Problem Set for Assessment, Treatment and Rehabilitation
for Serious Mental Illness (SMI)

In modern psychiatric treatment and rehabilitation, the Master Treatment Plan is organized around a list of specific Problem Titles. A treatment and rehabilitation program can be described in terms of the Problems that can be treated in that program. The complete list of such Problem Titles is the program’s Problem Set.

Each Problem in this Problem Set reflects a specific problem which:
1. Can be identified and distinguished from other Problems in people with SMI
2. Is known to cause serious problems and barriers to better functioning in people with SMI
3. Has an etiology, or cause, which is at least partially understood scientifically
4. Can be effectively treated with specific treatments having scientifically established effectiveness

The Problem Titles use scientific terminology rather than colloquial language, for the same reason that medical diagnoses are given in terminology rather than colloquial language. To ensure complete understanding of the Problems in a Master Treatment Plan, the Problem Titles must always be accompanied by a Problem Description that identifies in colloquial language how the problem is expressed in a particular individual, how it will be clinically assessed, and how it will be treated. Both Problem Titles and Problem Descriptions are explained in this document.

The Problem Titles are ordered, from the most molecular level of biobehavioral functioning, neurophysiology, to the most molar, the complex social and environmental consequences of severe mental illness. Heuristically convenient categories of problems across the full range of biobehavioral functioning, also ordered from molecular to molar, are: Neurophysiological, Neurocognitive, Sociocognitive, Sociobehavioral and Socioenvironmental. It is also heuristically convenient to subcategorize Sociobehavioral problems as skill deficits, psychophysiological dysregulation, and combined.

Neurophysiological problems
1. Episodic neurophysiological dysregulation of the central nervous system
2. Tonic dysregulation of the central nervous system

Neurocognitive problems
3. Post-acute neurocognitive impairment
4. Residual neurocognitive impairments

Sociobehavioral problems – skill deficits
9. Self care skill deficit
10. Independent living skill deficit
11. Disorder management deficit
12. Occupational skill deficit
13. Interpersonal skill deficit

Sociobehavioral problems – psychophysiological dysregulation
14. Dysregulation of behavioral activation
15. Dysregulation of mood
16. Dysregulation of anger/aggression
17. Dysregulation of fear/anxiety
18. Dysregulation of appetitive behavior (hunger, thirst)
19. Dysregulation of sexual behavior

Sociobehavioral problems - combined
20. Substance abuse

Socioenvironmental problems
21. Rehabilitation nonadherence
22. Socialized psychiatric symptoms
23. Socially unacceptable behavior
24. Social-environmental conflict
25. Restrictive legal status
26. Unstable living conditions

II. Problem priority ratings

Before treatment begins, however, the Problems listed in a Master Treatment Plan must be prioritized. Some Problems must usually be treated before other Problems, and treatment of some Problems must be deferred for various reasons.

Prioritization does not refer to the "importance" of different problems. In the formal sense of a psychiatric treatment plan, all Problems are equally important. They all constitute significant barriers to personal and social functioning. However, it is the nature of mental illness that sometimes certain problems affect treatment choices and progress on other problems. For example, if the recovering person is currently suffering from acute psychosis, to the degree that participation in some rehabilitation activities may not be beneficial, or even harmful, some resolution of the acute psychosis may be prerequisite to those activities. Psychiatric rehabilitation requires the treatment plan to document such relationships between Problems, and to justify sequencing and deferring treatment of specific Problems. Properly sequenced treatment is more efficient and produces better outcome.

Prioritization of the Problems also clarifies the team's hypotheses about relationships between Problems, clarifies expectations about intervention response, helps justify selection of specific interventions, their timing and sequencing, and serves as a guide for later evaluations of progress and success.

Prioritization also solves a dilemma in which treatment teams sometimes find themselves. On the one hand, it is a reality that mental illness sometimes presents problems that cannot all be addressed at one time. If the treatment team attempts to address too many problems at once, they are subject to the criticism (usually from accreditation referees) that they are being unrealistic, unfocused or overly ambitious. On the other hand, if they do not address evident problems, or, more commonly, attempt to lump problems that can be addressed immediately together with problems that require preliminary resolution of other problems, they are subject to the criticism that they are neglecting important parts of the clinical presentation. The Integrated Paradigm allows the team to identify all relevant problems, while specifying the strategy by which those problems will be ddressed.

