NOSOLOGY IN CHILD AND ADOLESCENT MENTAL HEALTH
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Transcript NOSOLOGY IN CHILD AND ADOLESCENT MENTAL HEALTH
NOSOLOGY
IN CHILD AND ADOLESCENT
MENTAL HEALTH
Graham Martin
The University of Queensland
[email protected]
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