NOSOLOGY IN CHILD AND ADOLESCENT MENTAL HEALTH

1. NOSOLOGYIN CHILD AND ADOLESCENT MENTAL HEALTH Graham Martin The University of Queensland g.martin@uq.edu.au

2. Case Study Jason

3. 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

4. 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

5. 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

6. 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 co-variation between signs and symptoms Definition and Components of a Disorder

7. 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)

9. 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

10. 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

11. 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

12. 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.

13. 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

14. 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”

15. 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

16. 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

17. 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

18. 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

19. 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)

20. Schizophrenia - Positive Symptoms • Thought disorder • disorganised, irrational thinking • Delusions of • persecution • grandeur • control • Hallucinations • perception of stimuli that are not actually present; mostly voices

21. Schizophrenia - Negative symptoms • Absence of normal behaviours • Flattened emotional response • Poverty of speech • Lack of initiative • Inability to experience pleasure • Social withdrawal

22. 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”

23. 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

24. 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

25. 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

26. 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

27. 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)

28. 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

29. 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:

30. Aetiology • Biological/Cognitive • genetic or hereditary bases • maturation of the brain • 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)

31. 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

32. 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)

33. The Diathesis-Stress Paradigm Adapted from Monroe and Simons (1991)

34. 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

35. 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

36. 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

37. 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

38. 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

39. Operant Conditioning of Problematic Behaviour C+ R S Aggressive behaviour Toy of other child Positive reinforcement “gets the toy” C- R S Cancellation of appointment Thought about dentist Negative reinforcement “fear is gone”

40. 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

41. 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

42. Counter-conditioning

43. 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

44. 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

45. Psychodynamic Therapy • Therapy Considerations: • NOT brief – multiple sessions over long time frame • 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

46. 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

47. 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.

48. Psychodynamic Developmental View of Anxiety Disorders • Attachment – 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

49. 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

50. 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