Maryland LCSW-C Study Guide

Clinical Diagnosis: Major Depressive Disorder (MDD)

  • Definition: A mood disorder characterized by discrete episodes of depressed mood and/or loss of interest or pleasure with associated cognitive, vegetative, and psychomotor symptoms.

Key Diagnostic Features / Duration

  • Symptoms Duration: Symptoms must persist for ≥ 2 weeks.
  • Core Symptoms: Must have either a depressed mood or the inability to experience pleasure (anhedonia) from activities that were once enjoyable.
  • Total Symptoms Required: At least 5 of the following:
    • Depressed mood
    • Anhedonia
    • Significant weight/appetite change
    • Insomnia or hypersomnia
    • Psychomotor agitation or retardation
    • Fatigue
    • Worthlessness or excessive guilt
    • Impaired concentration
    • Recurrent thoughts of death or suicidal ideation (SI).

Differential Diagnosis

  • Persistent Depressive Disorder (chronicity issues)
  • Bereavement (focus on timing and preserved self-esteem initially)
  • Bipolar Disorders (consider past hypomania or mania to rule out).

Assessment Cues

  • Utilize PHQ-9 for severity assessment; inquire about suicidal thoughts directly, changes in sleep/appetite, and functional impairment.
  • Rule out potential medical or substance-induced causes through thorough history and laboratory tests as needed.

Common Interventions / Clinical Tips

  • Evidence-Based Interventions:
    • Antidepressants (SSRIs/SNRIs)
    • Cognitive Behavioral Therapy (CBT) focusing on behavioral activation
    • Interpersonal Therapy.
  • Safety Considerations: Implement safety planning for those expressing SI; consider a higher level of care if symptoms are severe.

Example Vignette

  • A client reports two weeks of no interest in hobbies, trouble sleeping, poor concentration at work, and passive suicidal thoughts.

Persistent Depressive Disorder (Dysthymia)

  • Definition: Chronic, lower-grade depressive symptoms lasting long-term.

Key Features / Duration

  • Symptoms Duration: Persists for ≥ 2 years in adults with depressed mood most days.
  • Symptoms Severity: Generally less severe than MDD, but chronic; symptoms never absent for more than 2 months.

Differential Diagnosis

  • Major Depressive Episodes superimposed on dysthymia (considered "double depression")
  • Cyclothymia (milder mood swings)
  • Personality Disorders characterized by chronic low mood.

Assessment Cues

  • Use the PHQ-9, inquire about self-harm history, and assess triggers for emotional dysregulation, interpersonal patterns, and substance use.

Treatment Options

  • Evidence-Based Interventions:
    • Antidepressants (SSRIs/SNRIs)
    • Cognitive Behavioral Therapy (CBT)
    • Interpersonal Therapy.
  • Safety Planning: Ensure safety for clients expressing SI; explore the need for higher levels of care if the situation is severe.

Example Vignette

  • A client consistently presents with low energy and depressive symptoms but describes being functional enough to maintain daily routines.

Post-Traumatic Stress Disorder (PTSD)

  • Definition: A psychiatric condition following exposure to actual or threatened death, serious injury, or sexual violence.

Key Features / Duration

  • Symptom Clusters:
    • Intrusion (e.g., flashbacks, nightmares)
    • Avoidance (of reminders)
    • Negative alterations in cognition and mood
    • Heightened arousal and reactivity.
  • Duration Requirement: Symptoms must persist for ≥ 1 month; if symptoms last less than 1 month, diagnose as Acute Stress Disorder.

Differential Diagnosis

  • Acute Stress Disorder (symptoms present for <1 month)
  • Adjustment Disorder without trauma exposure or fewer PTSD-specific symptoms
  • Major Depressive Disorder and potential substance-induced symptoms.

Assessment Cues

  • Employ trauma-informed approaches and ask non-retraumatizing questions; screen for suicidality and substance use.
  • Assess for the presence of dissociation or complex PTSD that may arise from prolonged trauma.

Treatment Strategies

  • Combining Approaches: Effective intervention often incorporates psychotherapy (such as CBT, behavioral activation) alongside medication.

Example Vignette

  • A client recounts feeling "down" for years, managing to function yet lacking energy; the client acknowledges having occasional major depressive episodes during this time.

Conduct Disorder (CD)

  • Definition: A repeated pattern of behavior, typically in children or adolescents, characterized by violations of social norms and the rights of others.

Key Features / Duration

  • Common Behaviors: Aggression towards people or animals, destruction of property, deceitfulness or theft, and serious rule violations.
  • Specifiers: Based on the age of onset, severity, and presence of callous–unemotional traits.

Differential Diagnosis

  • Oppositional Defiant Disorder (less severe behaviors and absence of severe violations)
  • ADHD with comorbidity (to rule out impulsivity)
  • Conduct related to trauma or attachment disorders.