The four-category coding scheme below efficiently expresses the treatment team’s strategy for sequencing treatment and dealing with relationships between different Problems:

Priority 1: The Problem is accessible for treatment, and no other Problems are expected to interfere with intervention and solution.

Priority 2: There is another Problem that is expected to interfere with intervention and/or solution, so that progress is not expected to be optimal, but due to circumstantial reasons, intervention will proceed anyway. Circumstantial reasons for intervention might include: 1) the potential benefits of intervention outweigh the cost, even when response is suboptimal; 2) intervention must be provided for safety, legal or humanitarian reasons whether optimal response is expected or not. 3) intervention produces valuable clinical data that would not be available without intervention.

Priority 3: There is a Problem that is expected to interfere with intervention and/or solution, such that intervention is not justified until the preemptive Problem is resolved to some degree.

Priority 4: Further resolution of the Problem is neither necessary nor expected. Intervention is either discontinued altogether, or continued with the expectation that it will maintain the status quo rather than produce further changes (e.g. use of “maintenance” medication regimens to prevent recurrence of acute psychosis).

III. Problem definitions and descriptions

Neurophysiological level of functioning

Problem title: Episodic neurophysiological dysregulation of the central nervous system
Problem definition: A neurophysiological condition characterized by episodes of acute psychosis having highly variable clinical expression, including extreme subjective distress, extreme affective responses from euphoric to dysphoric, blunted affective responses, hallucinations, disruption of cognitive functioning, bizarre or socially unacceptable behavior, extreme irritability and explosiveness. Distinct patterns of abnormality within this Problem are traditionally associated with ‘schizophrenia,’ ‘schizo-affective disorder,’ ‘severe or psychotic depression,’ ‘delusional disorder’ and ‘bipolar disorder.’ Recent research on medication response in individuals diagnosed with ‘borderline personality disorder’ has linked that diagnosis to this type of dysregulation. However, specific characteristics vary highly within and across diagnostic categories. The clinical presentation may meet the criteria for multiple diagnostic categories. In addition to discrete episodes, this Problem may include an enduring neurophysiological vulnerability requiring continued intervention to prevent recurrence.

The neurophysiological mechanisms involved are incompletely understood, and numerous specific mechanisms are probably involved in different ways in different individuals. Clinical response to medication is also highly variable, and the optimal regimen may prove to be a single compound or a combination of compounds across different drug families. The critical indication is not the effectiveness of any particular type of neurophysiological-level treatment, but a clear pattern of positive clinical response to a known regimen. Data relevant to identification of this Problem generally come from subjective report of the recovering person, observations by key informants in the natural environment, social history, and ongoing assessment of response to neurophysiological-level interventions (which may include psychosocial and environmental as well as pharmacological modalities). Ongoing assessment of this Problem usually includes gradual discrimination between clinical expressions directly produced by the dysregulation and expressions which are behaviorally similar but are not resolved by optimal neurophysiological intervention. The latter must be further evaluated as possibly representing more molar-level Problems. A detailed and protracted functional analysis of behavior may be necessary to complete this process.

Evidence of previous positive response to medications in the antipsychotic and/or antidepressant families is highly suggestive of this pattern of dysregulation. Subjective report, observations by key informants, and ystematic behavioral observation are key sources of treatment response data. Neurocognitive assessment is often helpful in evaluating response to intervention, although some baseline data is generally required for comparison.

Problem title: Tonic dysregulation of the central nervous system
Problem definition: A neurophysiological condition characterized by continuous (non-episodic) cognitive, affective, psychophysiological and/or behavioral dysfunction. Distinct patterns of abnormality within this Problem are associated with ‘residual schizophrenia,’ ‘depression,’ ‘dysthymic disorder,’ ‘anxiety disorder(s),’ and ‘explosive disorder.’ However, specific characteristics vary highly within and across diagnostic categories, and the clinical presentation may meet criteria for multiple diagnostic categories. The dysregulation may be iatrogenic, produced by medications, usually by those being used to treat episodic dysregulation, or by the drugs being used to control the side effects of other drugs (especially anticholinergic drugs).

Tonic neurophysiological dysregulation may be difficult to differentiate from episodic dysregulation. Tonic dysregulation should be considered as a separate Problem when 1) the clinical picture does not include evidence of episodic fluctuations, 2) there is evidence of iatrogenic effects, or 3) the effective intervention is qualitatively different from the intervention that most effectively controls episodic dysregulation. Indications of tonic dysregulation often occur as “residual” impairments, i.e. ones that remain after effective control of an episodic dysregulation. Behaviors associated with tonic dysregulation are also associated with neurocognitive, sociocognitive, sociobehavioral and socioenvironmental problems. Contributions from these domains should be systematically assessed in the course of defining and treating any tonic dysregulation Problem.

