
Board of Directors/Board of Trustees is governance for human
services organizations; they are there to protect the
organization. According to (Hoefer & Watson, 2014), there are
four ways the board of trustees governs human service
organizations. Facilitating that the government attains the
expected legal obligations, while in operation as per its vision
and mission, as well as shielding the assets of the business. It is
there to ensure the organization is operating efficiently and
ensuring that the perspectives and viewpoints of the members
are represented. The responsibilities of the board fall into four
major categories: Legal and fiduciary,
1. Legal and fiduciary,
2. Oversight,
3. Fundraisers, and
4. Representation of constituencies and viewpoints.
Funding came come from several sources, such as block grants,
annual festivals, and state funds.
Since there is greater competition for resources, it affects
human services because non-profit superintendents tend to
function in a field that has rare properties as well as augmented
rivalry for those resources. Funding from the government at
local, state, and federal levels are strained as a result of
political burden in a bid to reduce the rates of taxes. Contracted
payments to non-profit organizations are often delayed for
months, causing non-profits to face financial problems (Watson
& Hoefer, 2014). In human services, the number of skills being
required is higher for human service agencies because the range
of skills needed to cope in such an environment; its need is
more demanding. Administrators should be knowledgeable in
budgeting, community collaboration, and fundraising. The need
for evidence-based practices is important to receive funding and
resources; the organizations must become more effective in how

8. they serve the needs of clients, and how it can be measured,
which is why their use of technology is important and has been
incorporated in organizations.
I have looked into different funding for my program, and I
would contact the pharmaceutical makers like Procter & Gamble
for assistance for annual funding and/or scholarships to help
with the cost of my program since they are the makers. I will
consider contacting NACAR since they are sponsors of Jack
Daniels and other alcohol distributers for assistance. The Food
and Drug Administration is another option I will consider
contacting for scholarships and funds for my program. They
may be willing to offer funds, grants, or contribute other ways
in helping patients that do not have money or medical insurance
to cover expense not covered by the program. With the funds in
place, the facility will be equipped and fully stocked with all
the required medications, sufficient beds for the clients, lab,
and other equipment needed to keep the facility fully running.
The long-term I hope to achieve in my program is to establish at
least five partnerships on favorable terms over five years.
Accomplishing this goal, I can have a sufficient amount of
sponsors needed to keep the funds coming in to support the
facilities and their needs. I will promote flyers, ads, and other
educational sources showing the dangers of alcohol and drugs,
and display signs showing the penalty and consequences of it,
by doing this it will help to control some of the substance abuse
in the community. Budget control is something needed to make
sure the funds are used for the sole purpose of the program, and
not for things that do not contribute much to the program. By
keeping track of the spending, it will keep the budget under
control, money would be saved, and there would be no
unnecessary spending.
Organizing a yearly festival in the community is something that
I will invest in. Having a festival will help the staff to get
familiar with the community and understand their wants and
needs while raising money and having fun. Media coverage such
as television, radio, and the local newspaper is also something

9. that will help to put my program out there. Some people are not
aware that the program exists, and it is there to help the people
of the community. Putting this information out there not only
helps the people, but it could bring in more sponsors.
Leaders use data to promote a number of things, such as
community awareness, activities, and accomplishments.
Possible ways that I could use data relevant to each of my
objectives would be through process measures, observation, and
feedback. I will have an event log that will cover events such as
the planned annual festival, media coverage, and marketing.
Each staff member will be given a log to keep up with dates; it
would have records of who was involved, people that
contributed, and the outcome of the event. Observation will be
used to collect data by observing how the program is going, is
everything done correctly, and what areas need to be improved.
Lastly, there is feedback. I would look for feedbacks from
places like social media to get information about their opinion,
wants needs, and insights. This shows that you care and value
them as the people of the community, which will make more
people interested and come forth, making the program more
successful, and it will keep the funds coming in.
Wk 5 - Case Study Assessment
Review the case studies in chapters 4, 5, and 6 of The Clinical
Assessment Workbook.
Choose one case study to use in completing this assignment.
Complete the University of Phoenix Material: College of Social
Sciences Master of Science in Counseling Biopsychosocial
Assessment DSM-5.
Note: Access the Biopsychosocial Assessment via the College
of Social Sciences Resources website > Marriage, Family &
Child Therapy > Biopsychosocial Assessment.

10. Include a brief conceptualization of the case. Your total
response should be between 700 and 1,050 words.
4 Bipolar and Related Disorders
Bipolar and Related Disorders (BP) is now an independent
category in the DSM-5, separating it from Depressive Disorders
with placement immediately after Schizophrenia Spectrum and
Other Psychotic Disorders. This move reflects a growing
understanding of dimensionality in many disorders, with overlap
in terms of symptoms and other risk factors along a continuum
of severity. The seven mental disorders covered in this section
are characterized as chronic, taxing, disruptive, and
multifactorial involving mood lability and extremes of behavior.
The term multifactorial disorder refers to one caused by the
interaction of genetic and environmental factors. Mood
lability is defined as frequent or intense changes or shifts in
mood over a short time period (APA, 2013).
This section of the DSM-5 is generally organized around three
different types of episodes that, in turn, serve as building blocks
for determining specific diagnoses. An episode is a period of
time during which a client evidences a particular set of
symptoms and as a result, experiences a pronounced alteration
in mood and/or a change in his or her social, vocational, and
recreational functioning. Specifically, the three episodic states
are major depressive, manic, and hypomanic. Some changes
from the previous version of the DSM include replacement of
the Mixed Episode criteria with a Mixed Features Specifier that
can be applied to all episode types in Bipolar I and/or Bipolar II
disorder. Also, With Anxious Distress Specifier was added for
use when at least two out of five anxious distress symptoms are
present (see criteria, APA, 2013, p. 149) during the majority of
the most recent episode (depressive, manic, hypomanic) as it
was associated with greater suicide risk, lengthier illness
period, and partial to nonresponse in treatment. Additionally,
the criteria for mania and hypomania were refined to help

11. alleviate some confusion around what constitutes an episode
across the entire developmental spectrum, including the
addition of changes in energy/activity as a core symptom. The
goal was to imbue a lifespan perspective and to adjust
diagnostic criteria to achieve a better fit when treating
individuals with bipolar disorder (APA, 2013).
The most disruptive disorders in this cluster include Bipolar I
(manic and major depressive episodes) and Bipolar II
(hypomanic and major depressive episode). Each is diagnosed
based on the number and pattern of episodes the individual has
experienced in his or her lifetime. In the coding of each
disorder, attention is given to the severity of symptoms and
specific characteristics of the most recent episode. Cyclothymic
Disorder represents a more chronic condition that is generally
less disruptive to the individual's functioning. By definition, a
set of symptoms severe enough to meet criteria for one of the
three major episodes is not present. In Cyclothymic Disorder, an
alternating pattern of mood states is present but not as severe as
major depressive or hypomanic episodes (APA, 2013).
Two of the diagnoses in this section are determined by the
etiological factors relevant to the illness. Specifically,
Substance/Medication-Induced Bipolar Disorder is used when
the problematic bipolar episode is directly related to the use of
a recreational drug, prescribed medication, or a toxin (e.g.,
lead, carbon monoxide). Similarly, Bipolar and Related
Disorder due to Another Medical Condition is used when a
bipolar episode is directly related to a diagnosable organic
problem (APA, 2013).
The final two diagnostic categories in this chapter include
Other Specified Bipolar and Related Disorder and Unspecified
Bipolar and Related Disorder. First, Other Specified Bipolar
and Related Disorders category is used when an individual's
symptoms fail to fit any of the more specific diagnoses in this
category and the clinician wishes to provide the reason for this,
which must also be provided. This category may be especially
helpful when assessing children, whose bipolar symptom

12. presentation may not meet the specific criteria for another
bipolar disorder. Some examples of such presentations include:
“Short-duration hypomanic episodes (2–3 days) and major
depressive episodes; Hypomanic episodes with insufficient
symptoms and major depressive episodes; Hypomanic episode
without prior major depressive episode; and Short-duration
cyclothymia (less than 24 months)” (for details see APA,
2013 p. 148). Meanwhile, Unspecified Bipolar and Related
Disorder is used when the individual's symptoms are similar to
bipolar related disorders but they fail to meet the full criteria
for any disorder in this category and the clinician chooses not to
specify the reason. This usually happens when there is
insufficient information to make a more specific diagnosis
and/or more time is needed, for example, when there is
uncertainty over whether substances or medical illness is
causing symptoms (APA, 2013).
The Bipolar and Related Disorder section in the DSM-5
includes a comparatively large number of specifiers, including
some that are reflected in the fourth and fifth digit of the
numeric coding. Specifiers provide extra insight on the
underlying disorder (e.g., course, severity), and a full
description of the relevant specifiers is included in the DSM
(APA, 2013, pp. 149–154).
Advances in science and clinical research over the last quarter
of a century have deepened our understanding of the diagnosis
and treatment of debilitating mental conditions including
bipolar disorder. Individuals experiencing psychotic symptoms
of either Depression or Mania, which often coexist with other
conditions, will likely not seek treatment independently.
However, their behavior may well result in others arranging
involuntary mental health treatment on their behalf. The
clarification of diagnostic criteria in the DSM-5 for bipolar and
related disorders is expected to help in clinical assessment and
treatment.
Assessment
There are many challenges and complexities to diagnosing

