Acknowledgments and an Invitation |
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xvii | |
Getting Oriented to the Clinician's Thesaurus |
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1 | (20) |
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What is the Clinician's Thesaurus and What Does It Do? |
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1 | (1) |
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How This Book is Organized |
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2 | (1) |
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Understanding the Style and Format of the Chapters |
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3 | (4) |
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A Functional Guide to Report Construction |
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7 | (6) |
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Further Guidelines and Advice on Report Writing |
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13 | (3) |
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Some Ways to Use the Clinician's Thesaurus |
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16 | (1) |
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A Cautionary Note and Disclaimer |
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17 | (4) |
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PART I Conducting a Mental Health Evaluation |
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1 Beginning and Ending the Interview |
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21 | (5) |
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1.1 Structuring the Interview |
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21 | (1) |
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1.2 Introducing Yourself and Noting Possible Communication Difficulties |
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21 | (1) |
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1.3 Assessing the Client's Understanding of the Interview Situation |
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22 | (1) |
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1.4 Obtaining Informed Consent |
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23 | (1) |
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1.5 Other Points for All Interviews |
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23 | (1) |
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1.6 Eliciting the Chief Concern/Complaint/Issue |
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24 | (1) |
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1.7 Eliciting the Client's Understanding of the Problem |
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24 | (1) |
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1.8 Dimensionalizing the Concern/Problem |
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24 | (1) |
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25 | (1) |
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2 Mental Status Evaluation Questions/Tasks |
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26 | (18) |
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2.1 Introduction to the Mental Status Questions |
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26 | (1) |
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2.2 Background Information Related to Mental Status |
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27 | (1) |
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2.3 Rancho Los Amigos Cognitive Scale |
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27 | (1) |
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28 | (1) |
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28 | (2) |
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30 | (1) |
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30 | (1) |
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2.8 Comprehension of Language |
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31 | (1) |
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2.9 Eye-Hand Coordination/Perceptual-Motor Integration/Dyspraxia/Constructional Ability |
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31 | (1) |
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32 | (2) |
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34 | (1) |
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35 | (1) |
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36 | (1) |
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2.14 Similarities/Analogies |
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36 | (1) |
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36 | (1) |
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2.16 Calculation Abilities |
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37 | (1) |
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2.17 Abstract Reasoning/Proverbs |
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38 | (1) |
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38 | (1) |
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39 | (1) |
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39 | (1) |
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40 | (1) |
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40 | (1) |
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2.23 Insight into Disorder |
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40 | (1) |
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2.24 Strengths and Coping |
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41 | (1) |
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2.25 Mental Status Evaluation Checklist |
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41 | (3) |
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3 Questions about Signs, Symptoms, and Other Behavior Patterns |
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44 | (39) |
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3.1 Introduction to the Questions about Signs, Symptoms, and Behavior Patterns |
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44 | (1) |
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3.2 Abuse (Nonsexual)/Neglect of Spouse/Elder |
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45 | (1) |
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3.3 Abuse (Nonsexual)/Neglect of Child |
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46 | (1) |
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3.4 Abuse (Sexual) of Child or Adult |
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46 | (1) |
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47 | (1) |
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48 | (1) |
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3.7 Body Dysmorphic Disorder |
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48 | (1) |
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3.8 Compliance-Noncompliance with Treatment |
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48 | (1) |
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49 | (1) |
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50 | (1) |
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51 | (2) |
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3.12 Dissociative Experiences |
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53 | (1) |
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54 | (2) |
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3.14 Gay and Lesbian Identity Formation |
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56 | (1) |
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56 | (2) |
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58 | (1) |
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58 | (1) |
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58 | (1) |
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59 | (1) |
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3.20 Organicity/Cognitive Disorders |
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60 | (1) |
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60 | (1) |
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61 | (1) |
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62 | (1) |
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62 | (1) |
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63 | (2) |
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3.26 Sexual Identity/Transgender Issues |
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65 | (1) |
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66 | (1) |
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3.28 Substance Abuse: Drugs and Alcohol |
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67 | (8) |
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3.29 Substance Use: Tobacco and Caffeine |
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75 | (1) |