The techniques and instruments most useful for assessing tonic neurophysiological dysfunction are generally those used to assess episodic dysfunction, in addition to the assessments used to evaluate the role of more molar Problems contributing to the clinical picture (this serves to articulate the neurophysiological Problem through a process of elimination).

Neurocognitive level of functioning

Problem title: Post-acute neurocognitive impairment
Problem definition: Impairment in cognitive functioning, in the relatively molecular domains generally addressed by neuropsychological assessment, attributable to the lingering effects of one or more episodes of acute psychosis. Post-acute neurocognitive impairment must be distinguished from impairment that is resolved by neurophysiological treatment of episodic or tonic neurophysiological dysregulation, and from residual neurocognitive impairments. Post-acute neurocognitive impairment is that which responds to the passage of time and/or psychosocial intervention after optimal neurophysiological stabilization. Post-acute impairment sometimes requires fairly intensive therapeutic intervention, so the passage of time since acute psychosis is not in itself a sufficient criterion.

Neuropsychological assessment is generally most useful for evaluating post-acute impairments, when used systematically in a longitudinal frame of reference.

Problem title: Residual neurocognitive impairments
Problem definition: Impairment in cognitive functioning, in the relatively molecular domains generally addressed by neuropsychological assessment, that does not respond to any known neurophysiological or psychosocial intervention. This Problem must be identified through a process of elimination that establishes the ineffectiveness of all available interventions.

Neuropsychological assessment is generally most useful for evaluating residual impairments, when used systematically in a longitudinal frame of reference. After identification of the impairments as residual, the role of further assessment is to articulate the nature of the impairment for the purpose of designing prosthetic or compensatory interventions.

Sociocognitive level of functioning

Problem title: Social problem-solving insufficiency
Problem definition: Insufficient ability to identify problematic situations, analyze relevant factors, generate a seable range of solutions, and evaluate the effectiveness of chosen solutions, not attributable to the effects of neurophysiological dysregulation or neurocognitive impairment. A wide range of behavioral characteristics may be associated with this sociocognitive Problem, ranging from passivity and dependence to belligerence and aggression. The key characteristic is inability to engage in the cognitive processes necessary for management of routine problems in daily living and/or ordinary interpersonal conflicts. Social behavior may show a lack of problem solving activity, or persistent use of an ineffective solution.

The expressions of this Problem may have considerable overlap with expressions of other Problems. This Problem is the better choice when there is evidence and/or expectation that interventions at other levels will not ully resolve the problem-solving insufficiency and its related behaviors. For example, mood-linked attribution problem should be used when there is evidence and/or expectation that a psychotherapeutic intervention focused on modification of intropunitive attributions, and a subsequent normalization of mood, would produce optimal social problem solving. Similarly, social skill deficit should be used when the problem solving insufficiency is limited to interpersonal conflict, and is expected to respond optimally to social skills training. The distinguishing factors are the scope of problem solving difficulties (limited to particular situations vs. generalized) and the expectation of success in broadly focused problem solving therapy.

Problem title: symptom-linked attribution problem
Problem definition: Constellations of beliefs, attitudes, attributions and related sociocognitive characteristics (e.g. locus of control dimensions) which constitute recognized psychiatric “symptoms,” usually identified as “delusions,” including delusions of persecution (paranoid delusions), disfigurement, disease or injury (somatic delusions), having special abilities or powers (grandiose delusions) and personal guilt or evilness (mood-congruent delusions in psychotic depression). Particular beliefs may combine these themes, e.g. that one is a famous historical figure and is being persecuted because of that. In some cases, it may be unclear whether the beliefs are independent of perceptual anomalies, e.g. the belief that one is hearing the voice of the devil, or that one is receiving secret signals from others (ideas of reference). Symptom-linked attributions vary in stability, internal consistency and complexity, ranging from vague, intermittent, amorphous allusions to highly stable, logically coherent and fully articulated narrative accounts.