13. bipolar disorder. Individuals assessed on the basis of current
clinical features alone (versus past history) are often
misdiagnosed because of symptom overlap, especially with
depression. This is further complicated by data that shows
nearly 35% of individuals with bipolarity have to wait at least
10 years between first seeking treatment and receiving the
correct diagnosis (Garcia-Castillo et al., 2011; Hirschfeld,
Lewis, & Vornik, 2003; Kaye, 2005; Phillips & Kupfer, 2013).
Recent findings suggest higher prevalence rates for bipolar
disorders of 3–5% in contrast to earlier estimates (1–1.1%)
drawing attention to the underdiagnosis of this devastating
illness (Angst et al., 2010; Angst et al., 2012; Kupfer, 2005).
Adding to this complexity is the heavy financial burden of
bipolar and related disorders, which was estimated to be US
$151 billion in 2009 (Dilsaver, 2011).
In addition, the reliability of self-report is very uncertain if
someone is experiencing psychotic symptoms. The stigma of
mental illness and the fear of psychiatric treatment may lead to
underreporting symptoms. Consequently, it is often helpful to
gather data from collateral sources, such as close friends or
relatives, employers, or other professionals, to specify both the
timing and severity of symptoms. Assessment may be further
complicated by co-occurring conditions (medical, psychiatric,
and substance problems). Being able to differentiate age-
appropriate behaviors from the symptoms of bipolarity is
especially important when dealing with children. Knowledge of
diagnostic specifiers and their pharmacological implications is
key to successful assessment and will greatly improve the
treatment of this lifelong disorder. Furthermore, research is
limited on the effects that race/ethnicity, gender, and/or age
may have on standardized screening measures and assessment
tools. Appreciating these cultural differences and understanding
any bias that may exist is essential to decreasing disparities in
diagnosis and treatment.
Assessment Instruments
Depression When assessing depressive symptoms in bipolar

14. disorder, many rating scales and tools can be useful. The Patient
Health Questionnaire (PHQ-9) is a simple, self-administered
screening measure of depression that was developed and studied
in primary care settings. It generally takes under 10 minutes to
complete. The PHQ-9 combines 8 questions related to DSM-IV
depression diagnostic criteria (APA, 2000) along with 1
question about suicidal ideation, which are summed to produce
a total score. Also, an additional question on functional status
(which is not scored) is provided to help with treatment
planning. Individuals rate their problems/feelings over the “past
2 weeks” on a 4-point scale (from 0 = not at all to 3 = nearly
every day) with total scores ranging from 0 to 27. When total
score is under 5, depression severity is seen as none to minimal.
Totals ranging from 5, 10, 15, and 20 represent thresholds for
mild, moderate, moderately severe, and severe depression,
respectively (Kroenke & Spitzer, 2002).
The PHQ-9 has excellent internal consistency and strong
psychometrics including criterion and convergent validity. At
the recommended cutoff score of 10 or higher, the PHQ-9 has a
sensitivity of 88% and specificity of 88% for identifying
patients with a major depressive episode (Kroenke, Spritzer, &
Williams, 2001). Also, in comparison to 9 other measures of
depression, the PHQ had a positive predictive value of 7.1
versus 2.9, meaning that the PHQ had a higher chance of
catching major depression (Kroenke & Spritzer, 2002). It
demonstrated good sensitivity (89.5%) and specificity (77.5%)
at a recommended cutoff of 11 or above in adolescents, which
was similar to adult studies (Richardson et al., 2010). The PHQ
was able to detect major and minor depression among geriatric
primary care patients (Lamers et al., 2008) and effective in
ethnic and racially diverse patients (Chung, Kroenke, Delucchi,
& Spitzer, 2006).
For those instances in which an adult is unable or unwilling to
take a self-report instrument, the Hamilton Rating Scale for
Depression (HAM-D; Hamilton, 1967) is an assessment
instrument completed by the interviewer. It is normally used

15. when the interviewer has some knowledge of the client's
affective status and strong evidence of symptoms of depressive
disorder. The HAM-D scale has been widely used in clinical
trials and takes about 30 minutes by a trained interviewer to
administer. The 21-item (but scoring is based on the first 17)
and other versions (with more and less items) are available.
Eight items are measured on a 5-point Likert scale (0 = not
present to 4 = severe); the remaining nine are scored from 0–2
(0 = none/absent to 2 = severe). The HAM-D addresses the
issues of depressed mood, suicide, anxiety, general somatic
symptoms, and loss of interest in work and recreational
pursuits. This difference in weighting reflects the author's belief
that some symptoms carry more importance (e.g., depressed
mood and suicidal ideation). To obtain a Total Score, items are
summed with higher scores indicative of greater severity
(anchor points from 0–7 = normal; 8–13 = mild; 14–18 =
moderate; 19–22 = severe depression; and above 23 equates to
very severe depression). Psychometrics for HAM-D-17 from
various studies report an internal consistency of .83, inter-rater
reliability range of .80–.98, and test–retest reliability of .81
(Cusin, Yang, Yeung, & Fava, 2009). Although, the HAM-D is
extensively utilized as a standard for measuring depression, it
has some important liabilities from questions about inter-rater
reliability, as is often the case when clinical judgment is
involved, to failure to include all symptom domains,
particularly reverse symptoms along with uneven weighting of
symptoms (Cusin et al., 2009; Khullar & McIntyre,
2004; Kobak, Lipsitz, & Feiger, 2003).
When older adults are being assessed, the presentation of
depressive symptoms may vary somewhat from those of other
adults. The Geriatric Depression Scale (GDS; Brink et al.,
1982) is a well-known instrument designed to assess depressive
symptoms in older adults. It is available in 30-item, 15-item,
10-item, 4-item, or 1-item versions. With the exception of the 1-
item version of the GDS, all of the shorter versions are highly
correlated with the original 30-item version (D'Ath, Katona,

16. Mullan, Evans, & Katona, 1994). The GDS has high internal
consistency (.94 with 1-week test–retest score .85) and has been
validated in a large number of studies with excellent concurrent
validity. The scale has been found reliable and valid for
depression screening across different age, gender, and ethnic
populations and is in the public domain.
The Clinical Global Impressions Scale–Bipolar Version (CGI–
BP; Spearing, Post, Leverich, Brandt, & Nolen, 1997) is a
modification of The Clinical Global Impressions Scale
(CGI; Guy, 1976). This simple, clinician-rated tool is used to
assess global illness severity and treatment response in
individuals with bipolar disorders when self-reported scales
may not be feasible. The original scale was revised to help
quantify manic and depressive symptoms/episodes with severity
scores ranging from 1 (normal/not ill) to 7 (most severely ill).
The CGI–BP can measure illness phases (e.g., manic,
depressive, and total illness) as well as evaluate treatment
response in bipolar illness (both acute and long-term
prevention). Changes were made to clarify definitions, time
periods, and variables in an effort to standardize framework.
However, limitations remain due to the instruments very design
bias, and the author cautions about the need to gather additional
information from self-report and symptom-driven scales as well
as longitudinal measures (Spearing et al., 1997).
Mania In order to assess manic symptoms in adults, two self-
report instruments have been shown to have excellent reliability
and validity. The Internal State Scale (ISS) (Bauer, Crits-
Cristoph, & Ball, 1991) is a 15-item instrument in which clients
indicate the intensity of their mood by marking a line denoting
the level of severity of symptoms. The scale has four subscales,
including well-being, perceived conflict, depression, and
activation. Mania is assessed by a well-being score equal to or
higher than 125 and an activation score equal to or greater than
200. Each item is “biphasic.” For example, on the items
indicating well-being, clients who mark the lower end of the
line (scale) are assessed to have depressive symptoms, whereas

17. clients who mark the upper end of the line are assessed to have
manic symptoms.
The Self-Report Manic Inventory (SRMI) (Shugar, Schertzer,
Toner, & Di Gasbarro, 1992) is a 47-item scale that includes
statements that clients mark “true” or “false” depending on the
presence or absence of symptoms during the prior month. The
instrument has been validated as a screening tool for the
severity of manic symptoms in adults. The scale has a maximum
score of 47.
The Mood Disorder Questionnaire (MDQ; Hirschfeld, et al.,
2000) is a brief, 15-item screening instrument for the
occurrence or absence of bipolar disorder that takes under 10
minutes to complete. Each affirmative answer is assigned one
point and all points are summed for a total score (from 0 to 13).
For a positive screen the respondent needs to answer “yes” to 7
out of 13 items on question 1; “yes” to co-occurrence in
question number 2; and “moderate” or higher on question 3
(Hirschfeld et al., 2000). The MDQ was found to have a .73
(sensitivity) and .90 (specificity) in psychiatric outpatients
(Hirschfeld et al., 2000) and a sensitivity of .28 and a
specificity of .97 in the general population (Das, Olfson,
Gameroff, Pilowsky, & Blanco, 2005). In a study of primary
care patients being treated for depression sensitivity/specificity
was .58 and .93, respectively (Hirschfeld, Cass, Holt, &
Carlson, 2005). Furthermore, the MDQ was determined better at
screening for bipolar I than for bipolar II due to question
number 3 and how hypomania presents (Kaye, 2005).
Tuckman's Mood Thermometers (MT; Tuckman, 1988) is an
easy, 5-item tool designed for use with adolescents that
measures affect on 5 dimensions: tension (panicky to tranquil),
confusion (befuddled to certain—which is reversed measured),
anger (vicious to loving), fatigue (exhausted to vigorous—
which is reversed measured), and depression (depressed to
ecstatic). Each item is rated from 0 (absence of symptoms) to
100 (extreme level of symptoms) to produce an index score or
combined to produce two composite scores. MTs show good

18. concurrent validity (Corcoran & Fischer, 2013). In a small study
of adolescents with a history of suicide attempts and depression,
Carlson (2006) found the MT had good internal consistency
(alpha .88) for each variable and (alpha .887) for an overall
mood score. Reliability analysis via test–retest measures ranged
from .50 to .64 (.57 average) suggesting that the variables
measure “state” versus “trait” symptoms (Carlson, 2006, p. 88).
For bipolar clients who are unable to complete a self-report
instrument, the Young Mania Rating Scale (YMRS; Young,
Biggs, Ziegler, & Meyer, 1978) can be completed by a skilled
practitioner. This scale is used to evaluate manic symptom
severity and treatment response and takes approximately 30
minutes to complete. The scale contains 11 items measuring
internal mood states and behaviors experienced by the client
and reported to the practitioner. Each item is rated by severity
on a scale with “0” equal to an absence of symptoms/ normalcy
to “4 or 8” indicating extreme deviation. There are four items
that are graded on a 0 to 8 scale (irritability, speech, content,
and disruptive-aggressive behavior) and given greater weight,
while the remaining seven items are graded on a 0 to 4 scale
(elevated mood, increased motor activity-energy, sexual
interest, sleep, language–thought disorder, appearance, and
insight). Scores may range between 0 and 60 with higher scores
indicating greater symptom severity and more psychopathology.
YMRS has shown validity in the assessment of mania in adult
inpatients and research demonstrates that it may be useful in
assessing the severity of mania in adolescents. Young et al.,
(1978) reported good internal consistency (.80) and excellent
inter-rater reliability (.93) and correlation with similar validated
measures of mania. Other studies of adolescents (ages 5–17) and
pediatric outpatients found good internal consistency (alpha
from .80 and .91) (Serrano, Ezpeleta, Alda, Matalí, & San,
2011; Youngstrom, Danielson, Findling, Gracious, & Calabrese,
2002). The YMRS is a well-utilized assessment measure of
bipolar disorders in adults and children. However, three items
(dealing with sexual interest, appearance, and insight) showed