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3.30 Suicide and Self-Destructive Behavior |
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76 | (2) |
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78 | (5) |
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PART II Standard Terms and Statements for Wording Psychological Reports |
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4 Beginning the Report: Preliminary Information |
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83 | (9) |
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4.1 Heading and Dates for the Report |
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83 | (1) |
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4.2 Sources of Information for the Report |
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83 | (1) |
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4.3 Identifying Information about the Client |
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84 | (1) |
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4.4 Self-Sufficiency in Appearing for Examination |
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85 | (1) |
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86 | (1) |
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4.6 Reliability/Validity Statements |
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87 | (2) |
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4.7 Confidentiality Notices |
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89 | (2) |
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4.8 Ethical Considerations in Report Writing |
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91 | (1) |
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92 | (5) |
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5.1 Statement of Referral Reason |
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92 | (1) |
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5.2 Common Referral Reasons for Children at Home |
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93 | (1) |
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5.3 Common Referral Reasons for Children at School |
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93 | (2) |
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5.4 Common Referral Reasons for Children at Both Home and School |
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95 | (2) |
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6 Background Information and History |
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97 | (10) |
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6.1 History/Course of the Present/Chief Complaint/Concern/Problem/Illness |
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97 | (1) |
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6.2 Medical History and Other Findings |
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98 | (1) |
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6.3 Personal, Family, and Social Histories, and Current Social Situation |
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99 | (3) |
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102 | (1) |
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6.5 Social History for a Disability Examination |
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103 | (1) |
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6.6 Family Genogram/Family Tree/Pedigree |
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104 | (3) |
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B The Person in the Evaluation |
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7 Behavioral Observations |
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107 | (11) |
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107 | (3) |
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110 | (1) |
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111 | (3) |
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114 | (3) |
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7.5 Other Behavioral Observations |
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117 | (1) |
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8 Responses to Aspects of the Examination |
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118 | (9) |
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8.1 Reaction to the Context of the Evaluation |
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118 | (2) |
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8.2 Attention/Concentration/Effort |
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120 | (1) |
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8.3 Response to the Methods of Evaluation/Tests/Questions |
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121 | (1) |
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8.4 Persistence/Motivation |
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122 | (1) |
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8.5 Relationship with the Examiner |
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123 | (2) |
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8.6 Response to Success/Failure/Feedback |
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125 | (2) |
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127 | (5) |
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127 | (1) |
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127 | (1) |
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9.3 Self-Image/Self-Esteem |
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128 | (1) |
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9.4 Social Sophistication/Manners |
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128 | (1) |
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129 | (1) |
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9.6 Other Aspects of Self-Presentation |
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129 | (3) |
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10 Emotional/Affective Symptoms and Disorders |
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132 | (14) |
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10.1 General Aspects of Mood and Affects |
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132 | (1) |
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133 | (1) |
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134 | (2) |
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136 | (1) |
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136 | (1) |
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137 | (1) |
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137 | (5) |
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142 | (1) |
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143 | (1) |
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144 | (1) |
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10.11 Seasonal Affective Disorder |
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144 | (1) |
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145 | (1) |
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10.13 Other Affects/Emotional Reactions |
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145 | (1) |
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11 Cognition and Mental Status |
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146 | (17) |
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11.1 No Pathological Findings: Summary Statements |
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146 | (1) |
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147 | (1) |
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147 | (1) |
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11.4 Concentration/Task Persistence |
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147 | (1) |
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11.5 Consciousness Levels |
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148 | (1) |
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148 | (1) |
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149 | (1) |
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149 | (1) |
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150 | (1) |
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11.10 Intelligence, Development, and Cognition: Assessment |
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151 | (1) |
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11.11 Intelligence Scores: Classifications |
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152 | (1) |
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153 | (3) |
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11.13 Moral/Social Judgment and Knowledge |
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156 | (1) |
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11.14 Motivation for Change: Summary Statements |