Symptom-linked attributions are often associated with neurophysiological dysregulation, especially of the episodic type. Some delusions are associated with neurocognitive impairments and/or tonic neurophysiological dysregulation, e.g. that familiar people, places or things have been replaced by substitutes (Capgrass syndrome). When the attributions are so closely linked to neurophysiological dysregulation that resolution of the latter resolves the former, the attributions are subsumed under the neurophysiological Problem title and included in its Problem Description. The symptom-linked attribution Problem title should be used when the attribution problem persists after other indications of acute psychosis are resolved, and further neurophysiological and/or neurocognitive interventions are ineffective. Also, if the problematic attributions are demonstrably linked to performance of a “mental patient” social role, and/or there is evidence and/or expectation that a contingency management or related intervention would fully resolve the problem, the Problem title ‘socialized psychiatric symptom’ should be used instead.

Symptom-linked attributions are generally best assessed with a combination of anamnestic measures (e.g. structured interviews) that rate the person’s expression of the belief, and functional behavioral analysis that identifies the in vivo antecedents and consequences of professing the belief. This Problem is generally expected to respond optimally to specialized cognitive behavioral therapy interventions that combine interpersonal support, logical disputation and formulation of alternative attributions.

Problem title: mood-linked attribution problem
Problem definition: Constellations of beliefs, attitudes, attributions and related sociocognitive characteristics (e.g. locus of control dimensions) that function to produce and/or maintain specific affective states, when the frequency or persistence of those affective states poses a barrier to optimal functioning. The most common expression of this problem is fatalistic and intropunitive belief patterns associated with dysthymia and chronic depression. The attributional constellation contributes an overall suppression of effective personal and social functioning, and also represents a vulnerability to episodes of severe disruption spanning all levels of functioning (major depression). Often, the attributional constellation is part of a larger picture, including a neurophysiological diathesis, social skills deficits and psychophysiological dysregulation, which combine to produce both tonic dysthymia and episodic exacerbations. At the opposite pole of the dysphoric-euphoric dimension, a pattern of unrealistically positive self-perception and denial of problems is associated with hypomania, a vulnerability to mania, and eventually to major depression as well (when the defensive function of the attributions breaks down). A third possible constellation of beliefs, attitudes and attributions includes patterns related to other peoples’ hostile intentions, personal powerlessness and beliefs about personal entitlement, associated with angry mood and belligerent interpersonal behavior. This constellation is distinct from a symptom-linked attribution problem to the degree that it is independent of bizarre beliefs, grossly inaccurate perceptions of social situations, and other social cognition and behavior associated with psychotic states.

Because of the frequent links between mood-linked attributions and problems in neurophysiological, psychophysiological and sociobehavioral functioning, careful attention must be given to specification of these links as alternative or additional Problem titles. Mood-linked attributions should be identified as a separate problem when there is evidence and/or expectation that a specialized intervention focusing on attributional functioning will contribute uniquely to recovery. Failure of the problem to respond to resolution of psychotic states or psychopharmacotherapy is a key indication (this does not mean that the neurophysiological hypothesis should always be tested before others are entertained). Psychosocial interventions for depression generally combine cognitive, psychophysiological and sociobehavioral components, so use of the attributional Problem title should be limited to situations where the attributional component is hypothesized to be an especially powerful or unique contributor, and the optimal intervention is expected to be one almost exclusively focused on self-perception and related social cognition. In many cases, the attributional Problem title should be accompanied by a neurophysiological, psychophysiological or skill-related Problem title(s), indicating an hypothesis that there are relatively independent contributions to the clinical picture at multiple levels.

Problem title: achievement-linked attribution problem
Problem definition: Constellations of beliefs, attitudes, attributions and related sociocognitive characteristics (e.g. locus of control dimensions) regarding one’s life circumstances, responsibilities and personal functioning, when those characteristics constitute a barrier to achieving better functioning and a better quality of life. These may include the belief that a restricted, institutional life is the best available, that the responsibilities and benefits of being a competent adult are undesirable, or that a high-risk and/or dissolute lifestyle is unavoidable. The constellation is often associated with specific patterns of behavior, including persistent pursuit of a self-destructive lifestyle, e.g. that of a “street person,” an itinerant religious figure or habitual criminal. It may be associated with unrealistic, fantasy based personal aspirations, e.g. winning the lottery, becoming a rock‘n’role star, running for president.

For the purposes of rehabilitation planning, the most salient consequence of this sociocognitive pattern is a disinterest in treatment or rehabilitation. The person may experience ambivalence regarding self-destructive or unrealistic aspirations, in which case interest and engagement in rehabilitation is partial or sporadic. There may be no ambivalence, and the person may actively resist the intentions of others to obtain treatment and rehabilitation.