19. low rates of endorsement in children and should be reevaluated
for use in a juvenile measure (Youngstrom et al., 2002).
Emergency Considerations
Assessing and managing suicide risk is one of the most
important components of clinical practice, especially when
treating individuals with bipolar and related disorders. Having a
Bipolar and Related Disorder is a risk factor for both suicide
attempts and the primary cause of premature death from suicide
(Gonda et al., 2012; Kupfer, 2005). A large epidemiological
study by Simon, Hunkeler, Fireman, Lee, & Savarino (2007)
showed among individuals treated for bipolar disorders; 1 per
1,000 person-years die by suicide; 5.6 per 1,000 person-years
attempt suicide leading to hospitalization and almost 14%
attempt suicide not leading to hospitalization. These numbers
were echoed in World Mental Health Survey Initiative, which
showed that 1 in 4 individuals with BP-I and 1 in 5 individuals
with BP-II have a history of suicide attempts (Merikangas et al.,
2011). Furthermore, when differentiating between individuals
with bipolar II disorder and those with bipolar I disorder or
unipolar depression the major clinical feature is the risk of
suicide (MacQueen & Young, 2001). For both adults and
adolescents, having a bipolar disorder is a predictive factor for
completed suicide, and early illness onset is a risk factor for
suicidal behavior (Borges, Angst, Nock, Ruscio & Kessler,
2008; Goldstein et al., 2012).
In some situations, people experiencing severe emotional
distress may constitute a danger to themselves or others.
Suicidal thinking is part of the diagnostic criteria for a major
depressive episode. In some major depressive episodes, and in
most manic episodes, some degree of psychosis is present. In
these situations, practitioners must attend to issues about the
client's safety and secure whatever level of supervision and
treatment is necessary. A comprehensive suicide risk assessment
will help identify the major risk factors for suicidal behavior.
Suicidal and emotionally distressed individuals are often not
reliable sources for self-report. This can impede risk assessment

20. and heighten the need to seek information from others including
family and friends. The risk of suicide attempts increases if the
individual has a comorbid anxiety disorder and/ or substance
abuse disorder, and the risk of suicide mortality increases if
the client has a co-occurring anxiety disorder (Simon et al.,
2007). Risk management strategies must be ongoing and should
include a crisis plan that involves emergency resources such as
emergency departments, telephone crisis centers, and local
inpatient/outpatient mental health services. Internet resources
can be efficiently exploited.
Cultural Considerations
Cultural variations impact symptom expression and, therefore,
they can affect the diagnostic process. Addressing cross-cultural
and gender differences is paramount when treating individuals
who suffer from bipolar disorder. Cultural attitudes also
influence whether individuals will seek help and which
treatment approaches may be most effective. Multiple studies
have found that individuals from Hispanic and Asian
backgrounds are more likely to report physical ailments and less
likely to report emotional symptoms when suffering from
mental illness. In many cultures, the stigma surrounding mental
illness is very strong, and the pressure “not to shame the
family” often leads to underreporting symptoms. Cultural
sensitivity education and training for English-speaking
practitioners are important aspects of competent mental health
practice.
In keeping with findings from the previous National
Comorbity Survey (NCS) data from the National Comorbidity
Survey Replication (NCS-R) showed that disadvantaged ethnic
groups have a lower lifetime risk for psychiatric disorders.
However, new data emerged revealing that this lower risk
emerges at a very young age (typically before age 10), and
although they have a lower lifetime risk, they are more likely to
be persistently ill. The lower prevalence for non-Hispanic
Blacks and Hispanics over non-Hispanic whites held true for all
mood disorders (including depression) except for the lifetime

21. prevalence of bipolar and related disorders (4.9%, 4.3%, and
3.2%, respectively) (Breslau et al., 2006).
Another caution relates to the tendency for minority group
members to receive more serious or more stigmatized
psychiatric labels. For example, there is some evidence that
Caucasians are more likely to be diagnosed with Bipolar I
Disorder, while minority clients with the same symptom
presentation are diagnosed with schizophrenic disorders
(Neighbors, Trierweiler, Ford, & Muroff, 2003). Also, African
Americans with bipolar disorder tend to present with more
severe psychotic symptoms and be more likely prescribed
antipsychotics (Kupfer, Frank, Grochocinski, Houck, & Brown,
2005; Strakowski, McElroy, Keck, & West, 1996). Many feel
the symptom expression of bipolarity in African Americans may
be misconstrued. For example, Gonzalez et al., (2010) uses the
example of how a persecutory delusion might be assessed as
motivated by anxiety rather than as a symptom of psychosis. A
study of data from the National Epidemiologic Survey on
Alcohol and Related Conditions (NESARC; 2001–2002) suggest
that clinician biases rather than fundamental racial/ethnic
differences in symptom presentation are responsible for the
misdiagnosis of bipolar disorders (Perron, Fries, Kilbourne,
Vaughn, & Bauer, 2010).
Several studies report racial and ethnic differences in regards
to access to care and service utilization, with African
Americans and Hispanics receiving fewer psychiatric
medications and fewer referrals for psychiatric treatment than
for Whites. Additionally, when referred for care they had a
higher rate of inpatient hospitalization versus outpatient
services (Gonzalez et al., 2010; Harris, Edlund, & Larson,
2005; Hatzenbuehler, Keyes, Narrow, Grant, & Hasin,
2008; Nejtek, Kaiser, Vo, Hilburn, Lea, & Vishwanatha, 2011)
especially for poor, inner-city clients with dual-diagnosis for
mood and substance abuse disorders. Additionally, data showed
that Blacks and Hispanics with co-occurring mood and
substance abuse disorders were five times less likely to receive

22. psychotropic medication than Whites, and less likely to receive
psychiatric treatment services (Nejtek et al., 2011). These
findings underscore the need to address racial and ethnocentric
bias during the diagnostic and treatment process.
The prevalence of bipolar disorder is relatively equal by
gender. However, studies show that the lifetime rates of BP-I
and subthreshold BP are greater in males, while females had
higher rates of BP-II (Merikangas et al., 2011). Findings from
the National Depressive and Manic-Depressive Association
2000 Survey show that females are more likely to be
misdiagnosed with depression and males are more likely to be
misdiagnosed with schizophrenia (Hirschfeld et al., 2003). This
may be due to the fact that female gender is a significant risk
factor for being diagnosed with depression, even when scores on
validated screening measures of depressive symptoms are
similar to males (WHO, 2002). However, recent studies have
found no gender differences in the distribution of depressive
episodes or time spent in depression, or in the rates of
antidepressant use (Baldassano et al., 2005; Diflorio & Jones,
2010). However, some studies report that women were more
likely than men to receive psychotropic medications (Nejtek et
al., 2011). Other differences exist in terms of suicidal
behaviors; women have a higher rate of suicide attempts, but
men have a higher rate of death by suicide (Simon et al., 2007).
Gender differences are also reported in comorbidity patterns,
with women more likely to have cooccurring eating disorder and
males more likely to have comorbid substance use disorder
(Suominen et al., 2009). In terms of substance-related disorder,
more men report a lifetime history of alcohol abuse, but when
compared to the lifetime risk for alcoholism in the general
population, women with bipolar disorder have a greater risk for
alcoholism (Frye et al., 2003). Furthermore, using data from the
NESARC (2001–2002) Goldstein & Levitt (2008) determined
that approximately 30% of individuals of both genders with
bipolar disorder have a lifetime comorbid anxiety disorder
(which is associated with poorer treatment response and

23. increased global illness severity, functional impairment, and
suicidality), and comorbid substance use disorder (which is
associated with delayed recovery, relapse, symptom burden, and
increased disability), and that early identification and treatment
of these comorbid conditions may help ease illness severity and
the burden of bipolar disorder. Finally, one of the most
pronounced gender differences between men and women with
bipolar disorder seems to be the effect that childbirth appears to
have on triggering postpartum bipolar episodes in women
(Diflorio & Jones, 2010).
Gender differences in mental health utilization and symptom
reporting as well as gender roles and stereotypes can affect
accurate diagnosis and treatment of psychological disorders.
Conformity to traditional gender roles for men, which
emphasize emotional fortitude and self-reliance, may negatively
impact the expression of symptoms, need for support, and
willingness to seek help. Women are socialized to be more
emotionally expressive and are more likely to disclose
symptoms and seek help. Gender sensitivity training and
strategies aimed at decreasing biases and barriers to help
seeking have important diagnostic and therapeutic implications.
Treatment adherence can have a positive effect for individuals
with bipolar disorder. Kriegshauser et al., (2010) examined
gender differences in this domain and reported that for women,
fear over medication related weight gain has a negative effect,
as did alcohol abuse as a form of self-medication for men. No
gender differences were found in terms of the experience of
stigma, drug abuse as a form of self-medication, or for the
desire to decrease irritability/impulsivity. Both genders valued
social supports, but women ranked more meaningful
relationships higher suggesting that it could be employed as a
positive factor more readily. Authors propose involving family
and close friends in treatment strategies for women, whereas
men could possibly benefit from support groups especially those
aimed at substance use. These gender differences could be used
as motivating factors with clients and used to inform clinical

24. practice.
Social Support Systems
Bipolar and related disorders are serious, recurring, chronic
illnesses that can overwhelm support resources and cause
impairment in social, occupational, or other areas of
functioning. Recent studies have found that social impairments
in individuals with bipolar and related disorders were similar in
type and severity to those seen in individuals with
schizophrenia (Dickerson, Sommerville, Origoni, Ringel, &
Parente, 2001). Providing support for an individual with a
chronic illness is inherently stressful. Conflicts between family,
friends, and the person with the disorder can arise due to
disruptive thoughts and behaviors and extreme mood swings on
the part of the symptomatic individual. Caregiver burden is high
and largely neglected in bipolar disorder (Ogilvie, Morant, &
Goodwin, 2005). Research attests to the low rates of treatment
in important areas of personal functioning. The assessment of
social functioning is a significant criteria feature of the
Diagnostic and Statistical Manual (APA, 2013). The goals for
treatment must be more than compliance for many bipolar
patients. Providing clients and caregivers with realistic
expectations and practical advice on illness management along
with sources of support, such as peer and psychoeducational
support groups, can help mitigate the impact of the illness.
Caregivers should be encouraged to meet with others to share
coping strategies. Joining a group can be hard for individuals
experiencing symptoms of the disease. Treatment strategies for
individuals with bipolar disorder must consider the stigma
associated with the disease, the impact of symptoms on social
functioning, and the risk of not maintaining positive social
networks, which is high in this population. Some Internet
resources for support, education, and advocacy are listed below.
· www.nami.org: Web site of the National Alliance on Mental
Illness, a grassroots advocacy group, with clear and basic
information on full array of mental disorders, support, and
awareness.

