Transcript NOSOLOGY IN CHILD AND ADOLESCENT MENTAL HEALTH

NOSOLOGY
IN CHILD AND ADOLESCENT
MENTAL HEALTH
Graham Martin
The University of Queensland
g.martin@uq.edu.au
Case Study
Jason
Recent History of Diagnostic Systems

1939 - WHO added mental disorders to the
International List of Causes of Death
 1948 - WHO expanded list to International Statistical
Classification of Diseases, Injuries, and Causes of
Death (ICD)
 1952 - Diagnostic and Statistical Manual (DSM-I)
American Psychiatric Association
 1968 - DM-II published
– 185 categories similar to the WHO system
– not widely accepted
Recent History of Diagnostic Systems
cont.
 1980
- DSMIII
– classification based on scientific evidence not
clinical consensus
– Neurosis terminology dropped
– Diagnostic criteria to increase reliability
– Introduction of multi-axial approach
– 265 mental disorders
 1987 - DSMIIIR - minor changes, 297 categories
 1994 - DSMIV - 354 categories, 17 major headings
 1992 - ICD-10 from WHO
Diagnostic and Statistical Manual
of Mental Disorders 4th ed.
(DSM-IV)

Concerned with classifying ‘mental
disorders’
– 2 defining characteristics:
 Significant personal distress in the person affected
 Significant adaptive failure

A classification of the disorders that people
experience
Definition and Components of a
Disorder

Disorder - enduring
group of associated
characteristics
 Objective data and
subjective self-reports
 Three domains provide
the basic elements for
conceptualising
emotional and
behavioural problems
Sign – observable
(measurable) and objective
characteristic
 Symptom – subjective
report of the person
 Syndrome – patterns of covariation between signs and
symptoms

Key Aspects of DSM-IV
 Guide to clinical practice, research, and description of mental
disorders
 Developed using a systematic and explicit process. Consensus
based on research and review of evidence
 Theoretically neutral; does not consider theories of etiology of
disorders
 Explicit statements and criteria for mental disorders
meant to be used as guidelines-- not a cookbook
 Work in progress
 Uses a categorical approach to group disorders into types
(e.g., Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence or Personality Disorders)
Why Do We Need Diagnoses?
Standard
nomenclature
Defined realms of pathology
Communication among professionals
A label for administrative functions
A label for families that
– Helps them understand
– Places their child in context
– Connects them to others
Disadvantage of Diagnoses
 A final
common denominator that may not
accurately reflect all individual cases
 Difficult to capture developmental changes
– Do they reflect continuity over time?
 May be associated with misinformation
– Name may either not represent or even misrepresent the
actual pathology
 Serve
as a label for administrative functions
 Diagnostic Labels can be misused
Advantages of DSM-IV
Classification

Advantages over other classifications
– Descriptive - low inference
– Based on explicit criteria
– Shared across training and research programs
– High reliability
– Revised on the basis of epidemiological study
from DSM-III to DSM-III-R to DSM-IV
DSM-IV as a Multiaxial
System
Five
“axes” or categories of information
utilized in order to ensure assessment of
adjustment and functioning, not simply
symptoms
 Multiaxial
Format: Way of recording information
in a convenient and widely understood format.
 Promotes the application of a biopsychosocial
model of describing a client’s difficulties.
DSM-IV as a Multiaxial System
Axis I: Clinical Disorders and Other
Conditions That May Be a Focus of
Clinical Attention
Axis II: Personality Disorders and Mental
Retardation
Axis III: General Medical Conditions
Axis IV: Psychosocial and Environmental
Problems
Axis V: Global Assessment of Functioning
Axis I – Clinical Disorders
 This
category is the basic body of DSM-IV
 These clinical conditions (usually) bring the patient
to attention
 Can be further differentiated by the use of subtypes
and specifiers
– Subtypes - e.g., Conduct Disorder has two subtypes
based on the age of onset of problems (Childhood vs.
Adolescence)
– Specifiers – provide an opportunity to define a more
homogeneous subgrouping of individuals, e.g.,
Stereotypic Movement Disorder may have the specifier
“With Self-Injurious Behavior”
Axis II – Personality Disorders or
Mental Retardation