Assessment of this Problem must carefully take into account the accuracy of the individual’s beliefs about the nature of the mental illness and expectations for recovery. If the problem is hypothesized to be primarily the consequence of inaccurate beliefs and/or lack of skills regarding the nature and management of the mental illness (“I have a disabling mental illness, there’s nothing I can do about that, therefore I’m doomed to a dissolute life.”), and there is an expectation that education and skill training in this domain would resolve the problem, it should be characterized as a disorder management skill deficit instead. Providers and others must be specially careful to not be influenced by stereotypic beliefs of their own, regarding the achievement potential of people with mental illness. A thorough and accurate assessment of the person’s true achievement potential is necessary. Similarly, all must be careful to respect each others’ values – people do not always agree about the desirability of particular lifestyles.

The criterion of team consensus is the primary safeguard regarding these considerations. When the recovering person is not ambivalent and resistant to treatment or rehabilitation, rehabilitation can only occur when a legal authority or substitute decision maker is overriding the person’s wishes. In such cases, choice of this Problem title must reflect the best possible accommodation of the person’s aspirations within the legal mandate to provide treatment.

Choice of this Problem title reflects an hypothesis that the person will develop more realistic and/or more self-serving aspirations in response to rehabilitation counseling, negotiation with providers and substitute decision makers, success in achieving rehabilitation goals, greater knowledge about the nature of the mental illness, and general improvement in personal and social functioning. In this sense, the Interventions for this Problem may be all the Interventions in the entire Rehabilitation Plan. Including the attributional Problem title serves to ensure monitoring of progress in the sociocognitive domain, not to prescribe specific Interventions. This would be indicated by assigned a Priority 3 to the Problem title, indicating specific interventions are not currently being applied (Priority 3 does not necessarily indicate that no progress is expected). The person may also benefit from individual cognitive behavioral therapy, similar to that used to address symptom-linked and mood-linked attribution problems, modified to focus on one’s beliefs about personal responsibility and dignity, personal worth and success, and short- and longer-term life goals. This would be a specific Intervention under the attributional roblem title.

Sociobehavioral level of functioning

Skill deficits:
General definition of skill deficits: Failure to effectively perform behaviors necessary to accomplish a specifiable purpose, when the failure is not wholly attributable to specific problems at more molecular levels of functioning, i.e. neurophysiological dysregulation or cognitive impairment. For the purposes of rehabilitation for disabling mental illness, skills organize themselves into categories of functionally related elements. These categories comprise the specific skill decifit Problem Titles.

Skills represent complex combinations of abilities, spanning all levels of biobehavioral functioning, plus acquired information stored in memory, in continuous interaction with complex environmental conditions. The acquired information is often quite extensive and complex, accumulated over the entire course of human development. Skill deficits represent problems in any or all of these domains. A skill deficit Problem title should be identified when it is hypothesized that optimal rehabilitation benefit will be achieved with skill training interventions, i.e. interventions designed to establish effective performance through providing information (education), guided rehearsal of key components of the desired skill, in vivo practice, coaching and related techniques.

Skill deficits have both competence and performance dimensions. A competence failure denotes an inability to perform the skill under optimal environmental conditions. A performance failure denotes non-performance of the task under the environmental conditions in which the skill is normally required. Performance failures may be attributable to insufficient information and/or failure to apprehend the conditions requiring the skill. Performance failures may also be due to prevailing environmental conditions that do not sufficiently prompt or reward performance of the skill. If this obtains to the degree that sufficient skill performance results from changes in environmental conditions, without improvement in competence, the skill training intervention may be limited to contingency management or related manipulations of environmental conditions. Often a combination of environmental manipulation and competence-oriented skill training produces optimal skill acquisition.

If environmental manipulations are used to enhance skill acquisition, and are expected to lead to better skill performance under natural conditions, the intervention logically falls under the skill deficit Problem title. However, if special environmental conditions are thought to be required on a more permanent basis, i.e. as partof a prosthetic environment, the Rehabilitation Plan should identify a separate residual neurocognitive Problem. The neurocognitive Problem should identify inability to respond to antecedents and consequences of normal proximity sufficient for performance of the specified skill(s), in its Problem Description.