25. · www.mentalhealthamerica.net: Mental Health America's
advocacy Web site addressing the full spectrum of mental and
substance use conditions including information on cultural,
gender, and ethno-specific issues.
· www.dbsalliance.org: Largest national education and
advocacy group on Mood Disorders.
· www.isbd.org: Clinical education and research resource from
The International Society for Bipolar Disorders.
Suicide and Emotional Crisis Hotlines 1-800-SUICIDE (1-
800-784-2433) 1-800-723-TALK (1-800-723-8255)
Differential Diagnosis
Bipolar and related disorders are complex illnesses and this
carries over to differential diagnosis separation. The most
common challenge in making diagnoses among bipolar disorders
relates to the rule-out criteria included in nearly all of the
disorders in this chapter. Specifically, clinicians are expected to
ensure that the symptoms are not generated through the direct
physiological effects of a substance (e.g., recreational drugs,
prescription drugs, toxins) or by a general medical condition.
As the research bears out, these disorders go primarily
underdiagnosed due to misdiagnosis, often as major depressive
disorder (MDD). Other disorders involved in differential
diagnosis include: other psychotic disorders, such as
schizophrenia or schizoaffective disorder; anxiety disorders;
conduct disorders; and Attention Deficit/Hyperactivity
Disorder, especially in children. Just as giving an antidepressant
without a mood stabilizer (primary treatment for unipolar
depression) may destabilize someone with bipolar disorder;
giving a stimulant (primary treatment for ADHD) can lead to
mood destabilization in children with bipolar and related
disorders. Often children suffering with bipolar related
symptoms fell short of meeting criteria, which is one of the
reasons given for the use of the “Other Specified Bipolar and
Related Disorder” category.
There is, however, a strong tendency among clinicians to
assume non-physiological etiology as evidenced by the case

26. examples in this chapter. Only in Case 4.1, Helen Stonewall,
were physiological considerations made, and these efforts were
clearly not generated by the mental health practitioner.
· 4.DD–1 Choose one case from among Cases 4.2, 4.3, and 4.4.
List four questions you would ask to help rule out physiological
causes.
Inherent in making bipolar and related disorder diagnoses is
differentiating the intensity and length of symptoms. For
example, the symptoms for cyclothymic disorder are similar but
not as intense or as debilitating as those for a bipolar 1
disorder. Also, the distinction between hypomanic and manic
episodes is simply that in Hypomania, the intensity of mood
disturbance is not sufficient to cause serious psychosocial
impairment and/or result in hospitalization. Similarly, a set of
symptoms that has not lasted for the requisite time period to
meet criteria may well result in an unspecified bipolar diagnosis
(at least until the time frame is reached).
Case 4.1
Identifying Information
Client Name: Helen Stonewall
Age: 32 years old
Ethnicity: African American
Marital Status: Married
Children: Sonya, age 5
Background Information
You are a caseworker in the emergency room of a large urban
hospital. You work the day shift from 8 a.m. to 5 p.m. Several
hours before you came to work, the police brought the client to
the emergency room in restraints. The following information
was gathered from the police at intake.
Intake Information
The police state that Helen Stonewall, a 32-yearold African-
American woman, was found dancing half naked in the middle
of a busy intersection in the center of the city at approximately
2 a.m. She appeared to be high on drugs when the police

27. approached her. She told the police that she hadn't taken any
drugs and that she was “just high on life.” She said she wasn't
doing anything wrong, just “having a party.” Witnesses stated
that Helen had started the evening at a local restaurant and bar.
She had been with a couple of gentlemen who seemed to know
her. She began telling jokes and buying everyone at the bar
drinks.
At first, she seemed like a person just having fun, but she
kept getting louder and more rowdy as the night progressed. The
two men left, but she stayed at the restaurant telling them
loudly, “I'm just getting warmed up here.” She sang and danced
and finally ended up shoving all the glasses onto the floor and
standing on the bar talking as fast as she could. Customers got
irritated, and the bartender asked her to leave. She ignored his
request and started singing at the top of her lungs. Finally, the
bartender had to force her off the bar and push her out the door.
At that point, she began dancing and singing in the street. The
bartender told police that she had no more than two drinks
throughout the evening. When the police attempted to get Helen
out of the road, she became belligerent and began swearing at
the officers. They had to take her out of the middle of the
intersection by force and handcuff her to get her into the police
car.
Lab tests indicated no evidence of excessive alcohol or other
drugs. The physician on duty had prescribed a sedative, and
Helen went to sleep at approximately 5 A.M.
· 4.1–1 Based on the intake information alone, which
psychiatric disorders seem most likely? What type(s) of
information will you be interested in during the initial interview
to help you narrow down the choices of diagnoses?
Initial Interview
You go to see Helen at 9:30 a.m. She is lying in bed quietly
staring at the ceiling. She seems very subdued in comparison to
the description of the previous night. Helen glances at you as
you enter the room but makes no attempt to sit up. You tell her

28. who you are and your reasons for wanting to talk to her. Helen
makes no response to your introduction. You ask Helen if she
has any relatives you could call for her. Helen looks over at you
and says, “I just want to die. If it weren't for my baby, I'd've
been dead a long time ago.”
“What's your baby's name?” you ask.
“Sonya,” Helen replies. “I'm such a lousy mother lying here
like this. I should be home taking care of her.”
“Where is Sonya now?” you ask.
“She's with my sister. She stayed with my sister last night,”
Helen responds. “I knew I was racing so I took her over to my
sister's house.”
“You were racing?” you query.
“Yeah, you know, I start racing sometimes, feeling real good
and full of energy like nothing can stop me,” Helen says. “But
not now; I feel lousy now, like I just want to be left alone to
die.”
“Can you tell me what happened last night?” you ask.
“It's like living on a roller coaster,” Helen tells you. “One
minute you're way up there, and the next minute you're in the
blackest hole you can imagine.”
“And last night, you were way up there?” you query.
“Yeah, I was just feeling good and having a good time. It's
like you're racing and you can't slow down. Like you're high or
something, but I didn't take any drugs. I don't do drugs. This
just comes over me sometimes, and I feel like I could take on
the world.”
“Have you ever felt this way before?” you ask.
“Oh yeah, up and down, that's how I am,” Helen says.
“So, sometimes you feel really good and up, and then,
sometimes you feel really down. Is that right?” you ask.
“Yeah, I'm scared I'm beginning to crash now. It's bad when
you come down. It feels real bad,” Helen says. “It lasts for
weeks and weeks . . . just down all the time.”
“How often does this happen, going from one extreme to
another?” you ask. “Once a day or once a week or once a

29. month?”
“See, for a few weeks I feel great. I can do anything—stay up
all night having a good time. I don't sleep or eat or slow down. I
just keep on going for a week, maybe two. Then, I begin to
crash.”
“Do you hear voices or see things when you're feeling high?”
you ask.
“No, except for my own voice. I can't stop talking either. Gets
me into trouble, sometimes,” Helen admits.
“What else happens when you're feeling high?” you ask.
“I want to party. I can party all night when I'm high. I'm the
life of the party,” Helen says glumly.
“Have you ever gotten in trouble before, like you did last
night?” you ask.
“Oh yeah,” Helen agrees. “I've gotten thrown out of places
lots of times, but I usually just move on down the street.”
“Are you employed?” you ask Helen.
“I've tried to keep a job. Just can't seem to stick with it,”
Helen replies.
“How are you feeling right now?” you query.
“Feel like hell,” Helen tells you. “This is a rotten way to live,
I'm telling you.”
“How long does the crashing last?” you ask Helen.
“Sometimes a few days, sometimes a few weeks,” Helen says
bleakly.
“Describe for me what these down times are like for you,”
you ask.
“It's like I'm a balloon and someone stuck a needle in me. I'm
so sad that nothing looks good. It's hard to get out of bed and
face the world . . . I sleep and sleep and sleep. When I do get
up, I'm so tired that it feels like I'm carrying around invisible
weights.”
“What kinds of things go through your mind when you feel
like this?”
“I can't think of anything I want to do,” Helen tells you. “I
can't seem to make myself think anything all the way through.