The intent of this axis is to reflect more
enduring or stable characteristics of the
client’s adjustment which affects
functioning.
 This information in conjunction with Axis I
constitutes the mental health diagnosis
proper
Axis III – General Medical
Conditions

Includes current physical disorders or
conditions that are potentially relevant to
the understanding or management of a case
 Examples might include:
– Juvenile onset diabetes
– Genetic testing indicates abnormal chromosome
Axis IV – Psychosocial and
Environmental Problems
 Used
to list psychological, social and environmental
problems that contribute to a client’s dysfunction and
adjustment
 Categories and Examples:
– Primary support group – death of family member
– Related to social environment – living alone
– Educational – illiteracy
– Occupational – unemployment
– Housing – unsafe neighbourhood
– Economic – extreme poverty
– Access to healthcare – transportation unavailable
– Interaction with legal system/crime – victim of crime,
incarceration
Axis V – Global Assessment of
Functioning

Reflects the examiner’s overall judgment of
the client’s mental health and adjustment on
a scale of 0-100
Overview of DSM-IV Categories
Disorders
usually first diagnosed in
infancy, childhood or adolescence
– Involve early emotional/intellectual disorder
Substance-related disorders
– Ingestion of a drug impairs
social/occupational functioning
Schizophrenia
– Involves faulty contact with reality
– May involve delusions (disordered thoughts)
Schizophrenia - Positive Symptoms
Thought disorder
– disorganised, irrational thinking
Delusions of
– persecution
– grandeur
– control
Hallucinations
– perception of stimuli that are not actually
present; mostly voices
Schizophrenia - Negative symptoms

Absence of normal behaviours
 Flattened emotional response
 Poverty of speech
 Lack of initiative
 Inability to experience pleasure
 Social withdrawal
Types of Schizophrenia
Undifferentiated schizophrenia
– delusions, hallucinations and disorganised behaviour,
but meet no other categories
Catatonic
schizophrenia
– various motor disturbances - catatonic postures
Paranoid
schizophrenia
– delusions of persecution, grandeur or control
Disorganised schizophrenia
– thought disorder, inappropriate emotions, “word salad”
Other Classes of Disorders
 Mood disorders
– Involve large swings in emotional affect
 Anxiety disorders
– Involve some form of irrational or overblown fear
 Somatoform disorders
– Involve physical symptoms that have no known
physiological cause
 Dissociative disorders
– Involve a sudden alteration of consciousness that affects
memory and identity
Types of Mood Disorder

Major depressive disorder
– deeply sad and discouraged, likely to lose weight and
energy, suicidal thoughts and feelings of self-reproach

Mania
– exceedingly euphoric, irritable, more active than usual,
distractible, unrealistic high self-esteem

Bipolar disorder
– episodes of mania or of both mania and depression
Types of Anxiety Disorder

Specific phobias
– fear of objects or situations, avoidance even though
they know that their fear is unwarranted, disrupts life

Panic disorder
– sudden panic attacks, frequently with agoraphobia

Generalised anxiety disorder
 Obsessive-compulsive disorder
 Posttraumatic stress disorder
 Acute stress disorder
Types of Somatoform Disorders

Somatization disorder
– multiple physical complaints

Conversion disorder
– loss of motor or sensory function

Pain disorder
– severe and prolonged pain

Hypochondriasis
– misinterpretation of minor physical sensations as
serious illness