Skills deficits are generally identified through functional assessment, emphasizing direct observation of skill performance under optimal and natural conditions. Case history information usually contributes to identification and characterization of skill deficits. However, historical information is usually anecdotal, not quantitative, and incomplete with regard to environmental conditions that may support or suppress skill performance. Often, careful functional behavioral analysis is required to distinguish between performance failure consequent to low competence and performance failures due to “motivational” problems. The latter may include sociocognitive constellations of belief that skill performance is not desirable, environmental conditions insufficient to prompt andreward skill performance, and/or stronger incentives to perform incompatible social roles, e.g. the role of an incompetent mental patient. When such factors are hypothesized, the skill deficit Problem should be accompanied by additional Problems to identify and address those factors, i.e. as achievement-linked attribution problems and/or environmental conflicts.

Problem title: self care skill deficits
Problem definition: Insufficient competence and/or performance of skills related to personal care, grooming, hygiene, nutrition and health.

Problem title: independent living skill deficits
Problem definition: Insufficient competence and/or performance of skills related to the demands of routine adult living, including housekeeping, personal budgeting and banking, utilization of public resources (library, public transportation, etc.), maintenance of wardrobe (purchasing clothing, minor repairs, laundry), household shopping and cooking.

Problem title: disorder management deficits
Problem definition: Insufficient competence and/or performance of skills related to management of mental illness, including understanding nature and purpose of medication, identification of psychotic symptoms and warning signs of psychotic episodes, management of residual symptoms and deficits, and management of stress.

Problem title: leisure/recreational skill deficits
Problem definition: Insufficient competence and/or performance of skills related to planning and managing leisure time.

Problem title: occupational skill deficits
Problem definition: Insufficient competence and/or performance of skills related to maintaining a work role or similar social role, e.g. as a volunteer in a service program, a member of a psychosocial clubhouse program, or participant in an activities program. This Problem includes skills generally related to all or most occupational functioning, not skills required for particular vocational pursuits. These include skills relevant to job punctuality, self-regulation and pacing, following instructional protocols, appropriately using problem-solving in unfamiliar situations, and maintaining interpersonal relationships appropriate to the occupational setting.

Problem title: interpersonal skill deficits
Problem definition: Insufficient competence and/or performance of skills related to interpersonal interactions, including making conversation, expressing needs, making requests, identifying and resolving ordinary conflicts, establishing and maintaining friendships.

Psychophysiological dysregulations:
General definition of psychophysiological dysregulation: Failure to effectively regulate one’s state of psychophysiological activation, resulting in subjective distress, cognitive impairment, and/or disruption of skill performance. Psychophysiological dysregulation organizes itself into distinct patterns, reflecting the relatively independent activity of neurophysiological systems, especially patterns of autonomic activation. These patterns comprise the specific Problems.

Psychophysiological regulation involves acquired abilities, most generally the ability to produce particular patterns of activation needed for optimal performance of specific skills. Neurocognitive, sociocogitive and sociobehavioral processes operate in coordination, using information stored in memory, to achieve psychophysiological regulation. Selection of a psychophysiological dysregulation Problem Title reflects an hypothesis that functional subjective distress and/or behavioral problems are attributable to processes distributed across these levels. It also reflects an expectation that resolution of the distress and/or behavioral problem will be optimally achieved by skill training interventions, i.e. interventions designed to improve psychophysiological regulation through providing information (education), guided rehearsal of key components of the desired skill, in vivo practice, coaching and related techniques.

The subjective and behavioral expressions of psychophysiological dysregulations are highly variable, and are also associated with neurophysiological dysregulation, cognitive impairments and other sociobehavioral skill deficits. The role of neurophysiological dysregulation should be assessed, and the psychophysiological Problem should not be used if there is an expectation that neurophysiological intervention would resolve the behavioral problems. Similarly, neurocognitive, sociocognitive, skill deficit or environnmental Problem titles should be used when there is an expectation that interventions at these levels would resolve the problems.

Problem title: dysregulation of behavioral activation
Problem definition: Disruption of normal cycles of behavioral activity and rest or sleep, reversal of diurnal sleep-wake periods (up all night and asleep all day), to the degree that it causes subjective distress, cognitive impairment, impairment of instrumental skill performance, and/or difficulty adhering to a daily routine of necessary activities. This Problem should be identified when data indicate that the dysregulation is functionally independent from neurophysiological dysregulation, and cannot be resolved through intervention at the neurophysiological level.