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157 | (1) |
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157 | (1) |
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157 | (1) |
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11.17 Reasoning/Abstract Thinking/Concept Formation |
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158 | (1) |
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159 | (1) |
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159 | (3) |
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11.20 Test Judgment: Summary Statements |
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162 | (1) |
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11.21 Other Summary Statements for Mental Status |
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162 | (1) |
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12 Abnormal Signs, Symptoms, and Syndromes |
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163 | (46) |
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163 | (1) |
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12.2 AIDS Dementia Complex |
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164 | (1) |
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12.3 Attention-Deficit/Hyperactivity Disorder |
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164 | (4) |
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12.4 Autism Spectrum Disorders |
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168 | (1) |
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12.5 Battered-Woman Syndrome |
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169 | (1) |
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12.6 Body Dysmorphic Disorder |
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170 | (1) |
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12.7 Chronic Fatigue Syndrome |
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171 | (1) |
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171 | (1) |
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172 | (1) |
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173 | (1) |
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174 | (1) |
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12.12 Depersonalization and Derealization |
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175 | (1) |
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175 | (1) |
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175 | (3) |
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12.15 Fetal Alcohol Syndrome |
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178 | (1) |
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178 | (1) |
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179 | (1) |
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180 | (1) |
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12.19 Impulse-Control Disorders |
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180 | (2) |
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182 | (1) |
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183 | (1) |
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12.22 Oppositional Defiant Disorder |
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184 | (1) |
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12.23 Pain Disorder/Chronic Pain Syndrome |
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184 | (1) |
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185 | (1) |
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185 | (1) |
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12.26 Postconcussive Syndrome |
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186 | (1) |
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12.27 Posttraumatic Stress Disorder |
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186 | (2) |
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12.28 Premenstrual Dysphoric Disorder |
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188 | (1) |
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12.29 Rape Trauma Syndrome |
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189 | (1) |
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12.30 Reactive Attachment Disorder |
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190 | (1) |
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191 | (1) |
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12.32 School Refusal/Avoidance/"Phobia," |
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192 | (1) |
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12.33 Self-Injurious Behavior |
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193 | (1) |
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12.34 Sexual Abuse, Child |
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193 | (1) |
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12.35 Sexual Impulsivity/"Addiction"/"Compulsion," |
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194 | (1) |
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12.36 Side Effects of Psychotropic Medications/Adverse Drug Reactions |
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195 | (1) |
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196 | (2) |
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198 | (1) |
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12.39 Substance Use, Abuse, and Dependence |
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198 | (4) |
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202 | (5) |
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207 | (2) |
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209 | (30) |
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13.1 Models of Personality Diagnosis |
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209 | (2) |
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211 | (1) |
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13.3 Cognitive or Thinking Styles |
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212 | (1) |
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13.4 A and B Personality Types |
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212 | (2) |
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13.5 "Addictive" Personality |
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214 | (1) |
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13.6 Aggressive Personality |
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214 | (1) |
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13.7 Antisocial Personality |
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214 | (2) |
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13.8 Authoritarian Personality |
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216 | (1) |
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13.9 Avoidant Personality |
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217 | (1) |
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13.10 Borderline Personality |
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218 | (1) |
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13.11 Codependent Personality |
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219 | (2) |
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13.12 Compulsive Personality |
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221 | (1) |
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13.13 Dependent Personality |
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222 | (2) |
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13.14 Dissociative Identity Disorder |
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224 | (1) |
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13.15 Histrionic Personality |
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225 | (1) |
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13.16 Hypochondriacal Personality |
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226 | (1) |
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13.17 Narcissistic Personality |
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227 | (1) |
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13.18 "Nervous" Personality |
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228 | (1) |
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13.19 Normal/Healthy Personality |
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229 | (1) |
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13.20 Obsessive Personality |
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230 | (1) |
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13.21 Paranoid Personality |
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231 | (1) |
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13.22 Passive-Aggressive Personality |
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232 | (1) |