30. Like making a decision about something no matter how trivial is
just impossible. Sometimes, I just wish I were dead.”
“Are you wishing you would die now?” you ask.
“Not yet . . . but it usually does get to that point when I
crash.”
“Have you ever seen a doctor for these changes in your
mood?” you ask.
“One doctor told me it was just a female thing,” Helen states.
“Maybe it's more than a female thing,” you suggest. “Maybe
there's some medication that could help even out your moods.
Would you be willing to talk to a doctor about how you've been
feeling?” you ask.
“Okay. I guess it wouldn't hurt,” Helen says.
· 4.1–2 To what extent do you think Helen may be a danger to
herself? What other information would be useful in determining
her risk?
· 4.1–3 What would you like to know about Helen's social
support system? Are there any steps you would take (given the
client's permission) to assure that her support system stays
intact?
· 4.1–4 What internal and external strengths do you see in
Helen's case?
· 4.1–5 What is your primary diagnosis?
· 4.1–6 What specifiers would you include with your diagnosis?
· 4.1–7 What psychosocial and cultural factors could impact
your diagnosis?
Case 4.2
Identifying Information
Client Name: Connie Kellogg
Age: 36 years old

31. Ethnicity: Caucasian
Marital Status: Married
Occupation: Homemaker
Children: Three children; currently pregnant with her fourth
child
Intake Information
Little information was obtained from a phone call interview
with Mrs. Kellogg by the intake worker. She stated that her
psychiatrist in Massachusetts had referred her to Dr. Browning
in Southfork, Oklahoma, for prescription monitoring. Dr.
Browning has referred her to the Southfork Counseling Center
to see a therapist. She requested an appointment with a therapist
and said only that she had been hospitalized recently in
Massachusetts before moving with her husband and children to
Oklahoma. She stated that it was very important that she begin
therapy immediately but did not want to discuss any details of
the problems she has been experiencing lately. The intake
worker scheduled her for the first available appointment with
you later in the week.
Initial Interview
Connie Kellogg is an attractive, 36-year-old woman whose
warm and effervescent personality is apparent from the first
meeting. You notice that Connie is several months pregnant.
Connie appears eager to get to your office and asks you how
long you have lived in Southfork. You explain to her that you
moved to Southfork after completing your master's degree 2
years ago.
“When did you move to Southfork?” you ask. Connie wriggles
in her chair and enthusiastically begins talking about her
husband being relocated to Oklahoma to accept a new position
with his company, which develops software for computer
companies. She states that she's never lived in the Midwest,
having grown up in Boston. She moved to another town in
Massachusetts when she got married 10 years ago.
“We've been in Southfork for 3 months, and I feel like a fish
out of water,” Connie tells you. “I've got most of the

32. responsibility for taking care of my three children and as you
can see, I'm about to have another one. Bob, my husband,
travels 3 or 4 days a week with his job, so I'm stuck at home
with my children most of the time . . . not that I'm complaining.
Bob has a good job and he has to travel, but it's a lot of work
for me, and I haven't made a lot of friends yet. When I lived in
Revere, Massachusetts, I had a lot of neighbors who were young
mothers like me with kids, and we'd get together and babysit for
each other and take our children to different activities. It was
nice until I got sick.”
“What happened when you got sick?” you ask Connie.
“Well, I've always been a pretty optimistic, upbeat type
person with a lot of energy. Then, suddenly, I had no energy. I
was drained. I was so tired I couldn't move and just got
completely depressed. I was suicidal and felt hopeless about
everything. I thought here I am with three little children and I
can't get off the couch to take care of them. I felt like a
complete failure as a mother, just completely worthless. I didn't
want to do anything except sleep and block out the entire world.
I wasn't interested in sex with my husband. I didn't care if I
lived or died. It just got so bad that the psychiatrist I was seeing
put me in the hospital.” Connie slinks down in her chair and
sighs deeply.
She takes a deep breath and then begins talking again.
“Everything just looked so black. I couldn't imagine feeling any
worse . . . and my poor kids. All I could think about was that I
would die and they would be motherless. And then I began to
feel better. I mean like overnight I felt a whole lot better. I had
plenty of energy, and thoughts and ideas just flew through my
head and I was on top of the world again. I told the doctor I was
just fine and he should let me go home.”
“How long had you been in the hospital when you began
feeling so much better?” you inquire.
“About 4 weeks,” Connie sighs. “Then I was okay—or so I
thought.”
“So initially, you were really depressed when you went into

33. the hospital, and then you began to feel much better. Were you
taking any medication?” you ask.
“Well, that's the really scary part about this problem I have.
You see, the feeling of being on top of the world didn't last very
long. Pretty soon, I was in the depths of despair again, and the
medicine I was on wasn't working. So, the doctor said I really
needed to be on Lithium. I didn't want to take anything because
by then, I knew I was pregnant again. But I was so depressed I
didn't know what else to do. I'm so worried about the medicine
affecting the baby. The doctor has put me on a low dosage until
the baby is born. I'm just keeping my fingers crossed the baby
will be okay. Do you think that makes me a bad mother?”
“It sounds as if the psychiatrist thinks you really need to be
taking Lithium right now,” you respond. “You're trying to take
care of yourself.”
“He told me it was absolutely necessary if I wanted to stay
out of the hospital,” Connie replies. “I never want to go through
that experience again. And I'm not sure it's really helping. I
have to go get my blood tested every 2 weeks, and I'm not sure
I've got enough of the medication in me to do me any good. I
have days when I feel like I can function pretty well, and then
there are other days when I feel like I'm sliding into a black
hole and can't get out of it. It's an awful feeling.”
· 4.2–1 At this point in the interview, what diagnoses are you
considering? What information do you feel you need to
complete your initial assessment?
“These feelings of depression just started about a year ago? Is
that correct?” you inquire.
“Yes, I never felt down in the dumps and completely hopeless
like I have this year. You know, I remember as a child, my
father would have periods of deep depression. He was like Dr.
Jekyll and Mr. Hyde. Some days he'd be great to be around and
he'd play with us and laugh. Other times, he was really scary.
He'd sit in a dark room and stare out the window for hours, and
if any of us kids did anything that perturbed him, he'd get so

34. angry that he'd take us behind the house and give us all a
whipping with his belt. You could never tell what kind of mood
he'd be in. I was scared of him my whole childhood. I sure hope
I'm not turning into someone like him.”
“Did your father ever see a doctor about his moods?” you ask.
“No, he thinks only crazy people see psychiatrists. I told Bob
not to tell my parents I was in the hospital. They would have
disowned me. They are strict, conservative Catholics, and
believe me, they wouldn't ever understand. They'd tell me I'd be
okay if I went to confession.”
It seems to you that Connie identifies with her father's mood
swings to some degree, and you decide to get more information
about Connie's family of origin at this time. “Tell me what it
was like for you growing up in Boston,” you say.
Connie sits back in her chair and looks out the window.
“Well, it was your typical Catholic family growing up in the
sixties and seventies, I guess. I have five siblings—two older
brothers, an older sister, and two younger sisters. My parents
were strict and fairly religious. We went to confession on
Saturdays and Mass on Sundays every week without fail. My
mother cared for us while my father worked. We were a middle-
class family, I guess. We never had a lot of money, but we
weren't starving to death either. My parents sent us all to a
Catholic school that cost more than public school but wasn't
like a private school. I think I bought into all the Catholic guilt
thing and have a real problem with feeling guilty about
everything. My father reinforced that feeling of guilt all the
time. He was very distant and authoritarian. We got punished a
lot as children, and although I don't think I really thought so at
the time, it was pretty harsh punishment by today's standards.
And it seemed like I was always in the way when my father got
mad, and I got punished more than my sisters and brothers.”
“How do you feel about that time growing up?” you inquire.
“I guess I consider it a pretty normal childhood,” Connie
suggests. “All the kids in the Catholic school I attended grew up
much the same way as I did. I think my mother saved us all

35. from my father's wrath on many occasions. She had a way of
diverting his attention away from us when we were in the line
of fire.”
“And what is your relationship like now, with your parents?”
you ask.
“Since I've been in the hospital, I've discovered I have all this
anger toward my father,” Connie states. “I've been scared of
him my whole life, and I'm tired of feeling that way and I hate
how he made me feel. I've never really had any self-esteem and
have always felt like I'm cowering in the corner afraid of my
own shadow because of what he did to me.”
“And your mother? How do you get along with her?” you ask.
“We get along well. We always have. I think we have a lot in
common and she's had to put up with a lot, too,” Connie says
with a smile.
· 4.2–2 Discuss how much support Connie is likely to receive
from her family of origin. Preliminarily, do you have any
thoughts about how that support could be maximized?
“Do you feel that the way you were raised has something to
do with the depression you've been experiencing, or do you
think it's unrelated to your childhood experiences?” you ask.
“I don't really know,” Connie states. “It's something I want to
figure out. The doctor told me some of this could be a
neurochemical problem. Sometimes, I feel great and full of
energy. In fact, it's hard to slow down. I become really talkative
and friendly. It's like everything speeds up. Thoughts run
through my head really fast, and I can't even sleep when I feel
that good. It's like being high.”
“How often does that happen?” you ask.
“It seems to happen about once a month after I've been really
depressed,” Connie states. “But it doesn't last as long as the
depressed periods.”
“Do you ever feel that you place yourself in highrisk or
dangerous situations when you have a ‘high’ feeling?” you
query.

36. “No, I don't think so,” Connie reflects. “I have some pretty
fantastic thoughts, but I don't actually do anything. I've got to
think about my children and the one on the way.”
“Okay, so you feel depressed a lot of the time, and sometimes,
about once a month, you feel pretty good and full of energy.
How long do you usually have that ‘high’ feeling?” you ask.
“It can last from 3 or 4 days up to a week before I begin
sliding downward again,” says Connie. “I always hope it will
last longer, but it never does.”
“So, it sounds like one of your goals is to learn how to cope
with some of these ups and downs you've been experiencing?”
you ask.
Connie says enthusiastically, “Yes, exactly, I need some help
with the best way of coping with these moods, especially during
this pregnancy.”
“Would it be all right with you if I talked to the psychiatrist
who is prescribing the medication for you?” you inquire. “I'll
need you to sign a consent form.”
“Absolutely. I'll give you his phone number,” Connie asserts.
“And would you like to make an appointment on a weekly
basis?” you ask.
Connie nods her head vigorously and says, “I'm so glad I've
found someone I can talk to who doesn't look at me as if I'm
crazy. I definitely want to come once a week to talk to you.”
“Okay. We'll schedule an appointment for next week,” you
reply.
Connie leaves your office with a little bounce in her step and
talks about going to shop for the new baby as you walk her to
the reception area.
· 4.2–3 From this preliminary interview, it would seem that
Connie may not have much social support in Southfork. How
would you go about exploring that issue? How important do you
think securing local support would be?
· 4.2–4 What is your primary diagnosis?