Assessment Cues

  • Required information from collateral reports (e.g., teachers, caregivers), legal involvement, and risk assessments for potential violence or recidivism.

Treatment Plan

  • Evidence-Based Approaches:
    • Trauma-focused Cognitive Behavioral Therapy (CBT)
    • Prolonged Exposure Therapy (PE)
    • Cognitive Processing Therapy (CPT)
    • Eye Movement Desensitization and Reprocessing (EMDR), depending on clinician's competency.

Example Vignette

  • A 15-year-old has been apprehended for vandalism and theft, recent reports of cruelty to animals, and regular school absenteeism.

Oppositional Defiant Disorder (ODD)

  • Definition: A persistent pattern of angry or irritable mood, argumentative/defiant behavior, or vindictiveness towards authority figures.

Key Features / Duration

  • Symptoms Duration: Symptoms must last for a minimum of 6 months.
  • Common Behaviors: Frequent temper loss, arguing with adults, deliberately annoying others, blaming others for personal mistakes, acting spiteful or vengeful.

Differential Diagnosis

  • Conduct Disorder (look for signs of aggression, destruction, or theft)
  • Typical Adolescent Rebellion (consider the severity, frequency, and resultant impairment)
  • Mood Disorders or Learning Disorders leading to frustration or maladaptive responses.

Assessment Cues

  • Gather information from multiple informants; evaluate family stressors and parenting approaches, and check for past trauma.

Treatment Options

  • Interventions: Parent training programs, family therapy, school-based behavioral plans, promoting consistent boundaries and reinforcement strategies.

Example Vignette

  • A child persistently refuses to follow teachers' instructions, blames peers for mistakes, and experiences frequent tantrums at school.

Bipolar I Disorder

  • Definition: Presence of at least one manic episode; depressive episodes are common but not mandatory.

Key Features / Duration

  • Mania Description: Typically characterized by elevated or irritable mood, increased energy, grandiosity, decreased need for sleep, pressured speech, and indulging in risky activities.
  • Duration Requirement: Mania lasts ≥ 1 week or any duration if hospitalization is necessary; during mania, psychotic features may be included.

Differential Diagnosis

  • Substance or Medication-Induced Mood Disorders (consider effects from stimulants or steroids)
  • ADHD (confused with chronic impulsivity versus episodic mania)
  • Borderline Personality Disorder (affective instability versus distinct manic episodes).

Assessment Cues

  • Inquire about elevated mood history, potential risky decision-making, previous hospitalization, and check for mood cycling and rapid shifts.

Treatment Approaches

  • Medications: Mood stabilizers (e.g., lithium, valproate) and antipsychotics for acute mania; psychotherapy enhances adherence and psychoeducation while ensuring safety to manage impulsivity.

Example Vignette

  • A client frequently sacrifices sleep (2–3 hours a night), spends large amounts of money impulsively, and entertains grandiose plans, ultimately leading to job loss.

Bipolar II Disorder

  • Definition: Characterized by at least one hypomanic episode and one Major Depressive Episode (MDE), but without ever experiencing a full manic episode.

Key Features / Duration

  • Hypomania: Similar to mania but must last for at least 4 days with milder impairment; does not require hospitalization; observable changes in behavior by others should be evident.
  • Co-morbid Depressive Burden: Often misdiagnosed due to a significant depressive component.

Differential Diagnosis

  • Cyclothymia (considered a milder, chronic form)
  • Major Depressive Disorder (essential to ask about hypomanic episodes).

Assessment Cues

  • Investigate historical periods of heightened energy or productivity distinctly different from baseline; collateral histories are beneficial here.

Treatment Plans

  • Medications: Include mood stabilizers alongside psychotherapy, and be cautious in using antidepressants due to the risk of triggering hypomania.

Example Vignette

  • Client describes episodes of unusually heightened energy and productivity lasting about 4-5 days, followed by prolonged depressive spells.

Generalized Anxiety Disorder (GAD)

  • Definition: A mental health disorder characterized by excessive, uncontrollable worry about multiple areas of life along with related physical and psychological symptoms.

Key Features / Duration

  • Symptoms Duration: Worry must persist for ≥ 6 months, occurring most days.
  • Common Symptoms: Restlessness, fatigue, difficulty concentrating, muscle tension, irritability, and sleep disturbance.

Differential Diagnosis

  • Panic Disorder (associated episodic panic attacks)
  • Adjustment Disorder with Anxiety (fewer specific symptoms)
  • Medical Causes (such as hyperthyroidism) along with substance use.

Assessment Cues

  • Utilize the GAD-7 screening tool to evaluate levels of worry; scrutinize for avoidance, functional impairment, and comorbid mood disorders.

Treatment Options

  • Interventions: Focus on CBT (worry exposures, cognitive restructuring), consider SSRIs/SNRIs, and introduce relaxation training and mindfulness techniques.