Body dysmorphic disorder
– preoccupied with an imagined defect in appearance
Other Disorders
 Sexual/gender identity disorders
– Involve dysfunction or discomfort with sexual function or
identity
 Sleep disorders
– Involve disturbance in amount of sleep or events during
sleep
 Eating disorders
– Involve under- or over-eating
 Factitious disorder
– Involved in persons who produce or complain of
psychological symptoms (sick role)
Other Disorders
 Impulse
control disorder
– Involve several conditions in which a person’s behavior is
inappropriate or out of control
 Personality
disorders
– Involve enduring, inflexible and maladaptive patterns of
behavior and inner experience
 Other
conditions that may be the focus of clinical
attention
– not regarded as mental disorders per se but still may be a
focus of attention and treatment, someone who enters the
mental health system can be categorized, even in the
absence of a formally designated mental disorder
Aetiology

Definition: The study of the cause(s) of
disorders
Example:
Factors Influencing Emotional Development:
 emotional and behavioral problems do NOT
stem from one source only, rather from a
blend of influences. The influencing factors
can be broken down into four areas:
Aetiology
Biological/Cognitive
– genetic or hereditary bases
– maturation of the brain
2. Social Cognition
– emergence of object permanence and schemes
for familiar events
– cognitive maturation that leads to a broader
understanding of emotions in self and other
– temperament and responsiveness to caregiver
(reciprocal interaction)
1.
Aetiology
3. Immediate Environment
– modeling of emotions and behaviors by others
– feedback from caregivers (S>R)
– caregiver responsiveness to child’s signals
(attachment)
4. Sociocultural Context
– presence or absence of stressors within family
(attachment)
– value placed on emotional expression
– norms regarding emotional display rules
The Diathesis-Stress Paradigm
…
is an integrative paradigm
…
focuses in the interaction between a predisposition
towards disease – the diathesis – and environment, or
life disturbances – the stress
 Diathesis
can be biological (e.g. genetic) or
psychological (cognitive style, specific childhood
experience)
The Diathesis-Stress Paradigm
Adapted from Monroe and Simons (1991)
Psychopathology in Developmental
Context

Early Childhood
Preschoolers:
 have a high activity level
 need structure to help them focus on a task
 need rules
 enjoy make believe and symbolic play
 are concrete in their thinking
 are the center of the world (egocentric thought)
 seek approval and attention from caregivers
 have a hard time understanding emotional differences
 live in the here and now
Psychopathology in Developmental Context
cont.
Middle Childhood
(Ages 7-12)
Elementary school children:
C
prefer concrete to abstract explanations
C
can process multistep directions
C
can plan ahead
C
begin anticipate the consequences of their behavior
C
don’t fully understand their influence/impact on others
C
begin to show greater control over the expression of
their emotions
C
want to be like their peers
C
model and compare themselves to others
Psychopathology in Developmental Context
Adolescence
(Ages 12-18)
Adolescents:
C
can use their language skills in a calculated manner to
enrich, establish, or damage relationships
C
can understand abstract reasoning
C
question their self-image and identity; Who am I?
C
may have feelings of being invincible and take risks
C
are often preoccupied with their own behavior and
themselves; believe others are preoccupied with them,
too
C
can empathize with others
C
peer acceptance is vital
Learning Paradigms

Learning paradigms argue that abnormal
behavior is learned as are normal behaviors
– Classical conditioning
– Operant conditioning
– Modeling

Behaviourism focuses on the study of
observable behavior
Ch 2.19
Operant Conditioning

Behaviors have consequences
– Positive reinforcement: behaviors followed by
pleasant stimuli are strengthened
– Negative reinforcement: behaviors that
terminate a negative stimulus are strengthened

Behavior can be shaped using method of
successive approximations
– Reward a series of responses that approximate
the final response
Operant Conditioning of Problematic Behaviour
S
Toy of other child
S
Thought about
dentist
R
Aggressive behaviour
R
Cancellation of appointment
C+
Positive reinforcement
“gets the toy”
CNegative reinforcement
“fear is gone”
Modeling

Learning can occur in the absence of
reinforcers
 Modeling involves learning by watching and
imitating the behaviors of others
– Models impart information to the observer