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13.23 Sadistic Personality |
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233 | (1) |
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13.24 Schizoid Personality |
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234 | (1) |
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13.25 Schizotypal Personality |
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235 | (1) |
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13.26 Self-Defeating Personality |
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235 | (4) |
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C The Person in the Environment |
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14 Activities of Daily Living |
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239 | (6) |
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239 | (1) |
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14.2 Assistance Level Required/Degree of Independence |
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239 | (1) |
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240 | (1) |
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14.4 Chores/House Care/Domestic Skills |
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240 | (1) |
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240 | (1) |
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240 | (1) |
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14.7 Hazard Recognition and Coping |
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241 | (1) |
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14.8 Living Situation/Level of Support Needed |
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242 | (1) |
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14.9 Quality of Performance |
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242 | (1) |
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242 | (1) |
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243 | (1) |
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243 | (1) |
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243 | (1) |
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243 | (2) |
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15 Social/Community Functioning |
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245 | (2) |
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245 | (1) |
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15.2 Involvement in Social/Community Activities |
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246 | (1) |
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15.3 Problems/Conflicts in Community Relating |
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246 | (1) |
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16 Couple and Family Relationships |
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247 | (5) |
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16.1 Systemic Family Constructs |
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247 | (1) |
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16.2 Assessment of Families at Intake |
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248 | (1) |
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16.3 Family Interviewing Method |
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249 | (1) |
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16.4 Child Rearing/Raising: Aspects |
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250 | (1) |
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16.5 Couple Relationships: Aspects |
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251 | (1) |
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251 | (1) |
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17 Vocational/Academic Skills |
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252 | (8) |
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252 | (3) |
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255 | (1) |
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17.3 Language Skills: Reading and Writing Ability |
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256 | (1) |
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257 | (1) |
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17.5 Special Considerations for Disability Reports |
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257 | (1) |
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17.6 Vocational Competence/Recommendations |
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257 | (3) |
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18 Recreational Functioning |
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260 | (2) |
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18.1 Entertainment: TV/Radio/Music |
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260 | (1) |
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260 | (1) |
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260 | (1) |
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261 | (1) |
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18.5 Participation/Performance Quality |
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261 | (1) |
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19 Other Specialized Evaluations |
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262 | (11) |
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19.1 Coping Ability/Stress Tolerance |
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262 | (1) |
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19.2 Culturally Sensitive Formulations |
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262 | (2) |
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19.3 Developmental Stages |
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264 | (1) |
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19.4 Financial Competence/Competence to Manage Funds |
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264 | (1) |
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19.5 Homosexual Identity: Stages of Formation |
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265 | (1) |
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19.6 Impairment's Effects on a Person |
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266 | (1) |
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266 | (1) |
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267 | (1) |
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19.9 Religious and Spiritual Concerns |
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268 | (1) |
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19.10 Testamentary Competence/Competence to Make a Will |
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269 | (4) |
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20 Summary of Findings and Conclusions |
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273 | (3) |
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273 | (1) |
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20.2 Beginning the Summary |
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273 | (1) |
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20.3 Summary of Previous Information |
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273 | (1) |
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20.4 Relevant Findings and/or Conclusions |
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274 | (1) |
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20.5 Diagnostic Statement |
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274 | (1) |
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20.6 Consultations and Further Evaluations |
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274 | (1) |
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20.7 Summarizing Treatment |
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274 | (2) |
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21 Diagnostic Statement/Impression |
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276 | (31) |
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21.1 Qualifiers for Diagnosis |
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276 | (1) |
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276 | (1) |
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277 | (1) |
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277 | (1) |
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278 | (4) |
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21.6 Stress and Adjustment Disorders |
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282 | (1) |
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21.7 Personality Disorders |
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283 | (1) |
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21.8 Impulse-Control Disorders Not Elsewhere Classified |
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284 | (1) |