37. · 4.2–5 What specifiers would you include with your diagnosis?
· 4.2–6 What psychosocial and cultural factors could impact
your diagnosis?
Case 4.3
Identifying Information
Client Name: Gloria Suarez
Age: 31 years old
Ethnicity: Hispanic
Educational Level: High school diploma
Marital Status: Divorced
Children: Jose, age 4; Aubriana, age 2
Intake Information
Gloria Suarez is a 31-year-old single mother who contacted the
Gulf Coast Counseling Center concerning therapy for herself.
She told the intake worker that she was feeling very down and
exhausted and needed to see someone soon. The intake worker
scheduled an appointment for her with you, her counselor, in 2
days. Gloria arrived on time for her appointment with you.
Intake Interview
Gloria presents as a quiet, young woman who smiles shyly and
shakes hands with you in the waiting room. She says that she
doesn't really know why she came today except that she's been
so tired recently. Gloria indicates that she works as a cashier for
Ding Dong Discount and has been separated for the past 3 years
because she can't afford a divorce. She feels that since her
separation her life has been spinning out of control.
A year ago, her older sister died of hepatitis after a long
battle with drugs and alcohol. Gloria describes her as a sweet
but completely crazy sister. She hasn't had any contact with her
parents since she left home at 18 years old. She states that her
father was also an abusive alcoholic and her mother never
protected Gloria or her sister from the abuse.
When you ask her about her mood, she tells you it's generally
been “blue.” “I seem to be exhausted all the time. Between

38. trying to take care of my kids and working shifts at Ding Dong,
I barely know whether its night or day.
Do you ever have times when you feel okay or more like you
did before the separation?” you ask.
Gloria sighs deeply and says, “Actually, yes, every once in a
while I have times when I have a lot more energy, but I also get
extremely irritable. I scream at my kids and feel very frustrated
with my job, but I'm not so tired and down in the dumps. I even
go out dancing and enjoy hanging out with my friends.”
“How often do you feel that way over a period of a year?” you
ask.
“Like I said, it's every once in a while. Most of the time I'm
exhausted. I'd say maybe 2 or 3 times a year.”
“How long has this feeling of exhaustion been going on this
time?” you query.
“Probably for the past 3 months,” Gloria responds.
“I begin to feel real hopeless about my life and feel like I
have nothing to look forward to.”
“Do you ever think about suicide?” you question carefully.
“To be perfectly honest, I have thought about just taking a
bunch of pills and going to sleep forever, but my kids keep me
from doing it.”
“Have you seen a doctor and gotten a physical exam
recently?” you ask.
“I took my kids for shots before school started but I don't
have much money,” she responds as she stares out the window.
“Have you been feeling suicidal recently?” you ask.
“No, it's been quite a while since I've been that down but I try
not to think about it. I know my kids need me and that's what
keeps me going.”
“What about your appetite?” you ask.
“I don't feel like eating when I get so down but when I'm
feeling better, I make up for it,” she says with a smile.
“And how well have you been sleeping?” you ask.
Gloria seems to relax a bit and says, “I could sleep all the
time if I didn't have to work and get up with my children.”

39. “It sounds like you've been coping with all these emotional
ups and downs for quite a while. Tell me about how you've
handled all of this. It sounds like a whole lot to deal with as a
single parent.”
“Well, I'll tell you one thing for sure. After my sister died, I
wouldn't touch drugs, and alcohol just reminds me of my dad
and how abusive he was.”
“You know, you've told me a lot about yourself today and it
sounds like you could really use someone to talk to further
about how to begin feeling better. But, first, I'd really like you
to see a doctor for a complete physical and I know someone you
could see for a very low cost. Would you be willing to start by
going to the doctor?” you ask.
“You're probably right. It's been a long time since I've had a
physical,” Gloria responds. “But I'd like to see you again, too.”
“Absolutely, we will schedule another appointment for next
week and I will give you a card so you can call the doctor's
office and make an appointment with her.”
Gloria looks relieved and says, “I'm glad I came in today. I
almost skipped it.”
“I'm really glad you came today, too,” you respond. “I think I
can help you with some of these challenges you've been dealing
with on your own. There's times when we all need some extra
help.”
· 4.3–1 What are some of Gloria's strengths?
· 4.3–2 What diagnoses would you want to rule out in this case?
· 4.3–3 What resources might be valuable to utilize in this case?
· 4.3–4 Do you think Gloria should be referred to other
professionals for further evaluation? If so, to whom would you
make a referral?
· 4.3–5 What is your primary diagnosis for Gloria Suarez?

40. · 4.3–6 What psychosocial and cultural factors could be
impacting Gloria?
References
American Psychiatric Association. (2000). Diagnostic and
statistical manual of mental disorders (4th ed., text rev.).
Washington, DC: Author.
American Psychiatric Association. (2013). Diagnostic and
statistical manual of mental disorders (5th ed.). Arlington, VA:
Author.
Angst, J., Cui, L., Swendsen, J., Rothen, S., Cravchik, A.,
Kessler, R. C., et al. (2010). Major depressive disorder with
subthreshold bipolarity in the National Comorbidity Survey
Replication. The American Journal of Psychiatry, 167(10),
1194–1201.
Angst, J., Gamma, A., Bowden, C. L., Azorin, J. M., Perugi, G.,
Vieta, E., et al. (2012). Diagnostic criteria for bipolarity based
on an international sample of 5635 patients with DSM-IV major
depressive episodes. European Archives of Psychiatry and
Neurological Sciences, 262(1), 3–11.
Baldassano, C. F., Marangell, L. B., Gyulai, L., Ghaemi, S. N.,
Joffe, H., Kim, D. R., et al. (2005). Gender differences in
bipolar disorder: Retrospective data from the first 500 STEP-BD
participants. Bipolar Disorders, 10, 153–162.
Bauer, M. S., Crits-Cristoph, P., & Ball, W. A. (1991).
Independent assessment of manic and depressive symptoms by
self-rating. Archives of General Psychiatry, 48, 807–812.
Borges, G., Angst, J., Nock, M. K., Ruscio, A. M., & Kessler,
R. C. (2008). Risk factors for the incidence and persistence of
suicide-related outcomes: A 10-year follow-up study using the
National Comorbidity Surveys. Journal of Affective Disorders,
105(1–3), 25–33.
Breslau, J., Gaxiola-Aguilar, S., Kendler, K. S., Su, M.,
Williams, D., & Kessler, R. C. (2006). Specifying race-ethnic
differences in risk for psychiatric disorder in a US national
sample. Psychological Medicine, 36(1), 57–68.

41. Brink, T. L., Yesavage, J. A., Lum, O., Heersema, P., Adley, M.
B., & Rose, T. L. (1982). Screening tests for geriatric
depression. Clinical Gerontologist, 1, 37–44.
Carlson, K. T. (2006). Mood variability in adolescent suicide:
Importance in domains of self-schemas in adolescent
suicide. Child & Youth Care Forum, 35(2), 79–99.
Chung, H., Kroenke, K., Delucchi, K., & Spitzer, R. (2006).
Using the patient health questionnaire-9 to measure depression
among racially and ethnically diverse primary care
patients. Journal of General Internal Medicine, 21(6), 547–552.
Corcoran, K., & Fischer, J. (Eds.). (2013). Measures for clinical
practice and research: Adults (Vol. 2). New York: Oxford
University Press.
Cusin, C., Yang, H., Yeung, A., & Fava, M. (2009). Rating
Scales for Depression. In L. Baer & M. A. Blais
(Eds.), Handbook of clinical rating scales and assessment in
psychiatry and mental health. Current clinical psychiatry (pp.
7–35). Boston: Humana Press.
Das, A. K., Olfson, M., Gameroff, M. J., Pilowsky, D. J.,
Blanco, C., et al. (2005). Screening for bipolar disorder in a
primary care practice. The Journal of the American Medical
Association, 293(8), 956–963.
D’Ath, P., Katona, P., Mullan, E., Evans, S., & Katona, C.
(1994). Screening, detection and management of depression in
elderly primary care attenders. I: The acceptability and
performance of the 15-item Geriatric Depression Scale and the
development of shorter versions. Family Practice, 11, 260–266.
Dickerson, F. B., Sommerville, J., Origoni, A. E., Ringel, N. B.,
& Parente, F. (2001). Outpatients with schizophrenia and
bipolar I disorder: Do they differ in their cognitive and social
functioning? Psychiatric Research, 102, 21–27.
Diflorio, A., & Jones, I. (2010). Is sex important? Gender
differences in bipolar disorder. International Review of
Psychiatry, 22(5), 437–452.
Dilsaver, S. C. (2011). An estimate of the minimum economic
burden of bipolar I and II disorders in the United States:

42. 2009. Journal of Affective Disorders, 129(1–3), 79–83.
Frye, M. A., Salloum, I. M. (2006). Bipolar disorder and
comorbid alcoholism: Prevalence rate and treatment
considerations. Bipolar Disorders, 8, 677–685.
Garcia-Castillo, I., Fernandez-Mayo, L., Serrano-Drozdowskyij,
E., Carmona, R., Martin-Calvo, M. J., Ovejero, S., et al. (2011).
Early detection of hypomania episodes in patients with affective
disorder. Revista de Psiquiatría y Salud Mental, 149(5), 89–97.
Goldstein, B., & Levitt, A. J. (2008). The specific burden of
comorbid anxiety disorders and of substance use disorders in
bipolar I disorder. Bipolar Disorders, 10(1), 67–78.
Goldstein, T. R., Ha, W., Axelson, D. A., Goldstein, B. I., Liao,
F., Gill, M. K., et al. (2012). Predictors of prospectively
examined suicide attempts among youth with bipolar
disorder. Archives of General Psychiatry, 69(11), 1113–1122.
Gonda, X., Pompili, M., Serafini, G., Montebovi, F., Campi, S.,
Dome, P., et al. (2012). Suicidal behavior in bipolar disorder:
Epidemiology, characteristics and major risk factors. Journal of
Affective Disorders, 143(1–3), 16–26.
Gonzalez, J. M., Bowden, C. L., Berman, N., Frank, E., Bauer,
M. S., Kogan, J. N., et al. (2010). One-year treatment outcomes
of African-American and Hispanic patients with bipolar I or II
disorder in STEP-BD. Psychiatric Services, 61(2), 164–172.
Guy, W. (1976). The Clinical Global Impression Scale.
In ECDEU assessment manual for psychopharmacology—
revised (pp. 218–222). Rockville, MD: U. S. Department of
Health, Education and Welfare, ADAMHA, MIMH
Psychopharmacology Research Branch.
Hamilton, M. (1967). Developing a rating scale for primary
depressive illness. British Journal of Social and Clinical
Psychology, 6, 278–296.
Harris, K. M., Edlund, M. J., & Larson, S. (2005). Racial and
ethnic differences in the mental health problems and use of
mental health care. Medical Care, 43(8), 775–784.
Hatzenbuehler, M. L., Keyes, K. M., Narrow, W. E., Grant, B.
F., & Hasin, D. S. (2008). Racial/ethnic disparities in service