Problem title: dysregulation of mood
Problem definition: A pattern of behavior and psychophysiological activation which produces extreme mood fluctuations and/or persistence of one or more mood states that normally would be transient and situation-dependent. The clinical picture may be that associated with the diagnostic and paradiagnostic descriptors for affective disorders, including dysthymia, depression, hypomania, mania and paranoia (when used to describe a persistent mood of anger or belligerence). This type of Problem is often one component of a clinical picture that includes neurophysiological and sociocognitive components. The contributions of all components must be carefully assessed. The most effective rehabilitation strategy will in many cases involve a combination of neurophysiological, sociocognitive and sociobehavioral interventions. This Problem Title should be used when sociobehavioral interventions designed to strengthen a person’s affective self-regulation skills are expected to contribute independently to overall outcome.

Problem title: dysregulation of anger/aggression
Problem definition: A pattern of psychophysiological dysregulation associated with extreme, explosive and/or socially unacceptable anger and/or aggression. The clinical picture may conform to the diagnostic criteria for explosive personality disorder, but when observed in the context of severe mental illness it is usually not diagnosed separately. This Problem Title should be used when data indicate the relevant behavior is at least partially independent of neurophysiological, cognitive and socioenvironmental factors, and a sociobehavioral intervention designed to strengthen self-regulation skills is expected to contribute independently to overall outcome.

Problem title: dysregulation of fear/anxiety
Problem definition: Dysregulation of psychophysiological processes associated with fear and/or anxiety. The dysregulation may be expressed as subjective experience of abnormally intense psychophysiological arousal, abnormally frequent experience of arousal of otherwise normal intensity, behavioral avoidance of anxiety-producing situations, or some combination of these. In the presence of avoidance behavior, the anxiety motivating the avoidance may escape direct subjective awareness. Avoidance may be expressed at neurocognitive and/or sociocognitive levels of functioning, when it is often associated with the paradiagnostic concepts of repression, denial, somatization or dissociation. The clinical picture may conform to the diagnostic criteria for anxiety disorders or dissociative dysorders. However, expressions of this type of dysregulation are observed in many individuals who do not meet the criteria, especially when the clinical picture is dominated by sociocognitive avoidance. Borderline personality disorder is increasingly the diagnostic choice in such cases. People with severe and disabling mental illnesses often show this type of dysregulation, although it is often not diagnosed as a comorbid condition. This Problem Title should be used when the optimal rehabilitation strategy is expected to include a sociobehavioral intervention designed to educate the person about the nature of anxiety and its self-regulation, block avoidance behaviors and extinguish conditioned psychophysiological responses to feared stimuli.

Problem title: dysregulation of appetitive behavior
Problem definition: Dysregulation of behaviors associated with hunger and thirst. The diagnostic categories of eating disorders incorporate many of these behavior patterns, although the behavior is not always produced primarily by a psychophysiological dysregulation. Polydipsia, dysregulation of fluid intake, may also reflect a psychophysiological dysregulation. Medication side effects, medical conditions not associated with mental illness, neurocognitive impairments, dysfunctional beliefs and attributions, deficient social problem-solving, and socio-environmental circumstances may eclipse the role of psychophysiological dysregulation. This problem title should be used when it is expected that a psychophysiological skill training intervention, intended to strengthen a person’s ability to understand and manage hunger or thirst is expected to contribute uniquely to overall rehabilitation outcome.

Polydipsia deserves special mention, as it is a psychophysiological dysregulation especially frequent in people with disabling mental illness. Polydipsia is dysregulation of fluid intake, usually associated with persistent thirst. It occurs across a range of severity, with consequences ranging from subject discomfort to life-threatening disruption of blood chemistry. Polydipsia is poorly understood. It may be a side effect of psychotropic medication, at least in some cases. When it cannot be eliminated through judicious psychopharmacotherapy, psychosocial interventions are sometimes helpful. These interventions generally include education and skill training, and sometimes also contingency management or related socio-environmental interventions (discussed in Chapter 10).

Problem title: dysregulation of sexual behavior
Problem definition: Dysregulation of the psychophysiological aspects of sexual functioning, which may include frigidity, anorgasmia, erectile dysfunction, ejaculatory dysfunction and paraphilia. Sexual dysfunctions are often associated with neurophysiological dysregulation, neurocognitive impairment, dysfunctional social cognition, social skill deficits, and socio-environmental problems. This Problem Title should be used when there is evidence that impairment of specific psychophysiological mechanisms associated with normal sexual desire and/or sexual response are contributing independently to the clinical picture, and that interventions designed to strengthen the person’s control over those mechanisms will contribute uniquely to overall rehabilitation outcome.