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284 | (4) |
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21.10 Eating and Elimination Disorders |
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288 | (1) |
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21.11 "Organic" Cognitive Conditions |
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289 | (2) |
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21.12 Substance-Related Disorders |
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291 | (4) |
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21.13 Psychotic Disorders |
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295 | (1) |
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296 | (2) |
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21.15 Somatoform Disorders |
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298 | (1) |
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21.16 Psychological Factors Affecting a Medical Condition |
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298 | (1) |
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21.17 Dissociative Disorders |
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299 | (1) |
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21.18 Sexual Dysfunctions and Disorders |
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299 | (2) |
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21.19 Factitious Disorders |
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301 | (1) |
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21.20 Medication-Induced Movement Disorders |
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302 | (1) |
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302 | (3) |
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21.22 Axis IV: Psychosocial and Environmental Problems |
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305 | (1) |
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21.23 Axis V: Global Assessment of Functioning Scale |
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305 | (2) |
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307 | (5) |
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307 | (1) |
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22.2 Treatments of Choice |
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308 | (1) |
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22.3 Treatment Options/Case Disposition |
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309 | (1) |
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22.4 Types of Therapies/Services |
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309 | (3) |
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312 | (2) |
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23.1 General Prognostic Statement |
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312 | (1) |
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313 | (1) |
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314 | (5) |
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24.1 Value of the Information |
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314 | (1) |
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24.2 Thanking the Referrer |
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314 | (1) |
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24.3 Continued Availability |
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314 | (1) |
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315 | (1) |
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315 | (4) |
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PART III Useful Resources |
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25 Treatment Planning and Treatment Plan Formats |
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|
319 | (19) |
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25.1 The Flow and Nature of Treatment Planning |
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319 | (1) |
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25.2 Some Advice on Writing Treatment Plans |
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319 | (1) |
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25.3 Various Formats for Treatment Plans |
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320 | (4) |
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25.4 A Treatment Plan Format for Case Conceptualization |
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324 | (9) |
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25.5 Treatment Plan Components for Clients with Substance Abuse |
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|
333 | (2) |
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25.6 Treatment Plan Components for Crisis Interventions |
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|
335 | (1) |
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25.7 Checklist of Strengths |
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|
335 | (1) |
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25.8 Outcome Measures/Goal Achievements |
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|
336 | (2) |
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26 Formats for Reports, Evaluations, and Summaries |
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|
338 | (7) |
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26.1 A Standard Format for Reports of Evaluations |
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|
338 | (1) |
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26.2 Format for Psychodynamic Evaluations: Developmental Model |
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|
339 | (1) |
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26.3 The Psychodynamic Diagnostic Manual |
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|
340 | (1) |
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26.4 Themes for Evaluations from an Existential Perspective |
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|
340 | (1) |
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26.5 Adlerian Evaluations |
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|
340 | (1) |
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26.6 Transactional Analysis |
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|
341 | (1) |
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26.7 Nursing Diagnoses and Treatment Planning |
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|
342 | (1) |
|
26.8 Vocational and Nonclinical Personality Evaluations |
|
|
342 | (1) |
|
26.9 Formats for Therapy Notes |
|
|
343 | (2) |
|
27 Treatments for Specific Disorders and Concerns |
|
|
345 | (6) |
|
27.1 Abuse/Aggression/Violence/Impulsive Behaviors |
|
|
345 | (1) |
|
27.2 Anorexia Nervosa and Bulimia Nervosa |
|
|
345 | (1) |
|
27.3 Antisocial Personality Disorder |
|
|
346 | (1) |
|
|
346 | (1) |
|
|
346 | (1) |
|
27.6 Attention-Deficit/Hyperactivity Disorder |
|
|
346 | (1) |
|
|
346 | (1) |
|
27.8 Body Dysmorphic Disorder |
|
|
346 | (1) |
|
27.9 Borderline Personality Disorder |
|
|
347 | (1) |
|
|
347 | (1) |
|
27.11 Dissociative Identity Disorder |
|
|
347 | (1) |
|
|
347 | (1) |
|
27.13 Gambling, Pathological |
|
|
347 | (1) |
|
27.14 Hypochondriacal Personality |
|
|
347 | (1) |
|
27.15 Obsessive-Compulsive Disorders |
|
|
348 | (1) |
|
|
348 | (1) |
|
|
348 | (1) |
|
27.18 Posttraumatic Stress Disorder |
|
|
348 | (1) |
|
27.19 Religious and Spiritual Concerns |
|
|
348 | (1) |
|
27.20 Schizophrenia and Psychosis |
|
|
349 | (1) |
|
|
349 | (1) |
|
|
349 | (1) |
|
|
349 | (1) |
|
|
350 | (1) |
|
28 Listing of Common Psychiatric and Psychoactive Drugs |
|
|
351 | (8) |
|
28.1 List of Medications by Trade and Generic Names |
|
|
351 | (6) |
|
28.2 Finding Street Drugs' Names |
|
|
357 | (1) |
|
28.3 Results of Medication Treatment: Descriptors |
|
|
357 | (1) |
|
28.4 Drug Resources for the Clinician |
|
|
357 | (2) |
|
29 Psychiatric Masquerade of Medical Conditions |
|
|
359 | (8) |
|
|
359 | (1) |
|
|
360 | (1) |
|
|
360 | (1) |
|
|
360 | (1) |
|
|
361 | (1) |
|
29.6 Organic Brain Syndrome/Dementia |
|
|
361 | (2) |
|
|
363 | (1) |
|
29.8 Medication-Induced Psychiatric Conditions |
|
|
364 | (3) |
|
|
|
A Abbreviations in Common Use |
|
|
367 | (4) |
|
A.1 Clinicians/Mental Health Professionals |
|
|
367 | (1) |
|
|
368 | (1) |
|
A.3 Diagnoses and Conditions |
|
|
368 | (1) |
|
|
369 | (1) |
|
A.5 General Aids to Recording |
|
|
369 | (1) |
|
|
370 | (1) |
|
|
370 | (1) |
|
|
370 | (1) |
|
B Annotated Readings in Assessment, Interviewing, and Report Writing |
|
|
371 | (1) |
|
|
371 | (1) |
|
|
372 | (1) |
|
|
372 | (2) |
|
Feedback Solicitation Form |
|
|
374 | (1) |
|
About the Clinician's Electronic Thesaurus, Version 7.0 |
|
|
375 | (2) |
|
Additional Productivity Features |
|
|
375 | (1) |
|
|
376 | (1) |
|
|
376 | (1) |
References |
|
377 | (10) |
Index |
|
387 | |