43. utilization for individuals with co-occurring mental health and
substance use disorders in the general population: Results from
the National Epidemiologic Survey on alcohol and related
conditions. The Journal of Clinical Psychiatry, 69(7), 1112–
1121.
Hirschfeld, R. M., Cass, A. R., Holt, D. C., & Carlson, C. A.
(2005). Screening for bipolar disorder in patients treated for
depression in a family medicine clinic. Journal of the American
Board of Family Medicine, 18(4), 233–239.
Hirschfeld, R. M., Lewis, L., & Vornik, L. A. (2003).
Perceptions and impact of bipolar disorder: How far have we
really come? Results of the national depressive and
manicdepressive association 2000 survey of individuals with
bipolar disorder. The Journal of Clinical Psychiatry, 64(2), 161–
174.
Hirschfeld, R. M., Williams, J. B., Spritzer, R. L., Calabrese, J.
R., Flynn, L., Keck, P. E., Jr., et al. (2000). Development and
validation of a screening instrument for bipolar spectrum
disorder: The Mood Disorder Questionnaire. The American
Journal of Psychiatry, 157(11), 1873–1875.
Kaye, N. S. (2005). Is your depressed patient bipolar? Journal
of the American Board of Family Medicine, 18(4), 271–281.
Khullar, A., & McIntyre, R. S. (2004). An approach to
managing depression. Defining and measuring
outcomes. Canadian Family Physician, 50(10), 1374– 1380.
Kobak, K. A., Lipsitz, J. D., & Feiger, A. (2003). Development
of a standardized training program for the Hamilton Depression
Scale using internet-based technologies: Results from a pilot
study. Journal of Psychiatric Research, 37, 509–515.
Kriegshauser, K., Sajatovic, M., Jenkins, J. H., Cassidy, K. A.,
Muzina, D., Fattal, O., et al. (2010). Gender differences in
subjective experience and treatment of bipolar disorder. Journal
of Nervous and Mental Disease, 198(5), 370–372.
Kroenke, K., & Spritzer, R. L. (2002). The PHQ-9: A new
depression and diagnostic severity measure. Psychiatric Annals,
32(9), 1–7.

44. Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-
9 validity of a Brief Depression Severity Measure. The Journal
of General Internal Medicine, 16(9), 606–613.
Kupfer, D. J. (2005). The increasing medical burden in bipolar
disorder. The Journal of the American Medical Association,
293(20), 2528–2530.
Kupfer, D. J., Frank, E., Grochocinski, V. J., Houck, P. R.,
Brown, C., et al. (2005). African-American participants in a
bipolar disorder registry: Clinical and treatment
characteristics. Bipolar Disorders, 7(1), 82–88.
Lamers, F., Jonkers, C. C., Bosma, H., Pennix, B. W.,
Knottnerus, J. A., & van Eijk, J. T. (2008). Summed score of
the Patient Health Questionnaire-9 was a reliable and valid
method for depression screening in chronically ill elderly
patients. Journal of Clinical Epidemiology, 61, 679–687.
MacQueen, G. M., & Young, L. T. (2001). Bipolar II disorder:
Symptoms, course & response to treatment. Psychiatric
Services, 52(3), 358–361.
Merikangas, K. R., Jin, R., He, J. P., Kessler, R. C., Lee, S.,
Sampson, N. A., et al. (2011). Prevalence and correlates of
bipolar spectrum disorder in the World Mental Health Survey
Initiative. Archives of General Psychiatry, 68(3), 241–251.
Neighbors, H. W., Trierweiler, S. J., Ford, B. C., Muroff, J. R.
(2003). Racial differences in DSM diagnosis using a semi-
structured instrument: The importance of clinical judgment in
the diagnosis of African Americans. Journal of Health and
Social Behavior, 44(3), 237–256.
Nejtek, V. A., Kaiser, K., Vo, H., Hilburn, C., Lea, J., &
Vishwanatha, J. (2011). Are there racial ethnic differences in
indigent, inner-city clients with dual-diagnosis? Journal of Dual
Diagnosis, 7(1–2), 26–38.
Ogilvie, A. D., Morant, N., & Goodwin, G. M. (2005). The
burden on informal caregivers of people with bipolar
disorder. Bipolar Disorders, 7, 25–32.
Perron, B. E., Fries, L. E., Kilbourne, A. M., Vaughn, M. G., &
Bauer, M. S. (2010). Ethnic group differences in bipolar

45. symptomatology in a community sample of persons with bipolar
I disorder. Journal of Nervous and Mental Disease, 198(1), 16–
21.
Phillips, M. L., & Kupfer, D. J. (2013). Bipolar disorder
diagnosis: Challenges and future directions. The Lancet,
381(9878), 1663–1671.
Richardson, L. P., McCauley, E., Grossman, D. C., McCarty, C.
A., Richards, J., Russo, J. E., et al. (2010). Evaluation of the
patient health questionnaire-9 item for detecting major
depression among adolescents. Pediatrics, 126(6), 1117–1123.
Serrano, E., Ezpeleta, L., Alda, J. A., Matalí, J. L., & San, L.
(2011). Psychometric properties of the Young Mania Rating
Scale for the identification of mania symptoms in Spanish
children and adolescents with attention deficit/hyperactivity
disorder. Psychopathology, 44, 125–132.
Shugar, G., Schertzer, S., Toner, B. B., & DiGasbarro, J.
(1992). Development, use, and factor analysis of a self-report
inventory for mania. Comparative Psychiatry, 33, 325–331.
Simon, G., Hunkeler, E., Fireman, B., Lee, J. Y., & Savarino, J.
(2007). Risk of suicide attempt and suicide death in patients
treated for bipolar disorder. Bipolar Disorders, 9(5), 526–530.
Spearing, M. K., Post, R. M., Leverich, G. S., Brandt, D., &
Nolen, W. (1997). Modification of the Clinical Global
Impressions (CGI) Scale for use in Bipolar Illness (BP): The
CGI-BP. Psychiatry Research, 73(3), 159–171.
Strakowski, S. M., McElroy, S. L., Keck, P. E., & West, S. A.
(1996). Racial influences on diagnosis in psychotic
mania. Journal of Affective Disorders, 39, 157–162.
Suominen, K., Mantere, O., Valtonen, H., Arvilommi, P.,
Leppamaski, S., & Isometsa, E. (2009). Gender differences in
bipolar disorder type I and II. Acta Psychiatrica Scandinavica,
120(6), 464–473.
Tuckman, B. W. (1988). The Scaling of Mood. Educational and
Psychological Measurement, 48(2), 419–427.
World Health Organization. (2002). Gender and mental health.
Retrieved March 10, 2014,

46. from http://whqlibdoc.who.int/gender/2002/a85573.pdf.
Young, R. C., Biggs, J. T., Ziegler, V. E., & Meyer, D. A.
(1978). A rating scale for mania: Reliability, validity and
sensitivity. British Journal of Psychiatry, 1, 429–435.
Youngstrom, E. A., Danielson, C. K., Findling, R. L., Gracious,
B. L., & Calabrese, J. R. (2002). Factor structure of the Young
Mania Rating Scale for use with youths ages 5 to 17
years. Journal of Clinical Child and Adolescent Psychology, 31,
567–572.
5 Depressive Disorders
Disorders
The diagnoses in the Depressive Disorders section of the DSM-
5 (APA, 2013) are characterized by changes in a person's
emotional state (e.g., sadness, irritability) that coincide with
somatic symptoms (e.g., aches, insomnia) and cognitive
disturbances (e.g., negative thinking, poor concentrating) that
are sufficiently severe to cause significant clinical distress
and/or disruption in psychosocial functioning. This category
contains diagnoses that were previously listed in the DSM-IV-
TR (APA, 2000) under the Mood Disorders Category and later
divided into two groups “Depressive Disorders” and “Bipolar
Disorders” due to differences in etiology and treatment
approaches. Depression like mania is a mood disorder that can
influence and disrupt an individual's normal functioning. The
term mood refers to an internally experienced emotional state
that influences an individual's thinking and behavior. A related
term, affect, refers more specifically to the external
demonstration of one's mood or emotions. This distinction is
important because affect and mood may differ; that is, people
do not always display accurately in their affect what their mood
actually is.
This section of the DSM-5 is organized around eight
Depressive Disorders, some of the most prevalent and often
chronic but also treatable mental health conditions. Research
has led to an understanding that the chronicity of depression as