Example Vignette

  • A client expresses daily anxieties over health, finances, and family with related muscle tension and sleep issues persisting over the past year.

Schizophrenia

  • Definition: A chronic psychotic disorder marked by substantial disturbances in thought processes, perceptions, language, and behavior leading to functional impairment.

Key Features / Duration

  • Core Symptoms: Must meet 2 or more of the following:
    • Delusions
    • Hallucinations
    • Disorganized speech
    • Grossly disorganized or catatonic behavior
    • Negative symptoms (e.g., flattened affect, avolition).
  • Symptoms Duration: Should persist for ≥ 6 months (including prodromal, active, and residual phases); active symptoms must be present for at least 1 month.

Differential Diagnosis

  • Schizoaffective Disorder (mood episode occurring concurrently or in proportion)
  • Substance-Induced Psychosis (e.g., from amphetamines, PCP)
  • Medical/Nurological Causes (e.g., brain tumors or autoimmune encephalitis).

Assessment Cues

  • Conduct a Mental Status Examination (MSE), evaluate for insight and functioning in work and relationships, along with assessing for substance use and risk regarding command hallucinations.

Treatment Approaches

  • Medications: Include antipsychotic medications (first and second generation), coupled with psychosocial interventions, supported employment, and family psychoeducation.

Example Vignette

  • A young adult presents with 6 months of social withdrawal, flat affect, auditory hallucinations that comment on behavior, and declining work performance.

Borderline Personality Disorder (BPD)

  • Definition: A pervasive pattern of instability in interpersonal relationships, self-image, affects, and impulsivity beginning in early adulthood.

Key Features / Duration

  • Critical Characteristics:
    • Frantic efforts to avoid real or imagined abandonment
    • Unstable and intense interpersonal relationships (cycle from idealization to devaluation)
    • Identity disturbance and impulsivity
    • Recurrent suicidal or self-harming behaviors
    • Affective instability, chronic feelings of emptiness, and intense anger.

Differential Diagnosis

  • Bipolar Disorder (focus on episodicity versus emotional reactivity)
  • PTSD/Complex Trauma (symptomatic overlap on emotional dysregulation)
  • Other Personality Disorders (e.g., antisocial or histrionic disorders).

Assessment Cues

  • Assess history, self-harm, emotional regulation triggers, interpersonal patterns, and levels of substance use; safety planning remains crucial.

Treatment Options

  • Effective Methodologies: Dialectical Behavior Therapy (DBT) is the gold standard; consider mentalization-based therapy, schema therapy; medications should target comorbid conditions (anxiety, mood).

Example Vignette

  • A client cycles between idealizing and devaluing romantic partners, engages in impulsive spending, and has a history of cutting during crises.

Human Development & Major Theorists

Erik Erikson — Psychosocial Stages (8 stages)

  • 1. Trust vs. Mistrust (0–1 yr): Establishing basic trust if needs are met; failure leads to mistrust.
  • 2. Autonomy vs. Shame/Doubt (1–3 yrs): Developing independence through achievements (e.g., toilet training).
  • 3. Initiative vs. Guilt (3–6 yrs): Engaging in goal-directed play, demonstrating assertiveness.
  • 4. Industry vs. Inferiority (6–12 yrs): Gaining competence in school or work skills.
  • 5. Identity vs. Role Confusion (Adolescence): Formulation of a sense of self or vocational identity.
  • 6. Intimacy vs. Isolation (Young Adult): Forming intimate relationships and commitments.
  • 7. Generativity vs. Stagnation (Middle Adulthood): Contributing positively to the next generation.
  • 8. Integrity vs. Despair (Older Adult): Reflecting on life and achieving acceptance.

Treatment Considerations

  • Assess self-harm histories, emotional dysregulation triggers, interpersonal dynamics, and substance usage; safety planning strategies are deeply integrated.

Example Vignette

  • Clients with dramatic shifts in relationships may alternate between idealizing and devaluing partners, highlighting emotional instability.

Mnemonic Recall

  • Mnemonic for Stages: “Trust And I Identify Intense Generations’ Integrity” (The first letters of each of Erikson’s stages).

Jean Piaget — Cognitive Development (4 stages)

  • 1. Sensorimotor (0–2 yrs): Recognizing object permanence; sensory exploration.
  • 2. Preoperational (2–7 yrs): Cultivating symbolic thought; characterized by egocentrism and magical thinking (no conservation).
  • 3. Concrete Operational (7–11 yrs): Implementing logical operations on tangible objects; understanding conservation and decentration.
  • 4. Formal Operational (12+ yrs): Engaging in abstract reasoning and hypothetical-deductive reasoning.

Mnemonic Recall

  • Mnemonic for Stages: “SPCF” (Sensorimotor, Preoperational, Concrete, Formal).

Sigmund Freud — Psychosexual Stages & Structural Model

  • 1. Oral Stage (0–1 yr): Focus on feeding; fixation