Children learn about aggression watching
aggressive models
Behaviour Therapy

Behavior therapy uses learning methods to
change abnormal behavior, thoughts and
feelings
– Behavior therapists use operant conditioning
techniques as well as modeling
– Counter-conditioning: learning a new response


Systematic desensitization: relaxation is paired with a
stimulus that formerly induced anxiety
Aversive conditioning: an unpleasant event is paired with
a stimulus to reduce its attractiveness
Counter-conditioning
Systematic Desensitization

Deep Muscle relaxation technique

List of feared situations (hierarchy)

Step-by-step, while relaxed, the patient imagines the
graded series of anxiety-provoking situations

A state of response antagonistic to anxiety is
substituted for anxiety = counter-conditioning
Biological Approaches to
Treatment

The biological approach argues that
abnormal behavior reflects disorders
biological mechanisms (usually in the brain)
 The approach to treatment is usually to alter
the physiology of the brain
– Drugs alter synaptic levels of neurotransmitters
– Surgery to remove brain tissue
– Induction of seizures to alter brain function
Psychodynamic Therapy
 Therapy Considerations:
1.NOT brief – multiple sessions over long time frame
2.Client must be committed
 Psychodynamic therapy
tries to get the patient to bring
to the surface their true feelings, so that they can
experience them and understand them.
 Psychodynamic Psychotherapy uses the basic
assumption that everyone has an unconscious mind
(AKA the subconscious), and that feelings held in the
unconscious mind are often too painful to be faced.
 We come up with defences to protect us knowing about
these painful feelings. An example of one of these
defences is called denial
Psychodynamic Therapy cont.

Assumption that these defences have gone wrong
and are causing more harm than good, thus, help is
needed.
 Goal is to unravel them since it is assumed that
once you are aware of what is really going on in
your mind the feelings will not be as painful.
 Attitude of unconditional acceptance by therapist,
i.e., the therapist holds the client in high regard
because s/he is a person, no matter the problem
Psychodynamic Therapy cont.

Therapist tries to develop a relationship
with client, to help him/her discover what is
going on in their unconscious mind.
 To discover more about you than you are
aware of, the therapist uses interpretations,
which are a way of making sense to you
about what is going on, in order to help you
become aware of your unconscious feelings.
Psychodynamic Developmental View of Anxiety Disorders
– Infants at 18 months of age become
concerned about loss of “love object” – forerunner
of separation anxiety
 Loss of caretaker’s love (15-36 months) – anxiety
over loss of caretaker’s love and approval, girls
more vulnerable
 Castration anxiety or fear of loss of body parts
(2.5-5 years) – boys more vulnerable – aggressive,
assertive urges lead to anxiety resulting in
inhibition as defense mechanism
 Attachment
Psychodynamic Developmental View of Anxiety
Disorders cont.
 Loss
of approval from the conscience or superego
(3-5 years) – many external experiences are
internalized – the voice of conscience warns child
that certain thoughts and activities will be bad →
lowered self-esteem, guilt and possible depression
 Loss of social approval (6-10 years) – fear of being
in “spotlight”, stage fright, and resulting fear of
performing → inhibition as defense which is a
vicious cycle
Cognitive-Behavioral Treatment of Anxiety
Disorders
 Exposure-based Strategies
– Systematic Desensitization – 3 steps: relaxation
training, construction of the anxiety hierarchy,
and pairing of relaxation with gradual
presentation of anxiety-provoking situation
– Flooding – repeated and prolonged exposure
(real or imagined) to the feared stimulus with
the goal of extinguishing the anxiety response
 Contingency Management – used to modify
antecedent and consequent events that may
influence the acquisition or maintenance of anxious
behavior
Psychological Assessment

The goal of psychological assessment is to
determine cognitive, emotional, personality
and behavioral factors in psychopathology
 Techniques of assessment include
– Psychological tests
– Educational tests
– Neuropsychological tests
– Clinical interviews
– Informant ratings/Behaviour checklists
Psychological Tests