47. well as severity can cause serious impairment and this change is
reflected in the DSM-5.
Other more controversial changes include the elimination of
the “bereavement exclusion” for major depressive episodes in
recognition that often grief and depression co-occur with a
detailed note to aid differentiation. This change acknowledges
that typical bereavement often has a much longer duration than
the previous two-month duration. In addition, new dimensional
cross-cutting symptom measures can be found in Section III of
the DSM-5 (APA, 2013, pp. 733–744) and online at
(http://www.psychiatry.org/practice/dsm/dsm5/online-
assessment-measures). The Depressive Disorder section in the
DSM-5 includes a comparatively large number of specifiers.
The inclusion of descriptive (e.g., with melancholic features),
severity (e.g., mild), and course (e.g., in partial remission)
specifiers is testimony to the variety that is evident in
depressive disorders and to the desire to bolster clinical utility.
For example the new “with anxious distress” descriptive
specifier is used when anxiety is present during a major
depressive episode, and “with mixed features” for use when
manic/ hypomanic symptoms co-occur. Although a listing of the
relevant specifiers is included in each disorder's diagnostic
criteria, it can be confusing to try to determine which apply.
Therefore, practitioners are encouraged to familiarize
themselves with detailed descriptions provided for each
disorder. For a complete listing see the DSM-5 (APA, 2013, pp.
184–188).
The most serious disorders in this chapter include Disruptive
Mood Dysregulation Disorder (DMDD), Major Depressive
Disorder (MDD), both single episode and recurrent, and
Persistent Depressive Disorder (Dysthymia). In the coding of
each disorder, attention is given to the severity of symptoms,
the frequency of temper outbursts (in the case of DMDD), and
the length and timing of depressive episodes (in the case of
MDD and Dysthymia). The newly introduced “Disruptive Mood
Dysregulation Disorder (DMDD)” was added to help

48. differentiate unrelenting irritability and frequent severe
emotional/behavioral outbursts from the symptoms of childhood
bipolar disorder in order to help reduce misdiagnosis. Children
with this disorder often develop depressive or anxiety disorders
as they grow (APA, 2013). It is diagnosed before 10 years of
age with the stipulation that the child must be developmentally
at least 6 years of age, and validated in children from ages 7 to
18. These outbursts must occur 3 or more times per week for
over a year and be grossly disproportionate in terms of
magnitude/duration to the circumstances, coincide with
anger/irritability that is present for the majority of most days,
with both symptoms observed in at least two out of three
settings such as living, academic, and social (APA, 2013). For a
listing of differential diagnoses and other criteria see the DSM-
5 (APA, 2013, p. 156).
The hallmark illness of depression is Major Depressive
Disorder. Few changes were made to this diagnosis outside of
bereavement as discussed earlier. Detailed directions are
provided to help distinguish grief from this disorder (see APA,
2013, p. 161). For diagnosis, five or more symptoms (one of
which is either depressed mood or anhedonia) must occur for 2
weeks and signify a departure from preceding functioning. Of
note, in children depressed mood is often demonstrated by
irritability. The symptoms must result in significant clinical
distress impairing personal, vocational, or other areas of
functioning. Also, the disorder cannot result from the biological
effects of a substance or another medical problem (APA, 2013).
Coding follows from whether singular or recurrent episode and
includes the descriptive/features, severity, and course status
specifiers (for guidelines see APA, 2013, p. 162). By recurrent,
“there must be an interval of at least 2 consecutive months
between separate episodes in which criteria are not met for a
major depressive disorder” (APA, 2013, p. 162).
Dysthymic Disorder (DSM-IV-TR) was merged with Chronic
Major Depressive Disorder to create a new diagnosis called
Persistent Depressive Disorder (APA, 2013). Research has

49. shown that in terms of personal burden this condition can be as
disabling as major depression. By definition, this is a chronic
condition requiring both a continuous depressed mood and the
presence of 2 or more out of 6 criteria symptoms (e.g.,
hypersomnia, poor concentration). Given the habitual nature and
often inward expression of these symptoms, especially in early-
onset cases, clinicians may need to inquire directly about the
presence of criteria symptoms. Both criteria must present for a
period of 2 or more years (1 year in children), with a period of
no more than 2 months where these criteria are not met (APA,
2013). The impairment must be clinically significant and disrupt
functioning in social, employment, or other consequential
realms. With this edition, major depressive disorder may also be
present for 2 years with this diagnosis but it is coded via
specifiers (for a listing see APA, 2013, p. 169). Criteria
exclusions include no manic/hypomanic episodes, the
impairment cannot be better explained by cyclothymic or
schizophrenia spectrum or other psychotic disorder or
attributable to the effects of a substance or another medical
condition (APA, 2013).
Premenstrual Dysphoric Disorder is a now a diagnosis moving
from the appendix section for further study in the DSM-IV-TR
(APA, 2000). This disorder's predominant features include
psychological symptoms like mood shifts and irritability along
with physical symptoms (tender breasts) in relation to the
timing of menses. Diagnostic criteria require that for most
menstrual cycles within a consecutive 12-month period, at least
five symptoms must present in the week before the occurrence
of menstruation, show betterment within days of onset, and
remit within a week post onset. Of the five symptoms, at least
one must be from Criterion A including: rapid changes in mood
and their expression (e.g., tears, sensitivity to rejection),
irritability and or anger, depressed mood and anxiety, and at
least one from Criterion B including: decreased interest, lack of
energy, difficulty thinking, changes in appetite, feeling out of
control or overwhelmed, insomnia/hypersomnia, and physical

50. symptoms. Again, symptoms must cause clinically significant
distress, not just the normal fluctuations in emotional and
physical symptoms due to menses experienced by most women.
Although this disorder may arise with another depressive and/or
mental disorder, the symptoms cannot be just a worsening of
symptoms from another disorder. Also, diagnosis requires that
the symptoms are not the result of a substance (of abuse or
medication) and are not due to another mental or medical
disorder (APA, 2013).
Two of the diagnoses in this section are determined by the
etiological factors relevant to the depressive disorder. First of
all, Substance/Medication-Induced Depressive Disorder is used
when the problematic depressed mood is directly related to the
use of a substance such as a commonly abused drug, prescribed
medication, or a toxin (e.g., lead, carbon monoxide). Similarly,
Depressive Disorder Due to Another Medical Condition is
utilized when the depressed mood is understood to be directly
connected to the effects of another medical condition (APA,
2013).
Finally, two categories are used in the event of diagnostic
uncertainty. First, Other Specified Depressive Disorder category
is used when symptoms associated with a depressed mood
resulting in significant impairment and distress do not meet the
full diagnostic criteria for any disorder in this chapter. This
category is used to convey the explicit explanation for why the
presentation fails to meet criteria, which is identified in the
diagnosis. For example, if symptoms last for more than 4 days
but less than the required 14 days, “short-duration depressive
episode” would be used. Other example applications are
included in the DSM-5 (APA, 2013, p. 183). Finally,
Unspecified Depressive Disorder is similar to the prior
diagnosis in that it too has symptoms that do not quite fit the
diagnostic criteria requirements, but in this case, the clinician
lacks information to be able to specify the reason, typically in
emergency care settings (APA, 2013).
Assessment

51. When assessing someone who you suspect may have a
depressive disorder, particular attention will be focused on the
person's emotional functioning. Although a thorough history of
the presenting problem is required to make a diagnosis of a
depressive disorder, it may be difficult for the client to present
detailed and accurate information. People who are severely
depressed can be virtually mute, or those experiencing mixed
mood states may be unable to express themselves coherently.
Someone with a history of psychiatric treatment may fear
rehospitalization and deliberately minimize symptoms.
Consequently, it is often helpful to gather data from collateral
sources, such as close friends or relatives, employers, or other
professionals, to specify both the timing and severity of
symptoms.
Assessment Instruments
Anger One of the key symptom criteria for DMDD is severe
irritability/angry mood. The State-Trait Anger Expression
Inventory-2 for Children and Adolescents (STAXI-2
CA; Brunner & Spielberger, 2009) is a developmentally
sensitive self-report measure to assess both state and trait anger
with scales for expression and anger control in children aged 9
to 18 years (with the Spanish version validated on children aged
7–17 years). This 35-item measure (in its second edition) is
based on the longer adult version of the State-Trait Anger
Expression Inventory (STAXI, Spielberger, 1988; STAXI-
2; Spielberger, 1999) rated on a 3-point Likert scale from 1 (not
at all/hardly ever) to 3 (very much/often). The STAXI-2 CA
takes under 15 minutes to administer/score and includes 5
scales: Trait Anger, Anger Expression-Out, Anger Expression-
In, State Anger, Anger Control, and 4 subscales (e.g., state
anger feelings, trait angry temperament). A Spanish version is
available with strong psychometrics (del Barrio, Aluja, &
Spielberger, 2004). Numerous studies have validated this
instrument (Brunner & Spielberger, 2009), and Gambetti and
Giusberti (2009) have reported good-to-excellent construct
validity.

52. For adults, the State-Trait Anger Scale (STAS; Spielberger,
Jacobs, Russell, & Crane, 1983) can be used to evaluate feelings
of anger both as a “state” (e.g., an individual's experience of
anger in the immediate present), which tends to be subjective
and varies in intensity, and as a personality “trait” (e.g., the
individual's tendency or frequency to feel anger in general),
which tends to be relatively stable. This instrument contains 30
items, 15 items make up the state-anger scale (SAS) and 15
items comprise the trait-anger scale (TAS). Items are rated on a
4-point Likert scale; for the SAS 1 = not at all to 4 = very much
so; for the TAS 1 = almost never to 4 = almost always. Scoring
is accomplished by summing all items for each scale. A 10-item
short form for both scales is also available. Higher scores
equate to greater state and trait anger respectively. Each scale
has shown good reliability and internal consistency and has
been validated on high school aged students through adults
(Corcoran & Fischer, 2013b).
The Anger Expression Scale for Children (AESC; Steele,
Legerski, Nelson, & Phipps, 2009) is a 26-item questionnaire
that measures anger expression and hostility in children aged 6
to 18 years. This self-report measure is a composite of items
from existing and validated anger/expression scales (e.g.,
STAXI, Spielberger, 1988) as well as newer items and uses a 4-
point Likert scale from 1 = almost never to 4 = almost always
with higher scores indicating greater experience and expression
of anger. The AESC includes four subscales: Trait Anger, Anger
Expression, Anger In, and Anger Control and has been found to
be a reliable measure in the initial validation study but further
research is warranted (Steele et al., 2009).
Depression The most widely known and extensively utilized
assessment instrument for ascertaining depressive
symptomatology in adults is the Beck Depression Inventory II
(BDI-II; Beck, Steer, & Brown, 1996). This brief, self-
administered instrument consists of 21 items and takes under 10
minutes to complete, presented in a multiple-choice format that
measures both the presence and degree of depression in