Other sociobehavioral Problems:

Problem title: Substance abuse
Problem Definition: A persistent pattern of using alcohol or other drugs to induce an altered state of consciousness, when such use contributes uniquely to other problems or deficits in a person’s neurophysiological, cognitive and/or sociobehavioral functioning. Problems consequent to substance abuse may include increased vulnerability to episodic neurophysiological dysregulation and acute psychosis and socially unacceptable behaviors associated with obtaining substances of abuse. This Problem Title should be used when it is expected that an intervention intended to reduce the person’s use of substances is expected to contribute uniquely to rehabilitation outcome.

Socio-environmental problems

Problem title: Rehabilitation nonadherence
Problem definition: A persistent pattern of nonadherence to treatment and/or rehabilitation regimens, when such regimens are expected to produce better personal and social functioning and some degree of recovery from disabling mental illness. The nonadherence may or may not be consistent with the person’s subjectively experienced and/or expressed desires. This Problem Title should be used when the nonadherence cannot be attributed solely to neurophysiological, cognitive or sociobehavioral factors, when interventions directed at those factors do not fully resolve the nonadherence, and when socio-environmental intervention is required, at least temporarily, to establish adherence and facilitate recovery.

Problem title: Socialized psychiatric symptoms
Problem definition: Behaviors which are observationally similar to expressions of neurophysiological dysregulation (e.g. psychotic symptoms) or cognitive impairment, but which function as social operants, and effect specifiable environmental consequences or support performance of a “mental patient” social role. This Problem Title should be used when evidence indicates that the behavior in question does not respond to neurophysiological, cognitive or sociobehavioral interventions, and is expected to respond to socio-environmental interventions.

Problem title: Socially unacceptable behavior
Problem definition: Specific behaviors which exploit or harm others, or which are otherwise not generally tolerated in normal social environments. This Problem Title should be used when evidence indicates that the behavior in question does not respond to neurophysiological, cognitive or sociobehavioral interventions, and is expected to respond to socio-environmental interventions. It may be necessary to use this Problem Title in cases where the behavior in question is hypothesized to result from some combination of more molecular factors, but where intervention at more molecular levels is not expected to produce results quickly enough to prevent harm. In such cases, this Problem Title should be used in conjunction with socio-environmental interventions to prevent harm pending resolution of more molecular problems.

Problem title: Social-environmental conflict
Problem definition: A problem involving conflict between the recovering person and others in the recovering person’s social environment, wherein changes in the recovering person’s neurophysiological, cognitive or sociobehavioral functioning are not expected to fully resolve the conflict. The goals of interventions under this Problem Title are therefore expected to include changes in the recovering person’s behavior and the behavior of others in the recovering person’s social environment. The conflict may be between the recovering person and others, or it may be a conflict between the behaviors of others and the best interests of the recovering person. Examples include hostility, emotional over-involvement, or behavior inconsistent with the recovering person’s abilities and autonomy, on the part of friends or family. This Problem Title should be used when it is expected that interventions intended to change the behavior of others as they interact with the recovering person will contribute uniquely to overall rehabilitation outcome.

Problem title: Restrictive legal status
Problem definition: Conflict between the recovering person and a legal authority, wherein the legal authority imposes restrictions on the recovering person’s rights, due to past determinations of risk, dangerousness or lack of legal competence. The restrictions may be anachronistic, reflecting conditions that have changed since original imposition of the restrictions. Alternatively, the restrictions may reflect a continuing appraisal by the legal authority that despite changes in the recovering person, the risks attendant to recurrence of dangerous behavior are such that safety demands continued restrictions. In either case, changes in the recovering person’s personal and social functioning are insufficient to remove the restrictions. This Problem Title should be used when it is expected that socio-environmental intervention will be required. The intervention would either induce the legal authority to change the restrictions, or create an environment in which the recovering person can pursue rehabilitation and optimal personal and social functioning within the constraints that the restrictions represent.

Problem title: Unstable living conditions
Problem definition: Environmental circumstances that prevent establishment of a stable living situation, which may include financial limitations, unavailability of suitable housing, or unavailability of necessary support services. Such circumstances are usually associated with problems in the recovering person’s personal and social functioning. This Problem Title should be used when improvements in functioning are not expected to fully stabilize the person’s living condition, or when more molecular interventions are not expected to produce stabilization quickly enough to provide for the person’s safety and comfort. In both cases, a socio-environmental intervention is required, on either a temporary or permanent basis. Efforts to make sure the person has a place to live and necessary services, e.g. in discharge planning, are the interventions most associated with this problem.