Psychological tests are standardized
procedures designed to measure a person’s
performance on a task or to assess his or her
personality
 Psychological tests include:
– Personality inventories
 Minnesota Multiphasic Personality Inventory
– Projective personality tests
 Rorschach Inkblot test
– Intelligence tests
Projective Tests

Projective tests provide ambiguous stimuli
that are interpreted by the test subject
according to unconscious needs/impulses
– Rorschach Inkblot Test: person is asked to
explain each of 10 ink blots (half of the blots are
in color while half are black and white)
– Thematic Apperception Test: person is shown a
series of pictures and asked to explain the story
behind each
Projective Tests - Rorschach
Intelligence Tests

Intelligence (IQ) tests can be used to
– provide a standardized assessment of a
person’s current mental abilities
– diagnose learning disabilities
– determine whether a person is mentally
retarded
– identify intellectually gifted children
Example of Nonverbal Intelligence Task
Examples of Verbal Intelligence
Tasks

Knowledge
– Definition of the word “table”
– Name the seven continents

Analogies
– Dog:Cat as ??:??
 E.g., Day:Night
Examples of Educational Test
Domains
 Phonological
Processing
 Reading Comprehension
 Arithmetic Abilities
 Written Expression
Neuropsychological
Assessment

Brain-behaviour relations assessed
– Tests validated on neurologically-impaired
individuals so that Task A is sensitive to Frontal
Lobe functioning, for example
Test of Planning – Frontal
Lobe
Clinical Interviews

An interview is any interpersonal encounter
in which language is used to gather
information about a client
– A clinical interviewer pays attention to how the
client answers questions posed by the
interviewer
– Clinical interviews involve a degree of empathy
for the problems of the client
– Clinical interviews can be highly structured or
very informal
Behavioral Assessment
Behavioral and
cognitive assessments are made
using the SORC system:
– S (Stimuli): refers to the environmental situations that
precede the problem
– O (Organismic): refers to physiological and
psychological factors operating “under the skin”
– R (Overt Responses): what are the responses and are
these a problem?
– C (Consequent Variables): are there events that are
punishing or reinforcing for the client?
Behavioral Methods

Direct observation of behavior
 Self-monitoring
– Reactivity: behavior changes during monitoring

Interviews
 Self-report inventories
 Other procedures
– Thought listing
Causal Modeling of Psychopathology
Distinguishing levels of analysis
• Biological
• Psychological
• Behavioural
From Morton & Frith 1995
Causal Modeling
Distinguishing levels of analysis
• Biological
• Psychological
• Behavioural
???
poor peer relations
Causal Modeling
Distinguishing levels of analysis
• Biological
• Psychological language social cognition introvert
impairment? impairment?
• Behavioural
poor peer relations
personality?
Causal Modeling
Distinguishing levels of analysis
• Biological
• Psychological language social cognition introvert
impairment? impairment?
• Behavioural
?poor verbal
comprehension
personality?
poor peer relations
?poor recognition ?good sibling
of thoughts/feelings relations
Causal Modeling
E.g. of biologically-defined disorder (‘A’)
• Biological
• Psychological
• Behavioural
Fragile-X
?
?
gaze avoidance low IQ
?
spatial
Causal Modeling
E.g. of cognitively-defined disorder (‘X’)
• Biological
?
• Psychological
theory of mind deficit
• Behavioural
Genes
?
social communication impaired
handicap difficulties imagination
Causal Modeling
E.g. of behaviourally-defined disorder (‘V’)
• Biological
?
Genes?
• Psychological
poor
inhibition?
delay
aversion?
• Behavioural
impulsive/inattentive
Causal Modeling
Environmental effects possible at each level
• Biological
e.g. Phenylketonuria
diet
• Psychological
e.g. dyslexia
orthography
• Behavioural
e.g. literacy problems
school absence